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10377545-DS-9 | 10,377,545 | 23,317,873 | DS | 9 | 2127-11-14 00:00:00 | 2127-11-23 16:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
Stereotactic brain biopsy on ___
History of Present Illness:
Mr. ___ is a ___ man reportedly without significant
past medical history transferred from ___ after
presenting with concern for a new-onset seizure.
Mr. ___ son reports hearing Mr. ___ waking from
sleep
around 3:10 AM this morning and "speaking to himself," at which
time Mr. ___ reportedly used the restroom without incident.
After his soon then used the restroom, he found Mr. ___
face
down on the ground, stuttering with a "th" sound and "kicking"
his legs against the ground. These movements lasted for roughly
2
minutes, during which time Mr. ___ son activated EMS and
opened the front door. Following cessation of the movements, Mr.
___ was noted to be confused and speaking in nonsensical
portmanteaus, reportedly combining "technical terms" from his
employment as an ___ in response to EMS
questions. He was subsequently taken to ___, where
he received 1,500 mg of levetiracetam, as well as dexamethasone
due to CT imaging findings concerning for potential neoplasm. CT
of the C-spine, chest, and A/P were also obtained, and were
notable only for a 7 mm non-obstructive UPJ stone. Following
transfer to ___, Mr. ___ son has noted improvement in
Mr. ___ speech and ability to cooperate with an
examination, though feels that he has not yet fully returned to
his baseline.
Of note, Mr. ___ son notes that Mr. ___ has had
increased fatigue over the past six months, prompting him to
fall
asleep during long conversations or to retire earlier to bed
after returning from work. Mr. ___ has also had increasing
difficulty following conversations with his son over this time,
though has not been noted to have difficulty navigating to
unfamiliar places or misplacing objects throughout the home. Mr.
___ also notably continues to work as an ___
___
at ___ for three days per week.
Unable to obtain review of systems due to speech disturbance.
Past Medical History:
None reported
Social History:
___
Family History:
Negative for stroke, brain malignancy, or
demyelinating disease.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: T: 97.6 P: 69 R: 18 BP: 118/67 SpO2: 100% RA
General: Somnolent but rousable to voice, in NAD
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple, no nuchal rigidity
Pulmonary: No tachypnea or increased WOB
Cardiac: RRR
Abdomen: ND
Extremities: mild BLE edema
Skin: no rashes noted
Neurologic:
-Mental Status: Somnolent but rousable to voice, not oriented to
time or place (reports ___, but "houseschool" instead of
hospital). Perseverative speech with neologisms, reporting that
he had a "sleepdown" as his chief complaint. Nevertheless able
to
repeat short phrases and follow midline and appendicular
commands. Naming impaired, with neologisms as above. No
dysarthria.
-Cranial Nerves:
II, III, IV, VI: PERRL 4 to 2 mm ___. EOMI without nystagmus.
Left ptosis, reportedly new.
V: Unable to assess.
VII: Mild R NLFF, reportedly chronic.
VIII: Hearing intact to conversation.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline.
-Motor: Mild right-sided pronation without drift.
Delt Bic Tri WrE FFl FE IP Quad Ham TA
L 5 ___ ___ 5 5 5
R 5 ___ 5 4+ 5 5 5 5
-Sensory: No deficits to light touch or pinprick. No extinction
to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
-Coordination: No intention tremor or dysmetria on FNF
bilaterally.
-Gait: Able to stand on own weight and take one step.
===================================================
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 1238)
Temp: 97.6 (Tm 98.3), BP: 125/69 (111-139/63-75), HR: 57
(55-62), RR: 20 (___), O2 sat: 99% (96-99), O2 delivery: Ra
General: Awake, alert, in NAD
HEENT: small healing lac R eyebrow, no scleral icterus noted,
MMM
Neck: Supple
Pulmonary: No tachypnea or increased WOB
Cardiac: extremities warm and well perfused
Abdomen: Nondistended
Extremities: minimal BLE edema
Skin: no rashes noted, skin check of extremities, face, and
back
revealed no obvious melanotic macules
-Mental Status: Awake, alert, oriented to person, says he is in
___ then corrects himself. Able to recognize ___ when given options. Continues to process questions slowly
and answers slowly. Perseverates on feeling "magnificent."
Importantly, he was able to relay that the results from his
brain
biopsy have not yet been finalized, and is aware that he is
going
to rehab with a follow-up in brain tumor clinic. Able to follow
certain midline commands however demonstrates intermittent
right-sided neglect. Today demonstrates mild apraxia with finger
substitution, improved from prior. On afternoon re-examination
pt
finds difficulty in shaking hands with R hand, frustrated that
arm does not go where he wants it to go.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2 mm ___. EOMI without nystagmus.
Visual fields intact bilaterally. Mild left ptosis.
V: Sensation intact and equal V1-V3
VII: Mild R NLFF, reportedly chronic, mild droop on activation
(son reports this has been there since his car accident in ___
VIII: Hearing intact to conversation with hearing aids.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline.
-Motor: No drift (improved from prior). Normal bulk and tone in
upper and lower extremities. Muscle strength ___ throughout
however struggles to hoist self up in bed. No adventitious
movements.
-Sensory: No deficits to light touch, pain, or temperature.
-DTRs:
Bi Tri ___ Pat Ach
L 2 1 1 2 1
R 2 1 1 2+ 1
-Coordination: No intention tremor or dysmetria on FNF
bilaterally.
-Gait: Not tested
Pertinent Results:
___ 08:24AM BLOOD WBC-14.0* RBC-5.11 Hgb-14.2 Hct-43.3
MCV-85 MCH-27.8 MCHC-32.8 RDW-15.3 RDWSD-47.4* Plt ___
___ 06:20AM BLOOD WBC-14.4* RBC-4.38* Hgb-12.0* Hct-36.9*
MCV-84 MCH-27.4 MCHC-32.5 RDW-15.3 RDWSD-47.1* Plt ___
___ 07:07AM BLOOD WBC-11.1* RBC-4.77 Hgb-13.3* Hct-40.8
MCV-86 MCH-27.9 MCHC-32.6 RDW-15.6* RDWSD-48.3* Plt ___
___ 08:24AM BLOOD Neuts-92.7* Lymphs-4.1* Monos-2.0*
Eos-0.2* Baso-0.4 Im ___ AbsNeut-12.97* AbsLymp-0.57*
AbsMono-0.28 AbsEos-0.03* AbsBaso-0.06
___ 06:34AM BLOOD ___ PTT-18.8* ___
___ 08:24AM BLOOD Glucose-112* UreaN-17 Creat-0.9 Na-144
K-4.4 Cl-103 HCO3-24 AnGap-17
___ 07:07AM BLOOD Glucose-77 UreaN-16 Creat-0.8 Na-145
K-4.3 Cl-104 HCO3-24 AnGap-17
___ 05:20AM BLOOD LD(___)-159
___ 08:24AM BLOOD ALT-19 AlkPhos-64 TotBili-0.6
___ 08:24AM BLOOD Lipase-29
___ 08:24AM BLOOD cTropnT-<0.01
___ 07:07AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.0
___ 05:20AM BLOOD TSH-5.2*
___ 05:20AM BLOOD T4-5.8
___ 05:20AM BLOOD CRP-4.9
___ 05:20AM BLOOD CRP-4.9
___ 05:20AM BLOOD b2micro-2.9*
___ 05:20AM BLOOD HIV Ab-NEG
___ 08:24AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
QUANTIFERON(R)-TB GOLD NEGATIVE
SED RATE BY MODIFIED 2 < OR = 20 mm/h
WESTERGREN
CSF:
___ 04:55PM CEREBROSPINAL FLUID (CSF) TNC-3 RBC-1 Polys-0
___ ___ 04:55PM CEREBROSPINAL FLUID (CSF) TotProt-45 Glucose-62
LD(LDH)-27
Test Result Reference
Range/Units
BETA ___ MICROGLOBULIN, CSF 2.18 0.36-2.56 mg/L
=====================================
___ CTA head/neck:
1. Dental amalgam streak artifact limits study.
2. Dominant, 3.5 x 2.5 cm heterogeneous left paramedian parietal
lobe mass
with surrounding vasogenic edema, mild local mass effect, and
partial
effacement of the posterior left lateral ventricle.
3. Additional, 1.8 x 1.5 cm heterogeneous mildly hyperdense mass
within the right parietal temporal lobe, also demonstrating mild
local mass effect and surrounding vasogenic edema. Given the
multiple intracranial masses, metastatic disease is favored,
with multifocal primary neoplasm felt less likely.
4. No evidence for acute intracranial hemorrhage or vascular
territorial
infarction. Please note MRI of the brain is more sensitive for
the detection of acute infarct.
5. 9 mm hypodensity within the left internal capsule may
represent a late
subacute to early chronic infarct, with focal mass lesion felt
less likely.
6. Multifocal atherosclerotic disease throughout the cervical
and intracranial vasculature, as above, without high-grade
stenosis, occlusion, or aneurysm greater than 3 mm.
___ CSF Cytology:
Rare atypical cells with eccentric nuclei in a background of
reactive lymphocytes and monocytes.
___ MRI w/wo:
1. Study is moderately degraded by motion.
2. Multiple irregular, heterogeneously enhancing, mixed solid
and cystic
parenchymal lesions involving the left parietal lobe, right
temporal lobe, and left thalamus, concerning for metastatic
disease.
3. Mild associated vasogenic edema with local mass effect,
particularly
involving the dominant left parietal lesion.
4. No evidence for ventricular obstruction or downward
herniation.
5. No vascular territorial infarction and no acute intracranial
hemorrhage.
6. Paranasal sinus disease , as described.
___ Second opinion CT torso:
1. No evidence for a primary malignancy in the chest and
parenchymal organs of the abdomen and pelvis.
2. An indeterminate 1.7 cm lesion in the lower pole of the right
kidney most likely represents a hyperdense cyst. This could be
confirmed with ultrasound.
3. Nonobstructing 7 mm stone in the distal left ureter, a 1 cm
nonobstructing stone in the distal urethra
4. Multiple liver cysts
___ Renal u/s:
Simple bilateral cortical renal cysts.
___ ___:
1. No evidence of intracranial hemorrhage status post biopsy.
2. Lesions in the posterior right temporal lobe, the left
thalamus and the
left parietal-occipital lobes are overall unchanged with a
similar amount of mass effect on the left lateral and third
ventricles.
Brief Hospital Course:
Mr. ___ is a ___ year old man with mild cognitive decline
who presented to ___ after first-time seizure and
was subsequently transferred to ___ for concerning imaging
findings found to have three rim-enhancing, heterogenous lesions
in the L parietal lobe, L thalamus, and R temporal lobe; frozen
section from brain biopsy on ___ revealing high-grade glioma
with final pathology pending.
On admission to ___ Neurology he was alert and in no distress,
endorsing only a mild headache on full review of systems. His
exam was notable for difficulty with orientation, processing,
naming, memory, apraxia, and attention. He was initially able to
follow midline commands but unable to perform cross-body
commands. He had no major deficits in primary motor and sensory
function, reflexes, or coordination.
He was continued on levetiracetam 750mg BID (at ___ he had
received 1500mg levetiracetam +dexamethasone) and did not
require lorazepam for seizure rescue during his current
hospitalization. He has not had any seizures since admission.
A significant workup was initiated for multifocal brain lesions,
including infectious and neoplastic etiologies. Infectious
workup was unrevealing. CT torso did not reveal a primary
malignancy. A brain biopsy on ___ revealed high-grade
glioma (Based upon frozen section). He was started on
dexamethasone 2mg PO daily once this was established.
His exam was relatively stable throughout his hospitalization.
Although his cognition remains impaired, apraxia, orientation,
and ability to follow cross-body improved mildly after he was
started on dexamethasone for cerebral edema.
We have discussed the possible implications of these results at
length with Mr. ___ and his son, ___, who has been at the
hospital every day with his dad. This included prognosis and
management options, which will be finalized in the
___ clinic once the full pathology details are
available.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Dexamethasone 2 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Famotidine 20 mg PO BID
5. LevETIRAcetam 1000 mg PO Q12H
6. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration:
14 Doses
7. Senna 17.2 mg PO DAILY:PRN Constipation
8. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Multifocal high-grade glioma, likely glioblastoma multiforme
with final pathology pending (biopsy done ___
Discharge Condition:
Mental Status: alert, oriented to person and sometimes place.
Mild cognitive impairment demonstrating difficulty with
processing, naming, memory, and attention.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair. Lacks insight into physical limitations with some
impulsivity and near-falls in shower. Assistance required with
any ambulation or OOB activity.
Discharge Instructions:
Mr. ___,
You were admitted with an event concerning for seizure. We found
that you have three masses in your brain. One of them was
biopsied, and the very preliminary report is that it is a type
of cancer called a glioma.
-Call the ___ clinic at ___ to have sutures
removed on approx. ___. Alternately, sutures can be removed at
brain tumor clinic follow up on that day.
It was a pleasure taking care of you.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10377744-DS-21 | 10,377,744 | 27,366,727 | DS | 21 | 2143-11-08 00:00:00 | 2143-11-08 17:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Optiray 350
Attending: ___.
Chief Complaint:
weakness, hyponatremia
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
___ with panhypopituitary, HTN, HL who presented today from the
ED with 3 days of nausea, vomiting, weakness and dizziness. This
began while she was at work on ___, with multiple episodes
of non-bloody emesis as well as dizziness. She reports she may
have had some abdominal pain that preceded these symptoms by a
couple days. She continued to take all of her home medications
including prednisone throughout these symptoms.
.
In the ED, her initial vitals were 98 70 92/57 18 100%. She was
found to have a sodium of 110 and was given 2L of normal saline.
Transferred to the FICU for sodium correction.
.
On arrival to the ICU, she continues to feel dizzy with some
abdominal pain, but overall feels improved.
Past Medical History:
hypertension
hyperlipidemia
panhypopituitarism due to ___ syndrome
gastritis
positive PPD (finished INH, ___
Social History:
___
Family History:
Mother: hypertension
Physical ___:
ADMISSION EXAM:
.
Vitals: 98.2 75 95/50 13 96%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mildly 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:
.
___ 12:30PM BLOOD WBC-6.4 RBC-4.13* Hgb-12.2 Hct-32.9*
MCV-80*# MCH-29.5 MCHC-37.0*# RDW-11.8 Plt ___
___ 12:30PM BLOOD Neuts-78.5* Lymphs-13.1* Monos-4.4
Eos-1.4 Baso-2.7*
___ 12:30PM BLOOD Glucose-81 UreaN-8 Creat-0.6 Na-110*
K-4.8 Cl-75* HCO3-21* AnGap-19
___ 05:04PM BLOOD Calcium-7.3* Phos-3.1 Mg-1.4*
___ 12:30PM BLOOD Osmolal-238*
___ 05:04PM BLOOD TSH-<0.02*
___ 08:59PM BLOOD T4-11.4 T3-95 calcTBG-0.87 TUptake-1.15
___ Free T4-2.1*
___ 05:04PM BLOOD Cortsol-4.0
___ 05:00PM BLOOD freeCa-1.06*
___ 01:05AM BLOOD freeCa-1.11*
___ 02:11PM BLOOD Lactate-1.4
.
.
IMAGING STUDIES:
___ CT HEAD W/O CONTRAST - There is no acute intra-axial or
extra-axial hemorrhage, mass, midline shift, or territorial
infarct. Ventricles, sulci, and basilar cisterns are
unremarkable and stable in configuration compared to prior. Note
is made of a lipoma within the quadrigeminal plate cistern on
the right. Orbits are symmetric and unremarkable. Paranasal
sinuses included on this exam are clear. Skull and extracranial
soft tissues are unremarkable.
.
___ CHEST (PA & LAT) - Right basilar opacity is probably
atelectasis, but could represent early or developing pneumonia
in the appropriate clinical setting.
.
Cardiovascular Report ECG Study Date of ___ 12:38:32 ___
Normal sinus rhythm with Q-T interval prolongation. Compared to
the previous
tracing of ___ the Q-T interval is significantly longer.
Clinical
correlation is suggested.
.
MICROBIOLOGIC DATA:
___ Blood culture - ngtd
___ MRSA screen - no ___
DISCHARGE LABS:
___ 11:30AM BLOOD WBC-5.5# RBC-4.24 Hgb-12.5 Hct-34.8*
MCV-82 MCH-29.4 MCHC-35.9* RDW-12.7 Plt ___
___ 06:15AM BLOOD Glucose-70 UreaN-16 Creat-0.6 Na-144
K-4.6 Cl-108 HCO3-28 AnGap-13
___ 11:30AM BLOOD Calcium-8.9 Phos-1.5*# Mg-2.2
___ 08:59PM BLOOD T4-11.4 T3-95 calcTBG-0.87 TUptake-1.15
___ Free T4-2.1*
Studies pending at discharge:
None
Brief Hospital Course:
___ yo female with PMH significant for panhypopituitarism in the
setting of postpartum hemorrhage ___ syndrome),
hypertension, hyperlipidemia admitted with viral gastroenteritis
and adrenal crisis associated with hyponatremia to 110 and
hypotension.
#Adrenal crisis/Hyponatremia:
Patient presented with hyponatremia and hyponatremia to 110 in
the setting of an acute illness. It was felt that the patient
was relatively adrenally insufficent given his acute illness and
was treated with IVF and stress dose hydrocortisone. Sodium
rapidly improved and GI symptoms resolved quickly as well.
Endocrine was consulted and recommended D5W in addition to DDAVP
0.1mcg IV x1 to promote free water reabsorption and prevent too
rapid of correction of sodium. HOwever, they did note that rapid
correction of sodium in the setting of steroid repletion was
okay and expected. Patient was transitioned from stress dose
steroids to a rapid prednisone taper and was discharged on a
rapid taper to return to his previous maintenance prednisone
regimen of 5mg po daily as his acute illness had resolved.
Patient will follow with endocrine as an outpatient.
#HYPOTHYROIDISM - Patient has known diagnosis of postpartum
hemorrhage leading to panhypopituitarism. Admission TSH < 0.02
with TFTs demonstrating T4 11.4, T3 95, free T4 2.1. Initially
IV Levothyroxine was used for replacement but was switched to PO
Levothyroxine dosing when GI issues resolved. Patient will
follow with endocrine as an outpatient.
.
CHRONIC CARE
#GASTRITIS - Patient was continued on omeprazole 20 mg PO daily
#HYPERLIPIDEMIA - Pastient was continued on Simvastatin 5 mg PO
daily
.
#Contact: ___ (daughter) - ___
#Code: FULL
#Disposition:
Patient was discharged to follow up with Endocrinology in one
week and PCP ___ 3 weeks. She will have labs prior to her
Endocrine follow up appointment. Patient was counseled on
symptoms of adrenal insufficiency and told to call her doctor if
she experiences any neurologic symptoms.
Medications on Admission:
HCTZ 12.5mg daily
Levothyroxine 125 mcg daily
Losartan 50mg daily
Omeprazole 20mg daily
Prednisone 5mg daily
Simvastatin 5mg daily
Calcium carbonate 500mg / Vitamin D 200 unit BID
Discharge Medications:
1. prednisone 5 mg Tablet Sig: as directed Tablet PO as
directed: Please take:
4 tablets on ___
2 tablets on ___ ___ tablet/daily thereafter.
Disp:*35 Tablet(s)* Refills:*2*
2. simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day: Please do not restart until ___.
7. losartan 50 mg Tablet Sig: One (1) Tablet PO once a day:
Please do not start until ___.
8. Outpatient Lab Work
Please draw
1) CBC
2) Chem 7
and send labs STAT. Thanks
Discharge Disposition:
Home
Discharge Diagnosis:
Hyponatremia
Adrenal insufficiency
Viral gastroenteritis
Panhypopituitarism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a viral gastroenteritis and adrenal
insufficiency causing very low sodium levels. Your viral
gastroenteritis improved and your symptoms improved with
appropriate steroid replacement. You are being discharged on a
prednisone taper.
You should take 20mg of prednisone on ___, 10mg of
prednisone on ___ and resume your usual 5mg daily of
prednisone on ___.
You should also follow up with both your PCP and ___
in the next few weeks as detailed below.
You are being given a prescription to have your labs drawn on
the morning ___. Please arrive a few hours
before your appointment to have your labs drawn in the ___
or ___ Associates laboratory.
Please call your doctor if you experience any fevers, chills,
low energy, malaise, abdominal pain, feel as if you are going to
pass out, or notice any focal weakness, difficulties moving, or
changes in sensation.
Followup Instructions:
___
|
10377951-DS-2 | 10,377,951 | 27,882,555 | DS | 2 | 2120-10-29 00:00:00 | 2120-10-29 07:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
leg pain
Major Surgical or Invasive Procedure:
___ Microdiscectomy LEFT
History of Present Illness:
This patient is a ___ year old male who complains of LEFT
LEG PAIN. Patient presents with significant left leg pain
and numbness. Patient had an MRI which showed a left-sided
disc herniation at L3-L4. Patient denies any fevers or
chills. The patient denies any bowel or bladder issues.
Past Medical History: Deviated septum, status post surgery in
___.
Current Medications: Aleve and tramadol.
Allergies: No known drug allergies.
Social History: ___
Family History: Negative.
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Hospital course was otherwise unremarkable.
On the day of discharge the patient was afebrile with stable
vital signs, comfortable on oral pain control and tolerating a
regular diet.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet extended release(s) by mouth
every six (6) hours Disp #*100 Tablet Refills:*0
2. Diazepam 2.5-5 mg PO Q6H:PRN pain, spasm
RX *diazepam 5 mg 0.5 - 1 tab by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*50 Capsule Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4-6h Disp #*50 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Herniated lumbar disc
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: Minimally Invasive
Microdiscectomy
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit or stand more than ~45 minutes without moving around.
Rehabilitation/ Physical Therapy:
___ ___ times a day you should go for a walk
for ___ minutes as part of your recovery. You can walk as
much as you can tolerate.
___ Limit any kind of lifting.
Diet: Eat a normal healthy diet. You may have
some constipation after surgery.
Brace: You do not need a brace.
Wound Care: Remove the dressing in 2 days. If
the incision is draining cover it with a new sterile dressing.
If it is dry then you can leave the incision open to the air.
Once the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead. You can either
have them mailed to your home or pick them up at the clinic
located on ___. We are not allowed to call in narcotic
prescriptions (oxycontin, oxycodone, percocet) to the pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
___ At the 2-week visit we will check your
incision, take baseline X-rays and answer any questions. We may
at that time start physical therapy.
___ We will then see you at 6 weeks from the
day of the operation and at that time release you to full
activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound
Followup Instructions:
___
|
10378026-DS-6 | 10,378,026 | 24,981,696 | DS | 6 | 2129-08-08 00:00:00 | 2129-08-08 14:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
SMA thrombus and renal infarcts
Major Surgical or Invasive Procedure:
___: Exploratory laparotomy, SMA embolectomy and
ABThera placement
___: Second look laparotomy and closure of open abdomen
History of Present Illness:
___ with cognitive delay/?dementia and afib (two weeks off
Xarelto) who presented to OSH with nausea. CT showed SMA
occlusion and left renal infarct. He was started on heparin
drip,
received Metoprolol for HR 130s and 3L NS. He was transferred to
___.
Past Medical History:
Medical History
CAD, DM, B-cell lymphoma, s/p rituximab with resolution, atrial
fib, HLD
Surgical History: denies, no surgical scars
Social History:
___
Family History:
unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
====================================
T 98.2 HR 118 BP 172/89 RR 24 SatO2 100% RA
Combative
Oriented to person, disoriented to time and place
Irregular heart rate
CTA bil
Abdomen soft, mild tenderness to palpation ___ R lower abdomen
Umbilical hernia without skin changes, appears non tender
No edema, palpable DP bilaterally
DISCHARGE PHYSICAL EXAM:
====================================
VS: 24 HR Data (last updated ___ @ 2224)
Temp: 97.8 (Tm 99.2), BP: 137/84 (101-166/58-84), HR: 78
(51-108), RR: 18 (___), O2 sat: 96% (96-99), O2 delivery: Ra
GENERAL: Alert, interactive, NAD
HEENT: NC/AT, EOMI, sclera anicteric w/o injection, clear OP,
MMM
CARDIAC: Irregular rhythm, regular rate, II/VI systolic murmur
LUNGS: CTAB, no wheezes, unlabored respirations
ABDOMEN: soft, non-distended, no ttp, +BS, midline surgical
incision c/d/I w/ staples ___ place
EXTREMITIES: No lower extremity edema, 2+ radial/DP pulses
SKIN: No rash, warm
NEUROLOGIC: A/Ox2, moving upper extremities with purpose
Pertinent Results:
ADMISSION LABS:
======================================
___ 11:26PM BLOOD WBC-11.0* RBC-4.36* Hgb-13.4* Hct-40.7
MCV-93 MCH-30.7 MCHC-32.9 RDW-14.2 RDWSD-48.1* Plt ___
___ 11:26PM BLOOD ___ PTT-150* ___
___ 06:10PM BLOOD Glucose-253* UreaN-19 Creat-1.0 Na-144
K-3.2* Cl-101 HCO3-18* AnGap-25*
___ 11:26PM BLOOD Calcium-7.7* Phos-2.7 Mg-1.7
___ 11:33PM BLOOD Type-ART pO2-402* pCO2-37 pH-7.39
calTCO2-23 Base XS--1
___ 06:17PM BLOOD Lactate-7.1*
___ 08:23PM BLOOD Glucose-204* Lactate-4.6* Na-142 K-2.8*
Cl-109*
___ 11:33PM BLOOD Glucose-153* Lactate-3.1* K-3.3
MICROBIOLOGY
======================================
__________________________________________________________
___ 12:11 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
__________________________________________________________
___ 3:36 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 3:36 pm BLOOD CULTURE Source: Line-peripheral.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:13 pm Mini-BAL
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 CFU/mL Commensal Respiratory Flora.
KLEBSIELLA OXYTOCA. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
STAPH AUREUS COAG +. 10,000-100,000 CFU/mL.
GRAM NEGATIVE ROD #2. ~4000 CFU/mL.
FURTHER WORKUP ON REQUEST ONLY.
Isolates are considered potential pathogens ___ amounts
>=10,000
cfu/ml.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
>100,000 CFU/mL.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested ___ cases of treatment
failure ___
life-threatening infections..
KLEBSIELLA OXYTOCA. 10,000-100,000 CFU/mL.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
| STAPH AUREUS COAG +
| | KLEBSIELLA
OXYTOCA
| | |
AMPICILLIN/SULBACTAM-- 4 S =>32 R
CEFAZOLIN------------- <=4 S =>64 R
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S 2 I
CIPROFLOXACIN---------<=0.25 S <=0.25 S
CLINDAMYCIN----------- <=0.25 S
ERYTHROMYCIN---------- <=0.25 S
GENTAMICIN------------ <=1 S <=0.5 S <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S <=0.25 S
OXACILLIN------------- 0.5 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S =>16 R <=1 S
RELEVANT STUDIES
======================================
___ TTE:
The left atrial volume index is moderately increased. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF = 70%). Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are moderately thickened. There is mild aortic
valve stenosis. Trace aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
___ CT HEAD W/O CONTRAST:
1. No evidence of mass, hemorrhage or recent infarction.
2. Ventricular enlargement raises the possibility of
communicating
hydrocephalus.
3. Findings indicating chronic small vessel ischemia.
___ CT HEAD W/O CONTRAST: No acute intracranial process.
DISCHARGE LABS
======================================
___ 08:00AM BLOOD WBC-6.3 RBC-3.46* Hgb-10.4* Hct-33.1*
MCV-96 MCH-30.1 MCHC-31.4* RDW-15.5 RDWSD-53.6* Plt ___
___ 08:00AM BLOOD ___ PTT-33.3 ___
___ 08:00AM BLOOD Glucose-97 UreaN-9 Creat-0.8 Na-145 K-4.4
Cl-109* HCO3-27 AnGap-9*
Brief Hospital Course:
Mr. ___ is a ___ male with A. fib, cognitive
impairment who was admitted with SMA and left renal artery
emboli ___ the setting of anti-coagulation noncompliance at home.
# SMA EMBOLUS
# LEFT RENAL ARTERY EMBOLUS:
Patient presented with abdominal pain, nausea, and vomiting with
elevated lactate. CT abdomen/pelvis at outside hospital showed
thrombus within SMA throughout majority of the SMA. Patient had
history of A. Fib and had been off anti-coagulation for two
weeks. He had exploratory laparotomy, SMA thrombectomy, and
ABThera vac placement over his abdomen. Patient developed
hemorrhagic shock from muscular hemorrhage ___ the SICU and had
second look laparotomy and abdominal closure. Patient was
anti-coagulated with heparin gtt and transitioned to warfarin,
remaining hemodynamically stable. He will be discharged on
warfarin to a rehab facility.
# ATRIAL FIBRILLATION:
Patient has A. fib and was non-compliant with Xarelto. He
developed A. fib w/ RVR ___ the ICU requiring diltiazem gtt which
was transitioned to PO diltiazem. Patient was discharged on
Metoprolol Succinate XL 75 mg PO daily, Diltiazem ER 360 mg PO
daily, and warfarin for anti-coagulation.
# HYPOXEMIA:
# ASPIRATION PNEUMONIA:
Patient was intubated ___ and was extubated on
___. Patient had suspected aspiration of tube feeds on
___ and subsequently became more unresponsive throughout the
day. He was re-intubated for airway protection and successfully
extubated ___. Patient had fever, known aspiration event,
and leukocytosis and was treated for aspiration pneumonia with
Zosyn from ___ and then Cefepime from ___. Sputum
culture grew Klebsiella oxytoca sensitive to Cefepime and coag +
staph aureus. Patient failed speech and swallow bedside eval on
___ and recommendation was for strict NPO. Tolerating PO intake
now and meeting nutritional requirements. Dobhoff removed ___
and patient tolerating PO intake.
# DYSPHAGIA:
Patient had Dobhoff feeding tube placed while intubated. Feeding
tube was kept after patient had aspiration event. Speech and
swallow evaluated patient and recommended strict NPO. Patient
was re-evaluated four days later and patient tolerated diet
advancement. Nutrition evaluated patient and determined patient
had adequate PO intake to meet nutritional requirements. Dobhoff
feeding tube was removed prior to discharge.
#CAD: Continued Atorvastatin 80 mg QHS, not on asa 81 given
bleed this admission
#HTN: continued amlodipine
#Nutrition: continued MVI/minerals and supplements per nutrition
recs
#Cognitive impairment: not formally diagnosed. Known to have
behavioral disturbances and paranoia at home (e.g. calling FBI
on meals on wheels). Currently amenable to team's plan including
going to rehab. Has HCP signed ___ chart. SW consulted for future
guardianship pursual as current HCP does not want to be decision
maker permanently. This may be further discussed after
discharge. Seroquel was discontinued and patient remained calm
and amenable to team plan throughout the week prior to
discharge.
#DM: newly diagnosed this admission and monitored on SSI
TRANSITIONAL ISSUES
===============================
[] Vascular Surgery follow-up scheduled for ___ at 10
AM. Patient has CTA abdomen/pelvis ordered for the same day and
should have prior to vascular surgery follow-up appointment. CTA
is to evaluate for any interval changes ___ the SMA after SMA
embolectomy.
[] General Surgery follow-up scheduled for ___ at 1 ___.
[] initiated on Coumadin this admission given better ability to
monitor INR over xarelto and given noncompliance with medication
___ the past
[] HCP amenable to assisting with healthcare decisions; however,
may consider guardianship pursual ___ the future as there is
concern about ability to care for himself
[] DNR/DNI
[] HCP ___ ___ ___
Medications on Admission:
amlodipine 10 mg daily
atorvastatin 80mg daily
metoprolol succinate 100 mg ER daily
Xarelto 20 mg daily (non-compliant)
Discharge Medications:
1. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID
2. Diltiazem Extended-Release 360 mg PO DAILY
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Warfarin 2 mg PO ONCE Duration: 1 Dose
5. Metoprolol Succinate XL 75 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
SMA Embolus
Left renal artery embolus
Hemorrhagic shock
Aspiration Pneumonia
Atrial fibrillation with RVR
Secondary diagnosis:
Coronary artery disease
Diabetes mellitus
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. ___,
It was a pleasure taking care of you at ___.
Why was I here?
- You were having nausea, vomiting, and abdominal pain. You had
a CT scan of your abdomen which showed a blood clot ___ one of
your abdomen and kidney arteries.
What was done for me while I was here?
- You had surgery to remove the blood clots from your abdomen
and kidney arteries.
- You had bleeding after your surgery and had a repeat surgery
to stabilize the bleeding.
- You had pneumonia and were treated with antibiotics.
- You had difficulty swallowing and had a feeding tube placed to
give you nutrition. When your swallowing improved, your feeding
tube was removed.
- You were started on a different blood thinner called Coumadin.
You are on a blood thinner because you have a heart arrhythmia
called atrial fibrillation.
What should I do when I go home?
- You should take all of your medications as prescribed.
- You should attend all of your follow-up appointments.
We wish you the best ___ the future.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10378079-DS-33 | 10,378,079 | 20,155,894 | DS | 33 | 2131-06-26 00:00:00 | 2131-06-27 22:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient received Ommmya shunt placement on ___. She
tolerated the procedure well.
She complains of sudden onset headache that woke her up from her
sleep at 2 AM today. She reports there is no change in the
severity of the pain since, it is ___, diffuse, non radiating,
accompanied with 4 episodes of vomiting.
She denies weakness or numbness, bowel or bladder retention or
incontinence. She reports she had some subjective fevers before
but no chills. No recorded temperatures to confirm fevers.
No blood seen in vomitus. No other sx per pt. No gait imbalance,
no bowel or bladder habit changes per pt.
Past Medical History:
-CNS lymphoma (see below)
-Depression
-HSV infection during MTX treatment in the past
-GERD
-HTN
Oncological History:
She initially presented with headaches, dizziness, and diplopia
and then had a head MRI of the brain showed a tectal mass and
three areas of nodular enhancement on the ventricular surfaces,
concerning for brain metastases with ventricular seeding.
-___: Stereotactic biopsy confirmed high-grade B-cell
lymphoma.
-___: CT torso negative.
-___: Started 5 cycles of induction high-dose methotrexate.
Social History:
___
Family History:
She has 6 healthy children and a nephew with a brain tumor.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
VITAL SIGNS: 98.7 PO 140 / 70 99 16 97% RA
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly. Eyes PERRL bilaterally.
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis;
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves II-XII are within normal limits excluding
visual acuity which was not assessed, no nystagmus; strength is
___ of the proximal and distal upper and lower extremities;
reflexes are 2+ of the patellar, and Achilles tendons
DISCHARGE PHYSICAL EXAM:
VS: 98.1 PO 114 / 70 80 18 98 RA
GEN: Alert, responsive, NAD
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly. Eyes PERRL bilaterally.
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves II-XII are within normal limits excluding
visual acuity which was not assessed, no nystagmus; strength is
___ of the proximal and distal upper and lower extremities;
reflexes are 2+ of the patellar, and Achilles
tendons
Pertinent Results:
ADMISSION LABS
___ 02:40PM BLOOD WBC-14.3*# RBC-2.41* Hgb-7.9* Hct-25.3*
MCV-105* MCH-32.8* MCHC-31.2* RDW-23.0* RDWSD-84.0* Plt ___
___ 02:40PM BLOOD Neuts-78* Bands-5 Lymphs-7* Monos-6 Eos-0
Baso-0 ___ Myelos-4* AbsNeut-11.87* AbsLymp-1.00*
AbsMono-0.86* AbsEos-0.00* AbsBaso-0.00*
___ 02:40PM BLOOD Glucose-126* UreaN-6 Creat-0.5 Na-136
K-4.0 Cl-102 HCO3-24 AnGap-14
___ 02:40PM BLOOD Calcium-8.7 Phos-4.2 Mg-1.9
___ 02:40PM BLOOD ___ Folate-9.9
___ 02:40PM BLOOD Lactate-1.0
DISCHARGE LABS
___ 04:45AM BLOOD WBC-4.2 RBC-2.30* Hgb-7.7* Hct-24.0*
MCV-104* MCH-33.5* MCHC-32.1 RDW-22.2* RDWSD-83.4* Plt ___
___ 04:45AM BLOOD Glucose-163* UreaN-8 Creat-0.6 Na-139
K-4.4 Cl-103 HCO3-27 AnGap-13
___ 04:45AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.1
MICROBIOLOGY
___ 2:40 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 5:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
IMAGING
___ ___
IMPRESSION
1. Compared to ___, no significant change. No
evidence of
infarction, hemorrhage, edema or mass.
2. As before, the patient is status post right Ommaya reservoir
placement.
3. Sinus disease as above.
CXR ___:
No acute intrathoracic process.
Brief Hospital Course:
___ is a ___ with a history of a tectal
primary CNS lymphoma, who now has an aggressive non-Hodgkin's
systemic lymphoma being treated with rituximab/EPOCH (Cycle 4
Day 1: ___ Cycle end: ___ with IT chemotherapy
prophylaxis, s/p Ommaya placement ___, presenting two days
after the procedure with an acute headache and vomiting but
without evidence of acute process on CT head.
1. Headache: Differential includes possible post procedural
headache vs infectious complication vs new mechanical
obstruction from port placement, though CT is reassuring against
hemorrhage or ventricular obstruction. The patient was been
evaluated by neurosurgery, who feels that acute process is
unlikely according to repeat CT and that no intervention is
indicated. Patient was afebrile and hemodynamically stable;
headache improved throughout admission; patient without new
neurological deficit. Blood, urine cultures without growth. Pain
was controlled with Tylenol and PO oxycodone.
2. Orbital Swelling: Per neurosurgery, orbital swelling was
complication of port placement and not concerning for infection.
Patient does not have pain in the eye, vision changes, fever,
leukocytosis.
3. Leukocytosis: Patient with WBC of 48.6 on ___ prior to
admission, trended down to 4.2 on discharge. Could have been ___
to neupogen administration with ongoing chemotherapy.
4. IT Chemotherapy for Aggressive Systemic Lymphoma: She is at
risk for CNS progression or leptomeningeal involvement. She is
being treated with multiple cycles of rituximab/EPOCH Per Neuro
onc- needs IT chemotherapy. Will receive IT chemotherapy at
appointment on ___.
5. CNS Lymphoma: Stable, though patient should have repeat HIV
testing as outpatient (last negative in ___.
6. Macrocytic Anemia: Appears near her recent baseline. Likely
___ known lymphoma and chemotherapy. Folate WNL, B12 above
normal.
-Continue to trend CBC
***TRANSITIONAL ISSUES***
-Patient scheduled for IT methotrexate for CNS prophylaxis on
___ with Dr. ___. Please see appointment above.
-Started on dexamethasone 4mg po daily for headache
-Code: Full
-Contact: Phone: ___ ___ cell, ___ SON'S PHONE
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. FLUoxetine 40 mg PO DAILY
3. LaMIVudine 100 mg PO DAILY
4. Filgrastim 480 mcg SC Q24H
5. Nystatin Oral Suspension 5 mL PO QID:PRN mouth pain
6. Simvastatin 40 mg PO QPM
7. Sulfatrim (sulfamethoxazole-trimethoprim) 400-80 (10mL) mg
oral DAILY
8. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Dexamethasone 4 mg PO DAILY
RX *dexamethasone 4 mg 1 tablet(s) by mouth daily Disp #*14
Tablet Refills:*0
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. Acyclovir 400 mg PO Q8H
4. Filgrastim 480 mcg SC Q24H
5. FLUoxetine 40 mg PO DAILY
6. LaMIVudine 100 mg PO DAILY
7. Nystatin Oral Suspension 5 mL PO QID:PRN mouth pain
8. Simvastatin 40 mg PO QPM
9. Sulfatrim (sulfamethoxazole-trimethoprim) 400-80 (10mL) mg
oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Headache
Secondary Diagnosis:
CNS Lymphoma
Leukocytosis
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 ___ with
worsening headache. In the Emergency Department you had a CT
scan which did not show anything concerning. This is likely due
to the recent ___ reservoir placement. You were treated with
pain medications, and this improved. We also started you on a
medication called Dexamethasone, which you should take daily
until you follow-up with Dr. ___ as an outpatient.
You are scheduled to follow-up with Dr. ___ on ___ for your
ongoing therapy. See below for details.
It was a pleasure taking care of you,
Your ___ Team
Followup Instructions:
___
|
10378079-DS-38 | 10,378,079 | 25,618,479 | DS | 38 | 2131-10-06 00:00:00 | 2131-10-06 21:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with a history of a tectal primary
CNS lymphoma, who now has an aggressive non-Hodgkin's systemic
lymphoma being treated with rituximab/EPOCH with IT chemotherapy
prophylaxis, s/p Ommaya placement.
Patient states that she has had a few weeks of a lower back
pain. Symptoms have progressively gotten worse the point where
she is unable to walk now due to the pain. No fevers or chills.
Endorses a cough and some shortness of breath. This is new over
last 3 days. Denies any bowel or bladder incontinence. No
numbness or tingling in her lower extremities. Denies any falls
or trauma to her back.
In the ER, patient had a normal rectal tone per ER report, she
had Lower t-spine and l-spine tenderness. amd ___ strength in
bilateral lower extremities. she underwent CT of T and L spine
which showed Interval progression of T12 and L3 vertebral body
compression deformities. No new fractures were noted.
She was admitted for pain control. On floor here pt reports
that
the pain has been present since last 4 weeks. She mentions that
the pain has worsened progressively in the last 2 weeks and
because of the pain sshe is hardly able to move. She mentions
that she has some sx of urge incontinence in the last week. "I
lose urine before I reach the toilet" no retention. no lower
extremity weakness or sensory changes.
Her pain is mostly in lower back, ___ ___nd ___ on
movements. She tries not o move because of the pain.
REVIEW OF SYSTEMS:
GENERAL: No fever, chills,
HEENT: No sores in the mouth, painful swallowing, DENIED
DYSPHAGIA.
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. No recent change in bowel habits, hematochezia, or melena.
GU: No dysuria or change in bladder habits.
MSK: as above.
DERM: Denies rashes, itching, or skin breakdown.
NEURO: No headache, visual changes, numbness/tingling,
paresthesias, or focal neurologic symptoms.
Past Medical History:
(1) a stereotaxic mid-brain biopsy on ___,
(2) received 5 cycles of induction high-dose methotrexate
(3) s/p 8 cycles of maintenance high-dose methotrexate until
___,
(4) s/p total left hip replacement on ___ for
osteonecrosis,
(5) bx of right cervical lymph node ___ at ___
that showed aggressive nonHodgkin's lymphoma, unclassified but
intermediate between diffuse large cell and Burkitt's lymphoma,
(6) admission to ___ Service on ___ for evaluation and
management of lymphoma with 39.4 WBC, 10.0 Hb, 29.9 Hct and 109
plt
(7) LP ___ with ___ WBC, 473-550 RBC, 44 protein, and
received one dose of IT methotrexate,
(8) started C1 EPOCH on ___,
(9) CSF showed 7 WBC, 473 RBC, 44 protein, and received IT MTX
(10) LP ___ 11 WBC ___ RBC 149 prtn 111 LDH rec'd
IT
MTX
(11) head MRI on ___ showed no gross lymphoma in the brain,
(12) received rituximab 100 mg on ___,
(13) received rituximab 600 mg on ___,
(14) C2 EPOCH on ___,
(15) received IT methotrexate on ___,
(16) received IT liposomal cytarabine on ___,
(17) echocardiogram showed normal EF at 60%,
(18) C3 EPOCH with rituximab and IT liposomal cytarabine on
___,
(19) C4 EPOCH with rituximab and IT liposomal cytarabine on
___,
(20) ___ reservoir placement on ___, and admission to
OMED
(22) C4 IT liposomal cytarabine on ___
(23) C5 IT liposomal cytarabine and rituxan on ___
(24) C5 of EPOCH on ___
PAST MEDICAL HISTORY:
- CNS lymphoma/systemic lymphoma as above
- Depression
- HSV infection during MTX treatment in the past
- GERD
- HTN
- Cold aggluitinin disease (resolved)
- HBcAb Positive; VL negative
Social History:
___
Family History:
she has 6 healthy children and a nephew with a brain tumor.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
VITAL SIGNS: 98.1 PO 137 / 78 73 16 93 RA
HEENT: MMM, no OP lesions,
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB, no wheezes or crackles.
Back- lower back tenderness. Pt refuses palpation of back
because
of pain. Pain present in both midline and bilateral lower back
as
well. She guargs her back when moving. No tenderness in thoracic
or cervical verterbral region.
ABD: BS+, soft, NTND,
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: B/L ___ ___ strength. Normal sensation on both lower
extremities. Tested DTR but absent in both patella.
DISCHARGE PHYSICAL EXAM:
GEN: lying in bed, NAD
Neuro: ___ L ankle dorsiflexion, ___ L eversion. ___ inversion,
___ ankle flexion, ___ throughout otherwise
HEENT: mmm;
CV: RRR, +S1/S2, no M/R/G
PULM: CTAB
ABD: non-distended, soft, non-tender
LIMBS: No edema, clubbing, warm distal extremities
SKIN: No rashes or skin breakdown
Pertinent Results:
ADMISSION LABS:
___ 10:31PM BLOOD WBC-4.4 RBC-2.90* Hgb-10.0* Hct-31.2*
MCV-108* MCH-34.5* MCHC-32.1 RDW-16.3* RDWSD-64.4* Plt ___
___ 10:31PM BLOOD Neuts-59 Bands-0 ___ Monos-7 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-2.60 AbsLymp-1.50
AbsMono-0.31 AbsEos-0.00* AbsBaso-0.00*
___ 10:31PM BLOOD Glucose-148* UreaN-16 Creat-0.5 Na-136
K-4.4 Cl-98 HCO3-24 AnGap-18
___ 10:31PM BLOOD Calcium-9.1 Phos-4.0 Mg-2.2
IMAGING:
CT T&L spine ___:
IMPRESSION:
1. Study is mildly degraded by motion plan streak artifact
secondary to
patient's left hip prosthesis.
2. Interval progression of T12 and L3 vertebral body compression
deformities compared to ___ prior exam, as
described.
3. No definite new fractures identified.
4. Multilevel degenerative changes as described, most pronounced
at L3-4,
where there is mild vertebral canal narrowing.
5. Question right upper lobe nonspecific patchy opacities versus
artifact. If findings are not artifactual, differential
considerations include infectious, inflammatory, neoplastic
etiologies. If clinically indicated, consider dedicated chest
imaging.
MRI T&L spine ___:
IMPRESSION:
1. Pathologic compression fracture of T12 and likely L5
vertebral bodies.
2. Mild compression fractures of L1 and L5 are new from ___. Chronic compression fractures of T12 and L3 vertebral
bodies.
3. Mild multilevel degenerative changes within the thoracolumbar
spine, as
detailed above.
ADDENDUM Addendum to impression 1:
The compression fractures at T12 may be secondary to
osteoporosis or
underlying pathologic process. Since this process has been
going on for
sometime, it is difficult to make a distinction on imaging alone
at this
stage. However, the compression of the superior endplate of L5
has an
appearance of osteoporotic compression. Please note, there is
redemonstration of T1 hypointensity at C2 through C4 levels.
Dedicated cervical spine MRI is recommended to further assess.
The cervical spine MRI will help in further assessing for bony
infiltrative process.
___ CT Chest:
IMPRESSION:
The previously noted FDG avid nodule in the right upper lobe is
in fact
composed of multiple small peribronchial nodules which have
decreased in size and number on today's study compared to
previous PET-CT done ___. This favors an improved
infective process. Mycobacterium should be considered in the
differential diagnosis. No thoracic lymphadenopathy.
___ CT Head w/o contrast:
1. No evidence of acute hemorrhage, edema, or mass effect.
2. Increased aerosolized secretions in the maxillary sinuses
bilaterally, suspicious for acute sinusitis.
___ L SPINE W/O CONTRAST
IMPRESSION:
1. Status post T12, L5 kyphoplasty.
2. There are T11, L1, L4 compression fractures, which are new
since ___, with suggestion of edema on motion degraded STIR
images,
suggesting component of acute or chronic compression fractures.
3. There is moderate central canal narrowing at T10-T11,
T11-T12, T12-L1
levels, similar.
4. Multilevel degenerative changes in the lumbar spine as above.
___ HEAD AND CTA NECK
IMPRESSION:
1. Right frontal approach Ommaya reservoir
2.
3. Right pulmonary apex opacities, new since ___ reflect
infection. Normal head and neck CTA.
___ L-SPINE W/O CONTRAST
Final Report
EXAMINATION: CT L-SPINE W/O CONTRAST Q331 CT SPINE.
INDICATION: ___ year old woman with h/o CNS lymphoma, hodgkins,
h/o
compression fractures, s/p T12 and L5 over weekend. New onset
weakness //
eval for acute pathology.
TECHNIQUE: Non-contrast helical multidetector CT was performed.
Soft tissue
and bone algorithm images were generated. Coronal and sagittal
reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.9 s, 35.3 cm; CTDIvol = 40.2 mGy
(Body) DLP =
1,388.7 mGy-cm.
Total DLP (Body) = 1,389 mGy-cm.
COMPARISON: CT L-spine without contrast from ___.
FINDINGS:
Patient status post kyphoplasties of the T12 and L5 vertebral
levels. Bones
appear diffusely osteopenic. There has been interval vertebral
body height
loss of the L1 vertebrae compared to the prior exam in ___,
compatible with likely subacute compression fracture, no
significant
retropulsion is seen.
Alignment is otherwise maintained. There is multilevel
degenerative changes
seen in the lumbosacral spine including loss of intervertebral
disc height,
facet joint arthropathy, and osteophyte formation. Mild
multilevel spinal
canal narrowing is identified due to posterior osteophyte
formation and disc
bulge. There is no evidence of neural foraminal stenosis. There
is no
prevertebral soft tissue swelling.There is no evidence of
infection or
neoplasm. Limited views of the abdomen are remarkable for
atherosclerotic
calcifications in the intra-abdominal aorta.
IMPRESSION:
1. Patient is status post kyphoplasties of the T12 and L5
vertebral levels.
There has been interval vertebral body height loss of the L1
vertebrae and
compared to the prior exam in ___, likely subacute
compression
fracture.
2. Diffuse osteopenia and multilevel degenerative changes are
similar to prior
exam in ___.
___
FINDINGS:
1. T12 and L5 compression fractures corresponding to the known
CT and MRI
locations.
2. Successful T12 vertebral body biopsy
3. Successful kyphoplasty at the T12 level with good cement
filling of the
superior endplate, the area of fracture
4. Successful L5 vertebral body biopsy
5. Successful kyphoplasty at the L5 level with good cement
filling of the
entire vertebral body including the superior endplate.
IMPRESSION:
Successful kyphoplasty of T12 and L5 with biopsies of both areas
as well.
___: BONE, BIOPSY FOR TUMOR
SPECIMEN 1: BONE, LUMBAR VERTEBRAE 5, BIOPSY.
DIAGNOSIS:
FRAGMENTS OF BONE WITH MATURING TRILINEAGE HEMATOPOIESIS WITH NO
EVIDENCE
OF MYELOMA, LYMPHOMA OR MYELOID NEOPLASM. SEE NOTE.
SPECIMEN 2: BONE, THORACIC VERTEBRAE 12, BIOPSY.
DIAGNOSIS:
FRAGMENTS OF BONE WITH MATURING TRILINEAGE HEMATOPOIESIS WITH NO
EVIDENCE
OF MYELOMA, LYMPHOMA OR MYELOID NEOPLASM. SEE NOTE.
Note: Sections are of fragments of cancellous bone with bone
marrow element showing
maturing trilineage hematopoiesis. By immune histochemistry CD3
and CD5 highlight
scattered interstitial T cells. By CD4 and CD8 immunostain the
majority of T cells are CD4
positive. PAX5 highlights few scattered B cells. CD138
highlights few scattered plasma cells
that are polyclonal for kappa and lambda immunostain . The
overall morphology and
immunophenotypic pattern is consistent with the above diagnosis.
Clinical correlation is
recommended.
___ HEAD W/O CONTRAST
IMPRESSION:
1. No acute intracranial abnormality on noncontrast head CT.
2. Unchanged Ommaya reservoir with normal and unchanged
ventricular size.
3. No significant change in aerosolized secretions in the
bilateral maxillary
sinuses and ethmoidal air cells, again concerning for acute
sinusitis.
___: BONE MARROW
CYTOGENETIC DIAGNOSIS: 46,XX[20] Normal female karyotype.
INTERPRETATION/COMMENT: Every metaphase bone marrow cell
examined appeared to be
karyotypically normal. No cells were found with the complex
abnormal karyotype with rearrangement
of the BCL6 gene that was observed in bone marrow collected on
___. In addition, there was no
evidence by FISH of interphase cells with rearrangement of BCL6
(see below).
FISH: NEGATIVE for BCL6 REARRANGEMENT. No evidence of interphase
bone marrow cells
with the previously observed 96/___/16) rearrangement of the BCL6
gene.
___: BONE MARROW, BIOPSY, CORE
PATHOLOGIC DIAGNOSIS:
BONE MARROW ASPIRATE AND CORE BIOPSY
DIAGNOSIS:
CELLULAR MARROW ASPIRATE WITH MARKED MYELOID HYPOPLASIA AND
LEFT-SHIFT,
ERYTHROID PREDOMINANCE, WITH MEGALOBLASTIC AND DYSPLASTIC
MATURATION (SEE
NOTE).
ABUNDANT STORAGE IRON WITH DECREASED SIDEROBLASTS SUGGESTIVE OF
ANEMIA
OF INFLAMMATION.
___: marrow-Immunophenotyping
DIAGNOSIS:
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: ___, Kappa,
Lambda, TCR alpha/beta and TCR gamma/delta, and CD antigens
2,3,4,5,7,8,10,11c,13,14,16,19,20,23,25,33,34,38,45,56,64,117
and 57.
RESULTS:
10-color analysis with linear side scatter vs. CD45 gating is
used to evaluate for leukemia/lymphoma.
69% of total acquired events are evaluable non-debris events.
The viability of the analyzed non-debris events, done by 7-AAD
is 87%.
CD45-bright, low side-scatter gated lymphocytes comprise 36% of
total analyzed events.
B cells are scant in number precluding evaluation of clonality
and further characterization.
T cells comprise 85% of lymphoid gated events and express mature
lineage antigens (CD3, CD5, CD2 and CD7). A significant subset
(50%) of CD3 positive T cells shows dim variable expression/loss
of CD7. T cells have a helper-cytotoxic ratio of 0.4. There is a
population of double positive (CD4 positive/CD8 positive) cells
comprising 8% of CD3 positive events which is of unclear
significance.
60% of CD8 positive T cells co-express CD57 which is consistent
with large granular lymphocytes.
CD8 positive T cells appear to be TCR alpha beta expressing
cells and no significant population of TCR gamma-delta
expressing cells is present.
T cells are negative for CD25.
CD56 positive, CD3 negative natural-killer cells represent 8% of
gated lymphocytes.
No abnormal events are identified in the "blast" gate.
INTERPRETATION
Immunophenotypic findings consistent with involvement by a
population of T cell large granular lymphocytes (CD3
positive/CD8 positive/CD57 positive) that represent
approximately 37% of lymphoid gated events. T cell receptor
gamma gene rearrangement PCR performed at NeoGenomics was
positive (see OMR for full test details) consistent with the
presence of a clonal T-cell population. If persistent, the
findings raise the possibility of involvement by a T large
granular lymphocytic leukemia which typically manifesting
clinically with neutropenia and splenomegaly. Peripheral blood
flow cytometry may be contributory. Correlation with clinical,
laboratory and morphologic (see separate bone marrow biopsy
report ___ is recommended. Flow cytometry may not detect
all abnormal cell populations due to topography, sampling or
artifacts of sample preparation.
DISCHARGE LABS:
___ 06:07AM BLOOD WBC-7.3# RBC-2.58* Hgb-8.4* Hct-27.8*
MCV-108* MCH-32.6* MCHC-30.2* RDW-16.2* RDWSD-63.9* Plt ___
___ 06:07AM BLOOD Glucose-131* UreaN-15 Creat-0.5 Na-137
K-4.6 Cl-102 HCO3-22 AnGap-18
___ 06:07AM BLOOD ALT-19 AST-15 LD(LDH)-230 AlkPhos-158*
___ 06:07AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ with a history of a tectal primary
CNS lymphoma, who now has an aggressive non-Hodgkin's systemic
lymphoma being treated with rituximab/EPOCH with IT chemotherapy
prophylaxis, s/p Ommaya placement admitted for back pain.
# Back pain
# Lumbar and thoracic compression fractures, both acute and
chronic
# Osteoporosis
She has been having worsening lower back pain over the last few
weeks. Her pain is non-radiating, she had no weakness, numbness
or incontinence. She underwent CT and MRI of her thoracic and
lumbar spine. Ortho-spine was consulted. Likely due to
osteoporotic compression fractures although per neuroradiology
cannot definitively rule out metastatic disease. No clinical
concerns for cord compression. Discussed with Dr. ___
neuro-oncology who feels this is all osteoporotic fractures and
has a low suspicion for metastatic disease given that recent
PET-CT was negative and no other signs of active disease.
Neuro-radiology also recommending an MRI cervical spine to
further evaluate for infiltrative disease but patient does not
want to undergo another MRI at this time. Patient trialed on
narcotics however was not able to tolerate as inadequate pain
control and hallucinations/delirium with high dose narcotics.
Underwent kyphoplasty of T12 and L5 vertebrae without
complications. Consider ___ acid in one month as patient
failed alendronate.
# Acute L foot drop: On ___ nursing noted new LLE foot drop.
Code Stroke called. Per Neurology not c/w CVA. MRI-L spine
limited but no gross abnormalities to explain L foot drop, no
cord compression. Given history of metastatic B-cell Lymphoma an
primary CNS lymphoma, patient underwent intrathecal chemotherapy
with Ara-C while inpatient.
# High Grade B-Cell Lymphoma
# Neutropenia
On DA-EPOCH/R Cycle 6 and intrathecal cytarabine. BMB (___)
showed marked myeloid hypoplasia and left-shift, erythroid
predominance, w/ megaloblasts and dysplastic maturation along
with decreased sideroblasts suggestive of anemia of chronic
disease. The cytogenetics are still pending. Viral study panel
antigens and cultures negative. Marrow ICH - negative for BCL 6
rearrangement, negative MDS panel. She had worsening neutropenia
likely chemotherapy effect as she has not been started on other
new medications and no signs of infection. Potential culprit
drugs (naproxen, alendronate, Bactrim) were held, and bone
marrow biopsy showed diffuse cellular growth arrest, indicating
drug vs. viral etiology. Patient had ___ recovery filgrastim.
- has follow up appointment with Dr. ___ for ___
- follow up with Dr. ___ as an outpatient at end of ___
- continue folic acid
- continue acyclovir 400 mg TID per Dr ___
- ___ acid in one month as failed alendronate
- Follow-up with outpatient oncologist
- Continue TMP/SMS SS daily and acyclovir ppx.
# Cough: reporting new productive cough, afebrile without
leukocytosis and CXR clear. CT chest for reeval known pulmonary
nodule decreased in size with non-specific findings, rule out
TB. Patient ruled out with NAAT negative, AFB concentrated x3,
negative Quant Gold in setting of resolved neutropenia.
# Hypertension: continue amlodipine 5mg daily.
# Depression: Continued home fluoxetine
# HLD: Held home simvastatin as she had not been taking it as
outpatient.
# Chronic HBV: HBsAb/HBcAb positive. HBV VL neg in ___.
-Continue lamivudine.
FEN:
- Regular diet
PAIN: as above
DVT PROPHYLAXIS:
- Heparin 5000 units SC BID
ACCESS:
Port
CODE STATUS:
- Full code Presumed
CONTACT INFORMATION:
- ___- husband ___ ___
Dispo:home with services
TRANSITIONAL ISSUES
====================
[ ] Consider outpatient MRI C-Spine to further evaluate for
infiltrative process if patient willing
[ ] Consider ___ acid in one month as patient failed
alendronate.
[ ] Taper dexamethasone
[ ] has follow up appointment with Dr. ___ for ___
[ ] follow up with Dr. ___ as an outpatient at ___ of ___
[ ] continue acyclovir 400 mg TID per Dr ___
[ ] Continue TMP/SMS SS daily and acyclovir ppx
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dexamethasone 0.5 mg PO ASDIR
Tapered dose - DOWN
2. amLODIPine 5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Famotidine 20 mg PO Q12H
5. FLUoxetine 40 mg PO DAILY
6. LaMIVudine 100 mg PO DAILY
7. Senna 8.6 mg PO BID:PRN constipation
8. Sulfatrim (sulfamethoxazole-trimethoprim) 400-80 (10mL) mg
oral DAILY
9. Acyclovir 400 mg PO TID
10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
11. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Calcium Carbonate 1000 mg PO DAILY
RX *calcium carbonate 400 mg (1,000 mg) 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % Apply 1 patch to lower back Daily
Disp #*30 Patch Refills:*0
4. Morphine SR (MS ___ 30 mg PO Q12H
RX *morphine [___] 30 mg 1 capsule(s) by mouth twice a day
Disp #*15 Capsule Refills:*0
5. Pantoprazole 40 mg PO Q12H
6. Senna 8.6 mg PO BID:PRN constipation
7. Acyclovir 400 mg PO TID
8. amLODIPine 5 mg PO DAILY
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Famotidine 20 mg PO Q12H
11. FLUoxetine 40 mg PO DAILY
12. LaMIVudine 100 mg PO DAILY
13. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
RX *oxycodone 10 mg ___ tablet(s) by mouth q4h:prn Disp #*15
Tablet Refills:*0
14. Sulfatrim (sulfamethoxazole-trimethoprim) 400-80 (10mL) mg
oral DAILY
15. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Lower back pain due to multiple thoracic and lumbar compression
fractures
Neutropenia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
You were admitted with worsening back pain. You had an MRI of
your spine which showed multiple fractures of your spine most
likely due to osteoporosis. You were seen by the spine surgery
team, they recommended using a brace as needed for pain. Your
white blood cell count was low, but you were given an injection
which caused it to recover. Please follow-up with your
oncologists for further treatment of your lymphoma.
Followup Instructions:
___
|
10378079-DS-39 | 10,378,079 | 22,526,341 | DS | 39 | 2131-11-03 00:00:00 | 2131-11-03 21:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ year-old lady with unclassified
aggressive NHL with brain involvement who is referred from ECF
for FTT.
Per ECF paperwork, patient has been having increasing
generalized weakness, immobility and decreased PO intake. Of
note, had WBC 14 on ___ leading to initiation of CTX which was
d/c'd on ___ given improvement in WBC. In the ED she complained
of left leg pain.
ED initial vitals were 97 112 105/62 18 97% RA
Prior to transfer vitals were 98.2 109 129/90 16 98% RA
ED labs were significant for:
-CBC: WBC: 6.3. HGB: 11.0*. Plt Count: 242. Neuts%: 79.2*.
-Chemistry: Na: 134. K: 4.7. Cl: 96. CO2: 20*. BUN: 11. Creat:
0.5. Ca: 9.2. Mg: 2.0. PO4: 4.1.
Lactate:
-Coags: INR: 1.0. PTT: 30.4.
-LFTs: ALT: 17. AST: 13. Alk Phos: 184*. Total Bili: 0.2.
CT Head w/o contrast: No acute intracranial process. Right
frontal approach ventricular catheter is again seen with stable
configuration of the ventricles.
CXR: Low lung volumes limiting exam. Bibasilar opacities likely
atelectasis though infection would be difficult to exclude.
L ___: No DVT
On arrival to the floor, patient reported pain in her LLE which
subsided before she could get pain medication. She denies other
sources of pain
Patient denies fevers/chills, night sweats, headache,
weakness/numbnesss, shortness of breath, cough, chest pain,
abdominal pain, nausea/vomiting, diarrhea, dysuria and new
rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
(1) a stereotaxic mid-brain biopsy on ___,
(2) received 5 cycles of induction high-dose methotrexate
(3) s/p 8 cycles of maintenance high-dose methotrexate until
___,
(4) s/p total left hip replacement on ___ for
osteonecrosis,
(5) bx of right cervical lymph node ___ at ___
that showed aggressive nonHodgkin's lymphoma, unclassified but
intermediate between diffuse large cell and Burkitt's lymphoma,
(6) admission to ___ Service on ___ for evaluation and
management of lymphoma with 39.4 WBC, 10.0 Hb, 29.9 Hct and 109
plt
(7) LP ___ with ___ WBC, 473-550 RBC, 44 protein, and
received one dose of IT methotrexate,
(8) started C1 EPOCH on ___,
(9) CSF showed 7 WBC, 473 RBC, 44 protein, and received IT MTX
(10) LP ___ 11 WBC ___ RBC 149 prtn 111 LDH rec'd
IT
MTX
(11) head MRI on ___ showed no gross lymphoma in the brain,
(12) received rituximab 100 mg on ___,
(13) received rituximab 600 mg on ___,
(14) C2 EPOCH on ___,
(15) received IT methotrexate on ___,
(16) received IT liposomal cytarabine on ___,
(17) echocardiogram showed normal EF at 60%,
(18) C3 EPOCH with rituximab and IT liposomal cytarabine on
___,
(19) C4 EPOCH with rituximab and IT liposomal cytarabine on
___,
(20) Ommaya reservoir placement on ___, and admission to
OMED
(22) C4 IT liposomal cytarabine on ___
(23) C5 IT liposomal cytarabine and rituxan on ___
(24) C5 of EPOCH on ___
PAST MEDICAL HISTORY:
- CNS lymphoma/systemic lymphoma as above
- Depression
- HSV infection during MTX treatment in the past
- GERD
- HTN
- Cold aggluitinin disease (resolved)
- HBcAb Positive; VL negative
Social History:
___
Family History:
She has 6 healthy children and a nephew with a brain tumor.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.0 PO 128/93 106 18 97 RA
GENERAL: Chronically-ill appearing lady, in no distress lying,
in
bed comfortably. Has Omaya visible.
HEENT: Anicteric, PERLL, Mucous membranes moist, OP clear.
CARDIAC: Regular rate and rhythm, normal heart sounds, no
murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness. Left sided plantar flexor contracture, per
patient
not new.
NEURO: A&Ox1, mildly decreased strength in LLE otherwise
preserved. Normal sensation to light touch. CN II-XII intact.
SKIN: No significant rashes.
DISCHARGE PHYSICAL EXAMINATION:
VS: 98.1 ___ ___ RA
GENERAL: Chronically-ill appearing lady, in no distress lying,
in
bed comfortably. Has Omaya visible.
HEENT: Anicteric, PERLL, Mucous membranes moist, OP clear.
CARDIAC: Regular rate and rhythm, normal heart sounds, no
murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: A&Ox1, 5+ strength proximal muscles of LLE. Left and
right foot drop. wrist drop present and weak handgrip. . Normal
sensation to light touch. CN II-XII intact.
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS:
___ 03:30PM BLOOD WBC-6.3 RBC-3.29*# Hgb-11.0*# Hct-34.8#
MCV-106* MCH-33.4* MCHC-31.6* RDW-15.8* RDWSD-62.2* Plt ___
___ 03:30PM BLOOD Neuts-79.2* Lymphs-17.6* Monos-1.9*
Eos-0.3* Baso-0.2 Im ___ AbsNeut-5.01# AbsLymp-1.11*
AbsMono-0.12* AbsEos-0.02* AbsBaso-0.01
___ 03:30PM BLOOD ___ PTT-30.4 ___
___ 03:30PM BLOOD Glucose-158* UreaN-11 Creat-0.5 Na-134
K-4.7 Cl-96 HCO3-20* AnGap-23*
___ 03:30PM BLOOD ALT-17 AST-13 AlkPhos-184* TotBili-0.2
___ 03:30PM BLOOD Albumin-3.7 Calcium-9.2 Phos-4.1 Mg-2.0
___ 03:58PM BLOOD Lactate-1.3
DISCHARGE LABS:
___ 02:53AM BLOOD WBC-4.1 RBC-2.90* Hgb-9.7* Hct-30.6*
MCV-106* MCH-33.4* MCHC-31.7* RDW-15.6* RDWSD-60.6* Plt ___
___ 02:53AM BLOOD Glucose-107* UreaN-11 Creat-0.4 Na-138
K-3.7 Cl-102 HCO3-25 AnGap-15
MICROBIOLOGY:
BCX ___ NGTD
UCX ___ NGTD
IMAGING/STUDIES:
CXR ___
Low lung volumes limiting exam. Bibasilar opacities likely
atelectasis though infection would be difficult to exclude.
___ L ___
No evidence of deep venous thrombosis in the left lower
extremity veins.
CT HEAD ___
No acute intracranial process. Right frontal approach
ventricular catheter is again seen with stable configuration of
the ventricles.
Discharge Labs
================
___ 02:53AM BLOOD WBC-4.1 RBC-2.90* Hgb-9.7* Hct-30.6*
MCV-106* MCH-33.4* MCHC-31.7* RDW-15.6* RDWSD-60.6* Plt ___
___ 02:53AM BLOOD Plt ___
___ 02:53AM BLOOD Glucose-107* UreaN-11 Creat-0.4 Na-138
K-3.7 Cl-102 HCO3-25 AnGap-15
___ 02:53AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.9
Brief Hospital Course:
Ms. ___ is a ___ with PMH of unclassified aggressive
NHL (primary CNS), on EPOCH rituximab with IT chemotherapy, also
with h/o GERD, HTN, hepatitis, cold agglutinin disease and
depression who presents from ECF with FTT and encephalopathy
found to have new neurologic findings found to have likely
progressive disease. The decision was made, in discussion with
family and with neuro/oncology to transition to comfort focused
care and the patient was discharged home with hospice.
1. Encephalopathy, Failure to Thrive: On presentation, patient
was alert and oriented to self, and sometimes place but not to
date. This was thought to be secondary CNS involvement by
lymphoma vs. related to increased use of narcotics with possible
side effect of constipation. CT head was without acute changes
and infectious work-up was unrevealing. Her lymphoma was
evaluated as below. Her pain regimen was decreased from MS
contin 30mg q8hrs to 30mg q12hrs and she was started on a bowel
regimen.
2. Non-Hodgkins Lymphoma/ Goals of Care: The patient was found
to have worsened neurologic symptoms, namely, new wrist drip.
This, associated with encephalopathy and FTT were suggestive of
progression of CNS disease. The patient and family were involved
with Goals of care discussion and informed that further
treatment would not provide benefit. The patient and her family
decided to stop treatment and transition to comfort focused
care. She was made DNR/DNI and discharged home with hospice
services. She was continued on acyclovir as this was thought to
be in keeping with her goals of care, to support her comfort.
3. Chronic pain: In left leg and back due to pathological
fracture. Her MS ___ was adjusted as above due to concerns
regarding her mental status. She was continued on oxycodone PRN
and baclofen for contracture. She was continued on senna and
docusate PRN.
4. Depression: continued home fluoxetine
5. Hypertension: discontinued amlodipine and aspirin, in keeping
with goals of care.
6. GERD: continued home pantoprazole
7. Hepatitis: continued lamivudine
Transitional Issues:
- please continue to monitor comfort, titrate pain medications
as needed
- please monitor for constipation
- patient's family expressed interest in transporting patient to
___ in order to see her grandchildren. Discussed that she
would likely need air ambulance transportation to accomplish
this, if she was found to be stable enough for travel after
discharge home. The patient and family can follow-up with air
ambulance companies after discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO TID
2. amLODIPine 5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. FLUoxetine 40 mg PO DAILY
5. LaMIVudine 100 mg PO DAILY
6. Senna 8.6 mg PO BID:PRN constipation
7. Acetaminophen 1000 mg PO Q8H
8. Calcium Carbonate 1000 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Morphine SR (MS ___ 30 mg PO Q8H
11. Pantoprazole 40 mg PO Q12H
12. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
13. Aspirin 81 mg PO DAILY
14. Baclofen 5 mg PO BID
15. Bisacodyl ___AILY:PRN constipation
16. FoLIC Acid 1 mg PO DAILY
17. GuaiFENesin ER 600 mg PO Q12H
18. Heparin 5000 UNIT SC BID
19. Milk of Magnesia 30 mL PO PRN 2d without bm
20. Ondansetron ODT 4 mg PO Q8H:PRN nausea
21. CefTRIAXone 1 gm IV Q24H elevated WBC
Discharge Medications:
1. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides 8.6 mg 1 tablet by mouth two times per day Disp
#*60 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*0
3. Morphine SR (MS ___ 30 mg PO Q12H
RX *morphine 30 mg 1 capsule(s) by mouth every 12 hours Disp
#*60 Capsule Refills:*0
4. Acyclovir 400 mg PO TID
RX *acyclovir 400 mg 1 tablet(s) by mouth three times per day
Disp #*90 Tablet Refills:*0
5. Baclofen 5 mg PO BID
RX *baclofen 10 mg 0.5 (One half) tablet(s) by mouth two times
per day Disp #*30 Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth two times per
day Disp #*60 Capsule Refills:*0
7. FLUoxetine 40 mg PO DAILY
RX *fluoxetine 40 mg 1 capsule(s) by mouth every day Disp #*30
Capsule Refills:*0
8. GuaiFENesin ER 600 mg PO Q12H
RX *guaifenesin 600 mg 1 tablet(s) by mouth every 12 hours Disp
#*40 Tablet Refills:*0
9. LaMIVudine 100 mg PO DAILY
RX *lamivudine 100 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
10. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
11. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
RX *oxycodone 10 mg ___ tablet(s) by mouth every 4 hours Disp
#*60 Tablet Refills:*0
12. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth two times per day
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
================
1) Encephalopathy
2) Failure to thrive
Secondary Diagnosis
===================
1) Non-Hodgkins Lymphoma
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 ___,
It has been a pleasure caring for you during your stay at ___.
You were admitted to the hospital for confusion and increased
weakness. You were give a lidocaine patch to help treat the pain
from your lymphoma. You had new findings on your neurology exam
such as weakness in your wrist. This implies your lymphoma has
spread, despite the treatment you have been receiving. After
dicussion between your doctors and family ___ have chosen to
stop medical treatment of the lymphoma and go home to pursue
care focused on comfort.
We wish you the best.
Sincerely,
Your ___ Care team
Followup Instructions:
___
|
10378448-DS-14 | 10,378,448 | 28,242,168 | DS | 14 | 2143-02-05 00:00:00 | 2143-02-06 09:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___
Chief Complaint:
Transfer from OSH for alcoholic hepatitis
Major Surgical or Invasive Procedure:
ENDOSCOPY ___
ENDOSCOPIC ULTRASOUND ___ with 2 bands applied
History of Present Illness:
This is a ___ man with a history of chronic alcohol use
disorder (6 beers and 2 shots of vodka each day) who presented
to
the ___ emergency department after labs at his primary care
doctor's office showed hypokalemia 2.5 and hypomagnesemia 1.4.
At
___, he was thought to be in acute liver failure. His
potassium and mag repleted, and was transferred to ___ for
further evaluation.
Reports he is here because he was so directed by his physician.
Would not have come to the ED otherwise.
He reports that he coughs frequently, bringing up white sputum,
worsening in the past few weeks. Can't hold down food - either
vomits it up right after eating or has diarrhea, tries to pass
BMs several times per hour at home. Noticed abdomen getting more
distended along with bilateral leg swelling x3 months. Denies
ever having withdrawals. 7 lb weight loss last ___ weeks.
No f/c, no night sweats, no headaches, chest pain, palps,
dyspnea, abdominal pain. Denies feeling foggy or confused.
Of note, had a recent admission to ___ because
he was vomiting blood. Unclear whether variceal in origin as
reportedly diagnosed with gastritis by endoscopy (___). Had a
single jet black stool during that hospitalization but no bloody
or black stools otherwise.
Normally seen at ___.
In the ED:
- Initial vital signs were notable for: T98.0 ___ BP 135/71 R16
94% RA
- Exam notable for:
scleral icterus, palatal jaundice. Abdomen soft, distended +
distension. 2+ circumferential pitting edema to the knee
bilaterally and into dependent thigh bilaterally. +Asterixis.
Normal mood and mentation, A/Ox3
- Labs were notable for:
___ 05:00PM BLOOD WBC: 17.8* RBC: 3.04* Hgb: 10.3* Hct:
30.8* MCV: 101* MCH: 33.9* MCHC: 33.4 RDW: 16.8* RDWSD: 62.0*
Plt
Ct: 279
___ 05:00PM BLOOD Neuts: 78.6* Lymphs: 12.1* Monos: 7.8
Eos:
0.4* Baso: 0.4 Im ___: 0.7* AbsNeut: 13.98* AbsLymp: 2.16
AbsMono: 1.39* AbsEos: 0.08 AbsBaso: 0.08
___ 05:00PM BLOOD ___: 20.4* PTT: 24.0* ___: 1.9*
___ 05:00PM BLOOD Glucose: 107* UreaN: 4* Creat: 0.8 Na:
137
K: 4.2 Cl: 90* HCO3: 33* AnGap: 14
___ 05:00PM BLOOD ALT: 40 AST: 218* AlkPhos: 321* TotBili:
12.2*
___ 05:00PM BLOOD Lipase: 22
___ 05:00PM BLOOD Albumin: 3.0* Calcium: 8.5 Phos: 2.9 Mg:
1.8
___ 05:00PM BLOOD HBsAg: NEG HBs Ab: NEG HBc Ab: NEG HAV
Ab:
POS*
___ 05:08PM BLOOD Lactate: 2.1* K: 4.1
- Studies performed include:
Point-of-care ultrasound: Evidence of moderate ascites, but no
fluid pocket with 5 cm of bowel clearance in 2 planes.
Liver/Gallbladder US
1. Coarsened echogenic nodular liver concerning for cirrhosis
with small volume ascites.
2. Patent flow within the main portal vein and central branches
though velocities are sluggish.
3. Splenomegaly measuring 15.1 cm.
4. Partially visualized small left pleural effusion.
5. Gallbladder sludge.
CXR
Low lung volumes are noted. There is a small left pleural
effusion and adjacent compressive atelectasis. There is no
focal
consolidation or pneumothorax. The cardiomediastinal silhouette
is within normal limits. No acute osseous abnormalities are
identified
- Patient was given:
IV K and Mg
- Consults:
GI consulted
Vitals on transfer:
Upon arrival to the floor, ___ Temp: 99.2 PO BP:
120/70
L Sitting HR: 96 RR: 18 O2 sat: 93% O2 delivery: Ra
REVIEW OF SYSTEMS: negative as per above
Past Medical History:
Alcohol Abuse
Bleeding Esophageal Varices
Gastroesophageal Reflux Disease
Hypomagnesemia
Hypokalemia
Gout
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: ___ Temp: 99.2 PO BP: 120/70 L Sitting HR: 96
RR: 18 O2 sat: 93% O2 delivery: Ra
General: Alert and interactive
HEENT: PERRLA, EOMA. icteric sclera without injection. MMM, OP
clear.
CV: ___ early systolic murmur loudest at the apex.
Pulm: CTAB, no wheezes or crackles
Abd: +BS, distended. tender to palpation RUQ. Liver percussed at
10 cm. No fluid wave.
Extremities: 1+ pitting edema bilaterally to the knees.
Skin: jaundiced. Warm. Telangectasias noted.
Neuro: CN ___ intact. A/ox3, can ___ backwards, no ifs ands
or buts, naming, and recalls ___.
DISCHARGE PHYSICAL EXAM:
VS: 24 HR Data (last updated ___ @ 1504)
Temp: 98.6 (Tm 98.6), BP: 121/67 (103-121/57-68), HR: 78
(72-78), RR: 18, O2 sat: 96% (94-97), O2 delivery: RA
HEENT: icteric sclera without injection
CV: RRR, ___ early systolic murmur loudest at the apex
Pulm: CTAB, no wrr
Abd: +BS, mildly distended. NT. No rebound/guarding.
Skin: jaundiced. warm. telangectasias noted.
Neuro: AOx3, no asterixis
Pertinent Results:
ADMISSION LABS:
--------------
___ 05:00PM BLOOD WBC-17.8* RBC-3.04* Hgb-10.3* Hct-30.8*
MCV-101* MCH-33.9* MCHC-33.4 RDW-16.8* RDWSD-62.0* Plt ___
___ 05:00PM BLOOD Neuts-78.6* Lymphs-12.1* Monos-7.8
Eos-0.4* Baso-0.4 Im ___ AbsNeut-13.98* AbsLymp-2.16
AbsMono-1.39* AbsEos-0.08 AbsBaso-0.08
___ 05:00PM BLOOD ___ PTT-24.0* ___
___ 05:00PM BLOOD Glucose-107* UreaN-4* Creat-0.8 Na-137
K-4.2 Cl-90* HCO3-33* AnGap-14
___ 05:00PM BLOOD ALT-40 AST-218* AlkPhos-321*
TotBili-12.2*
___ 05:00PM BLOOD Albumin-3.0* Calcium-8.5 Phos-2.9 Mg-1.8
___ 05:00PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-POS*
___ 04:00PM BLOOD IgM HAV-NEG
___ 05:00PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 04:39AM BLOOD ___
___ 05:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 05:00PM BLOOD HCV Ab-NEG
___ 05:08PM BLOOD Lactate-2.1* K-4.1
___ 04:39AM BLOOD CERULOPLASMIN-Test
DISCHARGE LABS:
--------------
___ 05:20AM BLOOD WBC-13.9* RBC-2.44* Hgb-8.1* Hct-25.9*
MCV-106* MCH-33.2* MCHC-31.3* RDW-20.3* RDWSD-77.5* Plt ___
___ 05:20AM BLOOD Glucose-90 UreaN-10 Creat-0.8 Na-139
K-4.5 Cl-102 HCO3-27 AnGap-10
___ 05:20AM BLOOD ALT-44* AST-144* LD(LDH)-329*
AlkPhos-176* TotBili-6.5*
___ 05:20AM BLOOD Calcium-8.1* Phos-3.1 Mg-1.5*
=
=
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================================================================
IMAGING RESULTS
___ ABD LIMIT, SINGLE OR
Targeted grayscale ultrasound images were obtained of the four
quadrants of
the abdomen, revealing moderate, anechoic ascites. The largest
pocket is in
the right lower quadrant.
___ Endoscopic Ultrasound
Esophagus:
Two cords of the small varices were seen in the lower esophagus.
A hiatal hernia is also noted. The area of the previous nodule
at the GEJ seen yesterday was able to be located but notably
smaller than on prior EGD. EUS evaluation noted flow, consistent
with underlying varix. When investigated with washing and gentle
manipulation, the are began to bleed consistent with a bleeding
GOV varix. 2 bands were applied for hemostasis successfully. One
band placed at bleeding varix right above GEJ. Second band
placed one centimeter proximal at 33cm.
Stomach: Limited evaluation of the stomach was notable for
clotted blood and a small hiatal hernia.
Findings:
- Two cords of the small varices were seen in the lower
esophagus. A hiatal hernia is also noted. The area of the
previous nodule at the GEJ seen yesterday was able to be located
but notably smaller than on prior EGD. EUS evaluation noted
flow, consistent with underlying varix. When investigated with
washing and gentle manipulation, the are began to bleed
consistent with a bleeding GOV varix.
- Limited evaluation of the stomach was notable for clotted
blood and a small hiatal hernia.
___ EGD
Esophagus:
- Lumen: A medium sized hiatal hernia was seen.
- Mucosa: Grade B esophagitis with no bleeding was seen in the
distal esophagus.
- Protruding lesions: 2 cords of grade I varices were seen in
the distal esophagus. The varices were not bleeding.
- Additional esophagus findings: Distal esophagus around the GE
junction in the area of the esophagitis and hiatal hernia sac
there was a nodule with some exudate on the edge and some
increased vascularity. Case discussed with liver attending. No
evidence of banding. Unclear if this is a fundic gland polyp.
Stomach:
- Mucosa: Diffuse congestion, petechial and mosaic mucosal
pattern of the mucosa was noted in the stomach fundus and
stomach body. These findings are compatible with portal
hypertensive gastropathy.
Duodenum:
-Mucosa: Normal mucosa was noted in the whole examined duodenum.
Impressions:
- Varices in the distal esophagus.
- Esophageal hiatal hernia.
- Grade B esophagitis in the distal esophagus.
- Congestion, petechiae and mosaic mucosal pattern in the
stomach fundus and stomach body compatible with normal portal
hypertensive gastropathy.
- Normal mucosa in the whole examined duodenum.
- Distal esophagus around the GE junction in the area of the
esophagitis and hiatal hernia sac there was a nodule with some
exudate on the edge and some increased vascularity. Case
discussed with liver attending. No evidence of banding. Unclear
if this is a fundic gland polyp.
___
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with cirrhosis, ascites// Evaluate for acute
hepatobiliary pathology, including pvt (please obtain with
Doppler)
TECHNIQUE: Right upper quadrant ultrasound
COMPARISON: Outside hospital ultrasound of the right upper
quadrant from
earlier today.
FINDINGS:
The liver is coarsened, echogenic with poor penetration
concerning for
cirrhosis. The contour of the liver appears subtly nodular. A
tiny cyst
within the left hepatic lobe measures up to 8 mm. Small volume
ascites is
noted. Gallbladder contains sludge. CBD measures 5 mm in
diameter.
Sonographic ___ sign is negative. Right kidney measures 11.2
cm and is
normal in grayscale appearance. The spleen is enlarged
measuring 15.1 cm in length. A small left pleural effusion is
partially visualized. The left kidney measures 13.1 cm in
length and appears normal. Free fluid tracks into the lower
abdomen, small in overall volume.
Doppler: Main portal vein, anterior and posterior right and left
portal venous branches are patent with hepatopetal flow.
However, note is made of sluggish flow within the portal venous
branches measuring between 17 and 28 centimeters/second. Left,
right and middle hepatic veins are patent. IVC appears patent.
The main hepatic artery appears patent with a normal waveform.
IMPRESSION:
1. Coarsened echogenic nodular liver concerning for cirrhosis
with small
volume ascites.
2. Patent flow within the main portal vein and central branches
though
velocities are sluggish.
3. Splenomegaly measuring 15.1 cm.
4. Partially visualized small left pleural effusion.
5. Gallbladder sludge.
___
EXAMINATION: CR - CHEST PA LATERAL
INDICATION: History: ___ with cirrhosis, leukocytosis// pna?
TECHNIQUE: Frontal and lateral view radiographs of the chest.
COMPARISON: None.
IMPRESSION:
Low lung volumes are noted. There is a small left pleural
effusion and
adjacent compressive atelectasis. There is no focal
consolidation or
pneumothorax. The cardiomediastinal silhouette is within normal
limits. No
acute osseous abnormalities are identified.
Brief Hospital Course:
Mr. ___ is a ___ man with a history of chronic
alcohol use disorder, transferred here from an OSH for hypoK/
hypoMag and concern for decompensated cirrhosis and acute
alcoholic hepatitis. Course was complicated by acute c.
difficile infection and variceal bleed s/p banding.
# UPPER GI BLEED
# VARICEAL BLEED
# PORTAL HYPERTENSIVE GASTROPATHY
___ concern for UGIB given dark guiaic(+) stool with hgb drop.
He underwent EGD on ___ which showed no active bleeding but
demonstrated portal hypertensive gastropathy, as well as nodule
with exudate at distal esophagus/GE junction with increased
vascularity. Redemonstrated 2 non-bleeding cords of grade I
varices in distal esophagus. Unfortunately on ___ he developed
hematemesis and bright red blood per rectum requiring 2 units of
pRBC. Due to concern for bleeding at nodule seen previously,
repeated EGD with EUS was performed on ___ and the nodule was
found to be a bleeding varix. S/p banding x2. He was treated
with octreotide, IV PPI, sucralafate, and CTX. With plan to
continue BID PPI and sucralafate for two weeks and to complete a
7day course of SBP prophylaxis with cipro on ___. He was also
started on nadolol for bleeding ppx.
Of note, on prior admission to OSH he had a large Hgb drop and
EGD at that time had shown only esophagitis and gastritis for
which PPI therapy was initiated. Therefore it was continued on
discharge.
#C. difficile
Patient with positive culture and toxin on stool studies. No
known antibiotic exposure. He was treated with PO Vancomycin
though the course should be restarted from the time of the end
of his Cipro course, which is ___. Therefore the end date of
his PO vancomycin is ___.
# Presumed Alcoholic Cirrhosis c/b Bleeding Esophageal Varices
# Acute Alcoholic Hepatitis
# Alcohol use disorder
The patients exam and lab findings are most likely related to
decompensated cirrhosis in the background of chronic alcohol use
disorder. Most likely acute alcoholic hepatitis on background of
chronic alcoholic liver disease, ___ DF on admission was
___. Hepatitis serologies were negative as were ___, AMA, and
anti-smooth. Serum ceruloplasmin was within normal limits. He
was treated with lactulose, rifaximin. Small volume ascites not
amenable to tap. Was not initiated on diuretics this admission.
A vitamin K trial was initiated due to elevated INR and there
was some improvement. Patient was counseled on alcohol cessation
and recommendation for outpatient support for helping with
alcohol cessation but unfortunately patient was
pre-contemplative this admission and not ready to stop drinking
entirely despite significant counseling and warning.
# Hypokalemia
# Hypomagnesaemia
Patient presented with severe hypokalemia and hypomagnesaemia in
the setting of nausea and vomiting with poor PO intake. He has
now been repleted and is within normal limits. Etiology is
likely related to his vomiting, diarrhea and poor PO intake.
These electrolytes were repleted as needed.
#GERD
Treated with home pantoprazole 40mg BID due to varices
TRANSITIONAL ISSUES
===================
[] HBV vaccine #1 was ___, finish vaccination outpatient
[] Monitor for need for paracentesis
[] Patient started on Lasix on day before discharge. Please
monitor weight and adjust as needed. Discharge weight is 82.19
kg.
[] Check electrolytes on ___ to be reviewed by PCP.
[] Encourage alcohol cessation. Patient unfortunately was
pre-contemplative this admission.
[] Would benefit from ongoing nutritional counseling and
support, recommend outpatient nutritionist counseling for
alcoholic hepatitis.
[] magnesium started due to chronic low mag,would recheck at
next appointment and discontinue if able
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. FoLIC Acid 1 mg PO DAILY
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Pantoprazole 40 mg PO Q12H
4. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
5. Sucralfate 1 gm PO QID
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*3 Tablet Refills:*0
2. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Lactulose 30 mL PO TID
RX *lactulose 10 gram/15 mL (15 mL) 30 ml by mouth three times a
day Disp #*3000 Milliliter Refills:*0
4. Magnesium Oxide 280 mg PO DAILY
Do not take with ciprofloxacin
RX *magnesium oxide 250 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
6. Nadolol 20 mg PO DAILY
RX *nadolol 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
8. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*60 Tablet Refills:*0
10. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin [Vancocin] 125 mg 125 mg by mouth four times a
day Disp #*44 Capsule Refills:*0
11. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
12. Pantoprazole 40 mg PO Q12H
RX *pantoprazole [Protonix] 40 mg 1 tablet(s) by mouth twice a
day Disp #*30 Tablet Refills:*0
13. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram/10 mL 1 g by mouth four times a day Disp
#*600 Milliliter Refills:*0
14.Outpatient Lab Work
Please draw chem 10 panel and fax to Dr. ___,
___.
Discharge Disposition:
Home
Discharge Diagnosis:
#ALCOHOLIC HEPATITIS
#ALCOHOLIC CIRRHOSIS
#C. DIFFICLE INFECTION
#ESOPHAGEAL VARICES
#UPPER GI TRACT BLEEDING
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 elevated liver
enzymes.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You had bleeding from your GI tract and you had an EGD with
banding of the bleeding vessels.
- Other studies were performed which showed you had an infection
in your colon called C DIFFICILE
- You were given antibiotics for your infection.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- You must never drink alcohol again or you will die - your
liver cannot survive another round of hepatitis.
- 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)
- You must ensure to follow up with appointments with your
doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- 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 was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10379173-DS-2 | 10,379,173 | 28,583,242 | DS | 2 | 2190-03-10 00:00:00 | 2190-03-10 16:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Delirium/Urinary Tract Infection
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ Dementia, Hip fracture s/p intramedullary nail, chronic
sacral decubitus ulcer with osteomyelitis, recurrent UTIs,
chronic
indwelling Foley catheter, Grave's disease, osteoporosis and a
movement disorder NOS, admitted recently (___) to OSH ICU
for urosepsis and chronic stage IV sacral ulcer presenting with
confusion and whole body stiffness x 1 week. Patient has been
bed bound for many months after prolonged ICU stay. She has been
seeing wound care at ___ for sacral wound. Her recent MRI
was concerning for possible osteomyelitis and she is scheduled
for outpatient bone biopsy. Due to intermittent confusion over
the last week, a U/A was performed and was consistent with UTI.
She has completed a 5 day course of Cipro, but symptoms have
continued so the son brought her to the ED. Denies fever,
chills, abdominal pain, nausea, vomiting. Denies focal weakness,
numbness or tingling. Reports bilateral leg stiffness with pain.
Urine/blood cultures were positive for proteus and Ecoli during
ICU admission.
CT abd/pelvis also showed b/l pyelonephritis/hydronephrosis with
marked bladder distension. Has hx of MDR UTIs and had growth of
proteus and E coli from urine cultures at BI-N with blood
cultures growing proteus and alpha hemolytic strep. She was
narrowed to ceftriaxone and completed a ___dmitted
to ___ on ___ with hospital acquired Stage IV sacral
ulcer.
Per Patient care Referral form dated ___ - "Son ___
insists on patient being sent to ___ against clinical
judgement. Patient reported to be not in distress and exhibits
no s/sx UTI/ no burning on urination. Recent u/a showed
colonization vs contamination. Patient was about to be straight
cath'ed for repeat UA but son refused."
The history of this sacral ulcer began when Ms. ___ suffered
an right sided hip fracture in ___ complicated by a provoked
segmental pulmonary embolism for which she received 6 months of
therapeutic anticoagulation. During recovery from this insult
Ms. ___ experienced significant deconditioning along with
bilateral knee contractures; the combination of which have left
her
non-ambulatory currently and led to the development of the
pressure ulcer. She is able to stand with assistance at physical
therapy for about 20 minutes.
In the ED, initial VS were 98.4, HR 85, BP 107/68 RR 14 98%RA
Exam in the ED: awake and alert to person, able to state is in
hospital but unsure which and unsure of date. Pt appears in no
acute distress at this time and is not voicing complaints of
pain. Pt skin pwd. RR even/unlabored, no distress, pt with no
noted ___ deformities
Labs showed normal BMP and CBC, no leukocytosis, UA- cloudy,
Large leuks, Mod blood, 30 protein, WBC >182, Epi 0
Imaging showed No acute fracture or dislocation. There is
extensive amount of heterotopic bone formation at the left hip
joint,
IVF at 250cc/h with 1 gm Ceftrixone was started
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports feeling "fine", reports
some R>L pain in lower foot, denies pain with urinating, any
fevers. She is unable to follow a conversation and answer
questions. She does not know her name, where she is or the year.
Her son is concerned for delirium, upset that Foley in place for
10 days without monitoring. He wants urology evaluation, concern
for "Proteus" syndrome. He also wants ultrasound for rigidity
for legs. He reports confusion ongoing for about 6 months in the
setting of "abuse" by rehab center.
REVIEW OF SYSTEMS:
Denies fever, headache, vision changes, rhinorrheashortness of
breath, chest pain, abdominal pain, hematochezia, dysuria,
hematuria.
Past Medical History:
Dementia
Hypothyroidism
L hip fx s/p ORIF ___
Recurrent UTI while with chronic indwelling foley
Stage IV sacral decub ulcer c/b chronic osteomyelitis
Cervical stenosis
PE/DVT (previously on Coumadin/xarelto)
Hiatal hernia - should sit upright for meals
Grave's disease
Anemia
Surgical debridement of decubitus ulcer
Social History:
___
Family History:
Non Contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS 98.1 BP 128/64 HR 78 RR 18 100%RA
GENERAL: NAD, AOOx0, elderly, pale woman with exopthalmus
HEENT: Significant bilateral exophthalmus, EOMI, PERRL,
anicteric sclera, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, systolic murmur best heard over left
para-sternal border, no gallops, or rubs
LUNG: symmetric air entry, bibasilar crackles, breathing
comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding,
EXTREMITIES: no edema, left foot internally rotated/contracture,
contracture of knees bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, minimal rigidity of lower extremities,
most prominently in hands.
SKIN: warm and well perfused
Left Stage IV sacral ulcer, sized about 6x4 cm, with visualized
granulation tissue, no noted purulent drainage
Stool noted in rectal vault, rectal bag overlying
DISCHARGE PHYSICAL EXAM:
=========================
VS 97.5 BP 125/67 HR 66 RR16 96 RA
GENERAL: NAD, AOOx2-3
HEENT: PERRL, Notable bilateral exophthalmos unchanged, MMM
NECK: nontender supple neck, no LAD,
CARDIAC: RRR, S1/S2, unchanged systolic murmur best heard over
left sternal border
LUNG: symmetric air entry, no wheezes, breathing comfortably
without accessory muscle use
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: no peripheral edema, contracture of knees
bilaterally
NEURO: Rigidity in upper arms, but with intact full passive ROM,
knee movement limited by contractures
SKIN: Left Stage IV sacral ulcer, sized about 6x4 cm, minimal
erythema around ulcer, no new drainage noted
Pertinent Results:
ADMISSION LABS:
=================
___ 02:10AM URINE GR HOLD-HOLD
___ 02:10AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-LG
___ 02:10AM URINE RBC-166* WBC->182* BACTERIA-NONE
YEAST-NONE EPI-0
___ 11:35PM GLUCOSE-118* UREA N-30* CREAT-0.9 SODIUM-138
POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-25 ANION GAP-17
___ 11:35PM ALT(SGPT)-10 AST(SGOT)-18 ALK PHOS-104
___ 11:35PM WBC-9.2 RBC-4.03 HGB-12.0 HCT-38.3 MCV-95
MCH-29.8 MCHC-31.3* RDW-14.6 RDWSD-50.7*
___ 11:35PM NEUTS-52.9 ___ MONOS-6.8 EOS-3.3
BASOS-0.7 IM ___ AbsNeut-4.87 AbsLymp-3.31 AbsMono-0.62
AbsEos-0.30
PERTINENT LABS:
================
___ 11:35PM VIT B12-610
___ 11:35PM TSH-4.3*
DISCHARGE LABS:
================
___ 06:38AM BLOOD WBC-6.9 RBC-3.53* Hgb-10.4* Hct-33.5*
MCV-95 MCH-29.5 MCHC-31.0* RDW-14.4 RDWSD-49.9* Plt ___
___ 06:38AM BLOOD Glucose-101* UreaN-21* Creat-0.9 Na-140
K-4.4 Cl-107 HCO3-24 AnGap-13
MICRO:
=======
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h. ___ MORPHOLOGY.
PROTEUS MIRABILIS. QUANTITATION NOT AVAILABLE.
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| | PROTEUS
MIRABILIS
| | |
AMIKACIN-------------- <=2 S <=2 S <=2 S
AMPICILLIN------------ 8 S 4 S 8 S
AMPICILLIN/SULBACTAM-- 4 S 4 S 8 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R =>4 R
GENTAMICIN------------ =>16 R =>16 R =>16 R
MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S <=4 S
TOBRAMYCIN------------ 8 I 8 I 8 I
TRIMETHOPRIM/SULFA---- <=1 S <=1 S =>16 R
IMAGING and OTHER STUDIES:
==========================
___ Hip X-Ray: The patient is post normal-appearing right
hip arthroplasty with long cemented femoral stem. A right sided
intramedullary rod extends throughout the length of the femoral
diaphysis with proximal fixation nail extending into
the femoral head and single distal interlocking screw. There is
an extensive heterotopic bone formation centered at left greater
trochanter and inferomedial aspect of the left femoral neck
(presumed post previous intertrochanteric fracture with no
fracture line identified). Vascular calcifications are seen in
the left lower extremity. There is joint space narrowing and
osteophyte formation in the left hip and left knee (some of
which could relate to non/reduced ambulation. There is no acute
fracture or dislocation. Moderate stool throughout the colon.
Prior Sacral Ulcer MRI indicates a 6.8 x 1.0 x 3.9cm defect at
the sacrum with presacral edema and a T1 hypointense signal at
S5 and STIR hyperintensity in that same region. Presacral edema
and enhancement is noted without visible fluid collection or
abscess.
Brief Hospital Course:
___ yo F with hx of dementia, Hip fracture s/p intramedullary
nail, chronic sacral decubitus ulcer with osteomyelitis,
recurrent UTIs given history of chronic indwelling Foley
catheter presenting with concerns for acute encephalopathy.
#Acute Encephalopathy: Patient initially presented to ___ with
concerns for a urinary tract infection given UA showing high
WBCs, but patient also has with history of colonization and
contamination given prior indwelling Foley. Patient had a
history of recent treatment in ___ with Nitrofurantoin,
Levofloxacin. No new medication changes, electrolyte changes.
History of recent tx in ___ with Nitrofurantoin, Levofloxacin.
Notably, she had a recent admission at ___ ___
with fevers, hypotension, with frank pus from indwelling foley,
with ICU admission at the time. She was treated with broad
spectrum antibiotics, with urine growing alpha hemolytic strep
and proteus at the time, along with oxygen requirement,
bilateral hydronephrosis due to pyelonephritis, with
recommendation to discontinue Foley. She was alert and
arousable, oriented to only self on admission, which improved
with reorientation. She was initially treated with IV
ceftriaxone. Her electrolytes, CBC, TSH, B12 were all normal,
with no other infectious etiology. Given collateral information,
she appeared to be at baseline as far as mental status, and was
alert an oriented to self and year on discharge, and antibiotics
were discontinued. Her urine culture grew E.coli and Proteus,
which she has known to be colonized with before, so further
treatment was deferred. She was evaluated by nutrition who
recommended a regular diet with Ensure supplementation. Physical
therapy recommended discharge to Rehab to improve her functional
status.
#Stage IV Sacral Decubitus Ulcer: Patient noted to have a 3 x 7
x 1.5 cm ulcer in left upper buttock with deepest portion
located at the 5 o'clock position. Otherwise, the wound is 1 cm
in depth elsewhere. The wound bed was relatively clean( 90% red
) with only 10 % yellow slough and a dark purple/black area
within the wound bed. There was no visible bone or tendon.
Drainage was moderate serous with scant purulence. There was no
odor, erythema or other sign of infection. Wound care
recommended cleaning ulcer and filling wound with aquacel along
with softsorb, recommended securing with medipore with soft
cloth tape. We recommend changing the dressing daily. Per recent
plastics note in ___, there was no need culture or biopsy at
this time given the status as an open/draining wound and with no
indication for operative coverage with a flap or skin graft at
this time. If patient out of bed, please request roho cushion
from ___ and limit sit time to 1 hour at a time. Patient has
outpatient follow up with Orthopedics on ___,
please reschedule as appropriate.
CHRONIC ISSUES:
================
#Chronic Constipation: Continued on home bowel regimen including
Senna 17.2 po qhs, Dulcolax 10mg PR daily PRN, Miralax 17gm po
daily, enema if needed.
#History of provoked DVTs: Completed Lovenox for 6 months, and
now per hematology, and per their recommendations,continued on
Aspirin 81 daily.
#Anemia:Continued home Ferrous 325 mg daily
#Graves Disease: Continued home Levothyroxine 50 daily.
#Hyperlipidemia: Continued Atorvastatin 20 mg daily
TRANSITIONAL ISSES:
===================
-Please ensure patient has wound care follow up, she follows
with ___, and also has Orthopedics follow
up on ___
-Encourage independence with ADLs and functional mobility as pt
is at risk for deconditioning
-Please AVOID indwelling Foley catheter given patient's history
of urosepsis and recurrent UTIs.
-Please limit sitting time to 1 hour on ___ overlay as pt
unable to reposition independently and has stage IV sacral
ulcer.
-If out of bed, please request roho cushion from ___ and limit
sit
time to 1 hour at a time.
-Full Code
-EMERGENCY CONTACT HCP: ___ ___ (son)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Acetaminophen 650 mg PO Q4H:PRN Pain
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Vitamin D ___ UNIT PO DAILY
6. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
7. Lactobacillus acidoph-L.bulgar 1 million cell oral BID
8. Ferrous Sulfate 325 mg PO DAILY
9. cranberry 450 mg oral DAILY
10. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Ferrous Sulfate 325 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. cranberry 450 mg oral DAILY
9. Lactobacillus acidoph-L.bulgar 1 million cell oral BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
-Delirium
-Stage 4 Sacral Pressure Ulcer
Secondary Diagnosis:
-Chronic Constipation
-History of provoked DVTs
-Graves Disease
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ on ___ with concerns of a
urinary tract infection. Your laboratory tests were all normal,
and you did not have an infection in your urine. The wound on
your sacrum did not look to be infected. You were seen by
nutritionist, wound care specialists, and physical therapists
and it is now safe for you to go to rehab to continue your
ongoing care.
We wish you the best
Happy Belated Birthday!
Your ___ Care team
Followup Instructions:
___
|
10379173-DS-5 | 10,379,173 | 28,196,126 | DS | 5 | 2190-06-11 00:00:00 | 2190-06-12 19:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Altered mental status, UTI
Major Surgical or Invasive Procedure:
___ line placement ___
History of Present Illness:
___ F w/ h/o recurrent drug resistant UTIs, chronic sacral
decubitus ulcer c/b osteomyelitis, dementia, p/w altered mental
status, concern for PNA. Patient currently lives at a rehab
facility and has a small stage 4 sacral decub incurred in
___ after hip surgery in ___. Pt requires 100% assistance
with activities of daily living. The patient is confused and
unable to corroborate the history. She was brought to BI urgent
care with worsening cough for the past 10 days with decreased
sleeping and at times alteration in mentation. Chest x-ray
obtained at urgent care was felt to have increased opacification
(though subsequently read as negative). She was advised to come
to the ED.
In the ED, initial vitals: 100.3 90 117/59 18 96% RA. Labs
notable for WBC 10.4 w/ normal diff, Hgb 12.2, plts 434, BUN/Cr
___, K 5.3, HCO3 24, Lactate 2.5. UA w/ >182 WBCs, 33 RBCs,
moderate bacteria, no epis. CXR without acute cardiopulmonary
process. Flu swab was negative. The patient was started on
Vancomycin 1g and Pip/tazo 4.5g, and received 1L NS. SBP in the
ED ranged from 90-130s; her fever resolved without intervention.
Vitals prior to transfer were: 98.2 67 131/49 23 99% RA.
Currently, the patient is sleepy but arousable and denies any
specific complaints.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
Dementia
Hypothyroidism
L hip fx s/p ORIF ___
Recurrent UTI while with chronic indwelling foley
Stage IV sacral decub ulcer c/b chronic osteomyelitis
Cervical stenosis
PE/DVT (previously on Coumadin/xarelto)
Hiatal hernia - should sit upright for meals
Grave's disease
Anemia
Surgical debridement of decubitus ulcer
Social History:
___
Family History:
Non Contributory
Physical Exam:
PHYSICAL EXAM ON ADMISSION
==========================
Vitals - 98.7 128/71 84 18 98% RA
GENERAL: NAD, sleepy but arousable
HEENT: Dry MM.
CARDIAC: RRR, S1 S2
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND.
EXTREMITIES: No edema
BACK: ~4x5 cm stage 4 sacral ulcer with clean base, clean
edges, no induration or erythema, mild serous drainage
SKIN: No rashes
NEURO: A&Ox1. Confused.
PHYSICAL EXAM ON DISCHARGE
==========================
Vitals 97.6 108/56 75 18 97%RA
GENERAL: NAD, lethargic
HEENT: Moist MM.
CARDIAC: RRR, S1 S2
LUNGS: CTAB, good air movement bilaterally.
ABDOMEN: NABS. Soft, NT, ND.
EXTREMITIES: No edema
BACK: ~4x5 cm stage 4 sacral ulcer dressed. no surrounding
induration or erythema, mild serous drainage
SKIN: No rashes
NEURO: A&Ox2. Alert
Pertinent Results:
LABS ON ADMISSION
=================
___ 07:00PM BLOOD WBC-10.4* RBC-4.12 Hgb-12.2 Hct-38.5
MCV-93 MCH-29.6 MCHC-31.7* RDW-15.3 RDWSD-52.4* Plt ___
___ 07:00PM BLOOD Neuts-64.0 ___ Monos-8.1 Eos-1.6
Baso-0.4 Im ___ AbsNeut-6.64* AbsLymp-2.65 AbsMono-0.84*
AbsEos-0.17 AbsBaso-0.04
___ 07:00PM BLOOD Plt ___
___ 07:00PM BLOOD Glucose-102* UreaN-25* Creat-0.9 Na-137
K-5.3* Cl-99 HCO3-24 AnGap-19
___ 07:00PM BLOOD Calcium-9.8 Phos-3.7 Mg-2.3
___ 06:25PM BLOOD Lactate-2.5*
LABS ON DISCHARGE
==================
___ 01:56PM BLOOD WBC-10.3* RBC-3.53* Hgb-10.5* Hct-33.1*
MCV-94 MCH-29.7 MCHC-31.7* RDW-15.2 RDWSD-51.4* Plt ___
___ 08:09AM BLOOD Glucose-89 UreaN-19 Creat-0.8 Na-137
K-4.9 Cl-102 HCO3-27 AnGap-13
MICROBIOLOGY
============
Urine Culture ___
URINE CULTURE (Preliminary):
___ MD (___) RESQUESTS FOSFOMYCIN SENSITIVITIES
___.
NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA.
10,000-100,000 ORGANISMS/ML.. Cefepime = (<2 MCG/ML).
MEROPENEM = (<1 MCG/ML).
sensitivity testing performed by Microscan.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
NON-FERMENTER, NOT PSEUDOMONAS
AERUGINOSA
|
AMIKACIN-------------- 8 S
CEFEPIME-------------- S
CEFTAZIDIME----------- =>32 R
CEFTRIAXONE----------- <=4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=2 S
IMAGING
========
ECG ___
Sinus rhythm at upper normal rate. Compared to the previous
tracing
of ___ the rate is now faster. Otherwise, probably
unchanged.
CXR ___
FINDINGS:
AP upright and lateral views of the chest provided. Volumes are
low limiting assessment. The imaged portions of both lungs
appear clear.
Cardiomediastinal silhouette appears unchanged with top-normal
heart size
again noted. Imaged bony structures are intact with chronic
left ribcage
deformities re- demonstrated.
IMPRESSION:
As above. No acute findings.
___ Imaging PICC LINE PLACMENT SCH
1. The accessed vein was patent and compressible.
2. Brachialvein approach single lumen right PICC with tip in
the cavoatrial junction.
Brief Hospital Course:
___ F w/ h/o recurrent drug resistant UTIs, chronic sacral
decubitus ulcer c/b osteomyelitis, dementia, p/w altered mental
status, likely due to recurrent UTI
# Delirium: Most likely etiology is UTI, given pyuria on UA in
ED and AMS consistent with UTI. Osteo also was a possibility but
less likely to cause systemic Sx and physical exam revealed
clean wound. No focal neurological signs c/f stroke. UTI treated
with zosyn empirically and subsequently with cefepime after
sensitivities returned. Cefepime day 1: ___.
# UTI: History of multi-drug resistant UTIs in setting of
non-obstructive chronic stones that were scheduled for
lithostropy and stent placement. Zosyn discontinued on ___
(___). Cefepime started based on sensitivities (day 1:
___. Floor team was in discussions with Dr. ___
scheduling ___ procedure either during her abx treatment
or soon thereafter.
# Productive Cough: CXR without signs of pneumonia. Patient has
remained afebrile without leukocytosis and has had productive
cough x 2 weeks according to son. No SOB or O2 requirement. Most
likely post-viral cough. Patient had saline nebs PRN and
symptomatic control. After two days as inpatient, cough
dissipated.
# Pre-existing chronic sacral ulcer: Wound care was consulted
and recs were followed. Continued zinc, vit C
# HLD:
Continued Atorvastatin 20 mg PO QPM
# Hypothyroidism: Continued Levothyroxine Sodium 50 mcg PO DAILY
TRANSITIONAL ISSUES
[]Will need CBC with diff and LFTs on ___, fax to
___ attn. Dr. ___
[]Patient taken off aspirin in anticipation of urological
procedures. Was started after she was on anticoagulation x 6
months s/p PE that she developed after L hip surgery. No known
cardiac disease.
[]day 1 cefepime ___. Full 10 day course runs upto and
including ___.
[]may benefit from ___ cefepime if procedure is after
her abx course has finished.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Senna 17.2 mg PO QHS
9. Vitamin D ___ UNIT PO DAILY
10. Zinc Sulfate 220 mg PO DAILY
11. Acetaminophen 1000 mg PO BID:PRN 60 min before dressing
change
12. Lactobacillus acidophilus 1 billion cell oral BID
13. Fosfomycin Tromethamine 3 g PO 1X/WEEK (___)
14. Vagifem (estradiol) 10 mcg vaginal 2X/WEEK
15. methenamine hippurate 1 gram oral BID
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. Ascorbic Acid ___ mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Docusate Sodium 100 mg PO BID
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Senna 17.2 mg PO QHS
7. Vitamin D ___ UNIT PO DAILY
8. Zinc Sulfate 220 mg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Lactobacillus acidophilus 1 billion cell oral BID
11. methenamine hippurate 1 gram oral BID
12. Multivitamins 1 TAB PO DAILY
13. Vagifem (estradiol) 10 mcg vaginal 2X/WEEK
14. CefePIME 1 g IV Q24H Duration: 8 Days
15. Outpatient Lab Work
CBC with diff and LFTs on ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
urinary tract infection
altered mental status
dementia
SECONDARY DIAGNOSIS
===================
chronic stage IV decubitus ulcer
hyperlipidemia
hypothyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Ms. ___,
You were admitted to ___ with
a cough and an infection in the urine. You were treated with IV
antibiotics and will be discharged on IV antibiotics that you
will receive through a ___ line. You will be able to have the
line removed once your antibiotics are finished.
Dr. ___ urologist is currently trying to schedule your
procedure within the week or early next week. If you do not hear
from his office within 2 days of discharge, please call them to
inquire.
It was a pleasure taking part in your care
Your ___ Team
Followup Instructions:
___
|
10379185-DS-6 | 10,379,185 | 22,831,206 | DS | 6 | 2135-07-05 00:00:00 | 2135-07-06 09:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fatigue, left ear bleeding
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ ___ M PMHx R fronto-parietal stroke, HTN, GERD,
recent hospital stay 9.20-9.24 for AMS attributed to TIA with
incidental finding of saddle PE that stay started on AC,
presents for L ear bleeding and increased fatigue.
Per hx given to ED by daughter-in-law, since last night he has
been more fatigued. He is usually very active. He is otherwise
mentating at his baseline.
In the ED initial vitals were: 97.6 89 125/68 18 94%.
- Labs significant for normal CBC and Chem7 (BUN mildly elevated
to 26), INR 1.7. UA with Tr Leuk and 4 Bacteria. Lactate 2.5.
- CXR with hazy bibasilar L > R opacities likely atelectasis but
infection cannot be excluded. Old calcified granuloma projecting
over lateral R lower lung called in Findings, not previously
commented per ___ CXR read though is apparent there too.
- CT Head w/o acute bleed. Bilateral soft tissue densities were
found.
- In discussion with ED resident, patient had gauze in L ear
that was removed, no fresh bleeding, source of bleed could not
be visualized but do not think he is acutely bleeding.
- Patient was given CTX 1g and 500mg Azithromycin and admitted
for PNA and fatigue.
Vitals prior to transfer were: 98 80 110/67 16 95% RA.
On the floor, history is taken primarily through daughter who
patient nodding along. Patient was lethargic starting last night
with labored breathing, this morning did not want to wake up or
be active. No fevers, chills, cough. Patient agrees he had
shortness of breath and associated sharp CP with this SOB, but
this has resolved now on the floor. No abdominal pain, urinary
or bowel symptoms, joint or muscle pains. He has had L ear
bleeding when bearing down to stool, has not had before, no
other bleeding from other orifices.
Past Medical History:
Pt recent moved from ___ 1.5 months ago, and family is
unaware of most of his history.
- Stroke- approximately ___ years ago, etiology unknown to
patient
and family
- Likely MCI given his Donepazil
- Likely Hypertension Given Losartan
- Likely GERD given Ranitidine
- Chronic Left Knee pain
- s/p choelctystectomy in ___.
Social History:
___
Family History:
- 1 grandchild with seizures, type unknown. Otherwise no known
history of seizure or stroke.
Physical Exam:
ON ADMISSION:
VS - Temp 98 HR 80 BP 110/67 RR 16 O2 95% RA
GENERAL: pleasant, cooperative with physical exam when
directions translated into ___, NAD
HEENT: NCAT, pupils symmetric, anicteric scleara, pink
conjunctiva, dried blood in L auditory canal (none on R), MMM,
poor dentition
NECK: no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: central obesity, soft, NT, ND, +BS
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact, ___ strenght ___
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
AT DISCHARGE:
VS - Temp 98 HR 80 BP 110/67 RR 16 O2 95% RA
GENERAL: pleasant, cooperative with physical exam when
directions translated into ___, NAD
HEENT: NCAT, pupils symmetric, anicteric scleara, pink
conjunctiva, dried blood in L auditory canal (none on R), MMM,
poor dentition
NECK: no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: central obesity, soft, NT, ND, +BS
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact, ___ strenght ___
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
___ 03:45PM ___ PTT-41.2* ___
___ 03:45PM PLT COUNT-176
___ 03:45PM NEUTS-55.1 ___ MONOS-10.4 EOS-1.7
BASOS-1.0
___ 03:45PM WBC-5.7 RBC-5.41 HGB-16.2 HCT-49.5 MCV-91
MCH-30.0 MCHC-32.8 RDW-15.7*
___ 03:45PM estGFR-Using this
___ 03:45PM GLUCOSE-132* UREA N-26* CREAT-1.1 SODIUM-138
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-26 ANION GAP-11
___ 04:30PM URINE MUCOUS-RARE
___ 04:30PM URINE RBC-2 WBC-4 BACTERIA-NONE YEAST-NONE
EPI-0
___ 04:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR
___ 04:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:30PM URINE UHOLD-HOLD
___ 04:30PM URINE HOURS-RANDOM
___ 04:30PM URINE UHOLD-HOLD
___ 04:30PM URINE HOURS-RANDOM
___ 06:47PM LACTATE-2.5*
Brief Hospital Course:
___ ___ M PMHx R fronto-parietal stroke, HTN, GERD,
recent hospital stay 9.20-9.24 for AMS attributed to TIA with
incidental finding of saddle PE that started on AC, presents for
L ear bleeding and increased fatigue.
# Increased Fatigue: Patient back to baseline on the floor after
being dosed with ABx in the ED. No SOB or pleuritic chest pain.
He is recorded as being 93-100% on RA and in sinus rhythm,
reducing concern for new PE, and family has been administering
Lovenox and Coumadin, able to recount dosages and frequency. No
sputum production or cough. No fevers or chills. He also had a
normal white count. We had very low suspicion for a pneumonia on
the floor. Of note, he had no other obvious source for fatigue -
clear UA, intact neurologic exam, no anemia, unremarkable Chem7.
- Stopped CTX/Azithro as low suspicion for PNA
- Continued systemic AC
- Trended H/H-stable
# L Ear Bleeding: Patient has undefined soft tissue densities on
head CT with no previous hx bleeding, but bleeding with bearing
down for stools, likely because he is on AC. Unless actively
extravasating, likely needs ENT evaluation as outpatient; for
now, will start laxatives to help ease BMs.
- Senna/Colace/Miralax to prevent straining
- ENT appointment requested via care connections as outpatient
# Elevated Lactate: Mildly elevated at 2.5. Unclear as to what
the underlying cause may have been, patient did have diminished
PO intake. Patient was given gentle bolus overnight, normalized
to 1.5 in AM.
- 500cc NS overnight
- AM lactate improved = 1.5
# Treatment of PE: Continued ASA, enoxaparin to warfarin bridge,
trend INR.
# s/p Stroke: Continued ASA, systemic anticoagulation as above.
# MCI: Continued home donepazil.
# GERD: Continued home ranitidine.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Donepezil 5 mg PO HS
3. Enoxaparin Sodium 80 mg SC Q12H
4. Ranitidine 75 mg PO DAILY
5. Warfarin 4 mg PO DAILY16
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Donepezil 5 mg PO HS
3. Ranitidine 75 mg PO DAILY
4. Warfarin 4 mg PO DAILY16
5. Enoxaparin Sodium 80 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
Discharge Disposition:
Home
Discharge Diagnosis:
fatigue
left ear bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospital stay
at ___. When you came in, you
complained of some bleeding from your left ear while straining
in the bathroom. Your granddaughter noted that you were having
some difficulty breathing with some shortness of breath and some
sharp chest pain which resolved. There was some concern for
pneumonia and you were started on antibiotics, however, we did
not believe you had the clinical signs of pneumonia and your
labs and vital signs remained stable. Your symptoms have
improved and it is now safe for you to be discharged. Please be
sure to take all of your medications as prescribed and keep your
followup appointments. We are arranging for you to see an Ear,
Nose and Throat specialist, so that you may have your ear
formally examined by an expert. We wish you the very best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10379461-DS-13 | 10,379,461 | 24,027,497 | DS | 13 | 2124-10-26 00:00:00 | 2124-10-26 12:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
MVA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old female who was transferred from an outside
hospital after an MVA. Per report, the patient was the
unrestrained passenger in a vehicle that was traveling
approximately 15mph, the car did sustain significant
front end damage. She was found to be in a crumpled position
underneath the dash board. LOC is unknown. She was amnestic to
the event.
Past Medical History:
dementia
hypothyroid ds
Hyperlipidemia
Social History:
___
Family History:
NC
Physical Exam:
On Admssion:
O: T:97.7 BP: 130/93 HR: 103 R 21 O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: R ___, L unable to examine EOMs R intact
Neck: collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power 4+ right UE; BLE limited due to
pain. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: Normal bilat
Toes downgoing bilaterally
At discharge:
Alert to self and hospital
PERRL
EOMs intact, R periorbital ecchymosis
Face symmetrical
No pronator drift
MAE with good strength
Pertinent Results:
___ CT C-spine
No acute cervical spine fractures. Normal alignment.
___ CT head
1. There is an 8-mm extra-axial hemorrhage overlying the right
frontoparietal lobe with a biconvex appearance most suggestive
of an epidural hematoma. 2. Extensive left frontal subgaleal
hematoma with supraorbital and infraorbital components.
3. Tiny hyperdense focus visualized in a sulcus in the right
temporal lobe is suggestive of a tiny focus of subarachnoid
hemorrhage versus partial volume averaging.
L hip X-rays ___
1. No definite acute fracture or dislocation. If there is
continued clinical concern for left hip fracture, consider
correlation with hip MRI.
2. Tricompartmental mild-to-moderate osteoarthritic changes of
the left knee secondary to chondrocalcinosis.
L Femur X-rays ___
1. No definite acute fracture or dislocation. If there is
continued clinical concern for left hip fracture, consider
correlation with hip MRI.
2. Tricompartmental mild-to-moderate osteoarthritic changes of
the left knee secondary to chondrocalcinosis
CT head ___
1. Stable appearance of right frontoparietal epidural hematoma.
2. No other apparent foci of hemorrhage.
3. Stable large left orbital subgaleal hematoma.
Brief Hospital Course:
Ms. ___ was admitted to the ___ under the care of Dr.
___ Q1 hr neuro checks for EDH. She remained stable with
some disorientation to time that was consistent with her
basline status due to dementia. Repeat CT head was stable.
Imaging of the left leg was negative for fracture. She was seen
by the medicine service and there were no acute issues and they
would not take over her care. She was transfered to the floor.
Her collar was cleared by the ___ as she had no fracture or
pain. ___ and OT were consulted and they felt that she was safe
to go home with 24hr supervision. The daughter will be home with
her over the weekend and a home ___ will be assisting on ___.
Medications on Admission:
ASA
Discharge Medications:
Patient may take tylenol for pain
Discharge Disposition:
Home
Discharge Diagnosis:
EDH
Discharge Condition:
Neurologically stable
Discharge Instructions:
Instructions for Follow up for Subdural, Epidural or
Subarachnoid Hemorrhages
Non-Surgical
You may take tylenol for pain. You do not need to take it if
you do not have pain.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
DO not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, or Ibuprofen etc. until follow up.
*****If you were on Aspirin prior to your injury, you may
safely resume taking this on ___
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
10379484-DS-10 | 10,379,484 | 27,781,554 | DS | 10 | 2133-03-18 00:00:00 | 2133-03-20 21:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / albuterol / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
dysuria, chills, aches
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with atrial fibrillation not on AC, GERD, meningioma who was
seen in ED yesterday for dysuria with positive urinalysis, sent
home on nitrofurantoin, who presents with "feeling awful" with
worsening dysuria, generalized body aches. She was also noted to
have Cr elevation to 1.3. Culture is growing unspeciated GNRs.
She also complains of cough, although it seems to be more
chronic. Denies dyspnea, chest pain, abdominal pain, diarrhea,
melena, BRBPR, rash, neck stiffness.
In the ED, initial vitals: 99.4 80 150/60 18 96% Nasal Cannula
- Exam notable for:CTAB
No CVAT
- Labs notable for: BUN/Cr ___, K 3.5, UA neg leuks, trace
ketones, lactate 1.4, flu neg
- Imaging notable for:
CXR Mild vascular congestion, unchanged. Chronic middle lobe
collapse. No definite focal consolidation to suggest pneumonia.
EKG Atrial fibrillation @ 87 bpm, Probable LVH with secondary
repol abnrm Inferior infarct, old, Anterior Q waves, possibly
due to LVH
- Pt given: CTX 1 gm, 1L NS
- She developed acute respiratory distress in ED with IVF. CXR
showed pulmonary edema. She briefly required BiPAP in the ED.
On arrival to the floor, pt reports that she still feels awful.
Two days ago developed dry, "musical" cough then chills
("shaking like a leaf"). She also had dysuria, poor appetite,
some nausea. No rhinorrhea, sore throat, abdominal pain,
fevers/chills, dyspnea, chest pain, or sick contacts. No
lightheadedness, but she did trip with her walker and hurt her
ankle. She did not fall.
ROS:
As per HPI; Otherwise negative
Past Medical History:
PMH:
Afib not on anticoagulation
GERD and Gastritis on EGD
Right frontal convexity meningioma
Hypertension
Spinal stenosis
Arthritis
PSH:
2 prior hip operations with additional revisions
L partial mastectomy
Cataract surgery in ___
Social History:
___
Family History:
Parents are deceased- died at old age. Sister ___, brother ___.
Brother with arthritis. Her daughter, at age ___, has arthritis.
But her sons, ages ___ and ___, are healthy.
Physical Exam:
ADMISSION EXAM:
Vitals: 97.9
PO 148 / 55
R Lying 95 20 92 2L
General: Alert, oriented x3, no acute distress
HEENT: Sclerae anicteric, dry oral mucosa, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Generally clear throughout with transmitted upper airway
sounds
CV: Irregularly irregular, 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, Left foot with ecchymoses over dorsal aspect. No TTP of
lateral/medial malleoli or metatarsals. Full ankle ROM.
Neuro: CN2-12 intact, no focal deficits
DISCHARGE
Vitals: 98.0, 166/88, 94 bpm, 92%RA
General: Awake watching walking to nursing station with walker
on her own, looks younger than age, does not cough during our
entire encounter.
HEENT: Moist mucosa, glasses in place
Lungs: lungs are clear with good movement, comfortable on room
air
CV: Mostly regular, PACs few
Abdomen: Mild distension (her baseline), soft, NT/ND bowel
sounds present
GU: no foley
Ext: warm, well perfused, mild edema of RLE with overlying
xerosis diffuse
Neuro: no focal deficits, walking easily with walker, speech
clear, face symmetric
Pertinent Results:
ADMISSION LABS:
___ 11:51PM BLOOD WBC-11.8*# RBC-4.18 Hgb-11.7 Hct-36.7
MCV-88 MCH-28.0 MCHC-31.9* RDW-14.7 RDWSD-46.9* Plt ___
___ 11:51PM BLOOD Neuts-85.1* Lymphs-4.2* Monos-8.0 Eos-2.1
Baso-0.1 Im ___ AbsNeut-10.03*# AbsLymp-0.50* AbsMono-0.94*
AbsEos-0.25 AbsBaso-0.01
___ 12:17PM BLOOD ___ PTT-27.1 ___
___ 11:51PM BLOOD Glucose-122* UreaN-30* Creat-1.3* Na-140
K-3.5 Cl-97 HCO3-27 AnGap-20
___ 12:17PM BLOOD Calcium-8.1* Phos-3.2 Mg-2.0
___ 03:25AM BLOOD Lactate-1.4
___ 02:04AM URINE Color-YELLOW Appear-Clear Sp ___
___ 02:04AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 02:04AM URINE RBC-<1 WBC-10* Bacteri-FEW Yeast-NONE
Epi-1 TransE-<1
MICROBIOLOGY:
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
STUDIES:
___ CXR: Mild vascular congestion, unchanged. Chronic
middle lobe collapse. No definite focal consolidation to
suggest pneumonia.
___ 06:36AM BLOOD WBC-4.4 RBC-3.73* Hgb-10.9* Hct-33.2*
MCV-89 MCH-29.2 MCHC-32.8 RDW-14.3 RDWSD-45.7 Plt ___
___ 06:44AM BLOOD Glucose-150* UreaN-17 Creat-1.1 Na-138
K-3.8 Cl-98 HCO3-23 AnGap-21*
___ 06:36AM BLOOD proBNP-4060*
Brief Hospital Course:
___ with atrial fibrillation not on AC, GERD, meningioma who
presents with dysuria, cough/chills most likely consistent with
acute viral syndrome/URI and UTI. Had ECOLI >100k, initially on
Ceftriaxone switched to cefpodoxime for 7 day course. Given
worsening resp sx during admission given nebs/inhalers and
Azithromycin for antiinflammatory effect (for 5 day course). UTI
sympotoms quickly improved with Respiratory much improved. Cough
ongoing and infrequent. Patient has difficulty sleeping and hip
pain, per patient chronic and she uses oxycodone at home for
this.
seen by our ___ and cleared for home
TRANSITIONAL
-- PCP ___ on ___, discuss insomnia further and her use of
Opioids
-- Cefpodoxime and Azithromycin on discharge
BY PROBLEM:
# Hypoxemia - Resolved. On ___ started 2L NC as her RA SaO2 was
in the ___. Seems that diuresis did help as her BNP was 4000+
and did have crackles on ___ and was not getting Lasix (at home
40mg PO daily). No evid of chf exacerbation otherwise. Does have
ILI / Bronchitis and likely also contributing. On SQH and only
in hospital a few days to suggest PE. Volume status seems that
she is euvolemic to hypovolemic
-- cont ILI treatment as below
-- continue PO Lasix 20mg/day (40mg/day at home), monitor GFR
closely given her poor po intake
-- prn ipratropium
# MALAISE
# BRONCHITIS, COUGH - Improving overall. c/w ILI vs atypical
pneumonia. ___ some suggestion of LLL consolidation on cxr. No
h/o aspiration. Possibly atypical bacterial process thus Azithro
added.
-- Azithromycin started on ___ x 5 days (QTc on ___
pending)
-- standing APAP for now given ongoing pain
- Symptomatic treatment: Guaifenesin-Dextromethorphan,
Ipratropoium
# UTI, ECOLI with resistances: Positive urine cx with dysuria.
No CVA TTP/fever/n/v to suggest pyelo, symptoms improved now.
- Initially on Ceftriaxone, now Cefpodoxime since ___
(though urinary penetration less than ideal, best option given
sensitivities at this time) - ___ for 7 days
# Hypokalemia - resolved
# Hypernatremia - resolved
# ___: Resolved. Cr 1.2 on arrival, baseline 1.0. Likely
pre-renal, as resolved with IVF. Cr back at baseline now.
-- likely combination of poor freewater intake and poor
nutritional intake and Lasix use (though has BNP of 4000 and in
afib)
-- encourage better nutrition and free water intake
-- restart Lasix as above
# CODE STATUS - discussed in detail with patient on ___, she is
clear and understands details of the conversation, adamant to
avoid any interventions such as CPR / Intubation. Does want to
have DNR / DNI order.
-- inform HCP later today.
# Constipation - increase Bowel reg on ___, now had several BMs
on ___
# Hypertension
# Atrial fibrillation: Not on anti-coagulation since GI bleed in
___. Rate-controlled.
- home metoprolol 25mg BID
- home Amlodipine 5mg/ BID
# Spinal stenosis
# Insomnia - an issue while she is here. Apparently oxycodone
helps both pain and sleep at home
-Continue home mirtazapine
-Trial Trazodone qHS
-- cont home oxycodone ___ q8h prn
CHRONIC
# GERD/Gastritis:
# Thrombocytopenia
- Mild and chronic, I wonder about chronic underlying ITP,
medication effect (PPI) can consider further outpatient workup
- Continue home omeprazole for GERD/gastritis though could be
contributing to some low PLT, outpatient follow up
#Misc:
-Continue home ASA/docusate/MVI/Ferrous sulfate/INH Fluticasone
# CODE STATUS: DNR / DNI
# CONTACT: Name of health care proxy: ___
Relationship: son
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. Metoprolol Tartrate 25 mg PO BID
4. Mirtazapine 7.5 mg PO QHS
5. Omeprazole 20 mg PO BID
6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
7. Vitamin D 1000 UNIT PO DAILY
8. HydrOXYzine 10 mg PO QHS:PRN itchiness
9. Furosemide 40 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. amLODIPine 5 mg PO BID
12. Calcium Carbonate 500 mg PO BID
Discharge Medications:
1. Azithromycin 250 mg PO Q24H Duration: 5 Days
d1 = ___
RX *azithromycin [Zithromax] 250 mg 1 tablet(s) by mouth daily
Disp #*2 Tablet Refills:*0
2. Cefpodoxime Proxetil 200 mg PO Q24H Duration: 6 Days
d1 = ___, d7 = ___
RX *cefpodoxime 200 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
3. Cepacol (Sore Throat Lozenge) 1 LOZ PO TID
RX *benzocaine-menthol [Sore Throat (benzocaine-menth)] 15
mg-2.6 mg three times a day Disp #*18 Lozenge Refills:*0
4. Guaifenesin-Dextromethorphan ___ mL PO TID Duration: 5 Days
RX *dextromethorphan-guaifenesin [Antitussive DM] 100 mg-10 mg/5
mL 5 mL by mouth three times a day Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN constip
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth twice a day Refills:*0
6. Acetaminophen 650 mg PO Q6H
7. Docusate Sodium 200 mg PO BID
8. Furosemide 30 mg PO DAILY
RX *furosemide [Lasix] 20 mg 1.5 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*3
9. amLODIPine 5 mg PO BID
10. Aspirin 81 mg PO DAILY
11. Calcium Carbonate 500 mg PO BID
12. Metoprolol Tartrate 25 mg PO BID
13. Mirtazapine 7.5 mg PO QHS
14. Omeprazole 20 mg PO BID
15. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
16. Vitamin D 1000 UNIT PO DAILY
17. HELD- HydrOXYzine 10 mg PO QHS:PRN itchiness This
medication was held. Do not restart HydrOXYzine until you see
your pcp
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Urinary tract infection
Acute kidney injury
Acute viral syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
Why were you here:
-You had a viral infection, as well as a urinary tract infection
What was done:
-We gave you antibiotics
What to do next:
-Take all your medications as prescribed and follow-up with the
appointments listed below
We wish you all the best,
Your ___ team
Followup Instructions:
___
|
10379484-DS-7 | 10,379,484 | 20,973,084 | DS | 7 | 2131-05-23 00:00:00 | 2131-05-23 15:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / sulfur drugs / albuterol
Attending: ___
___ Complaint:
post mastectomy discomfort and swelling
Major Surgical or Invasive Procedure:
s/p Left breast partial mastectomy for invasive ductal carcinoma
on ___
History of Present Illness:
Mrs ___ is a ___ yo woman with history of atrial fibrillation
(on warfarin) s/p L breast partial mastectomy for invasive
ductal carcinoma re-admitted POD 4 with L breast hematoma. She
presented electively to the ___ on ___ ___. She
underwent left partial mastectomy on the day of presentation and
was discharged the following day without any immediate
complication. On ___ she developed nausea and vomiting
earlier in the evening and presented to ___ ER for evaluation.
On clinical exam she was found to have a left breast hematoma
and eccymosis extending down her lateral torso. Of note, her
operative incision was intact with no distension of the
hematoma. Labs, CT of the torso and left breast ultrasound were
performed and most remarkable for HCT drop from 34 to 27.Ms.
___ was admitted for hydration, observation and possible
evacuation of hematoma.
Past Medical History:
PMH:Right frontal convexity meningioma,Hypertension,
Arthritis,GERD,Spinal stenosis, Afib
PSH:L partial mastectomy,Cataract surgery in ___
prior hip operations with additional revisions
Social History:
She lives with her sister who is ___. No tobacco. Lifelong
non-smoker. No EtoH. Widowed x ___ years. She lives in an
apartment in ___. She has a housekeeper. Her sister
drives. Her sister does the accounting for the house. She does
her own personal accounts.
She is independent of bathing but has been taking sponge baths
recently due to fear of falls.
Her son is her HCP: ___ - 1 ___
___ ___
ADLS: Indep of dressing ambulating hygiene eating toileting
IADLS:Indep shopping accounting telephone use food preparation
Lives with: family
Walks with a walker and a cane.
Fall last year
+ gait
+ Visual aides
- Dentures
Family History:
Parents are deceased- died at old age. Sister ___, brother ___.
Brother with arthritis. Her daughter, at age ___, has arthritis.
But her sons, ages ___ and ___, are healthy.
Physical Exam:
VS:98.6 75 125/70 18 97%RA
General - Awake and alert. NAD. Oriented x 3. Pleasantly
conversant.
Left Breast - L breast soft, with marked ecchymosis extends down
flank, hematoma is stable and resolving.
CV - RRR
Pulmonary-clear
ABD-soft, nontender,nondistended
Ext - WWP. No edema.
Pertinent Results:
___ 07:00AM BLOOD WBC-4.3 RBC-3.49* Hgb-10.3* Hct-30.4*
MCV-87 MCH-29.6 MCHC-34.0 RDW-15.7* Plt ___
___ 07:08AM BLOOD Hct-24.7*
___ 07:55AM BLOOD WBC-5.8 RBC-3.32* Hgb-10.0* Hct-28.3*
MCV-85 MCH-30.2 MCHC-35.4* RDW-15.4 Plt ___
___ 03:45PM BLOOD WBC-6.0 RBC-3.13* Hgb-8.9*# Hct-27.3*
MCV-87 MCH-28.5 MCHC-32.6 RDW-15.7* Plt ___
___ 11:30AM BLOOD ___
Brief Hospital Course:
Ms. ___ ___ h/o atrial fibrillation (on warfarin) s/p left
breast partial mastectomy for invasive ductal carcinoma
re-admitted POD 4 for symptoms of nausea and vomiting of unclear
etiology and was found to have a left breast hematoma. Ms.
___ was admitted for hydration, observation and possible
evacuation of hematoma .Ultimately,decision was made not to take
her to OR for evacuation as her left breast hematoma was stable
and resolving.
Hospital course by systems:
Neuro:pleasantly alert,conversant, notable for short term memory
loss. Mildly anxious, no agitation.
Cardiac: patient with Rate controlled Afib,HR 70's,mildly
hypotensive, SBP 90-100. orthostatic VS were negative. Her
cardiac medications were titrated,her Valsartan and Lasix was
discontinued. She continued on Metoprolol, Amlodipine and
remained normotensive (SBP 120's). Cardiology were consulted
regarding Coumadin therapy and risk/benefit indication given her
age and rate controlled afib. Per cardiology fellow, who spoke
with her cardiologist ___, who recommended
continuing holding Coumadin until her breast hematoma resolves
and until she is seen in outpatient cardiac clinic in
approximately ___ week.
Pulmonary: Patient remained stable from pulmonary standpoint.
GI/GU/FEN: Patient received IV fluids overnight and she was
heplocked on HD 2.She was started on a diet. Patient with
intermittent nausea/gas pain, She was started on simethicone and
PPI for GERD. HD 4,Patient with low urine output overnight,
voided 50 cc over 9 hours. Bladder scanned for 160 cc;
thereafter voided without any intervention.
Wound: Patient with resolving left breast hematoma.
ID: Patient remained afebrile and had no signs or symptoms of
wound infection.
HEME: Patient found to have acute anemia due to blood loss from
surgery. On, HD 3, she was transfused with 1 unit RBC for HCT
24.7, post transfusion HCT 30.4. stool guaiac negative.
Prophylaxis:Patient ambulated with cane and assistance by
nursing staff.
On HD 4, Ms. ___ was deemed stable for discharge to extended
care facility.
Medications on Admission:
1. Acetaminophen 1000 mg PO Q6H
Never exceed 4000 mg in 24 hours
2. Amlodipine 5 mg PO BID
3. Diazepam 5 mg PO QHS:PRN anxiety
4. Escitalopram Oxalate 10 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Metoprolol Tartrate 25 mg PO BID
7. Mirtazapine 7.5 mg PO QHS
8. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*15 Tablet Refills:*0
9. TraZODone 25 mg PO QHS:PRN insomnia
10. Valsartan 80 mg PO DAILY
11. Warfarin 3 mg PO DAILY16
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Escitalopram Oxalate 10 mg PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Metoprolol Tartrate 25 mg PO BID
5. Mirtazapine 7.5 mg PO QHS
6. Omeprazole 20 mg PO DAILY
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
8. Simethicone 80 mg PO TID
9. Acetaminophen 650 mg PO Q6H:PRN pain
10. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
11. TraZODone 25 mg PO QHS:PRN insomnia
12. Diazepam 5 mg PO QHS:PRN anxiety
13. Docusate Sodium 100 mg PO DAILY
14. Ferrous Sulfate 325 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Left breast hematoma secondary to anti-coagulation for atrial
fibrillation
2. Left Breast Cancer
3. Atrial Fibrillation
4. Spinal Stenosis with Gait unseteadiness
5. 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:
Discharge Instructions:
PERSONAL CARE:
1. Please wear surgical bra for support,keep your incision
covered with a clean, sterile gauze that you change daily.
2. You may shower daily with assistance as needed and pat your
incision dry.
ACTIVITY:
1. You may resume your regular diet.
2. Walk several times a day.
3. DO NOT lift anything heavier than 5 pounds or engage in
strenuous activity for 6 weeks following surgery.
MEDICATIONS:
1. Resume your regular medications and take any new medications
as ordered.
2. You may take your normal pain medication (Percocet) that you
regularly take at home. You may switch to Tylenol or Extra
Strength Tylenol for mild pain as directed on the packaging.
Please note that Percocet have Tylenol as an active
ingredient, so do not take these meds with additional Tylenol.
3. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
4. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
ANTICOAGULATION:
1. Your warfarin is on hold until you follow-up with your
outpatient cardiologist.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness,swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
___
|
10379484-DS-8 | 10,379,484 | 20,944,057 | DS | 8 | 2132-07-07 00:00:00 | 2132-07-07 15:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / albuterol / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Bilateral hip pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old female with a history of bilateral hip
replacement, hypertension and atrial fibrillation who presents
with bilateral hip pain after running out of her oxycodone, also
found to have possible RLL opacity concerning for pneumonia. Per
OMR, patient requested early oxycodone refill for ongoing hip
pain and was denied. She denies any recent trauma or falls and
ambulates with a walker.
In the ED, initial vital signs were: 98.5 89 146/64 18 97% RA.
Labs were notable for Lactate of 1.3, Cr of 1.2, H/H of ___
and WBC of 8.9. CXR showed a new medial right base opacity,
which may reflect pneumonia in the correct clinical setting. The
patient was given: Zofran 4mg X 1, CTX 1gm and Azithromycin
500mg, Oxycodone 5mg and Acetaminophen 1000mg X 1. Vitals prior
to transfer were: 99.8 93 117/64 16 92% RA.
Upon arrival to the floor, she reports the history above. She
also reports a cough but denies fevers, chest pain, shortness of
breath, abdominal pain, N/V/D.
REVIEW OF SYSTEMS: Reports bilateral hip pain and cough. Denies
fever, chills, CP, SOB, N/V/D.
Past Medical History:
PMH:Right frontal convexity meningioma,Hypertension,
Arthritis,GERD,Spinal stenosis, Afib
PSH:L partial mastectomy,Cataract surgery in ___
prior hip operations with additional revisions
Social History:
She lives with her sister who is ___. No tobacco. Lifelong
non-smoker. No EtoH. Widowed x ___ years. She lives in an
apartment in ___. She has a housekeeper. Her sister
drives. Her sister does the accounting for the ___. She does
her own personal accounts.
She is independent of bathing but has been taking sponge baths
recently due to fear of falls.
Her son is her HCP: ___ - ___ ___
___ ___
ADLS: Indep of dressing ambulating hygiene eating toileting
IADLS:Indep shopping accounting telephone use food preparation
Lives with: family
Walks with a walker and a cane.
Fall last year
+ gait
+ Visual aides
- Dentures
Family History:
Parents are deceased- died at old age. Sister ___, brother ___.
Brother with arthritis. Her daughter, at age ___, has arthritis.
But her sons, ages ___ and ___, are healthy.
Physical Exam:
ADMISSION PHYSICAL:
GENERAL: NAD, lying in bed
HEENT: NC/AT, no scleral icterus, PERRLA, EOMI
NECK: supple, no LAD
CARDIAC: RRR, normal S1/S2, no murmurs
PULMONARY: clear to auscultation without wheezing
ABDOMEN: soft, non-tender, non-distended
EXTREMITIES: warm, well-perfused, no edema
NEUROLOGIC: A&Ox3, CN II-XII grossly normal
DISCHARGE PHYSICAL:
VITALS: Tm98 BP110s/50s HR50s-70s 94RA
GENERAL: NAD, appears much younger than stated age
HEENT: NC/AT, no scleral icterus, PERRLA, EOMI
CARDIAC: RRR, II/VI systolic murmur at LSB, no rubs or gallops
PULMONARY: decreased right lower breath sounds but otherwise
CTAB
ABDOMEN: soft, non-tender, non-distended
EXTREMITIES: warm, well-perfused, no edema. Patient in hip brace
NEUROLOGIC: A&Ox3, grossly intact
Pertinent Results:
ADMISSION LABS:
___ 03:30AM ___ PTT-27.2 ___
___ 03:30AM PLT COUNT-184
___ 03:30AM NEUTS-87.2* LYMPHS-5.0* MONOS-6.8 EOS-0.1*
BASOS-0.1 IM ___ AbsNeut-7.78* AbsLymp-0.45* AbsMono-0.61
AbsEos-0.01* AbsBaso-0.01
___ 03:30AM WBC-8.9 RBC-3.87* HGB-11.0* HCT-33.5* MCV-87
MCH-28.4 MCHC-32.8 RDW-14.8 RDWSD-46.9*
___ 03:30AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 03:30AM estGFR-Using this
___ 03:30AM GLUCOSE-103* UREA N-31* CREAT-1.2* SODIUM-136
POTASSIUM-3.4 CHLORIDE-98 TOTAL CO2-25 ANION GAP-16
___ 03:41AM LACTATE-1.6
___ 03:41AM ___ COMMENTS-GREEN TOP
___ 06:30AM URINE MUCOUS-RARE
___ 06:30AM URINE RBC-2 WBC-110* BACTERIA-MOD YEAST-NONE
EPI-<1
___ 06:30AM URINE BLOOD-TR NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-6.0
LEUK-MOD
___ 06:30AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:30AM URINE UHOLD-HOLD
___ 06:30AM URINE HOURS-RANDOM
MICRO:
FLU A & B PCR - NEGATIVE
BLOOD CULTURE X 2 ON ___ NGTD
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING:
CXR ON ___
IMPRESSION: New medial right base opacity, which may reflect
pneumonia in the correct clinical setting.
HIP FILMS ___
There are bilateral extended total hip arthroplasty is in-situ.
There is
abundant callus formation around the proximal right femur with
cerclage wires seen at this site. There is bony buttressing
along the distal aspect of the femoral prosthesis. No acute
fracture seen. Moderate vascular calcification.
There is heterotopic ossification around the left hip joint. No
periprosthetic loosening or periprosthetic fracture seen.
Severe degenerative changes in the lumbar spine.
DISCHARGE LABS:
___ 06:07AM BLOOD WBC-6.7 RBC-4.12 Hgb-11.7 Hct-36.6 MCV-89
MCH-28.4 MCHC-32.0 RDW-15.1 RDWSD-48.8* Plt ___
___ 06:07AM BLOOD Glucose-83 UreaN-14 Creat-1.1 Na-143
K-4.1 Cl-103 HCO3-28 AnGap-16
___ 06:07AM BLOOD Calcium-9.2 Phos-2.8 Mg-2.3
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of bilateral
hip replacement who presents with bilateral hip pain after
running out of her oxycodone. Hospital course included treatment
for CAP and E. coli UTI.
#HIP PAIN: The patient has chronic bilateral hip pain and shares
she had run out of her oxycodone and presented to the ED for
pain control as her PCP did not refill it. Per her PCP, the
patient has been on this regimen of oxycodone for an extended
period of time, and it is unusual for her to run out and that is
why he did not refill it. She had an X-ray done of her pelvis
that showed no acute pathology as a cause for worsening pain,
and her pain was controlled was started back on the oxycodone.
Team spoke with the PCP, who will continue to follow her pain
management. She was also continued on home tramadol and a
lidocaine patch to the right hip was added to her pain regimen.
#CAP and UTI: Patient had also reported chills upon admission.
She had a CXR with a right medial base opacity, and urine
cultures were growing E coli. She was HDS with intact
respiratory status. She was initially started on
ceftriaxone/azithromycin for CAP, as ceftriaxone would also
cover UTI. Ceftriaxone was transitioned to levofloxacin. Once
urine cultures sensitivities returned, showing cipro resistance,
and she was given a third dose of ceftriaxone to complete a
total 3 day course for an uncomplicated UTI. Total CAP course
___ for five day course.
#Indigestion: the patient reports feelings of being "sick to her
stomach" but is unable to clarify further. EKG with no evidence
of ischemia. She denied any nausea/vomiting or pain and says
this is her baseline indigestion and her PCP confirmed this. She
was given maalox 30 ml QID prn and zofran 4 mg po q 8 h prn with
mild relief.
#Vaginal/rectal bleeding: Patient reports chronic vaginal and
rectal bleeding but declines any further workup. Further
discussion regarding evaluation of these sources of bleeding can
be held with her PCP as an outpatient.
#HYPERTENSION: Continued home amlodipine and metoprolol.
#ATRIAL FIBRILLATION: Not on anticoagulation after discussion
with family and PCP, may be secondary to age vs other
comorbidities. Continued home Metoprolol tartrate 25 mg BID.
#GERD: Continued home Omeprazole.
#Depression: Continued home escitalopram and mirtazapine.
#Asthma: Continued home flovent.
#Iron deficiency anemia: as above, patient has declined further
workup. Continued ferrous sulfate.
TRANSITIONAL ISSUES:
- Pain management with oxycodone for bilateral hip pain
- Last day of antibiotics levofloxacin/azithromycin for CAP:
___
- Patient had reported chronic vaginal bleeding, but said she
does not desire further workup. Continue to follow.
- Discuss whether or not patient would benefit from
anticoagulation for afib
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amlodipine 5 mg PO DAILY
2. Escitalopram Oxalate 10 mg PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Metoprolol Tartrate 25 mg PO BID
5. Mirtazapine 7.5 mg PO QHS
6. Omeprazole 20 mg PO DAILY
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
8. Simethicone 80 mg PO TID
9. Acetaminophen 650 mg PO Q6H:PRN pain
10. TraMADol 25 mg PO Q6H:PRN pain
11. TraZODone 25 mg PO QHS:PRN insomnia
12. Diazepam 5 mg PO QHS:PRN anxiety
13. Docusate Sodium 100 mg PO DAILY
14. Ferrous Sulfate 325 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Docusate Sodium 100 mg PO DAILY
4. Escitalopram Oxalate 10 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Metoprolol Tartrate 25 mg PO BID
8. Mirtazapine 7.5 mg PO QHS
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Simethicone 80 mg PO TID
12. TraMADol 25 mg PO Q6H:PRN pain
13. Vitamin D 1000 UNIT PO DAILY
14. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
belching/dyspepsia
15. Azithromycin 250 mg PO Q24H Duration: 4 Doses
16. Levofloxacin 750 mg PO Q48H
17. Lidocaine 5% Patch 1 PTCH TD DAILY
18. Polyethylene Glycol 17 g PO DAILY
19. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth q6h
prn Disp #*20 Tablet Refills:*0
20. TraZODone 25 mg PO QHS:PRN insomnia
21. Diazepam 5 mg PO QHS:PRN anxiety
RX *diazepam 5 mg 1 tablet by mouth qhs prn Disp #*5 Tablet
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
Chronic bilateral hip pain
Community acquired pneumonia
Urinary tract infection
SECONDARY DIAGNOSES
Nausea
Hypertension
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at the ___. You were admitted
for management of your hip pain. Your pain was managed well with
oxycodone. You will continue to follow up with your primary care
physician for pain control.
In addition, you had signs and symptoms concerning for both a
pneumonia (lung infection) and for a urinary tract infection.
You were treated with antibiotics and felt better.
We wish you the best of luck in your health.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10379635-DS-9 | 10,379,635 | 28,777,948 | DS | 9 | 2154-07-16 00:00:00 | 2154-07-16 11:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / hydrochlorothiazide
Attending: ___.
Chief Complaint:
Cough, myalgias
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with medical history notable for severe COPD,
colonic adenoma, CAD, CHF (LVEF 30% to 35% s/p ICD), HTN, HLD
who
presents with two days of flu-like symptoms as well as one day
of
substernal burning that worse with activity. Symptoms began two
days ago and include cough, congestion, body aches, fever,
shortness of breath, and rhinorrhea. He also reports new onset
substernal burning that is worse with activity. Burning is not
similar to prior MI and is not associated with food. He reports
some orthopnea, no lower extremity swelling.
In the ED, initial vital signs were 100.2 96 168/80 18 94% RA.
Exam showed bilateral rhonchi, bibasilar crackles. JVP was not
elevated. There is no was no edema. Labs showed K 5.4, Cr 1.1,
BNP 592, bicarbonate 20, anion gap 18. Testing was positive for
influenza A. Patient was provided albuterol nebulizers,
ipratropium and tiotropium, oseltamivir 75 mg x 1, carvedilol
3.125 mg x 1, aspirin 81 mg x 1, acetaminophen 1000 mg x 1, and
fluticasone-salmeterol diskus. CXR showed now edema and
hyperinflated lungs.
Currently, the patient feels better. He is not short of breath,
with no chest pain, no myalgias, no fever. There are no
reported
sick contacts. He received his flu shot this year.
Review of systems:
10 pt ROS negative other than noted.
PAST MEDICAL HISTORY:
-CAD: Cath ___ with severe RCA and LCx disease not
amenable
to PCI and moderate LAD disease.
-CARDIOMYOPATHY: LVEF 35%, s/p ICD.
-ALCOHOL ABUSE - started at age ___ -- increased to 1 case
beer/day; stopped drinking at age ___ after inpt detox, AA.
Abstinent since.
-COLONIC POLYPS ___ colonoscopy-->single adenoma.
___ study normal. ___ study with 1
adenomatous, 1 hyperplastic polyp. Repeat ___ due ___ w/ Dr.
___.
-ERECTILE DYSFUNCTION
-HYPERTENSION
-HYPERCHOLESTEROLEMIA
-IRITIS
-LUNG NODULE - 3mm, seen on chest CT ___, stable on ___
repeat, new 1mm RUL nodule, recommended repeat CT in ___ year, All
nodules stable on ___ CT, likely granuloma, no need for further
surveillance
-SMOKING - quit ___
-CHRONIC OBSTRUCTIVE PULMONARY DISEASE - Severe
-DIVERTICULOSIS
MEDICATIONS AT HOME:
The Preadmission Medication list is accurate and complete
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Carvedilol 3.125 mg PO BID
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. albuterol sulfate 90 mcg/actuation INHALATION Q6H:PRN SOB,
wheezing
7. Cetirizine 10 mg PO DAILY:PRN allergies
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
9. Losartan Potassium 12.5 mg PO DAILY
10. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
11. Ibuprofen 800 mg PO DAILY:PRN Pain - Mild
ALLERGIES: hydrochlorothiazide
lisinopril (dizziness)
SOCIAL HISTORY: ___
FAMILY HISTORY:
Mother died of possible heart disease. Sister died of ovarian
cancer (age ___.
PHYSICAL EXAM:
Vitals: T: BP: P: R: O2:
GEN: Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP
clear, MMM.
Neck: Supple, JVP not elevated
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, bibasilar crackles,
scattered wheezes
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash.
Neuro: Cranial nerves ___ grossly intact, muscle strength ___
in
all major muscle groups, sensation to light touch intact,
non-focal.
PSYCH: Appropriate and calm.
LABS:
See below
STUDIES:
CXR on admission:
No acute cardiopulmonary process. Hyperinflated lungs.
Past Medical History:
HYPERTENSION
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
CONGESTIVE HEART FAILURE (EF 35% in ___
DIVERTICULOSIS
CORONARY ARTERY DISEASE
HYPERLIPIDEMIA
HYPERCHOLESTEROLEMIA
Social History:
___
Family History:
Mother died of possible heart disease. Sister died of ovarian
cancer (age ___.
Physical Exam:
Admission exam
100.3 132 / 71 85 20 94 RA
GEN: Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP
clear, MMM.
Neck: Supple, JVP not elevated
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, bibasilar crackles,
scattered wheezes
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash.
Neuro: Cranial nerves ___ grossly intact, muscle strength ___
in
all major muscle groups, sensation to light touch intact,
non-focal.
PSYCH: Appropriate and calm.
Discharge exam
97.9 135 / 84 71 18 95 Ra
gen: Thin male, well appearing, NAD
Lung: Diffuse end expiratory wheezes, no rhonchi, fair air
entry throughout.
Exam otherwise unchanged from admission
Pertinent Results:
___ 06:21AM BLOOD WBC-8.2 RBC-4.88 Hgb-14.4 Hct-43.9 MCV-90
MCH-29.5 MCHC-32.8 RDW-15.4 RDWSD-50.5* Plt ___
___ 06:10AM BLOOD WBC-5.2 RBC-4.84 Hgb-14.3 Hct-43.9 MCV-91
MCH-29.5 MCHC-32.6 RDW-15.6* RDWSD-51.7* Plt ___
___ 06:10AM BLOOD ___ PTT-31.9 ___
___ 06:21AM BLOOD Glucose-105* UreaN-22* Creat-1.1 Na-137
K-5.4* Cl-99 HCO3-20* AnGap-18
___ 06:10AM BLOOD Glucose-91 UreaN-12 Creat-0.9 Na-140
K-4.5 Cl-104 HCO3-25 AnGap-11
___ 06:21AM BLOOD cTropnT-<0.01 proBNP-592*
___ 06:10AM BLOOD ALT-29 AST-30 LD(LDH)-208 AlkPhos-75
TotBili-0.3
___ 06:10AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.1
___ 06:45AM OTHER BODY FLUID FluAPCR-POSITIVE*
FluBPCR-NEGATIVE
CXR
Single right ventricular lead is contiguous with a left chest
wall generator. Flattening of bilateral hemidiaphragms suggest
lung hyperinflation.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. Hyperinflated lungs.
Brief Hospital Course:
ASSESSMENT AND PLAN:
___ year old male with medical history notable for severe COPD,
colonic adenoma, CAD, CHF (LVEF 30% to 35% s/p ICD), HTN, HLD
who
presents with two days of flu-like symptoms.
# Influenza
# COPD: patient is high-risk flu case given chronic medical
conditions (CHF, COPD). BNP was in 500s and CXR without edema,
so unlikely to have volume overload component. He improved
rapidly with Tamiflu, and dyspnea resolved as did myalgias. He
was given standing bronchodilators but was not given steroids
for his COPD. He did remain somewhat symptomatic from cough,
so he will continue tessalon perles at home. His hypoxia
resolved. He was seen by ___ and was also cleared for discharge
home. He has five doses of Tamiflu treatment remaining. He was
also advised to use standing albuterol MDI for five days and
then to use prn dyspnea
# Chronic systolic heart failure
# CAD
# Hypertension: His carvedilol was continued, but losartan and
imdur held in the face of normotension during infection. His
pressures did start to rise as he was approaching discharge so
he was told to f/u with PCP before resuming imdur.
# Anion gap acidosis: lactate normal - AG acidosis resolved
greater than ___ hour spent on care on day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Carvedilol 3.125 mg PO BID
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. albuterol sulfate 90 mcg/actuation INHALATION Q6H:PRN SOB,
wheezing
7. Cetirizine 10 mg PO DAILY:PRN allergies
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
9. Losartan Potassium 12.5 mg PO DAILY
10. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
11. Ibuprofen 800 mg PO DAILY:PRN Pain - Mild
Discharge Medications:
1. OSELTAMivir 75 mg PO BID
2. Tessalon Perles (benzonatate) 100 mg oral Q12H:PRN
3. Albuterol Inhaler 2 PUFF IH Q8H
Use your albuterol inhaler 3 times a day for the next five days,
and then as needed.
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
7. Carvedilol 3.125 mg PO BID
8. Cetirizine 10 mg PO DAILY:PRN allergies
9. Ibuprofen 800 mg PO DAILY:PRN Pain - Mild
Use this sparingly as it can affect your kidney function
10. Losartan Potassium 12.5 mg PO DAILY
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
12. Tiotropium Bromide 1 CAP IH DAILY
13. HELD- Isosorbide Mononitrate (Extended Release) 30 mg PO
DAILY This medication was held. Do not restart Isosorbide
Mononitrate (Extended Release) until you see your PCP; right now
your blood pressure is not high and you do not need the
medication
Discharge Disposition:
Home
Discharge Diagnosis:
1. Influenza
2. COPD
3. Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted due to the flu and increased cough and
difficulty breathing. You have improved dramatically, and are
stable for discharge home.
You need to take five additional doses of Tamiflu to complete
your course. I have faxed a prescription to ___ on ___ in ___.
Please hold your blood pressure medicine isosorbide (imdur);
your blood pressures are not very elevated now due to infection,
and I want your PCP to check your blood pressure before you
resume taking the medication.
Followup Instructions:
___
|
10379765-DS-11 | 10,379,765 | 26,882,615 | DS | 11 | 2132-06-19 00:00:00 | 2132-06-19 11:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
groin pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PCP: unknown
CHIEF COMPLAINT: groin pain
HISTORY OF PRESENT ILLNESS:
___ male h/o R groin abscess s/p I&D on ___
complicated by 2 surgeries after that presents with R groin
pain. He was initially admitted to ___ in ___ and was on
vancomycin and augmentin and underwent I&D. He then went to ___
___ and had explroatory surgery and wide excision by Dr
___ urology given rapid progression of the infection.
There was necrotic gracillis muscle. There is question on if the
cultures grew MRSA or not (a note says it did however there is
not culture data in his OSH records). Subsequent notes state
wound grew MSSA pansensitive. He was discharged on linezolid and
dilaudid however per pt his insurance didnt cover linezolid so
it was switched to bactrim. Pt was readmitted ___ ___ for recurrent cellulitis and she underwent I&D for
necrotizing fascitis and required a wound vac and he was d/cd on
augmentin.
In the ED, initial vitals: 99.2 ___ 18 99% RA
- Labs notable for: WBC 11
- Imaging notable for: CT scan: Skin thickening and subcutaneous
soft tissue thickening along the right scrotum and right
inguinal region at the site of prior surgery, best seen on
series 3, image 39. This is likely due to a combination of
postsurgical changes with likely superimposed cellulitis. No
subcutaneous gas or fluid collection. Correlate clinically with
signs of infection.
- Pt given: vanc and zosyn
- Vitals prior to transfer:
Past Medical History:
R groin abscess ___ - multiple surgeries from urology
chronic pain
Social History:
___
Family History:
HTN, CAD, CVA in mother and grandparents
Physical Exam:
admission
99.2 ___ 18 99% RA
General: NAD, obese
HEENT: EOMI
Lungs: clear to auscultation bl no crackles wheeze
CV: normal S1 S2 RRR no GCMR
Abdomen: nontender pos BS
GU: R scrotum with scar tissue, tenderness
Ext: warm
Neuro: ambulates, moves all extremities
d/c vitals wnl and exam unchanged, groin area not tender
Pertinent Results:
___ 09:05AM BLOOD WBC-11.4* RBC-5.11 Hgb-14.8 Hct-42.7
MCV-84 MCH-29.1 MCHC-34.8 RDW-14.2 Plt ___
___ 09:05AM BLOOD Neuts-63.5 ___ Monos-4.7 Eos-1.8
Baso-0.5
___ 09:05AM BLOOD Glucose-99 UreaN-11 Creat-1.2 Na-140
K-3.9 Cl-101 HCO3-28 AnGap-15
___ 09:05AM BLOOD Plt ___
___ 09:05AM BLOOD Glucose-99 UreaN-11 Creat-1.2 Na-140
K-3.9 Cl-101 HCO3-28 AnGap-15
___ 09:21AM BLOOD Lactate-1.7
___ CT abd and pelvis
Skin thickening and subcutaneous soft tissue thickening along
the right scrotum and right inguinal region at the site of the
prior surgery, probably due to a combination of postsurgical
changes with likely superimposed cellulitis. No subcutaneous gas
or focal fluid collections.
___ scrotum u/s
diffuse edematous changes within the R hemiscrotum and soft
tissues no drainable fluid collection
___ MRI pelvis with and without gad
diffuse extensive edema involving subcutaneous and superficial
soft tissue of the right inguinoscrotal region extending to the
scrotum. No loculated fluid collection is seen. On MRI
examination it is difficult to exclude presence of soft tissue
gas. The deeper soft tissues in teh right hip, right thigh, and
pelvis are not involved. b/l testes are unremarkable. These
findings are consistent with cellulitis and soft tissue
osteomyelitis possiblility is Fourier's gangrene is not excluded
___ MRI
diffuse extensive soft tissue swelling and subcutaneous edema
invlving the right inguinal region which is less severe than
prior study compatiblie with patient's history of drainage.
However interval extension to the medial gluteal region and
perianal region on the right not seen on prior study. Interval
development of fluid collection in the right groin measuring 2 x
3 x 4.5cm with peripheral rim enhancement. This may be related
to abscess versus seroma. Again foutnier's ganagrene cannot be
excluded. clinical correlation is recommended.
Brief Hospital Course:
___ male h/o R groin abscess s/p I&D on ___
complicated by persistent infection requiring wide excisional
surgery and wound vac in ___ presents with R groin pain
concerning for cellulitis.
#R groin Cellulitis: CT abd and pelvis showed superimposed
cellulitis without subcutaneous gas or focal fluid collections.
Given concern that prior wound grew MRSA he was treated with
vancomycin/Unasyn. He will be discharged on Bactrim/Augmentin
for a total of ___nd will find a new PCP at ___. He
is not interested in seeing his prior urologist from ___
___ and after establishing care at ___ he can then find
a new urologist if needed. He was also discharged on miconazole
powder to help keep the area dry and treat any fungal element
that may be present.
#Chronic pain: He was continued on Ultram. He was instructed pt
to stop naproxen which he has taken daily for months given the
potential side effects including stomach ulcers and kidney
damage.
#OSA: pt reports OSA for years and he usually takes Flonase and
cetirizine which he says helps. I explained to him that he needs
CPAP
transitional issues:
#he needs CPAP mask for OSA
#f/u on groin cellulitis
#outside records re his scrotal cellulitis and surgeries will be
scanned into OMR
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
2. Gabapentin 400 mg PO BID
3. Naproxen 500 mg PO Q8H:PRN pain
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 13 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*26 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q8H Duration: 13 Days
RX *amoxicillin-pot clavulanate 250 mg-125 mg 1 tab by mouth
every eight (8) hours Disp #*39 Tablet Refills:*0
3. Gabapentin 400 mg PO BID
4. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
5. Miconazole Powder 2% 1 Appl TP BID:PRN yeast in groin
RX *miconazole nitrate [Zeasorb (miconazole)] 2 % apply powder
to groin twice a day Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
priamry: cellulitis
secondary: OSA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure caring for you here at ___. You came in
because you had cellulitis in your groin. You were treated with
IV antibiotics and you started to feel better. We want you to go
home on oral antibiotics and to followup with a primary care
doctor.
We hope you feel better,
___ team
Followup Instructions:
___
|
10380149-DS-5 | 10,380,149 | 27,748,450 | DS | 5 | 2121-05-07 00:00:00 | 2121-05-07 16:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Dyspnea on exertion / ___ edema
Major Surgical or Invasive Procedure:
___: Cardiac catherization
History of Present Illness:
Mr. ___ is a ___ yo male with severe aortic stenosis ___ of
0.681 cm2) who was transferred from ___ with worsening
dyspnea on exertion and ___ edema. Per patient he has developed
worsening DOE over the last few months where he can only walk 25
feet now, from a baseline of playing tennis three times per
week. Last evening he devloped orthopnea that caused him to
present to see his NP at ___, who recommended that he
present to the emergency department. He also describes one week
of productive cough, as well as fevers and chills last evening.
At ___ he had a CXR that showed pulm edema w/ a possible
R bilobar PNA for which he received ceftriaxone, azithro. No
lasix was given as his pressures were soft (SBP of 103). HR's
also noted to be in the 40's (in afib). Labs notable for a BNP
of 15,236, troponin of 0.045, INR of 1.4.
Pt was transferred to ___ for aortic valve replacement and
pacer evaluation. Per report his cardiologist in ___ not
comfortable performing procedure.
In the ED, initial vitals were 97.8 44 120/56 24 97%.
On the floor patient is very conversant and comfortable.
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, hemoptysis, black stools
or red stools. He denies exertional buttock or calf pain. All of
the other review of systems were negative.
Past Medical History:
- Severe aortic stenosis
- atrial fibrillation on coumadin
- HTN
- Glaucoma
Social History:
___
Family History:
His mother died of TB when he was age ___. His father had
bladder cancer. He has no brothers or sisters. He was
accompanied on today's visit by his son.
Physical Exam:
Physical Exam:
VS: T= 97.6 BP= 117/50 HR= 52 RR= 22 O2 sat= 97% RA
General: nad, lying comfortably
HEENT: no oral erythema
Neck: JVP elevated to halfway to the ankle of the mandible
CV: Bradycardic, ___ crecendo descrecendo best heard at the LUSB
Lungs: Crackles bilaterally at the bases
Abdomen: soft, nontender, nondistended
Ext: 1+ pitting edema to the shin
Pertinent Results:
Labs on admission:
___ 08:55PM BLOOD WBC-6.7 RBC-4.31* Hgb-12.5* Hct-39.8*
MCV-93 MCH-29.1 MCHC-31.5 RDW-14.0 Plt ___
___ 08:55PM BLOOD ___ PTT-36.3 ___
___ 08:55PM BLOOD Glucose-193* UreaN-32* Creat-1.7* Na-136
K-3.8 Cl-98 HCO3-28 AnGap-14
___ 08:55PM BLOOD ALT-48* AST-31 AlkPhos-92 TotBili-0.3
___ 08:55PM BLOOD Calcium-8.3* Phos-3.3 Mg-2.0
___ 03:38PM BLOOD Lactate-1.6
Labs on discharge:
___ 06:10AM BLOOD WBC-6.3 RBC-3.88* Hgb-12.0* Hct-35.7*
MCV-92 MCH-30.8 MCHC-33.5 RDW-14.0 Plt ___
___ 06:10AM BLOOD ___ PTT-33.5 ___
___ 06:10AM BLOOD Glucose-102* UreaN-19 Creat-1.3* Na-140
K-3.9 Cl-103 HCO3-28 AnGap-13
___ 06:10AM BLOOD Albumin-PND Calcium-8.9 Phos-3.7 Mg-2.1
Cardiac catherization ___:
1. Mild coronary artery disease
2. Patent distal abdominal aorta, iliac and CF arteries
bilaterally
ECHO ___:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (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 are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Critical aortic valve stenosis. Symmetric LVH with
normal global and regional biventricular systolic function. Mild
mitral regurgitation.
Brief Hospital Course:
Mr. ___ is a ___ yo male with severe aortic stenosis ___ of
0.681 cm2) who was transferred from ___ with worsening
congestive heart failure symptoms as well as pneumonia.
# Severe Aortic stenosis: ECHO on ___ confirmed critical AS
with valve area of 0.7 cm2. Given that he was symptomatic with
DOE and ___ edema he underwent evaluation for valve repair by
cardiac surgery and TAVR team. Cardiac cath and CT scan were
performed. Afterwards cardiac surgery decided that he was not a
candidate for surgical repair. He will therefore undergo a TAVR
with Dr. ___ in the near future. Pt was discharged with prn
lasix as needed for weight gain.
# Pneumonia - Pt described one week of increasing sputum
production, as well as fevers and chills. Given clinical
symptoms and concern for consolidation on CXR he was treated
with ceftriaxone and azithromycin x 7 days.
# Atrial fibrillation - Pt with slow a fib with rates in the
40's on admission. His beta-blocker was held and HR's increased
to 50's and 60's. He was discharged on coumadin.
# HTN: continued amlodpine, held metoprolol as above
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
please hold for sbp<100
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Multivitamins 1 TAB PO DAILY
6. Warfarin 4 mg PO DAILY16
7. Furosemide 20 mg PO DAILY
8. Ferrous Sulfate 325 mg PO TID
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Ferrous Sulfate 325 mg PO TID
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. Multivitamins 1 TAB PO DAILY
5. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
6. Warfarin 4 mg PO DAILY16
7. Azithromycin 250 mg PO Q24H Duration: 3 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
8. Furosemide 20 mg PO PRN weight gain greater than 3 pounds
9. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 3 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Critical Aortic stenosis
Secondary:
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization at ___. You
were admitted with shortness of breath and leg swelling that
resulted from your aortic stenosis, as well as pneumonia. You
had an evaluation for a valve replacement and this will be
performed by Dr. ___ in the next few weeks. You were also
treated for pneumonia, for which you will need to take another
three days of antibiotics.
It was pleasure taking care of you and good luck with the
upcoming valve replacement!
Followup Instructions:
___
|
10380149-DS-8 | 10,380,149 | 24,423,561 | DS | 8 | 2123-08-16 00:00:00 | 2123-08-16 12:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Status post fall on coumadin with left buttock hematoma, left
ninth rib fracture, stable small hemothorax.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Mr. ___ is a ___ yo male with a history of afib and
aortic
stenosis s/p TAVR on warfarin presenting after a mechanical fall
earlier today. At 1450 today, he was walking down stairs at his
swimming facility when the bag he was carrying began to slip off
his shoulder. As he was trying to catch the bag, he tripped and
fell down ___ stairs, landing on his back and left side. He was
on the ground very briefly before staff assisted him and called
EMS which transported him to ___. At the time, he only
noted pain in his back and left arm. He remembers the event
fully
and denies any loss of consciousness. He denies striking his
head, headache, vision changes, or dizziness. He did not
experience any shortness of breath or chest pain. He does
endorse
easy bruising secondary to warfarin anticoagulation.
At ___, he underwent CT head, c-spine, and torso which
revealed left ___ and 10th rib fractures. He also had a right
arm
laceration repaired and a left thigh hematoma with possible
active extravasation on imaging. His pain was well controlled
with morphine. Transferred to ___ for trauma evaluation.
At time of consultation, pt AFVSS without respiratory distress,
soft left thigh hematoma without distal neurovascular changes,
stable pelvis and hematocrit of 32 from 38 in the setting of
aggressive resuscitation.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia,
(-)Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Severe aortic stenosis
Atrial fibrillation (on coumadin)
Hypertension
Glaucoma
Hernia
Hx of pressure ulcers on coccyx
Social History:
___
Family History:
His mother died of TB when he was age ___. His father had
bladder cancer. He has no brothers or sisters. No family
history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
VITAL SIGNS:
Temp Tm 98.5 Tc 97.9 HR 70 BP 109/46 RR 18 O2100RA
General: NAD, alert and oriented x3
HEENT: No scleral icterus. Moist mucous membranes.
NECK: No JVD. Carotids 2+, brisk, and without bruits.
CARDIAC: Regular rate and rhythm. Normal S1 and S2. ___ systolic
murmur heard at the apex.
ABDOMEN: Soft, nontender, nondistended. Normoactive bowel
sounds.
EXTREMITIES: 2+ bilateral pitting edema in UE and ___.
Pertinent Results:
___ 11:07PM PLT COUNT-205
___ 11:07PM ___ PTT-38.0* ___
___ 11:07PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:35PM HCT-27.8*
___ 10:00AM GLUCOSE-138* UREA N-34* CREAT-1.4* SODIUM-139
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-23 ANION GAP-20
___ 10:00AM CALCIUM-8.4 PHOSPHATE-5.3* MAGNESIUM-2.1
___ 10:00AM WBC-13.7* RBC-3.08* HGB-9.3* HCT-28.8* MCV-94
MCH-30.2 MCHC-32.3 RDW-15.2 RDWSD-51.3*
___ 10:00AM PLT COUNT-181
___ 10:00AM ___ PTT-34.1 ___
___ 05:36AM HCT-30.3*
___ 02:11AM HCT-31.2*
___ 11:07PM GLUCOSE-125* UREA N-31* CREAT-1.3* SODIUM-136
POTASSIUM-5.7* CHLORIDE-98 TOTAL CO2-22 ANION GAP-22*
Brief Hospital Course:
This is a ___ coumadin (AVR) s/p mechanical fall, ___ hsp
CThead/cspine/torso notable for L9/10nd rib fx, L thigh hematoma
with extravasation. The patient has the following comorbidities:
PMH: HTN, atrial fibrillation, aortic stenosis s/p TAVR. The
patient had significantly blood loss with drop in hematocrit
from 30 to 24 and has coagulopathy given use coumadin prior to
admission. The patient has CKD with creat near 2.0 and is at
risk for ongoing blood loss, potential hypotension and worsened
renal failure and elevated risk of stroke with any need for
interruoption of anticoagulation. THe plan of care includes:
monitoring blood counts and clinical exam and transfusing RBCs
if indicated and obtaining ___ consult.
On ___ patient was discharged to rehab hospital in stable
condition given the level of care he agreed to accept.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Furosemide 20 mg PO EVERY OTHER DAY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
5. Warfarin 8 mg PO 3X/WEEK (___)
6. Warfarin 7 mg PO 4X/WEEK (___)
7. Aspirin 81 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. potassium gluconate 550 mg (90 mg) oral DAILY
10. Multivitamins 1 TAB PO DAILY
11. Garlic-X (garlic) 400 mg oral DAILY
Discharge Medications:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Furosemide 20 mg PO EVERY OTHER DAY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
5. Warfarin 8 mg PO 3X/WEEK (___)
6. Warfarin 7 mg PO 4X/WEEK (___)
7. Aspirin 81 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. potassium gluconate 550 mg (90 mg) oral DAILY
10. Multivitamins 1 TAB PO DAILY
11. Garlic-X (garlic) 400 mg oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Status post fall with injury
Discharge Condition:
Stable
Discharge Instructions:
* Your injury caused slightly displaced fracture of the left
9th rib fractures which can cause severe pain and subsequently
cause you to take shallow breaths because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10380647-DS-11 | 10,380,647 | 25,877,663 | DS | 11 | 2169-05-20 00:00:00 | 2169-05-20 18:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
withdrawal
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Mr. ___ is a ___ yo M w/ HIV on HAART, HCV cirrhosis s/p 2
cycles of treatment, and polysubstance abuse who was referred by
PCP for concern for withdrawal as well as new onset word finding
difficulty.
Patient endorses hx of methadone, IV fentanyl, cocaine and
benzodiazapine use that were discontinued approximately 12 days
prior to presentation. Patient states he had previously been
participating in a ___ clinic where he had a contact that
providing him with recreational drugs. He states he had been
using methadone for many years, however, had only started IV
fentanyl and cocaine fairly recently. Patient left clinic
approximately 12 days ago and has not used any of the above
substances since. Since ceasing use of recreational drugs,
patient has been having intermittent nausea and vomiting,
associated with constipation (last bowel movement five days
prior) as well as insomnia. Endorses significant dyspnea with
minimal exertion. No seizures, visual changes, loss of
consciousness.
Patient presented to ___ for scheduled appointment earlier today
and was noted to have new word finding difficulty as well as
auditory hallucinations, with exam notable for hypertension with
systolic>190. Given concerns for possible endocarditis with
septic emboli given neuro deficits, he was transferred to ED.
- Initial vital signs were notable for T 99.0, HR 65, BP 192/92,
RR 18, SpO2 100% RA
- Exam notable for: tremulous, non focal neuro exam
- Labs were notable for:
WBC: 18.0 -> 16.5
Hgb: 10.9 -> 9.7
Chem: K 3.1, Cl 111, HCO3 21, BUN 25, Cr 1.3, Mg 1.3, P 2.6
Lactate: 1.2
- Studies performed include:
CXR: No acute intrathoracic process.
CTH: No acute infarction observed
Blood culture, HBV/HCV, HIV studies pending
- Patient was given 2L NS, 40 mEq KCl, and 400mg Magnesium Oxide
Upon arrival to the floor, patient denies symptoms and endorses
the above history. States he is having word finding difficulty
for last 2 weeks and has never experienced this before, but
otherwise feels "sharp"
Past Medical History:
-Polysubstance use disorder
-HIV:HIV viral load that is
detectable less than 20 and a CD4 count of 735
-HCV s/p treatment x2:chronic hepatitis C genotype 1A, on Vosevi
of week ___. He is on Vosevi from ___ through ___ with an SVR date of ___.
-Hypertension
-CKD: Baseline 1.4
-Anxiety
-Hypothyroidism
-Seasonal allergies
Social History:
___
Family History:
Father: ___ at ___ ___ to MI, hx of lung cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
PHYSICAL EXAM:
VS-98.3; BP: 163/80; HR: 75; RR: 16;
GEN- tremulous, alert but having difficulty with word finding
HEENT- PERRLA, EOMI with bilateral nystagmusTongue fasiculations
CV- RRR, normal S1S2, no murmurs appreciated
Lungs: CTAB
Abdomen: Nontender nondistended
Neuro: CN II-XII intact. Slight left sided eyelid droop,
otherwise no abnormalities observed. Strength ___ upper and
lower extremities, intention tremor on finger to nose. ___
stroke scale testing.
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 721)
Temp: 98.4 (Tm 98.8), BP: 179/63 (131-180/63-100), HR: 80
(80-103), RR: 20 (___), O2 sat: 98% (95-99), O2 delivery: Ra
GEN- tremulous, alert, no appreciable word finding difficulty on
exam but patient endorsing presence of it
HEENT- PERRLA, EOMI
CV- RRR, normal S1S2, no murmurs appreciated
Lungs: CTAB
Abdomen: Nontender nondistended
Neuro: CN II-XII intact. Slight left sided eyelid droop,
otherwise no abnormalities observed. Strength ___ upper and
lower
extremities. ___ stroke scale testing.
Pertinent Results:
ADMISSION LABS:
___ 11:35AM BLOOD WBC-18.0* RBC-3.63* Hgb-10.9* Hct-34.0*
MCV-94 MCH-30.0 MCHC-32.1 RDW-15.6* RDWSD-52.6* Plt ___
___ 11:35AM BLOOD Neuts-77.8* Lymphs-16.1* Monos-5.1
Eos-0.3* Baso-0.2 Im ___ AbsNeut-14.00* AbsLymp-2.89
AbsMono-0.92* AbsEos-0.06 AbsBaso-0.03
___ 11:35AM BLOOD Glucose-110* UreaN-25* Creat-1.3* Na-147
K-3.1* Cl-111* HCO3-21* AnGap-15
___ 11:35AM BLOOD ALT-15 AST-19 AlkPhos-83 TotBili-0.5
___ 11:35AM BLOOD Albumin-3.6 Calcium-8.1* Phos-2.6*
Mg-1.3*
PERTINENT LABS:
___ 02:30AM BLOOD CK(CPK)-37*
___ 11:35AM BLOOD Lipase-61*
___ 02:30AM BLOOD HAV Ab-POS*
___ 02:30AM BLOOD HIV1 VL-Detected <
___ 04:20PM BLOOD Lactate-1.2
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-10.6* RBC-3.52* Hgb-10.5* Hct-32.8*
MCV-93 MCH-29.8 MCHC-32.0 RDW-15.9* RDWSD-54.2* Plt ___
___ 07:20AM BLOOD Glucose-93 UreaN-21* Creat-1.2 Na-148*
K-3.7 Cl-112* HCO3-22 AnGap-14
___ 07:20AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.0
MICRO:
___ 12:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
==========================================================
___ 3:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
==========================================================
___ 11:35 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
==========================================================
___ 4:10 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
==========================================================
IMAGING/RESULTS:
CXR ___:
No acute intrathoracic process.
NCHCT ___:
No acute intracranial process.
MRI HEAD W/ AND W/O CONTRAST ___:
1. No evidence of acute infarction, hemorrhage or intracranial
mass.
2. Nonspecific patchy white matter changes in the cerebral
hemispheres bilaterally, likely sequela of chronic small vessel
ischemic changes.
TTE ___:
The left atrial volume index is normal. 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. Normal right ventricular cavity size with normal free
wall motion. The aortic sinus diameter is normal for gender. The
aortic arch diameter is normal. The aortic valve leaflets (3)
are mildly thickened. No masses or vegetations are seen on the
aortic valve. There is no aortic valve stenosis. There is trace
aortic regurgitation. The mitral valve leaflets are mildly
thickened with no mitral valve prolapse. No masses or
vegetations are seen on the mitral valve. There is trivial
mitral regurgitation. The tricuspid valve leaflets appear
structurally normal. No mass/vegetation are seen on the
tricuspid valve. There is physiologic tricuspid regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: No 2D echocardiographic evidence for endocarditis.
Normal biventricular cavity sizes and regional/global
biventricular systolic function. Normal estimated pulmonary
artery systolic pressure. Compared with the prior TTE (images
not available for review) of ___, the findings are
similar.
Brief Hospital Course:
Mr. ___ is a ___ yo M with a history of HIV, hepatitis C with
recurrence secondary to IVDU s/p ___ treatment with Vosevi
referred to ___ by PCP for concern for possible opioid and
benzodiazepine withdrawal and work up notable for leukocytosis.
ACUTE PROBLEMS:
=========================
#Leukocytosis
Patient found to have a WBC count of 18.0 in the ED. Infectious
work up with CXR, UA, and blood cultures were unrevealing. TTE
was performed for evaluation of endocarditis which showed no
evidence of vegetations. Patient was initially started on broad
spectrum abx with ceftriaxone/vancomycin. These were
discontinued after 48 hours as cultures remained negative. WBC
downtrended during hospitalization with discharge WBC count of
10.6.
#Word Finding Difficulty
Patient describes having word finding difficulty which was
appreciated by his PCP during his office visit. Given his
history of IV substance use, there was concerns for possible
infectious etiology. Patient had NCHCT and MRI without evidence
of strokes or infectious etiology to explain his word finding
difficulty. Word finding difficulty appeared to improve on its
own during hospitalization and was not appreciated at time of
discharge.
#Polysubstance use disorder
#Concerns for withdrawal
Patient with history of polysubstance use disorder (opioids and
cocaine). Patient discontinued use of substances a few weeks
prior to presentation. During his admission, he was initially
monitored on CIWA and ___ but these were discontinued as it was
felt he was outside of the acute withdrawal window. Addiction
psychiatry was consulted during hospitalization and started on
Suboxone during the hospitalization. He plans to follow up with
addiction psychiatry as an outpatient.
#Hypertension
SBPs in 160-180s throughout his hospitalization. He was started
on amlodipine 5mg with plans to continue as an outpatient.
CHRONIC PROBLEMS:
==========================
# HIV
HIV VL undetectable at last check. CD4 > 700 at last check.
Remained on home Triumeq. HIV VL checked during hospitalization
and was pending at time of discharge.
# History of hypothyroidism- euthyroid clinically and by report
off medications.
TRANSITIONAL ISSUES:
==========================
[] follow up HIV VL
[] patient started on Suboxone during the hospitalization - has
outpatient follow with OBOT on ___
[] started amlodipine during hospitalization - consider
uptitration pending BP as outpatient
[] recheck Na at follow up as mildly hypernatremic at time of
discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO Q6H:PRN pain
2. ClonazePAM 1 mg PO TID
3. Methadone 70 mg PO ONCE
4. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral
DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL BID
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
6. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral
DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Leukocytosis
Word finding difficulty
Polysubstance use disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization!
WHY WERE YOU ADMITTED?
- You were having word finding difficulties.
- There was concern that you might have an infection.
WHAT HAPPENED DURING YOUR HOSPITALIZATION?
- You were started on antibiotics given concern for infection.
These were stopped after two days as we could not find any
source of infection.
- You had imaging of your head (CT and MRI) which did not show
any reason for your word finding difficulty.
- You were started on Suboxone during your hospitalization.
WHAT SHOULD YOU DO ONCE YOU GET HOME?
- Continue taking all of your medications as prescribed.
- Follow up with your doctors as ___ below.
Again, it was a pleasure.
All the best,
Your ___ Team
Followup Instructions:
___
|
10380837-DS-11 | 10,380,837 | 25,027,752 | DS | 11 | 2178-02-25 00:00:00 | 2178-02-25 10:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / lisinopril / lorazepam
Attending: ___.
Chief Complaint:
Pain, fevers
Major Surgical or Invasive Procedure:
Placement of percutaneous nephrostomy tube
History of Present Illness:
Patient is a ___ y/o male with dementia, bedbound (s/p left sided
BKA for PVD), BPH (has suprapubic tube), atrial fibrillation
(not anticoagulated) who has a history of recurrent UTIs. He
had developed UTIs at his ___ (___ and had
received courses of antibiotics. However, he started to
complain of left sided pain, and CT scan showed left sided
kidney stone. His ___ providers were working on getting him here
for lithotripsy or PCN, when he became acutely ill with T of 101
on ___. He was taken to ___ where BP "99/83" and
rectal temp was 103.3. He was given IV antibiotics and
transferred to ___ where he was seen by urology. CT scan
showed obstructing left sided renal stone at Left UPJ with
evidence of pyelonephritis. Thick urine, ? "purulent" vs
viscous drained from suprapubic catheter.
He is a poor historian given his dementia, but with his daughter
at the bedside, he denies nausea, vomiting or pain at the
present time. No abdominal pain or diarrhea.
Past Medical History:
1. BPH with suprapubic tube
2. Dementia
3. s/p L BKA for PVD
4. Atrial fibrillation
5. CHF
6. Cirrhosis
7. H/o gastric ulcer
8. H/o ischemic stroke
Social History:
___
Family History:
Non contributory.
Physical Exam:
98.8 128/93 ___
Gen: Elderly male, pleasant, lying in bed comfortably
Lung: CTA B
CV: RRR, no m/r/g
Abd: mild distension, soft, nabs
Ext: left BKA, right leg warm, 2+ DP pulses
neuro: AOX1, not aware of location, year.
Pertinent Results:
___ 10:45PM BLOOD WBC-13.1* RBC-2.78* Hgb-8.8* Hct-29.0*
MCV-104* MCH-31.7 MCHC-30.3* RDW-13.5 RDWSD-52.1* Plt ___
___ 03:05AM BLOOD ___ PTT-32.6 ___
___ 10:45PM BLOOD ALT-27 AST-57* AlkPhos-122 TotBili-0.5
___ 10:45PM BLOOD Albumin-2.1* Calcium-7.1* Mg-1.8
___ 08:50AM BLOOD WBC-8.0 RBC-2.94* Hgb-9.2* Hct-30.4*
MCV-103* MCH-31.3 MCHC-30.3* RDW-14.5 RDWSD-55.0* Plt ___
___ 08:50AM BLOOD Glucose-105* UreaN-7 Creat-0.9 Na-139
K-4.1 Cl-108 HCO3-27 AnGap-8
___ ___ Blood culture: E Coli, resistant to
cephalosporins, sensitive to zosyn
Coag negative staph
___ blood culture: NGTD
Urine cx
FLUID CULTURE (Final ___:
ESCHERICHIA COLI. >10,000 CFU/ML.
Cefepime sensitivity testing confirmed by ___.
PROTEUS MIRABILIS. > 10,000 CFU/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| PROTEUS MIRABILIS
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 4 S 8 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 2 S <=1 S
CEFTAZIDIME----------- 4 S <=1 S
CEFTRIAXONE----------- =>64 R <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R <=1
Ct scan report
LOWER CHEST: The imaged lung bases demonstrate mild bibasilar
atelectasis,
but no consolidation or large pleural effusion. The heart is
moderately
enlarged with extensive coronary artery calcification but no
pericardial
effusion.
ABDOMEN:
HEPATOBILIARY: The liver is nodular in contour which suggests
cirrhosis.
Attenuation of the liver slightly heterogeneous. The portal
vein is patent.
The gallbladder is contracted containing hyperdensities within
the lumen
reflective of stones. There is no evidence cholecystitis.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding. Scattered pancreatic calcifications are seen,
indicative of
chronic pancreatitis.
SPLEEN: The spleen measures 12 cm in greatest dimension, with no
focal
lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The right kidney is normal in size with no
hydronephrosis or renal
stones. Scattered vascular calcifications are noted about the
right kidney.
The left kidney contains multiple hyperdensities reflective of
renal stones
with the largest in the renal pelvis measuring up to 2.8 cm.
There is
moderate hydronephrosis and moderate perinephric stranding. No
evidence of
forniceal rupture. The left kidney demonstrates a mildly
delayed nephrogram.
GASTROINTESTINAL: The stomach and small bowel are normal in
caliber without
obstruction the large bowel contains oral contrast from a prior
cross-sectional study, without evidence of colitis. Enlarged
left perinephric
lymph nodes are likely reactive.
VASCULAR: There is no abdominal aortic aneurysm. There is heavy
calcium burden
in the abdominal aorta and great abdominal arteries, most severe
at the SMA.
Isolated gastric varices are noted.
PELVIS: The urinary bladder is decompressed via a suprapubic
catheter. The
prostate is moderately enlarged. No pelvic lymphadenopathy or
free fluid.
BONES AND SOFT TISSUES: There is extensive degenerative change
at L5-S1 with
partial fusion of the vertebral bodies. Extensive facet
arthropathy is noted
bilaterally from L3 through S1. Endplate deformity at the
superior aspect of
the L1 vertebral body is likely secondary to a Schmorl's node.
No concerning
osseous lesions.
IMPRESSION:
1. Multiple left-sided renal stones including an obstructive
stone at the UPJ
measuring up to 2.8 cm resulting in moderate hydronephrosis,
perinephric
stranding, and a delayed nephrogram. Moderate left periureteral
stranding is
also seen. Findings are compatible with pyelonephritis.
2. Nodular heterogeneous liver compatible with cirrhosis, with
mild
perigastric varices.
3. Pancreatic parenchymal calcifications compatible with
chronic
pancreatitis.
4. Extensive atherosclerotic disease of the aorta and main
branches,
particularly the SMA.
Brief Hospital Course:
___ y/o male with dementia, bedbound s/p left-sided AKA, h/o of
suprapubic tube admitted with obstructing left sided renal
stone, pyelonephritis and sepsis.
# Sepsis
# Pyelonephritis
# Nephrolithiasis, left sided partially obstructing renal stone
# Bacteremia - E.coli and CNS at ___
Pt initiated on broad antibiotics (zosyn) and is now s/p
percutanous nephrostomy tube (pus expressed at placement) and is
now draining appropriately. He received ~___ntibiotic course, initially intended as a ___ut
his hospitalization was complicated by pt pulling at lines,
pulling PICC and peripheral IV. His last full antibiotic day
was ___ when he took Augmentin (instead of zosyn) due to
lost IV access. He was followed this admission by urology and
they felt that given his clinical stability, underlying
dementia, and the challenges administering medical care (refusal
intermittently of VS, IVs, lab draws), the best plan for now
would be to finish his antibiotics (now done) and f/u as an
outpt with urology. He will have nephrostomy tube changes with
___ q3-4 months, and the first one has been scheduled for ___
here at ___. He should also have regular changes of his
suprapubic catheter (BPH) and this should be done with his
outpatient urologist in ___ (appt scheduled)
Percutaneous nephrostomy tube should put out at least 100 cc of
urine a day; if it does not, please ask RN to flush it with ___
cc of sterile saline. If it still does not put out urine, it
may need to be repositioned by ___ contact for BI ___ is ___
___ and ___ can be reached at ___.
Should he develop any complications such as recurrent infection
or recurrent clogged nephrostomy tube, then urology may consider
a more definitive procedure for stone removal such as
percutaneous nephrolithotomy or even nephrectomy. (He will have
regular f/u with his urologist at ___, but
may be referred to ___ for any of the above complications)
# Dementia with delirium: this has improved, appears now at
baseline
# Diarrhea: stool test for C. diff negative on ___. Probably a
side-effect of zosyn (common adverse effect). Diarrhea has
resolved over several days.
# Anorexia, malnutrition - reportedly not eating much prior to
hospitalization. Likely multifactorial including acute
illness/infection, delirium, underlying dementia. Discussed
with son, who is aware that pt's nutrition remains an issue. We
discussed that the best approach to pts in this situation is
often gentle encouragement to take whatever po they can. No
plans for feeding tube (and is not clinically recommended in
advanced dementia)
# Hypophosphatemia, Hypomagnesemia, Hypocalcemia, Hypokalemia -
most likely due to very poor PO intake. Repleted prn.
# Stage II pressure ulcer on coccyx
- wound care per RN
# Atrial fibrillation: Rate controlled, not anticoagulated.
Continued on metoprolol. Appears he was taking metoprolol XL
prior to admission -- can consider switching back, but at this
time pt is intermittently refusing VS and po meds
# Goals of Care: **Remains FULL CODE*** Discussed with son.
He reports that pt has been DNR/DNI in the past and there were
several hospitalizations in which he appeared (or family was
told at least) that he was likely not going to survive.
However, each time he survived and bounced back. Son has
concluded after these
incidents that for now he should remain full code. He states he
does understand that DNR/DNI is not the same as "do not treat."
Patient intermittently refusing medications here, but has been
stable for many days and appears comfortable.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 40 mg PO QPM
2. Aspirin 81 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Calcium Carbonate 500 mg PO QPM
6. TraZODone 100 mg PO QHS
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Calcium Carbonate 500 mg PO QPM
3. Omeprazole 20 mg PO DAILY
4. Simvastatin 40 mg PO QPM
5. TraZODone 100 mg PO QHS
6. Acetaminophen 1000 mg PO Q8H pain/fever
7. Docusate Sodium 100 mg PO BID
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Senna 17.2 mg PO QHS
10. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
11. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Urinary tract infection
Nephrolithiasis with urinary tract obstruction
Hydronephrosis
Sepsis
Delirium
Dementia
Hypertension
Discharge Condition:
Mental Status: AOx2, confused (chronic due to dementia).
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted with pain and fevers due to a kidney stone
that was blocking the passage of urine from your left kidney.
You developed a urinary tract infection that led to a blood
stream infection (sepsis) for which you were treated with
antibiotics. You received a nephrostomy tube to help drain the
blocked urine. You should continue to followup regularly with
your urologist; you are scheduled to return in ___ to have
the drain changed. If you have any problems with the
nephrostomy tube (like it not draining urine) please call ___
___ or ___ at ___ at ___
Followup Instructions:
___
|
10381182-DS-12 | 10,381,182 | 26,081,413 | DS | 12 | 2122-10-16 00:00:00 | 2122-10-16 20:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Non-fluent aphasia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with history of type 1
diabetes mellitus on insulin, otherwise no significant past
medical history who presents after waking up this morning with
expressive aphasia. History provided by patient and parents via
collateral.
Mr. ___ was in his usual state of health until this morning.
Prior to that, he went out last night with a few friends to play
darts. He said he had two beers, otherwise denies any drug use,
denies marijuana, denies the possibility of an accidental
ingestion. His girlfriend was not with him at the time, but
reports that there was no mention of unusual behavior by his
friends. He returned home at 11:30PM and went to sleep in his
usual state of health.
The patient woke up this morning at 0530, and recalls checking
his glucose which was 76. He recalls reporting a generalized,
holocephalic headache. He then has minimal recollection of the
events that followed. His mother woke up when he did at ___,
and
notes that this was earlier than he usually wakes up. He walked
into the kitchen and started eating a donut, which was unusual
for him as he does not like donuts. She was concerned that he
was
hypoglycemic and gave him two glasses of orange juice to drink.
She checked his glucose after and it was 176. She tried to talk
to him and noted that he was minimally verbal. He answered "I
___ go back" to all questions asked. He seemed to attend to
her
but was either nonverbal or saying "I ___ go back" in response
to questions. Concerned, EMS was called and patient presented to
___ for further evaluation.
Parents note that he has never exhibited this behavior before.
His sugars generally run in the 100 to 200 range, as far as they
are aware. When he does run high or low, he complains of fatigue
and does not have issues with language or speech.
At ___, NIHSS was 5, scoring predominantly for
expressive aphasia (minimal verbal output, followed simple
commands only). He was out of the window for tPA given he woke
up
with symptoms. He was then transferred to ___ urgently, before
more thorough evaluation could be completed, for consideration
of
thrombectomy. At ___ was 2, scoring for moderate
aphasia
only. He underwent STAT CTA Head/Neck and CT perfusion which did
not reveal any large vessel occlusion, and CT perfusion also did
not reveal evidence of infarct.
His symptoms have overall gradually improved since this morning.
He is now able to string together several words at a time, which
he could not do before, and relate some history.
Prior to this morning, parents report the patient has been
stressed over the last week. He works allocating money for a
___, and it is the end of the fiscal year, where
he has had increased pressure and demands at work. In addition,
his diabetes was recently found to be poorly controlled at his
routine endocrinology checkup this summer (A1c 9.7). Otherwise,
family denies any recent changes to his health. Denies recent
illness including no recent fevers or chills. No medication
changes. They report he has never done drugs to their knowledge,
and his alcohol use is minimal.
Past Medical History:
Type 1 Diabetes Mellitus, on insulin, poorly controlled (A1c
9.7)
History of lyme disease remotely
Social History:
___
Family History:
Denies family history of early stroke or
premature CAD. No history of seizures in family.
Physical Exam:
Admission Physical Examination:
Vitals:
Tm 98.9F/ Tc 98.6F, HR 110s-130s (sinus tachycardia), BP
120s-140s/70s-80s, RR 14, O2 99% RA
General: Awake, alert, in no acute distress
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: warm, well perfused; regular on telemetry
Pulmonary: breathing non labored on room air
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert. Expressive aphasia; When
answering
questions, strings together up to ___ words in a sentence. Often
says "I think it was a lot of nervous...this morning" and
perseverates on this phrase throughout the interview. When asked
orientation questions, says "This morning, this morning."
Attentive to examiner, unable to complete attention tasks. Can
repeat very simple, brief phrases only (i.e. "Today is a sunny
day") but cannot repeat longer ("The cat always hid under the
couch") or more grammatically complex ("No ifs ands or buts")
phrases. Naming intact to all objects on stroke card except
"hammock". No paraphasias. No dysarthria. Normal prosody. No
apraxia; can pantomime brushing teeth, combing hair and using a
nail and hammer. He can read sentences on stroke card. He
struggles with writing. When asked to write "Today is a sunny
day", writes 'Today" and then is unable to proceed further. No
evidence of hemineglect. No left-right confusion. He is able to
follow one step midline and appendicular commands, but not more
complex commands. When asked about recent events in news,
perseverates on "this morning."
- Cranial Nerves: Mydriasis; pupils 6>4mm and briskly reactive.
VF full to finger wiggling. EOMI, no nystagmus. Funduscopic exam
reveals crisp disc margins bilaterally. V1-V3 without deficits
to
light touch bilaterally. No facial movement asymmetry. Hearing
intact to finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
L 5 5 5 5 ___ 5 5 5 5 5
R 5 5 5 5 ___ 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait: Normal initiation. Narrow base. Normal stride length and
arm swing. Stable without sway. Negative Romberg.
Discharge Physical Examination:
Vitals:
T 98.5F, HR 101, BP 116/73, RR 20, O2 97% RA
General: Awake, alert, in no acute distress
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: warm, well perfused; regular on telemetry
Pulmonary: breathing non labored on room air
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Alert and oriented to person, place, and date.
Attentive and able to name ___ backwards and correctly spell
"world" backwards. Registered ___ words and able to retrieve ___
after 5 min. Speech was fluent, but perhaps a little slower than
usual with mild word finding difficulty that manifested in
patient having to contemplate the occasional word choice.
Patient was able to talk in full, grammatically correct
sentences. Normal prosody and no paraphasic errors. Intact
repetition of "no ifs and or buts" and "Today is a sunny day in
___. Intact comprehension. He was able to name all objects
on the stroke card, but took a few seconds to find the word for
"hammock". In general, patient was able to relate the events of
the day, but seemed to have limited insight into what might have
caused it. He kept emphasizing that he was nervous this morning
and that he thought his state may have been due to his diabetes.
He remembered being unable to communicate clearly this AM and
endorsed feeling frustrated. Able to copy a rectangle but not to
draw a cube from memory (loss of 3D features). Able to put the
numbers on a clock face and draw the hands at ten past eleven.
When asked how a "ruler" and a "watch" are similar, he said
"they both have the same numbers"; asked to clarify, he said
"they both have numbers like 4, 6, and 12". When asked how a
train and a bicycle are similar, he said "they both go in the
same direction".
- Cranial Nerves: Mydriasis; pupils 6>4mm and briskly reactive.
VF full to finger wiggling. EOMI, no nystagmus. Funduscopic exam
reveals crisp disc margins bilaterally. V1-V3 without deficits
to
light touch bilaterally. No facial movement asymmetry. Hearing
intact to finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
L 5 5 5 5 ___ 5 5 5 5 5
R 5 5 5 5 ___ 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait: Normal initiation. Narrow base. Normal stride length and
arm swing. Stable without sway. Negative Romberg.
Pertinent Results:
___ 07:20AM BLOOD WBC-7.4 RBC-5.20 Hgb-14.8 Hct-45.8 MCV-88
MCH-28.5 MCHC-32.3 RDW-13.7 RDWSD-43.8 Plt ___
___ 10:24AM BLOOD WBC-12.0* RBC-5.18 Hgb-14.5 Hct-44.7
MCV-86 MCH-28.0 MCHC-32.4 RDW-13.4 RDWSD-42.3 Plt ___
___ 10:24AM BLOOD Neuts-85.4* Lymphs-9.3* Monos-4.5*
Eos-0.1* Baso-0.4 Im ___ AbsNeut-10.10* AbsLymp-1.10*
AbsMono-0.53 AbsEos-0.01* AbsBaso-0.05
___ 07:20AM BLOOD Plt ___
___ 10:24AM BLOOD Plt ___
___ 10:24AM BLOOD ___ PTT-30.0 ___
___ 07:20AM BLOOD Glucose-67* UreaN-13 Creat-0.8 Na-141
K-4.8 Cl-102 HCO3-23 AnGap-16
___ 10:24AM BLOOD Creat-0.8
___ 10:24AM BLOOD Glucose-266* UreaN-10 Creat-1.0 Na-137
K-4.9 Cl-96 HCO3-22 AnGap-19*
___ 10:24AM BLOOD ALT-14 AST-22 AlkPhos-59 TotBili-0.3
___ 10:24AM BLOOD Lipase-15
___ 07:20AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.1
___ 10:24AM BLOOD Albumin-4.5 Calcium-10.2 Phos-3.4 Mg-1.9
___ 10:24AM BLOOD TSH-2.5
___ 10:24AM BLOOD Free T4-1.1
___ 10:29AM BLOOD Glucose-258* Na-135 K-4.5 Cl-97
calHCO3-25
IMAGES:
MRI Brain w/wo contrast ___:
IMPRESSION:
1. No intracranial abnormality.
2. Mild paranasal sinus disease, as above.
XR Chest ___:
IMPRESSION:
No acute cardiopulmonary process. No focal consolidation to
suggest
pneumonia.
CTA Head and Neck ___:
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage,
edema, or mass. The ventricles and sulci are normal in size and
configuration.
There is a mucous retention cyst and mild mucosal thickening in
the left
maxillary sinus. The visualized portion of the remaining
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The visualized portion of the orbits are
unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal
intracranial branches appear normal without stenosis, occlusion,
or aneurysm formation. The left PCA is diminutive in comparison
to the right, likely congenital. The left A1 segment is also
diminutive compared to the right, likely congenital. The dural
venous sinuses are patent.
CTA NECK:
The carotid and vertebral arteries and their major branches
appear normal with no evidence of stenosis or occlusion. There
is no evidence of internal carotid stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs are clear. The visualized
portion of the thyroid gland is within normal limits. There is
no lymphadenopathy by CT size criteria.
IMPRESSION:
1. No acute intracranial abnormalities identified.
2. Patent Circle of ___ without evidence of aneurysm or
stenosis.
3. No evidence of internal carotid artery stenosis by NASCET
criteria.
4. No asymmetric perfusion abnormalities identified.
Brief Hospital Course:
Mr. ___ is a ___ year old man with history of type 1 DM insulin
dependent who presents after waking up this morning with
expressive aphasia. Initial NIHSS at OSH 5, scoring
predominantly for expressive aphasia. Patient transferred here
for possible endovascular intervention. On imaging, NCHCT is
unremarkable, no vessel occlusion on CTA H/N. Not tPA candidate
given out of window. Not endovascular candidate given no vessel
occlusion noted. Admission exam notable for expressive aphasia
(but improved from OSH), able to string only ___ words together,
quite perseverative, can read but not write; can follow only
simple commands. General exam notable for pupillary dilation and
tachycardia. On discharge exam, his expressive aphasia has
resolved, his speech fluent with comprehension, repetition, and
naming intact.
# Expressive (non-fluent) aphasia
Presented with expressive aphasia and was evaluated for stroke.
___ stroke scale at admission was 2 (down from 5 at ___). tPA
was not administered because out of window (last well 11:30 ___
on ___. Overall low suspicion for stroke given improving
deficits, minimal stroke risk factors apart from diabetes. His
TSH, free T4 were WNL. Head MRI with and without contrast showed
no intracranial abnormality. CTA of head and neck with and
without contrast showed no acute intracranial abnormalities, a
patent Circle of ___ without evidence of aneurysm or
stenosis, no evidence of internal carotid artery stenosis by
NASCET criteria, and no asymmetric perfusion abnormalities.
Urine toxicology negative. Preliminary EEG report showed
left-sided slowing. Final EEG report pending.
# Type 1 diabetes
Mr. ___ T1DM is poorly controlled (A1c 9.7). Blood glucose on
admission was elevated at 266. We administered fixed dose
insulin (Humalog ___ 40 units BID at breakfast and at dinner)
and sliding scale insulin. He should follow up with his diabetes
care provider to discuss diet, exercise, and insulin regimen.
# Initial concern for pneumonia
Chest X-ray was done because of clinical concern for pneumonia.
CXR however shows no acute cardiopulmonary process and no focal
consolidation to suggest pneumonia. Patient was not tachypneic,
afebrile, therefore not treated.
# Transitional issues
Counseled to abstain from driving for 6 months because of
abnormal sensorium as per EEG. Patient instructed to follow up
with neurology to monitor seizure activity.
Medications on Admission:
insulin regular human 100 unit/mL injection ___ID
insulin lispro 100 unit/mL subcutaneous PRN
Discharge Medications:
1. Humalog ___ 55 Units Breakfast
Humalog ___ 50 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
2. HumaLOG Mix ___ (insulin lispro protamin-lispro) 50
subcutaneous BID
Discharge Disposition:
Home
Discharge Diagnosis:
Transient aphasia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were transferred from an outside hospital to ___ and
admitted into the hospital for further evaluation of abnormal
speech and confusion which you experienced on the morning of
___. The work-up included neuroimaging (CT scan of the
head, CT scan of the head vessels, as well as MRI of the brain)
- all scans were within normal limits, specifically negative for
stroke and/or brain lesions. Electroencephalography was
completed and per preliminary report showed slowing on the left
side of the brain. This finding can be seen after a seizure, but
it can also be seen in the setting of hypoglycemia alone. Blood
work was unrevealing. Given the neurologic changes and question
of possible seizure, the ___ law prohibits you
from driving for 6 months following the incident. Additionally
you should avoid swimming alone and climbing high places.
Your insulin home regimen (Humalog 75/25) for type 1 diabetes
mellitus was started, glucose ranged from 67-220's.
Transitional issues:
- Emphasized importance of good glycemic control, which includes
insulin use per primary Endocrinologists recommendation, as well
as regular meals. Discussed risks of hypoglycemia with alcohol
use.
- Please schedule a follow-up appointment with your primary care
doctor within ___ weeks of discharge.
- Please follow-up with your Endocrinologist as previously
scheduled.
- Please schedule follow-up appointment with General Neurology
at ___ within 6 months or
sooner if needed
Followup Instructions:
___
|
10381436-DS-4 | 10,381,436 | 20,855,287 | DS | 4 | 2162-12-18 00:00:00 | 2162-12-18 09:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
left intertrochanteric femur fracture
Major Surgical or Invasive Procedure:
Trochanteric femoral nail on ___
History of Present Illness:
___ male with a history of MS ___ fall with left hip pain. Pt
states that he fell yesterday on the street. He was walking with
walker and lost his balance falling on to his left hand. He was
able to get up afterwards and continue on with minimal pain in
his left hand; however since then has had worsening weakness in
his left hand and fell last night because of it. He states he
got
up to go to the bathroom, lost his balance again but unable to
use left hand to catch himself (he is right hand dominant). He
fell onto left hip, no head strike but unable to get up
afterwards due to pain. His wife helped him to bed and because
of
continued pain came to the Emergency Room. He denies numbness or
tingling distally. He has never injured this leg in the past.
Past Medical History:
Multiple Sclerosis
Osteoporosis
Social History:
___
Family History:
NC
Physical Exam:
Upon Admission:
General: Well-appearing male in no acute distress.
Pelvis is stable
Left lower extremity:
- Skin intact
- Left leg is held in external rotation and shortened compared
to
right lower extremity. He has tenderness to palpation over the
anterior proximal hip. no overlying erythema.
- unable to range the hip due to pain. Full ROM at the ankle and
distally.
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
Upon discharge:
Vitals: Temp: 99.4 AdultAxillary BP: 117/71 R Lying
HR: 82 RR: 18 O2 sat: 99% O2 delivery: Cpap
General: Well-appearing, breathing comfortably
MSK:Left lower extremity:
- Skin intact
- Dressing is c/d/I, no surrounding erythema
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
Pertinent Results:
___ 11:42AM BLOOD WBC-7.0 RBC-3.71* Hgb-12.0* Hct-35.7*
MCV-96 MCH-32.3* MCHC-33.6 RDW-12.3 RDWSD-43.1 Plt ___
___ 11:42AM BLOOD Neuts-82.6* Lymphs-7.5* Monos-9.1
Eos-0.1* Baso-0.4 Im ___ AbsNeut-5.75 AbsLymp-0.52*
AbsMono-0.63 AbsEos-0.01* AbsBaso-0.03
___ 11:42AM BLOOD ___ PTT-26.9 ___
___ 11:42AM BLOOD Plt ___
___ 11:42AM BLOOD Glucose-125* UreaN-18 Creat-0.7 Na-138
K-5.1 Cl-100 HCO3-24 AnGap-14
___ 06:00AM BLOOD WBC-5.3 RBC-2.42* Hgb-7.8* Hct-23.5*
MCV-97 MCH-32.2* MCHC-33.2 RDW-12.4 RDWSD-43.6 Plt ___
___ 07:10AM BLOOD Hct-23.3*
___ 06:00AM BLOOD Glucose-113* UreaN-25* Creat-0.7 Na-141
K-4.6 Cl-104 HCO3-29 AnGap-8*
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left intertrochanteric femur fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for placement of trochanteric femoral
nail for fixation of left hip fracture, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications. The
patient was given ___ antibiotics and anticoagulation
per routine. His post-operative HCT down trended to 23.4, though
the patient was asymptomatic therefore blood transfusion was
deemed to be unnecessary at the time. 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
weight bearing as tolerated to the left lower extremity, and
will be discharged on lovenox 4omg daily x4weeks for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
Aubagio 14mg Daily
Forteo 20mcg/dose daily
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times daily
Disp #*68 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*50 Tablet Refills:*0
3. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*28 Syringe
Refills:*0
4. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 to 2 tablet(s) by mouth every four (4)
hours Disp #*28 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides 8.6 mg 1 tab by mouth twice daily Disp #*50
Tablet Refills:*0
6. Aubagio (teriflunomide) 14 mg oral DAILY MS
7. Forteo (teriparatide) 20 mcg/dose - 600 mcg/2.4 mL
subcutaneous daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left intertrochanteric femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated to left lower extremity
Resident covering
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40 mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
Weightbearing as tolerated to left lower extremity
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.
Please remain in the splint until follow-up appointment. Please
keep your splint dry. If you have concerns regarding your
splint, please call the clinic at the number provided.
Call your surgeon's office with any questions.
Followup Instructions:
___
|
10381484-DS-15 | 10,381,484 | 27,486,461 | DS | 15 | 2172-08-03 00:00:00 | 2172-08-05 13:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with stage IV (pT3 pN2a pM1b) colon
cancer s/p laparoscopic low anterior resection with removal of a
rectosigmoid mass and two drop mets, also s/p 7 cycles of XELOX
adjuvant therapy (stopped ___ side effects), now presenting
twice today to the ED with abdominal pain, admitted for
refractory abdominal pain.
Patient was seen in the ED this morning and had a CT abdomen
without acute process. Was felt to have functional abdominal
pain.
His abdominal pain improved after initial ED visit this morning
and so he was discharged to his oncology f/u clinic visit.
THere, hisabd pain returned and was ___. Dr. ___ for
po Dilaudid, but when nursing was trying to dispense the PO med
he was out of his chair, bending over chair c/o increased pain
and then vomited. Pt
assisted back to chair, VS 139/80 98.2-50-16, Sat 99%. Episode
lasted 5 min and he was unable to take po pain med. At that
point MD made decision to transfer pt back to ER for further
workup.
He was worried about going home and having to go back to ER
during the night. As such he received IV Dilaudid 0.5mg prior to
transfer to ambulance stretcher for ___ abdominal pain.
In the ED, initial VS were: 13:35 7 98.8 50 144/88 18 100% RA
Labs were notable for: lactate 2.1.
Imaging included: CT a/p with contrast on first visit, see below
Treatments received: 1L NS, simethicone 80mg, morphin 5mg
Despite IV morphine had persistent writhing pain in the ED and
was admitted for pain control.
On arrival to the floor, patient reports pain started a few days
after CT scan last ___ (had chest CT). This type of pain
started only after getting surgery ___, a total of 3 times,
each time he was admitted and it was felt to be ___ bowel reg
noncompliance or constipation and pain resolved with BMs.
The pain is intermittent (comes and goes), but over the last few
days each time it comes back it gets worse. Morphine helps, food
makes it worse, and movement. Bowel movements also make it
better. Pain is "strong," ___, across anterior upper abdomen.
Denies constipation, reports 1BM daily, before surgery had
constipation but now reports regular BMs. Describes pain as
"gas" and "severe bloating." Denies ETOH use and NSAID use, does
have history of GERD but doesnt take anything for it.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- endoscopy for rectal bleeding performed on ___. It showed
a fungating, circumferential mass of malignant appearance in the
sigmoid colon at 18cm. The mass caused a complete obstruction.
Biopsy of this mass revealed fragments of adenoma with
high-grade dysplasia and focal adenocarcinoma, with intact
expression of MLH-1, PMS-2, MSH-2, and MSH-6.
- CT torso on ___ showed no evidence of distant metastases
- referred to Dr. ___ palpated a nodule in the rectum.
- MRI of the pelvis was performed on ___ which showed an
ill-defined sigmoid mass, approximately 15 cm above the anal
verge, with extension across the muscularis propria, suspicious
for T3 disease. It also revealed a 1.6 x 1.5 cm mass abutting
the anterior aspect of the rectum and posterior aspect of the
seminal vesicles, 7 cm above the anal verge, that was suspicious
for a drop metastasis.
- laparoscopic low anterior resection on ___. Path revealed
colonic adenocarcinoma in the resected rectosigmoid colon. Tumor
size was 3.6cm, low grade, staged pT3. Margins were negative.
Of the 15 nodes examined, 6 were positive, thus staged pN2a.
Finally, a separate nodule of adenocarcinoma was identified 9 cm
distal to the primary tumor involving pericolonic adipose
tissue, serosa, and muscularis propria, consistent with
metastasis of the primary tumor. Furthermore, the resected
peritoneal nodule showed metastatic adenocarcinoma with
perineural invasion. Thus, this was staged pM1b. Of note, KRAS
mutation was detected.
- ___ port placement
- ___ admitted for abdominal pain, OSH CT was
reviewed here and felt to be not concerning for any acute
intra-abdominal process including leak or abcess however there
was a high stool burden and gas. Pt discharged on bowel
regimen.
- ___ ED visit for abdominal pain, KUB reassuring,
discharged after bowel regimen
- ___ C1D1 XELOX (Xeloda 1000mg BID)
- ___ admission for abdominal pain, no clear obstruction
but improved with NG tube for decompression
- ___ admission for constipation due to bowel med
noncompliance
PAST MEDICAL HISTORY:
Rectal cancer as above
Lipoma
Social History:
___
Family History:
Negative for colon cancer, inflammatory bowel disease, uterine
cancer. He does have history of lipomas in his family.
Physical Exam:
ON ADMISSION:
VS: 98.2 118/74 45 18 97RA
GENERAL: very uncomfortable gentleman leaning over sitting on
the side of bed, friend at bedside
___: NC/AT, EOMI, MMM, sclera anicteric
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: poor effort, but clear to auscultation, no wheezes or
rhonchi
ABD: bowel sounds present, TTP in bilateral upper quadrants,
negative murphys sign, minimal TTP RLQ, no rebound, +voluntary
guarding, no CVA tenderness but discomfort anteriorly with CVA
tenderness
EXT: No lower extremity pitting edema
NEURO: face symmetric, MAE, gait WNL, orientedx3
SKIN: Warm and dry, without rashes
ON DISCHARGE:
VS: Tmax 98.9 Tc 97.6 HR ___ BP ___ RR 18 SpO2
96-98% RA, I/O 24h ___, 8h 30/NR
GENERAL: Patient in moderate pain, but improved from yesterday
___: NC/AT, EOMI, MMM, sclera anicteric
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: poor effort, but clear to auscultation, no wheezes or
rhonchi
ABD: bowel sounds present, resolved tenderness, negative murphys
sign, minimal TTP RLQ, no rebound, +voluntary guarding, no CVA
tenderness
EXT: No lower extremity pitting edema
NEURO: face symmetric, MAE, gait WNL, orientedx3
SKIN: Warm and dry, without rashes
Pertinent Results:
ADMISSION LABS:
___ 02:20AM BLOOD WBC-9.6# RBC-5.22 Hgb-15.6 Hct-46.1
MCV-88 MCH-29.8 MCHC-33.8 RDW-12.5 Plt ___
___ 02:20AM BLOOD Plt ___
___ 02:20AM BLOOD Glucose-123* UreaN-15 Creat-1.2 Na-140
K-3.7 Cl-101 HCO3-25 AnGap-18
___ 02:20AM BLOOD Albumin-4.5 Calcium-9.9 Phos-2.4* Mg-2.0
___ 02:20AM BLOOD Lactate-2.1*
IMAGING:
CT ABD & PELVIS WITH CO ___:
IMPRESSION:
1. Normal appendix.
2. Small amount of nonspecific free fluid in the right lower
quadrant and
pelvis, which is new over the interval.
MICROBIOLOGY:
NONE
DISCHARGE LABS:
___ 05:54AM BLOOD WBC-7.8 RBC-4.89 Hgb-14.6 Hct-43.0 MCV-88
MCH-29.9 MCHC-33.9 RDW-12.0 Plt ___
___ 05:54AM BLOOD Plt ___
___ 05:54AM BLOOD Glucose-87 UreaN-12 Creat-1.1 Na-138
K-3.7 Cl-99 HCO3-30 AnGap-13
___ 05:54AM BLOOD Calcium-9.4 Phos-4.1 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ man with stage IV (pT3 pN2a pM1b) colon
cancer s/p laparoscopic low anterior resection with removal of a
rectosigmoid mass and two drop mets, also s/p 7 cycles of XELOX
adjuvant therapy (stopped ___ side effects), now presenting
twice today to the ED with abdominal pain, admitted for
refractory abdominal pain.
# ABDOMINAL PAIN: Patient was admitted with refractory abdominal
pain. Exam was unremarkable for peritoneal signs, but notable
for diffuse abdominal tenderness. LFTs and lipase were
unremarkable. Abdominal CT demonstrated normal appendix and now
evidence of obstructive processes. The patient was made NPO and
managed with PCA dilaudid, IV reglan, simethicone, and increased
bowel regimen. An EGD was originally planned but not pursued
since the patient's abdominal pain markedly improved. The
patient's pain was likely from dysmotility in the setting of his
previous colon surgeries and constipation as his symptoms
improved with moving his bowels. He was eating a regular diet
and was discharged with a bowel regimen.
# Stage IV (pT3 pN2a pM1b) colon cancer. In terms of his colon
cancer he is disease free, with no signs or symptoms concerning
for recurrence. CEA low, with recent outpatient ___ showing
only lymphoid aggregates on path, and plan for f/u imaging q3
months. No chemotherapy was administered during this
hospitalization.
# GERD: Pt denies that acid is much of the problem.
-Continued home Pantoprazole
TRANSITIONAL ISSUES:
[]CODE STATUS: Full
[]Discharge bowel regimen: Colace and senna with PRN Miralax and
Bisacodyl if no BM for greater than 2 days. Reglan PRN nausea
[]Consider elective removal of port cath if patient will not
have further chemo treatments
[]Consider followup outpatient EGD if patient develops worsening
abdominal pain
[]Patient will have Med Onc followup
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
2. Senna 8.6 mg PO BID constipation
RX *sennosides [___] 8.6 mg 1 tablet by mouth twice a day
Disp #*60 Tablet Refills:*0
3. Simethicone 40-80 mg PO QID:PRN gas pains
RX *simethicone [Bicarsim] 80 mg 1 tablet by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
4. Metoclopramide 10 mg PO Q8H:PRN Nausea
RX *metoclopramide HCl [Reglan] 10 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*30 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Please take if no bowel movements for more than 2 days
6. Bisacodyl 10 mg PO DAILY:PRN constipation
Please take if no bowel movements for more than 2 days
RX *bisacodyl [Alophen] 5 mg 2 tablet(s) by mouth once a day
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Abdominal Pain
Colon Cancer
Secondary:
Gastroesophageal Reflux Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
the ___. As you know, you were
admitted with abdominal pain. We did imaging of your abdomen
which did not show any blockages. We treated your pain with IV
medictions and your pain improved. We felt your abdominal pain
was likely related to your bowel not moving well and
constipation. Since your symptoms improved, we did not do a test
to look at your gastrointestinal tract. Please continue to take
your medications to move your bowels. If you do not have a bowel
movement for more than 2 days with colace and senna, you may
take medications called Miralax or Bisacodyl as instructed.
Please followup with your cancer doctor as below.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10381484-DS-17 | 10,381,484 | 25,659,319 | DS | 17 | 2175-10-27 00:00:00 | 2175-10-27 18:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
pollen
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Patient is a ___ year old M with history of stage IV metastatic
sigmoid adenocarcinoma s/p LAR ___, 7 cycles of XELOX, with
subsequent metastasis to spenic bed s/p lap splenectomy,
gastric
wedge resection (___), with metastatic disease to the liver,
found on recent CT A/P to have worsening hepatic metastatic
disease with increasing soft tissue density with necrotic nodes
in jejunal wall with plan for palliative FOLFOX, who presents
with worsening abdominal pain.
Patient states that he has had 1 month history of worsening
diffuse abdominal pain that has acutely worsened over last
several days. Started having nausea yesterday evening without
emesis. Also experiencing early satiety, has had minimal PO
intake, able to tolerate some small bites and liquids. Still
passing gas, last bowel movement was yesterday evening, however
it was small and constipated. Denies any urinary symptoms no
burning or pain on urination, no recent fevers or chills.
On arrival to the ED,
Initial VS: T 98.6 HR 77 BP 151/86 RR 18 O2 100%RA
Exam:
GA: Comfortable
Neuro: Cranial nerves II -XII intact, 5 out of 5 strength
bilaterally upper and lower extremities, full sensation
bilaterally
HEENT: No scleral icterus
Cardiovascular: Normal S1, S2, regular rate and rhythm, no
murmurs/rubs/gallops, 2+ peripheral pulses bilaterally
Pulmonary: Clear to auscultation bilaterally
Abdominal: Soft, tender to palpation left upper and lower
quadrants, nondistended, no masses, no CVA tenderness
Extremities: No lower leg edema
Integumentary: No rashes noted
Labs notable for:
- WBC 12.4 with 74% neutrophils, Hb 13.1, K 4.2, BUN 16, Cr 1.0,
LFTs within normal limits, lipase 20
Administered:
___ 02:14 IV Morphine Sulfate 4 mg
___ 02:14 IV Ondansetron 4 mg
___ 02:41 IVF NS
___ 04:14 IVF NS 1000 mL
___ 04:15 IV Morphine Sulfate 4 mg
___ 05:52 IV Morphine Sulfate 4 mg
___ 08:53 IV Morphine Sulfate 4 mg
___ 12:48 IVF NS 125cc/hr
Imaging:
CT A/P WC:
1. Closed loop small-bowel obstruction of the jejunum measuring
up to 2.8 cm.
2. Stable, metastatic disease as described above.
Colorectal surgery consulted for potential surgical
intervention.
SUBJECTIVE: Patient confirms the above history. Currently
complaining of mild diffuse abdominal pain, no nausea, no
vomiting.
Past Medical History:
PAST ONCOLOGIC HISTORY:
PAST ONCOLOGIC HISTORY: Reconciled in OMR.
Colon cancer stage IIIC (T3N2M0) of the sigmoid colon with
progressive metastatic disease
- ___ Colonscopy for weight loss of 26 lbs in a year
revealed a fungating, circumferential mass of malignant
appearancae was found in the sigmoid colon at 18cm. Biopsy
consistent with adenocarcinoma. CT torso revealed 3.7 cm segment
of the mid sigmoid colon demonstrating circumferential wall
thickening in keeping with tumor. There is no associated bowel
obstruction at present time. Adjacent mesenteric lymph nodes
measuring up to 6 mm in short axis dimension are noted. No
evidence of metastatic disease within the chest, abdomen, or
pelvis.
- ___ MR pelvis revealed Ill-defined sigmoid mass,
approximately 15 cm above the anal verge, as seen on the CT
examination from ___, with extension across the
muscularis propria. This is suspicious for T3 disease. 1.6 x 1.5
cm mass abutting the anterior aspect of the rectum and posterior
aspect of the seminal vesicles, 7 cm above the anal verge, is
suspicious for a drop metastasis as it is not convincingly
arising from rectal wall. This likely corresponds to the
palpable
finding on physical exam. Intrapelvic lymphadenopathy adjacent
to
the sigmoid mass, some with morphology suspicious for tumor
involvement.
- ___ Undderwent LAR. Path revealed colonic
adenocarcinoma
in the resected rectosigmoid colon. Tumor size was 3.6cm, low
grade, staged pT3. Margins were negative. Of the 15 nodes
examined, 6 were positive, thus staged pN2a. Finally, a separate
nodule of adenocarcinoma was identified 9 cm distal to the
primary tumor involving pericolonic adipose tissue, serosa, and
muscularis propria, consistent with metastasis of the primary
tumor. Furthermore, the resected peritoneal nodule showed
metastatic adenocarcinoma with perineural invasion. Thus, this
was staged pM1b. Of note, KRAS mutation was detected.
- ___ to ___ admitted for abdominal pain, OSH CT
was reviewed here and felt to be not concerning for any acute
intra-abdominal process including leak or abcess however there
was a high stool burden and gas. Pt discharged on bowel
regimen.
- ___ ED visit for abdominal pain, KUB reassuring,
discharged after bowel regimen
- ___ C1D1 XELOX (Xeloda 1000mg BID)
- ___ to ___ Admission for n/v and abd pain. CT
showed mildly dilated stomach and proximal small bowel, but no
evidence of obstruction. He underwent NGT decompression with
good
bilious output and improvement in symptoms and was slowly
advanced to regular diet.
- ___ C1D1 XELOX (Xeloda 1000mg BID)
- ___ to ___ admission for abd pain and
constipation. CT showed multiple mildly distended loops of ileum
with fecalized contents and a narrow caliber of the terminal
ileum. Stool and air seen in the colon. Symptoms improved
with
aggressive bowel regimen.
- ___ C3D1 XELOX (Xeloda 1500mg BID)
- ___ C4D1 XELOX (Xeloda 1500mg BID)
- ___ C5D1 XELOX (Xeloda 2000mg BID)
- ___ C6D1 XELOX (Xeloda 2000mg BID)
- ___ C7D1 XELOX (Xeloda 2000mg BID)
- ___ CT torso with no evidence of recurrence or
metastases
- ___ colonoscopy showed multiple tiny 2 mm polypoid
lesions which showed to be lymphoid aggregates on path
- ___ CT torso with no evidence of recurrence or
metastases
- ___ CT abdomen in the ED for abdominal pain showed ___
- ___ CT abdomen in the ED for abdominal pain showed ___
but indeterminate liver lesion
- ___ CT torso ___ with stable liver lesion
- ___ Colonoscopy revealed a single polyp, pathology
consistent with adenoma.
- ___ CT torso showed a new lesion in the splenic hilum
concerning for recurrence
- ___ PET CT showed avid lesion in the spleen, no other
sites of disease
- ___ Splenectomy revealed metastatic colon cancer
- ___ CT torso showed ___
- ___ CT torso extensive recurrence in the spenic bed and
nodes, CEA rising
- ___ Biopsy of the splenic bed confirmed metastatic
adenocarcinoma
- ___ CT torso showed increase in metastatic disease
- ___ CT torso showed increase in metastatic and
concerning new areas in the liver
PAST MEDICAL HISTORY:
Colon Ca as above
Lipoma
DVT
Social History:
___
Family History:
Negative for colon cancer, inflammatory bowel disease, uterine
cancer. He does have history of lipomas in his family.
Physical Exam:
Admission Physical Exam
=========================
PHYSICAL EXAM:
VS: T 97.7 BP 122/74 HR 44 RR 16, O2 99%RA
GENERAL: Comfortable, in NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: Bradycardic, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABD: Soft, minimal TTP in lower abdomen, no rebound or guarding,
no peritoneal signs
EXT: 2+ peripheral pulses no c/c/e
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
NEURO: CN II-XII intact no focal neurological deficits
Discharge Physical Exam
=========================
GENERAL: Comfortable, in NAD, lying in bed
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: Bradycardic, S1/S2, no MRG
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
ABD: Soft, minimal TTP in epigastrium, no rebound or guarding,
no
peritoneal signs, non distended, non-tympanitic
EXT: 2+ peripheral pulses no c/c/e
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
NEURO: CN II-XII intact no focal neurological deficits
Pertinent Results:
Admit Labs
==========
___ 01:50AM BLOOD WBC-12.4* RBC-4.41* Hgb-13.1* Hct-40.3
MCV-91 MCH-29.7 MCHC-32.5 RDW-13.2 RDWSD-44.1 Plt ___
___ 01:50AM BLOOD Neuts-74.0* Lymphs-15.8* Monos-7.0
Eos-2.6 Baso-0.4 Im ___ AbsNeut-9.15* AbsLymp-1.95
AbsMono-0.87* AbsEos-0.32 AbsBaso-0.05
___ 01:50AM BLOOD Plt ___
___ 01:50AM BLOOD Glucose-110* UreaN-16 Creat-1.0 Na-141
K-4.2 Cl-102 HCO3-26 AnGap-13
___ 01:50AM BLOOD Albumin-4.3
Pertinent Labs
==============
___ 01:50AM BLOOD Glucose-110* UreaN-16 Creat-1.0 Na-141
K-4.2 Cl-102 HCO3-26 AnGap-13
___ 06:23AM BLOOD Glucose-123* UreaN-9 Creat-0.8 Na-143
K-3.7 Cl-104 HCO3-27 AnGap-12
___ 06:01AM BLOOD Glucose-122* UreaN-11 Creat-0.9 Na-140
K-4.4 Cl-101 HCO3-25 AnGap-14
___ 06:18AM BLOOD Glucose-113* UreaN-16 Creat-1.0 Na-139
K-4.0 Cl-101 HCO3-25 AnGap-13
___ 05:30AM BLOOD Glucose-89 UreaN-14 Creat-0.9 Na-139
K-3.8 Cl-101 HCO3-26 AnGap-12
___ 01:50AM BLOOD Neuts-74.0* Lymphs-15.8* Monos-7.0
Eos-2.6 Baso-0.4 Im ___ AbsNeut-9.15* AbsLymp-1.95
AbsMono-0.87* AbsEos-0.32 AbsBaso-0.05
Imaging
=========
___ 9:___BD & PELVIS WITH CONTRAST
FINDINGS:
LOWER CHEST: Imaged lung bases are clear aside from mild
dependent
atelectasis. The imaged portion of the heart is unremarkable.
ABDOMEN:
HEPATOBILIARY: A capsular implant is again noted along the
hepatic dome
measuring approximately 1.8 x 1.8 x 3.0 cm, slightly increased
in size from
prior. The lesion involving segment 3 is noted on series 2,
image 22
measuring approximately 2.5 x 2.3 cm. Main portal vein and
central branches
are patent. No biliary ductal dilation is seen. The
gallbladder appears
normal.
PANCREAS: The pancreas enhances normally. A lesions are seen.
SPLEEN: The spleen is surgically absent. Within the left upper
quadrant,
there is an ill-defined mass containing several areas of
calcification with
relative central hypodensity. This lesion abuts the greater
curvature of the
stomach and measures approximately 8.3 x 6.5, not significantly
changed in
overall size when compared to the most recent prior exam. This
finding remain
concerning for malignancy.
ADRENALS: Adrenals are normal.
URINARY: Mild right hydroureteronephrosis is noted with slight
delay in
excretion of contrast. Given tumor implant in the region of the
right distal
ureter best seen on series 2, image 68, findings likely reflect
partial
tethering of the right distal ureter with resultant partial
obstruction. Left
kidney enhances normally with prompt excretion of contrast.
GASTROINTESTINAL: Suture material noted along the proximal
stomach. Stomach
is fluid distended and abuts a mass in the left upper abdomen in
the
splenectomy bed which is grossly unchanged in size. The
duodenum is
unremarkable. There is a small bowel obstruction which can be
traced to the
level of a jejunal mass best seen on series 2, image 44. This
tumor causes
significant obstruction at this level though the lumen is not
completely
occluded. Additional points of relative caliber transition for
example in the
right lower abdomen on series 601 image 21 likely reflect
partial destruction
due to serosal implants. A bilobed mass is noted in the
small-bowel mesentery
of the right lower abdomen on series 2, image 58 not
significantly changed in
overall size. Distal small bowel is decompressed. The appendix
is normal.
The colon contains a moderate fecal load. Fiducials are seen
adjacent to the
rectum.
PELVIS: The urinary bladder and distal ureters are unremarkable.
Small volume
ascites is noted.
REPRODUCTIVE ORGANS: Multiple fiducial markers are noted within
the prostate
which appears heterogenous.
LYMPH NODES: A bilobed soft tissue lesion is again noted just
anterior to the
right common iliac bifurcation, unchanged from recent prior. No
retroperitoneal lymphadenopathy. No pelvic sidewall or inguinal
adenopathy.
Several mesenteric nodules for example in the left mid abdomen
on series 2,
image 42 measuring 11 mm in short axis appears similar to prior.
VASCULAR: There is no abdominal aortic aneurysm. No
atherosclerotic disease
is noted.
BONES: No worrisome bony lesion is seen.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Partial small-bowel obstruction the level of a jejunal mass.
Additional
sites of subtle stricture in the small bowel could reflect the
presence of
additional small-bowel metastatic lesions. Small volume
ascites.
2. Metastatic disease in the abdomen and pelvis appears grossly
stable though
a hepatic capsular implant appears slightly increased in size.
3. New mild right hydroureteronephrosis likely due to partial
obstruction of
the right distal ureter due to an adjacent metastatic lesion.
NOTIFICATION: D/w Dr. ___ (Surgery)
BY ELECTRONICALLY SIGNING THIS REPORT, I THE ATTENDING PHYSICIAN
ATTEST THAT ___ HAVE REVIEWED THE ABOVE IMAGES FOR THE ABOVE
EXAMINATION(S) AND AGREE WITH THE FINDINGS AS DOCUMENTED ABOVE.
___, MD
___, MD electronically signed on WED ___ 11:49 ___
Discharge Labs
================
___ 05:30AM BLOOD WBC-11.1* RBC-4.01* Hgb-11.8* Hct-35.6*
MCV-89 MCH-29.4 MCHC-33.1 RDW-12.9 RDWSD-42.1 Plt ___
___ 05:30AM BLOOD Plt ___
___ 05:30AM BLOOD Glucose-89 UreaN-14 Creat-0.9 Na-139
K-3.8 Cl-101 HCO3-26 AnGap-12
___ 06:01AM BLOOD ALT-13 AST-15 LD(LDH)-166 AlkPhos-63
TotBili-0.4
___ 05:30AM BLOOD Calcium-8.8 Phos-3.7 Mg-1.9
Brief Hospital Course:
Mr. ___ is a ___ year old male with stage IV metastatic
sigmoid adenocarcinoma s/p lower abdominal resection, mets to
splenic bed s/p splenectomy, gastric wedge re-section, with
metastatic disease to liver, found on recent CT A/P to have
worsening hepatic metastatic disease with increasing soft tissue
density with necrotic nodes in jejunal wall, presenting with
abdominal pain. Was found to have malignant partial SBO on CT
A/P. Was evaluated by colorectal surgery however surgical
intervention was deferred and patient was instead started on
palliaitve FOLFOX C1D1 ___. Patient tolerated 48 hours of
FOLFOX well, was also tolerating a regular diet and having bowel
movements prior to discharge. Of note, with history of R gastroc
DVT, was non-adherent to Eliquis prior to admission, was briefly
on a heparin drip and transitioned to lovenox, however decision
was made to continue with Eliquis BID to promote adherence on
discharge.
#Stage IV metastatic sigmoid adenocarcinoma
#Malignant SBO - History of stage IV metastatic sigmoid
adenocarcinoma s/p lower abdominal resection, mets to splenic
bed s/p splenectomy, gastric wedge re-section, with metastatic
disease to liver, found on recent CT A/P to have worsening
hepatic metastatic disease with increasing soft tissue density
with necrotic nodes in jejunal wall, presenting with abdominal
pain. Was found on CT A/P to have partial malignant SBO at the
level of a jejunal mass. Also with additional sites of subtle
stricture possibly reflecting presence of additional small bowel
metastatic lesions. Imaging showing hepatic capsular implant
appearing slightly increased in size, also with new mild right
hydroureternephrosis likely due to partial malignant
obstruction. Was evaluated by colorectal surgery, surgical
intervention was deferred. Patient was instead started on
palliaitve FOLFOX C1D1 ___. Was also tolerating a regular
diet and having bowel movements prior to discharge. Received
dexamethasone during hospitalization to help relieve SBO, was
discharged with planned dexamethasone taper 2mg ___,
followed by 1mg on ___ without plan for ongoing maintenance
dosing, however future steroid plan to be determined by primary
oncologist. Arranged for follow-up on ___. Plan per primary
oncologist for additional IVF on ___ and ___ given at risk
for dehydration.
#Deep Venous Thrombosis - History of DVT R gastroc (___),
for which he was previously prescribed eliquis 5 BID. The
patient had been non-adherent for
months to current admission. Given initially considering
surgical intervention, he was briefly placed on a heparin drip,
however after surgical intervention was deferred he was
transitioned to lovenox. Given ongoing issues with adherence and
tolerating POs, decision was made to re-start eliquis 5mg BID in
order to better promote adherence.
#Mild Right Hydroureteronephrosis - Mild right
hydroureteronephrosis noted on ___ CT A/P which was not seen in
previous CT A/P ___, secondary to metastatic partial
obstruction. Renal function was normal during hospitalization,
as without CVA tenderness.
#Bradycardia - EKG showing stable sinus bradycardia ___,
which is chronic with no higher grade block on repeat EKG.
#Dental Infection - Recent dental infection per OMR review, was
referred to ___. Per patient had a root canal
performed, no evidence of current infection on exam or tooth
pain.
TRANSITIONAL ISSUES
=======================
[ ] NEW/CHANGED MEDICATIONS
- Started dexamethasone taper 2mg ___, followed by 1mg ___ with
no maintenance dosing. Future steroids ASDIR per primary
oncologist for ___
- Re-started eliquis 5mg BID for right gastroc DVT
- Discharged with Zofran, bisacodyl, senna, Colace PRN
[ ] Palliative FOLFOX C1D1 ___ with day 15 ___
[ ] Consider additional dexamethasone PRN ASDIR by primary
oncologist for ___
[ ] IVF on ___ and ___ given at risk for dehydration at
primary oncology follow-up
[ ] With new mild Right Hydroureteronephrosis secondary to
partial malignant obstruction
[ ] Continue to assess medication adherence to eliquis
#CODE STATUS: Full Code
Medications on Admission:
none
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *bisacodyl [Laxative (bisacodyl)] 5 mg 2 tablet(s) by mouth
Daily:PRN Disp #*30 Tablet Refills:*0
3. Dexamethasone 1 mg PO DAILY
Take 2mg ___ and 1 mg ___ and then stop taking
Tapered dose - DOWN
RX *dexamethasone 1 mg 1 tablet(s) by mouth ASDIR Disp #*30
Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
RX *docusate sodium 100 mg 1 tablet(s) by mouth BID:PRN Disp
#*30 Tablet Refills:*0
5. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth Q8H:PRN Disp #*15
Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *sennosides [senna] 8.6 mg 1 by mouth BID:PRN Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
==================
#Malignant Small Bowel Obstruction
#Mild Right Hydroureteronephrosis
Chronic Diagnoses
==================
#Adenocarcinoma of the sigmoid colon
#Deep Venous Thrombosis
#Bradycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You came into the hospital because of worsening abdominal pain
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were found on your CT of the abdomen to have an
obstruction or constriction of the bowel because of your cancer
- We started you on chemotherapy to help relieve the obstruction
in your bowel
- We helped control your pain
- You were also given a blood thinner for the blood clot in
your leg
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medications as prescribed and keep
your follow-up appointments as listed below
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10381484-DS-18 | 10,381,484 | 24,324,627 | DS | 18 | 2175-11-21 00:00:00 | 2175-11-23 13:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
pollen
Attending: ___.
Chief Complaint:
R arm pain
subjective fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ yo ___ speaking man with stage IV
sigmoid adenocarcinoma s/p LAR (___), progression of disease
to spleen s/p splenectomy/distal pancreatectomy/wedge
gastrectomy
(___), on palliative FOLFOX, ___ DVT ___ on Xarelto, who
presented with right arm pain and subjective fevers/chills x 3
days.
Mr. ___ was hospitalized ___ for malignant partial SBO
in s/o progression of his metastatic colon cancer. During that
admission, Mr. ___ reported poor compliance to apixaban,
which was stated on ___ for RLE DVT. He was briefly on
heparin
gtt before being discharged back on apixaban.
He was then seen in follow up with ___ on ___ for
C1D15 FOLFOX. He reported apixaban made him feel unwell with
poor
appetite. He switched to rivaroxaban, in the hope that daily
dosing would improve compliance, and advised that symptoms were
likely ___ malignancy rather than anticoagulation.
On interview, Mr. ___ reports that the pharmacy did not
receive the script for rivaroxaban, so he has not been on AC for
at least 2 weeks. He did not continue taking apixaban, believing
it to be contributing to his abdominal discomfort and poor
appetite.
Subjectively, Mr. ___ reports he noted right arm/axilla pain
___ days ___ to presentation. The pain is ___ ___ut
feels as if someone is cutting him from inside with any
movement.
Around this time, he also noted that the underside of his right
upper arm was "hot" and swollen. He had subjective fevers on and
off for a week which caused sweats and chills. He reports he
noted some right shoulder pain when taking in a deep breath 1
week ago, but did not have any pleuritic pain since then.
Pertinent negatives:
No chest pain, no shortness of breath, cough/hemoptysis. No
nausea, diarrhea, dysuria, cold symptoms. no sick contacts. no
tooth pain.
In the ED: Tmax 100.7 F | 76 | 122/78 | 100% RA. A CT Chest
demonstrated "dilated right axillary vein, with adjacent fat
stranding, possibly reflecting a deep venous thrombosis.
Recommend upper extremity ultrasound for further evaluation".
There was no evidence of acute disease within the chest.
A RUE U/S was performed and has not yet been interpreted.
He received IV dilaudid, vanc/zosyn, and heparin gtt ___ to
admission
All other review of systems are negative unless stated otherwise
Past Medical History:
PAST ONCOLOGIC HISTORY:
PAST ONCOLOGIC HISTORY: Reconciled in OMR.
Colon cancer stage IIIC (T3N2M0) of the sigmoid colon with
progressive metastatic disease
- ___ Colonscopy for weight loss of 26 lbs in a year
revealed a fungating, circumferential mass of malignant
appearancae was found in the sigmoid colon at 18cm. Biopsy
consistent with adenocarcinoma. CT torso revealed 3.7 cm segment
of the mid sigmoid colon demonstrating circumferential wall
thickening in keeping with tumor. There is no associated bowel
obstruction at present time. Adjacent mesenteric lymph nodes
measuring up to 6 mm in short axis dimension are noted. No
evidence of metastatic disease within the chest, abdomen, or
pelvis.
- ___ MR pelvis revealed Ill-defined sigmoid mass,
approximately 15 cm above the anal verge, as seen on the CT
examination from ___, with extension across the
muscularis propria. This is suspicious for T3 disease. 1.6 x 1.5
cm mass abutting the anterior aspect of the rectum and posterior
aspect of the seminal vesicles, 7 cm above the anal verge, is
suspicious for a drop metastasis as it is not convincingly
arising from rectal wall. This likely corresponds to the
palpable
finding on physical exam. Intrapelvic lymphadenopathy adjacent
to
the sigmoid mass, some with morphology suspicious for tumor
involvement.
- ___ Undderwent LAR. Path revealed colonic
adenocarcinoma
in the resected rectosigmoid colon. Tumor size was 3.6cm, low
grade, staged pT3. Margins were negative. Of the 15 nodes
examined, 6 were positive, thus staged pN2a. Finally, a separate
nodule of adenocarcinoma was identified 9 cm distal to the
primary tumor involving pericolonic adipose tissue, serosa, and
muscularis propria, consistent with metastasis of the primary
tumor. Furthermore, the resected peritoneal nodule showed
metastatic adenocarcinoma with perineural invasion. Thus, this
was staged pM1b. Of note, KRAS mutation was detected.
- ___ to ___ admitted for abdominal pain, OSH CT
was reviewed here and felt to be not concerning for any acute
intra-abdominal process including leak or abcess however there
was a high stool burden and gas. Pt discharged on bowel
regimen.
- ___ ED visit for abdominal pain, KUB reassuring,
discharged after bowel regimen
- ___ C1D1 XELOX (Xeloda 1000mg BID)
- ___ to ___ Admission for n/v and abd pain. CT
showed mildly dilated stomach and proximal small bowel, but no
evidence of obstruction. He underwent NGT decompression with
good
bilious output and improvement in symptoms and was slowly
advanced to regular diet.
- ___ C1D1 XELOX (Xeloda 1000mg BID)
- ___ to ___ admission for abd pain and
constipation. CT showed multiple mildly distended loops of ileum
with fecalized contents and a narrow caliber of the terminal
ileum. Stool and air seen in the colon. Symptoms improved
with
aggressive bowel regimen.
- ___ C3D1 XELOX (Xeloda 1500mg BID)
- ___ C4D1 XELOX (Xeloda 1500mg BID)
- ___ C5D1 XELOX (Xeloda 2000mg BID)
- ___ C6D1 XELOX (Xeloda 2000mg BID)
- ___ C7D1 XELOX (Xeloda 2000mg BID)
- ___ CT torso with no evidence of recurrence or
metastases
- ___ colonoscopy showed multiple tiny 2 mm polypoid
lesions which showed to be lymphoid aggregates on path
- ___ CT torso with no evidence of recurrence or
metastases
- ___ CT abdomen in the ED for abdominal pain showed ___
- ___ CT abdomen in the ED for abdominal pain showed ___
but indeterminate liver lesion
- ___ CT torso ___ with stable liver lesion
- ___ Colonoscopy revealed a single polyp, pathology
consistent with adenoma.
- ___ CT torso showed a new lesion in the splenic hilum
concerning for recurrence
- ___ PET CT showed avid lesion in the spleen, no other
sites of disease
- ___ Splenectomy revealed metastatic colon cancer
- ___ CT torso showed ___
- ___ CT torso extensive recurrence in the spenic bed and
nodes, CEA rising
- ___ Biopsy of the splenic bed confirmed metastatic
adenocarcinoma
- ___ CT torso showed increase in metastatic disease
- ___ CT torso showed increase in metastatic and
concerning new areas in the liver
PAST MEDICAL HISTORY:
Colon Ca as above
Lipoma
DVT
Social History:
___
Family History:
Negative for colon cancer, inflammatory bowel disease, uterine
cancer. He does have history of lipomas in his family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
================================
VITALS: T 99.2, 112/66, 65, 98% RA
General: Well appearing young Hispanic man, resting in bed
comfortably
Neuro:
Cranial nerves: PERRL, EOMI, palate elevates symmetrically,
facial sensation intact bilaterally
Alert and oriented, provides clear and cogent history
HEENT: Oropharynx clear, moist mucus membranes, no sinus
tenderness, no swelling/erythema in gingiva
Cardiovascular: RRR no murmurs
Chest/Pulmonary: Clear to auscultation bilaterally
Abdomen: Well healed surgical scars. Mildly tender to palpation
in the LLQ, chronic per patient. No rebound or guarding
Extr/MSK:
Underside of right upper arm is pink and slightly swollen.
Mildly
tender to palpation. Erythema outlined with pen; about 15 cm
extending from axilla down the arm
No swelling of LUE
No ___ edema, calf tenderness
Skin: + Tattoos over legs. Erythema of RUE as above. No rashes
seen elsewhere
Access: R POC, nontender to palpation, c/d/I
DISCHARGE PHYSICAL EXAM:
=========================
vitals
T 97.9 PO BP 108 / 65 HR 60 RR 15 98 RA
General: Well appearing young Hispanic man, resting in bed
comfortably
HEENT: Oropharynx clear, moist mucus membranes, no
lymphadenopathy
Cardiovascular: RRR no murmurs
Chest/Pulmonary: Clear to auscultation bilaterally
Abdomen: Well healed surgical scars. Mildly tender to palpation
in the LLQ, chronic per patient. No rebound or guarding
Extr/MSK:
Underside of right upper arm less erythematous than yesterday,
with no appreciable swelling. Mildly tender to deep palpation.
No swelling of LUE
No ___ edema, calf tenderness
Skin: + Tattoos over legs. Erythema of RUE as above. No rashes
seen elsewhere
Neuro: CN ___ grossly intact; no focal neuro deficits; AAOx4
Pertinent Results:
ADMISSION LABS:
===================
___ 02:19AM BLOOD WBC-10.6* RBC-4.14* Hgb-12.4* Hct-37.2*
MCV-90 MCH-30.0 MCHC-33.3 RDW-12.8 RDWSD-41.6 Plt ___
___ 02:19AM BLOOD Neuts-58.5 ___ Monos-15.4*
Eos-1.9 Baso-0.5 NRBC-0.3* Im ___ AbsNeut-6.18*
AbsLymp-2.46 AbsMono-1.62* AbsEos-0.20 AbsBaso-0.05
___ 02:19AM BLOOD Glucose-123* UreaN-14 Creat-1.0 Na-136
K-4.3 Cl-96 HCO3-28 AnGap-12
___ 02:19AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.3
RUE ULTRASOUND:
=================
IMPRESSION:
Occlusive thrombosis of the axillary vein and proximal portion
of one of the
paired brachial veins in the right upper extremity.
Non-occlusive thrombus
around the catheter in the right subclavian vein.
CT CHEST
==============
IMPRESSION:
1. Dilated right axillary vein, with adjacent fat stranding,
possibly
reflecting a deep venous thrombosis. Recommend upper extremity
ultrasound for
further evaluation.
2. Otherwise, no acute intrathoracic abnormality.
3. Stable prominent anterior paracardiac nodes.
4. Redemonstration of an ill-defined mass within the left upper
quadrant and a
hepatic dome lesion, slightly increased in size, both concerning
for
malignancy.
DISCHARGE LABS:
=================
___ 05:10AM BLOOD WBC-7.2 RBC-3.97* Hgb-11.7* Hct-35.9*
MCV-90 MCH-29.5 MCHC-32.6 RDW-13.1 RDWSD-43.2 Plt ___
___ 05:10AM BLOOD Plt ___
___ 04:06AM BLOOD Neuts-40.5 ___ Monos-16.5*
Eos-3.8 Baso-0.6 NRBC-0.4* Im ___ AbsNeut-3.27 AbsLymp-3.10
AbsMono-1.33* AbsEos-0.31 AbsBaso-0.05
___ 05:10AM BLOOD Glucose-108* UreaN-12 Creat-0.9 Na-141
K-4.5 Cl-102 HC___ AnGap-12
Brief Hospital Course:
TRANSITIONAL ISSUES:
=========================
[ ] started on rivaroxiban for AC - will take 15 BID for 20 days
and then decrease to 20mg daily.
[ ] There is a ___ authorization pending for the rivaroxaban
starter pack that will likely be approved early ___. His
___ clinic will ensure the PA is approved and contact the
family.
SUMMARY:
================
___ yo ___ speaking man with stage IV sigmoid adenocarcinoma
on palliative FOLFOX, DVT ___ not adherent to AC due to
issues with filling prescription, who presented with right arm
pain and subjective fevers/chills x 3
days and was found to have likely RUE DVT.
ACUTE ISSUES:
===========================
# RUE DVT, new encounter
# RLE DVT, ___. Difficulty with apixaban adherence previously
and recently switched to rivaroxaban, but did not receive
medication yet so has been off AC for at least 2 weeks ___ to
admission. CT Chest w/ contrast showing likely RUE DVT. Has R
POC, so likely
in s/o catheter and malignancy w/ noncompliance of AC. He had
some right shoulder pain associated w/ deep breathing 1 week
ago,
raising question of PE. Reviewed images with radiology
overnight;
there was no evidence of central PE and likely no segmental PE.
Subsegments not very well visualized ___ motion artifact and
fact
that this was not CTA. RUE ultrasound ___ positive for
occlusive thrombus involving R axillary vein and brachial vein.
Treated with heparin gtt and then restarted on Rivaroxaban ___.
Because rivaroxaban had not been approved by his insurance at
the time of discharge, he was given 1.5mg/kg of lovenox on ___
in the evening to bridge him for 24 hours. His primary
oncologist's office planned to follow-up on the ___
authorization and contact the family once it was approved
tomorrow. If not approved, the plan would be to come to ___
clinic for lovenox again. The sister of the patient ensured she
would be able to fill the scrip tomorrow and we carefully
reviewed the importance of not missing a dose.
# Leukocytosis, Resolving(At baseline. Without neutrophilic
predominance or left shift)
# 3 days fever/chills
# Right arm swelling/erythema
Received vanc/zosyn in ED. Has erythema, swelling, tenderness of
RUE; Otherwise ROS unrevealing for other source of infxn. Has
mild leukocytosis at baseline and white count has normalized
today, with patient afebrile and asymptomatic. LFTs within
normal limits. Antibiotics were discontinued and he remained
afebrile.
#Stage IV sigmoid adenocarcinoma on palliative FOLFOX ___.
next due for C2D1 on ___ oxali ___ ___: s/p LAR ___, 7 cycles of XELOX, with subsequent
metastasis to spenic bed s/p lap splenectomy, and gastric wedge
resection (___), with metastatic disease to the liver, recent
admit ___ for malignant partial SBO improved with
conservative mgmt. and initiation of palliative FOLFOX.
#Cancer-associated pain
- Continued hydromorphone 2 mg ___ tabs q4 PRN
- BM regimen PRN ordered (not requiring at home)
- T/b with oncologist regarding continuing FOLFOX C2D1
#Insomnia
Started mirtazapine ___ continue
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
3. Mirtazapine 15 mg PO QHS
4. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
5. Rivaroxaban 20 mg PO DAILY
Discharge Medications:
1. Rivaroxaban 15 mg PO BID
with food
RX *rivaroxaban [___] 15 mg (42)- 20 mg (9) 1 tablets(s) by
mouth see below Disp #*1 Dose Pack Refills:*0
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
3. Mirtazapine 15 mg PO QHS
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-------------
Deep Venous Thrombosis of the RUE
Leukocytosis
Stage IV sigmoid adenocarcinoma on palliative FOLFOX
Secondary:
--------------
Insomnia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had pain in your right arm and it was discovered you had a
blood clot.
- You had fevers and chills.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given medications to prevent further blood clotting.
- Your fever and chills were determined to be due to your blood
clot and cancer, and not due to an infection.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- It is very important that you take your medication called
Rivaroxaban, as it will prevent you from getting more blood
clots in the future.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10381484-DS-19 | 10,381,484 | 20,384,105 | DS | 19 | 2175-12-23 00:00:00 | 2175-12-23 15:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
pollen
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ yo ___ speaking man with stage IV
sigmoid adenocarcinoma s/p LAR (___), progression of disease
to spleen s/p splenectomy/distal pancreatectomy/wedge
___, on palliative FOLFOX (last chemo on ___,
prior DVT ___ on ___ who presented with gradual onset of
abdominal pain and emesis with imaging concerning for a partial
bowel obstruction.
In the ED, he reported 3 episodes of food filled emesis and
subjective fevers and chills. He has not had bowel movements
since the pain. Exam was notable for periumbilical and
epigastric tenderness with guarding and positive rebound. CRS
was consulted who felt this was not an acute surgical issue.
Pain improved with 0.5 of IV Dilaudid x 2.
On arrival to the floor, he is able to say that he feels great.
His friend helps to translate for him. He denies any abdominal
pain or nausea. He states that he had a bowel movement earlier
in the night after he received the pain medication.
He states that he would like to go home. I encouraged him to
trial clears and then try eating in the morning. He agreed with
this plan.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
Colon cancer stage IIIC (T3N2M0) of the sigmoid colon with
progressive metastatic disease
- ___ Colonscopy for weight loss of 26 lbs in a year
revealed a fungating, circumferential mass of malignant
appearance was found in the sigmoid colon at 18cm. Biopsy
consistent with adenocarcinoma. CT torso revealed 3.7 cm segment
of the mid sigmoid colon demonstrating circumferential wall
thickening in keeping with tumor. There is no associated bowel
obstruction at present time. Adjacent mesenteric lymph nodes
measuring up to 6 mm in short axis dimension are noted. No
evidence of metastatic disease within the chest, abdomen, or
pelvis.
- ___ MR pelvis revealed Ill-defined sigmoid mass,
approximately 15 cm above the anal verge, as seen on the CT
examination from ___, with extension across the
muscularis propria. This is suspicious for T3 disease. 1.6 x 1.5
cm mass abutting the anterior aspect of the rectum and posterior
aspect of the seminal vesicles, 7 cm above the anal verge, is
suspicious for a drop metastasis as it is not convincingly
arising from rectal wall. This likely corresponds to the
palpable
finding on physical exam. Intrapelvic lymphadenopathy adjacent
to
the sigmoid mass, some with morphology suspicious for tumor
involvement.
- ___ Undderwent LAR. Path revealed colonic
adenocarcinoma
in the resected rectosigmoid colon. Tumor size was 3.6cm, low
grade, staged pT3. Margins were negative. Of the 15 nodes
examined, 6 were positive, thus staged pN2a. Finally, a separate
nodule of adenocarcinoma was identified 9 cm distal to the
primary tumor involving pericolonic adipose tissue, serosa, and
muscularis propria, consistent with metastasis of the primary
tumor. Furthermore, the resected peritoneal nodule showed
metastatic adenocarcinoma with perineural invasion. Thus, this
was staged pM1b. Of note, KRAS mutation was detected.
- ___ to ___ admitted for abdominal pain, OSH CT
was reviewed here and felt to be not concerning for any acute
intra-abdominal process including leak or abcess however there
was a high stool burden and gas. Pt discharged on bowel
regimen.
- ___ ED visit for abdominal pain, KUB reassuring,
discharged after bowel regimen
- ___ C1D1 XELOX (Xeloda 1000mg BID)
- ___ to ___ Admission for n/v and abd pain. CT
showed mildly dilated stomach and proximal small bowel, but no
evidence of obstruction. He underwent NGT decompression with
good
bilious output and improvement in symptoms and was slowly
advanced to regular diet.
- ___ C1D1 XELOX (Xeloda 1000mg BID)
- ___ to ___ admission for abd pain and
constipation. CT showed multiple mildly distended loops of ileum
with fecalized contents and a narrow caliber of the terminal
ileum. Stool and air seen in the colon. Symptoms improved
with
aggressive bowel regimen.
- ___ C3D1 XELOX (Xeloda 1500mg BID)
- ___ C4D1 XELOX (Xeloda 1500mg BID)
- ___ C5D1 XELOX (Xeloda 2000mg BID)
- ___ C6D1 XELOX (Xeloda 2000mg BID)
- ___ C7D1 XELOX (Xeloda 2000mg BID)
- ___ CT torso with no evidence of recurrence or
metastases
- ___ colonoscopy showed multiple tiny 2 mm polypoid
lesions which showed to be lymphoid aggregates on path
- ___ CT torso with no evidence of recurrence or
metastases
- ___ CT abdomen in the ED for abdominal pain showed ___
- ___ CT abdomen in the ED for abdominal pain showed ___
but indeterminate liver lesion
- ___ CT torso ___ with stable liver lesion
- ___ Colonoscopy revealed a single polyp, pathology
consistent with adenoma.
- ___ CT torso showed a new lesion in the splenic hilum
concerning for recurrence
- ___ PET CT showed avid lesion in the spleen, no other
sites of disease
- ___ Splenectomy revealed metastatic colon cancer
- ___ CT torso showed ___
- ___ CT torso extensive recurrence in the spenic bed and
nodes, CEA rising
- ___ Biopsy of the splenic bed confirmed metastatic
adenocarcinoma
- ___ CT torso showed increase in metastatic disease
- ___ CT torso showed increase in metastatic and
concerning new areas in the liver
- ___ Admitted with malignant SBO
- ___ C1D1 FOLFOX6
- ___ ___ FOLFOX (oxaliplatin at 65 ___
neuropathy)
- ___ C2D1 FOLFOX (oxaliplatin at 65 ___ neuropathy
PAST MEDICAL HISTORY:
Colon Ca as above
Lipoma
DVT
Social History:
___
Family History:
Negative for colon cancer, inflammatory bowel disease, uterine
cancer. He does have history of lipomas in his family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=============================
Vitals: T: 98.4 PO BP:119/66 L Lying HR: 94 RR: 18 Sp02: 96 RA
GENERAL: Lying in bed appearing comfortable.
LUNGS: On RA, no increased work of breathing, no wheezes, rales
or ronchi.
HEART: RRR no m/r/g
ABD: Soft, non-tender, non-distended, + BS (but minimal)
EXT: No edema.
DISCHARGE PHYSICAL EXAM:
=============================
VITALS: ___ 0852 Temp: 98.7 PO BP: 124/69 HR: 60 RR: 16 O2
sat: 100% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: Alert and in no apparent distress
EYES: Anicteric, no conjunctival injection, pupils equally round
CV: Heart regular, no murmur, no S3, no S4.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-tender in all quadrants, non-distended. No
rebound or guarding.
EXT: Warm and well perfused. No ___ edema.
NEURO: Alert, oriented, face symmetric, gaze conjugate with EOM,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate mood and affect
Pertinent Results:
ADMISSION LABS:
========================
___ 09:20AM BLOOD WBC-9.5 RBC-3.75* Hgb-11.2* Hct-34.7*
MCV-93 MCH-29.9 MCHC-32.3 RDW-16.7* RDWSD-54.6* Plt ___
___ 09:20AM BLOOD Neuts-86.1* Lymphs-8.0* Monos-4.8*
Eos-0.4* Baso-0.4 NRBC-0.8* Im ___ AbsNeut-8.16*
AbsLymp-0.76* AbsMono-0.46 AbsEos-0.04 AbsBaso-0.04
___ 09:20AM BLOOD Glucose-142* UreaN-11 Creat-0.7 Na-141
K-4.2 Cl-102 HCO3-25 AnGap-14
___ 10:30AM BLOOD ALT-13 AST-15 AlkPhos-65 TotBili-0.2
___ 10:30AM BLOOD Lipase-24
___ 10:30AM BLOOD Albumin-4.0
___ 10:37AM BLOOD Lactate-1.1
DISCHARGE LABS:
========================
___ 05:52AM BLOOD WBC-6.8 RBC-3.73* Hgb-11.1* Hct-34.1*
MCV-91 MCH-29.8 MCHC-32.6 RDW-16.5* RDWSD-54.6* Plt ___
___ 05:52AM BLOOD Neuts-45.6 ___ Monos-14.8*
Eos-2.8 Baso-0.6 NRBC-1.0* Im ___ AbsNeut-3.11 AbsLymp-2.44
AbsMono-1.01* AbsEos-0.19 AbsBaso-0.04
___ 05:52AM BLOOD ___ PTT-30.6 ___
___ 05:52AM BLOOD Glucose-106* UreaN-9 Creat-0.9 Na-142
K-3.9 Cl-103 HCO3-28 AnGap-11
___ 05:52AM BLOOD ALT-11 AST-13 LD(LDH)-206 AlkPhos-60
TotBili-0.4
___ 05:52AM BLOOD Albumin-3.8 Calcium-9.2 Phos-4.3 Mg-2.1
PERTINENT STUDIES:
========================
CT ABD/PELVIS W/ CONTRAST ___
IMPRESSION:
1. Dilated loops of small bowel in the mid abdomen, likely
jejunal loops, with transition point at the unchanged 3.6 x 2.4
x 2.5 cm soft tissue mass, which appears contiguous with the
wall of the jejunum, consistent with partial/early small-bowel
obstruction.
2. Unchanged moderate right hydronephrosis due to patient's 3
focal peritoneal soft tissue lesions in the right lower
quadrant, which are unchanged compared to prior.
3. Trace perihepatic ascites.
4. Additional, unchanged, chronic findings, as above.
Brief Hospital Course:
___ is a ___ yo ___ speaking man with stage IV
sigmoid adenocarcinoma s/p LAR (___), progression of disease
to spleen s/p splenectomy/distal pancreatectomy/wedge
___, on palliative FOLFOX (last chemo on ___,
prior DVT ___ on ___ who presented with gradual onset of
abdominal pain and emesis with imaging concerning for a partial
bowel obstruction, his symptoms subsequently resolved and he was
able to tolerate food well.
Active Issues:
#Partial SBO: He had abdominal pain and vomiting with imaging
concerning for partial SBO. His symptoms completely resolved and
he had a bowel movement in the emergency room before coming to
the floor. He continued to have flatus on the floor without a
second bowel movement. His diet was advanced from clears to
regular diet and he was able to tolerate food without any
issues. Colorectal surgery evaluated him and signed off prior to
his discharge. I expressed the preference to monitor him until
he had another bowel movement but he preferred to be discharged
home. He was counseled on the risk of recurrent obstruction and
warning signs that should prompt return to the hospital. This
was done with the assistance of a ___ interpreter. The
patient stated he had someone who could translate discharge
instructions written in ___.
Chronic Issues:
#Stage IV sigmoid adenocarcinoma on palliative FOLFOX
Prior: s/p LAR ___, 7 cycles of XELOX, with subsequent
metastasis to spenic bed s/p lap splenectomy, and gastric wedge
resection (___), with metastatic disease to the liver, recent
admit ___ for malignant partial SBO improved with
conservative mgmt and initiation of palliative FOLFOX. He has a
f/u with oncology on ___.
#Cancer-associated pain: Continued hydromorphone 2 mg ___ tabs
q4 PRN with bowel regimen.
#Insomnia: Continue home mirtazapine.
Transitional Issues:
[ ] Will need to ensure he takes senna when he takes his
Dilaudid.
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.
The patient was seen and examined today. Greater than 30 minutes
were spent on discharge planning and coordination.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
2. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. Mirtazapine 15 mg PO QHS
5. Rivaroxaban 20 mg PO DAILY
Discharge Medications:
1. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
3. Mirtazapine 15 mg PO QHS
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
6. Rivaroxaban 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Partial Small Bowel Obstruction
Abdominal Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were brought to the hospital because you had significant
abdominal pain and we found that you had a partial bowel
obstruction. While you were here, your symptoms resolved and
you started to feel much better. We gave you some food which
you were able to eat without issue. You had a bowel movement and
passed some gas. We preferred to continue to observe you until
you had another bowel movement but you expressed a strong desire
to return home.
If you have any worsening abdominal pain, swelling, or other
symptoms you should return to the hospital.
We encourage you to make sure that take Senna whenever you take
your pain pills to make sure you don't get constipated.
It was a pleasure taking care of you,
-Your ___ Team
Followup Instructions:
___
|
10381484-DS-21 | 10,381,484 | 25,100,289 | DS | 21 | 2176-02-17 00:00:00 | 2176-02-17 23:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
pollen
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a pleasant ___ with stage IV sigmoid
adenocarcinoma s/p LAR (___) with subsequent POD involving
spleen now s/p splenectomy/distal pancreatectomy/wedge
gastrectomy (___) currently on palliative C1D25 Irinotecan
and
DVT on rivaroxaban who p/w diffuse abdominal pain, concern for
malignant bowel obstruction.
Sx started yesterday w/ diffuse abd pain, + nausea, no vomiting,
+ diarrhea at 2 am.
Of note, recently admitted ___ for abdominal pain thought
to be related to neoplasm but no acute pathology otherwise seen
on CT. Discharged on dilaudid and apap. He subsequently
represented to the ED with abdominal pain ___ and CT showed
persistent R hydronephrosis iso malignant obstruction, 3 pelvic
soft tissue masses (mild interval increase in size), and large
mass in the splenectomy bed (no interval change). No SBO on this
CAT scan. He presents this time to ED with diffuse abdominal
pain, diarrhea, and nausea. Patient was afebrile and mildly
hypertensive upon arrival. Labs were all largely unremarkable.
Repeat CT A/P shows concern for SBO ___ omental implant in the L
mid abdomen, additionally thickening of the bowel wall in the L
mid abdomen concern for an additional submucosal metastatic
lesion. Patient was administered dilaudid and IVF. He refused
placement of an NGT in the ED. Colorectal was consulted, no
acute
indication for surgical intervention. Of note, patient last took
xeralto at 12AM ___. Patient was admitted for IVF, bowel rest,
serial abdominal exams.
On arrival to the oncology service, pt noted he had zero abd
pain
and zero nausea. Admits to passing gas, no stool yet, and
feeling
"very hungry."
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
As per last ___ clinic note by Dr ___:
"Colon cancer stage IIIC (T3N2M0) of the sigmoid colon with
progressive metastatic disease, KRAS mutated, MSI intact
- ___ Colonscopy for weight loss of 26 lbs in a year
revealed a fungating, circumferential mass of malignant
appearance was found in the sigmoid colon at 18cm. Biopsy
consistent with adenocarcinoma. CT torso revealed 3.7 cm segment
of the mid sigmoid colon demonstrating circumferential wall
thickening in keeping with tumor. There is no associated bowel
obstruction at present time. Adjacent mesenteric lymph nodes
measuring up to 6 mm in short axis dimension are noted. No
evidence of metastatic disease within the chest, abdomen, or
pelvis.
- ___ MR pelvis revealed Ill-defined sigmoid mass,
approximately 15 cm above the anal verge, as seen on the CT
examination from ___, with extension across the
muscularis propria. This is suspicious for T3 disease. 1.6 x 1.5
cm mass abutting the anterior aspect of the rectum and posterior
aspect of the seminal vesicles, 7 cm above the anal verge, is
suspicious for a drop metastasis as it is not convincingly
arising from rectal wall. This likely corresponds to the
palpable
finding on physical exam. Intrapelvic lymphadenopathy adjacent
to
the sigmoid mass, some with morphology suspicious for tumor
involvement.
- ___ Undderwent LAR. Path revealed colonic
adenocarcinoma
in the resected rectosigmoid colon. Tumor size was 3.6cm, low
grade, staged pT3. Margins were negative. Of the 15 nodes
examined, 6 were positive, thus staged pN2a. Finally, a separate
nodule of adenocarcinoma was identified 9 cm distal to the
primary tumor involving pericolonic adipose tissue, serosa, and
muscularis propria, consistent with metastasis of the primary
tumor. Furthermore, the resected peritoneal nodule showed
metastatic adenocarcinoma with perineural invasion. Thus, this
was staged pM1b. Of note, KRAS mutation was detected.
- ___ to ___ admitted for abdominal pain, OSH CT
was reviewed here and felt to be not concerning for any acute
intra-abdominal process including leak or abcess however there
was a high stool burden and gas. Pt discharged on bowel regimen.
- ___ ED visit for abdominal pain, KUB reassuring,
discharged after bowel regimen
- ___ C1D1 XELOX (Xeloda 1000mg BID)
- ___ to ___ Admission for n/v and abd pain. CT
showed mildly dilated stomach and proximal small bowel, but no
evidence of obstruction. He underwent NGT decompression with
good
bilious output and improvement in symptoms and was slowly
advanced to regular diet.
- ___ C1D1 XELOX (Xeloda 1000mg BID)
- ___ to ___ admission for abd pain and
constipation. CT showed multiple mildly distended loops of ileum
with fecalized contents and a narrow caliber of the terminal
ileum. Stool and air seen in the colon. Symptoms improved with
aggressive bowel regimen.
- ___ C3D1 XELOX (Xeloda 1500mg BID)
- ___ C4D1 XELOX (Xeloda 1500mg BID)
- ___ C5D1 XELOX (Xeloda 2000mg BID)
- ___ C6D1 XELOX (Xeloda 2000mg BID)
- ___ C7D1 XELOX (Xeloda 2000mg BID)
- ___ CT torso with no evidence of recurrence or
metastases
- ___ colonoscopy showed multiple tiny 2 mm polypoid
lesions which showed to be lymphoid aggregates on path
- ___ CT torso with no evidence of recurrence or
metastases
- ___ CT abdomen in the ED for abdominal pain showed ___
- ___ CT abdomen in the ED for abdominal pain showed ___
but indeterminate liver lesion
- ___ CT torso ___ with stable liver lesion
- ___ Colonoscopy revealed a single polyp, pathology
consistent with adenoma.
- ___ CT torso showed a new lesion in the splenic hilum
concerning for recurrence
- ___ PET CT showed avid lesion in the spleen, no other
sites of disease
- ___ Splenectomy revealed metastatic colon cancer
- ___ CT torso showed ___
- ___ CT torso extensive recurrence in the spenic bed and
nodes, CEA rising
- ___ Biopsy of the splenic bed confirmed metastatic
adenocarcinoma
- ___ CT torso showed increase in metastatic disease
- ___ CT torso showed increase in metastatic and
concerning new areas in the liver
- ___ Admitted with malignant SBO
- ___ C1D1 FOLFOX6
- ___ C1D15 FOLFOX (oxaliplatin at 65 ___
neuropathy)
- ___ C2D1 FOLFOX (oxaliplatin at 65 ___ neuropathy
- ___ CT torso shows stable disease
- ___ Treatment delayed per patient preference
- ___ C3D1 FOLFOX (oxaliplatin at 65 ___
neuropathy)
- ___ Patient requested to defer dose, CEA rising
- ___ C1D1 ___
PAST MEDICAL HISTORY (per OMR):
as above
Social History:
___
Family History:
Negative for colon cancer, inflammatory bowel disease, uterine
cancer. He does have history of lipomas in his family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITAL SIGNS: 97.7 PO 134 / 81 54 18 99 RA
General: NAD, Resting in bed comfortably
HEENT: MMM, no OP lesions
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no peritoneal signs
LIMBS: WWP, no ___, no tremors
SKIN: No notable rashes on trunk nor extremities
NEURO: CN III-XII intact, strength b/l ___ intact
PSYCH: Thought process logical, linear, future oriented
ACCESS: R Chest port site intact w/o overlying erythema,
accessed
and dressing C/D/I
DISCHARGE PHYSICAL EXAM:
==========================
VITAL SIGNS: 24 HR Data (last updated ___ @ 850)
Temp: 98.8 (Tm 98.8), BP: 132/81 (132-149/80-83), HR: 53
(53-55), RR: 18, O2 sat: 99%
General: NAD, Resting in bed comfortably
HEENT: MMM, no OP lesions
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, non distended, mildly tender to palpation in
LLQ, no
peritoneal signs
LIMBS: WWP, no ___, no tremors
SKIN: No notable rashes on trunk nor extremities
NEURO: CN III-XII intact, strength b/l ___ intact
PSYCH: Thought process logical, linear, future oriented
ACCESS: R Chest port site intact w/o overlying erythema,
accessed
and dressing C/D/I
Pertinent Results:
ADMISSION LABS:
===============
___ 04:00AM BLOOD WBC-8.0 RBC-3.62* Hgb-10.9* Hct-33.2*
MCV-92 MCH-30.1 MCHC-32.8 RDW-14.5 RDWSD-48.7* Plt ___
___ 04:00AM BLOOD Neuts-54.1 ___ Monos-13.3*
Eos-10.9* Baso-0.5 Im ___ AbsNeut-4.33 AbsLymp-1.65
AbsMono-1.06* AbsEos-0.87* AbsBaso-0.04
___ 04:00AM BLOOD Plt ___
___ 09:25PM BLOOD PTT-45.9*
___ 04:00AM BLOOD Glucose-108* UreaN-12 Creat-1.1 Na-140
K-3.8 Cl-103 HCO3-25 AnGap-12
___ 04:00AM BLOOD ALT-18 AST-16 AlkPhos-67 TotBili-<0.2
___ 04:00AM BLOOD Albumin-4.0 Calcium-9.2 Phos-3.6
DISCHARGE LABS:
================
___ 05:30AM BLOOD WBC-6.4 RBC-3.49* Hgb-10.5* Hct-32.2*
MCV-92 MCH-30.1 MCHC-32.6 RDW-14.5 RDWSD-48.6* Plt ___
___ 05:30AM BLOOD Plt ___
___ 11:30AM BLOOD PTT-115.4*
___ 05:30AM BLOOD Glucose-104* UreaN-6 Creat-1.0 Na-141
K-3.6 Cl-102 HCO3-29 AnGap-10
___ 05:30AM BLOOD Calcium-8.5 Phos-4.4 Mg-1.8
IMAGING:
=========
___BD & PELVIS WITH CO
IMPRESSION:
1. Findings concerning for small bowel obstruction secondary to
a 3.2 cm
omental implant in the left mid abdomen. No signs to suggest
bowel ischemia.
2. Relatively hyperdense, asymmetric thickening of the bowel
wall in the left mid abdomen (601:75, 2:48) likely represents an
additional submucosal
metastatic lesion.
3. Persistent moderate to severe right-sided
hydroureteronephrosis with a
delayed right nephrogram secondary to malignant obstruction of
the right
distal ureter, similar to prior.
4. Re-demonstration of the 3 previously noted omental implants
in the
abdomen/pelvis measuring up to 3.6 cm, similar to prior.
5. Re-demonstration of a large 7.1 cm mass in the splenectomy
bed as well as a 2.2 cm omental implant fat in the liver dome.
Brief Hospital Course:
HOSPITAL COURSE:
=====================
___ with stage IV sigmoid adenocarcinoma s/p LAR (___) with
subsequent POD involving spleen now s/p splenectomy/distal
pancreatectomy/wedge gastrectomy (___) currently on
palliative C1D25 Irinotecan and DVT on rivaroxaban who p/w
diffuse abdominal pain, concerning for malignant small bowel
obstruction.
# Stage IV Sigmoid Adenocarcinoma s/p LAR ___
# S/p splenectomy/distal pancreatectomy/wedge gastrectomy
(___)
# Malignant SBO
A CT scan performed on the day of admission showed a small bowel
obstruction secondary to a 3.2 cm omental implant in the left
mid abdomen and with no signs to suggest bowel ischemia. Pt
noted his symptoms are continuing to improve since arriving to
the ED. Upon discharge and during his hospital course, he did
not have nausea or vomiting, and is passing gas. He did not pass
any stool from the time of admission for discharge. His exam was
not concerning for acute abdomen and was only notable for LLQ
tenderness on palpation which started to resolve during his
hospital course. After speaking to his oncologist (Dr.
___, it was determined that since he could tolerate clear
liquids as well as yogurt, he could be discharged with close
follow up. He will follow up with his appointment with Dr.
___ on ___. If he could not tolerate any PO intake, the
plan was to start inpatient chemotherapy. Colorectal surgery was
also consulted and agreed that surgery was not needed now if
chemotherapy is an option. Please note that there have been some
issues with compliance with chemotherapy in the past, there
might be some process of denial.
# hx DVT
Due to his potential for surgical intervention, his rivaroxaban
was held and he was started on a heparin gtt. After confirming
that there was no need for surgery, he was restarted on his
rivaroxaban.
Greater than 30 min were spent in discharge coordination and
care
TRANSITIONAL ISSUES:
======================
[ ] Please ensure that Mr. ___ follows up with his
outpatient oncologist on ___.
[ ] Please ensure that Mr. ___ has a bowel movement. He has
not had one during his stay in the hospital. He has been passing
gas and his abdominal exam was unremarkable upon discharge. This
was discussed with Dr. ___ agreed that if the patient
could tolerate even soup, then it was reasonable to discharge
and follow up with him next week.
[ ] Please ensure that Mr. ___ can continue tolerating PO
intake.
ACCESS: PORT
CODE STATUS: Full code, presumed
#HCP/Contact: friend ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
2. Ondansetron 8 mg PO Q8H:PRN nausea
3. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
4. Rivaroxaban 20 mg PO DAILY
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
7. Acetaminophen 650 mg PO Q8H
8. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
6. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
7. Rivaroxaban 20 mg PO DAILY
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
=========
Malignant small bowel obstruction
SECONDARY:
===========
Stage IV adenocarcinoma
History of DVTs
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because of abdominal pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We performed imaging that showed that intestines were being
compressed from your cancer, causing obstruction.
- We gave you pain medication, and allow your intestines to
rest.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please ensure that you follow-up with the outpatient
oncologist next ___. This is absolutely essential.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10381484-DS-22 | 10,381,484 | 22,964,619 | DS | 22 | 2176-03-04 00:00:00 | 2176-03-05 13:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
pollen
Attending: ___.
Chief Complaint:
diarrhea, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old man with a history of stage IV
sigmoid adenocarcinoma s/p LAR (___) with subsequent disease
progression involving the spleen now s/p splenectomy/distal
pancreatectomy/wedge gastrectomy (___), currently on
palliative Irinotecan, as well as history of DVT on rivaroxaban,
who presents with diarrhea and abdominal pain for 3 days.
The patient states that he has had diarrhea and abdominal pain
for the past 3 days. He also notes feeling weak. Does not report
melena or hematochezia. No nausea or vomiting. No fever or
chills. He has been able to eat and drink at home. The diarrhea
has been occurring ___ and the patient feels like he is
constantly on the toilet.
On arrival to the ED:
Initial vitals- T 98.7, HR 70, BP 132/95, RR 16, O2 sat 100% RA
Physical exam- Tender left lower quadrant to palpation.
Otherwise normal physical exam.
Labs notable for- Hgb 11.6, WBC 6.4, chem-7 and LFTs wnl,
lactate 1.0
Imaging notable for- CT A/P: 1. Stable malignant obstruction of
the right kidney resulting in moderate to severe
hydroureteronephrosis, unchanged compared to prior exam.
2. Redemonstration of a large 6.9 cm mass in the splenectomy bed
with multiple omental, peritoneal, and pelvic implants
consistent with metastatic foci. These are not substantially
changed in size compared to recent CT abdomen pelvis dated ___.
3. Stable asymmetric wall thickening of left mid abdominal wall
bowel loop, likely representing a additional focus of submucosal
metastatic disease.
4. No imaging evidence to suggest colitis, diverticulitis, or
bowel
obstruction.
In the ED, the patient received 1 dose of morphine 4mg and 1L of
NS.
Vital signs on floor transfer- T 97.8, HR 61, BP 133/84, RR 16,
O2 sat 100% RA
On arrival to the floor, the patient confirmed the above
history. He is quite bothered by the frequency of his diarrhea.
Also describes left sided abdominal pain. Does not report
fevers, chills, chest pain, shortness of breath, nausea, and
vomiting.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
As per last ___ clinic note by Dr ___:
"Colon cancer stage IIIC (T3N2M0) of the sigmoid colon with
progressive metastatic disease, KRAS mutated, MSI intact
- ___ Colonscopy for weight loss of 26 lbs in a year
revealed a fungating, circumferential mass of malignant
appearance was found in the sigmoid colon at 18cm. Biopsy
consistent with adenocarcinoma. CT torso revealed 3.7 cm segment
of the mid sigmoid colon demonstrating circumferential wall
thickening in keeping with tumor. There is no associated bowel
obstruction at present time. Adjacent mesenteric lymph nodes
measuring up to 6 mm in short axis dimension are noted. No
evidence of metastatic disease within the chest, abdomen, or
pelvis.
- ___ MR pelvis revealed Ill-defined sigmoid mass,
approximately 15 cm above the anal verge, as seen on the CT
examination from ___, with extension across the
muscularis propria. This is suspicious for T3 disease. 1.6 x 1.5
cm mass abutting the anterior aspect of the rectum and posterior
aspect of the seminal vesicles, 7 cm above the anal verge, is
suspicious for a drop metastasis as it is not convincingly
arising from rectal wall. This likely corresponds to the
palpable
finding on physical exam. Intrapelvic lymphadenopathy adjacent
to
the sigmoid mass, some with morphology suspicious for tumor
involvement.
- ___ Undderwent LAR. Path revealed colonic
adenocarcinoma
in the resected rectosigmoid colon. Tumor size was 3.6cm, low
grade, staged pT3. Margins were negative. Of the 15 nodes
examined, 6 were positive, thus staged pN2a. Finally, a separate
nodule of adenocarcinoma was identified 9 cm distal to the
primary tumor involving pericolonic adipose tissue, serosa, and
muscularis propria, consistent with metastasis of the primary
tumor. Furthermore, the resected peritoneal nodule showed
metastatic adenocarcinoma with perineural invasion. Thus, this
was staged pM1b. Of note, KRAS mutation was detected.
- ___ to ___ admitted for abdominal pain, OSH CT
was reviewed here and felt to be not concerning for any acute
intra-abdominal process including leak or abcess however there
was a high stool burden and gas. Pt discharged on bowel regimen.
- ___ ED visit for abdominal pain, KUB reassuring,
discharged after bowel regimen
- ___ C1D1 XELOX (Xeloda 1000mg BID)
- ___ to ___ Admission for n/v and abd pain. CT
showed mildly dilated stomach and proximal small bowel, but no
evidence of obstruction. He underwent NGT decompression with
good
bilious output and improvement in symptoms and was slowly
advanced to regular diet.
- ___ C1D1 XELOX (Xeloda 1000mg BID)
- ___ to ___ admission for abd pain and
constipation. CT showed multiple mildly distended loops of ileum
with fecalized contents and a narrow caliber of the terminal
ileum. Stool and air seen in the colon. Symptoms improved with
aggressive bowel regimen.
- ___ C3D1 XELOX (Xeloda 1500mg BID)
- ___ C4D1 XELOX (Xeloda 1500mg BID)
- ___ C5D1 XELOX (Xeloda 2000mg BID)
- ___ C6D1 XELOX (Xeloda 2000mg BID)
- ___ C7D1 XELOX (Xeloda 2000mg BID)
- ___ CT torso with no evidence of recurrence or
metastases
- ___ colonoscopy showed multiple tiny 2 mm polypoid
lesions which showed to be lymphoid aggregates on path
- ___ CT torso with no evidence of recurrence or
metastases
- ___ CT abdomen in the ED for abdominal pain showed ___
- ___ CT abdomen in the ED for abdominal pain showed ___
but indeterminate liver lesion
- ___ CT torso ___ with stable liver lesion
- ___ Colonoscopy revealed a single polyp, pathology
consistent with adenoma.
- ___ CT torso showed a new lesion in the splenic hilum
concerning for recurrence
- ___ PET CT showed avid lesion in the spleen, no other
sites of disease
- ___ Splenectomy revealed metastatic colon cancer
- ___ CT torso showed ___
- ___ CT torso extensive recurrence in the spenic bed and
nodes, CEA rising
- ___ Biopsy of the splenic bed confirmed metastatic
adenocarcinoma
- ___ CT torso showed increase in metastatic disease
- ___ CT torso showed increase in metastatic and
concerning new areas in the liver
- ___ Admitted with malignant SBO
- ___ C1D1 FOLFOX6
- ___ C1D15 FOLFOX (oxaliplatin at 65 ___
neuropathy)
- ___ C2D1 FOLFOX (oxaliplatin at 65 ___ neuropathy
- ___ CT torso shows stable disease
- ___ Treatment delayed per patient preference
- ___ C3D1 FOLFOX (oxaliplatin at 65 ___
neuropathy)
- ___ Patient requested to defer dose, CEA rising
- ___ C1D1 ___
PAST MEDICAL HISTORY:
Sigmoid adenocarcinoma
DVT
Social History:
___
Family History:
Negative for colon cancer, inflammatory bowel disease, uterine
cancer. He does have history of lipomas in his family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: T98.1 PO, BP 115 / 75, HR 59, RR 18, O2 sat 100% on RA
GENERAL: thin, middle-aged man, lying down in bed, appears
comfortable and in no acute distress
HEENT: oropharynx clear, without erythema or exudate, MMM
NECK: supple
LUNGS: clear to auscultation bilaterally, no wheezes, rales, or
rhonchi
HEART: regular rate and rhythm, nl s1/s2, no murmurs, rubs, or
gallops
ABD: soft, non-distended, tenderness to palpation in the LLQ,
normal bowel sounds
EXT: warm and well-perfused, no lower extremity edema
SKIN: no rashes
NEURO: A&Ox3, moving all 4 extremities with purpose
ACCESS: Port
DISCHARGE PHYSICAL EXAM:
========================
Vitals: ___ 0350 Temp: 98.5 PO BP: 135/88 HR: 65 RR: 18 O2
sat: 99% O2 delivery: RA
GENERAL: thin, middle-aged man, sitting up in bed, appears
comfortable and in no acute distress
HEENT: oropharynx clear, without erythema or exudate, MMM
NECK: supple
LUNGS: clear to auscultation bilaterally, no wheezes, rales, or
rhonchi
HEART: regular rate and rhythm, nl s1/s2, no murmurs, rubs, or
gallops
ABD: soft, non-distended, tenderness to palpation in the LLQ,
normal bowel sounds
EXT: warm and well-perfused, no lower extremity edema
SKIN: no rashes
NEURO: A&Ox3, moving all 4 extremities with purpose
ACCESS: Port
Pertinent Results:
ADMISSION LABS:
===============
___ 04:30AM BLOOD WBC-6.4 RBC-3.88* Hgb-11.6* Hct-35.9*
MCV-93 MCH-29.9 MCHC-32.3 RDW-13.9 RDWSD-46.4* Plt ___
___ 04:30AM BLOOD Neuts-47.6 ___ Monos-13.5*
Eos-9.5* Baso-0.6 Im ___ AbsNeut-3.07 AbsLymp-1.82
AbsMono-0.87* AbsEos-0.61* AbsBaso-0.04
___ 04:30AM BLOOD Glucose-105* UreaN-15 Creat-1.1 Na-140
K-4.4 Cl-104 HCO3-25 AnGap-11
___ 04:30AM BLOOD ALT-18 AST-18 AlkPhos-69 TotBili-<0.2
___ 04:30AM BLOOD Albumin-4.2
___ 04:47AM BLOOD Lactate-1.0
DISCHARGE LABS:
===============
___ 08:00AM BLOOD WBC-6.6 RBC-3.57* Hgb-10.8* Hct-33.3*
MCV-93 MCH-30.3 MCHC-32.4 RDW-13.8 RDWSD-46.5* Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD Glucose-90 UreaN-16 Creat-1.0 Na-142
K-4.0 Cl-103 HCO3-25 AnGap-14
___ 08:00AM BLOOD ALT-14 AST-13 AlkPhos-59 TotBili-<0.2
___ 08:00AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.0
MICRO:
======
___ 4:15 am BLOOD CULTURE #1.
Blood Culture, Routine (Pending): No growth to date.
___ 4:30 am BLOOD CULTURE #2.
Blood Culture, Routine (Pending): No growth to date.
IMAGING:
========
___ CT ABD/PELVIS
1. Stable malignant obstruction of the right kidney resulting in
moderate to severe hydroureteronephrosis, unchanged compared to
prior exam.
2. Redemonstration of a large 6.9 cm mass in the splenectomy bed
with multiple
omental, peritoneal, and pelvic implants consistent with
metastatic foci.
These are not substantially changed in size compared to recent
CT abdomen
pelvis dated ___.
3. Stable asymmetric wall thickening of left mid abdominal wall
bowel loop,
likely representing a additional focus of submucosal metastatic
disease.
4. No imaging evidence to suggest colitis, diverticulitis, or
bowel
obstruction.
Brief Hospital Course:
Mr. ___ is a ___ year-old man with a history of stage IV
sigmoid adenocarcinoma s/p LAR (___) with subsequent disease
progression involving the spleen now s/p splenectomy/distal
pancreatectomy/wedge gastrectomy (___), currently on
palliative Irinotecan, as well as history of DVT on rivaroxaban,
who presented with diarrhea and abdominal pain for 3 days likely
secondary to irinotecan.
ACUTE ISSUES
#Abdominal pain
#Diarrhea: The patient's current presentation is most likely
secondary to a known side effect of his chemotherapy, as
irinotecan is quite diarrheogenic. While infection is also
possible, this would seem less likely given the patient's lack
of recent travel or eating unusual foods. CT abdomen and pelvis
in the ED showed no evidence of infection or colitis. Normal WBC
count on labs. The patient was given Lomotil with improvement in
his symptoms and pain.
#Metastatic sigmoid adenocarcinoma: Currently on palliative
irinotecan with no evidence of disease progression on CT scan.
Plan for next cycle on ___.
CHRONIC ISSUES
#DVT: Continued home rivaroxaban.
TRANSITIONAL ISSUES
[] patient has had problems with medication non-compliance in
the past; should continue to encourage taking medications as
prescribed
[] has high healthcare utilization (inpatient); encourage
patient to call ___ clinic with problems prior to coming in
to the ED
[] plan for cycle 2 of irinotecan on ___
[] should have ___ conversation regarding code status with
patient; indicated during hospitalization that he is at least
considering DNR/DNI and no prior documentation of formal
conversation with outpatient provider
#HCP/CONTACT: Name of health care proxy: ___
Relationship: Friend
Phone number: ___
#CODE STATUS: FULL CODE (presumed)
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. Rivaroxaban 20 mg PO DAILY
2. Acetaminophen 650 mg PO Q8H
3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
7. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Medications:
1. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
RX *diphenoxylate-atropine 2.5 mg-0.025 mg 1 tablet(s) by mouth
every 6 hours Disp #*30 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q8H
3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
7. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
8. Rivaroxaban 20 mg PO DAILY
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
diarrhea ___ irinotecan
Secondary:
metastatic sigmoid adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why was I admitted to the hospital?
- You were having diarrhea and abdominal pain
What was done while I was in the hospital?
- You had a CT scan that showed your cancer was stable; there
was no sign of an infection
- You received a medication to slow down your bowels and felt
better; we think your diarrhea was a side effect of your
chemotherapy
What should I do when I get home from the hospital?
- Be sure to take all of your medications as prescribed,
especially your rivaroxaban
- If you are having symptoms, please call the ___ clinic
first to talk with one of the providers there; their number is
___.
- If you have fevers, chills, worsening abdominal pain, nausea,
vomiting, worsening diarrhea, or generally feel unwell, please
call your doctor or go to the emergency room
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
10381484-DS-24 | 10,381,484 | 23,579,949 | DS | 24 | 2176-04-23 00:00:00 | 2176-04-23 17:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
pollen
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old male history of stage IV sigmoid
adenocarcinoma disease s/p LAR (___) with progressive
metastatic disease involving spleen s/p splenectomy/distal
pancreatectomy/wedge gastrectomy (___), on palliative
irinotecan, course complicated by DVT on rivaroxaban, malignant
bowel obstruction, and abdominal pain due to presumed Meckel's
diverticulitis who is admitted from the ED with acute on
chronic
abdominal pain with imaging concerning for acute obstruction and
persistent ? Meckel's diverticulitis.
Patient recently hospitalized from ___ - ___ with similar
abdominal pain. Course was notable for possible inflamed
appendix
vs Meckel's diverticulum. After extensive consultation with
surgery, no intervention was planned and he was started on
ciprofloxacin/flagyl. It was ultimately felt that chemotherapy
would provide best hope for palliation. Pain was controlled with
MS ___, hydromorphone, and phenazopyridine. He was discharged
on ___ with plan to resume chemotherapy on ___.
Patient reports his pain was persistent, but somewhat controlled
on discharge. However over the last few days his pain has
worsened. It seems to be the same pain as before, primarily a
constant mid abdominal pain that gets up to ___. Yesterday, he
felt like he was hungry and ate more than usual; the pain then
became so severe he could not stand up. He also had assocated
nausea without emesis and felt like the food 'sat there'. His
last BM was last night. He denies flatus today. He reports no
FC.
No CP, SOB or cough. He notes mild dysuria. No leg pain or
swelling.
In the ED, initial VS were pain 10, T 100.0, HR 67, BP 143/90,
RR
18, O2 100%RA. Labs notable for Na 139, K 3.9, HCO3 25, Cr 1.1,
Ca 9.1, Mg 2.1, P 3.0, ALT 8, AST 16, ALP 56, LDH 202, Lipase
19,
TBili <0.2, WBC 11.9, HCT 35.0, PLT 295. Lactate 0.9. UA 1 RBC
and 1 WBC. CXR showed no acute process. CT a/p showed worsening
malignant obstruction of small bowel due to mass in mid-jejunum
along with stable appearance of 12 mm dilated fluid filled blind
tubular structure felt either obstructed appendix or cystic
implant and stable right hydroureteronephrosis and metastatic
disease burden. Surgery was consulted, final recs pending but
deferred emergent surgical intervention. Patient spent an
extended period of time in the ED and received multiple doses of
IV dilaudid along with LR and IV CTX. VS prior to transfer were
pain 7, T 98.2, HR 56, BP 134/94, RR 14, O2 97%RA.
Past Medical History:
Colon cancer stage IIIC (T3N2M0) of the sigmoid colon with
progressive metastatic disease, KRAS mutated, MSI intact
- ___ Colonscopy for weight loss of 26 lbs in a year
revealed a fungating, circumferential mass of malignant
appearance was found in the sigmoid colon at 18cm. Biopsy
consistent with adenocarcinoma. CT torso revealed 3.7 cm segment
of the mid sigmoid colon demonstrating circumferential wall
thickening in keeping with tumor. There is no associated bowel
obstruction at present time. Adjacent mesenteric lymph nodes
measuring up to 6 mm in short axis dimension are noted. No
evidence of metastatic disease within the chest, abdomen, or
pelvis.
- ___ MR pelvis revealed Ill-defined sigmoid mass,
approximately 15 cm above the anal verge, as seen on the CT
examination from ___, with extension across the
muscularis propria. This is suspicious for T3 disease. 1.6 x 1.5
cm mass abutting the anterior aspect of the rectum and posterior
aspect of the seminal vesicles, 7 cm above the anal verge, is
suspicious for a drop metastasis as it is not convincingly
arising from rectal wall. This likely corresponds to the
palpable
finding on physical exam. Intrapelvic lymphadenopathy adjacent
to
the sigmoid mass, some with morphology suspicious for tumor
involvement.
- ___ Undderwent LAR. Path revealed colonic
adenocarcinoma
in the resected rectosigmoid colon. Tumor size was 3.6cm, low
grade, staged pT3. Margins were negative. Of the 15 nodes
examined, 6 were positive, thus staged pN2a. Finally, a separate
nodule of adenocarcinoma was identified 9 cm distal to the
primary tumor involving pericolonic adipose tissue, serosa, and
muscularis propria, consistent with metastasis of the primary
tumor. Furthermore, the resected peritoneal nodule showed
metastatic adenocarcinoma with perineural invasion. Thus, this
was staged pM1b. Of note, KRAS mutation was detected.
- ___ to ___ admitted for abdominal pain, OSH CT
was reviewed here and felt to be not concerning for any acute
intra-abdominal process including leak or abcess however there
was a high stool burden and gas. Pt discharged on bowel
regimen.
- ___ ED visit for abdominal pain, KUB reassuring,
discharged after bowel regimen
- ___ C1D1 XELOX (Xeloda 1000mg BID)
- ___ to ___ Admission for n/v and abd pain. CT
showed mildly dilated stomach and proximal small bowel, but no
evidence of obstruction. He underwent NGT decompression with
good
bilious output and improvement in symptoms and was slowly
advanced to regular diet.
- ___ C1D1 XELOX (Xeloda 1000mg BID)
- ___ to ___ admission for abd pain and
constipation. CT showed multiple mildly distended loops of ileum
with fecalized contents and a narrow caliber of the terminal
ileum. Stool and air seen in the colon. Symptoms improved
with
aggressive bowel regimen.
- ___ C3D1 XELOX (Xeloda 1500mg BID)
- ___ C4D1 XELOX (Xeloda 1500mg BID)
- ___ C5D1 XELOX (Xeloda 2000mg BID)
- ___ C6D1 XELOX (Xeloda 2000mg BID)
- ___ C7D1 XELOX (Xeloda 2000mg BID)
- ___ CT torso with no evidence of recurrence or
metastases
- ___ colonoscopy showed multiple tiny 2 mm polypoid
lesions which showed to be lymphoid aggregates on path
- ___ CT torso with no evidence of recurrence or
metastases
- ___ CT abdomen in the ED for abdominal pain showed ___
- ___ CT abdomen in the ED for abdominal pain showed ___
but indeterminate liver lesion
- ___ CT torso ___ with stable liver lesion
- ___ Colonoscopy revealed a single polyp, pathology
consistent with adenoma.
- ___ CT torso showed a new lesion in the splenic hilum
concerning for recurrence
- ___ PET CT showed avid lesion in the spleen, no other
sites of disease
- ___ Splenectomy revealed metastatic colon cancer
- ___ CT torso showed ___
- ___ CT torso extensive recurrence in the spenic bed and
nodes, CEA rising
- ___ Biopsy of the splenic bed confirmed metastatic
adenocarcinoma
- ___ CT torso showed increase in metastatic disease
- ___ CT torso showed increase in metastatic and
concerning new areas in the liver
- ___ Admitted with malignant SBO
- ___ C1D1 FOLFOX6
- ___ C1D15 FOLFOX (oxaliplatin at 65 ___
neuropathy)
- ___ C2D1 FOLFOX (oxaliplatin at 65 ___ neuropathy
- ___ CT torso shows stable disease
- ___ Treatment delayed per patient preference
- ___ C3D1 FOLFOX (oxaliplatin at 65 ___
neuropathy)
- ___ Patient requested to defer dose, CEA rising
- ___ C1D1 Irinotecan
- ___ Admitted with recurrent malignant SBO
- ___ C2D1 ___
- ___ Admitted for inflamed ? Meckel's diverticulum cause
by extrinsic compression by malignancy
PAST MEDICAL HISTORY:
Sigmoid adenocarcinoma
DVT
Social History:
___
Family History:
Negative for colon cancer, inflammatory bowel disease, uterine
cancer. He does have history of lipomas in his family.
Physical Exam:
24 HR Data (last updated ___ @ 1116)
Temp: 98 (Tm 98.7), BP: 120/77 (109-120/65-77), HR: 55
(55-66), RR: 18 (___), O2 sat: 99% (97-99), O2 delivery: RA
GENERAL: Sitting in bed, NAD, uncomfortable, fatigued
HEENT: dry MM, EOMI
LUNGS: CTAB
HEART: RRR no R/M/G
ABD: soft, non-distended, mildly TTP periumbilically. No rebound
tenderness noted.
EXT: no peripheral edema
SKIN: warm and dry
NEURO: no focal neuro deficits
ACCESS: POC c/d/i
Pertinent Results:
CT A/P ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits.
There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: 1.8 cm right hepatic dome hypodensity is
unchanged (6:7).
There are few scattered subcentimeter hepatic hypodensities
which are too
small to characterize but likely represents hepatic cyst or
biliary
hamartomas, unchanged from prior. The remainder of the liver
demonstrates
homogenous attenuation throughout. 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: Surgically absent spleen. Redemonstrated in the
splenectomy surgical
bed is 6.9 x 4.4 x 7.7 cm metastatic soft tissue mass
inseparable from the
gastric fundus/cardia (06:19, 08:28).
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: Left kidney is normal in size and nephrogram. Right
kidney
demonstrates a delayed nephrogram and moderate to severe
hydronephrosis with
hydroureter which extends distally, terminating at instructing
3.7 x 2.0 cm
soft tissue mass just to the right of the mid pelvis (6:62).
GASTROINTESTINAL: Patient is status post partial gastrectomy and
partial
colectomy for metastatic sigmoid adenocarcinoma. There is no
bowel
obstruction. 2.4 x 3.2 x 3.4 cm eccentric mural thickening with
luminal
narrowing of the left abdominal jejunal loop (without
obstruction) which
likely represents a metastatic focus (6:49, 8:16), unchanged
from most recent
prior. The previously described 13 mm dilated fluid-filled
blind-ending
tubular structure within the right mid pelvis which appears
obstructed by the
same right pelvic soft tissue deposit obstructing the distal
right ureter,
thought to represent either an obstructed appendix or cystic
implant, is
re-demonstrated and unchanged from ___ CT abdomen
and pelvis.
Scattered omental and peritoneal implants are unchanged. There
is no free air
or evidence of perforation. The remainder of the small bowel
loops are normal
in caliber. The colon and rectum are within normal limits.
PELVIS: Re-demonstrated in the lower pelvis just to the right of
midline,
posterior to the urinary bladder, is a 2.4 x 2.5 x 2.7 cm
centrally
hypoattenuating soft tissue deposit which is likely also
metastatic, unchanged
from most recent prior CT. The urinary bladder is unremarkable.
There is no
free fluid in the pelvis. A fiducial markers are demonstrated
in situ.
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. No
atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. No interval change in appearance of the 13 mm dilated
fluid-filled
blind-ending tubular structure within the mid pelvis obstructed
by a
metastatic mesenteric soft tissue deposit thought to represent
an obstructed
appendix or cystic implant. No evidence of perforation.
2. No interval change in delayed nephrogram and degree of
moderate to severe
right hydronephrosis/ hydroureter secondary to distal
obstruction by
metastatic mesenteric soft tissue deposit.
3. Scattered metastatic soft tissue deposits detailed in body of
report are
unchanged.
CT AP ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits.
There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout. A
1.9 cm right hepatic dome hypodensity is unchanged (2:7).
Additional
scattered hepatic hypodensities including a 9 mm lesion in the
right hepatic
lobe (02:21) are also unchanged and are too small to
characterize. There is
no evidence of intrahepatic or extrahepatic biliary dilatation.
The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: The spleen is surgically absent. Re-demonstrated is an
ill-defined
metastatic soft tissue mass in the splenectomy bed measuring 6.6
x 5.2 x 4.1
cm, similar to prior (2:16, 601:26). As before, the mass is
indistinguishable
from the gastric fundus/cardia.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The left kidney again demonstrates normal size with
normal
nephrogram. The right kidney demonstrates a delayed nephrogram
with
persistent severe hydroureteronephrosis secondary to a 2.8 x 2.1
x 2.8 cm soft
tissue mass in the right mid pelvis (02:58). There is no
perinephric
abnormality.
GASTROINTESTINAL: As before, the patient is status post partial
gastrectomy
and partial colectomy for metastatic sigmoid adenocarcinoma.
Evaluation of
the bowel loops is mildly limited due to lack of oral contrast
and a paucity
of intra-abdominal fat. Within these limitations, there is
persistent
distension of the small bowel loops in the left hemiabdomen,
although this
appears progressed compared to the ___ study. As
before, there is
eccentric mural thickening and luminal narrowing of a left
abdominal jejunal
loop (02:51), with resultant upstream dilatation of the bowel
loops. There is
new trace adjacent ascites with mild peritoneal thickening
(02:51). A blind
ending 1.2 cm tubular structure in the mid pelvis appears
unchanged and again
appears obstructed by the same right pelvic soft tissue deposit
causing right
ureteral obstruction. As before, this is thought to represent
either an
obstructed appendix or a cystic implant (02:54). There is no
evidence of free
air. The remaining colon and rectum are within normal limits.
PELVIS: The urinary bladder and distal ureters are unremarkable.
Re-demonstrated is a 2.8 x 2.7 cm centrally hypoattenuating soft
tissue
deposit in the lower pelvis, which appears unchanged. Fiducial
markers are
again seen in the lower 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. No
atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
Small foci of sclerosis in the right femoral neck and right
iliac bone are
unchanged and likely represent bone islands.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Mildly limited exam due to the lack of oral contrast and
paucity of
intra-abdominal fat. Within these limitations, there is
worsening malignant
obstruction of the small bowel due to a mass in the mid jejunum
in the left
hemiabdomen. New trace ascites adjacent to the affected bowel
loops.
2. No significant interval change in appearance of a 12 mm
dilated,
fluid-filled, blind-ending tubular structure in the mid pelvis,
which is
likely obstructed by a mesenteric soft tissue deposit. As
before, this likely
represents an obstructed appendix or cystic implant.
3. Unchanged severe right-sided hydroureteronephrosis secondary
to obstruction
from a metastatic soft tissue deposit.
4. Unchanged metastatic soft tissue deposit in the splenectomy
bed, which is
indistinguishable from the gastric fundus/cardia.
5. Unchanged metastatic soft tissue deposit in the lower midline
pelvis
adjacent to the bladder.
CT AP ___
FINDINGS:
LOWER CHEST: Visualized lungs are within normal limits. There
is no evidence
of pleural or pericardial effusion.
ABDOMEN:
Study is slightly limited due to paucity of intra-abdominal fat
and crowding
of structures.
HEPATOBILIARY: Geographic hyperattenuation of large areas of
segments VII and
nearly the entire left hepatic lobe is likely perfusional. A
1.8 cm
hypodensity near the hepatic dome in segment VII (04:10) and a
1.1 cm
hypodensity in the periphery of segments VII/VIII (04:20) are
stable compared
to prior but new since the study of ___ and are
consistent with
metastasis. There is no evidence of intrahepatic or
extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: The spleen is surgically absent. Metastatic soft tissue
mass in the
splenectomy bed is stable from prior, measuring 7.9 x 5.3 x 4.3
cm (4:22,
6:24), previously 7.8 x 5.2 x 4.1 cm. However, it has markedly
increased in
size since ___.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The left kidney is normal in size and nephrogram. As
with prior, the
right kidney demonstrates a delayed nephrogram with persistent
severe
hydronephrosis secondary to a 3.2 x 3.0 x 2.6 cm soft tissue
mass in the right
mid pelvis (4:73, 6:29) which appears similar to slightly
increased in size,
previously measuring 2.8 x 2.1 x 2.8 cm.
GASTROINTESTINAL: The patient is status post partial gastrectomy
and partial
colectomy for metastatic sigmoid adenocarcinoma. There is
persistent
distention of small-bowel loops in the left hemiabdomen. An
implant in the
left lower quadrant measuring approximately 3.4 x 3.5 x 4.3 cm
(4:57, 6:18)
involves loops of small bowel with resultant upstream wall
thickening and
edema which has progressed since the previous study, likely due
to partial
small bowel obstruction. A blind-ending 1.2 cm tubular
structure in the mid
lower abdomen adjacent to a soft tissue implant (4:64) appears
unchanged
(4:60), possibly an obstructed appendix, Meckel's diverticulum,
or cystic
implant. The aforementioned soft tissue implant has slightly
increased in
size, currently measuring 3.2 x 2.9 x 2.8 cm (4:64, 6:23),
previously 2.8 x
2.1 x 2.8 cm. No free air.
The large bowel is mildly distended throughout and filled with
stool.
Adjacent to extensive pelvic implants, there is decreased bowel
diameter and
stool burden (4:70, 06:24) with stool and air seen distally
within the rectum,
possibly suggesting partial large bowel obstruction.
PELVIS: As described above, a 3.2 x 3.0 x 2.6 cm soft tissue
mass in the right
mid pelvis appears similar to slightly increased in size,
previously measuring
2.8 x 2.1 x 2.8 cm. The urinary bladder is unremarkable. No
definite free
fluid.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are
grossly
unremarkable.
LYMPH NODES: There is no definite retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No
atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
Small foci of sclerosis in the right femoral neck and right
iliac bone are
unchanged and likely represent bone islands.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Interval increase in size of left lower quadrant implant with
persistent
upstream small bowel dilation and worsening of upstream wall
thickening and
edema likely due to partial small bowel obstruction, although
superimposed
gastroenteritis cannot be excluded.
2. Interval increase in size of metastatic soft tissue implants
in the lower
abdomen and pelvis with resultant narrowing of the distal large
bowel within
the pelvis which may suggest possible partial large bowel
obstruction.
3. Metastatic splenectomy bed and hepatic lesions are stable
compared to prior
but increased since early ___.
4. No significant change in appearance of fluid-filled blind
ending tubular
structure in the mid lower abdomen possibly representing an
obstructed
appendix, Meckel's diverticulum, or cystic implant.
5. Severe persistent right hydroureteronephrosis secondary to
obstruction from
metastatic soft tissue deposit.
6. Geographic hyperenhancement involving large areas of both
hepatic lobes are
likely perfusional.
Brief Hospital Course:
Mr. ___ is a ___ year old male history of stage IV sigmoid
adenocarcinoma disease s/p LAR (___) with progressive
metastatic disease involving spleen s/p splenectomy/distal
pancreatectomy/wedge gastrectomy (___), on palliative
irinotecan, course complicated by DVT on rivaroxaban, malignant
bowel obstruction, and abdominal pain due to presumed Meckel's
diverticulitis who was admitted from the ED with acute on
chronic abdominal pain with imaging concerning for acute
obstruction and persistent ? ___'s diverticulitis. His
obstruction resolved with conservative measures and he received
chemotherapy with irinotecan while in house. His pain regimen
was optimized with the help of Palliative care. At time of
discharge he was having bowel movements and taking in p.o.
without nausea or vomiting.
# Peritoneal metstatic disease
# Small bowel obstruction
# Meckel's diverticulitis
# Constipation
Patient has extensive peritoneal metastatic disease leading to
recurrent small bowel obstruction along with the presumed
obstruction and inflammation of Meckel's diverticulum. His more
global bowel obstruction seems intermittent and was treated
conservatively with NPO and miVF. He did not required NG tube
placement. Colorectal surgery saw the patient while in house
with no indication for surgery. He was kept on cipro/flagyl for
coverage of ?Meckel's diverticulum inflammation. Ultimately his
SBO resolved and he was able to take in POs. His course was
complicated by severe constipation, which resolved with
scheduled senna BID, docusate, mag citrate, and suppository. His
acute on chronic abdominal pain from this was managed as below.
His antibiotics were discontinued on the day of discharge.
# Acute on chronic abdominal pain
Initially presented with acute exacerbation of his chronic
abdominal pain in the setting of his small bowel obstruction. He
was managed with IV Dilaudid initially and then was transition
back to his home dose of MS ___ 30mg twice daily. Throughout
the course his as needed Dilaudid was increased to 4 mg every 3
hours as needed pain. His long-acting MS ___ was up titrated
based on this requirement to 60 mg twice daily at discharge.
Palliative care recommended that he may continue the
hydromorphone ___ he has at home and that when he runs out,
his outpatient oncology team may consider switching this to
short-acting morphine 15 mg q4h PRN.
#Dysuria
Pt having some dysuria, no other s/sx of infection. UA was bland
no signs of infection.
# Fever/Low grade temperature
# Leukocytosis (resolved)
T 100.0 in ED; presumably has widespread inflammation from
bowel obstruction +/- diverticulitis. His WBC normalized and
remained normal throughout the remainder of his hospital stay.
He had no further fevers.
# Metastatic sigmoid adenocarcinoma
Started on ir___ ___. Tolerated chemotherapy. Seen by Dr.
___ patient, who felt it is important to have
patient undergo his next dose of chemotherapy on time. He is
scheduled to undergo chemotherapy after discharge this ___,
___.
# Hx of DVT
On rivaroxaban as outpatient, was transitioned to lovenox while
NPO and having poor PO intake. Upon discharge, patient
transitioned back to rivaroxaban, to be initiated at his home
dose the evening of discharge.
# Anemia in malignancy
The patient's H/H remained stable throughout his admission.
TRANSITIONAL ISSUES:
======================
[] Palliative care recommended that he may continue the
hydromorphone ___ he has at home and that when he runs out,
his outpatient oncology/palliative care team may consider
switching this to short-acting morphine 15 mg q4h PRN.
[] Would continue to optimize his bowel regimen PRN
[] Cipro/flagyl was stopped on ___, as patient had completed
chemotherapy and had reached his nadir
[] Patient has known hydronephrosis, may need a perc neph tube
if renal function declines
[] Should take next dose of xarelto at 1800 on ___
[] Xarelto required a prior authorization, so the patient was
given a free supply with the use of a coupon on ___. This PA
will need to be continued to be follow-up on.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 500 mg PO Q12H
2. MetroNIDAZOLE 500 mg PO Q8H
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
5. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
7. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
8. Rivaroxaban 20 mg PO DAILY
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
10. Phenazopyridine 100 mg PO TID
11. Ondansetron 8 mg PO Q8H:PRN nausea
12. Morphine SR (MS ___ 30 mg PO Q12H
Discharge Medications:
1. Bisacodyl ___AILY:PRN Constipation - Second Line
Only take after discussing with Oncologist
RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*12
Suppository Refills:*0
2. Metoclopramide 5 mg PO TID
RX *metoclopramide HCl 5 mg 1 tab by mouth three times a day
Disp #*90 Tablet Refills:*0
3. Morphine SR (MS ___ 60 mg PO Q12H
RX *morphine [MS ___ 30 mg 2 tablet(s) by mouth in the AM
and ___, take 1 tablet in the afternoon Disp #*35 Tablet
Refills:*0
RX *morphine 60 mg 1 tablet(s) by mouth twice a day Disp #*28
Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily Disp #*30 Packet Refills:*0
5. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 2 tab by mouth twice a day Disp
#*30 Tablet Refills:*0
6. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
7. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
8. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
9. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth Every 8 hours Disp
#*30 Tablet Refills:*0
10. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
11. Rivaroxaban 20 mg PO DAILY
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth qpm Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
============
Small bowel obstruction
Secondary
============
Metastatic sigmoid adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___!
He came to the hospital because you are having abdominal pain.
While you are here, you were found to have a blockage in your
bowels. Over time this got better. You were given antibiotics
to help prevent infection. You were seen by the palliative care
doctors who helped to increase your pain medicines to better
control your pain. You also had some constipation so you were
given medications to help with this. You were seen by your
outpatient Oncologist while in the hospital, who would like you
to have your next chemotherapy session as scheduled this ___,
___. Details of your appointment are below.
When you leave it is important you take your medications as
prescribed. It is also important you attend your follow-up
appointments as listed below. If you have any nausea, vomiting,
fevers, chills, severe constipation, or diarrhea, call your
oncologist and let them know or come to the ER immediately.
We wish you the best,
Your ___ Care team
Followup Instructions:
___
|
10381484-DS-29 | 10,381,484 | 25,362,840 | DS | 29 | 2176-08-14 00:00:00 | 2176-08-14 10:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
pollen
Attending: ___.
Chief Complaint:
Abdominal pain, concern for dislodged G tube
Major Surgical or Invasive Procedure:
Vented G tube replacement by ___ on ___
History of Present Illness:
___ is a ___ year old ___ man with
metastatic sigmoid adenocarcinoma, progressive through multiple
lines of therapy, c/b recurrent malignant SBO s/p venting G
(___) on home hospice, who presents with concern for
dislodged G tube and abdominal pain.
- 5 days ago, noticed decreased output from G tube and had
sensation that air seemed to be going in
- No acute changes, but finally decided to present to ED tonight
- While waiting for CT scan, tube fully dislodged (fell out; ED
resident clarified pt did not pull it out). Then started
developing abd pain and distension
- No nausea/vomiting. Prior to this, was passing gas, having BM
In the ED: T 98.9 F | 76 | 117/83 | 100% RA. He was noted on
exam
to have dry mucus membranes, abdominal distension, and diffuse
tenderness to palpation. While awaiting his CT scan, patient's G
tube spontaneously dislodged.
CT A/P demonstrated persistent malignant SBO. Colorectal surgery
was consulted and recommended against surgical intervention and
recommended ___ replacement of G tube. He was given 4 mg SC
morphine and 1 mg + 4mg + 1mg IV dilaudid. NGT placement was
discussed but declined by patient, given prior experiences of
significant discomfort.
On arrival to the floor, he shares that he is having ___ pain
in his abdomen, which worsened after the G tube fell out in the
ED. He also feels dehydrated. He shares that he did not like
inpatient hospice and has been living at home with a friend on
home hospice. Had been taking 4mg dilaudid PO for pain at home.
All other review of systems are negative unless stated otherwise
Past Medical History:
=== PAST MEDICAL HISTORY ===
DVT on lovenox
ONCOLOGIC HISTORY
-Colon cancer stage IIIC (T3N2M0) of the sigmoid colon with
progressive metastatic disease, KRAS mutated, MSI intact
- ___ Colonscopy for weight loss of 26 lbs in a year
revealed a fungating, circumferential mass of malignant
appearance was found in the sigmoid colon at 18cm. Biopsy
consistent with adenocarcinoma. CT torso revealed 3.7 cm segment
of the mid sigmoid colon demonstrating circumferential wall
thickening in keeping with tumor. There is no associated bowel
obstruction at present time. Adjacent mesenteric lymph nodes
measuring up to 6 mm in short axis dimension are noted. No
evidence of metastatic disease within the chest, abdomen, or
pelvis.
- ___ MR pelvis revealed Ill-defined sigmoid mass,
approximately 15 cm above the anal verge, as seen on the CT
examination from ___, with extension across the
muscularis propria. This is suspicious for T3 disease. 1.6 x 1.5
cm mass abutting the anterior aspect of the rectum and posterior
aspect of the seminal vesicles, 7 cm above the anal verge, is
suspicious for a drop metastasis as it is not convincingly
arising from rectal wall. This likely corresponds to the
palpable
finding on physical exam. Intrapelvic lymphadenopathy adjacent
to
the sigmoid mass, some with morphology suspicious for tumor
involvement.
- ___ Undderwent LAR. Path revealed colonic
adenocarcinoma
in the resected rectosigmoid colon. Tumor size was 3.6cm, low
grade, staged pT3. Margins were negative. Of the 15 nodes
examined, 6 were positive, thus staged pN2a. Finally, a separate
nodule of adenocarcinoma was identified 9 cm distal to the
primary tumor involving pericolonic adipose tissue, serosa, and
muscularis propria, consistent with metastasis of the primary
tumor. Furthermore, the resected peritoneal nodule showed
metastatic adenocarcinoma with perineural invasion. Thus, this
was staged pM1b. Of note, KRAS mutation was detected.
- ___ to ___ admitted for abdominal pain, OSH CT
was reviewed here and felt to be not concerning for any acute
intra-abdominal process including leak or abcess however there
was a high stool burden and gas. Pt discharged on bowel
regimen.
- ___ ED visit for abdominal pain, KUB reassuring,
discharged after bowel regimen
- ___ C1D1 XELOX (Xeloda 1000mg BID)
- ___ to ___ Admission for n/v and abd pain. CT
showed mildly dilated stomach and proximal small bowel, but no
evidence of obstruction. He underwent NGT decompression with
good
bilious output and improvement in symptoms and was slowly
advanced to regular diet.
- ___ C1D1 XELOX (Xeloda 1000mg BID)
- ___ to ___ admission for abd pain and
constipation. CT showed multiple mildly distended loops of ileum
with fecalized contents and a narrow caliber of the terminal
ileum. Stool and air seen in the colon. Symptoms improved
with
aggressive bowel regimen.
- ___ C3D1 XELOX (Xeloda 1500mg BID)
- ___ C4D1 XELOX (Xeloda 1500mg BID)
- ___ C5D1 XELOX (Xeloda 2000mg BID)
- ___ C6D1 XELOX (Xeloda 2000mg BID)
- ___ C7D1 XELOX (Xeloda 2000mg BID)
- ___ CT torso with no evidence of recurrence or
metastases
- ___ colonoscopy showed multiple tiny 2 mm polypoid
lesions which showed to be lymphoid aggregates on path
- ___ CT torso with no evidence of recurrence or
metastases
- ___ CT abdomen in the ED for abdominal pain showed ___
- ___ CT abdomen in the ED for abdominal pain showed ___
but indeterminate liver lesion
- ___ CT torso ___ with stable liver lesion
- ___ Colonoscopy revealed a single polyp, pathology
consistent with adenoma.
- ___ CT torso showed a new lesion in the splenic hilum
concerning for recurrence
- ___ PET CT showed avid lesion in the spleen, no other
sites of disease
- ___ Splenectomy revealed metastatic colon cancer
- ___ CT torso showed ___
- ___ CT torso extensive recurrence in the spenic bed and
nodes, CEA rising
- ___ Biopsy of the splenic bed confirmed metastatic
adenocarcinoma
- ___ CT torso showed increase in metastatic disease
- ___ CT torso showed increase in metastatic and
concerning new areas in the liver
- ___ Admitted with malignant SBO
- ___ C1D1 FOLFOX6
- ___ C1D15 FOLFOX (oxaliplatin at 65 ___
neuropathy)
- ___ C2D1 FOLFOX (oxaliplatin at 65 ___ neuropathy
- ___ CT torso shows stable disease
- ___ Treatment delayed per patient preference
- ___ C3D1 FOLFOX (oxaliplatin at 65 ___
neuropathy)
- ___ Patient requested to defer dose, CEA rising
- ___ C1D1 Irinotecan
- ___ Admitted with recurrent malignant SBO
- ___ C2D1 Irinotecan
- ___ Admit for recurrent SBO, concern for ___
diverticulitis
- ___ Readmitted for recurrent SBO
- ___ C3D1 Irinotecan (150 ___ diarrhea)
- ___ C4D1 Irinotecan (150 ___ diarrhea)
- ___ Treatment held ___ fatigue
- ___ C1D1 Weekly irinotecan 100 mg/m2 1, 8, 15 and 22 of
a 42-day cycle
- ___ Prolonged hospitalization for SBO
- ___: recurrent malignant SBO. S/p G tube placement
___. After discussion with oncology team, decision made to
focus
on quality of life and transition to home hospice
- ___: Malignant SBO, improved with venting G tube.
Discharged back to home hospice
Social History:
___
Family History:
Negative for colon cancer, inflammatory bowel disease, uterine
cancer. He does have history of lipomas in his family.
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
VITALS: ___ 0849 Temp: 97.5 PO BP: 127/86 L HR: 73 RR: 18
O2
sat: 100% O2 delivery: RA
General: Cachectic, chronically ill-appearing man lying still in
bed with eyes closed.
HEENT: dry mucous membranes, OP clear
CV: RR, no m/r/g
PULM: Unlabored breathing
ABD: Soft BS, mildly distended, soft, diffusely tender to
palpation without rebound. + gastrostomy tube site without
surrounding erythema or drainage
LIMBS: WWP, 2+ bilateral ___ edema
SKIN: No notable rashes on trunk nor extremities
NEURO: Alert and oriented. Moves all extremities equally.
PSYCH: Depressed affect. Thought process is linear.
ACCESS: Chest port site intact w/o overlying erythema, accessed
and dressing C/D/I
DISCHARGE PHYSICAL EXAM
==========================
VS: ___ ___ Temp: 98.6 PO BP: 115/80 L Sitting HR: 74 RR:
16 O2 sat: 96% O2 delivery: RA
General: Cachectic, chronically ill-appearing man sitting in
chair in NAD
HEENT: moist mucous membranes, OP clear
CV: RR, no m/r/g
PULM: Unlabored breathing
ABD: Soft BS, mildly distended, soft, mildly tender to
palpation without rebound. G tube site c/d/i
LIMBS: WWP, 2+ bilateral ___ edema
SKIN: No notable rashes on trunk nor extremities
NEURO: Alert and oriented. Moves all extremities equally.
PSYCH: Depressed affect. Thought process is linear.
ACCESS: Chest port site intact w/o overlying erythema
Pertinent Results:
ADMISSION LABS
====================
___ 02:15AM BLOOD WBC-6.1 RBC-3.09* Hgb-7.8* Hct-25.7*
MCV-83 MCH-25.2* MCHC-30.4* RDW-16.8* RDWSD-50.1* Plt ___
___ 02:15AM BLOOD Neuts-69.9 Lymphs-15.1* Monos-13.4*
Eos-1.0 Baso-0.3 Im ___ AbsNeut-4.26 AbsLymp-0.92*
AbsMono-0.82* AbsEos-0.06 AbsBaso-0.02
___ 02:15AM BLOOD ___ PTT-27.2 ___
___ 02:15AM BLOOD Glucose-121* UreaN-29* Creat-1.0 Na-135
K-4.5 Cl-97 HCO3-27 AnGap-11
___ 02:15AM BLOOD Albumin-3.2* Calcium-8.5 Phos-4.0 Mg-2.2
___ 02:15AM BLOOD ALT-12 AST-18 AlkPhos-61 TotBili-0.2
___ 02:15AM BLOOD Lipase-13
___ 02:15AM BLOOD proBNP-68
___ 03:50AM BLOOD Lactate-0.9
DISCHARGE LABS
====================
___ 05:50AM BLOOD WBC-4.9 RBC-3.02* Hgb-7.6* Hct-24.3*
MCV-81* MCH-25.2* MCHC-31.3* RDW-17.2* RDWSD-49.6* Plt ___
___ 05:50AM BLOOD Glucose-134* UreaN-20 Creat-0.8 Na-135
K-4.3 Cl-97 HCO3-28 AnGap-10
___ 05:50AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.0
MICROBIOLOGY
====================
___ 3:40 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
IMAGING
====================
___ CXR
IMPRESSION:
Comparison to ___. In the interval, the feeding tube was
removed. The right pectoral Port-A-Cath remains in stable
correct position. The partially imaged upper abdomen shows mild
intestinal distension but no evidence of free intra-abdominal
air. Normal size of the heart. Normal hilar and mediastinal
contours. No pulmonary edema. No pneumonia. No pneumothorax.
___ KUB
IMPRESSION:
Findings concerning for small bowel obstruction. No free
intraperitoneal air.
___ CT ABD/PELVIS
1. Dilated loops of small bowel, similar in configuration to the
___ CT examinations. There is a persistent
obstructing 2.7 cm mid-left mass at the transition point. No
perforation or pneumatosis.
2. Unchanged metastatic deposits adjacent to the gastrectomy
site and along the right pelvis.
3. Severe right hydroureteronephrosis from one of the metastatic
lesions,
unchanged from prior examinations.
4. Unchanged hepatic metastases.
5. Unchanged ___ opacities at the right lung base,
likely inflammatory from recent aspiration.
___ ULTRASOUND GUIDED G TUBE REPLACEMENT BY ___
FINDINGS:
1. Successful placement of a 18 ___ MIC gastrostomy tube
through a
pre-existing tract.
IMPRESSION:
Successful placement of a 18 ___ MIC gastrostomy tube. The
tube is ready for immediate use.
Brief Hospital Course:
___ ___ with metastatic sigmoid adenocarcinoma,
progressive through multiple lines of therapy, c/b recurrent
malignant SBO s/p venting G (___) on home hospice, who
presents with dislodged G tube x 5 days w/ severe abdominal pain
and distention, improved after G tube replacement and initiation
of dilaudid PCA.
# Displaced G tube
# Abdominal pain
Presented with 5 days of G tube discomfort/dysfunction.
Spontaneously dislodged in ED, with subsequent onset of severe
abdominal pain and bloating, c/w worsening of his chronic SBO in
absence of venting G. He was discharged to inpatient hospice
with dilaudid PCA on ___. Most recently had been on PO dilaudid
4mg (unknown frequency) at home prior to this admission. S/p
replacement of vented G tube on ___ by ___. Palliative Care was
consulted for pain control and clarification of GOC. Required
frequent IV dilaudid boluses for pain control, transitioned to
dilaudid PCA with pain well controlled on 1mg IVPCA basal per
hour with 1mg bolus q10 minutes prn.
# Insomnia
Pt c/o insomnia and "all-over body pain". Improved on lorazepam
and trazodone QHS.
# Metastatic sigmoid adenocarcinoma, on home hospice
Metastatic colon cancer complicated by recurrent malignant
obstructions. CT abd/pelvis this admission without significant
change in tumor burden from prior CT exams in ___,
including unchanged hepatic metastases and metastatic deposits
adjacent to gastrectomy site and along right pelvis. Discussed
with pt that his cancer has progressed through multiple lines of
therapy and unfortunately there are no additional treatments
available.
# Bilateral lower extremity edema
Likely anasarca in setting of malignancy and malnutrition. Also
would consider DVT given history as below, but lower suspicion
given bilateral and home apixaban. Pt declined TEDS and ACE
bandage wraps. Encouraged lower extremity elevation and
ambulation.
# Hx of DVT (diagnosed ___
Home apixaban held in setting of ___ procedure, restarted at
discharge.
TRANSITIONAL ISSUES:
[] manage pain as bale with PCA and uptitrate as needed
[] patient may vent G-tube per his preference for any worsening
abdominal pain or nausea
[] patient may eat my mouth as able for his comfort
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 may be inaccurate and requires
futher investigation.
1. Dexamethasone 4 mg PO DAILY
2. HYDROmorphone (Dilaudid) 2 mg IV Q3H:PRN Pain - Severe
3. HYDROmorphone (Dilaudid) 1 mg IVPCA Lockout Interval: 10
minutes Basal Rate: 1.5 mg(s)/hour 1-hr Max Limit: 5 mg(s)
4. amLODIPine 5 mg PO DAILY
5. Apixaban 5 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Polyethylene Glycol 17 g PO DAILY
9. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
Discharge Medications:
1. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line
flush
2. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
3. LORazepam 0.5 mg IV QHS
4. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
5. TraZODone 50 mg PO QHS:PRN insomnia
6. Apixaban 5 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. HYDROmorphone (Dilaudid) 1 mg IVPCA Lockout Interval: 10
minutes Basal Rate: 1.5 mg(s)/hour 1-hr Max Limit: 5 mg(s)
RX *hydromorphone 60 mg/30 mL (2 mg/mL) 1 mg IV hourly Disp #*1
Vial Refills:*0
9. HYDROmorphone (Dilaudid) 2 mg IV Q3H:PRN Pain - Severe
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. Polyethylene Glycol 17 g PO DAILY
12. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Encounter for palliative care
# Malignant small bowel obstruction
# Metastatic colon cancer
# Displaced G tube
# Insomnia
# Lower extremity edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted with concern that your G tube
was dislodge and abdominal pain due to your bowel obstruction.
Your G tube fell out in the ED and was replaced by the
Interventional Radiology team. We started you on IV pain
medications and you felt better. After discussion with you and
your hospice team, the decision was made to discharge you home
with hospice, which will monitor your symptoms closely and help
with symptom control and support.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10381538-DS-4 | 10,381,538 | 23,716,656 | DS | 4 | 2151-12-15 00:00:00 | 2151-12-16 17:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
ACE Inhibitors / diltiazem / haloperidol / Losartan / opiate
agonists
Attending: ___
Chief Complaint:
Left Subdural Hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with history of advanced ___
body dementia presented to OSH ED with new inability to
ambulate. His wife reports that the patient had an unwitnessed
fall 5 days ago
and has had ongoing behavioral changes over the last month with
increased outbursts and decreased communication (minimally
verbal baseline). The OSH ___ revealed a left SDH 33mm with
1cm MLS acute on chronic blood products, therefore he was
transferred to ___ ED for further evaluation and management.
He is on 81 mg ASA daily.
Past Medical History:
___ Body Dementia
HTN
Hypercholesterol
Social History:
___
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Gen: WD/WN, comfortable, NAD.
HEENT:
Pupils: PERRL ___
EOMs: will not follow
Extrem: Warm and well-perfused.
Neuro:
Mental status: intermittently awake, not cooperative with
exam/unable to follow commands
Orientation: will not answer orientation questions
Language: minimally verbal at baseline
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3mm
bilaterally.
III, IV, VI: Extraocular movements unable to be assessed
V, VII: Facial strength and sensation unable to be assessed .
VIII: Hearing intact to voice.
XII: Tongue unable to be assessed .
Motor: Will not follow commands for motor exam, however is
moving
all four extremities spontaneously and anti-gravity. Pronator
drift unable to be assessed.
__________________________________
PHYSICAL EXAM ON DISCHARGE:
Spontaneously opening eyes, non-verbal, not following commands.
Pertinent Results:
CT HEAD - ___:
Interval increase in left subdural hematoma in last 8 hours
(measuring up to 36 mm in maximum dimension from 32 mm).
Associated rightward shift has also slightly increased (12 mm,
previously 11 mm).
___ 11:25PM BLOOD WBC-9.0 RBC-3.83* Hgb-11.7* Hct-35.6*
MCV-93 MCH-30.5 MCHC-32.9 RDW-13.9 RDWSD-47.3* Plt ___
___ 11:25PM BLOOD Neuts-63.1 ___ Monos-8.5 Eos-3.8
Baso-0.2 Im ___ AbsNeut-5.64 AbsLymp-2.17 AbsMono-0.76
AbsEos-0.34 AbsBaso-0.02
___ 11:25PM BLOOD ___ PTT-27.0 ___
___ 11:25PM BLOOD Glucose-96 UreaN-14 Creat-1.0 Na-141
K-3.9 Cl-104 HCO3-25 AnGap-16
Brief Hospital Course:
Mr. ___ was admitted to the ICU at ___ on ___ for
close neurological monitoring in the setting of large
acute-on-chronic subdural hematoma. His Aspirin was held on
admission and Keppra was started for seizure prophylaxis.
Operative planning was initiated. Extensive discussion was had
with the patient's family, as well as his outpatient PCP &
Neurologist. The family decided that given his advanced dementia
they would defer surgical intervention and pursue Hospice care.
The patient was transferred to the inpatient floor, where he
remained hemodynamically stable. Palliative Care, Case
Management, and Social Work assisted in establishing home
hospice care. The patient was discharged in stable condition on
___. The ___ Hospice agency was extremely helpful in
facilitation this discharge. Through their agency, a general
prescription was provided for a "hospice bag" with the necessary
medications to keep the patient comfortable at home.
Medications on Admission:
Mirtazapine 7.5mg QHS
Atorvastatin 10 mg, daily
Verapamil ER (SR) 120mg BID
Sertraline 150 mg QHS
Valsartan 160mg-Hydrochlorothiazide 12.5 mg daily
Aspirin 81 mg daily
Vitamin D3 1,000 unit daily
Discharge Medications:
1. Atorvastatin 10 mg PO QPM
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Mirtazapine 7.5 mg PO QHS
4. Valsartan 160 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
7. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
8. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
9. Lorazepam 0.5 mg PO Q4H:PRN agitation
10. Senna 8.6 mg PO BID:PRN Constipation
11. OLANZapine (Disintegrating Tablet) 5 mg PO Q4H:PRN
delirium/restlessness
12. Sertraline 150 mg PO QHS
13. Verapamil 40 mg PO Q8H
RX *verapamil 40 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
14. Docusate Sodium (Liquid) 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left Subdural Hematoma
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to ___ after
you were found to have a large left subdural hematoma. After
discussion
with Dr. ___ your family, you were not taken for
surgery. You are now being sent home with hospice services.
Below are your other discharge instructions:
Activity: As Tolerated
Medications:
- We recommend avoiding blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin)
- You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction.
- You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
- Emotional and/or behavioral difficulties are common,
particularly in the setting of underlying dementia.
- Feeling more tired, restlessness, irritability, and mood
swings are also common.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
- Headache is one of the most common symptom after a brain
bleed.
- Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
- Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
- There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
- Severe pain, swelling, redness or drainage from the incision
site.
- Fever greater than 101.5 degrees Fahrenheit
- Nausea and/or vomiting
- Extreme sleepiness and not being able to stay awake
- Severe headaches not relieved by pain relievers
- Seizures
- Any new problems with your vision or ability to speak
- Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
- Sudden numbness or weakness in the face, arm, or leg
- Sudden confusion or trouble speaking or understanding
- Sudden trouble walking, dizziness, or loss of balance or
coordination
- Sudden severe headaches with no known reason
Followup Instructions:
___
|
10381607-DS-13 | 10,381,607 | 21,718,540 | DS | 13 | 2150-10-10 00:00:00 | 2150-10-13 00:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
___
Attending: ___
Chief Complaint:
left face/arm weakness and left arm numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year-old right-handed man with a history
of HTN, HLD and asthma who presented to the ED after acute onset
of left face/arm weakness and left arm numbness at 830am this
morning. Neurology was consulted as part of a code stroke
protocol.
Mr. ___ awoke at 3am the day of presentation with
difficulty
sleeping and took Unisom at that time. He was not weak and
there
was no numbness/tingling. He briefly aroused from sleep at 730am
when there was a noise in his house and he is unsure if he had
any tingling or weakness at that time. At ___, he awoke with
left face and entire arm tingling and numbness. He could not
raise his arm from the bed easily. He had more difficulty with
hand movements than shoulder movements. There was no numbness
or
weakness elsewhere. No other neurological symptoms. No
palpitations he recalls. EMS was activated and he was taken to
___ where vitals were T97.9 HR95 RR22 BP 205/99 ->
188/87 (without anti-hypertensives) and POX 99RA. There his
NIHSS was 8 for left arm weakness, left facial droop, mild
dysarthria, and numbness. Basic labs were normal. ___
without
signs of early ischemia. No IV tpa given, but the patient was
given ASA 324 and was urgently transported via medflight to
___. No antihypertensives given en route.
At ___, code stroke was called at approximately 1115am. At
that time, NIHSS 2 (left facial palsy) and the patient was
reporting improvement in symptoms, particularly numbness and
tingling was now distal to mid forearm and weakness was only of
the left wrist and hand. No IV tpa given. CTA head and neck in
the ED showed vascular dilatation of the distal R MCA inferior
division vasculature and on CT perfusion there was an area
suggestive of hyperemia (dec MTT, inc CBF, inc CBV). He was
given 2 IVF boluses of 500cc NS and started on maintenance IVF
and HOB <30 to maximize cerebral perfusion.
Later at 2pm, the patient had new onset of left perioral
numbness
that but no other symptoms and exam otherwise unchanged. Repeat
IVF bolus was given and he was kept flat in bed.
Of note, the patient notes that over the past couple of months,
he has had symptoms of a chest cold, but was actually starting
to
feel better the past ___ days. Also, he was not particularly
dehydrated the day prior to his symptom onset.
ROS: positive as above. Negative for HA, lightheadedness, or
confusion. Denies difficulty with producing or comprehending
speech. Denies loss of vision, blurred vision, diplopia,
vertigo,
tinnitus, hearing difficulty, dysarthria, or dysphagia. Denies
bowel or bladder incontinence or retention. Denies difficulty
with gait. On general review of systems, the patient denies
fevers, rigors, night sweats, or noticeable weight loss. Denies
chest pain, palpitations. Denies nausea, vomiting, diarrhea,
constipation, or abdominal pain. No recent change in bowel or
bladder habits. Denies dysuria or hematuria. Denies myalgias,
arthralgias, or rash.
Past Medical History:
- HTN - on 2 antihypertensives
- HLD - never required a statin
- asthma
Social History:
___
Family History:
Father's family history unknown as father was
adopted. In mother's side, there are no strokes or seizures or
neurological conditions.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals at 1115am: BP 176/96 HR 86 RR 14 POX 100 RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G, no carotid bruits
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental Status - Awake, alert, oriented x 3. Attention to
examiner easily maintained. Recalls a coherent history. Able to
recite months of year backwards. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Naming intact to stroke card, thumb and knuckles. No
paraphasias. Normal prosody. No dysarthria. No apraxia. No
evidence of hemineglect. No left-right confusion. No finger
agnosia.
- Cranial Nerves - PERRL 4->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. At rest there is slight LNFF. With activation there
is a moderate-severe lower facial palsy on the left. No
involvement of eye closure or brow furrowing on the left.
Hearing
intact to finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift bilaterally. No tremor
or asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 0 0 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - No deficits to light touch, pin bilaterally despite
subjective feeling of numbness and tingling distal to mid
forearm. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements on the right
- Gait - deferred to maintain cerebral perfusion.
===========================================================
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
ADMISSION LABS:
___ 11:20AM BLOOD WBC-9.7 RBC-4.57* Hgb-14.8 Hct-42.4
MCV-93 MCH-32.4* MCHC-34.9 RDW-11.5 RDWSD-38.6 Plt ___
___ 11:20AM BLOOD ___ PTT-29.8 ___
___ 06:15AM BLOOD Glucose-83 UreaN-14 Creat-0.9 Na-137
K-4.1 Cl-100 HCO3-26 AnGap-15
___ 11:20AM BLOOD ALT-32 AST-34 AlkPhos-111 TotBili-0.6
___ 11:20AM BLOOD cTropnT-<0.01
___ 09:42PM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:20AM BLOOD Albumin-4.4 Calcium-9.7 Phos-2.3* Mg-1.9
___ 02:22PM BLOOD %HbA1c-5.3 eAG-105
___ 06:15AM BLOOD Triglyc-77 HDL-43 CHOL/HD-4.3 LDLcalc-126
___ 11:20AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
IMAGING:
CTA HEAD AND NECK ___:
1. No stenosis by NASCET criteria in bilateral carotid arteries.
2. Small irregularities and a tiny ulcer are present at the left
internal
carotid artery origin. There are bilateral mild calcified
plaques at the
internal carotid artery origins. Atheromas are visualized on the
aortic arch.
CXR ___:
No acute cardiopulmonary abnormality.
MRI BRAIN ___:
1. Acute infarction in the cortex of the right precentral and
postcentral
gyri.
2. Normal MRA of the head.
TTE ___:
The left atrial volume index is normal. No atrial septal defect
or patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. The estimated right atrial pressure is
___ mmHg. Normal left ventricular wall thickness, cavity size,
and regional/global systolic function (biplane LVEF = 61 %). The
estimated cardiac index is normal (>=2.5L/min/m2). 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 structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is high normal. There is no pericardial effusion.
IMPRESSION: Mild mitral regurgitation with normal valve
morphology. Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. No definite
structural cardiac source of embolism identified.
DISCHARGE LABS: NONE
Brief Hospital Course:
Mr. ___ is a ___ year-old right-handed man with a history of
HTN, HLD and asthma who presented to the ED after acute onset of
left face/arm weakness and left arm numbness with MRI showing
acute ischemic infarct in the primary motor and sensory
cortecies.
# Acute ischemic infarct: On admission, the patient's
neurological exam revealed left lower face, hand and wrist
weakness, without objective sensory findings. MRI showed an
acute ischemic infarct in the right MCA distribution. He was
monitored on tele which showed sinus bradycardia. TTE was
without PFO or thrombus. CTA did not show any evidence of
stenosis. A1c 5.3. He was scheduled for a TEE but elected to
have this done as an outpatient. Etiology of stroke was thought
secondary to embolic cause. He was discharged with ___ of
___ monitor to monitor for atrial fibrillation. He will
follow-up with stroke neurology.
# HTN: His home amlodipine and HCTZ were initially held to allow
for perfusion and restarted on discharge.
# HLD: Patient is not on home treatment. His cholesteral panel
was HDL 43, LDL 126 triglycerides 77. Statin therapy should be
discussed an outpatient.
Transitional issus:
- f/u ___ data
- will need TEE as an outpatient, will be contacted by the
cardiology department with a time for procedure
- consider treatment for cholesterol
- no HCP chosen
- family contact: daughter ___: ___
- code: presumed FULL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Amlodipine 2.5 mg PO DAILY
3. Famotidine 10 mg PO DAILY
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
5. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
2. Famotidine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
4. Amlodipine 2.5 mg PO DAILY
5. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Acute ischemic infaract, right frontal lobe
Secondary diagnosis:
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to ___ with left facial droop, slurred
speech, left sided arm weakness and parasthesias. You had a CT
and MRI of your brain and found to have a stroke. You were
started on aspirin. You were also monitored on telemetry which
did not show any evidence of atrial fibrillation. Additionally,
you had an ultrasound of your heart which did not show any
evidence of clot. You will need a trans-esophageal
echocardiogram to further evaluate from clot in your heart. This
will be done as an outpatient. You will be contacted by someone
from the cardiology department to have this done at BID- ___.
If you do not get a call within 2 weeks, you should call
___ and ask to speak to the cardiology department for
scheduling trans-esophageal echocardiograms. You will be leaving
with a long-term monitor to check your heart rhythm after you
leave the hospital. You will follow-up with stroke neurology as
an outpatient.
It was a pleasure taking care of you,
Your ___ Neurologists
Followup Instructions:
___
|
10381829-DS-12 | 10,381,829 | 21,090,381 | DS | 12 | 2137-03-25 00:00:00 | 2137-03-25 11:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
sudden onset of R sided hemiparesis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ presents for right-sided hemiparesis. He is post-op day 6
from a left temporal craniotomy for tumor resection with Dr.
___ on ___. He reports he was doing quite well until
around 1630 on ___ when he had an acute onset of
right-sided hemiparesis. He denies headache, vision changes,
numbness, tingling, difficulty with speech. He initially
presented to ___ where he underwent a non-contrast head CT
that only revealed post-surgical changes. He was then
transferred to ___ for further evaluation and management. He
now reports that his symptoms are somewhat improving but he
still
has significant weakness.
Past Medical History:
Past Medical History: He has a thyroid mass which is benign on
biopsy. He does not have
diabetes, hypertension, hypercholesterolemia, or COPD.
Past Surgical History: He had an appendectomy for ruptured
appendicitis. He also had a cholecystectomy.
Social History:
___
Family History:
Family History: His mother has multiple sclerosis. His father
is healthy. He has a younger sister and she is healthy. He
does
not have children.
Physical Exam:
PHYSICAL EXAM:
Temp: 98.3 HR: 86 BP: 151/90 RR: 18 O2Sat: 98% RA
Gen: WD/WN, comfortable, NAD.
HEENT:
Pupils: PERRL ___, brisk
EOMs: Intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 5 to 3mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus, though requires head tilt to the right in order to
see without diplopia
V, VII: right-sided facial droop present.
VIII: Hearing intact to voice.
XII: Tongue deviated to right
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. + right-sided pronator drift
D B T Grip IP Q H AT ___ G
Sensation: Intact to light touch
Pertinent Results:
___ 06:45AM BLOOD WBC-13.2* RBC-4.63 Hgb-13.5* Hct-38.2*
MCV-83 MCH-29.2 MCHC-35.3 RDW-12.2 RDWSD-36.1 Plt ___
___ 06:45AM BLOOD Glucose-115* UreaN-11 Creat-0.7 Na-137
K-4.1 Cl-100 HCO3-24 AnGap-17
___ 06:35PM BLOOD ALT-29 AST-14 LD(LDH)-166 CK(CPK)-40*
AlkPhos-77 TotBili-0.5
___ 06:35PM BLOOD TotProt-6.3* Albumin-3.8 Globuln-2.5
Cholest-156
___ 06:35PM BLOOD %HbA1c-5.0 eAG-97
___ 06:35PM BLOOD Triglyc-147 HDL-37 CHOL/HD-4.2 LDLcalc-90
___ 06:35PM BLOOD TSH-0.20*
___ 12:45PM BLOOD T4-8.8 T3-97
___ 06:35PM BLOOD CRP-2.6
Brief Hospital Course:
Mr. ___ was admitted to the neurology stroke service. MRI
Brain revealed a subacute infarct in the left caudate. EEG
showed no epileptiform discharges. He was increased on Keppra to
1500 BID and steroid taper was increased from 2 mg BID to 4 mg
Q8h. During his admission, he was noted to have asymptomatic
tachycardia. TSH was 0.20 but T3 and T4 were wnl. Given the
tachycardia (140s) he was started on low dose propranolol 10 mg
TID with improvement in the HR (70s-100s). Because of the new
hemiplegia, he was planned to transition to fluoxetine 20 mg
daily from citalopram 10 mg daily, per ___ trial. Cross-taper
is described in discharge instructions. He also noted that he
had diplopia which is improved with head tilt to the right which
should be further discussed with Dr. ___ at next neurosurgery
visit; if not improving neuro-ophthalmology can be considered.
He will be discharged to rehab with follow up with neurosurgery
(post-op), neurooncology (path follow-up), and endocrinology
(low TSH and tachycardia).
-----------
Studies:
CTA H&N ___
1. Dental amalgam streak artifact limits study.
2. Status post resection of a left temporal and insular mass
with postsurgical
changes, as described above with stable 6 mm rightward midline
shift, and
approximately 8 mm extracranial fluid collection overlying
surgical bed.
3. Left lenticulostriate corresponding CT perfusion images
demonstrate a
match defect.
4. Matched perfusion defect within the left temporal lobe and
insula
correspond to surgical resection cavity.
5. Attenuated left superior division M2 segment of the middle
cerebral artery.
Otherwise, patent circle of ___.
6. No internal carotid artery stenosis by NASCET criteria.
7. Re-demonstration of patient's known left thyroid gland
lesion.
MRI Brain ___
1. Subacute infarction in the left caudate body, posterior limb
of the left
internal capsule, and left putamen in the lenticulostriate
distribution.
2. Edema and postoperative inflammatory changes in the resection
cavity in the
left temporal lobe with mass effect and rightward midline shift
of 6 mm,
unchanged from CT head ___.
EEG ___
IMPRESSION: This is an abnormal routine EEG in the awake and
asleep states due
to the presence of continuous slowing over the left hemisphere.
This finding
indicates focal cerebral dysfunction on the left side, as from a
structural
lesion. No epileptiform features were seen. Note is made of a
regular
tachycardia.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 90) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[x ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
#1 we expect a 30% reduction of LDL with this dose
#2 given recent surgery there is a 5% risk of bleed with high
dose atorvastatin
[ ] 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 (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 >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 - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LevETIRAcetam 1250 mg PO BID
2. Citalopram 10 mg PO DAILY
3. Dexamethasone 2 mg PO Q12H
Discharge Medications:
1. Artificial Tears ___ DROP RIGHT EYE PRN dry/itchy eyes
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
5. Citalopram 3.5 mg PO DAILY Duration: 3 Days
___
6. Docusate Sodium 100 mg PO BID
7. Famotidine 20 mg PO BID
8. FLUoxetine 10 mg PO DAILY Duration: 2 Weeks
___
9. FLUoxetine 20 mg PO DAILY
starting ___
10. HydrOXYzine 25 mg PO QHS:PRN Insomnia
11. Milk of Magnesia 30 mL PO Q6H:PRN Constipation
12. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
13. Propranolol 10 mg PO/NG TID
14. Citalopram 5 mg PO DAILY Duration: 4 Days
___
15. Dexamethasone 4 mg PO Q8H
16. LevETIRAcetam 1500 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left basal ganglia and posterior limb of internal capsule
ischemic 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:
Dear Mr. ___,
You were hospitalized due to symptoms of left sided weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
cholesterol 90
We are changing your medications as follows:
atorvastatin 10 mg nightly
Please take your other medications as prescribed.
Please followup with Neurolosurgery, neuro oncology, and
endocrinology.
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:
___
|
10381881-DS-14 | 10,381,881 | 21,161,617 | DS | 14 | 2182-12-15 00:00:00 | 2182-12-15 18:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
diverticulitis
pelvic abscess
Major Surgical or Invasive Procedure:
___ ___ drainage
___ sigmoid colectomy (open), diverting loop ileostomy
History of Present Illness:
___ PMH HTN recently admitted for sigmoid diverticulitis w/
intramural abscess now w/ enlarged abscess causing left
hydronephrosis and colouterine fistula. Patient was recently
admitted to ___ ___ with acute sigmoid
diverticulitis
with a 4x2x4 cm intramural abscess. She was treated with bowel
rest and levaquin/flagyl. She remained afebrile and
hemodynamically stable through the hospital stay and WBC was 9.2
on discharge. She was discharged with prescription for 12 more
days of levaquin/flagyl. Plan was to follow-up with PCP ___ 2
weeks for repeat exam/imaging. She reports that her pain never
really improved after admission and was ___ at time of
discharge
and has slowly worsened. She reports persistent anorexia and
frequent loose bowel movements. She has noted she is urinating
more than usual, but attributes this to drinking much more water
in an effort to stay hydrated.
She was also instructed to follow-up with her PCP within the
week
which she did on ___. Her PCP was concerned that
she
was not improving as expected and referred her to ___
earlier today for CT scan which showed interval increase in the
size of pelvic abscess as well as interval development of mild
left hydroureter and air within the uterus concerning for
colouterine fistula. She was transferred to ___ for further
intervention.
Past Medical History:
-HTN
-sigmoid diverticulitis with lateral sigmoid
-gout
Social History:
___
Family History:
-Mother with ___ procedure and reversal for perforated
diverticulitis in her ___ or ___, CABG in her later years
-Brother with colon cancer in his ___ as well as EtOH cirrhosis
(deceased in his ___
-Father deceased from CVA in his ___
Physical Exam:
Vitals Temp:98.4 BP:109/69 HR:90 RR:18 O2sat:98 Ra
GEN: NAD, siting in chair comfortably
HEENT: PERRLA, EOMI, no scleral icterus
CV: RRR
PULM: clear to auscultation bilaterally, non-labored breathing
ABD: soft, non distended, non tender, with ostomy bag that has
stool output. wound looks clean, dry and intact
EXT: warm and well perfused, no edema
NEURO: A&Ox3
Pertinent Results:
___ 04:09PM URINE HOURS-RANDOM
___ 04:09PM URINE UHOLD-HOLD
___ 04:09PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:09PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG*
___ 04:09PM URINE RBC-2 WBC-40* BACTERIA-FEW* YEAST-NONE
EPI-0
___ 03:20PM GLUCOSE-108* UREA N-10 CREAT-1.0 SODIUM-137
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-19* ANION GAP-16
___ 03:20PM estGFR-Using this
___ 03:20PM ___ PTT-27.6 ___
___ 02:44PM COMMENTS-GREEN TOP
___ 02:44PM LACTATE-2.8*
___ 02:30PM WBC-16.3* RBC-3.92 HGB-12.3 HCT-38.9 MCV-99*
MCH-31.4 MCHC-31.6* RDW-13.0 RDWSD-47.4*
___ 02:30PM NEUTS-82.6* LYMPHS-7.5* MONOS-8.1 EOS-0.1*
BASOS-0.7 IM ___ AbsNeut-13.44* AbsLymp-1.22 AbsMono-1.32*
AbsEos-0.02* AbsBaso-0.11*
___ 02:30PM PLT COUNT-298
Brief Hospital Course:
___ were admitted to ___ and
underwent sigmoid resection and loop ileostomy. ___ initially
came with diverticulitis recurrence and ___ were found to have
an increased pelvic abscess and a colovesical fistula. It was
decided to place a drain for bowel rest and to plan for sigmoid
resection and ileostomy. During your hospital stay it was noted
that ___ were not progressing appropriately. On ___ your drain
cultures came back with pseudomona aeruginosa and ___ were
started on cefepime and flagyl. ___ began to progress
appropriately. During the hospital stay ___ were also found to
have a positive stool culture for c. diff and ___ were started
on PO vancomycin. After your pain was well controlled, your
vital signs were stable and your labs were within normal limits,
it was decided to proceed with the sigmoid resection and loop
ileostomy. After an uncomplicated procedure ___ were taken to
the floor. ___ were started on a clear liquid diet on POD 1 and
once ___ tolerated ___ were given a regular diet. ___ had a JP
drain placed in the OR that has had minimal serosanguinous
output through out the hospital stay. The JP was removed on the
day of discharge. ___ have been progressing appropriately,
tolerating a regular diet, walking, with pain well controlled,
and vital signs within normal limits.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Allopurinol Dose is Unknown PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [8 Hour Pain Reliever] 650 mg 1 tablet(s) by
mouth Q8 Disp #*40 Tablet Refills:*0
2. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*20
Capsule Refills:*0
3. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
Duration: 5 Days
RX *ondansetron 4 mg 1 tablet(s) by mouth Q8 Disp #*10 Tablet
Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth Q4 Disp #*4
Tablet Refills:*0
5. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin [Firvanq] 25 mg/mL 5 ml by mouth four times a day
Refills:*0
6. Allopurinol ___ mg PO DAILY
7. Lisinopril 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
sigmoid diverticulitis
pelvic abscess
colovesical fistula
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please get an abdomen and pelvis CT scan with rectal contrast
and bring the live images plus the interpretation to your
appointment in ___ in ___.
Dear ___,
___ were admitted to ___ and
underwent sigmoid resection and loop ileostomy. ___ initially
came with diverticulitis recurrence and ___ were found to have
an increased pelvic abscess and a colovesical fistula. It was
decided to place a drain for bowel rest and to plan for sigmoid
resection and ileostomy. During your hospital stay it was noted
that ___ were not progressing appropriately. On ___ your drain
cultures came back with pseudomona aeruginosa and ___ were
started on cefepime and flagyl. ___ began to progress
appropriately. During the hospital stay ___ were also found to
have a positive stool culture for c. diff and ___ were started
on PO vancomycin. After your pain was well controlled, your
vital signs were stable and your labs were within normal limits,
it was decided to proceed with the sigmoid resection and loop
ileostomy. After an uncomplicated procedure ___ were taken to
the floor. ___ were started on a clear liquid diet on POD 1 and
once ___ tolerated ___ were given a regular diet. ___ had a JP
drain placed in the OR that has had minimal serosanguinous
output through out the hospital stay. The JP was removed on the
day of discharge. ___ have been progressing appropriately,
tolerating a regular diet, walking, with pain well controlled,
and vital signs within normal limits. ___ are recovering well
and are now ready for discharge. Please follow the instructions
below to continue your recovery:
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 is 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.
Monitoring Ostomy output/ Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.
*If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
OSTOMY DISCHARGE INSTRUCTIONS:
___ 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.
Followup Instructions:
___
|
10381914-DS-17 | 10,381,914 | 21,523,240 | DS | 17 | 2185-07-26 00:00:00 | 2185-07-26 13:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
___: laparoscopic cholecystectomy
History of Present Illness:
Mr. ___ is a ___ male with an episode of RUQ pain he
attributes to gallstones eight months ago who now presents with
pain since ___ afternoon. He was seen the in ___ ED on
___ night and observed overnight with improvement in his
pain by morning. He was discharged to home but his pain
persisted and he also reports a low grade fever to 100.1 and now
represents to ___ ED for evaluation. He denies nausea and
emesis, chest pain and SOB.
Past Medical History:
none
Social History:
___
Family History:
NC
Physical Exam:
Admission PE ___
Vitals: 99.0 83 126/72 16 98% RA
NAD, AAOx3
RRR
CTA b/l
soft, nondistended, tender to palpation in RUQ, no rebound, no
guarding, positive Murphys
no peripheral edema or cyanosis
Discharge PE: ___:
Vitals: 99.8, 75, 135/82, 18, 99% on RA
Gen: NAD, comfortable appearring man
Lungs: CTAB
CV: S1, S2, RRR
Abd: soft, appropriately tender at port sites, X 4 lap ports
sites with primary dressing, no staining
Ext.: Warm, well perfused, +PP
Neuro: Alert and oriented X3, MAE to command
Pertinent Results:
___ 01:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:30AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:00PM LACTATE-1.1
___ 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.0
LEUK-NEG
___ 07:55PM GLUCOSE-94 UREA N-14 CREAT-0.8 SODIUM-141
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-29 ANION GAP-15
___ 07:55PM ALT(SGPT)-35 AST(SGOT)-24 ALK PHOS-62 TOT
BILI-0.8
___ 07:55PM LIPASE-38
___ 07:55PM ALBUMIN-4.6
___ 07:55PM WBC-7.6 RBC-4.35* HGB-13.8* HCT-40.7 MCV-94
MCH-31.7 MCHC-33.8 RDW-13.1
___ 07:55PM NEUTS-66.5 ___ MONOS-7.1 EOS-2.0
BASOS-0.5
___ 07:00AM BLOOD WBC-7.6 RBC-4.38* Hgb-13.4* Hct-40.2
MCV-92 MCH-30.5 MCHC-33.3 RDW-12.6 Plt ___
___ 07:00AM BLOOD Glucose-94 UreaN-10 Creat-0.9 Na-139
K-4.4 Cl-100 HCO3-31 AnGap-12
___ 07:00AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.2
Brief Hospital Course:
Mr. ___ is a ___ year old who was admitted on ___ under
the acute care surgery service for management of acute
cholecystitis. He was taken to the operating room and underwent
a laparoscopic cholecystectomy by Dr. ___. Please see
operative report for details of this procedure. He tolerated the
procedure well and was extubated upon completion. He was
subsequently taken to the PACU for recovery.
He was transferred to the surgical floor hemodynamically stable.
His vital signs were routinely monitored and he remained
afebrile and hemodynamically stable. He was initially given IV
fluids postoperatively, which were discontinued when he was
tolerating PO's. His diet was advanced on the evening of ___ to
regular, which he tolerated without abdominal pain, nausea, or
vomiting. He was voiding adequate amounts of urine without
difficulty. He was encouraged to mobilize out of bed and
ambulate as tolerated, which he was able to do independently.
His pain level was routinely assessed and well controlled at
discharge with an oral regimen as needed.
On ___, he was discharged home with scheduled follow up in
___ clinic on ___.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
Do not drive or drink alcohol while on this medication.
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10382041-DS-2 | 10,382,041 | 29,030,020 | DS | 2 | 2188-08-31 00:00:00 | 2188-08-31 15:34:00 |
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:
ERCP X 2
attach
Pertinent Results:
Admission Labs:
===============
___ 07:05PM BLOOD WBC-8.4 RBC-4.02* Hgb-11.6* Hct-37.4*
MCV-93 MCH-28.9 MCHC-31.0* RDW-15.1 RDWSD-50.4* Plt ___
___ 07:05PM BLOOD Neuts-70.5 ___ Monos-8.3 Eos-0.4*
Baso-0.2 Im ___ AbsNeut-5.94 AbsLymp-1.68 AbsMono-0.70
AbsEos-0.03* AbsBaso-0.02
___ 07:05PM BLOOD ___ PTT-27.8 ___
___ 07:05PM BLOOD Glucose-99 UreaN-10 Creat-0.7 Na-141
K-4.1 Cl-101 HCO3-25 AnGap-15
___ 07:05PM BLOOD ALT-117* AST-108* AlkPhos-1636*
TotBili-1.9*
___ 07:00AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.6
___ 07:05PM BLOOD Albumin-3.8
___ 07:11PM BLOOD Lactate-1.5
Imaging:
========
CT Chest w/ Contrast:
No evidence of infection.
CT Abd/Pelvis w/ Contrast:
1. Deep venous thrombosis of the right common iliac vein and
right IVC.
2. Possible stone noted in the distal CBD, at the level of the
ampulla.
Recommend further evaluation with MRCP. This could also better
assess the
mild unexplained pancreatic duct dilation.
3. Hyperemia of the common bile duct, an expected finding in the
setting of recent ERCP.
Discharge Labs:
===============
___ 06:15AM BLOOD WBC-5.4 RBC-3.12* Hgb-8.9* Hct-28.3*
MCV-91 MCH-28.5 MCHC-31.4* RDW-14.6 RDWSD-47.9* Plt ___
___ 06:15AM BLOOD ___ PTT-66.7* ___
___ 06:15AM BLOOD Glucose-98 UreaN-7 Creat-0.6 Na-146 K-3.5
Cl-106 HCO3-27 AnGap-13
___ 06:15AM BLOOD ALT-51* AST-55* AlkPhos-875* TotBili-0.8
___ 06:15AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.8
Brief Hospital Course:
Mr. ___ is a ___ male with a PMHX of GERD, HLD, and
recurrent cholangitis with bacteremia, who again presented with
bacteremia in the setting of cholangitis.
# Transaminitis
# Biliary Obstruction s/p stent
# Cholangitis:
# Bacteremia:
Multiple recent episodes of biliary obstruction complicated by
cholangitis and bacteremia. He was scheduled for ERCP with Dr.
___ on ___ but then developed fever and was admitted on
___.
Given rising bilirubin to 2.4 on admission, it was suspected
that his fevers were secondary to cholangitis/intra-abdominal
process. Blood cultures from ___ and ___ were positive for
Klebsiella, also grown from previous positive cultures in ___
and ___.
He underwent ERCP with removal of stones and sludge. Given
recurrent/persistent bacteremia (three episodes in seven weeks),
there was some concern for additional source of infection or
lack of source control. CT torso was obtained and was negative
for abscess, though did note a common iliac DVT extending into
the IVC. There was also concern for ampullary stone on CT. He
underwent repeat ERCP and no stones were found.
He was initially treated with ceftriaxone/flagyl and narrowed to
cipro based on culture data.
He was also seen by ID who recommended an extended four week
course of ciprofloxacin (last day ___ due to the possibility
that clot was seeded in the setting of bacteremia or the source
of his recurrent bacteremia (unlikely but unable to rule out).
He will need a repeat ERCP in ___ weeks with spyglass
cholangiography to further evaluate previously noted hepatic
duct abnormality seen at ___.
# Iliac vein DVT, IVC thrombus:
Incidentally found to have right common iliac vein DVT extending
to IVC. Would consider provoked due to immobility and
inflammatory state. He was started on a heparin drip and
transitioned to apixaban at discharge and will need at least a
three month course.
There was some concern that clot could be seeded/infected in the
setting of recurrent/persistent bacteremia, though no clear
phlebitis seen on CT. Therefore ID recommended four week
antibiotic course as above.
# Fever
# Cough
# Pneumonia
CXR suggestive of pneumonia. He had fever (likely due to
bacteremia). He endorsed cough but no shortness of breath. He
was treated with a five day course of ceftriaxone/azithromycin.
# Severe Malnutrition
Has lost significant amount of weight over past couple months
likely secondary to intraabdoinal infection/complication. Seen
by nutrition who recommended ensure supplements
# GERD: continued home omeprazole 20mg BID
# HLD: held statin given transaminitis. Also held on discharge
due to potential interaction with ciprofloxacin (increased risk
of rhabdomyolysis). Can resume after ciprofloxacin course
completed
> 30 minutes spent on discharge coordination and planning
Transitional Issues:
====================
- discharged on ciprofloxacin for four week course (last day
___
- found to have iliac vein and IVC thrombus. Will need three
month course of anticoagulation for provoked DVT
- he will need a repeat ERCP in ___ weeks with spyglass
cholangiography to further evaluate previously noted hepatic
duct abnormality seen at ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID
2. Simvastatin 40 mg PO QPM
Discharge Medications:
1. Apixaban 10 mg PO BID
for 7 days, then decrease to 5mg twice a day
RX *apixaban [Eliquis] 5 mg (74 tabs) 10 mg by mouth twice a day
Disp #*1 Dose Pack Refills:*0
2. Ciprofloxacin HCl 500 mg PO BID
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*54 Tablet Refills:*0
3. Omeprazole 20 mg PO BID
4. HELD- Simvastatin 40 mg PO QPM This medication was held. Do
not restart Simvastatin until you finish taking ciprofloxacin
(simvastatin and ciprofloxacin can interact)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Bacteremia
Cholangitis
Acute DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came in with fevers. We found that you had another infection
in your bile ducts that spread to your blood. We treated you
initially with IV antibiotics, and then switched to oral
antibiotics once we identified the organism in your blood
(Klebsiella, the same bacteria that grew in the blood before).
Given your multiple recent infections, you had a CT scan to look
for any other sources of infection. This scan showed a blood
clot in the veins in your abdomen (right common iliac vein and
IVC). We started you on a blood thinner. You will need to
continue taking an oral blood thinner at home for the next three
months. Blood thinners increase the risk of bleeding. Please
avoid any contact sports, and if you fall and hit your head you
should come to the emergency room immediately (blood thinners
significantly increase your risk of bleeding into the head).
You were seen by the infectious disease team. They feel that it
is possible that the blood clot became infected. Because of this
they recommended a longer course of antibiotics. You should take
ciprofloxacin for one month (last day ___.
You will also need to follow up with the ERCP doctors for ___
repeat ERCP. Someone should call you with an appointment, but if
you do not hear from anyone please call ___ to schedule
an appointment.
It was a pleasure taking care of you, and we are happy that
you're feeling better!
Followup Instructions:
___
|
10382464-DS-21 | 10,382,464 | 21,171,914 | DS | 21 | 2114-10-06 00:00:00 | 2114-10-08 09:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ACE Inhibitors / amlodipine / clonidine
Attending: ___
Chief Complaint:
presyncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of SSS now on coumadin after dual-chamber pacemaker
placement ___, presents after 2 episodes of prescynope. Two
days ago, pt lost her balance as her was bent over and fell onto
a bureau, hitting her left back. That evening at ___
dinner, she experienced her first episode of presyncope: she was
at the table when she suddenly became hot, sweaty, and
lightheaded, but returned to baseline within one minute. On the
morning of admission, she was placing a heating pad to her sore
left-back and had a similar, but less severe sensation of heat,
diaphoresis and lightheadedness, that resolved within one
minute. Her daughter was concerned and brought her to the ED.
She denies any palpitations, chest pain, shortness of breath,
orthopnea, PND. Pt states she never had symptoms like this
before, with her prior admissions for atrial fibrillation. She
denies any medication changes since her pacemaker was placed one
month ago. She was in her usual state of health until 2 days
ago. She denies F/C, N/V/D. She c/o left low back pain but
otherwise denied CP, SOB, lightheadedness, or other complaints.
In the ED, initial vitals were 97.9 60 142/56 18 97% RA.
Orthostatics were negative. She had TTP on the left lower back
with concern for possible rib fracture from fall on exam.
Labs notable for INR of 3.8. Guaiac negative. Troponin x1
negative.
Per review of OMR notes, she was first diagnosed with atrial
fibrillation in ___ when she presented to ___
with rapid palpitations, lightheadedness, and nausea. She
underwent successful cardioversion to restore sinus rhythm.
Coumadin was initiated. LVEF was noted to be at 35% at the time.
She had recurrent symptoms one month later and was successfully
cardioverted to sinus with initiation of Amiodarone. She
presented again in ___ to ___ with presyncope
and racing palpitations. She was found to be in atrial flutter
and underwent ablation. She felt significantly better in sinus
rhythm.
In ___, she represented to ___ with
recurrent rapid atrial fibrillation with heart rates 120-130's.
As she had failed Amiodarone it was discontinued and Metoprolol
was aggressively titrated up, currently 150mg bid. During that
admission she had CHF. In addition she had acute cholecystitis
requiring cholecystectomy. When she was evaluated in ___,
she was found to be in sinus bradycardia with a heart rate in
the 40-50 range. Due to this bradycardia, LBBB, and depressed LV
function, she was referred for BiV pacemaker but was
unsuccessful in implanting an LV lead. She had a dual-chamber
pacer placed ___ and started on amiodarone and warfarin.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism. Cardiac review
of systems is notable for absence of chest pain, dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
or palpitations.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
Atrial fibrillation/flutter s/p ablation at ___ in ___
Congestive heart failure, LVEF 35%
LBBB
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD: dual-chamber pacemaker, DDD mode
3. OTHER PAST MEDICAL HISTORY:
Colon cancer, s/p right hemicolectomy in ___
Reflux esophagitis, hx of chronic gastritis
s/p right knee replacement
glucose intolerance
Osteoporosis per ___ (patient denies)
Hypothyroidism
Cholecystitis s/p cholecystectomy ___
oophorectomy, hysterectomy (___)
Glaucoma per ___
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION
VS: Wt=91.9kg T=98.3 BP=161/65 HR=60 RR=20 O2 sat=98%RA
General: slightly overweight woman in NAD
HEENT: MMM, OP clear
Neck: no JVD
CV: RRR, nl s1/s2, ___ sysolic murmur heard in aortic and
pulmonic areas
Lungs: CTAB
Abdomen: obese, soft, NT, normoactive BS
GU: no foley
Ext: warm, no edema
Neuro: AAOx3
Skin: no lesions or rashes noted
PULSES: 2+ radial pulse
DISCHARGE
General: slightly overweight woman in NAD
HEENT: MMM, OP clear
Neck: no JVD
CV: RRR, nl s1/s2, ___ sysolic murmur heard in aortic and
pulmonic areas
Lungs: CTAB
Abdomen: obese, soft, NT, normoactive BS
Ext: warm, no edema
Neuro: AAOx3
Pertinent Results:
ADMISSION LABS
___ 01:11PM BLOOD WBC-10.3 RBC-4.82 Hgb-12.5 Hct-40.2
MCV-83 MCH-26.0* MCHC-31.2 RDW-16.4* Plt ___
___ 01:11PM BLOOD Neuts-68.9 ___ Monos-6.8 Eos-0.8
Baso-0.5
___ 01:11PM BLOOD Glucose-112* UreaN-18 Creat-0.9 Na-140
K-4.1 Cl-99 HCO3-31 AnGap-14
___ 01:11PM BLOOD ___ PTT-41.9* ___
___ 01:11PM BLOOD cTropnT-<0.01
___ 09:30PM BLOOD CK-MB-2 cTropnT-<0.01
ECG ___: Atrial pacing. Intraventricular conduction delay.
Left ventricular hypertrophy. Inferolateral ST segment changes
may be due to left ventricular hypertrophy. Compared to the
previous tracing of ___ there is now atrial pacing. The QRS
morphology appears similar.
CT HEAD ___
There is no evidence of intracranial hemorrhage, acute major
vascular
territorial infarction, shift of the normally midline
structures, mass effect or edema. The ventricles and sulci are
mildly prominent, compatible with age-related global atrophy.
Periventricular and subcortical white matter hypodensities
likely reflect the sequelae of chronic small vessel ischemic
disease. The basal cisterns appear patent. The gray-white
matter differentiation is preserved. No fractures are
identified. The cranial and facial soft tissues are
unremarkable. The visualized paranasal sinuses, mastoid air
cells and middle ear cavities are clear.
IMPRESSION:
No acute intracranial process. Chronic small vessel ischemic
disease.
CT C-SPINE ___
FINDINGS: The cervical lordosis is preserved. There is no
evidence of fracture or acute malalignment in the cervical
spine. The prevertebral soft tissues are unremarkable. There
is no lymphadenopathy. The visualized lung apices are grossly
clear. The thyroid gland is unremarkable. Multilevel mild
degenerative changes are present in the cervical spine including
anterior and posterior osteophyte formation, multilevel facet
arthropathy, and subchondral cystic change.
IMPRESSION: No fracture or acute malalignment in the cervical
spine. Mild degenerative changes.
CT L-SPINE ___
FINDINGS: There is a compression deformity of the L3 vertebral
body with approximately 50% loss of height, and no evidence of
retropulsion of fracture fragments (420:29), likely chronic.
Multilevel disc space narrowing, facet arthropathy and anterior
and posterior osteophyte formation is noted, most prominent at
the T12-L1 level. There is no malalignment within the lumbar
spine.
The prevertebral soft tissues are unremarkable. A small left
dependent pleural effusion is noted, better characterized on the
concurrent CT of the chest, along with subtle cortical
disruption of the left posterior 11th rib at the costovertebral
margin (2:7). Sigmoid diverticulosis is noted, with no evidence
of diverticulitis. Dense atherosclerotic calcifications are
noted in the abdominal aorta and common iliac vessels.
IMPRESSION:
1. Compression deformity of the L3 vertebral body is likely
chronic; with no evidence of retropulsion of fracture fragments
or critical spinal canal narrowing.
2. Multilevel degenerative changes as described above, most
prominent at T12-L1.
3. Left posterior 11th rib fracture, appears acute.
CT CHEST WITHOUT IV CONTRAST ___
The intrathoracic aorta and pulmonary arteries are of normal
caliber. Dense atherosclerotic calcifications are present in
the aortic arch and descending thoracic aorta, as well as within
the coronary arteries and aortic valve. A dual lead pacemaker
device is in place, with leads terminating in the right atrium
and right ventricle.
The heart is mildly enlarged, with no pericardial effusion. The
esophagus is unremarkable. There is no pathologic enlargement
of the supraclavicular, axillary, mediastinal or hilar lymph
nodes by imaging size criteria, with the exception of a 13 mm
right lower paratracheal lymph node (2:19), likely reactive. A
small left pleural effusion is noted, with linear atelectasis or
scarring in the left lung base. Fluid is seen tracking along
the fissure (4:87). Mild air trapping is present in the lung
bases, along with mild emphysema. A punctate calcified
granuloma is present in the right upper lobe (4:52). No
concerning nodules or masses are identified. The airways are
patent to the subsegmental level.
Although the study is not designed for evaluation of
subdiaphragmatic structures, the imaged upper abdomen is
unremarkable. Cholecystectomy clips are noted. Mild
nonspecific fat stranding noted at the mesenteric root.
OSSEOUS STRUCTURES: Subtle cortical irregularity of the
posterior left 11th rib (301:88), and possibly the posterior
left 10th rib (301:77) near the costovertebral junction are
consistent with non-displaced fractures. No lytic or blastic
lesions suspicious for malignancy is present.
IMPRESSION:
1. Subtle non-displaced fractures of the posterior left ___,
and possibly 10th ribs, near the costovertebral junction.
2. Small left pleural effusion.
3. Mild cardiomegaly.
DISCHARGE LABS
___ 06:32AM BLOOD ___
Brief Hospital Course:
___ with afib/flutter s/p ablation in ___ and DDD dual chamber
pacemaker ___, on coumadin, presents after 2 short-lived
episodes of presyncope associated with diaphoresis, likely
vasovagal.
# presyncope: lasted minutes and were associated with
diaphoresis but no chest pain, palpitations or dypsnea. Pt was
observed to be atrially paced while on telemetry, and
experienced no further episodes of presyncope. Pacemaker was
interrogated and revealed no malfunction. No medication changes
since pacemaker placement. ACS ruled out with trop neg x 2 and
no ischemic changes on EKG. Presyncope was thought to be
vasovagal. Pt was instructed to follow up with
electrophysiologist Dr. ___ placed her pacemaker.
# Afib / Sick sinus syndrome s/p pacemaker on coumadin: INR
supratherapeutic at 3.8. Warfarin was held during admission. Pt
was instructed to check INR daily at home and call
___ clinic when INR <3.0 for warfarin dosing
instructions. Pt was maintained on metoprolol succinate XL 100
mg PO BID, and was discharged on scheduled reduction in
amiodarone dose to 200mg daily.
# Non-displaced rib fracture: Pt found with subtle nondisplaced
fracture of posterior left 11th rib, after direct impact trauma
to the area during a mechanical fall on ___. Pt discharged on
acetaminophen 1000mg q6h x 7 days for pain control.
# CHF (EF 35%): Pt appeared euvolemic during admission and was
maintained on furosemide 40 mg daily and irbesartan 150 mg
daily.
TRANSITIONAL ISSUE
- Electrophysiologist to consider possible changes in pacemaker
settings by reducing PR interval via RV pacing to optimize
ventricular synchronization, vs. maintaining atrial pacing with
current prolonged PR interval.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO DAILY
2. Citalopram 10 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO BID
7. Warfarin 7.5 mg PO DAILY
8. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral bid
9. Amiodarone 200 mg PO BID
10. Avapro (irbesartan) 150 mg oral daily
11. Metoprolol Succinate XL 100 mg PO BID
Discharge Medications:
1. Atorvastatin 10 mg PO DAILY
2. Avapro (irbesartan) 150 mg oral daily
3. Citalopram 10 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Metoprolol Succinate XL 100 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO BID
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral bid
10. Amiodarone 200 mg PO DAILY
RX *amiodarone 200 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
11. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 6 hours Disp
#*56 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Vasovagal syncope
Secondary
Atrial fibrillation and flutter s/p ablation and pacemaker
systolic congestive heart failure, compensated
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to take care of you at ___. You came in with
2 episodes of lightheadedness. Your description of what happened
is very consistent with what we call "vasovagal syncope" - the
same thing that happens to people when they faint. We monitored
your heart rhythm and saw that the pacemaker was functioning
properly. We had the electrophysiologists tweak the pacemaker so
that it does the best job to help the way your heart pumps,
given your heart failure. You should decrease your amiodarone to
1 pill daily.
Your INR was too high. The goal is 2.0-3.0 Don't take your
warfarin until your INR is less than 3.0. When your INR is less
than 3.0, call ___ clinic, tell
them the last time you took warfarin was ___ night, and
ask them how much you should take.
For your rib pain, you can take 1000mg tylenol every 6 hours.
Followup Instructions:
___
|
10382464-DS-22 | 10,382,464 | 29,596,890 | DS | 22 | 2115-07-18 00:00:00 | 2115-07-18 21:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ACE Inhibitors / amlodipine / clonidine / codeine
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Cardioversion
History of Present Illness:
___ year old woman w/PMH of HTN, HLD, CHF (EF 30%), Afib s/p
ablation and PPM, who presents with complaint of dyspnea.
Reports intermittent dyspnea and had a ___ lbs weight gain over
the last several days, with mild nausea. Has worsening orthopnea
and slept in a chair for several days. She called her
cardiologist and had her amiodarone and lasix doses increased.
Also with increased HR up to 110+ in past week. No chest pain.
No increase in leg swelling. She denies urinary symptoms.
In the ED, initial VS: 99.1 84 120/72 18 95% RA. Labs notable
for H/H 10.6/33.3, INR 4.8, Trop/CKMB neg, proBNP 3328. UA with
large leuk, few bacteria. EKG showing ... CXR showing small R
side pleural effusion. Patient was given Furosemide 40mg IV x1.
She was evaluated by Dr. ___ recommended admission for IV
diuresis and cardioversion.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
Atrial fibrillation/flutter s/p ablation at ___ in ___
Congestive heart failure, LVEF 35%
LBBB
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD: dual-chamber pacemaker, DDD mode
3. OTHER PAST MEDICAL HISTORY:
Colon cancer, s/p right hemicolectomy in ___
Reflux esophagitis, hx of chronic gastritis
s/p right knee replacement
glucose intolerance
Osteoporosis per ___ (patient denies)
Hypothyroidism
Cholecystitis s/p cholecystectomy ___
oophorectomy, hysterectomy (___)
Glaucoma per ___
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.4, BP 134/73, HR 83, RR 16, 94% on RA, Wt:
General: NAD, comfortable, pleasant, alert and oriented x3
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: irregular rate and rhythm, normal S1, physiologic splitting
of S2, no murmurs, clicks, rubs, gallops
Lungs: CTAB, no wheezing, rhonchi, rales, crackles
Abdomen: soft, NT/ND, BS+
Ext: WWP, no clubbing or cyanosis, 1+ pitting edema halfway up
bilateral lower legs
Pulses: 1+ DP pulses bilaterally
Neuro: moving all extremities grossly
DISCHARGE PHYSICAL EXAM:
VS: T= 98.0, BP= 119-136/65-71, HR= 57-60, RR= ___, O2 sat=
92-98% on RA
Wt: 99.1kg <- 98.7kg, I/O: 220/300 since MN, 1100/670 over past
24h
General: NAD, comfortable, pleasant, alert and oriented x3
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rate and rhythm, normal S1, S2, no murmurs, clicks,
rubs, gallops
Lungs: CTAB, no wheezing, rhonchi, rales, crackles
Abdomen: soft, NT/ND, BS+
Ext: WWP, no clubbing or cyanosis, 1+ pitting edema halfway up
bilateral lower legs
Pulses: 1+ DP pulses bilaterally
Neuro: moving all extremities grossly
Pertinent Results:
ADMISSION LABS:
___ 09:00AM BLOOD WBC-9.6 RBC-3.95* Hgb-10.6* Hct-33.3*
MCV-84 MCH-26.8* MCHC-31.8 RDW-18.3* Plt ___
___ 09:00AM BLOOD Neuts-70.0 ___ Monos-6.7 Eos-1.6
Baso-0.5
___ 09:00AM BLOOD ___ PTT-40.4* ___
___ 09:00AM BLOOD Plt ___
___ 09:00AM BLOOD Glucose-173* UreaN-36* Creat-1.1 Na-140
K-4.2 Cl-102 HCO3-26 AnGap-16
___ 09:00AM BLOOD CK(CPK)-45
___ 09:00AM BLOOD CK-MB-2 proBNP-3328*
___ 09:00AM BLOOD cTropnT-<0.01
PERTINENT RESULTS:
CBC TREND:
___ 09:00AM BLOOD WBC-9.6 RBC-3.95* Hgb-10.6* Hct-33.3*
MCV-84 MCH-26.8* MCHC-31.8 RDW-18.3* Plt ___
___ 06:14AM BLOOD WBC-7.6 RBC-4.00* Hgb-10.3* Hct-33.7*
MCV-84 MCH-25.7* MCHC-30.5* RDW-18.4* Plt ___
___ 05:06AM BLOOD WBC-10.8 RBC-3.97* Hgb-10.6* Hct-33.0*
MCV-83 MCH-26.8* MCHC-32.3 RDW-18.5* Plt ___
___ 05:20AM BLOOD WBC-12.4* RBC-4.08* Hgb-10.8* Hct-34.6*
MCV-85 MCH-26.4* MCHC-31.2 RDW-18.8* Plt ___
___ 05:05AM BLOOD WBC-11.6* RBC-3.81* Hgb-10.2* Hct-32.2*
MCV-85 MCH-26.7* MCHC-31.6 RDW-18.5* Plt ___
___ 05:00AM BLOOD WBC-9.3 RBC-3.59* Hgb-9.7* Hct-30.5*
MCV-85 MCH-27.0 MCHC-31.8 RDW-19.2* Plt ___
CHEM 7:
___ 09:00AM BLOOD Glucose-173* UreaN-36* Creat-1.1 Na-140
K-4.2 Cl-102 HCO3-26 AnGap-16
___ 06:14AM BLOOD Glucose-102* UreaN-35* Creat-1.2* Na-140
K-4.6 Cl-102 HCO3-30 AnGap-13
___ 05:06AM BLOOD Glucose-112* UreaN-32* Creat-1.2* Na-140
K-4.6 Cl-102 HCO3-31 AnGap-12
___ 05:20AM BLOOD Glucose-126* UreaN-44* Creat-1.4* Na-140
K-4.8 Cl-100 HCO3-28 AnGap-17
___ 05:05AM BLOOD Glucose-118* UreaN-49* Creat-1.4* Na-139
K-4.8 Cl-100 HCO3-28 AnGap-16
___ 03:35PM BLOOD Glucose-122* UreaN-48* Creat-1.3* Na-138
K-4.5 Cl-100 HCO3-29 AnGap-14
___ 05:00AM BLOOD Glucose-115* UreaN-51* Creat-1.3* Na-139
K-4.4 Cl-99 HCO3-31 AnGap-13
COAGULATION PROFILE:
___ 09:00AM BLOOD ___ PTT-40.4* ___
___ 06:14AM BLOOD ___ PTT-42.0* ___
___ 05:06AM BLOOD ___ PTT-41.5* ___
___ 05:20AM BLOOD ___ PTT-39.3* ___
___ 05:05AM BLOOD ___
___ 05:00AM BLOOD ___
IMAGING AND PROCEDURES:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is at
least 15 mmHg. Left ventricular wall thicknesses and cavity size
are normal. Overall left ventricular systolic function is
moderately depressed ( LVEF = 30%) secondary to.akinesis to
dyskinesis of the septum, and akinesis of the apex and anterior
wall 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) appear structurally normal with good leaflet excursion and
no aortic stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. The mitral valve leaflets do not fully coapt. The
effective regurgitant orifice is >=0.40cm2 Severe (4+) mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Moderate-severe regional and global left ventricular
systolic dysfunction c/w CAD. Severe functional mitral
regurgitation. Mildly dilated right ventricular cavity with
normal systolic function, moderate-severe tricuspid
regurgitation and severe pulmonary artery systolic hypertension.
Brief Hospital Course:
# Dyspnea: likely ___ to decompensation of her sCHF ___ to her
afib and poor rate control. Pt recently had amiodarone increased
to 300mg daily from 200mg daily but was still having HR up to
the 110s and having symptoms of dyspnea and presyncope. She was
admitted and had successful direct current cardioversion with
resultant HR in the ___ paced. She did not have any recurrence
of her tachycardia and did not have further episodes of
tachycardia or presyncope. Pt still had symptoms of dyspnea due
to her decompensated sCHF. She was diuresed with IV lasix and
had resolution of her symptoms. She is being discharged home
with an increase in her lasix dosing of 60 PO daily to 60 PO
BID. She will follow up with Dr. ___ on ___ for
further management of her atrial fibrillation.
# Leukocytosis: pt had initial UA positive for leukocytes,
leukocyte esterase, and few bacteria, but did not have any
urinary symptoms. UA showed bacteria and leukocytes. She was
initiated on a 3-day course of IV rocephin to treat her
uncomplicated UTI. She finished the course of antibiotics and
her leuckocytosis resolved. She did not have any persistent
urinary symptoms during admission.
# Atrial fibrillation: atrial fibrillation/flutter s/p ablation
at ___ in ___. She received DC cardioversion which
successfully controlled her rate back to the ___. She remained
asymptomatic and her HR remained in the 60-70s throughout
admission on her paced rhythm. Her Metoprolol Succinate was
increased from 100mg BID to ___ BID and she will be discharged
on 200mg amiodarone daily. During admission her INR was
initially therapeutic but was 1.5 on discharge. She was placed
on a lovenox bridge and instructed to check her INR at ___
___ clinic on ___ to follow up. She was
restarted on her home warfarin dose the day of the
cardioversion. She will need to follow up in ___
clinic on further management of her warfarin dosing.
# GERD: patient has been having increased heartburn over past
few days alleviated by maalox each time. She was discharged on
her home 20mg BID of omeprazole.
Transitions in care:
# Follow up with Dr. ___
# Amiodarone decreased from 300mg daily back to 200mg daily
# Increased lasix dose to 60mg BID from 60 mg daily
# Metoprolol increased to 150gm BID instead of 100mg BID
# Emergency contact: ___ (daughter) ___
# Code status: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 300 mg PO DAILY
2. Metoprolol Succinate XL 100 mg PO BID
3. Atorvastatin 40 mg PO DAILY
4. Furosemide 60 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. Levothyroxine Sodium 50 mcg PO DAILY
7. irbesartan 150 mg oral DAILY
8. Calcium Carbonate 500 mg PO BID
9. Warfarin 5 mg PO 4X/WEEK (___)
10. Warfarin 1.5 mg PO 3X/WEEK (___)
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
RX *amiodarone 200 mg 1 tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*0
2. Atorvastatin 40 mg PO DAILY
3. Calcium Carbonate 500 mg PO BID
4. irbesartan 150 mg oral DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Metoprolol Succinate XL 150 mg PO BID
RX *metoprolol succinate 100 mg 1.5 tablet(s) by mouth TWICE
DAILY Disp #*90 Tablet Refills:*0
7. Omeprazole 20 mg PO BID
8. Warfarin 5 mg PO 4X/WEEK (___)
9. Warfarin 7.5 mg PO 3X/WEEK (___)
10. Furosemide 60 mg PO BID
RX *furosemide 40 mg 1.5 tablet(s) by mouth TWICE DAILY Disp
#*90 Tablet Refills:*0
11. Enoxaparin Sodium 100 mg SC BID
Start: Today - ___, First Dose: Next Routine Administration
Time
Please give yourself the injections twice daily.
RX *enoxaparin 100 mg/mL 1 Injection SC TWICE DAILY Disp #*14
Syringe Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: atrial fibrillation with rapid ventricular
response
Secondary diagnosis: decompensated systolic congestive heart
failure, hypertension, urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were seen at the ___ because of
shortness of breath and palpitations. It was found that your
heart rate was elevated causing your symptoms. We did a
cardioversion procedure to slow your heart rate back down. As of
now, your heart rate is well controlled and we are discharging
___ home. Please follow up with Dr. ___ in the future for
your heart condition.
It was a pleasure taking care of ___.
Sincerely,
Your ___ Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10382575-DS-12 | 10,382,575 | 22,808,403 | DS | 12 | 2113-01-01 00:00:00 | 2113-01-01 19:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine
Attending: ___.
Chief Complaint:
fatigue, abnormal labs
Major Surgical or Invasive Procedure:
liver biopsy ___
EGD ___
History of Present Illness:
Ms. ___ is a ___ lady with a PMH signficant for
aplastic anemia and cryptogenic cirrhosis who presents to the ED
after outpatient labs showed new bilirubin elevation to 20.
The patient does not seem to know very well her history of liver
disease. When asked about liver problems, she reports that she
never knew she had liver disease until a few months ago when she
noticed increased abdominal swelling. For the past few weeks,
she started having lower extremity edema, and she was started on
furosemide and spironolactone, which improved the swelling.
Today, she went for routine follow up with her hematologist and
mentioned worsening fatigue. Incidentally, she was found to have
bilirubin of 20. Her hematologist, Dr. ___, discussed
with her gastroenterologist, Dr. ___, and wanted the
patient admitted. After discussion with her husband, they
preferred to come direct to the ___ rather than go to ___
___ first.
Looking through her outpatient records, she was seen in the
___ on ___ for new
cirrhosis. Per that note, she was hospitalized at ___ in
___ for fatigue. At that time, she was found to have anemia
requiring transfusions as well as new cirrhosis by labs and
imaging. She had a work up that included HAV, HBsAg, HBsAb,
HBcAb, HCV Ab, ___, AMA, ferritin, iron studies,
ceruloplasmin, and alpha 1 anti-trypsin, which were all
negative. Abdominal ultrasound with Doppler was normal as well.
She subsequently switched provider and started seeing Dr. ___
___ gastroenterology. She had a screening EGD on ___ at
___, but the report was not available.
In the ED, initial vitals were: T 98.3 HR 105 BP 108/67 RR 18
SAT 99% RA. Exam notable for no asterixis, spider angiomas over
the chest, ___ systolic murmur, distended but nontender abdomen,
jaundice, and lower extremity pitting edema.
Labs notable for INR 2.4, ___ 26.8, WBC 13.5, H/H 7.9/23.1, PLT
142, Retic 7.8%, Na 128, BUN/Cr ___, ALT 53, AST 106, LDH
380, TBili 17.2, albumin 3.0, trop-T <0.01. Diagnostic
paracentesis performed with 24 WBC and 138 RBC.
Preliminary liver ultrasound read showed:
1. The anterior right portal vein is patent, but with reversed
flow. Otherwise, imaged hepatic vasculature is patent with flow
in the appropriate direction.
2. Avascular cystic lesion in the right lobe measuring up to
2.3 cm may represent a hemorrhagic cyst. Per the patient's
report, she has previously been imaged at ___
___. Comparison to prior imaging is recommended. If not
available, short interval follow-up ultrasound is recommended.
3. Cirrhotic liver, recanalized umbilical vein, splenomegaly,
and large ascites.
On transfer, vitals were: T 98.9 HR 94 BP 105/54 RR 18 SAT 97%
RA.
On the floor, the patient reports feeling a bit tired, but
otherwise at her baseline level of health.
Review of systems:
(+) Per HPI. In addition, she has had a history of frequent
epistaxis and gum bleeding, for which she has aminocaproic acid
mouthwash as needed. Has also had significant weight loss in the
setting of starting diuretics. She reports a dry cough for the
past several weeks.
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies 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 melena or
hematemesis. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
- Aplastic anemia ___ yrs, maintained on regular iron and red
blood cell transfusions)
- Hypertension (no longer on medication)
- History of epistaxis
- Alcoholic cirrhosis c/b ascites
- Acute alcoholic hepatitis
Social History:
___
Family History:
Mother had ___ lymphoma and possibly pancreatic vs.
stomach cancer. Father had ___ disease. There is mention
in her outpatient records of autoimmune disorder in her brother,
possibly myasthenia ___.
Physical Exam:
ADMISSION:
Vital Signs: T 99.2 BP 101/60 HR 99 RR 20 SAT 96% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera icteric, MMM, oropharynx clear, EOMI, PERRL, neck
supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
loudest at the upper sternal borders Chest: Diffuse spider
angioma
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, significantly distended, bowel sounds
present, hepatomegaly difficult to appreciate with distension,
no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ peripheral pulses, 2+ lower
extremity pitting edema
Neuro: Grossly no deficits, no asterixis
DISCHARGE:
Vital Signs: 98.4 ___ 18 100%RA.
General: Alert, oriented, no acute distress. Jaundiced. Somewhat
anxious
HEENT: Sclera icteric, NCAT
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
loudest at the upper sternal borders
Chest: Diffuse spider angioma
Lungs: CTAB
Abdomen: Soft, non-tender, minimally distended, no rebound or
guarding
GU: No foley
Ext: Warm, well perfused, trace lower extremity pitting edema
Neuro: A&Ox3. Grossly no deficits, no asterixis
Pertinent Results:
ADMISSION/IMPORTANT LABS:
=======================
___ 06:40PM BLOOD WBC-13.5* RBC-2.07* Hgb-7.9* Hct-23.1*
MCV-112* MCH-38.2* MCHC-34.2 RDW-14.9 RDWSD-60.2* Plt ___
___ 06:40PM BLOOD Neuts-78.5* Lymphs-9.4* Monos-9.7 Eos-1.6
Baso-0.3 Im ___ AbsNeut-10.58* AbsLymp-1.27 AbsMono-1.31*
AbsEos-0.22 AbsBaso-0.04
___ 06:40PM BLOOD ___ PTT-40.1* ___
___ 06:40PM BLOOD Ret Aut-7.8* Abs Ret-0.16*
___ 06:40PM BLOOD Glucose-120* UreaN-15 Creat-0.8 Na-128*
K-3.9 Cl-93* HCO3-25 AnGap-14
___ 06:40PM BLOOD ALT-53* AST-106* LD(LDH)-380* AlkPhos-53
TotBili-17.2*
___ 06:40PM BLOOD Albumin-3.0* Calcium-8.5 Phos-2.6* Mg-1.7
Iron-145
___ 06:40PM BLOOD calTIBC-156* Hapto-<10* Ferritn-964*
TRF-120*
___ 05:40AM BLOOD HBcAb-Negative HAV Ab-BORDERLINE
___ 06:10AM BLOOD IgM HAV-Negative
___ 12:26PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 05:40AM BLOOD AFP-10.8*
___ 12:26PM BLOOD ___
___ 05:40AM BLOOD HCV Ab-Negative
___ 03:55PM BLOOD ALPHA-1-ANTITRYPSIN-Test
LABS AT DISCHARGE:
================
___ 06:20AM BLOOD WBC-15.9* RBC-2.24* Hgb-8.6* Hct-24.4*
MCV-109* MCH-38.4* MCHC-35.2 RDW-17.7* RDWSD-72.0* Plt ___
___ 06:20AM BLOOD ___ PTT-34.4 ___
___ 06:20AM BLOOD Glucose-99 UreaN-22* Creat-0.6 Na-127*
K-4.0 Cl-96 HCO3-21* AnGap-14
___ 06:20AM BLOOD ALT-61* AST-76* AlkPhos-55 TotBili-11.1*
___ 06:20AM BLOOD Calcium-9.0 Phos-3.8 Mg-1.7
IMAGING/STUDIES:
==============
___ Liver biopsy results:
Liver, needle core biopsy:
1. Established cirrhosis with prominent sinusoidal pattern of
fibrosis, confirmed by trichrome stain (Stage 4).
2. Mild macrovesicular steatosis with associated scattered foci
of ballooning degeneration, intracytoplasmic hyalin and lobular
neutrophils.
3. Patchy canalicular cholestasis.
4. Iron stain demonstrates focal mild iron deposition within
Kupffer cells and rare hepatocytes. Note: The findings are
consistent with a chronic active toxic/metabolic pattern of
injury with prominent lobular neutrophils and hyalin, most
likely due to a toxin induced cause. Clinical correlation is
needed. CLINICAL
___ Transjugular Bx:
IMPRESSION:
1. Portal hypertension with measured portosystemic gradient of
34 mm Hg.
2. Four 18 Gauge core biopsies of the liver sent for analysis.
___ EGD:
4 cords of grade I varices were seen in the esophagus. The
varices were not bleeding. Mosaic appearance in the whole
stomach compatible with portal hypertensive gastropathy. Normal
mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
___ RUQ:
IMPRESSION:
1. Coarsened, nodular liver consistent with provided history of
cirrhosis.
2. Sequelae of portal hypertension including large-volume
ascites and persistent splenomegaly. Patent portal vein.
3. 2.3-cm right hepatic dome simple cyst, unchanged. No new or
concerning focal hepatic masses.
4. Cholelithiasis and biliary sludge.
___ CXR:
IMPRESSION:
There is minimal blunting of left costophrenic angle and patchy
opacity at the left base which may reflect a combination of
atelectasis and or scarring in the setting of a small effusion
or chronic pleural thickening. An early infectious process
should also be considered. Clinical correlation is recommended.
No pulmonary edema or pneumothorax. Overall cardiac and
mediastinal contours are within normal limits.
___ 6:48 ___ LIVER US
IMPRESSION:
1. The anterior right portal vein is patent, but with reversed
flow. Otherwise, imaged hepatic vasculature is patent with flow
in the appropriate direction.
2. Avascular cystic lesion in the right lobe measuring up to 2.3
cm may represent a hemorrhagic cyst. Per the patient's report,
she has previously been imaged at ___.
Comparison to prior imaging is recommended. If not available,
short interval follow-up ultrasound is recommended.
3. Cirrhotic liver, recanalized umbilical vein, splenomegaly,
and large ascites.
Brief Hospital Course:
Ms. ___ is a ___ lady with a PMH signficant for
aplastic anemia and cryptogenic cirrhosis who presents with new
bilirubin elevation to 20 and evidence of decompensating
cirrhosis found to have alcoholic cirrhosis.
# EtOH hepatitis on cirrhosis: Complicated by ascites and grade
I varices (EGD ___. Per outpatient records, patient has had
an extensive work up for cirrhosis with no clear etiology, which
included consideration of viral hepatitis, NAFLD, autoimmune
hepatitis, PBC, ___ disease, hemochromatosis, alpha-1
antitrypsin deficiency (negative), portal vein thrombosis, or
Budd-Chiari syndrome. There is thought that she may have short
telomere syndrome, which would explain concurrent bone marrow
failure. Discussion with patient reveals some EtOH use,
collateral suggestive of significant use. Hep B and C negative.
AFP at 10.8 is mildly elevated. Clinically, she is stable with
no evidence of encephalopathy. Diagnostic paracentesis showed no
evidence of SBP. S/p therapeutic 5L paracentesis ___ for which
she was given 37.5 g albumin. She underwent repeat LVP on ___
with 6.6L removed and albumin was given. Autoimmune antibodies
were negative, Hep A borderline positive but IgM negative. Liver
Bx consistent with EtOH hepatitis, so she was started on 40
prednisone ___. Maddreys Discriminant Function was 64.4 ___.
Hyponatremia worsened with diuretics, therefore this was
discontinued.
# Aplastic Anemia
Managed with frequent iron and red cell transfusions. Baseline
hemoglobin appears to be 9 in outside labs. Labs here show Hgb
of 7.2 with low haptoglobin, suggesting possible hemolysis
though can be falsely low in cirrhosis. Difficult to interpret
causes of hemolysis with chronically low platelets and abnormal
coagulopathy with liver disease. Smear showed occasional
fragments, low concern for true hemolysis. B12 was elevated,
fibrinogen was > 100 (low concern for DIC). Received 1U PRBC
___.
# Hyponatremia: Pt had acute drop after paracentesis. Also
endorsing "drinking a lot of water". Mental status at baseline.
Managed with 2L fluid restriction. Managed with albumin and 2L
fluid restriction. Lasix/spironolactone discontinued due to
hyponatremia.
# Hyperglycemia: i/s/o steroids. Started on NPH insulin to take
once daily. Patient taught regarding insulin use and close
monitoring of blood sugars.
# Liver cyst: Noted to have Avascular cystic lesion on ___. RUQ
___ unchanged. Consider repeat RUQ for close monitoring
# Dispo: Patient will need close substance-abuse follow-up to be
eligible for transplant eval. Will need at least 6 months of
documented sobriety. Patient has been counseled extensively on
importance of not drinking. Plan to establish hepatology care
with Dr. ___.
TRANSITIONAL ISSUES:
===================
- Has follow up appointment on ___ with Dr. ___ to establish
care and for follow up.
- Check CBC, LFTs, Chem 7, and Albumin on ___
- F/u Lille score at follow up, plan for 1 mo steroids then
taper if responsive. One month of steroids to end ___.
- HgbA1c pending at time of discharge
- Noted to have Avascular cystic lesion on ___ unchanged on RUQ
___, consider repeat imaging.
- Hyperglycemic initially upon starting steroids. Discharged on
10U NPH daily
- 2L fluid restriction for hyponatremia
- Consider checking HFE as outpatient, as well as possible
workup for short telomere syndrome.
- Consider further work-up of elevated AFP if persistently
elevated in outpatient setting. Can be mildly elevated in acute
inflammation.
# CODE: FULL
# CONTACT: ___ (husband, cell: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 1 mg PO PRN Flying
2. Amicar (aminocaproic acid) 1.25 gm oral Q6H:PRN bleeding
3. Vitamin D Dose is Unknown PO DAILY
4. Furosemide 20 mg PO DAILY
5. Spironolactone 50 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. triamcinolone acetonide 0.5 % topical TID
Discharge Medications:
1. BD Ultra-Fine Nano Pen Needles (pen needle, diabetic) 32
gauge x ___ miscellaneous DAILY
2. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*50 Tablet
Refills:*0
3. Multivitamins 1 TAB PO DAILY
4. triamcinolone acetonide 0.5 % topical TID
5. Vitamin D 1000 UNIT PO DAILY
6. NPH 10 Units Breakfast
RX *insulin NPH human recomb [Humulin N KwikPen] 100 unit/mL (3
mL) AS DIR 10 Units before BKFT; Disp #*30 Syringe Refills:*0
7. Amicar (aminocaproic acid) 1.25 gm oral Q6H:PRN bleeding
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Alcoholic hepatitis
Cirrhosis
steroid induced hyperglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ because your bilirubin was elevated. You
were found to have acute alcoholic hepatitis. You were started
on a medication called prednisone, which in some people can help
their alcoholic hepatitis. You will need lab tests on ___
to determine if you should stay on this medication. You also had
your abdomen tapped (paracentesis) to remove fluid and relieve
discomfort. You may need this done as an outpatient as well.
We strongly recommend that you stop drinking all alcohol. To be
considered for transplant, you will need to be followed by
psychiatry or an abstinence program that can document your
sobriety.
During you hospitalization, you were found to have elevated
blood sugars. This was likely due to the prednisone. You were
started on NPH insulin in the hospital. Please monitor your
blood sugars closely and follow up with your PCP regarding this.
We have scheduled a follow up appointment for you with Dr. ___
___ you. Please see below.
We wish you the best in your care.
-Your ___ team
Followup Instructions:
___
|
10382575-DS-13 | 10,382,575 | 23,878,644 | DS | 13 | 2113-02-12 00:00:00 | 2113-02-12 17:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine
Attending: ___
Chief Complaint:
fever, shortness of breath
Major Surgical or Invasive Procedure:
___ guided paracentesis ___
exploratory laparotomy ___
___ guided thoracentesis ___
___ guided paracentesis ___
Diagnostic paracentesis ___
History of Present Illness:
Ms. ___ is a ___ lady with a PMH signficant for
aplastic anemia and cryptogenic and alcoholic cirrhosis who
presents with abdominal pain and cough
Patient has had increasing abdominal distension and shortness
of breath. The patient was recently discharged after an
admission for large volume paracentesis. Since discharge about 2
weeks ago she has had gradually increasing abdominal distention
and shortness of breath. She has a known history of hepatic
hydrothorax. She reports an associated nonproductive cough. No
shortness of breath is worse when lying down. He denies any
hemoptysis. She denies any abdominal pain, nausea, vomiting,
blood in the stool, melena. No change in mental status. The
patient does not feel that she is more jaundiced. No fevers. No
urinary symptoms.
Patient with recent admission from ___ to ___ - for acute
decompensation of her cirrhosis with elevated bilirubin to 20
found to have ETOH cirrhosis and alcoholic hepatitis. She was
started on prednisone 40 mg in the hospital on ___ and was
stopped on ___ as it was not shown to be effective as
given bilirubin still 12.
Patient need to have paracentesiswhich was scheduled as an
outpatient day prior to admission however patient was not
notified of appointment and could not get it done. She has been
admitted for these procedures.
In ED Initial vitals notable for: 99.9 119 152/89 20 97% RA
Exam notable for:
Labs notable for: Normal Chem 7.
9.5
13.5>--< 113
27.7 N:76.2 L:13.0 M:7.9 E:2.2 Bas:0.1 ___: 0.6
___: 23.3 PTT: 31.3 INR: 2.1
Lactate:2.5
ALT: 59 AP: 53 Tbili: 14.0 Alb: 3.4
AST: 54 Lip: 138
Patient underwent diagnostic para that showed 92 WBC with 65%
poly, 22% lymph. Protein 0.6
Imaging notable for: Large right pleural effusion with
compressive atelectasis in the right middle lower lung.
Patient was given: no medications.
Hepatology consulted and recommended: admission to ET.
Vitals prior to transfer: 98.4 109 146/77 20 96% RA
On the floor, patient has dry cough, SOB and abdominal
distension.
Past Medical History:
- Aplastic anemia ___ yrs, maintained on regular iron and red
blood cell transfusions)
- Hypertension (no longer on medication)
- History of epistaxis
- Alcoholic cirrhosis c/b ascites
- Acute alcoholic hepatitis
Social History:
___
Family History:
Mother had ___ lymphoma and possibly pancreatic vs.
stomach cancer. Father had ___ disease. There is mention
in her outpatient records of autoimmune disorder in her brother,
possibly myasthenia ___.
Physical Exam:
ADMISSION EXAM
==============
Vital Signs: 99.1 147 / 82 117 20 95 ra
General: Alert, oriented, no acute distress. Jaundiced.
HEENT: Sclera icteric, NCAT
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
murmur loudest at the upper sternal borders
Lungs: decreased breath sounds half way up right lung base, CTA
on right.
Abdomen: Soft, non-tender, distended with ascites, no rebound
or guarding
GU: No foley
Ext: Warm, well perfused,2 plus extremity pitting edema up to
knee
Neuro: A&Ox3. Grossly no deficits, no asterixis
DISCHARGE EXAM
==============
VS - patient refused
Full physical exam deferred for pt comfort.
General: NAD, lying comfortably in bed, breathing comfortably
Abdomen: non tender
Pertinent Results:
ADMISSION LABS
=============
___ 08:30PM ASCITES WBC-92* RBC-487* POLYS-65* LYMPHS-22*
MONOS-1* MESOTHELI-2* MACROPHAG-10*
___ 08:30PM ASCITES TOT PROT-0.6 GLUCOSE-153
___ 08:45PM ___ PTT-31.3 ___
___ 08:45PM PLT COUNT-113*
___ 08:45PM NEUTS-76.2* LYMPHS-13.0* MONOS-7.9 EOS-2.2
BASOS-0.1 IM ___ AbsNeut-10.28* AbsLymp-1.75 AbsMono-1.06*
AbsEos-0.30 AbsBaso-0.02
___ 08:45PM WBC-13.5* RBC-2.46* HGB-9.5* HCT-27.7*
MCV-113* MCH-38.6* MCHC-34.3 RDW-16.2* RDWSD-67.4*
___ 08:45PM LACTATE-2.5*
___ 08:45PM ALBUMIN-3.4*
___ 08:45PM LIPASE-138*
___ 08:45PM ALT(SGPT)-59* AST(SGOT)-54* ALK PHOS-53 TOT
BILI-14.0*
___ 08:45PM GLUCOSE-131* UREA N-19 CREAT-0.6 SODIUM-134
POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-22 ANION GAP-16
PERTINENT LABS
==============
___ 07:00PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln->12 pH-6.5 Leuks-MOD
___ 07:00PM URINE RBC-1 WBC-13* Bacteri-FEW Yeast-NONE
Epi-3 TransE-<1
___ 07:00PM URINE Color-AMBER Appear-Hazy Sp ___
___ 01:44PM ASCITES WBC-67* RBC-90* Polys-42* Lymphs-1*
Monos-21* Mesothe-9* Macroph-24* Other-3*
___ 01:44PM ASCITES TotPro-0.6 Glucose-148 Creat-0.4
LD(LDH)-45 Amylase-24 Albumin-LESS THAN
DISCHARGE LABS
=============
No labs on discharge
Most recent labs:
___ 01:42PM BLOOD WBC-40.6* RBC-2.76* Hgb-9.5* Hct-29.7*
MCV-108* MCH-34.4* MCHC-32.0 RDW-22.6* RDWSD-88.3* Plt Ct-62*
___ 01:42PM BLOOD Neuts-92.7* Lymphs-1.7* Monos-3.8*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-37.58* AbsLymp-0.69*
AbsMono-1.55* AbsEos-0.03* AbsBaso-0.09*
___ 01:42PM BLOOD Glucose-129* UreaN-63* Creat-0.9 Na-150*
K-3.8 Cl-115* HCO3-22 AnGap-17
___ 07:30PM BLOOD ALT-63* AST-117* AlkPhos-73 TotBili-10.1*
MICRO
=====
___ BCx Pending
___ BCx NGTD
___ Peritoneal FlCx enterococcus. No organisms on gram
stain.
___ Peritoneal cx w/ enterococcus
___ C.Diff Neg
___ UrineCx neg
___ BCx x2 Gram + cocci in chains; resistant->amp/vanc
___ Peritoneal Cx 4+ PMNs 2+ gram positive cocci in pairs
___ OR Cx 2+ GPC, 1+ GPR, 1+ yeast; 4+ PMN, WBC 3K;
enterococus
___ BCx No growth
___ BCx no growth
___ Peritoneal Cx No growth, WBC 12K
___ Pleural cx No growth
___ BCx no growth
___ Urine Cx <10,000 organisms/ml
___ 7:00 pm URINE Source: ___.
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 ORGANISMS/ML..
IMAGING
=======
___ CT A/P
1. Cirrhotic liver with evidence of chronic splenic vein
thrombosis.
2. Similar large volume ascites with enhancement of the
peritoneum, which
could be related to peritonitis.
3. Distended gallbladder containing gallstones and sludge within
it.
___ CT Chest
1. Diffuse bilateral ground-glass opacities throughout both
lungs with areas of focal consolidation in the upper lobes that
could represent pulmonary edema, however infection cannot be
completely excluded. Please correlate clinically.
2. Moderate to large bilateral pleural effusions with passive
atelectasis in both lower lobes
___ CT A/P
1. Expected evolution of hyperdense material within the pelvis
which may
represent enteric contents from focal bowel perforation or prior
hemorrhage with blood products. No evidence of acute hemorrhage
or contrast extravasation.
2. Cirrhosis with large volume ascites, patent umbilical vein
and esophageal varices.
3. Stable moderate right and small left non hemorrhagic pleural
effusions with bibasilar atelectasis.
4. Cholelithiasis with persistent mild gallbladder wall edema
secondary to
cirrhosis and ascites.
5. Significant decrease in non dependent free intraperitoneal
air with locules of gas within the mesentery adjacent to the
sigmoid colon.
6. Findings worrisome for peritonitis with mild diffuse
peritoneal thickening, unchanged since prior examination.
7. Foley catheter likely within the urethra.
___ ABD US
Large ascites in the abdomen.
___ CXR
Slight improvement in pulmonary edema
___ CT A/P
IMPRESSION:
1. Large volume intraperitoneal free air layering over a large
volume ascites. There is new hyperdense layering material within
the posterior cul-de-sac, when compared to the recent CT dated
___. These findings are concerning for bowel
perforation with possible leak of orally ingested contrast
presenting as hyperdense material in the pelvis. Bowel
perforation may be secondary to a perforated diverticulum given
the presence of extensive sigmoid diverticulosis and locules of
free air tracking into the adjacent mesentery. The hyperdense
material in the pelvis is less likely contrast
opacified blood given that the patient is hemodynamically
otherwise stable.
2. Uniform mild enhancement of the peritoneal lining may reflect
presence of underlying peritonitis.
3. Cirrhotic morphology of the liver with unchanged simple
hepatic cyst at the dome measuring 2.4 cm in diameter. This
scan is not optimized to look for HCC.
4. Patent portal vein, SMV and splenic vein with a few varices
at the gastric fundus and in the perisplenic region along with
re- cannalization of the umbilical vein.
5. Large right pleural effusion with underlying relaxation
atelectasis is
partially visualized.
6. Diffuse small bowel wall thickening and anasarca are likely
related to
ascites and hyperproteinemia.
___ CT abdomen/pelvis: IMPRESSION:
1. Extensive wall thickening oft the colon with relative sparing
of the cecum and sigmoid colon. This is nonspecific, and can
reflect infectious or inflammatory etiology. Portal colopathy
is less likely given relative sparing of the cecum.
2. Cirrhotic liver with a small amount residual ascites after
recent
paracentesis. Trace intraperitoneal free air is likely related
to recent
paracentesis.
3. Bilateral lower lobe consolidations and a moderate right
pleural effusion.
___: CT Chest w/contrast: IMPRESSION:
1. Multifocal airspace opacities involving the left lung to a
much greater
degree than the right, with rapid progression between ___ and ___. In the setting of fever, a rapidly
progressive multifocal pneumonia should be considered. An
asymmetrical pattern of pulmonary edema is considered less
likely. Alternative diagnoses such as pulmonary hemorrhage and
widespread aspiration are also possible in the appropriate
clinical setting.
2. Decreased right pleural effusion following recent
thoracentesis with
residual moderate sized pleural effusion remaining it and
associated adjacent atelectasis.
3. Please see separately dictated CT of the abdomen and pelvis
for complete description of subdiaphragmatic findings.
___ CXR: IMPRESSION:
Large right pleural effusion appears to be even more pronounced
than on the
prior study. Mild vascular congestion is present.
Cardiomediastinal
silhouette is unchanged. No definitive focal consolidation to
suggest
infectious process demonstrated.
___ CXR:IMPRESSION:
Compared to chest radiographs ___ and ___.
Large right pleural effusion which increased from ___ to ___ is now
displayed with the patient supine. I suspect it is smaller, but
I can't be
sure. There is no appreciable pneumothorax. Pulmonary
vasculature is more
engorged, even though the heart is normal size.
___ Chest x-ray: PA and lateral views of the chest provided.
There is a large right pleural effusion, new from prior exam
with associated compressive atelectasis in the right middle
lower lung. The left lung is clear aside from mild left lower
lung atelectasis. Heart size difficult to assess given
effacement of the right heart border. Bony structures are
intact. IMPRESSION: Large right pleural effusion with
compressive atelectasis in the right middle lower lung.
Brief Hospital Course:
___ with aplastic anemia and decompensated ETOH cirrhosis (MELD
NA 27) found to have alcoholic hepatitis s/p failed treatment
with prednisone, initially admitted with cough and abdominal
distension consistent with hepatic hydrothorax and abdominal
ascites. Hospital course was complicated by SBP with VRE and
candidiasis, worsening encephalopathy, worsening WBC and LFTs,
and finally, concern for cholecystitis at which point the
patient and her family decided to focus on symptom management
and quality of her remaining life, and rather than undergo
further invasive surgeries the decision was made to go to
hospice.
ICU Course:
Patient brought to the ICU for afib with RVR and hypotension.
Was controlled with beta blockade and patient converted to sinus
rhythm while in the ICU. Antibiotics changed from zosyn to
meropenem given the concern that patient developed SBP while on
zosyn. She was transferred to the medicine floor on ___.
SICU Course:
Patient was transferred to the SICU after 1 night on the
medicine floor concern for secondary bacterial peritonitis in
the setting of worsening free air seen on CT.
___: Ex lap, no resection, no clear source of SBP, copious
fibropurulent exudate. Yeast in addition to GPC, GPR in
peritoneal fluid, added fluc to ___.
___: 2u pRBC in early AM, Post transfusion Hct 29.9. 250cc
albumin 5% x5 + 50cc 25% albumin x1. Promote + fiber TF started
@10cc/hr. Neo@1.
___: 2u pRBC in early AM. Post transfusion Hct 30.2. RSBI 12,
passed SBT. Weaned off pressors.
___: Started lactulose q2h, pt began stooling with improvement
in mental status. Restarted TFs. Ascitic fluid cx showed VRE,
continued daptomycin and meropenem. BS consistently >200, so IV
hydrocortisone decreased to 25.
___: In early AM, pt began having runs of SVT to 180s w/
frequent ectopy, spontaneously broke to baseline rhythm of sinus
tach in 110s. Given 5 IV metoprolol with resolution. Put out
1.2L stool so lactulose was stopped; K+ 3.0, repleted. To get
therapeutic paracentesis today by primary team.
Medical Floor Course:
The patient was transferred to the medical floor after initial
improvement in hemodynamics and mental status. However, the
patient's WBC rose to 24.7 and she had ___ to 1.2 (baseline
Cr 0.7). Her mental status declined. She received a third
diagnostic paracentesis on ___ and was subsequently transferred
back to ___ for suspected ongoing peritonitis.
#Fever: Patient developed persistent intermittent on ___.
Patient was placed on empiric Vanc/Zosyn on ___. Infectious
work-up was negative (CXR negative, Ascitic fluid w/o SBP on
___, BCx pending, UCx pending). Differential also included PE
given tachycardia, though patient was satting well and was
without chest pain and Well's score only of 1.5. LENIs without
evidence of DVT. Only localizing sign was patient's cough,
though CXR was without evidence of PNA. Patient was without an
obvious source, but given risk for SBP, Vanc/zosyn was narrowed
to CTX and patient was given albumin for empiric treatment of
SBP on ___. Patient developed recurrent fevers and was
transitioned back to vanc/Zosyn on ___. LVP on ___ showed
>11,000 WBCs with elevated LDH and protein, felt to be secondary
peritonitis. Her thoracentesis that day also showed ___ WBCs.
After ex-lap for secondary peritonitis, the patient was started
on meropenem, daptomycin, and fluconazole.
# Tachycardia: Patient was tachycardic on admission and
continued to be so during hospitalization. Differential included
decompensated cirrhosis or infection given concurrent fever.
Multiple EKGs with poor baseline, but possibly with multi-focal
atrial tachycardia. In the setting of fevers, pt developed
worsening tachycardia. On ___, pt was triggered for tachycardia
to the 180's, during which time she was found to be in Afib with
RVR.
#Cough/SOB, resolving: Patient presented with worsening SOB and
cough. No evidence of PNA on CXR, no fevers, chills, mild
leukocytosis which could be from recent steroids. Patient with
large right sided hepatic hydrothorax, likely causing her cough
and SOB. Patient underwent thoracentesis with 1.5L of fluid
removed on ___ and patient's SOB improved, though she continued
to have some cough. Pt developed worsening SOB shortly after her
paracentesis, and CXR was c/w re-expanding hepatic hydrothorax.
Pt underwent diagnostic/therapeutic throacentesis on ___,
during which time 1.7L fluid were removed, and she was found to
have ___ WBCs in the thoracentesis fluid (see above)
# Ascites: As above, patient had a LV paracentesis on ___ with
removal of 5.5L fluid. Her ascites rapidly reaccumulated after
that. Repeat paracentesis on ___ removed 3L, but also showed
secondary peritonitis. Third paracentesis was performed on ___
for evaluation for continued peritonitis.
#Hepatic hydrothorax: Pt received a thoracentesis on ___ in the
setting of dyspnea and persistent cough. Her symptoms improved
immediately afterwards, but her fluid reaccumulated shortly
thereafter. Repeat ___ on ___ removed 1.7L fluid, but also
showed ___ WBCs.
# Epistaxis, resolved: Patient with nosebleed on ___, which has
stopped spontaneously. Patient has a history of nosebleeds in
the past, requiring cauterization. Patient remained
hemodynamically stable throughout admission.
# Aplastic Anemia: Managed with frequent iron and red cell
transfusions. Baseline hemoglobin appears to be 9. Work up on
last hospitalization was less concerning for hemolysis, patient
had low haptoglobin but likely decreased in setting of
cirrhosis. Patient received 4 U RBC while in the SICU.
#Alcoholic hepatitis and cirrhosis: MELD-Na 27 on admission.
Complicated by ascites and grade I varices (EGD ___. Liver
bx recently confirmed ETOH cirrhosis, other work up negative.
Patient stopped steroids ___ for alcoholic hepatitis. Patient
not transplant candidate yet given need to enroll in program for
sobriety. Patient had social work and nutrition consults to
optimize her. Patient was started on lactulose during admission
with improvement in asterixis and encephalopathy.
# Hyponatremia: Patient with worsening hyponatremia during
hospitalization, felt to be due to her liver disease. Patient
was placed on 1.5L fluid restriction and ***.
#Hx of Hyperglycemia: likely in setting of steroids,
discontinued on ___. Patient with mildly elevated blood sugars,
though has not required any insulin off sliding scale, so
discontinued.
#COAGULOPATHY: likely related to liver disease, remained stable
throughout admission.
SICU course 2:
___: Transferred to ___ for worsening abdominal pain, worsening
mental status/increasing confusion. Paracentesis completed prior
to transfer featured removal of 2L of ascitic fluid which by
gram stain met criteria for persistent SBP (3K WBC w/ 95% Nx).
CT AP was also completed prior to transfer which demonstrated
interval decrease in intraperitoneal free air though was noted
to feature persistent loculations of air within mesentery and
for these reasons tube feeds were held and the patient was
permitted ice chips by mouth. She was started on tramadol and
her lactulose was resumed.
___: WBC 24. 23, glucose values increasing, RISS increased, Abx
changed as per ID recommendations, GPC in blood culture. Concern
for infection.
___: Bedside paracentesis w/ US by ___, removed 7L for source
control. Got FFP x2 units prior to procedure. Tolerated, no
issues. ___ had decreased mental status, repeat labs normal,
blood cx sent per primary team. Na still 150, free H2O flushes
increased to 350 q6h.
___: Continued high residuals from tube feeds, restarted at 40;
started D5W gtt, 25 g albumin, Na continued elevated, kept
central line ___ difficult peripheral access
___: Abdominal binder. WBC 32.9. 5 staples at midportion of
incision removed, no dehiscence appreciated, packed with dry
gauze. CT C/AP: GB w/layering and mild distension, moderate B/L
pulm effusions, no acute intrabdominal cxn. Patient's CT scan
was discussed w/family, and family requested social work consult
which was placed. Incontinent and UOP marginal, given 1000cc 5%
albumin, foley replaced. Zosyn DCD, started meropenem and IV
flagyl per ID recs.
Medical Floor Course 2:
Patient was transferred to the medical floor on ___ for
management of symptoms and goals of care discussion.
# Goals of care
Patient expresses wishes to maximize comfort and symptom
management without further escalation of care or further
procedures. Patient wishes to discontinue vitals, labs, and
further ICU transfers. She named her husband as her HCP: ___
___ (cell: ___. She confirmed her code status as
DNR/DNI and wishes to be transferred to hospice care.
# Hepatic encephalopathy
We continued lactulose and rifaximin, with goal ___ BMs daily
# SBP
We continued ___ and fluconazole, transitioned to
PO linezolid and fluconazole on discharge
# Bilateral pleural effusions
Contributing to occasional tachypnea. She was breathing
comfortably on room air.
# Persistent sinus tachycardia
She was given 12.5mg metop x1 for symptomatic relief.
# Pain
She was continued on dilaudid and pain was well controlled.
TRANSITIONAL
============
- plan for antibiotics is to continue because they are likely
helping to maintain pt's clear mental status. Her infection will
likely worsen over the next ___ days, and if she is no longer
lucid then there is no indication for antibiotic coverage
- plan to continue lactulose/rifaxamin while the pt is agreeable
in order for her to be able to interact with her family: she may
refuse these at any time
- pt discharged with foley and flexiseal in place for comfort
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. triamcinolone acetonide 0.5 % topical TID
3. Vitamin D 1000 UNIT PO DAILY
4. Amicar (aminocaproic acid) 1.25 gm oral Q6H:PRN bleeding
Discharge Medications:
1. Fluconazole 400 mg PO Q24H Duration: 5 Days
RX *fluconazole 200 mg 2 tablet(s) by mouth once a day Disp #*5
Tablet Refills:*0
2. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q3H:PRN BREAKTHROUGH
PAIN
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN moderate to
severe pain
4. Lactulose 30 mL PO Q2H
5. Linezolid ___ mg PO Q12H Duration: 5 Days
RX *linezolid ___ mg 1 tablet(s) by mouth twice a day Disp #*5
Tablet Refills:*0
6. Rifaximin 550 mg PO BID
7. Amicar (aminocaproic acid) 1.25 gm oral Q6H:PRN bleeding
8. Multivitamins 1 TAB PO DAILY
9. triamcinolone acetonide 0.5 % topical TID
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
hepatic hydrothorax
asicites
spontaneous bacterial peritonitis
septic shock
bacteremia
fungemia
decompensated alcoholic cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your recent admission.
You initially came to the ___ with cough and shortness of
breath as a result of fluid in your lungs and abdomen because of
your liver disease. We removed the fluid, but unfortunately your
liver disease worsened and you developed some very serious
infections. While we did everything we could to treat these, you
continued to become more sick. You and your family decided that
given how sick you are and how much suffering you've been
through during this long hospitalization, it made sense to focus
on controlling your symptoms rather than aggressively doing more
invasive procedures. You were discharged to hospice so that you
could spend more time with your loved ones.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
10382912-DS-15 | 10,382,912 | 21,344,480 | DS | 15 | 2184-08-25 00:00:00 | 2184-08-25 13:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
falls
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History of Present Illness: patient unable to answer most
questions, but per report, the patient was exiting the bathroom
when he fell to the floor. His wife tried to help him but but he
kept going down to the floor. Per wife: Heard patient fall, got
him up and then he fell again, never passed out. Patient was in
the bathroom right before, exited and then fell. Patient fully
responsive but only mumbling. Wife finally got him into bed and
called ___. No lose of bowel or bladder. Patient was shaking
when on the bed. Hx of syncope in the past thought to be due to
"heat". In USOH prior to this incident no fevers of chills.
Notes patient has had decrease appetite and has not been taking
much fluids. Has been drinking more wine than usual at night
___ (usually just one). No hx of alcohol abuse. CT scan
wet read shows no abnormalities.
.
Denies feeling lighteaded, denies dizzyness, denies chest pain
discomfort or pressure, denies SOB, denies nausea, denies abd
pain.
Past Medical History:
1. Hypertension
2. Diabetes mellitus type 2
3. Hyperlipidemia.
4. SVT
5. History of prostate cancer in ___
6. Dementia
.
Social History:
___
Family History:
Parents lived to mid ___ and he is not sure about the etiology
of death. No history of premature CAD.
Physical Exam:
ON Admission
Vitals: 100.1 74 N 144/70 16 100%RA
General: alert but not oriented to day.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
.
On Discharge:
Physical Exam:
Vitals: (current and maX), 160/75, 60, 22, 94%RA
General: alert but not oriented to date.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
On admission
___ 01:00PM BLOOD WBC-8.3# RBC-4.08* Hgb-12.6* Hct-39.3*
MCV-96 MCH-30.9 MCHC-32.1 RDW-12.8 Plt ___
___ 01:00PM BLOOD Neuts-83.8* Lymphs-10.9* Monos-3.8
Eos-1.3 Baso-0.2
___ 01:00PM BLOOD Glucose-102* UreaN-13 Creat-1.5* Na-139
K-3.4 Cl-98 HCO3-26 AnGap-18
___ 09:30PM BLOOD CK(CPK)-196
___ 01:00PM BLOOD Calcium-9.6 Phos-3.6 Mg-1.8
.
Imaging
Head CT ___
No acute intracranial abnormality.
.
CXR ___
IMPRESSION: Subtle opacity in the left mid-to-lower lung may
represent
overlapping osseous structures, although possibility of
pneumonia impossible
to exclude. Recommend oblique views to clarify.
.
Discharge labs
___ 08:05AM BLOOD WBC-6.9 RBC-3.54* Hgb-10.6* Hct-33.4*
MCV-94 MCH-30.0 MCHC-31.8 RDW-12.8 Plt ___
___ 08:05AM BLOOD Glucose-122* UreaN-11 Creat-1.1 Na-138
K-3.2* Cl-100 HCO3-27 AnGap-14
___ 08:05AM BLOOD Albumin-3.8 Calcium-9.2 Phos-2.2* Mg-1.8
Brief Hospital Course:
Patient came in with baseline dementia per his wife. She stated
that he had fallen at home. While in the ED, he had a CT scan
which showed no acute process. His chest xray was unremarkable.
THe patient's UA came back indicating infection. He was started
on cefpodoxime 200mg PO BID. Unfortunately, the patient
continued to spike fevers. His urine culture came back negative.
A repeat CXR was ordered that showed LLL pneumonia. The patient
was started on levofloxacin and remained afebrile. The patient
was discharged in stable condition and will be followed up as an
outpatient.
Medications on Admission:
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day
ATENOLOL - 50 mg Tablet - 1 Tablet(s) by mouth once a day
ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 Tablet(s) by mouth
daily at bedtime
GLIMEPIRIDE - 2 mg Tablet - 1 Tablet(s) by mouth once a day
HYDROCHLOROTHIAZIDE - 12.5 mg Tablet - 1 Tablet(s) by mouth once
a day
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
MEMANTINE [NAMENDA] - 10 mg Tablet - one Tablet(s) by mouth
twice
a day after completing starter pack
PIOGLITAZONE [ACTOS] - 45 mg Tablet - 1 Tablet(s) by mouth once
a
day
Medications - OTC
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
7. glimepiride 2 mg Tablet Sig: One (1) Tablet PO once a day.
8. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
9. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. memantine 10 mg Tablet Sig: One (1) Tablet PO twice a day.
11. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1) UTI
2) dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___, you came in with fevers, chills, and were
determined to have a UTI. We evaluated you for other problems
but UTI was the only problem we came across. We started you on
appropriate antibiotics. You were sent home in stable condition.
The following changes were made to your antibiotics.
Please start cefpodoxime by mouth 200mg twice a day
Followup Instructions:
___
|
10382912-DS-16 | 10,382,912 | 21,404,037 | DS | 16 | 2186-12-23 00:00:00 | 2186-12-24 19:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH dementia, DMII brought in by EMS after being found
down by wife on the floor. Per report, wife ___ heard a crash
from the kitchen and found Mr. ___ down with mouth open and
eyes closed, unresponsive for 2min. Wife denies any shaking
movements, came to and was at mental baseline. When EMS arrived,
was hypotensive at 90/40 then 70/40, FSBG 417, IVF started.
In the ED intial vitals were: 0 97.2 60 122/70 99%RA. UA with
1000 glucose, serum glucose >300. He was given 2L IVF for
suspected orthostatic hypotension, lactate 4.4, recheck was 1.8.
CT head and Cspine done, abnormality noted (hygroma vs chronic
subdural hematoma) and patient seen and examined by
neurosurgery, found to be a neurological baseline, no role to
neurosurgical intervention. Haldol IV given for agitation.
Vitals prior to transfer were: 0 75 132/74 19 99% RA
On the floor, patient is wandering around the halls and wants to
go home. He is able to understand that he fell, but has no
recollection of events, has no acute complaints.
Per phone discussion with wife, she denies any prodromal
symptoms in the days leading to this event, but states she is no
longer comfortable taking care of him at home. Wife states he
eats sweets at home all the time, has an occasional beer, does
not drink enough fluids.
Past Medical History:
DEMENTIA vascular dementia.
DIABETES TYPE II
HYPERLIPIDEMIA
HYPERTENSION
PROSTATE CANCER H/o. in ___. Last PSA undetectable in ___.
SUPRAVENTRICULAR TACHYCARDIA
OSTEOARTHRITIS Lumbar Back pain ___ radiculopathy;
BLADDER CANCER ___
BACK PAIN
Social History:
___
Family History:
Parents lived to mid ___ and he is not sure about the etiology
of death. No history of premature CAD.
Physical Exam:
ADMISSION EXAM:
================
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, adentulous, nontender supple neck, no LAD, no
JVD
CARDIAC: RRR, nl 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: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, gait narrow based and steady
SKIN: unable to examine
DISCHARGE EXAM:
=================
GENERAL: NAD, AAOx1 (thought in ___, ___, didn't know
year). Bump near R temple, non-tender.
CARDIAC: RRR, nl 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: strength ___ in all extremities, no cyanosis,
clubbing or edema
Pertinent Results:
ADMISSION LABS:
================
___ 05:15PM BLOOD WBC-5.4 RBC-3.74* Hgb-11.4* Hct-34.3*
MCV-92 MCH-30.5 MCHC-33.2 RDW-12.5 Plt ___
___ 05:15PM BLOOD Glucose-338* UreaN-8 Creat-1.0 Na-136
K-3.8 Cl-99 HCO3-24 AnGap-17
___ 05:15PM BLOOD Calcium-9.4 Phos-2.8 Mg-1.7
___ 05:27PM BLOOD Lactate-4.4*
___ 09:04PM BLOOD Lactate-1.8
DISCHARGE LABS:
=================
___ 08:10AM BLOOD WBC-5.8 RBC-3.68* Hgb-11.0* Hct-33.0*
MCV-90 MCH-29.7 MCHC-33.2 RDW-12.4 Plt ___
___ 08:10AM BLOOD Glucose-207* UreaN-5* Creat-0.9 Na-141
K-3.7 Cl-102 HCO3-31 AnGap-12
___ 08:10AM BLOOD Calcium-9.6 Phos-2.8 Mg-1.6
STUDIES:
=================
___ CT Head w/o contrast: IMPRESSION:
Prominent extra-axial CSF density bilaterally suggesting
low-density subdural fluid collections, potentially chronic
subdural hematomas, effusions or hygromas, new since ___. No
definite acute intracranial process.
___ CT C-spine w/o contrast: IMPRESSION:
Degenerative changes without acute cervical spine fracture
identified.
Brief Hospital Course:
___ with DM, vascular dementia presenting s/p syncopal episode
likely due to dehydration secondary to hypoglycemia.
# Syncope: Though unable to assess prodromal symptoms due to
patient's dementia and lack of witness, wife's history of
patient's diet and lack of fluid intake along with known
progressing vascular dementia, glucosuria and elevated serum
glucose, elevated lactate argues for episode of global
hypoperfusion precipitating syncope.
Seizure is unlikely given immediately return to baseline, lack
of seizure history, lack of witnessed tonic-clonic movements.
Cardiogenic source is possible though arrhythmia would not
explain elevated lactate. No events on telemetry. No signs of
ischemia on EKG. Orthostatics were negative (after IVF
resuscitation). Presentation was consistent with hypovolemia
possibly related to poor po fluid intake from dementia and
osmotic diuresis from hyperglycemia.
# Dementia: Wife states she cannot care for him at home any
longer and would like assistance with placement. Patient is
ambulatory and wanders into the park, gets lost. The patient was
deemed fit for discharge to home with 24 hour supervision by
family. Case management provided a list of phone numbers for
adult care facilities.
# DMII: FSBG normalized after IVF. Suspect dietary nonadherence
as culprit. Last A1c 7.5% ___. Continued MetFORMIN
(Glucophage) 1000 mg PO BID.
# HTN: continue home meds, Cr at baseline.
Transitional issues:
-case management/social work for caregiver support and adult
housing/placement
-recheck A1c and uptitrate oral diabetes regimen as needed
# Code: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. QUEtiapine Fumarate 25 mg PO DAILY:PRN agitation
3. Atenolol 25 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Memantine 10 mg PO BID
6. Amlodipine 10 mg PO DAILY
7. Donepezil 5 mg PO QAM
8. Atorvastatin 40 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Donepezil 5 mg PO QAM
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Memantine 10 mg PO BID
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. QUEtiapine Fumarate 25 mg PO DAILY:PRN agitation
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Syncope
Secondary diagnosis:
Dementia
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 for a passing out spell at
home. We found you to be dehydrated with a high blood sugar. We
gave you IV fluids and you improved. We did not find any other
causes of loss of consciousness, and we now feel you are safe to
leave the hospital.
When you go home, please remember to drink plenty of fluid
throughout the day and avoid high sugar, high carbohydrate
foods.
The case manager has given you a list of places you can call to
arrange full time adult care. Please attend your appointment
with Dr. ___ on ___.
It was a pleasure taking care of you at ___!
Sincerely,
Your medical team
Followup Instructions:
___
|
10383045-DS-15 | 10,383,045 | 29,899,941 | DS | 15 | 2118-04-23 00:00:00 | 2118-04-23 16:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex
Attending: ___
Chief Complaint:
Recurrent headaches
Major Surgical or Invasive Procedure:
___ - PICC Placed
___ - PICC Removed
History of Present Illness:
Ms. ___ is a ___ yr F with PMH of DM c/b gastroparesis and
neuropathy, HTN, HLD, migraines, and genital herpes on Valtrex
who is transferred from OSH with recurrent headaches since this
past ___, with an incidental ICA aneurysm.
The patient reports development of headache last ___,
"stabbing" and well-localized over L orbit. Her headache
developed gradually, becoming worse day by day and requiring her
to stay home from work by ___ and ___. She began waking
up at night with headache starting ___, although states
she would take Fioricet with relief and be able to go back to
bed before headache returned in afternoon. No association with
positional changes. In the following days she also began to
notice L sided ptosis as well as binocular horizontal diplopia,
unclear if worst with near sight or distance.
At OSH, a CTA showed 2-3mm R ICA aneurysm, so she was
transferred to ___ for a neurosurgery evaluation. Neurosurgery
evaluated her in the ED, and determined that the aneurysm was an
incidental finding, not associated with her symptoms. They did
not recommend an intervention, but rather outpatient follow-up
in two weeks with Dr. ___.
On evaluation in the ED by neurology, the patient stated that
her headache has mostly resolved with medications given in ED.
On physical exam in the ED, patient had a L CN III palsy,
pupil-sparing, and L ptosis. Otherwise, her exam was non-focal.
CT/CTA do not explain pt's neurologic findings. Per neurology,
her clinical presentation was consistent with diabetic changes.
In the ED, initial VS were 98.4 79 129/67 94% RA.
Exam notable for ptosis, and pupil sparing.
Labs showed WBC 11.9, Hb 13, Platelets 422, CRP 5.3.
CTA head from OSH significant for 2-3mm R ICA aneurysm.
Received IV morphine x2, IVF, IV Zofran, IV nicardipine drip, IV
metoclopramide x2, IV diphenhydramine, IV procholorperazine x2.
She continued vomiting in the ED, and her oral intake was poor.
The decision was made to admit to medicine for further
management of her headaches.
On arrival to the floor, patient verifies the above information.
She reports that her headache is improved from when she
presented to the ED, but it still comes and goes. She still
reports that it is throbbing. She has no history of blood clots.
She does report that she lives in a wooded area, and has a dog.
Has not seen a tick on her. Nor does she report any rashes.
Past Medical History:
- T1DM complicated by diabetic gastroparesis, neuropathy
- HTN
- HLD
- Migraines (headache w/ n/v a few times a year)
- Genital herpes
Social History:
___
Family History:
Father-ALS
Physical ___:
ADMISSION PHYSICAL EXAM
======================
VS: 98.1 PO 153 / 73 78 18 94 Ra
GENERAL: NAD, patient purposely closing L eye
HEENT: Pupils PEARRL, L eye does not move past the midline. L
eyelid droop. Oropharynx clear, moist mucous membranes.
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: 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: ___ strength in upper and lower extremities. sensation
grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
========================
VS: 98.3 PO 174 / 81 77 18 96 RA
GENERAL: NAD, patient purposely closing L eye
HEENT: Pupils PEARRL, L eye adducts slightly medially past the
midline. L eyelid droop, improving. Oropharynx clear, moist
mucous membranes.
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: 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: ___ strength in upper and lower extremities. sensation
grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LAB RESULTS
====================
___ 06:39PM BLOOD WBC-11.9* RBC-4.03 Hgb-13.0 Hct-36.0
MCV-89 MCH-32.3* MCHC-36.1 RDW-11.2 RDWSD-36.3 Plt ___
___ 06:39PM BLOOD Neuts-64.4 ___ Monos-6.5 Eos-2.5
Baso-0.5 NRBC-0.2* Im ___ AbsNeut-7.64* AbsLymp-3.02
AbsMono-0.77 AbsEos-0.30 AbsBaso-0.06
___ 06:39PM BLOOD Glucose-100 UreaN-16 Creat-0.8 Na-137
K-4.1 Cl-98 HCO3-26 AnGap-17
___ 01:38PM BLOOD Calcium-9.2 Phos-2.8 Mg-1.8
___ 06:39PM BLOOD CRP-5.3*
___ 01:37PM BLOOD %HbA1c-9.6* eAG-229*
DISCHARGE LAB RESULTS
====================
___ 05:26AM BLOOD WBC-7.7 RBC-3.13* Hgb-10.0* Hct-28.9*
MCV-92 MCH-31.9 MCHC-34.6 RDW-11.8 RDWSD-39.3 Plt ___
___ 05:26AM BLOOD Glucose-127* UreaN-13 Creat-0.6 Na-140
K-4.3 Cl-103 HCO3-28 AnGap-13
___ 05:45AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.9
___ 01:37PM BLOOD %HbA1c-9.6* eAG-229*
MICROBIOLOGY
============
___ Lyme Serology: preliminary positive
___ Blood Culture: pending
___ Urine Culture: negative
IMAGING
=======
___ MR HEAD:
1. There is no evidence of acute intracranial process or
hemorrhage.
2. No evidence of cavernous sinus thrombosis or dural venous
sinus thrombosis.
3. No enhancing mass or abnormal enhancement.
4. Slightly prominent sulci for the patient's age suggesting
mild cortical volume loss, however, this finding is nonspecific.
Brief Hospital Course:
Ms. ___ is a ___ yr F with PMH of DM c/b gastroparesis and
neuropathy, HTN, HLD, migraines, and genital herpes on Valtrex
who was transferred to ___ from ___ after she presented with
recurrent headaches and ptosis. A CT scan of the head revealed
an incidental R ICA aneurysm. Neurosurgery evaluated the patient
and determined that the aneurysm was not the cause of her ptosis
and headaches. An MRI was without mass or hemorrhage. Neurology
and Neuro-ophtalmology evaluated the patient and determined that
the cause of the patient's symptoms was diabetic third nerve
palsy. Her headache slowly improved, and her blood sugars
improved as well. Lyme serologies came back preliminarily
positive on day of discharge, and she was started on
doxycycline. She was discharged home with close follow-up.
#DKA
#Type 1 Diabetes Mellitus
Patient has a history of poorly controlled T1DM complicated by
diabetic neuropathy and gastroparesis. Her HbA1c this admission
is 9.6%. She did not receive Lantus in ED on ___, and she
refused Lantus once she was admitted since she was nauseous and
not eating. Her VBG on ___ was without evidence of academia,
but a VBG on ___ showed a pH of 7.24 with a bicarb of 14. The
patient was admitted to the MICU on ___ for management of
diabetic ketoacidosis. Per protocol, an insulin drip was started
and her acidosis resolved. On ___, she was transitioned back to
her home dose of Lantus and a low dose novolog insulin sliding
scale. She continued to feel nauseous without a substantial
appetite so she was maintained on ___ normal saline IV
fluids. She was transferred back to the floor on ___. ___
diabetes helped to manage the patient's blood sugars while in
house. She should follow closely with her endocrinologist. Her
discharge insulin regimen is ***
#Diabetic Third Nerve Palsy
#Ptosis
#Eye pain
The patient's ptosis was deemed secondary to diabetic third
nerve palsy per neuro-ophthalmology and neurology. Physical exam
consistent with partial CN III palsy. MRI of the brain was
without masses or optic nerve inflammation. She was told to
patch her eye as symptoms can take weeks to months to resolve.
She should follow-up outpatient with neuro-ophthalmology.
#Lyme Disease
On day of discharge, the preliminary Lyme test came back
positive. It was sent to an outside lab for confirmatory
testing. The patient was started on doxycycline. She should
continue a ___ay 1 = ___. Day 14 = ___.
#Nausea/Vomiting
Likely secondary to headache and diplopia. There may also have
been a component of diabetic gastroparesis. Her symptoms were
controlled with IV Zofran. Her symptoms improved as her blood
sugar was controlled.
#R ICA aneurysm
Patient with an incidental 2-3mm ICA aneurysm seen on OSH CTA.
Per neurosurgery, this is not attributable to the patient's
symptoms, and patient should have outpatient follow-up in two
weeks with Dr. ___.
#HTN
She was continued on her home HCTZ and lisinopril.
TRANSITIONAL ISSUES
=================
- CTA showed incidental 2-3mm right ICA. The patient can follow
up in the ___ clinic with Dr ___ in ___ weeks.
- Patient should follow-up with neuro-ophthalmology.
- The patient should follow-up with her endocrinologist for
further management of her type 1 diabetes.
- She should complete 14 days of doxycycline for Lyme Disease.
Day 1 = ___. Day 14 = ___.
#CODE: Full (presumed)
#CONTACT: ___ (daughter), ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Headache
4. ValACYclovir 500 mg PO Q24H
5. Humalog 26 Units Breakfast
Humalog 4 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*28 Capsule Refills:*0
2. Gabapentin 100 mg PO TID
RX *gabapentin 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
3. Glargine 26 Units Breakfast
Insulin SC Sliding Scale using Novolog Insulin
4. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Headache
5. Atorvastatin 10 mg PO QPM
6. Hydrochlorothiazide 25 mg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. ValACYclovir 500 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Diabetic Third Nerve Palsy
Secondary Diagnosis:
- Type 1 DM complicated by DKA
- Headache
- Nausea/Vomiting
- Right ICA aneurysm
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 were transferred here from another hospital because you
developed an eyelid droop and blurry vision. You were also found
to have an aneurysm.
What did we do for you?
=======================
- While you were here, you developed diabetic ketoacidosis, and
you were transferred to the ICU for IV insulin.
- Your blood work gradually improved, and you were transferred
out of the ICU.
- The neurosurgery team evaluated you and determined that there
was no surgical intervention needed for your aneurysm.
- An MRI of your head did not show any bleeds or masses.
- The neurology team and the neuro-ophthalmology team evaluated
you.
- We think that the cause of your symptoms is from diabetic
third nerve palsy. This is something that we expect to take
several weeks to several months to improve.
- Your Lyme Disease test was also preliminarily positive, so we
started you on an antibiotic to treat it (doxycycline).
What do you need to do?
=======================
- Please wear an eye patch to help with the blurry vision.
- It is VERY important that you follow-up with your
endocrinologist within three days of discharge. If you would
like to be seen by ___ Endocrinologist, please call to
schedule an appointment: ___.
- It is important that you follow up with Dr. ___
Neuro-opthalmology for further evaluation of your eyelid droop.
(Appointment information below.)
- It is important that you follow up with Dr. ___ ___
___ for further evaluation of your aneurysm.
- Please monitor your blood sugars closely. Call your doctor or
come back to the hospital if your blood sugars remain below 70
or greater than 300. You should take 26 units of lantus in the
morning at 4 units of humalog with meals and also use a sliding
scale.
It was a pleasure caring for you. We wish you the best!
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10383358-DS-17 | 10,383,358 | 25,076,192 | DS | 17 | 2149-11-03 00:00:00 | 2149-11-12 03:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ presenting with 2 days of worsening LLQ pain with chills and
rigors at home. No associated vomiting and continues to mover
her
bowels and pass flatus. The pain has been focused in the LLQ
only
and she denies any vaginal discharge or dysuria. This is her
first episode of diverticulitis.
Past Medical History:
Past Medical History: borderline HTN attempting to control with
diet
Past Surgical History:
Knee surgery, C-section
Social History:
___
Family History:
Per records-
mother and maternal GM with T2DM
Physical Exam:
ADMISSION EXAM
-------------------
Vitals: 100.7 HR 95 BP 126/73 RR 16 94% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, TTP in LLQ ad suprapubic area, no
rebound or guarding, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
DC EXAM
----------
Vitals: 98.8 PO BP: 110 / 75 HR 50 RR18 O2: 98RA
GEN: AOx3, NAD
HEENT: moist mucous membranes
CV: RRR, no murmurs
PULM: CTAB
ABD: Soft, non-distended, mild TTP at LLQ, no rebound/guarding,
no masses appreciated
EXT: no ___
___ Results:
Blood
Hematology
COMPLETE BLOOD
COUNTWBCRBCHgbHctMCVMCHMCHCRDWRDWSDPlt Ct
___ 06:00 ___
___ 05:40 ___
___ 06:29 ___
___ 06:05
___
___ 23:00 ___
DIFFERENTIALNeutsBandsLymphsMonosEosBasoAtypsMetasIm
GranAbsNeutAbsLympAbsMonoAbsEosAbsBaso
___ 23:00 69.8 19.89.40.5*0.2
0.316.71*1.900.90*0.050.02
INCLUDES METAS, MYELOS AND PROS.
BASIC COAGULATION ___, PTT, PLT, INR)PTPTTPlt ___
___ 06:00 200
___ 05:40 175
___ 06:29 203
___ 06:05 185
___ 06:05 14.0*28.1 1.3*
___ 23:00 185
Chemistry
RENAL & GLUCOSEGlucoseUreaNCreatNaKClHCO3AnGap
___ 06:00 ___
___ 05:40 ___
___ 06:29 ___
___ 06:05 ___
___ 23:00 ___
CHEMISTRYTotProtAlbuminGlobulnCalciumPhosMgUricAcdIron
___ 06:00 8.93.62.1
___ 05:40 8.3*3.82.2
___ 06:29 8.73.52.3
___ 06:05 8.73.52.1
Urine
Hematology
GENERAL URINE ___
___ ___ YellowClear1.026
DIPSTICK
U
R
I
N
A
L
Y
S
ISBloodNitriteProteinGlucoseKetoneBilirubUrobilnpHLeuks
___ 22:50 NEGNEGTRNEG10NEGNEG6.0NEG
MICROSCOPIC URINE
EXAMINATIONRBCWBCBacteriYeastEpiTransERenalEp
___ 22:50 1<1NONENONE<1
OTHER URINE FINDINGSMucous
___ 22:50 RARE
Chemistry
URINE CHEMISTRYHours
___ 22:50 RANDOM
OTHER URINE CHEMISTRYUCG
___ 22:50 NEGATIVE1
NEGATIVE
FOR QUANTITATION OF POSITIVES, SEND SERUM FOR HCG
MICRO
-------
___ 6:05 pm URINE
SPECIMEN RECEIVED >12 HRS AFTER COLLECTION.
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Pending):
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Pending):
__________________________________________________________
___ 2:50 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
---------
___ 12:42 AM# ___ CT ABD & PELVIS WITH CO
1. Diverticulitis of the distal descending colon without focal
fluid
collection.
2. Non-occlusive left ovarian vein thrombosis in the region of
inflammation.
3. There is complex free fluid in the pelvis.
Brief Hospital Course:
Ms. ___ is a ___ who presented with her first episode of
complicated diverticulitis.
#Diverticulitis: Presented with LLQ tenderness, WBC of 9.6 that
peaked to 10.4, and imaging notable for diverticulitis in the
distal descending colon. Was initially kept NPO and was started
on IV antibiotics (ciprofloxacin and flagyl) on ___. On HD2,
was advanced to CLD which she tolerated well. Pain was
controlled with IV then PO pain medications. Patient was placed
on a bowel regimen and at time of discharge, pain was controlled
and patient was counseled on foods to eat and avoid at home.
Patient was discharged on PO Ciprolfoxacin and PO Flagyl for a
total 10 day course of antibiotics (last day ___. Discharge
WBC was 4.1
#Non-occlusive left ovarian vein thrombus: was noted on
admission CT, adjacent to area of diverticulitis. CT also
notable for complex free fluid in pelvis; likely in setting of
the inflammatory processes in the abdomen. These findings did
not require any further follow-up. Patient was notified of
findings and recommended to discuss at next PCP ___.
Transitional Issues
-------------------
[] Patient being discharged on Ciprofloxacin PO and
Metronidazole PO for a total course between ___
[] CT findings showed Non-occlusive left ovarian vein thrombus
with complex free fluid in pelvis; all likely in setting of
acute inflammatory process adjacent to the diverticulitis. No
further evaluation was done in the hospital, however patient was
advised to follow-up with PCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Excedrin Migraine (aspirin-acetaminophen-caffeine) 250-250-65
mg oral DAILY PRN headache
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*13 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
Hold for loose stools
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
3. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*21 Tablet Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
DO NOT DRIVE WHILE TAKING THIS MEDICATION. CAN CAUSE SEDATION
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
Daily Refills:*2
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 325 mg 1 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
7. Excedrin Migraine (aspirin-acetaminophen-caffeine)
250-250-65 mg oral DAILY PRN headache
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulitis
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 abdominal pain. You were
found to have diverticulitis (inflammation/infection of an
"out-pouching" of your bowels) on imaging.
Your imaging also showed some fluid in your pelvis and a
non-occlusive clot near your left ovarian vein, all which are
near to where you had the abdominal inflammation. These
findings did not require further follow up, but please discuss
these findings with your primary care doctor to determine if any
future re-imaging is needed.
In the hospital, you received bowel rest and slowly tolerated a
diet. Your pain was controlled and you received antibiotics.
When you go home
- Eat foods that are easy for you to digest and slowly get back
to your normal diet. Diet recommendations are included for you
below.
- Continue taking antibiotics till ___
- Follow up with your doctors.
It was a pleasure taking care of you,
--Your ___ Care Team
Followup Instructions:
___
|
10383860-DS-18 | 10,383,860 | 21,630,078 | DS | 18 | 2143-10-14 00:00:00 | 2143-10-16 10:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
oxycodone / aspirin
Attending: ___
Chief Complaint:
abdominal pain, nausea, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ female with a history of autoimmune
hepatitis related cirrhosis (c/b HE, ascites, and EVs), s/p
gastric bypass, and prior history of gallstone pancreatitis who
p/w N/V, elevated lipase, concerning for pancreatitis.
Three days ago, patient developed epigastric pain. Acute
worsening over the last 24 hours. Presented to OSH, where lipase
was greater than 1200. Patient received 500 cc of fluid at
outside hospital as well as 8 mg of Zofran and pain control. She
was transferred to ___ for further management. Patient states
that she has also had several days of nausea and nonbilious
nonbloody vomiting.
Bedside ultrasound revealed enlarged gallbladder with normal
wall, no pericholecystic fluid. Common bile duct less than 4 mm.
No ascites.
Patient's blood pressure in ED with systolics in the ___. Per
patient, this is normal for her. Blood pressure at last liver
transplant outpatient visit had patient's blood pressure at
91/57.
The patient states that her urine turned dark yesterday, and
that
was also when the fevers started.
Patient denies any fevers, chills, chest pain, shortness of
breath, urinary or bowel symptoms. Patient denies any melena or
bloody stools. She has diarrhea, but she reports it is at her
baseline since she takes lactulose and rifaximin.
Past Medical History:
Autoimmune hepatitis with portal hypertension
Esophageal varices
Hypothyroidism
Asthma
Anemia
Gastric bypass surgery
C-section
Social History:
___
Family History:
Mother ___ CIRRHOSIS
Father ___ END STAGE RENAL DISEASE
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.6PO 102 / 58 95 18 92 RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB
ABDOMEN: mildly distended, TTP in epigastric area and RUQ
EXTREMITIES: no cyanosis, clubbing, or edema, no asterixis
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: mildly jaundiced, no rashes
DISCHARGE PHYSICAL EXAM:
========================
Vitals: T 97.9 HR 69 BP 95/59 RR 18 O2 96% RA
GENERAL: lying in bed, NAD
HEENT: anicteric sclera, MMM
HEART: RRR, nl S1/S2, no murmurs, gallops, or rubs
LUNGS: expiratory wheezing heard throughout all lung fields, no
crackles or rhonchi, good air movement overall
ABDOMEN: mildly distended, mildly TTP in RUQ without
rebound tenderness or guarding, nontender in epigastrium.
Normoactive BS.
EXTREMITIES: no cyanosis, clubbing, or edema, no asterixis
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: mildly jaundiced, no rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 07:39PM BLOOD WBC-5.2 RBC-3.59* Hgb-11.8 Hct-33.4*
MCV-93 MCH-32.9* MCHC-35.3 RDW-14.7 RDWSD-49.7* Plt Ct-25*
___ 07:39PM BLOOD Neuts-81.4* Lymphs-9.0* Monos-8.8
Eos-0.2* Baso-0.4 Im ___ AbsNeut-4.26# AbsLymp-0.47*
AbsMono-0.46 AbsEos-0.01* AbsBaso-0.02
___ 07:39PM BLOOD ___ PTT-36.5 ___
___ 07:39PM BLOOD ___ 07:39PM BLOOD Glucose-78 UreaN-15 Creat-0.6 Na-138
K-3.7 Cl-106 HCO3-20* AnGap-12
___ 07:39PM BLOOD ALT-42* AST-69* LD(LDH)-206 AlkPhos-129*
TotBili-9.4* DirBili-7.0* IndBili-2.4
___ 07:39PM BLOOD Lipase-1117*
___ 05:50AM BLOOD Calcium-7.5* Phos-4.5 Mg-1.3* Cholest-100
___ 05:50AM BLOOD Triglyc-79 HDL-19* CHOL/HD-5.3 LDLcalc-65
___ 06:50AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 07:49PM BLOOD Lactate-2.1*
DISCHARGE LABS:
===============
___ 06:50AM BLOOD WBC-3.7* RBC-3.29* Hgb-10.8* Hct-31.5*
MCV-96 MCH-32.8* MCHC-34.3 RDW-15.6* RDWSD-53.4* Plt Ct-55*
___ 06:50AM BLOOD ___ PTT-35.8 ___
___ 06:50AM BLOOD Glucose-76 UreaN-9 Creat-0.4 Na-138 K-4.0
Cl-104 HCO3-22 AnGap-12
___ 06:50AM BLOOD ALT-26 AST-61* LD(LDH)-219 AlkPhos-125*
TotBili-5.2*
___ 06:50AM BLOOD Calcium-7.7* Phos-2.7 Mg-1.5*
Brief Hospital Course:
___ female with a history of autoimmune hepatitis
related cirrhosis (c/b HE, ascites, and EVs)(Childs C, MELD-Na
24), s/p gastric bypass, and prior history of gallstone
pancreatitis who p/w N/V, elevated lipase, LFTs, and E. coli
bacteremia concerning for pancreatitis and cholangitis.
ACUTE ISSUES:
=============
#Pancreatitis
The patient presented with RUQ/epigastric abdominal pain, nausea
and vomiting and was found to have a lipase over 1200. RUQ
ultrasound revealed cholelithiasis but no cholecystitis.
Etiology most likely a passed gallstone. She was made NPO and
started on IV fluids and pain medications. Her abdominal pain
and nausea improved over the following days. Her diet was slowly
advanced as tolerated and IV fluids were stopped after she was
taking in enough fluids by mouth. Pain medications were changed
from IV to oral and this was tolerated well.
#Cholangitis
The patient presented with fever, jaundice, RUQ pain, and
elevated bilirubin consistent with cholangitis. She was started
on Zosyn initially and this was changed to ceftriaxone and
metronidazole. MRCP showed cholelithiasis but no
choledocolithiasis, so she did not receive ERCP as the culprit
stone likely passed. Antibiotics were switched to oral
ciprofloxacin and metronidazole prior to discharge to be
continued for a ___. coli bacteremia
The patient had positive blood cultures for pan-sensitive E.
coli in the setting of her cholangitis, likely from
translocation. She was treated with Zosyn,
ceftriaxone/metronidazole, and sent home on oral
ciprofloxacin/metronidazole to complete a 2 week course on ___.
CHRONIC ISSUES:
===============
#Cirrhosis
Thought to be most likely secondary to autoimmune hepatitis vs.
___. Complicated by ascites, hepatic encephalopathy and
esophageal varicies. Patient being worked up for liver
transplant prior to cholecystectomy. She had daily MELD labs.
Her hold spironolactone was held while she was given IV fluids.
Her rifaximin and lactulose were continued. She continued her
home nadolol to prevent variceal bleeding.
#Coagulopathy
The patient has an elevated INR and thrombocytopenia related to
her liver disease. She had an active type and screen while in
the hospital and daily coagulation labs were drawn.
#Hypotension
The patient has consistent SBPs in the ___ at home. She was
continued on midodrine and prednisone.
#Hypothyroidism
She was continued on her home levothyroxine
TRANSITIONAL ISSUES:
===================
[ ] The patient will need to complete a 2 week course of
antibiotics for cholangitis and E. coli bacteremia with
ciprofloxacin and metronidazole. End date ___.
[ ] The patient would benefit from a cholecystectomy after liver
transplant workup to prevent future episodes of gallstone
pancreatitis and cholangitis. This is complicated by her
cirrhosis making such an operation risky.
[ ] Patient discharged with diarrhea and C. diff pending. Please
follow-up and initiate treatment with oral vancomycin for 14
days after ___ if positive.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. PredniSONE 3.75 mg PO DAILY
2. Midodrine 2.5 mg PO BID
3. Nadolol 20 mg PO DAILY
4. Spironolactone 50 mg PO DAILY
5. Calcium Carbonate 500 mg PO DAILY
6. Rifaximin 550 mg PO BID
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
10. Vitamin E 800 UNIT PO DAILY
11. Lactulose 30 mL PO TID
12. Famotidine 40 mg PO QHS
13. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
14. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*20 Tablet Refills:*0
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone 2 mg 1 tablet(s) by mouth every six (6) hours
Disp #*6 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
4. Midodrine 5 mg PO TID
RX *midodrine 5 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*1
5. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*12 Tablet Refills:*0
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
7. Calcium Carbonate 500 mg PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Famotidine 40 mg PO QHS
10. Furosemide 20 mg IV DAILY
11. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
12. Lactulose 30 mL PO TID
13. Levothyroxine Sodium 75 mcg PO DAILY
14. PredniSONE 3.75 mg PO DAILY
15. Rifaximin 550 mg PO BID
16. Spironolactone 50 mg PO DAILY
17. Vitamin D ___ UNIT PO DAILY
18. Vitamin E 800 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
==================
Pancreatitis
Cholangitis
SECONDARY DIAGNOSES
=====================
Cirrhosis
Autoimmune hepatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure being involved in your care.
Why you were admitted to the hospital:
==============================
You were admitted to the hospital because you had a fever,
nausea, and abdominal pain and were found to have lab
abnormalities consistent with inflammation of your pancreas and
cholangitis, which is an infection of the bile ducts. Bacteria
were also found in your blood, likely as a result of the
infection in your bile ducts.
What happened in the hospital:
========================
- To treat your pancreatitis, you were given IV fluids, pain
medications, and your diet was slowly advanced until you could
comfortably eat normally again.
- To treat your cholangitis and bacteria in your blood, you were
given IV antibiotics. These were switched to oral antibiotics
prior to discharge.
- You had an MRI to look at your liver, bile ducts, gallbladder,
and pancreas that showed gallstones but no stones in your bile
ducts. This suggests that your infection was caused by a stone
that passed.
What to do when you leave the hospital:
===============================
- Please take your antibiotics until they finish treating your
infection on ___.
- Please attend all of your follow-up appointments, including
those related to your liver transplant and future removal of
your gallbladder.
We wish you the best!
Your ___ Team
Followup Instructions:
___
|
10384049-DS-12 | 10,384,049 | 29,851,042 | DS | 12 | 2177-07-18 00:00:00 | 2177-07-17 16:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yr old male pt intoxicated, who presented with small
bifrontal SDH s/p fall, no LOC, no seizures.
Past Medical History:
None
Social History:
___
Family History:
NC
Physical Exam:
On Admission:
AVSS
awake, confused, oriented x ___
follows commands throughout
PERRL, EOMI, FSTM
No drift
MAE ___
sensation intact to light touch
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
On Discharge:
A&Ox3
L pupil surgical, R ___
EOMs intact
Face symmetrical
tongue midline
No pronator drift
Motor: ___ throughout
Pertinent Results:
head CT: small bifrontal and falcine SDH, no mass effect or
midline shift
Head CT ___:
Thin 2 mm subdural hemorrhage along the right frontoparietal
convexity and
thin parafalcine subdural hemorrhage without evidence of mass
effect
Brief Hospital Course:
___ y/o M who was intoxicated, presents with with bifrontal SDH
s/p fall. He was admitted to neurosurgery for monitoring
overnight. He was started on MVI, thalamine and folic acid. On
___, patient remained stable on exam, social work was consulted
and ___. His repeat head CT showed no increase in SDHs. On ___,
he was cleared to be discharged home by both ___ and SW. His pain
was under control and he was discharged in stable condition.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
2. LeVETiracetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*12 Tablet Refills:*0
3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen [Percocet] 5 mg-325 mg ___ tablet(s)
by mouth every four (4) hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Bifrontal SDH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
**You have been discharged on Keppra (Levetiracetam)for 6 more
days, you will not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
10384457-DS-12 | 10,384,457 | 24,737,154 | DS | 12 | 2138-02-02 00:00:00 | 2138-02-02 20:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Diffuse lower abdominal pain that migrated to the right lower
quadrant.
Major Surgical or Invasive Procedure:
___ laparoscopic appendectomy
History of Present Illness:
Mrs. ___ is a ___ year old female who presents with 18 hours
of abdominal pain that was originally diffuse lower abdominal
pain that migrated to the RLQ. The pain was associated with
chills, nausea, and emesis prior to admission. No diarrhea or
dysuria. No prior episodes of pain.
Past Medical History:
Asthma, allergies.
Social History:
___
Family History:
Non-contributory.
Physical Exam:
On admission:
PE: 98.7 65 113/71, 18, 100% on room air
Gen: no distress, alert and oriented x 3
HEENT: PERLA, EOMI, anicteric
Chest: RRR, lungs clear bilaterally
Abd: soft, nondistended, tender to palpation in RLQ, no rebound
or guarding, (+) Rosving's sign
Rectal:
Ext: no edema, warm
On discharge:
VS: Temp 98.6, HR 60, BP 100/50, RR 18, sat 99% on room air.
Neuro: AAO x 3. NAD.
General abdominal tenderness, more superficial near trocar
sites. Soft, non-distended.
Pertinent Results:
___ 12:24PM BLOOD WBC-13.6* RBC-4.19* Hgb-12.5 Hct-36.8
MCV-88 MCH-29.7 MCHC-33.8 RDW-13.3 Plt ___
___ 12:24PM BLOOD Neuts-89.1* Lymphs-7.4* Monos-3.1 Eos-0.2
Baso-0.2
___ 12:24PM BLOOD Glucose-111* UreaN-10 Creat-0.6 Na-138
K-4.0 Cl-101 HCO3-25 AnGap-16
___ 12:47PM BLOOD Lactate-1.5
___ CT abdomen and pelvis with contrast
Distended fluid-filled appendix measuring 10 mm with mucosal
hyperemia and surrounding periappendiceal stranding and trace
free fluid, concerning for uncomplicated acute appendicitis.
Brief Hospital Course:
Mrs. ___ was admitted on ___ under the acute care surgery
service for management of her acute appendicitis. She was taken
to the operating room and underwent a laparoscopic appendectomy.
Please see operative report for details of this procedure. She
tolerated the procedure well and was extubated upon completion.
She was subsequently taken to the PACU for recovery. She was
transferred to the surgical floor hemodynamically stable. Her
vital signs were routinely monitored and she remained afebrile
and hemodynamically stable. She was initially given IV fluids
postoperatively, which were discontinued when she was tolerating
oral intake. Her diet was advanced on the morning of ___ to
regular, which she tolerated without abdominal pain, nausea, or
vomiting. She was voiding adequate amounts of urine without
difficulty. She was encouraged to mobilize out of bed and
ambulate as tolerated, which she was able to do independently.
Her pain level was routinely assessed and well controlled at
discharge with an oral regimen as needed.
On the evening of ___, Mrs. ___ was discharged home in the
care of her parents. A follow-up appointment has been scheduled
with with the ACS service. She was hemodynamically stable and
afebrile. Discharge instructions were provided by myself and
the bedside RN.
Medications on Admission:
Allegra, singulair, zyrtec, veramyst, QVAR inhaler
Discharge Medications:
1. Montelukast Sodium 10 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
4. Acetaminophen 325-650 mg PO Q6H:PRN pain
5. Qvar *NF* (beclomethasone dipropionate) 80 mcg/actuation
Inhalation 3 puffs daily
6. Fexofenadine 180 mg PO DAILY
7. Veramyst *NF* (fluticasone furoate) 27.5 mcg/actuation NU
each nostril daily
8. Patanol *NF* (olopatadine) 0.1 % ___ 1 - 2 drops to each eye
twice daily
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for ___ weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" a couple weeks. You might
want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You could have a poor appetite for a couple days. Food may
seem unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
o If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10384955-DS-4 | 10,384,955 | 26,681,962 | DS | 4 | 2167-04-24 00:00:00 | 2167-04-30 16:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
fluticasone
Attending: ___.
Chief Complaint:
speech difficulty
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ yo M with a history of HTN, HLD, and recently
diagnosed HepC who presented to the ED with complaints of chest
pain, dyspnea on exertion, and lower extremity edema. Given his
cardiac risk factors, the patient was to be evaluated with
cardiac stress test. However, on further questioning by ED
physicians, there was concern for neurologic deficits on
history.
The patient reports that he was trying to talk and was mumbling
instead and couldn't get the words out properly. He felt that
his words were slurred. When he spoke his family thought he was
trying to be funny but this was not his intension. This first
occurred a few weeks ago but these symptoms occurred again on
___. Both times the symptoms were transient and would
fully resolve within that day.
The morning of presentation the patient reports a headache on
the L side that feels like "marbles inside of the head" and
sharp/stabbing. The headache lasted for 1 hour; this wakes him
up from sleep ___ x per week and then gradually resolves. The
patient does not have associated nausea. It is unknown whether
he has photophobia. This has been going on for a few months. The
patient has had headaches in the past but were persistent and
dull, due to HTN. They resolved once the patient started
antihypertensives.
The patient also reports L mouth tremulousness and numbness,
also present for a few months. This occurs occasionally but the
patient cannot remember how often. It is most prominent in the
morning when he wakes up. These are not temporally associated
with the headaches.
On neuro ROS, the pt reports chronic tinnitus, frequent
lightheadedness when standing. He denies headache, loss of
vision, blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. Denies focal
weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt reports feet/leg swelling,
SOB, chest pain, occassional palpitations. He denies recent
fever or chills. No night sweats or recent weight loss or gain.
Denies cough. 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:
Hepatitis C - recently diagnosed, possibly could undergo
treatment, no history of cirrhosis
HTN
HLD
Asthma
Social History:
___
Family History:
Brother with epilepsy, deceased of brain tumor age ___ (unknown
etiology of epilepsy, diagnosed age ___
Physical Exam:
Physical Exam on Admission:
Vitals:
T= 97.7F, BP= 144/80, HR= 52, RR= 18, SaO2= 98%
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Speech was not dysarthric. Able to follow both midline
and appendicular commands. Attentive, able to name ___ backward
without difficulty. Pt. was able to register 3 objects and
recall ___ at 5 minutes, ___ with category cueing. The pt. had
good knowledge of current events. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation. Funduscopic exam was
attempted but unable to fully visual discs so papilledema was
not able to be assessed.
III, IV, VI: EOMI without nystagmus. Normal saccades. +
exophoria
V: Facial sensation intact to light touch, pinprick in all
distributions, and ___ strength noted bilateral in masseter
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, and is equal ___ strength
bilaterally as evidenced by tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted.
Delt Bic ___ WrE FFl FE IO IP Quad Ham TA ___
L ___ 5 5
R ___ 5 5
-DTRs:
___ Pat Ach
L 0 0 0 0 0
R 0 0 0 0 0
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing.
Labs/Studies:
Physical Exam on Discharge:
Unchanged
Pertinent Results:
Labs
___ 10:24PM WBC-5.0 RBC-5.30 HGB-15.8 HCT-43.9 MCV-83
MCH-29.9 MCHC-36.1* RDW-14.7
___ 10:24PM cTropnT-<0.01
___ 10:24PM GLUCOSE-148* UREA N-14 CREAT-1.2 SODIUM-142
POTASSIUM-3.2* CHLORIDE-105 TOTAL CO2-26 ANION GAP-14
___ 04:50AM ALBUMIN-3.9
___ 04:50AM cTropnT-<0.01
___ 04:50AM ALT(SGPT)-43* AST(SGOT)-47* ALK PHOS-61 TOT
BILI-0.7
___ 10:15AM TSH-2.5
___ 10:15AM TRIGLYCER-208* HDL CHOL-33 CHOL/HDL-5.1
LDL(CALC)-93
___ 10:15AM %HbA1c-5.1 eAG-100
___ 10:15AM ALT(SGPT)-47* AST(SGOT)-54* CK(CPK)-51 ALK
PHOS-65 TOT BILI-0.9
___ 10:15AM GLUCOSE-94 UREA N-12 CREAT-1.1 SODIUM-140
POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-27 ANION GAP-14
Imaging
CTA head/neck
No significant abnormalities on CT of the head without contrast.
No
significant abnormalities on CT angiography of the head. No
evidence for sinus thrombosis.
MRI brain w/ and w/o contrast
No significant abnormalities are seen on MRI of the brain with
and without
gadolinium.
Brief Hospital Course:
Mr. ___ is a ___ yo M with a history of HTN, HLD, and
recently diagnosed HepC who presented to the ED with complaints
of chest pain, dyspnea on exertion, and lower extremity edema
concerning for cardiac chest pain with initial plan to work up
with cardiac stress testing. He also reported several episodes
of intermittent word finding difficulty/dysarthria. Presented
with chest pain to ED. 2 sets of cardiac enzymes and ECG not
concerning for acute coronary syndrome. Reported transient word
finding difficulty/dysarthria and headaches with symptoms
suggestive of increased intracranial pressure (eg. awoken from
sleep by his headaches). CT brain did not show any evidence of
hemorrhage. CTA head/neck showed patent vasculature, no venous
sinus thrombosis, or AVM, or aneurysm. MRI brain w/ and w/o
contrast ruled out stroke and mass lesion. Upon obtaining
additional history from him once he was admitted to the
Neurology service, he reported that his episodes of dysarthria
were only lasting for a word or two. There was low suspicion for
TIA as his episodes of speech difficulty were quite brief.
Transthoracic echocardiogram was deferred due to low suspicion
for TIA and given that he already had a TTE (non bubble study)
in ___ that showed a normal EF of 65% without evidence of
intracardiac thrombus or PFO/ASD. Headache may be due to
temporomandibular joint dysfunction or tension headaches. The
patient was started on aspirin 81mg qd. Will have cardiac
stress test as outpatient, communicated this to PCP, ___.
Medications on Admission:
Atenolol 75 mg PO BID
Amlodipine 2.5 mg PO QAM
Amlodipine 5 mg PO HS
Hydrochlorothiazide 25 mg PO DAILY
Moexipril 15 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*6
2. Atenolol 75 mg PO BID
3. Amlodipine 2.5 mg PO QAM
4. Amlodipine 5 mg PO HS
5. Hydrochlorothiazide 25 mg PO DAILY
6. Moexipril 15 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
possible TIA (low suspicion)
headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to the emergency room with chest pain. An EKG and
blood tests of your heart were normal. You will need a CARDIAC
STRESS TEST as an outpatient. We have let Dr. ___ about
this.
In the emergency room, you reported several episodes of slurred
speech and trouble finding words as well as headaches that wake
you up in the middle of the night. So, we admitted you to
neurology to rule out a stroke, blood clot, mass in your brain
with an MRI. The MRI of your brain was NORMAL, which is great!
We think your headache might be from grinding your teeth. We
did start you on a baby aspirin for stroke prevention.
We have made the following changes to your medications:
START
aspirin 81mg daily
On discharge:
Please call to schedule an appointment with Dr. ___ in
neurology:
___
You will need to schedule a cardiac stress test. Please talk to
Dr. ___ to help facilitate this.
It was a pleasure taking care of you, we wish you all the best
Followup Instructions:
___
|
10384987-DS-19 | 10,384,987 | 27,055,047 | DS | 19 | 2172-06-30 00:00:00 | 2172-07-06 09:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
bee stings
Attending: ___.
Chief Complaint:
Polytrauma s/p MCC
Major Surgical or Invasive Procedure:
___: Open reduction internal fixation right lateral condyle
proximal tibia fracture with depression and use of calcium
phosphate filler.
History of Present Illness:
This patient is a ___ year old male who complains of MCC. Patient
status post motor vehicle collision sustaining right
pneumothorax was multiple rib fractures. Chest tube was placed
with some clinical improvement. Patient was
tachycardic with increased work of breathing. Patient is given
pain medication and the chest tube was repositioned with
significant improvement in symptoms. In discussion, patient is
admitted to the ICU for continued pulmonary monitoring.
Past Medical History:
PMH: Lyme, OSA
PSH: Appendectomy, tonsillectomy
Social History:
___
Family History:
Father had MI @ ___, and Mother @ ___ yrs, both deceased, 2
brothers are healthy
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION
Constitutional: Agitated
HEENT: Normocephalic, atraumatic
Oropharynx within normal limits
Chest: Crackles right
Cardiovascular: Tachycardic
Abdominal: Soft, Nontender
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent
Pertinent Results:
___ 04:45AM BLOOD WBC-9.0 RBC-3.48* Hgb-11.0* Hct-33.2*
MCV-95 MCH-31.6 MCHC-33.2 RDW-13.3 Plt ___
___ 05:45AM BLOOD WBC-8.8# RBC-3.14* Hgb-10.3* Hct-29.4*
MCV-94 MCH-32.7* MCHC-34.9 RDW-13.2 Plt ___
___ 12:51PM BLOOD WBC-5.4 RBC-2.83* Hgb-9.5* Hct-26.6*
MCV-94 MCH-33.5* MCHC-35.6* RDW-13.0 Plt ___
___ 04:46AM BLOOD WBC-7.7 RBC-3.40* Hgb-10.9* Hct-31.7*
MCV-93 MCH-32.0 MCHC-34.3 RDW-13.5 Plt ___
___ 12:38AM BLOOD WBC-8.4 RBC-3.55* Hgb-11.5*# Hct-33.5*
MCV-94 MCH-32.5* MCHC-34.5 RDW-13.6 Plt ___
___ 10:13PM BLOOD WBC-14.2* RBC-4.52* Hgb-14.7 Hct-42.8
MCV-95 MCH-32.6* MCHC-34.4 RDW-13.5 Plt ___
___ 07:05PM BLOOD WBC-17.1* RBC-4.73 Hgb-15.5 Hct-44.3
MCV-94 MCH-32.7* MCHC-34.9 RDW-13.3 Plt ___
___ 04:45AM BLOOD Glucose-106* UreaN-20 Creat-0.7 Na-135
K-4.0 Cl-100 HCO3-23 AnGap-16
___ 05:00AM BLOOD Glucose-116* UreaN-20 Creat-0.7 Na-139
K-3.9 Cl-102 HCO3-27 AnGap-14
___ 05:45AM BLOOD Glucose-288* UreaN-14 Creat-0.8 Na-134
K-3.4 Cl-100 HCO3-24 AnGap-13
___ 04:46AM BLOOD Glucose-120* UreaN-15 Creat-0.8 Na-137
K-3.7 Cl-103 HCO3-27 AnGap-11
___ 12:38AM BLOOD Glucose-138* UreaN-23* Creat-1.1 Na-139
K-3.8 Cl-104 HCO___ AnGap-10
___ 05:45AM BLOOD TSH-0.74
Radiology:
X-ray Tib/Fib: There has been interval placement of a lateral
longitudinal plate and perpendicularly oriented screws
stabilizing a tibial plateau fracture. Alignment appears
improved
from the initial injury.
CT Chest: IMPRESSION:
1. Small right hemopneumothorax. Moderate pneumomediastinum. No
evidence of intra-abdominal injury.
2. Multiple right-sided rib fractures as described above. No
fractures in the thoracolumbar spine identified. The right
subclavian vein is not well seen in the area of trauma, this may
represent vessel injury or spasm however there is no adjacent
hemorrhage of any substantial size. Right subclavian artery
appears intact.
3. 2.8 cm right common iliac aneurysm with peripheral thrombus.
Celiac aneurysm measures 1.7 cm. Recommend follow up with
vascular surgery when clinically appropriate.
4. Fatty liver.
XRay Chest: IMPRESSION: Markedly displaced right second through
fourth rib fractures. Right-sided chest tube in place with no
substantial pneumothorax.
XRay Shoulder: IMPRESSION: Findings consistent with shoulder
separation involving the acromioclavicular joint. No definite
fracture involving the right shoulder although the possibility
of
a nondisplaced distal acromial fracture is not entirely
excluded.
___ ECHO a-fib, no abnormalities
Brief Hospital Course:
The patient is a ___ gentleman transferred from OSH
status post motorcycle collision resulting in multiple injuries
including right ___ rib fractures, right acromioclavicular
dissociation, right pneumothorax requiring a chest tube (at
OSH), and a right proximal tibia fracture. The patient
experienced LOC but GCS was 15 upon arrival to ___, and the
patient was complaining of chest pain. The patient became
hemodynamically unstable with notable flail chest and
tachycardia, so he was transferred to the ___ for close
monitoring. Acute Pain Service was consulted and an epidural was
placed. He then became hypotensive requiring fluid resuscitation
and neo drip for a short while. The epidural was then split and
the patient stabilized.
Orthopedics were consulted to address the patient's right
proximal tibia fracture and acromioclavicular dissociation. The
AC separation did not require surgery and was placed in a sling.
The patient was taken to the operating room on HD#3 for ORIF
right tibia. The patient tolerated the procedure well and was
successfully extubated postoperatively. He was transferred out
of the unit to the floor in hemodynamnicallt stable condition.
Initial work-up CT showed an incidental finding of a 1.7cm
celiac aneurym & 2.8 cm right common iliac aneurym. Vascular was
consulted for this, who felt there was no urgent operative
indication. The patient will follow-up with Dr ___ in 6 months
for repeat CTA.
On HD#4 Cardiology was consulted for new onset Atrial
fibrillation with RVR; the patient was found to have RBBB at
baseline. Patient did not have any CP, palpitation, SOB, or
lightheadedness but c/o pain all over his body aggravated with
movements. The cardiologists felt the new AF was likely
precipitated by the acute chest trauma and blood loss. He was
started on metoprolol with good effect.
On HD#6 the chest tube was d/c'd. Post pull CXR did not show any
recurrent pneumothorax and the patient's respiratory status was
improved. He was seen by Physical therapy and Occupational
therapy, who felt the patient met the criteria for a rehab at
the time of discharge, based on his injuries and functioning
below baseline.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
was out of bed with assist, was adherent with respiratory toilet
and incentive spirometry, and actively participated in the plan
of care. The patient received subcutaneous lovenox 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, out of bed with assist, voiding without assistance, and
pain was well controlled. The patient was discharged to rehab.
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 650 mg PO Q6H pain
2. Baclofen 10 mg PO TID
3. Diazepam 5 mg PO Q6H:PRN spasm
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
6. Famotidine 20 mg PO BID
7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
8. Lidocaine 5% Patch 2 PTCH TD QAM
9. Metoprolol Tartrate 25 mg PO BID
10. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Polytrauma:
Right proximal tibia fracture
Right ___ rib fracture
Right hemothorax
Right shoulder AC separation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr ___,
You were admitted to ___ after a motorcycle collision. You
sustained multiple injuries, including 8 right sided rib
fractures, a right lung injury, right shoulder separation, and
right tibia fracture. You were taken to the operating room with
the Orthopedic team for repair of the tibia fracture.
* Your injury caused 8 rib fractures which can cause severe pain
and subsequently cause you to take shallow breaths because of
the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
-Right lower extremity TDWB in ___
-Right upper extremity NWB, sling for comfort
Followup Instructions:
___
|
10385319-DS-6 | 10,385,319 | 22,825,754 | DS | 6 | 2174-08-14 00:00:00 | 2174-08-14 20:05:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p assault
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ s/p assault who presented to ___ on
the evening of ___. Per report he reportedly lost
consciousness in the field and then again at ___. He had facial
swelling and reportedly could not protect his airway. Four
attempts at endotracheal intubation were attempted. He was then
transferred to the OR for a tracheostomy, but anesthesia was
able to successfully intubate the patient on their ___ attempt.
He then underwent a CT scan of his face and c-spine and was
transferred to ___ for further management. Upon arrival to
___ he was hemodynamically stable with normal oxygen
saturations. Other than his facial edema he had no other
injuries identified on secondary survey. He then underwent CT
scans of his head, face, c-spine, and torso which revealed a
left orbial wall fracture, left maxillary sinus fracture, left
zygomatic arch fracture, and 2 small foci of SAH. He was
admitted to the trauma SICU for observation and treatment.
Past Medical History:
? bipolar disorder, chronic bronchitis
Social History:
___
Family History:
N/C
Physical Exam:
Gen: Intubated and sedated, able to follow commands, unable to
communicate
HEENT: ___, L periorbital ecchymoses and edema, left
subconjuctival hemorrhage, blood in nares, blood in right ear
canal from small laceration, no Battle sign, no septal hematoma,
no nasal deviation, trachea midline
Chest: RRR, lungs clear, no chest wall tenderness
Abd: soft, nontender, nondistended
Rectal: minimal tone, no gross blood
Ext: no long bone deformities, palpable pulses
Spine: no stepoffs
Pertinent Results:
___ 03:47PM GLUCOSE-110* UREA N-11 CREAT-0.8 SODIUM-139
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-29 ANION GAP-12
___ 03:47PM ALT(SGPT)-39 AST(SGOT)-51* LD(LDH)-268* ALK
PHOS-58 TOT BILI-0.6
___ 03:47PM ALBUMIN-4.1 CALCIUM-8.8 PHOSPHATE-3.3
MAGNESIUM-2.3
___ 03:47PM WBC-9.7 RBC-4.02* HGB-13.5* HCT-39.5* MCV-98
MCH-33.6* MCHC-34.2 RDW-12.9
___ 03:47PM PLT COUNT-189
___ 09:30AM LACTATE-1.7
___ 02:25AM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Brief Hospital Course:
See the HPI for presenting details. Upon weaning down his
sedation he was following commands and he extubated
successfully. His pain was initially controlled with IV
medications and this was transitioned to PO meds. He remained
normotensive with a normal HR throughout his stay. His oxygen
saturations remained normal on room air after extubation.
Plastic surgery was consulted and they recommened sinus
precautions, antibiotics, and an opthamology consult. They plan
on having him follow up in their clinic to discuss potential
operative repair. A detailed physical examination of his left
eye revealed no abnormalities so an Ophthamology consult was
deferred. We did not start antibiotics as there is no
indication for them in closed facial fractures. On ___ he was
started on a regular diet which he tolerated with no nausea or
emesis. His pain was well controlled on oral medications. He
was discharged with appropriate follow up with the plastic
surgeon.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Levofloxacin 500 mg PO Q24H Duration: 3 Days
RX *levofloxacin 500 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1) Subarachnoid hemorrhage
2) left orbital floor fracture
3) Left maxillary sinus fracture
4) left maxillary bone fracture involving the zygomatic process
5) right maxillary sinus fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Stable.
Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed. Specifically, please take your 2
day course of Levofloxacin, an antibiotic to treat your
aspiration pneumonia.
You may also take acetaminophen for pain (Tylenol) as directed,
but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 20
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician. It is very important
that you follow up with your plastic surgeon, Dr. ___,
regarding your facial fractures. We also recommend that you
follow up with a psychiatrist as an outpatient.
At home, you must obey strict "sinus precautions" due to your
facial fractures until further instructed by your plastic
surgeon, which include:
AVOID
___ blowing your nose
It is best to wipe away nasal secretions carefully. After 2
weeks, if you must blow your nose, blow gently through both
sides at the same time. Do not pinch your nose; do not blow just
one side at a time.
___ sneezing
If you must sneeze, keep your mouth open and do not pinch your
nose closed.
___ sucking
Do not drink through a straw. Do not smoke.
___ blowing
Do not play a wind instrument. Do not blow up balloons.
___ pushing or lifting
Do not lift or push objects weighing more than 20 pounds.
___ bending over
Keep your head above the level of your heart. Sleep with your
head slightly raised.
Followup Instructions:
___
|
10385370-DS-6 | 10,385,370 | 20,094,739 | DS | 6 | 2204-10-15 00:00:00 | 2204-10-16 16:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Atrial Fibrillation
Major Surgical or Invasive Procedure:
TEE Cardioversion ___
History of Present Illness:
___ PMH CAD, HTN, carotid artery stenosis, TIA who presents with
new onset AF found on outpatient EKG done for preop visit for
TCAR (transcarotid artery revascularization). He has no known
prior history of AF and given AF w/RVR he was referred in to the
ED.
Prior to the AF being found on EKG at his pre-op eval he says he
was having no new symptoms. He denies palpitations, CP, SOB,
cough, pain with inspiration, abdominal pain, nausea, vomiting,
lower extremity edema, lightheadedness, dizziness, fatigue.
On arrival to the ED his initial VS were 97.0 106 177/89 17 97%
RA. Basic labs, CXR and EKG were all obtained. For his AF w/RVR
he was first given Diltiazem 15mg IV with improvement in rates
so was then followed with Diltiazem 30mg PO. He was also started
on a hep gtt and given Mg and K repletion. He was admitted to
cardiology for further workup and management of his new AF.
Upon arrival to the floor, he says that he is feeling fine but
is
tired from waiting in the ED for so long.
Past Medical History:
CAD
HTN
Left carotid artery stenosis
Allergic rhinitis
BPH
Psoriasis
Epistaxis
TIA
Folliculitis
Social History:
___
Family History:
He says that his father had cardiac disease but he is not sure
the specifics of it.
Physical Exam:
ADMISSION
=========
VITALS: 97.4PO 165 / 89R Sitting 120 18 97 RA
GENERAL: Alert, NAD, sitting up on edge of bed
HEENT: atraumatic, normocephalic, EOMI, PERRL
CARDIAC: Irregularly irregular, no m/r/g
LUNGS: CTAB, no wheezes, ronchi or crackles
ABDOMEN: soft, NT, ND
EXTREMITIES: wwp, 1+ edema to bilateral shins
NEUROLOGIC: AAOx3, CN II-XII intact, strength ___ bilateral
upper
and lower extremities, speech fluent
DISCHARGE
=========
VITALS: Reviewed in OMR
GENERAL: Alert and oriented, no acute distress
ENT: NT/AC, MMM, EOMI
CV: Irregularly irregular, no murmurs, rubs, or gallops. +L
sided
carotid bruit.
RESP: CTAB, normal work of breathing
GI: NT/ND, BS+
EXT: Warm and well perfused, non-edematous
NEURO: CNII-XII grossly intact, no focal neurologic deficits
Pertinent Results:
ADMISSION
=========
___ 11:10AM WBC-5.5 RBC-4.90 HGB-14.7 HCT-44.4 MCV-91
MCH-30.0 MCHC-33.1 RDW-12.9 RDWSD-42.0
___ 11:10AM ___ PTT-35.4 ___
___ 11:10AM UREA N-26* CREAT-1.1 SODIUM-141
POTASSIUM-3.2* CHLORIDE-98 TOTAL CO2-32 ANION GAP-11
___ 04:45PM cTropnT-<0.01
___ 04:45PM TSH-1.3
DISCHARGE
=========
None
Brief Hospital Course:
SUMMARY
=======
Mr ___ is a ___ year old male with a PMH of CAD, HTN,
carotid artery stenosis, TIA who presents with new onset AF.
ACUTE ISSUES
============
# New AF w/RVR:
His last TTE was from a stress test back in ___ where he showed
excellent exercise capacity and EF >55%. There are multiple
possible etiologies for his new AF. Given his significant CAD
___ cath showed 3v disease s/p DES to OM) he could have
developed ischemic cardiomyopathy and should have TTE to eval
his cardiac function, however no anginal symptoms and trop
negative x1 with no ischemic EKG changes. Valvular disease also
a possibility given his history of long-standing HTN and CAD.
Also possibly iso age-related changes with new onset stable
atrial arrhythmia. He had good response to diltizem in the ED,
and was given a larger AM dose of his home metoprolol, and then
he was successfully cardioverted during TEE and started on
apixaban for anticoagulation (CHADs2VASC 6) with cardiology
follow up as outpatient. Did have some runs of atrial flutter on
telemetry prior to cardioversion, so might need amiodarone or
other antiarrhythmic as an outpatient.
CHRONIC ISSUES
==============
# Carotid stenosis:
Most recent ultrasound showed 80-99% L carotid stenosis. He has
been seen by vascular surgery as an outpatient. His options for
management were explained to him and he elected to pursue workup
for TCAR as part of the ___ II study. He presented for
pre-op planning for TCAR and that is when he was found to be in
AF w/RVR, which is an exclusion criteria for the study. Per
vascular surgery notes, even if he was a candidate he would have
wanted to wait until ___ to have any procedures done, so if
he changes his mind can reach out to vascular while inpatient
about options or if patient prefers can defer to outpatient
setting.
# CAD: (Last cath ___, 3v CAD with culprit OM s/p DES)
Continued home ___ 81mg, and Atorvastatin
# BPH:
Continued home Tamsulosin
# HTN:
Continued home losartan, chlorthalidone, and carvedilol
TRANSITIONAL ISSUES
===================
Discharge INR: 1.2
Discharge plt: 122
A1c: 5.8%
TSH: 1.3
[ ] Started on apixaban this admission, now on triple therapy
(___) due to Carotid stenosis. Defer to
outpatient cardiologist regarding anticoagulation/antiplatelet
going forward. Continue to monitor for signs of bleeding on
triple therapy. ___ need to drop aspirin
[ ] Please have patient see Vascular Surgery again as an
outpatient to revist surgical options for his carotid artery
stenosis
[ ] Continue to monitor for atrial fibrillation (patient was
completely asymptomatic this time) and consider amiodarone
versus uptitration of carvedilol for rate control if needed. ___
need anti-arrhythmic agent given afib/flutter combination seen
on telemetry this admission although maintained sinus rhythm
post cardioversion
[ ] Consider ziopatch as outpatient to monitor afib/flutter
burden
[ ] Consider formal TTE to look closely at valves and chambers
[ ] Follow up full read of TEE
#CODE: Full confirmed
#CONTACT: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever
2. Losartan Potassium 50 mg PO BID
3. metroNIDAZOLE 1 % topical DAILY
4. Ketoconazole Shampoo 1 Appl TP ASDIR
5. CARVedilol 12.5 mg PO BID
6. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
7. Desonide 0.05% Cream 1 Appl TP ASDIR
8. Fluocinonide 0.05% Cream 1 Appl TP ASDIR
9. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP ASDIR
10. Atorvastatin 80 mg PO QPM
11. sulfacetamide sodium (acne) 10 % topical BID
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain
13. sildenafil 50-100 mg oral ASDIR
14. Clopidogrel 75 mg PO DAILY
15. Aspirin 81 mg PO DAILY
16. Tamsulosin 0.4 mg PO QHS
17. Chlorthalidone 25 mg 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. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. CARVedilol 12.5 mg PO BID
6. Chlorthalidone 25 mg PO DAILY
7. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
8. Clopidogrel 75 mg PO DAILY
9. Desonide 0.05% Cream 1 Appl TP ASDIR
10. Fluocinonide 0.05% Cream 1 Appl TP ASDIR
11. Ketoconazole Shampoo 1 Appl TP ASDIR
12. Losartan Potassium 50 mg PO BID
13. metroNIDAZOLE 1 % topical DAILY
14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain
15. Sildenafil 50-100 mg oral ASDIR
16. sulfacetamide sodium (acne) 10 % topical BID
17. Tamsulosin 0.4 mg PO QHS
18. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP ASDIR
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
=======
Atrial Fibrillation
Secondary
=========
Coronary Artery Disease
Hypertension
Hyperlipidemia
Carotid Artery Stenosis
Benign Prostatic Hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were found to be in an abnormal heart rhythm called atrial
fibrillation.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were put under anesthesia and shocked to restore your
heart back to your normal heart rhythm.
- You were started on a blood thinner (Eliquis / Apixaban) to
reduce your risk of stroke associated with atrial fibrillation.
You should continue to follow up with your cardiologist about
this (below).
- You were continued on your home dose of carvedilol for rate
control
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:
___
|
10385501-DS-10 | 10,385,501 | 23,794,052 | DS | 10 | 2167-05-09 00:00:00 | 2167-05-10 11:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
shellfish derived
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with alcoholic cirrhosis/NASH, colon cancer,
and refractory ascites s/p TIPS ___ who was presenting with
confusion and headache. Family reports that the patient hasn't
taken his lactulose for ___ days, but has had 1 bowel movement
daily nonetheless. Endorses one episodes of non-bloody vomiting.
Denies fevers/chills, CP, SOB, abd pain. Denies any falls.
Of note, patient was recently admitted from ___ to ___
for increased dypsnea and worsening pleurel effusions. As an
outpatinet, the patient has been undergoing paracentesis weekly
and had a TIPS place for recurrent ascites. He was initially
managed with diuretics and albumin and had a therapeutic para on
___. He also had a thoracentesis on ___. He was
discharged on torsemide and spironolactone. He was scheduled to
have paracenteses every other week. His discharge weight was
111.5 kg. The family reports that they felt the patient was
slightly confused at the time of discharge as well.
Of note, it appears that lactulose was started at end of
___ after TIPS procedure at 15ml BID. This was not
mentioned in the previous discharge summary and it was not on
his discharge medication list.
- Initial VS in the ED: 97.8 69 114/73 16 97% RA.
- Labs were notable for INR 1.4 (baseline), Cr 2.0 (slighly
above baseline 1.8), Hgb 9.2/27.2 (baseline), Plt 58 (slightly
below baseline), TB 1.8 (baseline 1.4). Negative UA.
- Imaging: Liver Us with doppler with cirrhosis, small ascites
and R plueral effusion. Patent TIPS with decreased distal flow
since most recent study. CXR with stable bilateral pleural
effusions. CT Scan was ordered given ongoing headache and was
unremarkable for bleed. FYI, some pituitary prominence, so they
recommended outpatient pituitary MRI.
- Patient was given lactulose 30mL and had blood and uring
cultures drawn.
- Consulted hepatology who recommended admission to ET.
- Vitals on transfer: 98.6 65 127/80 18 100% RA
On arrival to the floor, patiet was examined sitting upright in
bed eating a sandwich. Per nurse ___ took care of him on
previous admission), patient seems slower and more confused. Mr.
___ was able to recounts some details of the past 3 days
since his discharge, but the details were unclear. He does
endorse a headache and currently denies any chest pain, nausea,
vomiting, diarrhea, constipation, or change in the size of his
abdomen or lower extremities. He does say that he usually has
___ bowel movements.
Past Medical History:
- Colon cancer.
- Cirrhosis (?EtOH/NASH) complicated by portal hypertension,
esophageal varices, coagulopathy
- Hypertension.
- Obesity
- MGUS
- History of solitary left kidney (R nephrectomy in the ___)
due to ruptured benign cyst
- History of gout.
Social History:
___
Family History:
No known family history of liver disease, liver cancer or colon
cancer.
Physical Exam:
>> Admission Physical Exam:
Vitals - 97.5 117/69 67 20 100% on RA
Wt: 103.4kg (prior discharge weight 111.5 kg)
GENERAL: Well-appearing gentleman in NAD, AOx3
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
dry mucous membranes
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes or rhonchi
ABDOMEN: moderately protuberant abdomen, +BS, nontender in all
quadrants, no rebound/guarding, no hepatomegaly, spleen palpably
3cm below right costal border
EXTREMITIES: no cyanosis, clubbing, trace edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. Mild resting tremor, + asterixis. Able
to slowly do days of week backward and forward with ___
mistakes.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
.
>> Discharge Physical Exam:
VITALS: 98.2 74 106/55 18 99/RA
I/O: 1110/500+ 2BM
Discharge Weight: 106.5kg
GENERAL: Well-appearing gentleman in NAD, lying in bed
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM.
NECK: nontender supple neck, no LAD, no JVD appreciated.
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: dimished breath sounds in R base, no wheezes or rhonchi
heard at bases.
ABDOMEN: moderately protuberant abdomen, +BS, nontender in all
quadrants, no rebound/guarding, no hepatomegaly, spleen palpably
3cm below right costal border
EXTREMITIES: no cyanosis, clubbing, trace edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. No asterixis. AAO to ___ and month
SKIN: warm and well perfused
Pertinent Results:
>> Admission Labs:
___ 03:45PM BLOOD WBC-4.0 RBC-2.64* Hgb-9.2* Hct-27.2*
MCV-103* MCH-35.0* MCHC-34.0 RDW-17.1* Plt Ct-58*
___ 03:45PM BLOOD Glucose-154* UreaN-56* Creat-2.0* Na-143
K-3.6 Cl-104 HCO3-30 AnGap-13
___ 03:45PM BLOOD ALT-38 AST-49* AlkPhos-141* TotBili-1.8*
.
>> Pertinent Reports:
# CT Head non-con (___): 1. No acute intracranial process.
2. Mild prominence of the pituitary gland. Recommend further
evaluation with non-emergent pituitary MRI. 3. Mild mucosal
thickening of the left maxillary sinus. 4. Opacification of the
left mastoid air cells may be due to chronic inflammation.
# Liver U/S with Doppler (___):
1. Cirrhosis with a small amount of ascites and a right pleural
effusion.
2. Patent TIPS.
3. Left portal vein not visualized.
4. Distended gallbladder containing sludge.
TIPS VELOCITIES: 86, 119 and 76 cm/second in the proximal, mid
and distal portions, respectively, previously 120, 186 than 136
cm/second.
# CXR (___): Small bilateral pleural effusions, not changed
in the interval, with streaky left basilar atelectasis.
.
___ Imaging CHEST (PA & LAT)
IMPRESSION:
In comparison with the study of ___, there is again
increased
opacification at the right base above an elevated hemidiaphragm,
consistent with atelectasis and possible small effusion.
Continued enlargement of the cardiac silhouette with tortuosity
of the aorta, but no evidence of vascular congestion.
>> Discharge Labs:
___ 07:15AM BLOOD WBC-3.5* RBC-2.49* Hgb-9.1* Hct-25.5*
MCV-102* MCH-36.4* MCHC-35.6* RDW-17.7* Plt ___
___ 05:20AM BLOOD ___ PTT-40.8* ___
___ 07:15AM BLOOD Glucose-168* UreaN-48* Creat-1.6* Na-141
K-4.2 Cl-104 HCO3-31 AnGap-10
___ 05:20AM BLOOD ALT-33 AST-43* AlkPhos-149* TotBili-0.9
___ 07:15AM BLOOD Calcium-8.9 Phos-4.7* Mg-1.7
>> MICRO:
___ 6:48 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
MICROCOCCUS/STOMATOCOCCUS SPECIES. PRESUMPTIVE
IDENTIFICATION.
IDENTIFICATION PERFORMED ON CULTURE # ___
___.
VIRIDANS STREPTOCOCCI. FINAL SENSITIVITIES.
Sensitivity testing performed by Sensititre.
CEFTRIAXONE REQUESTED PER ___ ___.
CEFTRIAXONE SENSITIVITIY TESTING PERFORMED BY ___..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
VIRIDANS STREPTOCOCCI
|
CEFTRIAXONE----------- 0.25 S
CLINDAMYCIN----------- 0.5 I
ERYTHROMYCIN---------- 4 R
PENICILLIN G---------- 0.5 I
VANCOMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS, CHAINS, AND CLUSTERS.
Reported to and read back by ___ ___ ___ 1215PM.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS, CHAINS, AND CLUSTERS.
Brief Hospital Course:
Mr. ___ is a ___ with a history of NASH/EtOH cirrhosis and
refractory ascites s/p TIPS ___, recent hospital stay for
volume overload, now presenting with increasing confusion.
.
>> ACTIVE ISSUES:
# Bacteremia: Micrococcus/stomatococcus and Strep Viridans.
Found incidentally on ED blood cultures as part of
encephalopathy workup. Possible contamination versus GI
translocation. Given high grade (cultures positive in less than
12 hours) opted to treat with short 2 week course of ceftriaxone
(narrowed from vancomycin after sensitivities returned). ID
followed during this admission. TTE negative for vegetations.
Last day of 14 day course = ___.
# Hepatic Encechalopathy / Confusion: Patient was not given
lactulose during past hospital stay due to adequate BMs then.
Here, confusion improved with lactulose, rifaxmin, and treatment
of bacteremia. Infectious workup otherwise unremarkable. TIPS
patent and perhaps contributing. If confusion in the future
despite lactulose/rifaxmin, consider TIPS evaluation with
venogram and potential downsizing.
# Pituitary Enhancement: CT-head on admission showedf mild
prominence of the pituitary gland. Recommend further evaluation
with non-emergent pituitary MRI to assess for an underlying
lesion.
# Headache: Non-specific, likely tension headache. Improved with
holding diuretics.
# ___ on CKD Stage IIIa: Creatinine above baseline after TIPS,
trended down to likely new baseline of 1.5 after holding
diuretics. Diuretics restarted at lower doses prior to
discharge.
# Portal HTN c/b ascites and hepatic hydrothorax: S/p TIPS for
refractory ascites on ___, and recent hospital stay for
aggressive diuresis. TIPS patent per RUQ doppler, although slow
flow in distal asepct. CXR without stable small b/l pleural
effusion with minimal ascites on ultrasound. Last para inpatient
___, last thoracentesis ___. His diuretics were initially held
then restarted at lower dose for goal "dry" weight 103 kg.
# Cirrhosis ___ NASH and ETOH: Chils Class B, MELD 19, has prior
h/o decompensation with PTH (as above), esophageal varices
(Grade I x 2 cords ___, encephalopathy as above. Not
transplant candidate. Generally stable this admission.
# Hypertension: (clonidine discontinued during last hospital
stay) Continued home carvedilol.
# GOUT: Continue home allopurinol
# Tachycardia - Patient had run of tachycardia overnight on
___, possibly SVT, in setting of his beta blockers being held
for ___. Stable after a few doses of metoprolol then transition
back to home carvedilol.
TRANSITIONAL ISSUES:
# Bacteremia: Ceftriaxone x 14 days (last day ___
# Please check CBC, Chem-10, Hepatic panel on ___ and ___ with
results faxed to the ___ at fax ___.
# Ascites: If reaccumulates, may need to resume outpatient
paracentesis schedule.
# Goal "dry" weight 103 kg.
# Recommend further evaluation with non-emergent pituitary MRI
to assess for an underlying pituitary lesion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Carvedilol 12.5 mg PO BID
4. Spironolactone 100 mg PO DAILY
5. Torsemide 100 mg PO DAILY
6. Vitamin D 1000 UNIT PO BID
7. Lactulose 15 mL PO BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Carvedilol 12.5 mg PO BID
4. Lactulose 30 mL PO QID
Titrate to ___ bowel movements daily
5. Lactulose 30 mL PO PRN RASS<0
6. Spironolactone 50 mg PO DAILY
7. Torsemide 40 mg PO DAILY
8. Vitamin D 1000 UNIT PO BID
9. Acetaminophen 650 mg PO Q8H:PRN pain
10. Bisacodyl 10 mg PR QHS:PRN constipation
11. CeftriaXONE 2 gm IV Q24H
12. Rifaximin 550 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES: 1. Bacteremia
SECONDARY DIAGNOSES: 1. Cirrhosis s/p TIPS procedure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You were admitted to
the hospital after not feeling well at home, and you were found
to have an infection in your blood stream. For this, you were
treated with intravenous antibiotics to continue for a total of
2 weeks ending
___.
Please see changes to your home medications below. Please follow
up with your primary care physician and your liver specialists
upon discharge from the rehab.
Take Care,
Your ___ Team.
Followup Instructions:
___
|
10385964-DS-16 | 10,385,964 | 25,330,346 | DS | 16 | 2183-06-11 00:00:00 | 2183-06-11 17:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Falls, weakness, subjective cognitive decline
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of discoid lupus, depression and anxiety,
dizziness, osteoporosis who presents with recurrent falls and
whole body weakness and subjective cognitive decline.
She reports that over the last few weeks she has felt
progressively weaker. She has had several falls, at least ___
due
to weakness where she lots her balance and had a hard time
standing up. On some of these she actually hit her head. She is
certain that she has not lost consciousness during the falls.
The
most recent fall was the day prior to presentation. She was
reaching over, lost her balance and was unable to stop herself
from falling slowly. She was unable to get up and was able to
call from her phone. She denies lightheadedness or dizziness on
standing routinely. She denies chest pain, palpitations,
shortness of breath, abdominal pain, nausea, vomiting or
diarrhea. She has had ongoing constipation issues for her whole
life and this may be slightly worse. She does note for the last
day a constant sensation of having to urinate, without dysuria
specifically. She denies fevers, chills, or flank pain. She
denies focal numbness or weakness.
She has a longstanding history of depression which has been
followed by a psychiatrist. She has no present SI or HI, but
does
feel that the last few weeks were stressful because of family
visits and due to trying to arrange for the new medication
fetzima. She has been on multiple medications and has had
several
medication changes over the years. She currently takes lorazepam
1mg four times daily. She started a new medication called
Fetzima
a few days ago after a long battle with insurance. Unfortunately
when she presented to the ED she was found to have a nonpruritic
urticarial type rash over the chest and abdomen. She denies any
other new medications, over the counter agents, or new soaps or
lotions.
Of note, she was seen several times over the last few months for
dizziness which was thought to be related to BPPV and was having
physical therapy for this. She was having persistent symptoms
and
so a neurologist visit and MRI had been planned but she had not
yet completed.
In the ED, initial vitals 98.3 105 153/86 18 97% RA. Exam
notable
for nonpruritic urticarial rash over her back with no other
abnormalities. Labs notable for Na 130, Cr 0.6, UA equivocal for
UTI with mod ___, neg nitrites, 11 WBC, few bacteria and no epis.
Troponin was negative. EKG was abnormal with anterolateral STD,
R
bundle morphology, TWI V2-V5, but upon comparison with priors in
the ___ record this is unchanged. CBC, LFTs and electrolytes
were otherwise wnl. Toxicology screen negative. Head CT showed
no
acute process and CXR was without consolidation. She was given
1L
of LR and 1g ceftriaxone. Neurology was consulted for gait
instability and felt likely toxic metabolic in etiology.
Of note, the patient had an Na of 130 on ___ at ___, and
131 in ___, so her hyponatremia appears to be chronic.
On the floor, she endorses the history above. She is very
uncomfortable with sensation of needing to urinate and
interrupts
the conversation to use the bedpan several times.
Past Medical History:
Hypercholesterolemia
Anticardiolipin antibody positive
Osteoporosis
Colon adenoma
Sleep apnea, obstructive
bh
Lumbar scoliosis
Discoid lupus
Impaired glucose tolerance
Connective tissue disease, undifferentiated
RBBB (right bundle branch block)
Dizziness
Social History:
___
Family History:
Father CAD/PVD - Early
Maternal Aunt Cancer - Lung
Maternal Uncle ___ pancreatic cancer [OTHER]
Mother ___
Other Cancer - Breast
Sister No Significant Medical History
Pertinent Negatives
Neg HX Cancer - Colon
Physical Exam:
Admission Physical Exam:
General: Alert, oriented, no acute distress, able to provide
coherent history and detailed medication list with ease
HEENT: Sclerae anicteric, dry MM, oropharynx clear, EOMI, PERRL,
neck supple
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, trace edema bilaterally, 2+ DPs
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
normal sensation, appropriate affect
Discharge Physical Exam:
General: Anxious appearing, pleasant, comfortable
HEENT: Sclerae anicteric, oropharynx clear, EOMI, PERRL,
neck supple
CV: Tachycardic, 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, trace edema bilaterally, 2+ DPs
Skin: Resolved raised red papules on torso and legs
Neuro: AAOx3, ___ strength upper/lower extremities, normal
sensation, appropriate affect
Pertinent Results:
IMAGING:
TTE ___:
IMPRESSION: Normal study
CTA Chest ___
IMPRESSION:
1. No pulmonary embolus or acute intrathoracic abnormality.
2. 6 mm left upper lobe pulmonary nodular focus. Please see
recommendations
below.
RECOMMENDATION(S): For incidentally detected single solid
pulmonary nodule
measuring 6 to 8 mm, a CT follow-up in 6 to 12 months is
recommended in a
low-risk patient, optionally followed by a CT in ___ months.
In a high-risk
patient, a CT follow-up in 6 to 12 months, and a CT in ___
months is
recommended.
EEG ___
IMPRESSION: This is a normal routine EEG in the waking and
asleep. No
epileptiform features are seen.
MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST; MRA NECK W&W/O
CONTRAST ___
IMPRESSION:
1. Study is moderately degraded by motion, especially on
postcontrast imaging.
2. No acute intracranial abnormality.
3. Extensive paranasal sinus disease with findings concerning
for acute
sinusitis, and nonspecific left mastoid fluid, as described.
4. Numerous probable calvarial hemangiomas as described. If
concern for
osseous metastatic disease, consider bone scan for further
evaluation.
5. Findings suggestive of pontine capillary telangiectasia, as
described.
6. 2 mm left internal carotid artery supraclinoid probable
infundibulum, with differential consideration of small aneurysm.
7. Otherwise, grossly patent circle of ___ without definite
evidence of
stenosis or occlusion.
8. Minimal probable atherosclerotic narrowing of bilateral
internal carotid artery origin without definite moderate or
high-grade stenosis by NASCET criteria.
9. Otherwise, grossly patent bilateral cervical carotid and
vertebral arteries without definite evidence of stenosis,
occlusion, or dissection, by NASCET criteria.
CT Head W/O Contrast ___
IMPRESSION:
1. No acute intracranial process.
2. Paranasal sinus disease, as above.
3. Tiny focal fluid in left mastoid air cell, nonspecific.
Labs:
___ 03:54PM BLOOD Glucose-117* UreaN-8 Creat-0.6 Na-130*
K-4.6 Cl-94* HCO3-24 AnGap-12
___ 03:00PM BLOOD Glucose-116* UreaN-6 Creat-0.5 Na-124*
K-4.0 Cl-88* HCO3-22 AnGap-14
___ 01:10PM BLOOD Glucose-128* UreaN-8 Creat-0.6 Na-127*
K-4.0 Cl-86* HCO3-25 AnGap-16
___ 05:55AM BLOOD Glucose-117* UreaN-5* Creat-0.6 Na-131*
K-4.2 Cl-92* HCO3-26 AnGap-13
___ 05:47AM BLOOD Glucose-109* UreaN-13 Creat-0.7 Na-138
K-4.4 Cl-99 HCO3-27 AnGap-12
Brief Hospital Course:
Transitional Issues:
[ ] Incidental findings: 6 mm left upper lobe pulmonary nodular
focus. RECOMMENDATION(S): For incidentally detected single solid
pulmonary nodule measuring 6 to 8 mm, a CT follow-up in 6 to 12
months is recommended in a low-risk patient, optionally followed
by a CT in ___ months. In a high-risk patient, a CT follow-up
in 6 to 12 months, and a CT in ___ months is recommended.
[ ] Continue to wean lorazepam if tolerated
[ ] Outpatient cognitive neurology follow up, with possible
neuropsychiatric testing
[ ] Patient interested in ___ partial program after
discharge from rehab
[ ] Patient interested in having BI PCP and ___, though
this should be discussed further with patient's current
providers
[ ] Consider further workup for patient's sinus tachycardia,
rates ___ at discharge
[ ] Patient with report of significant sedation on olanzapine 5
mg, switched to 2.5 QHS for insomnia but may be able to
uptitrate as an outpatient
[ ] Please recheck BMP in 1 week and ensure stability of sodium.
If worsening hyponatremia consider fluid restriction +/- salt
tabs.
___ with history of discoid lupus, depression and anxiety,
dizziness, and osteoporosis who presents with recurrent falls
and
whole body weakness w/ subjective cognitive decline.
ACUTE/ACTIVE PROBLEMS:
# Recurrent falls
# Memory/Cognitive deficits
# Weakness
Patient with several falls and diffuse weakness over the last
few
weeks. UTI may be contributing to weakness, though it does seem
that the falls preceded UTI symptoms and daughters note at least
2 weeks of cognitive decline where pt is no longer eating much,
slowed speech, depressed mood (unable to do tasks like answer
emails and perform basic math). Hypoactive delirium in the
setting of lorazepam use,
hyponatremia, and UTI felt to be the most likely cause of her
symptoms. Hyponatremia
of 130 dates back to ___ but worse on
admission to 124. Of note, she has had ongoing issues with
vertigo as an
outpatient and although she does not describe any dizziness
presently there may be some central disequilibrium contributing
to her symptoms. A TTE was performed that was unremarkable and
did not show any etiologies to explain her falls or weakness.
Patient has a significant amount of anticipatory anxiety and it
is unclear how much psychiatric comorbidities are contributing
at
this time. Patient stated that when she slid off the bed during
her last fall, she was so nervous that she could not get up, but
also
states that weakness was a part of it. MRI brain, MRA neck
___
performed and unremarkable. ___ eval demonstrating significant
difficulties with
balance below baseline. Per neurology, her mental status exam
highlights marked deficits in executive function, functional
pattern of dementia. Her effort appeared good. However,
instability does not appear to be from a structural lesion based
on sensory and strength testing. An EEG did not show any
epileptiform features. Her balance improved with decreasing her
lorazepam dose, improving hyponatremia, and treatment of her
UTI. However, her balance remained below baseline and it was
felt that she would benefit from ___ rehab. She should
follow up with her PCP and psychiatrist once she leaves the
rehab center. It might also be worthwhile to pursue cognitive
neurology follow up.
# Anxiety and depression:
Patient on multiple medications. Most
recently was started on Fetzima by her psychiatrist. She
developed a rash a few days after starting Fetzima, and this was
felt to be a drug rash, so Fetzima was stopped and a few days
later the rash resolved. The patient is at significant risk of
polypharmacy given multiple medications
and multiple medication changes. Her current presentation could
be hypoactive delirium in the setting of benzo use,
hyponatremia,
and UTI. Spoke w/ psychiatrist from ___ (Dr. ___- talked
about her difficult to control anxiety and depression, requiring
increases of wellbutrin to 450mg and remeron to 60mg, although
her symptoms ultimately returned and these doses were decreased
and other medications were tried. He strongly agreed that she is
off her baseline and agrees with further workup beyond
attributing symptoms to anxiety/depression. Her TSH and B12 were
within normal limits. RPR was negative. She was started on
olanzapine 2.5mg nightly to help with sleep given that her
trazodone was stopped due to concern for SIADH from trazodone.
She may also benefit from 2.5mg olanzapine as needed for anxiety
during the day. Her lorazepam dose was decreased from 1mg QID
PRN to 0.5mg TID. Her bupropion was continued. She was started
on ___ to help with sleep. She tolerated this medication
regimen well.
#Tachycardia:
Patient was frequently tachycardic to low 100s
throughout hospitalization. Telemetry showed sinus tachycardia.
Patient endorsing significant anxiety, which is the most likely
etiology. She had positive orthostatic vital signs on ___, but
unlikely the cause of her tachycardia, as this was the only day
she had positive orthostatics. Although a PE was felt to be
unlikely, given no shortness of breath or oxygen desaturations,
a d-dimer was obtained that was elevated at 983. Therefore a CT
PE was obtained that did not show any signs of PE, but did show
a pulmonary nodule (6 mm left upper lobe) that should be
followed up with a repeat CT scan in ___ months.
# Hyponatremia:
Chronic, though worse on admission. Serum osm 259, urine Na 124,
urine osm 529 c/w SIADH vs renal salt wasting. On
multiple psych meds which could be the etiology, although
trazadone and lorazepam are less likely than other psych meds
such as SSRIs to cause hyponatremia. She received salt tabs for
a few days while in the hospital and was fluid restricted to 2L.
Her sodium was 132 on ___.
# UTI:
Symptoms of urinary frequency and bladder spasms.
UA with leukocyte esterase and WBCs. Treated with CTX 1g daily
for intended 3 day course (___) Also received 2 days of
phenazopyridine. Symptoms resolved by ___. Urine culture
ultimately showed mixed bacterial flora consistent with fecal
contamination.
# Rash (resolved)
Torso rash and leg rash- not pruritic, slightly raised macular
rash, in some places appearing urticardial though in others not.
Likely drug reaction to Fetzima (levomilnacipran). Normal
eosinophils, no e/o mucosal involvement and no end organ damage
appreciable c/f DRESS.
- Hold Fetzima
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QSUN
2. Simvastatin 40 mg PO QPM
3. LORazepam 1 mg PO QID:PRN anxiety
4. BuPROPion (Sustained Release) 200 mg PO BID
5. TraZODone 50 mg PO QHS:PRN insomnia
6. Fetzima (levomilnacipran) 40 mg oral DAILY
7. Aspirin 81 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
10. One Daily For Women (multivit-iron-min-folic acid) ___ mg
oral DAILY
11. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 1200-1000
units oral DAILY
Discharge Medications:
1. OLANZapine 2.5 mg PO QHS
2. Ramelteon 8 mg PO QHS:PRN insomnia
3. LORazepam 0.5 mg PO TID anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth three times a day Disp
#*30 Tablet Refills:*0
4. Alendronate Sodium 70 mg PO QSUN
5. Aspirin 81 mg PO DAILY
6. BuPROPion (Sustained Release) 200 mg PO BID
7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 1200-1000
units oral DAILY
8. Docusate Sodium 100 mg PO BID
9. One Daily For Women (multivit-iron-min-folic acid) ___ mg
oral DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
11. Simvastatin 40 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
- Polypharmacy (over-medication)
- Hyponatremia (low sodium)
- UTI
- Anxiety/Depression
- Drug rash
Secondary Diagnoses:
- Osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You came to the hospital because you had noticed several
changes over the past few weeks, including falls, full body
weakness, and difficulty with memory and completing tasks that
you normally could do. You also had a recent increase in
urination and discomfort with urination. You also had a rash on
your torso and legs that was new.
What did you receive in the hospital?
- We were concerned about your recent falls and we did an MRI
of your brain and neck, which did not show any signs of strokes
or brain changes that would explain your falls or weakness. We
also did an ultrasound of your heart, which did not show any
problems with your heart that might explain your symptoms. Lab
tests showed that you had a urinary tract infection and low
sodium levels, both of which could be contributing to your
symptoms. Ultimately, we felt that a lot of your symptoms could
be due to over-medication. We tried decreasing the dose of
several of your medications and completely stopping other
medications. We believe that your rash was a reaction to one of
these medications (Fetzima), which we stopped. After adjusting
your medications, you performed better on cognitive/memory tests
and showed improvement with physical therapy.
What should you do once you leave the hospital?
- You should take your medications as prescribed
- You should follow up with your current PCP and current
psychiatrist until you make any changes to your providers
- ___ small lung nodule was seen on a CT scan you had- you should
have a repeat CT scan in ___ months to re-evaluate the nodule
We wish you the best!
Your ___ Team
Followup Instructions:
___
|
10386093-DS-4 | 10,386,093 | 28,621,266 | DS | 4 | 2135-06-09 00:00:00 | 2135-06-09 10:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bilateral Subdural hematomas
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a vibrant ___ year-old male who underwent a
non-contrast head CT today, ___, for staging of questionable
skin cancer on his face. The images revealed bilateral subacute
subdural hematomas. The patient was transferred to ___ for
further Neurosurgical evaluation.
Mr. ___ acknowledges that he has fallen approximately 1 - 2
months ago. He takes aspirin 325mg daily due to a history of
vascular disease. He had no neurologic deficits, loss of
consciousness or further issues after that fall.
Past Medical History:
Throat polyps, hepatitis, right femoral bypass, stenting of left
leg vessel (pt unsure what vessel), right hip fracture s/p
repair
Social History:
___
Family History:
NC
Physical Exam:
On Admission:
O: T: 98.2 HR 85 BP 121/73, RR 14, O2 Sat 93% on room air
Gen: WD/WN, comfortable, NAD.
HEENT: PERRL, EOMs intact.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch.
Toes downgoing bilaterally
On Discharge:
Intact
Pertinent Results:
CT Head ___:
Stbale bialteral subdural hematomas, formal read pending at time
of discharge
Brief Hospital Course:
Patient presented to ___ for evaluation of bilateral subdural
hematomas found on work up for skin cancer. He was admitted to
the floor for observation and remained stable overnight into
___. He was NPO in case surgical intervention was required
however repeat CT head showed stable bilateral subdural
hematomas and decision was made that he was safe to discharge to
home with followup. He agreed with this plan and was given
prescriptions for required medications, instructions for
follow-up, and all questions were answered prior to discharge.
We recommended that he hold his aspirin for the time being and
discuss it with his cardiologist/PCP regarding the utility of
continuing in setting of intracranial bleed.
Medications on Admission:
Aspirin 325', simvastatin (unknown dose) daily, iron daily,
Zantac daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Ranitidine 75 mg PO BID
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral Subdural Hematomas
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as pain medicine can
cause constipation. We generally recommend taking an over the
counter stool softener, such as Docusate (Colace) while taking
pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
DO NOT TAKE ASPIRIN. We recommend that you stop taking this
given the bleeding in your head. Please discuss this with your
cardiologist/primary care doctor
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
10386389-DS-10 | 10,386,389 | 21,422,154 | DS | 10 | 2203-12-23 00:00:00 | 2203-12-23 08:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Keflex
Attending: ___.
Chief Complaint:
Left post-mastectomy incision area cellulitis
Major Surgical or Invasive Procedure:
Stage 3 breast cancer s/p left mastectomy (___) complicated
with cellulitis
History of Present Illness:
Ms. ___ is a ___ woman with newly diagnosed stage IIIB left
breast cancer, found on routine imaging and thus received left
simple mastectomy with left sentinel node procedure on ___.
She presented to the ED on ___ with complaint of increasing
erythema and tenderness over the surgical site. Her
story is as follows:
She had been doing fine post discharge and had her JP drains
removed on ___ (output < 30cc), however, began to experience
increasing area of tenderness over the area along with erythema.
She presented to the clinic ___ and the area was inspected,
aspirated, sent for culture, and she was then discharged with
levafloxacin and cephalexin. She re-presented to the clinic with
expanding erythema along with lightheadedness and was then
referred to ___ ED.
At the time of interview, she complained of the same symptoms
(tenderness over the area, increased erythema, now fatigue). She
was afebrile and denied other constitutional symptoms. In the ED
she was put on vancomycin.
Past Medical History:
senile angiomas, benign
Basal cell cancer
CLS 4 cm cecal adenoma ___, CLS ___
Colon polyps
Diverticulosis
DM (diabetes mellitus), type 2
Esophageal reflux
Hyperlipidemia
Hypertension, essential
Hypothyroidism
Iron deficiency anemia
Osteopenia
Rosacea
Syncope
Urge incontinence
Social History:
___
Family History:
no breast or ovarian history, not ___
Physical Exam:
At the time of discharge, her physical exam was as follows:
VITAL SIGNS: 97.4 69 106/50 16 97% RA
GENERAL: AAOx3 NAD
HEENT: NCAT, EOMI, PERRLA, No scleral icterus, mucosa moist, no
LAD
CARDIOVASCULAR: R/R/R, S1/S2, NO M/R/G
PULMONARY: CTA ___, No crackles or rhonchi
GASTROINTESTINAL: S/NT/ND. No guarding, rebound, or peritoneal
signs. +BSx4
INCISION/WOUNDS: No obvious induration or fluctuance under the
incision. If there were fluid collections, it's not easily
appreciated. She is tender over the area and there is a 5cm
radius of erythema around incision.
EXT/MS/SKIN: No C/C/E; Feet warm. Good perfusion.
NEUROLOGICAL: Reflexes, strength, and sensation grossly intact
CNII-XII: WNL
Pertinent Results:
___ 06:26AM BLOOD WBC-6.7 RBC-4.46 Hgb-11.4 Hct-37.1 MCV-83
MCH-25.6* MCHC-30.7* RDW-13.3 RDWSD-39.8 Plt ___
___ 06:25AM BLOOD WBC-6.4 RBC-4.46 Hgb-11.5 Hct-37.2 MCV-83
MCH-25.8* MCHC-30.9* RDW-13.3 RDWSD-40.3 Plt ___
___ 06:15AM BLOOD WBC-7.2 RBC-4.49 Hgb-11.4 Hct-36.9 MCV-82
MCH-25.4* MCHC-30.9* RDW-13.4 RDWSD-39.9 Plt ___
___ 06:53PM BLOOD WBC-7.2 RBC-4.33 Hgb-11.2 Hct-36.2 MCV-84
MCH-25.9* MCHC-30.9* RDW-13.4 RDWSD-40.5 Plt ___
___ 06:26AM BLOOD Neuts-68.0 Lymphs-18.1* Monos-8.7 Eos-4.0
Baso-0.6 Im ___ AbsNeut-4.55 AbsLymp-1.21 AbsMono-0.58
AbsEos-0.27 AbsBaso-0.04
___ 06:53PM BLOOD Neuts-62.9 ___ Monos-9.3 Eos-3.6
Baso-0.6 Im ___ AbsNeut-4.55 AbsLymp-1.68 AbsMono-0.67
AbsEos-0.26 AbsBaso-0.04
___ 06:26AM BLOOD Plt ___
___ 06:25AM BLOOD Plt ___
___ 06:26AM BLOOD Glucose-181* UreaN-15 Creat-0.7 Na-136
K-4.2 Cl-100 HCO3-24 AnGap-16
___ 06:25AM BLOOD Glucose-115* UreaN-11 Creat-0.6 Na-141
K-4.9 Cl-102 HCO3-31 AnGap-13
___ 06:15AM BLOOD Glucose-125* UreaN-11 Creat-0.6 Na-136
K-4.4 Cl-100 HCO3-26 AnGap-14
___ 06:26AM BLOOD Calcium-9.5 Phos-3.9 Mg-1.8
___ 06:25AM BLOOD Calcium-9.9 Phos-3.9 Mg-1.9
Brief Hospital Course:
Ms. ___ was admitted to our service on ___ after her
course of outpatient PO antibiotic course did not show
improvement of her symptoms. She was put on vancomycin from
(___). Throughout the entire course, she was afebrile & her
WBC count normal. She tolerated the vancomycin course well, was
eating and ambulating as normal, and her area of erythema slowly
improved. She was put on PO Bactrim on ___ and will be
discharged home today with ___ with a 10 day course of continued
PO Bactrim. She will be seen by Dr. ___ on ___ in clinic.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 2.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Carbidopa-Levodopa (___) 1 TAB PO BID
5. Donepezil 5 mg PO QHS
6. Gabapentin 600 mg PO QHS
7. GlipiZIDE 10 mg PO DAILY
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Lisinopril 30 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Ranitidine 150 mg PO BID
12. Simvastatin 20 mg PO QPM
13. Tolterodine 4 mg PO DAILY
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 10 Days
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth twice a day Disp #*20 Tablet Refills:*0
2. amLODIPine 2.5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Carbidopa-Levodopa (___) 1 TAB PO BID
5. Cyanocobalamin 1000 mcg PO DAILY
6. Donepezil 5 mg PO QHS
7. Gabapentin 600 mg PO QHS
8. GlipiZIDE 10 mg PO DAILY
9. Levothyroxine Sodium 75 mcg PO DAILY
10. Lisinopril 30 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Ranitidine 150 mg PO BID
13. Simvastatin 20 mg PO QPM
14. Tolterodine 4 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cellulitis of left mastectomy incision area
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 have you on our service at the ___
___. Please read below for your discharge
instructions:
Personal Care:
1. You may keep your incisions open to air or covered with a
clean, sterile gauze that you change daily.
2. You may wear a surgical bra or soft, loose camisole for
comfort.
3. You may shower daily with assistance as needed.
4. The Dermabond skin glue will begin to flake off in about ___
days.
Activity:
1. You may resume your regular diet.
2. Walk several times a day.
3. DO NOT lift anything heavier than 5 pounds or engage in
strenuous activity for 6 weeks following surgery.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered .
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
3. Take prescription pain medications for pain not relieved by
Tylenol.
4. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
5. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
6. Please take your oral antibiotic as instructed. Please call
the office if you do not see improvement of your left incision
redness. (See below for more detail)
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
___
|
10386441-DS-8 | 10,386,441 | 26,725,151 | DS | 8 | 2112-09-01 00:00:00 | 2112-09-09 16:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vicodin
Attending: ___
Chief Complaint:
fevers, fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with history of asthma who presents with
fevers (Tm ~ 100.6) and fatigue/myalgias for 2 weeks with
anterior non-radiating chest pain and dyspnea on exertion. She
was seen by her PCP ___ ___ with 5 days of intermittent fevers,
with Tm ~100.7. She denied nausea, vomiting, sore throat,
rhinorrhea, diarrhea, urinary symptoms, rash. Labs at that
appointment including CBC, chem7, UA, Strep, EBV, and lyme
serologies were negative. Due to persistent fevers, additional
labs were checked on ___ which included LDH 167, CK 100,
D-dimer 2260, and blood cultures. Due to elevated D-dimer, she
was referred to the ED.
In the ED, initial vitals were: 99.0 90 123/73 22 100%. Labs
were notable for WBC 11.2, INR 1.0, D-dimer 554. EKG showed SR,
normal axis, and isolated TWI in III. Rt ___ was negative for
DVT and CTA chest was negative for pulmonary embolism.
On the floor, she is comfortable and asymptomatic.
Past Medical History:
Asthma
Dysthymic disorder
Patellar tendonitis
Social History:
___
Family History:
Parents without significant medical problems. Aunt with ovarian
cancer. Maternal great uncle had MI at ___. MGF had MI in mid
___. MGM had arrhythmia.
Physical Exam:
Admission Physical Exam:
VS: 97.5 95 113/54 99%RA
Gen: NAD
HEENT: No LAD, No JVD
CV: RRR, S1 and S2, no m/r/g
Pulm: CTAB
Abd: BS+, soft, ND, mildly tender, no HSM
Ext: Pain to palp bilat SI joints, pain on shoulder when
reaching across body, reproducible pain on sternum
Skin: No erythema or concerning lesions
Neuro: Grossly intact
Psych: Appropriate
Discharge Physical Exam:
VS: 98.2 136/74 93 20 97%ra
Gen: NAD, lying comfortably in bed
HEENT: MMM, no erythema
Cardiac: normal S1,S2, no m,r,g.
Resp: Lungs clear to ausculatation bilaterally
Abd: Soft, NT, ND, no HSM
Ext: WWP, no edema, cyanosis
MSK: Reproducible pain along lower sternum and right sternal
border. TTP in sacroiliac joint region bilaterally. TTP on
plantar surface of right heel. No TTP or deformities noted in
the MCP, PIP, DIP (both UE and ___, wrist, shoulders, knees,
ankles. Normal tone in UE and ___ bilaterally
Neuro: Grossly intact
Pertinent Results:
==ADMISSION LABS==
___ 03:30AM BLOOD WBC-11.2* RBC-4.96 Hgb-13.0 Hct-38.4
MCV-77* MCH-26.2 MCHC-33.9 RDW-13.5 RDWSD-37.4 Plt ___
___ 03:30AM BLOOD Neuts-69.8 ___ Monos-4.1* Eos-1.1
Baso-0.3 Im ___ AbsNeut-7.79* AbsLymp-2.71 AbsMono-0.46
AbsEos-0.12 AbsBaso-0.03
___ 03:30AM BLOOD ___ PTT-29.2 ___
___ 03:30AM BLOOD Glucose-108* UreaN-8 Creat-0.7 Na-138
K-3.8 Cl-103 HCO3-22 AnGap-17
___ 03:30AM BLOOD ALT-13 AST-21 AlkPhos-64 TotBili-0.3
___ 03:30AM BLOOD cTropnT-<0.01
___ 03:30AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.8
___ 03:30AM BLOOD D-Dimer-554*
___ 01:45AM URINE Color-Straw Appear-Clear Sp ___
___ 01:45AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 01:45AM URINE UCG-NEG
==DISCHARGE LABS==
___ 08:00AM BLOOD WBC-8.9 RBC-5.36* Hgb-13.8 Hct-43.8
MCV-82 MCH-25.7* MCHC-31.5* RDW-13.9 RDWSD-40.2 Plt ___
___ 08:00AM BLOOD Glucose-84 UreaN-8 Creat-0.7 Na-137 K-3.8
Cl-102 HCO3-18* AnGap-21*
___ 08:00AM BLOOD ALT-18 AST-24 LD(LDH)-211 AlkPhos-65
TotBili-0.4
___ 08:00AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.0
___ 08:00AM BLOOD TSH-4.1
___ 08:00AM BLOOD CRP-30.3*
___ 08:00AM BLOOD HIV Ab-Negative
==OTHER RESULTS==
___ LOWER EXT US
No evidence of deep venous thrombosis in the right lower
extremity veins.
___ CT CHEST ANGIO
No evidence of pulmonary embolism or aortic abnormality.
___ PELVIC XRAY
Normal pelvis x-ray
==RESULTS RETURNING AFTER DISCHARGE==
___ 08:00AM BLOOD HIV Ab-Negative
___ 08:00AM BLOOD SED RATE 11
Brief Hospital Course:
Ms. ___ presented with fevers, fatigue, and chest pain for
two weeks. She had an elevated DDimer but her CT angiogram was
negative and her ECG was normal. Her fevers and symptoms were
most suspicious for rheumatologic disease and she had an
elevated ESR/CRP. She had a pelvic xray to assess for ankylosis
spondylitis that was normal. She requires follow up with her
primary care physician within two weeks for further evaluation.
# FEVER: Patient presented with 2 weeks of intermittent fevers
and fatigue x 2 weeks. Outpatient w/u included negative negative
EBV abd lyme serologies. The symptoms were most likely c/w a
rheumatologic or CTD given the fatigue, SI tenderness, and
shoulder pain but could also be due to a viral illness. Given
normal ECG and readily reproducible chest pain, acute cardiac
process was unlikely. Infectious etiologies were also
considered. She had an elevated ESR and CRP. She had a pelvic
xray that was normal. She also had an HIV test sent that was
pending at the time of discharge and later returned negative.
She should see her primary care physician within two weeks to
consider further evaluation. She remained afebrile and
hemodynamically stable throughout her hospitalization.
# MUSCULOSKELETAL PAIN/Costochondritis: Given normal ECG and
negative CTA, PE is unlikely. DDimer is sensitive but not
specific so elevated DDimer in setting of normal CTA is
reassuring. The normal ECG and negative trops argue against
ACS. The reproducible nature of the CP is also reassuring that
this is not ACS and suggests that this is MSK in nature. She
also had sacroilitus on physical examination. She had a pelvic
xray that was normal.
Transitional Issues:
- Pt requires follow up with primary care physician ___ 2
weeks
- Consider sending HLA-B27 as an outpatient
- HIV test and ESR pending at time of discharge. HIV-Ab returned
as NEGATIVE after discharge and ESR back at 11 after discharge.
- Code: Full
- Contact: ___ (Mother) ___ (cell)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apri (desogestrel-ethinyl estradiol) 0.15-0.03 mg oral DAILY
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. Apri (desogestrel-ethinyl estradiol) 0.15-0.03 mg oral DAILY
3. Acetaminophen 325-650 mg PO Q6H:PRN pain
4. Naproxen 500 mg PO Q8H:PRN pain
RX *naproxen 500 mg 1 tablet(s) by mouth EVERY 8 HOURS AS NEEDED
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Fever of Unknown Etiology
Secondary Diagnoses:
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a plesaure caring for you at ___. You were admitted to
the hospital with fevers, fatigue, and chest pain for two weeks.
Your D-Dimer was high, but a CT scan showed that you did not
have an pulmonary embolism. You had other blood tests that
showed that there is inflammation in your body, but did not
identify the cause of your symptoms. You can take naproxen for
pain, but take this with food. You had a pelvic xray that was
normal. You should see your primary care physician within two
weeks. Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Team
Dear Ms. ___,
It was a plesaure caring for you at ___. You were admitted to
the hospital with fevers, fatigue, and chest pain for two weeks.
Your D-Dimer was high, but a CT scan showed that you did not
have an pulmonary embolism. You had other blood tests that
showed that there is inflammation in your body, but did not
identify the cause of your symptoms. You can take naproxen for
pain, but take this with food. You had a pelvic xray that was
normal. You should see your primary care physician within two
weeks. Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10386562-DS-12 | 10,386,562 | 21,391,032 | DS | 12 | 2169-05-27 00:00:00 | 2169-05-30 14:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Shellfish Derived
Attending: ___.
Chief Complaint:
Hallucinations
Major Surgical or Invasive Procedure:
1) ___ guided aspiration of right elbow and right hip.
2) PICC Line Placement
3) Transesophageal Echo
History of Present Illness:
___ with a history of CML, high cholesterol, hypertension,
presents to the ER with hallucinations. History is obtained
from the patient and his wife. They state that this problem
began about one month ago. Since that time, he received
treatment for a UTI, and had his pain medications discontinued.
Despite these changes, he has not had significant changes in his
symptoms. He describes these hallucinations as several
individuals, sometimes a total of 8. They did speak with him, no
commands, he often says that they will touch his skin. There was
no history is hallucinations prior to month ago when he started
on Gleevec for his leukemia. His dose was discontinued 5 days
prior to presentation along with his Allopurinol; he had one day
where he was hallucinations free, but has otherwise had these
hallucinations approximately every night around 2 AM. He has no
other medication changes, herbals, drug use.
.
ROS: He is maintaining his ADLs, I ADLs despite having some
persistent pain from his right hip. There is been no fevers,
chills, sweats. No abdominal pain. He been having normal regular
solid formed bowel movements. His only complaint at this time
otherwise his increased upper respiratory congestion and mucus
production. He has not been having any cough or shortness of
breath. All other ROS negative.
.
Vitals in the ER: 99.2 °F (37.3 °C), Pulse: 87, RR: 15, BP:
124/60, O2Sat: 98% , O2Flow: ra. He received Levofloxacin 750mg
IV, Tylenol, and NS 250cc.
.
Past Medical History:
HEMATOLOGIC HISTORY:
- ___: the patient is found to have leukocytosis with
immature myeloid forms, including myelocytes, metamyelocytes,
and
promyelocytes. RT-PCR for BCR-ABL was sent, and returned
positive for the ___ translocation with a BCR ABL1/ABL1 ratio
of
69.659%.
- ___ start Imatinib 100 mg daily
- ___ increase Imatininb to 200 mg daily
- ___ increase Imatininb to 300 mg daily
- ___ increase Imatininb to 400 mg daily
- ___ Since the last visit, the patient developed a
constellation of problems that are most likely related to this
treatment including the worsening anemia and kidney function,
the
thrombocytopenia and the lower extremity edema. He also received
1 unit PRBCs ___ in ___ clinic.
PMH:
-Hypertension
-Diabetes: controlled with pioglitazone, HbA1c:6.2% (___)
-Hyperlipidemia
-Spinal stenosis
-Trigeminal Neuralgia: last symptomatic over ___ years ago,
carbamazepine discontinued
-Pseudogout, manifesting as fevers of unknown origin until a
knee
effusion was tapped revealing crystals
-Polyarticular arthritis
-CKD: baseline creatinine of 1.7
-BPH with elevated PSA; prior prostate biopsy reportedly
negative
for malignancy
-S/P polypectomy of several adenomatous polyps
-Bilateral THAs in ___ and ___
.
Social History:
___
Family History:
Negative for coronary artery disease, diabetes, or cancer.
Physical Exam:
ADMISSION
VS: T 98.2 bp 123/66 HR 84 RR 18 SaO2 100 2L NC
GEN: NAD, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, obese, NT, ND, bowel sounds present
MSK: normal muscle tone and bulk
GU: rectal: prostate not tender or boggy, brown stool
EXT: No c/c, normal perfusion
SKIN: No rash, warm skin
NEURO: oriented x 3, normal attention, no focal deficits, intact
sensation to light touch
PSYCH: has insight into condition, calm, coperative
.
DISCHARGE
Vitals 97.8 152/78 p80 r20 95%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRLA
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB, no w/r/r
ABDOMEN: nondistended, +BS, nontender in all quadrants
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in all ___+ edema to B/L UE and ___. Wwelling of R elbow with
dressing in place over aspiration site.ROM ~135 degrees. sore to
palpation
Pertinent Results:
ADMISSION LABS
___ 07:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-LG
___ 07:30PM URINE RBC-1 WBC-32* BACTERIA-NONE YEAST-NONE
EPI-0
___ 04:51PM LACTATE-1.0
___ 04:35PM GLUCOSE-106* UREA N-37* CREAT-1.8* SODIUM-141
POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-25 ANION GAP-11
___ 04:35PM ALT(SGPT)-18 AST(SGOT)-30 ALK PHOS-64 TOT
BILI-0.4
___ 04:35PM LIPASE-35
___ 04:35PM ALBUMIN-3.6 CALCIUM-8.5 PHOSPHATE-2.7#
MAGNESIUM-1.9
___ 04:35PM WBC-3.7* RBC-2.39* HGB-7.9* HCT-25.1*
MCV-105* MCH-33.2* MCHC-31.6 RDW-18.9*
___ 04:35PM NEUTS-80.8* LYMPHS-10.4* MONOS-6.7 EOS-2.1
BASOS-0.1
___ 04:35PM PLT COUNT-105*
RELEVANT LABS
___ 4:50 pm BLOOD CULTURE #2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by ___. ___ ___ 10:00AM.
.
___ 5:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
.
___ 06:30AM BLOOD TSH-4.1
___ 04:35PM BLOOD ALT-18 AST-30 AlkPhos-64 TotBili-0.4
URINE STUDIES
___ 07:30PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
___ 07:30PM URINE RBC-1 WBC-32* Bacteri-NONE Yeast-NONE
Epi-0
___ 07:30PM URINE CastHy-2*
___ 07:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 12:23PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 12:23PM URINE RBC-59* WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
___ 12:23PM URINE Color-Straw Appear-Clear Sp ___
___ 06:15AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 06:15AM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE
Epi-<1
___ 06:15AM URINE Color-Straw Appear-Clear Sp ___
___ 3:29 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
JOINT FLUID STUDIES
___ 02:00PM JOINT FLUID ___ Polys-100*
___ ___ 02:00PM JOINT FLUID Crystal-FEW Shape-RHOMBOID
Locatio-INTRAC Birefri-POS Comment-c/w calciu
___ 01:30PM JOINT FLUID WBC-3450* ___ Polys-79*
___ Monos-16 NRBC-1* Macro-3
___ 01:30PM JOINT FLUID Crystal-NONE
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-5.0 RBC-2.97* Hgb-9.6* Hct-29.2*
MCV-98 MCH-32.4* MCHC-33.0 RDW-17.9* Plt ___
___ 07:25AM BLOOD ___ PTT-29.1 ___
___ 06:00AM BLOOD Glucose-103* UreaN-34* Creat-1.4* Na-143
K-3.9 Cl-104 HCO3-31 AnGap-12
___ 06:00AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.7
|
|
IMAGING
___ Head CT - no acute intracranial process
___ CXR IMPRESSION:
Low lung volumes. Left basilar opacity may reflect atelectasis
or infection in the correct clinical setting. Bilateral
calcified pleural plaques compatible with prior asbestos
exposure.
IMPRESSION: Chondrocalcinosis.
Conclusions
The left atrium is elongated. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic
function. The estimated cardiac index is normal (>=2.5L/min/m2).
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). The right ventricular cavity is
dilated with mild global free wall hypokinesis. The aortic root
is mildly dilated at the sinus level. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
masses or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
The left ventricular inflow pattern suggests impaired
relaxation. There is borderline pulmonary artery systolic
hypertension. No masses or vegetations are seen on the pulmonic
valve, but cannot be fully excluded due to suboptimal image
quality. There is a trivial/physiologic pericardial effusion.
IMPRESSION: No echocardiographic evidence of endocarditis or
pathologic valvular flow.Mild symmetric left ventricular
hypertrophy with preserved global systolic function. Mildly
dilated right ventricle with mild global hypokinesis. Borderline
pulmonary hypertension. Mildly dilated aortic root.
Compared with the prior study (images reviewed) of ___,
the right ventricle appears slightly larger and with mildly
depressed free wall systolic function. Pulmonary arterial
pressures are likely underestimated in the current study.
Conclusions
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium or left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). There are simple atheroma in the aortic arch. There
are complex (>4mm, non-mobile) atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve. Very mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Mild to moderate (___) mitral regurgitation is seen. No
vegetation/mass is seen on the pulmonic valve.
IMPRESSION: Mild-moderate mitral regurgitation with mildly
thickened leaflets but no discrete vegetaqtion. Very mild aortic
regurgitatation. No discrete vegetations identified. Complex,
non-mobile atheroma in the descending thoracic aorta.
FINDINGS: Low lung volumes are unchanged. Calcified bilateral
pleural
plaques are redemonstrated. Moderate cardiomegaly is slightly
larger compared to next most recent examination. There is no
evidence of pneumothorax or large pleural effusion. The
remainder of the chest is not appreciably changed.
IMPRESSION: New left PICC line terminates in the mid SVC.
Brief Hospital Course:
___ with CML who was admitted for visual hallucinations,
believed to be related to Imatinib (Gleevec) therapy for CML,
but uncertain. Other workup for his hallucinations incidentally
found a positive blood culture with MSSA, for which he was
treated with vancomycin. He also developed an acute flare of
pseudogout of his right elbow, and had pain and his right hip.
Both joints were tapped and grew negative cultures, although
this was in the setting of antibiotics already on board. Patient
was also treated for a 20lb volume overload secondary to IV
fluids and his CKD.
# MSSA bacteremia: Unclear source, though most obvious and
concerning is his recently painful/sore hip joint. Infectious
diseases and orthopedics consulted. Both right elbow (acutely
inflamed, see below) and right hip joint (which had been sore
for several weeks and evalauted by orthopedics at outpatient
recently) were aspirated by ___. Synovial fluid analysis grw
negative cultures, although this was after also receiving
vancomycin. TTE and TEE this admission negative for evidence of
vegetations/endocarditis. ID feels there is still a chance his
hip hardware could have been the source of the MSSA. Will
require IV vancomycin for at least 4 weeks total through a PICC
line and OPAT followup with Infectious Diseases. Patient also
has Ortho followup regarding hip, as negative cultures were in
setting of antibiotics already on board.
# R elbow Pseudogout: On ___ patient developed acute
painful, hot, erythematous swelling of his right elbow initially
concerning for infection (esp. given the positive MSSA). After
joint aspiration, synovial fluid cultures returned negative
(though with vancomycin on board). Fluid analysis consistent
with pseudogout crystals and formal evaluation by orthopedic
surgery consistent with pseudogout and not infectious join.
Patient treated with prednisone taper to be completed as an
outpatient. Pain controled with tylenol and lidocaine patches.
# Visual hallucinations: Resolved.Unclear etiology, but patient
had ___ blood culture bottles positive for MSSA. The time course
of the hallucinations is over at least a month, so if attributed
to MSSA, this indicates he has been seeding for some time. His
hallucinations may also have been an idiosyncratic reaction to
Imatinib (not improved with dose-reduction as an outpatient).
Dr. ___ he was planning on restarting Imatinib in
the near future, so can monitor for recurrence of symptoms then.
Not likely leptomeningeal disease given his CML response. RPR
negative and TSH normal. Not likely primary psychiatric disorder
presenting at this age.
# Volume overload with edema - Secondary to multiple nights of
maintanence fluids while NPO in case of OR washout of elbow
(which he did not require) as well as CKD and fluid retention.
Responded very well to multiple doses 40mg IV lasix and his
discharge weight was 170lbs. His goal weight is 160-165 lbs. We
instructed him to weigh himself daily and call his PCP if he
gains 3 pounds (especially since he will get IV vancomycin daily
for 19 more days).
CHRONIC ISSUES
# Chronic Mylogenous Leukemia - Imatinib treatment held given
hallucinations. Patient has outpatient followup appointment with
Heme/Onc.
# CKD IV with baseline creatinine of 1.6; stable
# BPH: Doxazosin held given concern that in elderly with CKD can
cause cognitive changes.
# HTN - Stable. Continued home Losartan
# DM2 - Held Home Actos and instead used HISS while inpatient.
# Chronic macrocytic Anemia secondary to malignancy and
inflammation - Continued vitamin B complex supplements.
TRANSITIONAL ISSUES:
1) Heme/Onc followup to possibly restart Imatinib.
2) Orthopedic follow-up with consideration for infected hip
joint
3) Steroid taper and pesudogout response
4) Infectious Disease followup to determine exact course of
treatment (currently planned for 4 weeks total IV vancomycin)
5) Goal weight 160-165 lbs. Outpatient PCP was emailed in
advance of discharge in case patient calls with weight
gain/fluid retention.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO DAILY
2. Doxazosin 8 mg PO HS
3. Lidocaine 5% Patch 1 PTCH TD DAILY
4. Losartan Potassium 25 mg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Vitamin B Complex 1 CAP PO DAILY
8. ferrous fumarate *NF* 324 mg (106 mg iron) Oral BID
9. Pyridoxine 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H pain
2. Atorvastatin 10 mg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD DAILY
RX *lidocaine 5 % (700 mg/patch) Apply 1 patch to elbow and 1
patch to hip daily Disp #*28 Transdermal Patch Refills:*2
4. Losartan Potassium 25 mg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
6. Pyridoxine 25 mg PO DAILY
7. Vitamin B Complex 1 CAP PO DAILY
8. Docusate Sodium 200 mg PO BID
RX *docusate sodium 100 mg 2 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*2
9. Senna 2 TAB PO BID
RX *sennosides [senna] 8.6 mg ___ tablets by mouth for
constipation Disp #*60 Tablet Refills:*2
10. Aspirin 81 mg PO DAILY
11. ferrous fumarate *NF* 324 mg (106 mg iron) Oral BID
12. Pioglitazone 45 mg PO DAILY
13. PredniSONE 10 mg PO DAILY Duration: 2 Days
Take on ___
Tapered dose - DOWN
RX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*2 Tablet
Refills:*0
14. PredniSONE 5 mg PO DAILY Duration: 5 Days
Take on ___, and ___ then STOP.
Tapered dose - DOWN
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*5 Tablet
Refills:*0
15. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg one-half tablet by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
16. Vancomycin 1000 mg IV Q 24H
RX *vancomycin 1 gram Administer 1000mg IV Solution Q24H Disp
#*20 Gram Refills:*0
17. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Visual Hallucinations, Staphylococcus Aureus
bacteremia, Pseudogout, Volume overload
Secondary: Chronic Myelogenous Leukemia, Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted because you were having
hallucinations (which may have been due to your Gleevec, or an
infection). In attempting to find the reason for hallucincations
we found bacteria in your blood, which can be serious. We tried
to look for a source of this bacteria, but found nothing
obvious. It may well be from your hip-joint, although we did not
grow any cultures. You will need treatment with IV antibiotics
for at least a total of 4 weeks, with routine blood monitoring.
You were also affected by a flare of pseudogout, for which we
treated you with pain control and steroids (prednisone), which
you will slowly taper off. You also retained fluid, so we gave
you medications to make you urinate more.
Please weigh yourself every day. Your goal weight is between 160
to 165 pounds. Your weight at discharge was 170 pounds. If your
weight increases by 3 pounds, call your doctor ___
___, MD ___ for instructions.
Please review your medication list carefully for the changes. I
will highlight here: You should STOP ___ until you follow up
with Dr. ___.
Your appointments are listed below.
Followup Instructions:
___
|
10386562-DS-14 | 10,386,562 | 22,701,838 | DS | 14 | 2169-06-16 00:00:00 | 2169-06-17 17:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Shellfish Derived / vancomycin
Attending: ___
Chief Complaint:
Fever, joint pain.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with hx of CML now w/ L shoulder pain, neck pain and
dyspnea. Patient currently taking daptomycin for MSSA with R
sided PICC line. He initially had PICC in his left arm that was
removed on ___ due to pain and concern for infectin causing
MSSA bacteremia. The patient reportedly has diffuse aches in his
joints but the shoulder is reported to be the worst. Question of
some mildly decreased mental status per family as well. Patient
endorses pain ___ in the left shoulder currently. No dyspnea,
fever, chills. Pt was originally admitted to the floor and
continued on antibiotics Dapto and cipro for prior infections.
His shoulder was tapped in the ED that revealed calcium
pyrophosphate crystals.
While on the floor he suddenly developed hypoxia to the ___ on
2L NC, he correspondingly also had an elevated BP to 170s/100s
and HR in the 130s with a RR of 40. An ekg obtained was
consistent w/ a.fib with rvr. He was then given 40mg of IV
lasix, IV morphine and a CXR was obtained. He was transfered to
the MICU for acute hypoxia and tachypnea.
On arrival to the MICU, His work of breathing had improved. His
initial VS 100.2, HR 125, BP 110/62,19 99% NRB. He was only able
to speak in one word sentences.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___: the patient is found to have leukocytosis with
immature myeloid forms, including myelocytes, metamyelocytes,
and promyelocytes. RT-PCR for BCR-ABL was sent, and returned
positive for the ___ translocation with a BCR ABL1/ABL1 ratio
of 69.659%.
- ___ start Imatinib 100 mg daily
- ___ increase Imatininb to 200 mg daily
- ___ increase Imatininb to 300 mg daily
- ___ increase Imatininb to 400 mg daily
- ___ Presented to ___ clinic with worsening anemia
and kidney function, thrombocytopenia and the lower extremity
edema. Worsening right hip pain as well. He had hallucinations
as well. He received 1 unit PRBCs in ___ clinic, and was
admitted and treated with antibiotics for MSSA bacteremia,
discharged on a course of Vancomycin IV via ___
-___ patient discharged off of imatinib to be restarted as
an outpatient
-___- re-presents to the ED with pain at ___ site and
question ___ line infection
PAST MEDICAL HISTORY:
-Hypertension
-Diabetes: controlled with pioglitazone, HbA1c:6.2% (___)
-Hyperlipidemia
-Spinal stenosis
-Trigeminal Neuralgia: last symptomatic over ___ years ago,
carbamazepine discontinued
-Pseudogout, manifesting as fevers of unknown origin until a
knee effusion was tapped revealing crystals. Repeat flare
___ of right elbow, synovial fluid confirmed.
-Polyarticular arthritis
-CKD: baseline creatinine of 1.7
-BPH with elevated PSA; prior prostate biopsy reportedly
negative for malignancy
-S/P polypectomy of several adenomatous polyps
-Bilateral THAs in ___ and ___
-MSSA Bacteremia ___ with 4 planned weeks OPAT
Social History:
___
Family History:
No known history of hematologic or oncologic dyscrasia. 1 of 2
brothers is deceased; 1 sister is deceased.
Physical Exam:
Physical exam at admission:
Vitals: T: 100.2 BP:177/100 P:133 R:40 O2:100% NRB
General: pt sitting upright with increased work of breathing,
only able to respond with one word answers
HEENT: Sclera anicteric, oropharynx clear, EOMI, PERRL
Neck: supple, JVP elevated, no LAD
CV: tachycardic rate, S1 + S2, no murmurs, rubs, gallops
Lungs: diminished breath sounds bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+
pitting edema to knees b/l
Neuro: grossly intact, no focal deficits noted
.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.5 - 126/72 - 100 - 18 - 99RA
GENERAL: NAD, pleasant elderly gentleman, lying in bed
SKIN: warm and well perfused, no excoriations, no rashes,
multiple bruises, dry skin
HEENT: EOMI, anicteric sclera, pink conjunctiva, patent nares
NECK: nontender supple neck w/ excess skin folds, no LAD, no JVD
CARDIAC: irregular rate but not tachycardic, S1/S2, no mrg
LUNG: clear to auscultation bilaterally, no crackles or wheezes
ABDOMEN: soft, obese, nondistended, +BS, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly
PULSES: 2+ radial pulses bilaterally
NEURO: CN II-XII intact, strength exam tested in BUEs: ___ in
upper arms (limited on left side ___ pain), hand grip ___
alert, oriented to person, not year, attempted to read calendar
(but calendar is wrong), oriented to place
EXT: 1+ pedal edema, no left arm edema
GU: no foley. holding urinal. urine is yellow.
Pertinent Results:
ADMISSION LABS:
___ 04:00PM JOINT FLUID ___ RBC-40* POLYS-92*
___ ___ 04:00PM JOINT FLUID NUMBER-FEW SHAPE-RHOMBOID
LOCATION-INTRAC BIREFRI-POS COMMENT-c/w calciu
___ 12:33PM ___ COMMENTS-GREEN TOP
___ 12:33PM LACTATE-1.2
___ 12:00PM GLUCOSE-159* UREA N-28* CREAT-1.8* SODIUM-138
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-25 ANION GAP-17
___ 12:00PM estGFR-Using this
___ 12:00PM CALCIUM-8.6 PHOSPHATE-3.5 MAGNESIUM-1.9
___ 12:00PM CRP-212.4*
___ 12:00PM WBC-26.9* RBC-3.09* HGB-9.9* HCT-30.7*
MCV-99* MCH-32.0 MCHC-32.2 RDW-17.7*
___ 12:00PM NEUTS-67 BANDS-5 LYMPHS-2* MONOS-9 EOS-0
BASOS-0 ___ METAS-15* MYELOS-2*
___ 12:00PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
BITE-OCCASIONAL
___ 12:00PM PLT SMR-NORMAL PLT COUNT-221
___ 12:00PM ___ PTT-35.0 ___
___ 12:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 12:00PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
___ 12:00PM URINE HYALINE-3*
___ 12:00PM URINE MUCOUS-RARE
.
OTHER PERTINENT LABS
___ 02:42AM BLOOD ALT-20 AST-39 CK(CPK)-40* AlkPhos-75
TotBili-0.6
___ 01:28AM BLOOD ALT-19 AST-43* LD(LDH)-472* AlkPhos-84
TotBili-0.4
___ 02:42AM BLOOD CK-MB-2 cTropnT-0.18* ___
___ 11:02AM BLOOD CK-MB-2 cTropnT-0.14*
___ 02:42AM BLOOD TSH-2.3
___ 12:00PM BLOOD CRP-212.4*
___ 03:13AM BLOOD IgG-634* IgA-89 IgM-42
___ 06:13AM BLOOD Type-ART Temp-40.1 PEEP-5 FiO2-40
pO2-144* pCO2-63* pH-7.25* calTCO2-29 Base XS-0 Intubat-NOT
INTUBA
___ 01:54AM BLOOD K-4.8 calHCO3-28
___ 03:20AM BLOOD Lactate-0.9
___ 12:33PM BLOOD Lactate-1.2
.
DISCHARGE LABS
___ 07:40AM BLOOD WBC-28.0* RBC-2.74* Hgb-8.5* Hct-26.9*
MCV-98 MCH-30.9 MCHC-31.5 RDW-17.6* Plt ___
___ 05:30AM BLOOD WBC-34.7*# RBC-2.69* Hgb-8.4* Hct-26.6*
MCV-99* MCH-31.4 MCHC-31.8 RDW-17.4* Plt ___
___ 05:30AM BLOOD Neuts-79* Bands-5 Lymphs-1* Monos-3 Eos-0
Baso-0 ___ Metas-3* Myelos-9*
___ 05:30AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-3+ Microcy-NORMAL Polychr-NORMAL Pappenh-OCCASIONAL
___ 07:40AM BLOOD Glucose-101* UreaN-67* Creat-1.8* Na-140
K-3.4 Cl-104 HCO3-28 AnGap-11
___ 05:30AM BLOOD Albumin-3.1* Calcium-8.1* Phos-3.0#
Mg-2.1
.
URINE STUDIES
___ 12:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 12:00PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 12:00PM URINE RBC-2 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
___ 12:00PM URINE CastHy-3*
___ 12:00PM URINE Mucous-RARE
___ 12:00PM URINE Mucous-RARE
___ 10:34AM URINE Color-DkAmb Appear-Cloudy Sp ___
___ 10:34AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
___ 05:21PM URINE Color-Red Appear-Cloudy Sp ___
___ 05:21PM URINE Blood-LG Nitrite-NEG Protein->300
Glucose-NEG Ketone-15 Bilirub-MOD Urobiln-1 pH-5.0 Leuks-TR
___ 05:21PM URINE RBC->182* WBC->182* Bacteri-FEW
Yeast-NONE Epi-0
.
URINE LYTES
___ 10:36PM URINE Eos-NEGATIVE
___ 06:04AM URINE Osmolal-347
___ 05:21PM URINE Osmolal-366
___ 06:04AM URINE Hours-RANDOM UreaN-256 Creat-60 Na-83
K-39 Cl-91
___ 05:21PM URINE Hours-RANDOM UreaN-339 Creat-153 Na-54
K-23 Cl-24
.
JOINT FUILD ANALYSIS
___ 04:00PM JOINT FLUID ___ RBC-40* Polys-92*
___ ___ 04:00PM JOINT FLUID Crystal-FEW Shape-RHOMBOID
Locatio-INTRAC Birefri-POS Comment-c/w calciu
.
MICROBIOLOGY
___ URINE CULTURE-FINAL - NO GROWTH
___ MRSA SCREEN-FINAL - NO GROWTH
___ BLOOD CULTURE -PENDING
___ JOINT FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL NO GROWTH
___ BLOOD CULTURE -FINAL - NO GROWTH
___ BLOOD CULTURE - FINAL - NO GROWTH
___ URINE CULTURE-FINAL - NO GROWTH
.
IMAGING/OTHER REPORTS
___ GLENO-HUMERAL SHOULDER X-RAY
IMPRESSION: No evidence of acute fracture or dislocation.
High-riding left humeral head again seen, which can be seen in
rotator cuff disease.
.
___ CHEST PA/LAT
IMPRESSION: Opacities projecting over the bilateral lung
fields, in part
relating to calcified pleural plaques, although increased
perihilar opacities compared to the prior study, left greater
than right, raise concern for pulmonary edema with possible
underlying infection, as above.
.
___ CHEST-PORTABLE
Perihilar opacities seen on the prior chest x-ray have
diminished . Calcified pleural plaques are again noted. No
failure is present. The costophrenic angles show mild blunting
of the left, but none on the right.
.
___ CT C-SPINE WIHTOUT CONTRAST
IMPRESSION: No acute fracture. Multilevel degenerative
changes. Mild anterolisthesis of C3 and C4, potentially due to
associated facet joint hypertrophic changes at this level.
Degenerative changes, more significantly at C5-C6 and C6-C7 as
above.
.
___ CT CHEST WITHOUT CONTRAST
IMPRESSION:
1. Non-aneurysmal moderately calcified thoracic aorta and
coronary arteries
2. Numerous calcified pleural plaques, unchanged from prior and
suggestive of prior asbestos.
3. Bibasilar atelectasis. No consolidation or pleural
effusion.
4. 2.3 cm right thyroid nodule. Non-emergent thyroid
ultrasound could be performed for further assessment.
5. New subcentimeter hyperdense right renal lesion. Ultrasound
could be
performed for further assessment.
.
___ EKG
Probable atrial flutter with 2:1 A-V conduction. Right
bundle-branch block. Compared to the previous tracing atrial
flutter is new. The other findings are similar.
Rate PR QRS QT/QTc P QRS T
153 0 ___ 0 0 -7
.
___ EKG
Sinus rhythm. Right ventricular conduction delay. Slowing of the
rate as
compared to the previous tracing of ___ and appearance of
sinus rhythm. Otherwise, no diagnostic interim change.
Rate PR QRS QT/QTc P QRS T
98 ___ 50 45 -10
.
___ EKG
Sinus rhythm with further slowing of the rate as compared to the
previous
tracing of ___. There is continued right ventricular
conduction delay and ST-T wave changes as previously recorded
without diagnostic interim change.
Rate PR QRS QT/QTc P QRS T
80 ___ 63 22 -14
.
___ ULTRASOUND BLES
No lower extremity DVT. Right 1.8 ___ cyst.
.
___ ULTRASOUND BUES
No evidence of deep venous thrombosis in bilateral upper
extremities
.
___ CT HEAD WITHOUT CONTRAST
There is no evidence of infarction, edema, hemorrhage, mass
effect or shift of normally midline structures. The sulci and
ventricles are prominent, likely age-related involutional
changes. Minimal confluent hypodensities in periventricular and
subcortical white matter distribution likely reflect sequela of
vessel ischemic disease. Basal cisterns are patent. There is no
hydrocephalus. Mild mucosal thickening of maxillary sinuses and
ethmoid air cells is noted. Otherwise, imaged paranasal sinuses
and mastoid air cells are well aerated. Vascular calcifications
are noted. Right lens prosthesis is in place.
IMPRESSION:
1. No evidence of hemorrhage or infarction. MRI is more
sensitive for
detection of acute ischemia.
2. Prominent sulci and ventricles, likely age-related
involutional changes.
3. Small vessel ischemic disease.
.
___ CARDIAC ECHO
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.5 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *7.3 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.4 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 70% >= 55%
Left Ventricle - Stroke Volume: 66 ml/beat
Left Ventricle - Cardiac Output: 5.01 L/min
Left Ventricle - Cardiac Index: 2.85 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.09 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 9 < 15
Aorta - Sinus Level: *3.7 cm <= 3.6 cm
Aorta - Ascending: *4.0 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 21
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A ratio: 0.70
Mitral Valve - E Wave deceleration time: *256 ms 140-250 ms
TR Gradient (+ RA = PASP): *31 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of ___.
LEFT ATRIUM: Mild ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free
wall hypokinesis.
AORTA: Mildy dilated aortic root. Focal calcifications in aortic
root. Mildly dilated ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No masses or vegetations on aortic valve, but cannot be fully
excluded due to suboptimal image quality. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No masses
or vegetations on mitral valve, but cannot be fully excluded due
to suboptimal image quality. Trivial MR. ___ inflow pattern c/w
impaired relaxation.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No masses or vegetations are seen on the aortic valve,
but cannot be fully excluded due to suboptimal image quality. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No masses or vegetations are seen on the
mitral valve, but cannot be fully excluded due to suboptimal
image quality. Trivial mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional left ventricular systolic
function. Dilated and hypokinetic right ventricle. No
significant valvular regurgitation. No echocardiographic
evidence of endocarditis. Dilated ascending aorta and aortic
sinus.
If clinically indicated, a transesophageal echocardiogram may
better assess for valvular vegetations.
.
___ LUNG SCAN V/Q
IMPRESSION: Low likelihood for acute pulmonary embolism.
.
___ RENAL U/S
The right kidney measures 10.3 cm.
The left kidney measures 9.77 cm.
Bilateral kidneys demonstrate cortical thinning, unchanged.
There is no
hydronephrosis, nephrolithiasis, or renal masses.
A Foley catheter is present and the bladder is decompressed.
IMPRESSION:
No hydronephrosis.
Brief Hospital Course:
>> BRIEF HOSPITAL COURSE
___ with CML with recent admission for MSSA bacteremia from
likely PICC line infection, left sided PICC line removed, right
sided put in and receving Daptomycin admitted for left sided
shoulder pain (found to be pseudogout), chest pain and fever. On
the floor, the patient had an acute episode of respiratory
distress with hypoxia to ___, associated with afib with RVR, and
hypertension requiring BiPap and ICU transfer. He improved on
Bipap, stabilized, and was transferred to the Oncology floor.
There, he was restarted on his imatinib, which he tolerated
well. Foley and PICC line were removed. He was discharged to a
rehabilitation facility for continued physical therapy.
.
>> ACTIVE ISSUES
#) Hypoxemia: The patient became acutely tachypnic and hypoxemic
on the floor associated with afib with RVR and hypertension. A
CXR was performed that was a poor study but did not show a
consolidation or flash edema. The patient had a CT chest done
the day previous that was clear as well. The patient was given
40mg IV lasix, with little UOP and morphine for resp distress.
The differential for his respiratory distress was initially
pulmonary edema vs PE. He was empirically started on a heparin
drip, which was discontinued when he negative upper and lower
extremity dopplers and a low probability V/Q scan. His
respiratory status remained stable thereafter. Suspect this
episode was related to some increased pulmonary edema in the
setting of new afib and dCHF.
# Leukocytosis and CML: The patient's WBC was elevated at
admission -- it was unclear if this was infection vs his known
CML. Infectious work up was negative at this time and his
primary oncologist believed the WBC was likely due to his CML.
His primary oncologist recommended restarting Gleevac, while he
was an inpatient. His WBC was improving at discharge.
#) Acute altered mental status: On ___ patient became altered
more so from baseline. CT head was negative. He had been
receiving narcotics for pain relief including IV morphine --
once his pain regimen was switched to tylenol with occassional
breakthrough dilaudid his mental status returned to his
baseline.
#) Acute renal failure: His creatinine was elevated to a peak of
3.5 -- the etiologu of his renal failure is unclear. His
potassium rose to 6.2 without ECG changes in setting of ARF. He
was given Lasix and Kayexalate and his potassium came down.
Initially it was thought that his daptomycin was contributing as
daptomycin can cause renal failure in 2-3% -- however urine
eosinophils were negative. Renal was consulted as initially they
believed this was instrinsic renal pathology. His Cr was down to
1.8 on discharge. Baseline is ~1.4-1.6.
#) UTI: U/A collected on ___ was concerning for infection.
Started on IV cipro on ___. Transitioned to PO cipro and
will complete a 10-day course.
#) Clots in foley: There were blood clots seen in the foley,
which was thought to be due to a traumatic foley placement. The
patient was started on CBI without improvement. Urology was
contacted and they recommended replacing his 3 way foley with a
large 2 way foley and stopping CBI. This was done and the
patient's hematuria improved. He was scheduled for follow-up
with urology and nephrology for further evaluation of hematuria
and renal failure (eg cystoscopy).
# Recent MSSA Infection: Being followed by ___ clinic for
ongoing daptomycin treatment. ID saw him as an inpatient and
recommended stopping his dapto a few days early as it was
thought that perhapts the daptomycin was contributing to his
acute renal failure. TTE was negative for vegetation.
# Shoulder Pain: Patient presented with pain in the ED. CPPD
crystals seen on aspiration consisten with pseudogout on
aspiration. No organisms grew from joint aspiration cultures.
Initially pain controlled with tylenol and dilaudid. After
sspeaking with Rheumatology patient was started on short
prednison taper. Per Rheum, the patient should continue on
prednisone 5mg daily until he follows up in ___ clinic
- which is scheduled.
# DM2 - Held home Actos. ISS while inpatient. His actos was NOT
restarted on discharge as it may not be the best choice given
patient's heart failure and hematuria. Consider alternative
agents as an outpatient. He had increased insulin requirements
on prednisone here and should remain on insulin while on
prednisone.
CHRONIC/INACTIVE ISSUES
# Chronic macrocytic Anemia secondary to malignancy and
inflammation - Continued vitamin B complex supplements.
# CAD: Continue aspirin, statin.
TRANSITIONAL ISSUE:
- Code status: DNR/DNI
- Emergency contact: HCP & wife ___ ___, nephew
___ ___ cell.
- Studies pending on discharge: Blood culture from ___ is
still pending.
- Given history of paroxysmal atrial fibrillation on this
hospitalization (still appears to be in atrial fibrillation),
consider anti-coagulation. Anti-coagulation not started on this
admission ___ recent hematuria, but once this resolves as an
outpatient, please consider.
- As his creatinine improves and his blood sugars normalize,
insulin regimen should be adjusted accordingly. Pioglitazone
likely should not be re-started given his heart failure status
and risk for lactic acidosis, and metformin is contra-indicated
with his baseline kidney dysfunction. Please explore alternative
oral medications for outpatient use.
- QTc on ___ was 412.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Daptomycin 420 mg IV Q24H
2. Acetaminophen 1000 mg PO Q8H:PRN pain
3. Aspirin 81 mg PO DAILY Start: In am
4. Atorvastatin 10 mg PO DAILY Start: In am
5. Docusate Sodium (Liquid) 100 mg PO BID
6. Losartan Potassium 25 mg PO DAILY Start: In am
7. Metoprolol Tartrate 12.5 mg PO BID Start: In am
8. Multivitamins 1 TAB PO DAILY Start: In am
9. Senna 2 TAB PO BID
10. Vitamin B Complex w/C 1 TAB PO DAILY Start: In am
11. Imatinib Mesylate 100 mg PO DAILY Start: In am
12. Ferrous Sulfate 325 mg PO DAILY
13. Pioglitazone 45 mg PO DAILY
14. Lidocaine 5% Patch 1 PTCH TD DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Docusate Sodium (Liquid) 100 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Senna 2 TAB PO BID
7. Vitamin B Complex w/C 1 TAB PO DAILY
8. Heparin 5000 UNIT SC TID
9. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
please hold for RR<12, sedation
10. PredniSONE 5 mg PO DAILY
should continue until follow up with rheumatology.
11. Imatinib Mesylate 100 mg PO DAILY
12. Ferrous Sulfate 325 mg PO DAILY
13. Lidocaine 5% Patch 1 PTCH TD DAILY
14. Losartan Potassium 25 mg PO DAILY
15. Metoprolol Tartrate 25 mg PO TID
16. Ciprofloxacin HCl 250 mg PO Q12H
until ___.
17. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
18. Pyridoxine 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Multiple myeloma
Pseudogout
Respiratory failure
Atrial fibrillation with rapid ventricular response
Hematuria
Acute on chronic kidney injury
Altered mental status
Secondary: Type 2 diabetes
Hypertension
BPH
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 admitted to ___
because of shoulder pain, which turned out to be pseudogout.
While you were admitted, you had difficulty breathing, for which
you were sent to the ICU. You were also found to have a fast,
irregular heart rate at that time (atrial fibrillation). You
improved in the ICU and were able to breathe well on room air.
Unfortunately you were less reponsive than normal, but you
improved after being treated for a UTI. You also had blood in
your urine, which improved by itself. Finally, you had kidney
dysfunction, which also improved.
You should follow up with Rheumatology, Urology, your primary
care doctor after discharge from the rehabilitation facility,
and your Oncologist, Dr. ___.
While you were here, some changes were made to your medications.
Please see your medication sheet for the changes.
Followup Instructions:
___
|
10386562-DS-15 | 10,386,562 | 24,266,920 | DS | 15 | 2169-07-06 00:00:00 | 2169-07-09 12:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Shellfish Derived / vancomycin
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___: Intra-articular steroid injection of Left shoulder.
History of Present Illness:
___ with h/o CML, HTN, DMII, h/o Afib with RVR, CKD (Cr 1.4-1.6)
presents with worsening SOB since the morning from rehab. Per pt
and his wife, last ___ approx 5d ago the pt developed chest
congestion and had a fever to approx 101. No recurrent fevers
but persistent chest congestion. No significant coughing or
nasal congestion. Pt reports SOB mostly DOE over the past few
days. No CP, palpitations. No abd pain, diarrhea, dysuria. Pt
with ___ edema that is worse and just started over the past
several weeks.
Pt recently admitted ___ with fever, shoulder pain.
During admission, pt had issues with hypoxemia and respiratory
distress in the setting of afib with RVR and HTN. Pt had neg UE
and ___ dopplers and low prob V/Q scan. Diuresis trial without
significant UOP. Pt required ICU transfer for BiPAP. He improved
on BiPAP and stabilized. Pt also admitted ___ for MSSA
bacteremia thought ___ PICC line infection.
At rehad today prior to transfer, the patient was given
albuterol nebs x2 & mucinex this AM, and then 40mg PO lasix at
2pm. At rehab, pt ambulates with walker. Pt noted to have
wheezing ___ and was getting albuterol nebs. Per rehab note,
pt with worsening wheezing and cough this AM and family
requested transfer to hospital.
In the ED, initial vitals were: 97.0 107 151/97 24 100% 3L. The
patient was briefly placed on BIPAP ___ with FiO2 50%. He was
transitioned to CPAP, given 40mg IV lasix. Pt had fever to
101.2, given tylenol ___ PR. Pt given an Ipratropium nebulizer
treatment, dilt ___ IV x1 for afib with RVR followed by 45mg PO
dilt. Pt given levoflox 750 IV x1. Transitioned to NRB prior to
transfer.
On arrival to the ICU, pt reports breathing comfortable. No SOB,
cough, CP. Feels chest congested still.
Past Medical History:
-CML on gleevec and prednisone
-Hypertension
-Diabetes: controlled with pioglitazone, HbA1c:6.2% (___)
-Hyperlipidemia
-Spinal stenosis
-Trigeminal Neuralgia: last symptomatic over ___ years ago,
carbamazepine discontinued
-Pseudogout, manifesting as fevers of unknown origin until a
knee effusion was tapped revealing crystals. Repeat flare
___ of right elbow, synovial fluid confirmed.
-Polyarticular arthritis
-CKD: baseline creatinine of 1.7
-BPH with elevated PSA; prior prostate biopsy reportedly
negative for malignancy
-S/P polypectomy of several adenomatous polyps
-Bilateral THAs in ___ and ___
-MSSA Bacteremia ___ with 4 planned weeks OPAT with dapto
Social History:
___
Family History:
No known history of hematologic or oncologic dyscrasia. 1 of 2
brothers is deceased; 1 sister is deceased.
Physical Exam:
Admission PE:
VS: 124/66, 113, 17, 99% on facetent and NC
GENERAL: A&Ox3, hard of hearing, pleasant, looks comfortable,
speaking in full sentences
HEENT: NCAT. MMM.
NECK: Supple, JVD.
CARDIAC: irregular, rate in 100s, no murmurs
LUNGS: breathing comfortably, not tachypeic, coarse bibasilar
rales with diffuse rhonchorous breath sounds, good bilateral air
movement
ABDOMEN: Soft, NT,ND. +BS.
EXTREMITIES: 2+ ___ edema up to knees, warm and well perfused
with 1+ DP pulses
SKIN: candidal rash in inguinal folds, small 0.5 flesh colored
and slight white papules on posterior scrotum
.
DISCHARGE PHYSICAL EXAM:
VS: 97.9 111/64 101 20 95% RA
GENERAL: NAD, pleasant elderly gentleman who looks comfortable,
smiling
CARDIAC: irregular rate, tachycardic, S1/S2, no mrg
LUNG: Good air entry b/l. Improved crackles at bilateral bases.
ABDOMEN: soft, obese, nondistended, +BS, no rebound/guarding, no
hepatosplenomegaly
GU: no foley
EXT: full flex/ext/rotation of bilateral arms
Pertinent Results:
Admission Labs:
___ 03:37PM LACTATE-1.9
___ 03:30PM GLUCOSE-172* UREA N-28* CREAT-1.5* SODIUM-143
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-30 ANION GAP-14
___ 03:30PM ALT(SGPT)-27 AST(SGOT)-28 CK(CPK)-39* ALK
PHOS-103 TOT BILI-0.3
___ 03:30PM cTropnT-0.07*
___ 03:30PM CK-MB-4 ___
___ 03:30PM ALBUMIN-3.5
___ 03:30PM WBC-14.6* RBC-2.69* HGB-8.6* HCT-27.8*
MCV-103* MCH-32.0 MCHC-31.0 RDW-18.2*
___ 03:30PM NEUTS-80* BANDS-2 LYMPHS-8* MONOS-6 EOS-0
BASOS-0 ___ METAS-2* MYELOS-2*
___ 03:30PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL TARGET-OCCASIONAL STIPPLED-OCCASIONAL
TEARDROP-OCCASIONAL ACANTHOCY-OCCASIONAL
___ 03:30PM PLT SMR-NORMAL PLT COUNT-368
___ 03:30PM ___ PTT-32.4 ___
DISCHARGE PHYSICAL EXAM
___ 07:35AM BLOOD WBC-16.2* RBC-2.86* Hgb-9.0* Hct-29.2*
MCV-102* MCH-31.5 MCHC-30.8* RDW-18.1* Plt ___
___ 07:10AM BLOOD Glucose-68* UreaN-68* Creat-2.7* Na-138
K-3.9 Cl-95* HCO3-32 AnGap-15
___ 07:35AM BLOOD Calcium-8.5 Phos-4.9* Mg-1.8
>> STUDIES:
- CXR ___: Calcified pleural plaques compatible with prior
asbestos exposure. No new focal consolidation to suggest
pneumonia.
.
CXR ___
Asbestos-related pleural plaque heavily calcified, is
longstanding. The
patient was in pulmonary edema on ___, subsequently
improved. Small region of consolidation developed in the right
lower lung on ___, has improved. This could be
atelectasis, particularly due to aspiration. Borderline
interstitial edema present yesterday has improved, but there
still marked chronic mediastinal venous and pulmonary vascular
engorgement. Pleural effusions are small if any.
MICRO
___ JOINT FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL
___ URINE CULTURE-FINAL
___ Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture-FINAL; Respiratory Viral Antigen
Screen-FINAL
___ MRSA SCREEN-FINAL
___ URINE CULTURE-FINAL
___ BLOOD CULTURE-FINAL
___ BLOOD CULTURE -FINAL
Brief Hospital Course:
BRIEF HOSPITAL COURSE
===============
___ year old gentleman with CML on gleevec, history of a-fib w/
RVR, CKD, recent admission to Omed for pseudogout complicated by
respiratory failure (bipap), UTI, AMS, ___, a-fib with RVR, who
presented with hypoxia and SOB. He was started on CPAP in ED,
got diltiazem for a-fib with RVR, and transferred to the ICU.
Given CXR with concern for ?aspiration pneumonia and recent
hospital admissions and well as residence at rehab he was also
covered for ha-Pneumonia and CA-pneumonia briefly, but more
likely cause for hypoxia appeared to be pulmonary edema.
Initially treated with antibiotics which were stopped,
aggressively diuresed in concordance with Cardiology team.
Diuresis was complicated by acute kidney injury, which
complicated discharge somewhat. Also found to have recurrence of
pseudogout in left shoulder; this improved after intra-articular
steroid injection. He was discharged to a rehab facility for
continued work with physical therapy. Weight on discharge was
145 pounds.
ACTIVE ISSUES
=========
# Hypoxia attributed to pulmonary edema: He reported chest
congestion and fevers which suggests possible infectious
etiology. Respiratory viral cultures/screens were negative. He
was started on ___ and community acquired pneumonia
coverage with linezolid and cefepime (due to allergies to PCN
and vancomycin), but these were discontinued given the more
likely etiology of pulmonary congestion causing hypoxia. He was
initially on a NRB mask in the ICU, but oxygen was weaned and he
tolerated room air well on the Oncology floor. Wells score was
2.5, he had no evidence of DVT, so pulmonary embolism was
thought to be much less likely. Cardiac enzymes were flat.
On exam his lungs were quite rhonchorous, with coarse rales at
bases (though no clear pulmonary process on CXR). Cardiology was
consulted for management of pulmonary congestion and diuresis,
and he diuresed well.
- Weight on discharge as above. He should continue on torsemide.
Furosemide was discontinued.
# Acute kidney injury: Creatinine elevated in the setting of
aggressive diuresis. Peak creatinine was 3.1 and diuresis was
briefly held. Creatinine was improving by the time of discharge
(2.7) He was discharged on torsemide.
# Atrial fibrillation with RVR: IN the emergency department, he
received a bolus of diltiazem and oral diltiazem. His metoprolol
was up-titrated on the Oncology floor for better rate control.
He was continued on home aspiring 81mg.
- Anticoagulation should be re-addressed as an outpatient.
.
# HTN: Normotensive during this admission. Losartan held for
acute kidney injury, and metoprolol was up-titrated (for rate
control of a fib). In addition, diuretic regimen was changed per
the Cardiology team; torsemide was started and furosemide was
stopped.
# CML: His imatinib was briefly held in the ICU, but restarted
on the Oncology floor.
INACTIVE ISSUES
==========
# DM: Continued home lantus and managed with humalog ISS in
house.
# CKD: Please see above discussion of kidney function.
TRANSITIONAL ISSUES
==============
PLEASE CHANGE HIS METOPROLOL TARTRATE 25mg TID TO METOPROLOL
SUCCINATE 200mg daily. We were unable to change this prior to
his discharge.
- Code status: DNR, ok to intubate.
- Emergency contact: HCP & wife ___ ___, nephew
___ ___ cell.
- Studies pending on discharge: None.
- Please re-address code status.
- No need for allopurinol.
- Given history of atrial fibrillation on this hospitalization,
consider anti-coagulation.
- As his creatinine improves and his blood sugars normalize,
insulin regimen should be adjusted accordingly. Pioglitazone
likely should not be re-started given his heart failure status
and risk for lactic acidosis, and metformin is contra-indicated
with his baseline kidney dysfunction. Please explore alternative
oral medications for outpatient use.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Docusate Sodium (Liquid) 100 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Senna 2 TAB PO BID
7. Vitamin B Complex w/C 1 TAB PO DAILY
8. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
please hold for RR<12, sedation
9. PredniSONE 5 mg PO DAILY
should continue until follow up with rheumatology.
10. Imatinib Mesylate 100 mg PO DAILY
11. Ferrous Sulfate 325 mg PO DAILY
12. Lidocaine 5% Patch 1 PTCH TD DAILY
13. Losartan Potassium 25 mg PO DAILY
14. Metoprolol Tartrate 25 mg PO TID
15. Glargine 6 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
16. Pyridoxine 25 mg PO DAILY
17. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
18. Azithromycin 500 mg PO ONCE Duration: 1 Doses
___
19. Furosemide 40 mg PO DAILY
start ___. Loperamide 2 mg PO BID:PRN loose stool
21. Milk of Magnesia 15 mL PO QHS: PRN constipation
22. Guaifenesin ER 600 mg PO Q12H
23. Calcium Carbonate 500 mg PO BID:PRN GI distress
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Docusate Sodium (Liquid) 100 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Lidocaine 5% Patch 1 PTCH TD DAILY
7. PredniSONE 5 mg PO DAILY
should continue until follow up with rheumatology.
8. Senna 2 TAB PO BID
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
10. Calcium Carbonate 500 mg PO BID:PRN GI distress
11. Imatinib Mesylate 100 mg PO DAILY
12. Loperamide 2 mg PO BID:PRN loose stool
13. Milk of Magnesia 15 mL PO QHS: PRN constipation
14. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
please hold for RR<12, sedation
15. Multivitamins 1 TAB PO DAILY
16. Pyridoxine 25 mg PO DAILY
17. Vitamin B Complex w/C 1 TAB PO DAILY
18. Guaifenesin ER 600 mg PO Q12H
19. Torsemide 10 mg PO DAILY
please hold for SBP<100
20. Glargine 6 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
21. Metoprolol Succinate XL 200 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Pulmonary edema
Pseudogout of left shoulder
Atrial fibrillation
Chronic myelogenous leukemia
Secondary: Hypertension
Type 2 diabetes
Acute on chronic 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 ___
because of difficulty breathing. You were originally admitted to
the ICU and improved there, and were transferred to the Oncology
floor. While here, you were stable and did well after we gave
you some medications that helped remove fluid from your lungs.
You also had some left shoulder pain while here, and were found
to have a recurrence of pseudogout in your left shoulder. This
pain improved a great deal after you got a steroid injection
from the Rheumatology team.
While you were here, some medications were changed.
Please START torsemide.
Please STOP furosemide.
Please STOP azithromycin.
Please INCREASE your metoprolol.
STOP losartan.
Please follow up with Dr. ___, Dr. ___, and
Urology as below.
Followup Instructions:
___
|
10386562-DS-16 | 10,386,562 | 27,324,245 | DS | 16 | 2169-08-19 00:00:00 | 2169-08-19 21:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Shellfish Derived / vancomycin / Amoxicillin
Attending: ___.
Chief Complaint:
fall, confusion
Major Surgical or Invasive Procedure:
left trochanteric bursa steroid injection (Solumedrol)
History of Present Illness:
___ with a medical history of CML on gleevac, Pseudogout, CKD
(baseline creatinine 2.0-2.7) with left knee pain for several
days, increasing confusion, and now mechanical fall resulting in
ED visit. He was in his normal state of health until
___ this past week when he started to develop
vague left lower extremity pain that appears to localize to the
knee. The pain is worse w/ movement. He has taken tylenol but
unclear if helping. The patient attributes these symptoms to
pseudogout. It became progressively worse over the week to the
extent that he could not ambulate (typically ambulates w/
walker) and was "crawling around like a dog." When walking back
from the bathroom on ___ he slipped and fell. He was
unable to get up by himself. After the fall he reports left
elbow pain, left hip pain, and right hand pain. Denies speech
changes, sensation changes.
.
Regarding his mental status, his wife feels that over the past
several days he is more confused than normal. He denies fever,
chills, cough. He endorses stable dyspnea on exertion that is
chronic. He has not taken oxycodone for his leg pain. Recent
medication changes include starting on allopurinol for gout
(ordered in OMR to start ___ but pt wife reports started ___,
starting ciprofloxacin for possible UTI (___) and starting no
finasteride for BPH (___).
.
Of note, he has a diagnosis of pseudogout, established in ___
when he presented with polyarticular arthritis. Joint aspiration
of his knee revealed CPPD crystals. Plain films of his knee
revealed chondrocalcinosis. He has had increasing flares
recently, this month he was seen by rheumatology who
administered an injection of steroids to his shoulder and was
started on a 12 day prednisone taper with significant
symptomatic improvement.
.
In the ED, initial vitals T:98.3 BP:119/64 HR:90 RR:18
O2:100%RA. Currently AAOx2, confused on date but pts. wife
states that is not that abnormal. Labs notable for WBC 12.8
(baseline CML), HCT 31.5, creatinine 2.3 (baseline 2.0 - 2.7).
UA w/ 1WBC, no bacteria, neg leuk/nitrite. Ct head w/ no acute
process,left ___ negative for DVT, CXR obtained, left
knee/tib/fib imaging obtained.
Past Medical History:
-CML on gleevec and prednisone
-Hypertension
-Diabetes: controlled with pioglitazone, HbA1c:6.2% (___)
-Hyperlipidemia
-Spinal stenosis
-Trigeminal Neuralgia: last symptomatic over ___ years ago,
carbamazepine discontinued
-Pseudogout, manifesting as fevers of unknown origin until a
knee effusion was tapped revealing crystals. Repeat flare
___ of right elbow, synovial fluid confirmed.
-Polyarticular arthritis
-CKD: baseline creatinine of 1.7
-BPH with elevated PSA; prior prostate biopsy reportedly
negative for malignancy
-S/P polypectomy of several adenomatous polyps
-Bilateral THAs in ___ and ___
-MSSA Bacteremia ___ with 4 planned weeks OPAT with dapto
Social History:
___
Family History:
No known history of hematologic or oncologic dyscrasia.
Physical Exam:
VS - Afebrile BP:113/58 HR:93 RR:18 O2: 100%RA
GENERAL - well-appearing elderly man, comfortable, hard of
hearing
HEENT - NC/AT, anicteric, OP clear
NECK - JVP not visualized
LUNGS - CTA bilat, good air movement, resp unlabored
HEART - PMI non-displaced, irregular rhythm, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - ecchymosis on upper extremities
NEURO - awake, oriented to self, hospital, can ___ forward in
<10 seconds, speech fluent, tongue midline, face symmetric,
PERRL, move upper extremity antigravity, right lower extremity
dorsiflex/plantar flex/extension ___, left lower extremity
plantar/dorsiflexion ___ but leg extension limited by knee pain,
gait not assessed
MSK: pain with flexion and extension of left elbow, left knee
appears slightly larger than right, no overlying erythema or
warmth, pain with flexion and extension
Discharge exam:
afebrile, normal vital signs. very hard of hearing
Left ___ with pain on lateral aspect
no knee or hip instability on exam
CV- occasionally irregular, no murmurs
Lungs- clear
Abdomen- soft
Neuro- no ___ weakness or numbness (able to flex left hip with
some difficulty, more flexion when pain is better controlled)
Pertinent Results:
___ 11:55AM BLOOD WBC-12.8* RBC-2.96* Hgb-9.9* Hct-31.5*
MCV-106* MCH-33.4* MCHC-31.4 RDW-18.5* Plt ___
___ 11:55AM BLOOD Neuts-84.5* Lymphs-9.4* Monos-5.0 Eos-0.7
Baso-0.4
___ 11:55AM BLOOD Glucose-193* UreaN-51* Creat-2.3* Na-140
K-4.1 Cl-102 HCO3-28 AnGap-
.
#CXR: pleural plaque, decreased lung volume, no opacity or
effusion
#L. KNEE FILM: Chondrocalcinosis, no effusion, + vascular
calcifications.
___: Negative for DVT.
#CT head: no acute process
Discharge labs:
___ RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
8.2 2.92 9.4 29.7 102 32.2 31.5 18.3 344
UreaN Creat Na K Cl HCO3 AnGap
54 2.1 143 4.6 106 33 9
CXR:
IMPRESSION: Extensive pleural plaque limits evaluation.
Allowing for this,
no obvious signs of infection.
Two views of the left elbow were reviewed:
There is no overt fracture, but fluid in the elbow cannot be
excluded. If
clinically warranted, correlation with cross-sectional imaging
might be
considered.
CT pelvis:
IMPRESSION:
1. Limited study due to streak artifact from bilateral total
hip prosthesis.
No fracture identified.
2. Sigmoid diverticulosis with a focus of mild sigmoid wall
thickening and
surrounding fat stranding in the left lower quadrant, new from
___. In the proper clinical setting, these findings may
represent mild acute
diverticulitis. Otherwise, in the absence of clinical symptoms,
these findings
may be due to a prior episode of diverticulitis but new from
___.
3. Enlarged prostate.
Ultrasound left hip:
IMPRESSION:
Small left greater trochanteric bursitis.
MR hip:
IMPRESSION:
1. Bilateral total hip arthroplasties limits evaluation of the
immediate
neighboring structures. However, no acute fracture is detected
in the
visualized bones.
2. Mild left greater trochanteric bursitis.
3. Right hamstring tendon attachment partial tear.
Brief Hospital Course:
#KNEE PAIN/PSEUDOGOUT: Patient with a history of crystal proven
pseudogout with increasing flares recently with progressively
worsening left knee pain over the past several days. X-ray
showing chondrocalcinosis. While OMR indicates allopurinol was
ordered on ___, around the same time that patient's symptoms
started, wife reports did not start taking until yesterday. His
presentations seems most c/w pseudogout. ___ negative for DVT.
No symptoms concerning for systemic infection at this time.
Neuro exam does not seem consistent w/ focal UMN abnormality.
Patient evaluated by both orthopedic surgery and rheumatology.
Extensive imaging did not reveal any fracture or obvious
malalignment of left hip prosthesis. Patient underwent left
trochanteric bursa injection, with some improvement in pain.
Additional exam revealed likely IT band syndrome on left thigh.
Patient's pain and stability with ambulation improved following
___ for IT band syndrome (massage left lateral thigh TID, ice,
lidocaine patches).
.
#MECHANICAL FALL: Patient w/ mechanical fall in the setting of
left knee pain. Management as above. Ambulatory with walker
with close supervision. Patient has no pain at rest, only with
ambulation.
.
#AMS: mental status normalized after pain controlled. Patient
is A and O x 3, very pleasant, very hard of hearing.
.
#CML: Continued Gleevac
.
#CKD: Creatinine at baseline. Renally dosed medication. Avoided
nephrotoxins
.
#DM2: held actos, continued on regular insulin SS. Restarting
Actos upon discharge, patient will likely not need regular
insulin SS (keeping on med list for now)
.
#Atrial fibrillation: continued beta blocker and aspirin 325 mg
.
#HL: continued statin
DNR
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q8H pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. PredniSONE 5 mg PO DAILY
5. Imatinib Mesylate 100 mg ORAL DAILY
6. Multivitamins 1 TAB PO DAILY
7. Vitamin B Complex 1 CAP PO DAILY
8. Torsemide 10 mg PO DAILY
9. Metoprolol Succinate XL 300 mg PO DAILY
10. Finasteride 5 mg PO DAILY
11. Ciprofloxacin HCl 250 mg PO Q12H
12. Allopurinol ___ mg PO EVERY OTHER DAY
13. Pioglitazone 45 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Torsemide 10 mg PO DAILY
7. Vitamin B Complex 1 CAP PO DAILY
8. Bisacodyl 10 mg PO DAILY:PRN constipation
9. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
10. Lidocaine 5% Patch 1 PTCH TD DAILY
11. Senna 1 TAB PO DAILY
12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
13. Allopurinol ___ mg PO EVERY OTHER DAY
14. Imatinib Mesylate 100 mg ORAL DAILY
15. Metoprolol Succinate XL 300 mg PO DAILY
16. Pioglitazone 45 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary diagnoses:
left IT band syndrome
left trochanter bursitis
Secondary diagnoses:
CML
CKD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane) and very close supervision.
Discharge Instructions:
You were admitted to the hospital with left leg pain. You
underwent extensive testing and were seen by both rheumatology
and orthopedic surgery. Multiple imaging studies revealed a
small area of inflammation near the left hip- this was injected
with a steroid. Imaging tests did not reveal any significant
problems with the left hip replacement. Your pain is likely
from a strained tendon on the outside of your left leg- you
should continue to receive physical therapy and massage this
three times daily.
Please see below for your follow up appointments and
medications.
Followup Instructions:
___
|
10386562-DS-17 | 10,386,562 | 26,699,119 | DS | 17 | 2169-09-25 00:00:00 | 2169-09-27 20:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Shellfish Derived / vancomycin / Amoxicillin
Attending: ___.
Chief Complaint:
Hallucinations
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of CML on Gleevec, HTN, HL, DM, spinal
stenosis, pseudogout, CKD, BPH, and several recent falls,
presenting now with hallucinations. Per his wife, he was
sitting at the edge of his bed on ___ night (4 days PTA),
about to get up, when the bed rolled back and he slipped and
fell on the floor. No LOC or head strike. His wife then fell
trying to get him up, and had to call EMS for assistance. No
intervention taken at time, as patient did not want to go to ED.
Since then, his wife reports he has been having hallucinations,
such as seeing animals or people in the home. However, on review
of his chart, he was actually having hallucinations before this
fall, as reported in an Oncology note from ___. Has had
hallucinations in the past, in the context of infection. Was
also some concern in past that hallucinations could be related
to taking Gleevec, and dose was decreased from 400 mg daily to
100 mg daily. Also has a history of confusion in setting of
pain. Saw his PCP today, who was concerned about his
hallucinations and referred him to ED for further evaluation.
On arrival to the ED, initial vitals were 97.4 66 136/84 20 93%.
On exam, a trauma survey was negative for any injuries, and he
had a stable pelvis with no reported hip pain. Labs notable for
Cr 2.3 (baseline 1.5 in ___, more recently ___, WBC 17.7
(recently has ranged ___. LFTs and lactate WNL. UA not
suggestive of UTI. CXR not suggestive of PNA. CT head negative
for any acute intracranial process, and CT c-spine negative for
fracture or vertebral malalignment. ED did not feel safe
discharging patient without a longer period of observation to
rule out infection; therefore he is being admitted to Medicine.
Vitals prior to transfer 97.4 91 135/92 18 99%. On arrival to
floor, patient complains of mild headache, neck pain, and
bilateral shoulder pain, which were present prior to his fall.
States he is hungry but has no other complaints. Denies recent
sick contacts.
Of note, patient has had several recent falls. Was admitted
last month after a mechanical fall in the setting of left knee
pain from pseuogout. He was also felt to have left IT band
syndrome. Initially had confusion, which resolved with
improvement in pain control. Did not have signs/symptoms of
infection at the time.
ROS: Positive as per HPI. Has chronic chills and recent loose
stools. No fever, sweats, weight change, vision changes, sore
throat, chest pain, dyspnea, cough, abdominal pain, nausea,
vomiting, constipation, bloody stools, dysuria, knee pain. Has
lower extremity edema that is improving.
Past Medical History:
-CML on Gleevec
-Hypertension
-Diabetes mellitus
-Hyperlipidemia
-Spinal stenosis
-Trigeminal Neuralgia
-Pseudogout
-Polyarticular arthritis
-CKD, baseline creatinine recently ___
-BPH with elevated PSA; prior prostate biopsy reportedly
negative for malignancy
-s/p polypectomy of several adenomatous polyps
-Bilateral THAs in ___ and ___
-MSSA Bacteremia ___
-Atrial fibrillation
-Lower extremity edema (preserved EF on echo ___
Social History:
___
Family History:
No known history of hematologic or oncologic dyscrasia.
Physical Exam:
ADMISSION EXAM:
VS - Temp 98.6 F, BP 156/78, HR 88, RR 18, SpO2 97% RA, weight
63 kg
GENERAL - elderly male, resting comfortably in NAD, hard of
hearing
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, dry MM, OP clear
NECK - supple, no JVD, no cervical LAD
HEART - irregularly irregular, no r/m/g
LUNGS - CTAB, no wheezes/rales/rhonchi, good air movement
ABDOMEN - normoactive bowel sounds, soft, non-distended,
non-tender, + splenomegaly, no guarding or rebound tenderness
EXTREMITIES - trace-1+ edema bilaterally, DP/PTs 1+ bilaterally
SKIN - no jaundice, scattered ecchymoses on lower extremities,
no lesions on feet
NEURO - awake, AAOx3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, gait
assessment deferred
MSK: diffuse tenderness to palpation of bilateral shoulders not
localized to the joints or tendons, no effusion; L knee slightly
larger than R but without clear effusion/warmth/erythema, no TTP
along knee joint line bilaterally
DISCHARGE EXAM:
T ___ BP 100-120/60-70 HR 80 RR 18 O2 Sat 100% RA
GENERAL: resting comfortably, NAD, hard of hearing
HEENT: sclerae anicteric, MMM
NECK: supple
HEART: irregularly irregular, no r/m/g
LUNGS: CTAB, no wheezes/rales/rhonchi, good air movement
ABDOMEN: normoactive bowel sounds, soft, slightly distended,
non-tender
EXTREMITIES: trace edema bilaterally, DP/PTs 1+ bilaterally
SKIN: no jaundice, scattered ecchymoses on lower extremities
NEURO: Vision is intact bilaterally at 4 feet. CN II-XII grossly
intact. Non focal.
Pertinent Results:
ADMISSION LABS:
___ 01:02PM BLOOD WBC-17.7* RBC-3.22* Hgb-10.4* Hct-32.6*
MCV-101* MCH-32.1* MCHC-31.8 RDW-17.5* Plt ___
___ 01:02PM BLOOD Neuts-79* Bands-0 Lymphs-3* Monos-5 Eos-0
Baso-2 ___ Metas-3* Myelos-8*
___ 01:02PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-NORMAL
Macrocy-2+ Microcy-NORMAL Polychr-1+ Target-OCCASIONAL
___ 01:02PM BLOOD ___ PTT-35.4 ___
___ 01:02PM BLOOD Glucose-141* UreaN-62* Creat-2.3* Na-140
K-4.2 Cl-100 HCO3-25 AnGap-19
___ 01:02PM BLOOD ALT-12 AST-23 AlkPhos-59 TotBili-0.3
___ 01:02PM BLOOD Albumin-3.8 Calcium-9.3 Phos-4.7* Mg-2.2
___ 01:12PM BLOOD Lactate-1.5
___ 01:02PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:02PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
___ 01:02PM URINE RBC-0 WBC-1 Bacteri-FEW Yeast-NONE Epi-1
OTHER PERTINENT LABS:
___ 02:40PM BLOOD CRP-170.8*
___ 06:30AM BLOOD CRP-136.5*
___ 02:40PM BLOOD ESR-60*
___ 06:30AM BLOOD ESR-52*
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-15.1* RBC-3.11* Hgb-9.7* Hct-31.6*
MCV-102* MCH-31.1 MCHC-30.6* RDW-17.3* Plt ___
___ 06:30AM BLOOD Glucose-99 UreaN-66* Creat-2.1* Na-136
K-4.3 Cl-103 HCO3-23 AnGap-14
___ 06:30AM BLOOD Calcium-8.1* Phos-4.2 Mg-2.0
MICROBIOLOGY:
Urine culture ___: mixed bacterial flora c/w contamination
Blood culture ___: pending, no growth at time of discharge
IMAGING:
CXR ___: Mild bibasilar atelectasis or scarring. Low lung
volumes. Calcified bilateral pleural plaques. No definite new
areas of focal consolidation is identified.
CT Head w/o contrast ___: No acute intracranial process.
CT C-spine w/o contrast ___:
1. No acute fracture or change in vertebral alignment.
2. Stable multilevel degenerative changes with mild spinal
canal narrowing and mild multilevel neural foraminal narrowing.
3. Calcified pleural plaques consistent with prior asbestos
exposure.
4. Stable hypodense nodule in the right thyroid lobe.
Brief Hospital Course:
___ with history of CML on Gleevec, HTN, HL, DM, spinal
stenosis, pseudogout, CKD, BPH, and several recent falls,
presenting now with hallucinations.
# Hallucinations: In past, hallucinations have occurred in
setting of infection, pain, and possibly related to his Gleevec.
During this admission, patient was afebrile without evidence of
an acute infectious process. Given concern about Gleevec
possibly contributing, this was initially held after contacting
his outpatient oncologist. The Geriatrics team was consulted,
and felt that patient has underlying cognitive impairment with
abnormal mini-cog and a history of functional decline over the
last few years, placing him at high risk for delirium. They
felt he his hallucinations were likely in setting of delirium,
secondary to pain from headache and possibly the Gleevec. They
also felt that he may have ___ body dementia, given cognitive
impairment, falls and fluctuating course. Did not recommend
treating the hallucinations, as he is not distressed by them.
He did not have further hallucinations in the hospital.
# Headache: CT head on admission negative for any acute
intracranial process. ___ have been tension-type headache, but
given tenderness to palpation over temporal areas bilaterally
and elevated ESR/CRP, was some concern for GCA. Rheumatology
consulted, and recommended Vascular surgery consult for temporal
artery biopsy. Did not feel patient needed to start on steroids
prior to biopsy, given overall lower suspicion for GCA.
Patient's headache then resolved over next ___ days without
intervention, and it was felt GCA was unlikely. Temporal artery
biopsy therefore not pursued. Pain was controlled with
acetaminophen as needed.
# Anion gap metabolic acidosis: No significant hyperglycemia or
ketones in urine to suggest DKA. Lactate WNL. Resolved with PO
hydration.
# Recent falls: Per report, seem to all have been mechanical in
nature. CT head and C-spine in ED unremarkable for acute
process. As above, some concern for ___ Body Dementia.
Patient seen by ___, and cleared for discharge home with ___.
# CML: Held Gleevec per outpatient oncologist as above on
presentation, but this was restarted on discharge. Per
oncology, unlikely to be cause of hallucinations.
# Elevated inflammatory markers: ESR/CRP significantly elevated
this admission, without clear etiology. Infectious work-up,
including UA, CXR, and blood cultures negative (though final
blood culture results still pending at time of discharge). Was
some concern for GCA given headache, but headache was somewhat
atypical and resolved without intervention, making this seem
less likely as above. Rheumatology followed the patient. He
did not have any evidence of a recurrent flare of his
pseudogout. Of note, his PSA is elevated, and an underlying
malignancy would be on differential. ESR/CRP were trending down
at time of discharge.
CHRONIC ISSUES:
# CKD: Recent baseline Cr ___. Cr was generally within this
range during admission.
# Hypertension: Continued home metoprolol, torsemide.
# Diabetes mellitus: Held home pioglitazone while in house;
resumed on discharge. HISS.
# Hyperlipidemia: Continued home statin.
# Atrial fibrillation: Continued home metoprolol, aspirin.
# Lower extremity edema: Continued home torsemide.
# Pseudogout: No active flare. Continued home allopurinol.
Was seen by Rheumatology.
# Polyarticular arthritis: Acetaminophen prn pain.
# BPH: Continued finasteride.
TRANSITIONAL ISSUES:
-During admission, Geriatrics consult team felt patient may have
underlying ___ Body Dementia. He may benefit from further
work-up in the outpatient setting.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Ferrous Sulfate 325 mg PO BID
3. Metoprolol Tartrate 100 mg PO TID
4. Atorvastatin 10 mg PO DAILY
5. Pioglitazone 45 mg PO DAILY
6. Imatinib Mesylate 100 mg PO DAILY CML
7. Torsemide 10 mg PO DAILY
8. Allopurinol ___ mg PO MWF
9. Finasteride 5 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO MWF
2. Atorvastatin 10 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Metoprolol Tartrate 100 mg PO TID
6. Torsemide 10 mg PO DAILY
7. Acetaminophen 1000 mg PO TID
8. Pioglitazone 45 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Imatinib Mesylate 100 mg PO DAILY CML
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Acute toxic-metabolic encephalopathy, Headache
Secondary: CML, anion gap metabolic acidosis, chronic kidney
disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted to the hospital after having hallucinations at
home. We were initially concerned about a possible infection,
but you did not have any signs of an infection while you were
here. You were seen by our Geriatrics consult service, who felt
that you had delirium. It is also possible you are developing a
type of dementia called ___ Body Dementia, and you should
discuss this with your primary care doctor.
While you were here, you reported a headache. The
rheumatologists felt your headache was not dangerous and did not
recommended any steroids or biopsy. Your headache improved with
Tylenol.
It is possible, though less likely, that your Gleevec is
contributing to your hallucinations. We held this medication
for you while you were here. You should resume taking this once
you leave the hospital.
Please weigh yourself every morning, and call your doctor if
your weight goes up more than 3 pounds.
Followup Instructions:
___
|
10386699-DS-17 | 10,386,699 | 29,955,927 | DS | 17 | 2152-06-09 00:00:00 | 2152-06-10 14:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Subdural Hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o M with significant cardiac history on Coumadin and plavix
presents with elevated INR of 3.___t OSH that shows
small parafalcine SDH. He was transferred to ___ for further
management. Once at ___, he was given Profilnine. Patient
reports that he was walking from the bed to the bathroom
and felt like he was falling forward. He usually ambulates with
a cane and states that he fell forward on the floor at around
8pm with loss of consciousness. The patient was uncertain of how
long he was unconscious. He awoke and felt asymptomatic so
stayed at home. Today, he presented to his PCP for ___ routine INR
check when the nurse noted ___ ecchymotic R eye. His INR was found
to be 3.9 and he was sent to OSH for a workup.
Patient reports an unintentional weight loss of 12 pounds in 1
month with constant achy LLQ abdominal pain with nausea. He
denies any headaches, changes in vision, dizziness, or
dysarthria.
Past Medical History:
CAD, MI, ischemic cardiomyopathy, single chamber ICD,
depression, DM2, HTN, dyslipidemia, COPD, stents x 4,
constipation, pancreatitis, PAF, ___ and 9th rib fx, s/p
cholecystectomy, bowel blockage with surgical exploration ___ yrs
ago.
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
O: T:98.4 BP:106/74 HR: 65 R: 16 O2Sats: 96%
Gen: WD/WN, comfortable, NAD.
HEENT: R periorbital ecchymosis
Pupils: 3-2mm bilaterally
EOMs: intact
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
DISCHARGE PHYSICAL EXAM:
==========================
VS - 97.7 102/63 57 18 99/RA
General: Thin gentlemen
HEENT: Bruise over R eye, NC, no other e/o trauma
Neck: Supple
CV: RRR, no m/r/g
Lungs: CBAT
Abdomen: Soft, ND, mild tenderness on deep palpation of
umbilicus but distractable exam, no hepatosplenomegaly, +BS
GU: No foley
Ext: No c/c/e
Neuro: CN II-XII intact
Skin: No rashes
Pertinent Results:
LABS:
======
___ 04:40AM BLOOD WBC-7.8 RBC-4.26* Hgb-12.9* Hct-41.0
MCV-96 MCH-30.3 MCHC-31.5 RDW-13.1 Plt ___
___ 05:35AM BLOOD WBC-6.0 RBC-3.89* Hgb-11.8* Hct-37.6*
MCV-97 MCH-30.3 MCHC-31.4 RDW-12.9 Plt ___
___ 05:00PM BLOOD ___
___ 05:35AM BLOOD ___ PTT-37.1* ___
___ 05:40PM BLOOD ___ PTT-35.4 ___
___ 04:40AM BLOOD ___ PTT-32.8 ___
___ 05:35AM BLOOD Glucose-135* UreaN-11 Creat-0.7 Na-142
K-3.9 Cl-101 HCO3-34* AnGap-11
___ 04:40AM BLOOD Glucose-75 UreaN-13 Creat-0.8 Na-141
K-4.3 Cl-104 HCO3-33* AnGap-8
___ 05:35AM BLOOD ALT-16 AST-20 AlkPhos-43 Amylase-57
TotBili-0.9
___ 05:35AM BLOOD Albumin-3.6 Calcium-8.4 Phos-2.9 Mg-1.8
___ 04:40AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.9
IMAGING:
========
CXR (___):
IMPRESSION: No definite acute cardiopulmonary process. Please
note that CT is more sensitive in detecting pulmonary nodules.
CT Scan Head (___):
IMPRESSION:
Stable left anterior parafalcine subdural hemorrhage.
Brief Hospital Course:
___ y/o M with PMH DM2, HTN, HLD, CAD s/p ___, ischemic
cardiomyopathy with ICD, depression, and chronic abdominal pain
transferred from ___ for ___ management after syncopal episode.
ACTIVE ISSUES:
===============
# Subdural Hematoma
Diagnosed after fall in setting of supratherapeutic INR.
Referred to ___ for further management. While here
neurosurgery evaluated and followed patient with no e/o
progression of SDH with INR reversed. Plavix/ASA resumed after
48 hours given recent ___. Coumadin instructed could be
resumed 10 days (___) after being in the hospital, per
neurosurgery with PCP to resume as appropriate for his paroxsmal
afib. While here no e/o neurological symptoms or complaints.
# Syncope
Longstanding history without clear etiology. On history of
presentation, appears to most likely be orthostatic hypotension
with report of syncope after standing up. Thought to be most
consistent with orthostasis due to lack of PO intake with
improvement noted after resuming diet and IVF hydration. Prior
episodes reported with admission during ___ for similar
presentation. No events on tele. Consulted EP who interrogated
ICD with no evidence of firing or events during reported events.
No clear evidence of acute etiology for his syncope.
# Abdominal Pain
Chronic, had been evaluated in the past including at ___ with
recommendation for GI follow-up. Unclear etiology. KUB negative.
CT abd at ___ without acute process or clear cause. Prior
reports improved after bowel regiment for constipation including
while here on standin bowel regiment. Does have concerning
features of weight loss but no GI bleed or melena. History was
not as c/w for gastroparesis. Negative amylase/lipase for
pancreatitis. LFTs unremarkable. Contributing is also recent
opiod use that may be causing gut slowdown with recommendation
to avoid using for abdominal pain. Continue follow-up closely
with GI as scheduled recommended.
CHRONIC ISSUES:
================
# CAD w/ ___
Reportedly had stents in ___. Had held Plavix/ASA for ___
given ___ per neurosurgery but resumed before dispo.
# Paroxsmal Afib
Was on ongoing coumadin therapy. Held given ___. Told by
neurosurgery could resume ___ with PCP resuming and
monitoring.
TRANSITIONAL ISSUES:
=====================
- F/u with GI for work-up of abdominal pain, nausea, and weight
loss
- Resume coumadin after ___ with close monitoring required
- Ensure f/u with cardiology
- Continue syncope evaluation
- Ensure routine cancer screening by PCP given weight loss
- Discuss with social work/case management to have service
consideration for patient
- Continued f/u with neurosurgery in 4 weeks with letter sent to
pt as a reminder
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 3.125 mg PO BID
2. Lisinopril 2.5 mg PO HS
3. Simvastatin 20 mg PO QPM
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheezing
5. MetFORMIN (Glucophage) 500 mg PO BID
6. ClonazePAM 1 mg PO TID
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Clopidogrel 75 mg PO DAILY
9. Nitroglycerin SL 0.3 mg SL PRN Chest Pain
10. Duloxetine 30 mg PO DAILY
11. TraZODone 25 mg PO HS:PRN Insomnia
12. Warfarin 5 mg PO DAILY16
13. Psyllium 1 PKT PO TID:PRN Constipation
14. Multivitamins 1 TAB PO DAILY
15. Ranexa (ranolazine) 500 mg oral BID
16. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
17. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheezing
2. Carvedilol 3.125 mg PO BID
3. ClonazePAM 1 mg PO TID
4. Clopidogrel 75 mg PO DAILY
5. Duloxetine 30 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Lisinopril 2.5 mg PO HS
8. Multivitamins 1 TAB PO DAILY
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
10. Simvastatin 20 mg PO QPM
11. TraZODone 25 mg PO HS:PRN Insomnia
12. Aspirin 81 mg PO DAILY
13. MetFORMIN (Glucophage) 500 mg PO BID
14. Nitroglycerin SL 0.3 mg SL PRN Chest Pain
15. Psyllium 1 PKT PO TID:PRN Constipation
16. Ranexa (ranolazine) 500 mg ORAL BID
17. Bisacodyl 10 mg PR HS:PRN Constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally Daily Disp #*30
Suppository Refills:*0
18. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice a day
Disp #*30 Capsule Refills:*0
19. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth Twice a day Disp
#*30 Capsule Refills:*0
20. Simethicone 40-80 mg PO QID:PRN Bloating, abdominal pain
RX *simethicone 80 mg 1 tablet by mouth Four times a day Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Subdural Hematoma
Constipation
Weight loss
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 as you had evidence a small,
but stable brain bleed known as a subdural hematoma. Our
neurosurgeons followed you here and no further treatment was
needed.
Your blood thinning medications were stopped while you were here
but the aspirin and plavix were restarted before you left since
you have stents in your heart. Your coumadin (warfarin) was held
but, per our neurosurgeons, can restart treatment on ___
after stopping for 10 days. You will need to follow-up with your
primary care physician to help restart your warfarin and ensure
proper monitoring.
Your lightheadness with falls is likely due to not eating or
drinking sufficiently. Your symptoms improved after giving you
fluids. Cardiology assessed your pacemaker and no evidence of an
abnormality in your heart rhythm. However, they continued to
recommend that you follow-up with your cardiologist shortly
after leaving the hospital.
Given your weight loss related to loss of appetite, you will
need to follow-up with gastroenterology (GI) who will be able to
perform further testing as needed and help treat your symptoms.
Please continue to take medications to help with your
constipation. Please avoid using too many pain medications for
your abdominal pain because it can slow your stomach down.
Please continue to take your normal medications as prescribed.
Take care.
- Your ___ Team
Followup Instructions:
___
|
10386699-DS-18 | 10,386,699 | 27,478,074 | DS | 18 | 2156-02-15 00:00:00 | 2156-02-16 11:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
worsening abdominal pain and nausea x1 week with known AAA
Major Surgical or Invasive Procedure:
___ - EVAR
History of Present Illness:
___ h/o known AAA, MI x3, a-fib, and T2DM p/w periumbilical pain
radiating to back x10 days. He underwent abdominal CTA and
carotid ultrasound 1 week ago at ___ due to
periumbilical pain intermittently radiating to back with known
4.9cm AAA. These symptoms have persisted and he now reports
nausea, dizziness, and diaphoresis with worsening pain. He
arrived to ___ ED via EMS.
Past Medical History:
CAD, MI, ischemic cardiomyopathy, single chamber ICD,
depression, DM2, HTN, dyslipidemia, COPD, stents x 4,
constipation, pancreatitis, PAF, ___ and 9th rib fx, s/p
cholecystectomy, bowel blockage with surgical exploration ___ yrs
ago.
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: T98.0 58 146/88 16 99%
Gen: uncomfortable
HEENT: NCAT, MMM
Cardio: RRR
Pulm: CTAB
ABD: soft, diffuse tenderness on light palpation, most TTP at
periumbilical region, nondistended. No palpable masses noted.
Back: mild L CVA tenderness
Extremities: No ___ edema, WWP
Pertinent Results:
Pertinent Admission Labs:
___ 03:25PM BLOOD WBC-8.9 RBC-4.07* Hgb-11.9* Hct-37.1*
MCV-91 MCH-29.2 MCHC-32.1 RDW-13.8 RDWSD-46.4* Plt ___
___ 03:25PM BLOOD Neuts-56.2 ___ Monos-8.5 Eos-5.4
Baso-0.9 Im ___ AbsNeut-5.03 AbsLymp-2.54 AbsMono-0.76
AbsEos-0.48 AbsBaso-0.08
___ 03:25PM BLOOD ___ PTT-38.2* ___
___ 03:25PM BLOOD Glucose-87 UreaN-23* Creat-1.2 Na-141
K-4.4 Cl-99 HCO3-29 AnGap-13
___ 05:20PM BLOOD CK-MB-1 cTropnT-0.03* proBNP-5617*
___ 03:25PM BLOOD Calcium-9.1 Phos-2.9 Mg-1.6
___ 03:38PM BLOOD Lactate-1.9
Pertinent Discharge Labs:
___ 05:12AM BLOOD WBC-8.9 RBC-3.39* Hgb-9.9* Hct-30.6*
MCV-90 MCH-29.2 MCHC-32.4 RDW-13.8 RDWSD-45.2 Plt ___
___ 05:12AM BLOOD Plt ___
___ 05:12AM BLOOD Glucose-108* UreaN-25* Creat-1.1 Na-138
K-4.9 Cl-98 HCO3-30 AnGap-10
___ 09:21AM BLOOD CK(CPK)-39*
___ 05:12AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.7
Imaging:
CTA abdomen ___. Infrarenal abdominal aortic aneurysm measuring 4.9 cm
maximally with
irregular outpouchings posteriorly which may represent
penetrating ulcers or
ulcerated atherosclerotic plaque. No evidence of active
rupture.
2. Linear hypodensity within the aneurysm makes a small focal
dissection
difficult to exclude of uncertain chronicity (series 2, image 52
through 54).
3. No priors currently available for direct comparison, which
would be
helpful.
CXR ___
No acute cardiopulmonary abnormality.
Brief Hospital Course:
P: ___ w/ symptomatic AAA now s/p EVAR
A: Underwent urgent uncomplicated EVAR ___
C: Metformin and Coumadin held for 48 hour ___
T: Patient to restart Coumadin and Metformin ___ in pm
Discharge Medications:
1. Docusate Sodium 100 mg PO DAILY:PRN constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth once a
day Disp #*10 Capsule Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*18 Tablet Refills:*0
3. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*10 Tablet Refills:*0
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
5. Aspirin 81 mg PO DAILY
6. Carvedilol 6.25 mg PO BID
7. Diazepam 5 mg PO Q12H:PRN anxiety
8. Digoxin 0.125 mg PO 3X/WEEK (___)
9. Escitalopram Oxalate 20 mg PO DAILY
10. MetFORMIN (Glucophage) 500 mg PO BID
Restart ___ in the evening
11. Midodrine 10 mg PO BID
12. QUEtiapine Fumarate 200 mg PO QHS
13. Simvastatin 40 mg PO QPM
14. Tiotropium Bromide 1 CAP IH DAILY
15. Venlafaxine XR 75 mg PO DAILY
16. Warfarin 2 mg PO 3X/WEEK (___)
Restart ___ at normal dose
17. Warfarin 4 mg PO 4X/WEEK (___)
Restart ___ at normal dose
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Symptomatic AAA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
MEDICATIONS:
Take Aspirin 81 mg (enteric coated) once daily and your home
Coumadin starting ___
Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT AT HOME:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart (use ___ pillows
or a recliner) every ___ hours throughout the day and at night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and go up and down stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for 1
week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call ___ for
transfer to closest Emergency Room.
Followup Instructions:
___
|
10386866-DS-3 | 10,386,866 | 28,641,140 | DS | 3 | 2113-11-14 00:00:00 | 2113-11-14 10:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic appendectomy
History of Present Illness:
The patient is a ___ female who presented to the
emergency department with signs and symptoms of acute
appendicitis. Her complete workup, including
history, physical examination, laboratory studies, and CT scan,
led to a high clinical and radiographic suspicion for acute
appendicitis. After extensive discussion with the patient and
her family regarding the risks, benefits,
alternatives, and complications of such a procedure, informed
consent was signed for appendectomy, and she was scheduled for
the operating room. Pending OR availability, she was
transferred to the operating room.
Past Medical History:
None
Social History:
___
Family History:
Non contributory
Physical Exam:
On Admission:
VS - T 97.0, HR 70, BP 115/72, RR 15, SaO2 100% RA
Gen: NAD, non-toxic
CV: RRR
Pulm: no respiratory distress, clear bilaterally
Abd: soft, non-distended, no scars. Tender in RLQ with guarding
and rebound. +Rovsing's sign.
Ext: wwp, no edema, palpable distal pulses
Prior to discharge:
VS: 98.5, 94, 104/58, 18, 98% RA
GEN: NAD, pleasant
CV: RRR, no m/r/g
PULM: CTAB
ABD: Laparoscopic incisions with occlusive dressing and c/d/i.
EXTR: Warm no c/c/e. +pp
Pertinent Results:
___ 06:28AM BLOOD WBC-17.2* RBC-2.57* Hgb-7.8* Hct-23.5*
MCV-91 MCH-30.4 MCHC-33.2 RDW-12.1 RDWSD-40.0 Plt ___
___ 06:28AM BLOOD Glucose-96 UreaN-14 Creat-0.7 Na-141
K-3.7 Cl-105 HCO3-23 AnGap-17
___ 06:28AM BLOOD ALT-22 AST-24 AlkPhos-69 TotBili-0.3
___ 06:28AM BLOOD Albumin-4.8
___ 05:55AM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:55AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 05:55AM URINE RBC-3* WBC-1 Bacteri-FEW Yeast-NONE
Epi-<1
___ 05:55AM URINE Mucous-RARE
___ CT ABD:
IMPRESSION: Acute appendicitis. No evidence of periappendiceal
fluid collection or rupture.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed acute appendicitis, WBC
was elevated at 17.2. The patient underwent laparoscopic
appendectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
tolerating clears, on IV fluids, and IV Morphine for pain
control. The patient was hemodynamically stable.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirrometry, 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 on POD 1, the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The patient was discharged home without
services. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
do not exceed more then 3000 mg/day
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the surgery service at ___ for evaluation
of abdominal pain. You were found to have acute appendicitis and
underwent laparoscopic appendectomy. You have done well in the
post operative period and are now safe to return home to
complete your recovery with the following instructions:
.
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, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
10386925-DS-30 | 10,386,925 | 21,189,064 | DS | 30 | 2134-06-26 00:00:00 | 2134-06-27 13:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro
Attending: ___.
Chief Complaint:
nausea and 3 episodes of bloody diarrhea
Major Surgical or Invasive Procedure:
endoscopy/colonoscopy ___
History of Present Illness:
___ female with history of cholangiocarcinoma s/p hepatic lobe
resection, commob bile duct excision, hepaticojejunostomy with
Roux-en-Y, multiple admissions for biliary sepsis w/ placement
of biliary drainage tubes, and recurrent C.diff, became
nauseated last evening around 8:30 pm after eating custard and
had some diarrhea. She woke this morning and had 3 episodes of
diarrhea with significant amount of blood (colored the water
"cherry red") since 6 am. Pt has hx of chronic C.Diff and
reports vanco stopped about 1.5 weeks ago per pt (last ___
per prio notes).
In the ED, initial vital signs were 98.8 96 105/62 15 100% RA.
Patient was noted to have periumbilical tenderness to palpation,
a large reducible hernia. She was also noted to have black
stools, and had an episode of dizziness. Her Hct went from 32
(on ___ to 26 (today), thus pt was transfused 1 u pRBCs in
setting of symptomatic anemia and black stools. Transplant
surgery was consulted who evaluated the patient and felt that
she had no acute surgical issue at this time. C. diff cultures
were sent, BCx were sent.
On the floor, VS were 98.1 124/71 74 rr 16 100RA WT 52.2kg. She
is in no acute distress. C/o intermittent RLQ pain, but is no
pain currently.
Review of Systems:
(+) chills, nausea, diarrhea, blood in toilet, dark stools with
blood
(-) fever, sore throat, cough, shortness of breath, chest pain,
abdominal pain, constipation, dysuria, foul smelling urine.
Past Medical History:
-Presumed cholangiocarcinoma (partially resected with HA
encasement)
-Endometrial cancer s/p XRT
-HTN
-HLD
-Hypothyroidism
-Recurrent UTIs
-Right anterior portal vein thrombosis seen on CT ___
-Enterococcal bacteremia (___)
-Clostridium Difficile (___)
PSH:
- ___ s/p removal of percutaneous biliary drains,
drains were placed in ___ via Roux limb for occluded
biliary stents
-A common bile duct excision, left lateral segmentectomy and
Roux-en-Y hepaticojejunostomy on ___, for what was
presumed to be a cholangiocarcinoma (no tissue dx)
-multiple biliary stents placed PTC's with R post duct drain &
RBD stent
-FNA right duct (___)
-lap cholecystectomy
-Hysterectomy
-___ ERCP/stent removal x1
-___ PTC with 2 ___ PTBD's in right ant system
-Pullback cholangiogram/removal of external PTBDs (___)
-Exchange of internal/external ___ BD (___)
Social History:
___
Family History:
Mother died of ovarian cancer at age ___, Father, hx HTN and DM,
died of stroke at age ___
Physical Exam:
ADMIT PE:
Vitals- 98.1 124/71 74 rr 16 100RA WT 52.2kg
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MM dry, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally decreased BS right
side, no wheezes, rales, ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, reducible epigastric hernia tender to deep palp,
tender in RLQ, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Rectal exam: no stool in rectal vault, guaiac negative
DISCHARGE PE:
Vitals- Tm 98.2 ___ ___ 18 96-97%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MM dry, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, reducible epigastric hernia tender to deep palp,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMIT LABS:
___ 12:20PM BLOOD WBC-6.9 RBC-2.85* Hgb-8.3* Hct-26.5*
MCV-93 MCH-29.2 MCHC-31.4 RDW-16.0* Plt ___
___ 12:20PM BLOOD Neuts-77.0* ___ Monos-3.9 Eos-0.3
Baso-0.3
___ 12:48PM BLOOD ___ PTT-30.5 ___
___ 12:20PM BLOOD Plt ___
___ 12:20PM BLOOD Glucose-99 UreaN-27* Creat-0.8 Na-140
K-3.9 Cl-106 HCO3-26 AnGap-12
___ 12:20PM BLOOD ALT-16 AST-26 AlkPhos-147* TotBili-0.4
___ 12:20PM BLOOD Lipase-26
___ 12:20PM BLOOD Albumin-3.4*
___ 12:33PM BLOOD Lactate-1.6
DISCHARGE LABS:
___ 06:10AM BLOOD WBC-4.5 RBC-3.28* Hgb-9.6* Hct-29.2*
MCV-89 MCH-29.4 MCHC-33.0 RDW-16.5* Plt ___
___ 06:10AM BLOOD Glucose-89 UreaN-17 Creat-0.7 Na-138
K-3.8 Cl-106 HCO3-27 AnGap-9
___ 06:10AM BLOOD LD(LDH)-144 AlkPhos-192*
___ 06:10AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.9
MICRO:
Time Taken Not Noted Log-In Date/Time: ___ 12:57 pm
STOOL CONSISTENCY: NOT APPLICABLE Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
STUDIES:
Colonoscopy ___: Internal hemorrhoids, Polyp in the sigmoid
colon
Otherwise normal colonoscopy to cecum
.
Endoscopy ___: Follow up biopsies; will ultimately need EUS
for submucosal mass, -Given unclear etiology of stricture and
history of presumed cholangiocarcinoma, would procede with
further imaging of this area including SBFT and MRCP
___ gastric biopsy: pending
.
MRCP ___: Pending
Brief Hospital Course:
___ with ___ recent C diff having completed PO vanc ~ 1 wk prior
to presentation, presumed cholangiocarcinoma s/p common bile
duct excision, left lateral segmentectomy and Roux-en-Y
hepaticojejunostomy (___) presents with acute
nausea, bloody diarrhea, and black stools in the ED blood
transfusion, symptoms now resolved.
.
# Anemia: Patient presented to hospital with bright red blood in
the toilet and a hct decrease from ___ to from 32 to 26
on presentation. Per report, patient may have had black stools
in the ED, however, pt denied any ETOH or NSAID consumption. She
received a total of 2 units PRBCs during her hospital stay. She
had no BRBPR while in the hospital. High dose PPI was started
initially and discontinued upon dicharge. On colonoscopy,
patient was found to have hemorrhoids and single polyp, likely
cause of bleeding thought to be from hemorrhoids. On endoscopy,
she was noted to have gastric mass which was biopsied and
duodenal stricture through which the scope was unable to pass.
MRCP was done to better evaluate this area, and in the setting
of mild elevation of alk phos, though chronic, there is concern
for recurrence of malignancy. Final read is pending upon
discharge. She will follow up with GI for biopsy results and
MRCP final, plans for future workup.
.
# Nausea/diarrhea: Patient presented with an episode of nausea
and diarrhea after eating custard and recently completing course
of antibiotics for C. diff. C. diff assay was negative and
symptoms resolved without further intervention.
.
CHRONIC ISSUES:
# Elevated alk phos: Patient has had elevated alkaline
phosphatases since ___ when she was diagnosed with presumed
cholangiocarcinoma. Alk phos levels were relatively low during
this hospitalization.
.
# Hypothyroidism: Patient continued on home regimen.
- Levothyroxine Sodium 100 mcg PO 5X/WEEK (___)
- Levothyroxine Sodium 50 mcg PO 2X/WEEK (___)
.
# Gallstones / occlusions of bile ducts: Patient continued home
regimen
- cont ursodiol 300 mg PO TID per home
.
TRANSITION ISSUES:
# Code: Full (discussed with patient)
# Communication: Patient and daughter ___ (daughter)
___ cell ___ (home)
# Follow up with GI, biopsies pending
# Follow up with Oncology
# Follow up with Transplant surgery
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO MTUWETHFRI
2. Levothyroxine Sodium 50 mcg PO SASUN
3. Ursodiol 300 mg PO TID
4. Acetaminophen Dose is Unknown PO Frequency is Unknown
5. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
hold for sedation adn rr<10
Discharge Medications:
1. Levothyroxine Sodium 100 mcg PO MTUWETHFRI
2. Levothyroxine Sodium 50 mcg PO SASUN
3. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
hold for sedation adn rr<10
4. Ursodiol 300 mg PO TID
5. Acetaminophen 325 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
duodenal stricture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking care of you at ___. You were admitted
because of your nausea and bloody stools. Your hematocrit was
found to be low and you were given two units of blood. You had a
colonoscopy that showed hemorrhoids. You also had an endoscopy
that showed a narrowing of the first part of your small
intestine, and you had an MRCP done to better evaluate this
finding. You were also found to have a mass in your stomach, and
a biopsy was taken.
It is very important for your health that you follow up with
your outpatient providers.
Please see the attached sheet for your updated medication list.
Followup Instructions:
___
|
10386925-DS-32 | 10,386,925 | 28,592,400 | DS | 32 | 2134-10-10 00:00:00 | 2134-10-13 18:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro / Oxycodone
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Fluid collection I and D ___
EGD ___
Picc placement and removal
History of Present Illness:
___ hx of unresectable cholangiocarcinoma s/p incisional
hernia repair (___) c/b C.diff colitis on PO Vancomycin
presents with abdominal pain. Patient reports intermittent pain
in her upper abdomen, and right side of her back for months. It
last varying lengths of duration. She developed the same pain
today that resolved prior to arriving in the ER. She denies N/V,
fever/chills, diarrhea, melena/hematochezia. She is passing
flatus with soft stools. She is able to tolerate POs but her
appetite has been decreasing the last few weeks.
Reguarding her post-operative course she was seen in clinic for
follow up and was noted to have some incisional erythema and was
started on Zyvox for which she just completed 4 days ago. In
addition there was a soft tissue mass noted in the right flank
where her prior PTBD was located, concerning for tumor seeding.
A CT A/P was obtained on ___ which demonstrated increased
ascites
as well as omental enhancement concerning for carcinomatosis. A
small fluid collection was noted in the subcutaneous tissue
under
the incision and a mass/phlegmon was noted in the right flank.
Aspiration was attempted of this area on ___ without results.
ROS: + per HPI. - fever/chills, CP, SOB, N/V, diarrhea, melena,
hematochezia, jaundice, night sweats.
Past Medical History:
-Presumed cholangiocarcinoma (partially resected with HA
encasement)
-Endometrial cancer s/p XRT
-HTN
-HLD
-Hypothyroidism
-Recurrent UTIs
-Right anterior portal vein thrombosis seen on CT ___
-Enterococcal bacteremia (___)
-Clostridium Difficile (___)
PSH:
- ___ s/p removal of percutaneous biliary drains,
drains were placed in ___ via Roux limb for occluded
biliary stents
-A common bile duct excision, left lateral segmentectomy and
Roux-en-Y hepaticojejunostomy on ___, for what was
presumed to be a cholangiocarcinoma (no tissue dx)
-multiple biliary stents placed PTC's with R post duct drain &
RBD stent
-FNA right duct (___)
-lap cholecystectomy
-Hysterectomy
-___ ERCP/stent removal x1
-___ PTC with 2 ___ PTBD's in right ant system
-Pullback cholangiogram/removal of external PTBDs (___)
-Exchange of internal/external ___ BD (___)
Social History:
___
Family History:
Mother died of ovarian cancer at age ___, Father, hx HTN and DM,
died of stroke at age ___
Physical Exam:
On Admission:
99.2 92 ___ 96% RA
Gen: A&O, NAD
CV: RRR, no M/R/G
Pulm: CTAB
Abd: soft, mild distension. Mild TTP periumbilical. RUQ incision
healed without hernia. There is minimal erythema over the medial
portion. There is a non-tender mass in the right flank area
where
prior PTBD was with overlyng erythema. This is non-tender.
Ext: w/d, 3+ lower extremity edema
DRE: no stool in vault, gauaic +
.
On Discharge:
VS: 98.1/98.1, 100/60-114/70, 88-101, 20, 93-96% RA
Gen: no acute distress, lying in bed
HEENT: no scleral icterus, EOMI, PERRL, MMM
Pulm: crackles left mid lung field and decreased breath sounds
right base
Card: regular rhythm, borderline tachy, nml S1S2, no r/m/g
Abd: distended, non-tender, drain in place over R flank lesion,
mild erythema of epigastric region, +BS
Ext: 1+ pitting edema B/L thighs and L UE
Neuro: non focal
Pertinent Results:
On Admission: ___
WBC-4.2 RBC-2.81* Hgb-8.2* Hct-24.3* MCV-86# MCH-29.1 MCHC-33.7
RDW-16.1* Plt Ct-35*#
___ PTT-29.1 ___
Glucose-107* UreaN-27* Creat-0.9 Na-131* K-3.9 Cl-97 HCO3-27
AnGap-11
ALT-14 AST-25 AlkPhos-100 TotBili-0.4 Lipase-14
Albumin-2.3* Calcium-7.5* Phos-2.1* Mg-1.9
Lactate-1.7
.
CT Scan ___
IMPRESSION:
1. No appreciable change compared to CT from ___ in
burden of
cholangiocarcinoma along the hepatic hilum with worsening
ascites, but similar peritoneal enhancement, omental stranding,
and a few nodes or nodules in the right upper quadrant. While
there is concern for peritoneal involvement by tumor, this is
not definitive and as the nodules have not clearly increased,
this could certainly be secondary the prior infections and liver
disease with portal vein compression.
2. Interval increase in size of tiny fluid and gas collection
in the
abdominal wall of the right flank with a more conspicuous skin
sinus track suggests progression of infection. As previously
mentioned, tumor infiltration would be unlikely but cannot be
completely excluded.
.
___ CT torso with con:
1. Slightly increasing biliary dilatation as compared to the
prior studies.
2. Known cholangiocarcinoma along the hepatic hilum with
worsening ascites and suggestion of erosion into the duodenum
as described above. Peritoneal nodules as well as portal vein
compression are stable.
3. Right lower lobe collapse. Small-to-moderate right-sided
pleural effusion and trace left pleural effusion.
___ ___:
IMPRESSION: No DVT in either lower extremities.
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 root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild aortic regurgitation. Mild to moderate tricuspid
regurgitation. Bilateral pleural effusions and ascites, not
further characterized on this cardiac study.
U/S L UE Veins ___:
Non-occlusive thrombus surrounding the PICC in the right
axillary and subclavian veins.
MICRO:
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTURE-FINALINPATIENT -- no
growth
___ SCREENMRSA SCREEN-FINALINPATIENT --
none isolated
___ FLUIDGRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-FINALINPATIENT -- no growth
___ STAIN-FINAL;
WOUND CULTURE-FINAL {PSEUDOMONAS AERUGINOSA};
WOUND CULTURE (Final ___:
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
ANAEROBIC CULTURE-FINAL -- no growthINPATIENT
___ STAIN-FINAL; WOUND
CULTURE-FINAL {PSEUDOMONAS AERUGINOSA}; ANAEROBIC
CULTURE-FINALINPATIENT
___. difficile DNA amplification
assay-FINAL -- no growthINPATIENT -- none isolated
___ VANCOMYCIN RESISTANT
ENTEROCOCCUS-FINALINPATIENT -- no growth
___ CULTUREBlood Culture,
Routine-FINALEMERGENCY WARD -- no growth
___ CULTUREBlood Culture,
Routine-FINALEMERGENCY WARD -- no growth
.
Labs During Hospitalization and on Discharge:
___ 05:46AM BLOOD WBC-7.3 RBC-2.75* Hgb-8.3* Hct-24.8*
MCV-90 MCH-30.0 MCHC-33.3 RDW-17.1* Plt ___
___ 07:22AM BLOOD ___
___ 07:55AM BLOOD Ret Aut-0.7*
___ 05:46AM BLOOD Glucose-94 UreaN-11 Creat-0.5 Na-133
K-3.8 Cl-106 HCO3-23 AnGap-8
___ 03:50PM BLOOD ALT-39 AST-80* AlkPhos-203* TotBili-0.9
___ 05:46AM BLOOD ALT-30 AST-30 LD(LDH)-263* AlkPhos-109*
TotBili-0.3
___ 07:38AM BLOOD proBNP-561*
___ 03:50PM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:41PM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:08AM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:28AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:40PM BLOOD Albumin-2.5*
___ 06:22AM BLOOD Albumin-2.3* Calcium-7.5* Phos-2.1*
Mg-1.9 Iron-31
___ 05:46AM BLOOD Albumin-1.9* Calcium-6.5* Phos-1.8*
Mg-1.9
___ 06:22AM BLOOD calTIBC-176* VitB12-427 Folate-11.8
Ferritn-157* TRF-135*
___ 06:55AM BLOOD Hapto-202*
___ 05:46AM BLOOD 25VitD-PND
___ 07:55AM BLOOD CEA-2.8 AFP-4.8
___ 06:34PM BLOOD Lactate-2.2*
___ 02:40PM BLOOD Lactate-1.1
___ 07:55AM BLOOD CA ___ -Test
___ 12:18PM URINE Color-Red Appear-Clear Sp ___
___ 12:18PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 12:18PM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0 TransE-<1
___ 12:18PM URINE CastHy-2*
___ 12:18PM URINE Mucous-OCC
Brief Hospital Course:
___ y/o female with extensive medical and recent surgical history
who presents with abdominal pain. On admission the patient
underwent CT of the abdomen and pelvis. There are several
notable findings, including a right flank wound (CT reports area
of abnormal enhancement in the right flank along the oblique
muscles previously described as a phlegmon; now shows interval
increase in size of central fluid and gas collection measuring
up to 1.6 cm of longest axis diameter with associated probable
fistulous tract communicating with the skin -- more likely to be
superinfected metastasis than pure phlegmon). The wound drained,
and patient was treated with antibiotics. She was initially on
a surgical service, but was transferred to oncology service.
Hospitalization complicated by hematemesis and hypotension
requiring brief MICU stay.
#. Right flank purulent mass: Pt had rupture of right flank
collection revealing purulence with CT scan demonstrating
fistulous tract from abdominal wall communicating with the skin.
Although initial culture after rupture was negative, repeat
aspiration overnight revealed Pseudomonas. Based on imaging, it
appears that the mass may be a tumor focus, superinfected, as
opposed to an abscess/phlegmon. ID recommended cefepime and
Flagyl, which will be continued until patient sees outpatient ID
physician ___ in follow up.
#. Cholangiocarcinoma with possible peritoneal carcinomatosis:
Not a surgical candidate. Therapeutic and diagnostic
paracentesis (for cytology) done on ___, but without definitive
evidence of cancer in the peritoneum. Normal CEA and AFP and CA
___. Treatment in future depending on staging and resolution of
acute infection. She will have medical oncology and radiation
oncology outpatient follow up.
# Hypotension: Patient became hypotensive in AM of ___ to
SBP in ___. Transferred to MICU. Responded well to 4L of IVF.
Resolved. Unclear event as precipitant but likely some form of
inflammatory response evident given WBC count elevation vs.
bleeding alone. Could have been related to inflammatory
response from tumor invasion and bleed versus transient biliary
obstruction. No clear infectious source found outside of flank
mass, which was already being treated. Volume depletion or HCT
drop alone could explain hypotension, but pt may have had
transient biliary obstruction (alk phos elevation, relative ___
elevation) which then resolved.
# GI bleed: Patient had hematemesis with hypovolemia. EGD shows
esophagitis and gastritis. Unclear if this is fully responsible
for the GI bleed, but given small volume hematemesis, this is
most likely cause, as opposed to duodenal tumor which was not
visualized and thus would be unlikely to cause hematemesis. GI
did not find much on EGD that would suggest tumor eroding into
dudeonum. Per GI, radiology reviewed films, and no clear
evidence of tumor communicating into duodenum. If pt were to
continue to have unexplained melena, then tumor into duodenum
would seem more likely. High-dose PPI and Carafate were
prescribed. No further GI bleeding after the EDG.
# Mixed cholestatic and hepatocellular transaminitis: Transient
obstruction seems likely given interval biliary dilation seen on
CT, combined with elevated alk phos and ___ + hepatocellular
picture. This may have played a role in the transient SIRS
response requiring ICU transfer.
#. C diff: PCR here was negative. Pt however gets recurrent C
diff with abx. Thus, she is being prophylaxed while on cefepime
with oral vanco 125 mg Q8h
# Worsening ascites: Likely from peritoneal carcinomatosis. Pt
was tapped ___. Then restarted on PO Lasix.
# Edema: Pt with anasarca. Likely from low albumin, >4L
repletion in ICU. ECHO nml.
# Right lung opacification: RLL collapse on CT on ___. Not
short of breath. No urgent need for bronch. Unclear etiology:
? mucous plug versus pleural effusion but effusion only small to
moderate. Per ICU, nothing clear to tap. Aggressive physical and
respiratory therapy.
# Rising INR: Most likely from poor nutrition. PO vitamin K 5
mg x 3 days was planned, but this was stopped ___ after only 1
dose due to LUE line-associated DVT as below.
# PICC-associated UE DVT: Patient had LUE swelling and, based on
UE venous US, an UE DVT. We cannot anticoagulate given bleed, so
removed PICC and placed another on the right side.
# Prophylaxis: Boots. Would hold off on heparin given continued
evidence of low grade GI bleed.
# Hypothyroid: stable. Continued home levothyroxine.
# Goals of care: This was readdressed. If pt were to clinically
decompensate, unlikely to do well given host of comorbidities
and recurrent illnesses. However, pt does want to be full code.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Levothyroxine Sodium 125 mcg PO DAILY
3. Prochlorperazine 2.5-5 mg PO Q6H:PRN nausea
4. Ursodiol 300 mg PO TID
5. Acetaminophen 650 mg PO Q8H:PRN pain
6. Vancomycin Oral Liquid ___ mg PO BID
7. Famotidine 20 mg PO DAILY
Discharge Medications:
1. Sucralfate 1 gm PO BID
RX *sucralfate 1 gram/10 mL 1 Suspension(s) by mouth twice a day
Disp #*14 Gram Refills:*0
2. CefePIME 2 g IV Q24H
RX *cefepime [Maxipime] 2 gram 2 grams IV Q24H Disp #*14 Unit
Refills:*0
3. Vancomycin Oral Liquid ___ mg PO Q8H
RX *vancomycin 125 mg 125 mg by mouth every eight (8) hours Disp
#*90 Unit Refills:*0
4. Acetaminophen 650 mg PO Q8H:PRN pain
5. Furosemide 20 mg PO DAILY
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Prochlorperazine 2.5-5 mg PO Q6H:PRN nausea
8. Ursodiol 300 mg PO TID
9. Calcium Carbonate 1000 mg PO TID W/MEALS
Do not take within 2 hours of taking levothyroxine
RX *calcium carbonate 400 mg (1,000 mg) 2 tablet, chewable(s) by
mouth three times a day Disp #*180 Tablet Refills:*0
10. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*42 Tablet Refills:*0
11. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth twice a day Disp #*60 Capsule Refills:*0
12. Potassium Chloride 20 mEq PO DAILY
RX *potassium chloride 10 mEq 2 capsules by mouth daily Disp
#*60 Capsule Refills:*0
13. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
daily Disp #*60 Capsule Refills:*0
14. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Hold for sedation
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
15. Outpatient Lab Work
Diagnosis: Skin/Soft tissue infection on cefepime
- weekly BMP,ALT,AST,CBC w/diff start ___ till cefepime
completion. Please fax to:
Dr. ___
and ___: Fax: ___
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Primary: Superinfected abdominal fluid collection, GI bleed,
Left upper extremity DVT (Axillary and subclavian)
Secondary: Cholangiocarcinoma
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 ___. You were
admitted for abdominal pain. A fluid collection was found which
tracked to your skin. This grew out a bacteria called
Pseudomonas. You are being treated for this with IV and oral
antibiotics. The fluid collection has improved.
You had an episode of low blood pressure and GI bleeding which
led to a stay in the ICU for a few days. An endoscopy showed
some inflammation in your esophagus and stomach and a small tear
but no active bleeding.
A PICC was placed in your left arm for the antibiotics, but this
caused a clot. Thus, this PICC was removed, and one was placed
on the right side.
You should have labs on ___ and then weekly to
ensure stability of your hematocrit and your renal and liver
function.
Please see attached for an updated medication list.
Followup Instructions:
___
|
10386925-DS-33 | 10,386,925 | 20,632,501 | DS | 33 | 2134-11-15 00:00:00 | 2134-11-15 14:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro / Oxycodone
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of metastatic
cholangiocarcinoma s/p stenting who presented to the ER with a
temp of 101.5 at home. 6 days ago she switched antibiotics from
cefepime to doxycyline for her abdominal wall infection. She
has had progressive redness over her abdomen since this time.
She reports temperatures which started 2 days ago and were as
high as 101. She took tylenol for this but when they persisted
today she came into the ER. She has occasional chills. She
denies other symptoms of cough, shortness of breath, urinary
symptoms, diarrhea or abdominal pain. She has leg swelling
which is improved since being on lasix. She takes 20 mg daily
because she feels that 40 mg is too much.
In the emergency department, initial vitals: 98.2 113 97/59 16
94%. Blood and urine cultures were obtained. She had a CXR
which was showed interval resolution of previously noted small
left pleural effusion, and interval decrease in size of small
right pleural effusion. Bibasilar atelectasis. She was given
vanc/cefepime. Transplant surgery was contacted and did not
feel intervention was warrented for her fever and rising alk
phos.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___: initially presented with jaundice. Imaging showed a
moderate intrahepatic ductal dilatation without evidence of
hepatic or pancreatic mass.
- ___: ERCP with stent placement. Brushings were negative
twice.
- ___: surgical resection showed encasement of the right
hepatic artery by presumed malignancy and a full resection was
not completed. Final pathology, however, demonstrated low-grade
dysplasia and findings worrisome for sclerosing cholangitis, but
no malignancy. She was hospitalized multiple times for biliary
strictures, abscesses, and bacteremia.
- ___ she underwent EUS with biopsy of a porta hepatis
mass. This was positive for malignant cells and consistent with
adenocarcinoma.
- ___ initially for incisional hernia repair. Her
hospitalization was complicated by lactobacillus bacteremia,
Clostridium difficile infection, and a wound infection.
- ___ hospitalized with abdominal pain, wound
infection/fistula, complicated by hematemesis and hypotension.
OTHER PAST MEDICAL HISTORY:
Biliary obstruction, as above: cholangiocarcinoma vs.
sclerosing cholangitis
- Stage IC endometrial cancer dx ___ incidentally during
vaginal
hysterectomy for uterine prolapse (in retrospect, mild vaginal
bleeding). Postoperative radiation recommended because ovaries
and tubes were grossly normal at surgery but were not assessed
pathologically. In addition, no LN assessment. XRT ___ to
___: 45 Gy in 5 fractions to entire pelvis using the
four-field technique with ___ MV photons. Vaginal apex received
an
additional 9 Gy and 5 fractions via opposed fields,
also with ___ MV photons. Multiple emergency room presentations
after radiation for nausea and vomiting consistent with partial
SBO. All these treated conservatively
- Hypertension.
- Hyperlipidemia.
- Hypothyroidism.
- Hx recurrent UTIs
- remote D&C, apparently benign
- Breast biopsy in ___ for atypical lobular hyperplasia.
Social History:
___
Family History:
Mother: Died of ovarian cancer at age ___.
Father: History of hypertension and diabetes. Died of stroke
at age ___.
Physical Exam:
VS: T98.6 BP 120/64 HR 106 RR 20 94% 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, mildly distended. Incision is clean and
well-healed. There is a 5 cm area of surrounding erythema
around surgical site. No induration or evidence of deep
infection.
EXTREMITIES: 2+ peripheral edema to the knees bilaterally. 2+
dorsalis pedis/ posterior tibial pulses.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout.
.
DISCHARGE EXAM:
PHYSICAL EXAM
VS: Tm 100.6 Tc97.9 bp 127/59 HR 82 RR 18 SaO2 96 RA
GENERAL: alert and oriented, slightly anxious
HEENT: No scleral icterus. Neck Supple, No LAD.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: CTAB, good air movement bilaterally.
ABDOMEN: NABS. Soft, distended. Incision is clean and
well-healed. There is a 5 cm area of surrounding erythema around
surgical site. No significant change
EXTREMITIES: peripheral edema to the knees bilaterally. normal
perfusion
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout.
.
Pertinent Results:
___ 07:45PM BLOOD WBC-11.0# RBC-2.88* Hgb-9.0* Hct-26.8*
MCV-93 MCH-31.3 MCHC-33.8 RDW-18.8* Plt ___
___ 07:45PM BLOOD Neuts-88.4* Lymphs-6.1* Monos-4.2 Eos-1.1
Baso-0.2
___ 07:45PM BLOOD Glucose-115* UreaN-18 Creat-0.8 Na-129*
K-5.0 Cl-94* HCO3-25 AnGap-15
___ 07:45PM BLOOD ___ PTT-33.4 ___
___ 07:45PM BLOOD ALT-25 AST-76* AlkPhos-278* TotBili-0.7
___ 07:45PM BLOOD Albumin-2.4* Calcium-7.7* Phos-3.3 Mg-1.7
.
CXR:
IMPRESSION:
Interval resolution of previously noted small left pleural
effusion, and
interval decrease in size of small right pleural effusion.
Bibasilar
atelectasis.
.
___ 06:20AM BLOOD Neuts-87.4* Lymphs-6.4* Monos-5.6 Eos-0.4
Baso-0.2
___ 12:10AM BLOOD Neuts-87.2* Lymphs-6.1* Monos-6.1 Eos-0.5
Baso-0.1
___ 06:25AM BLOOD WBC-12.4* RBC-2.56* Hgb-8.2* Hct-23.9*
MCV-93 MCH-31.9 MCHC-34.2 RDW-18.5* Plt ___
___ 06:20AM BLOOD WBC-10.2 RBC-2.52* Hgb-8.1* Hct-23.5*
MCV-93 MCH-32.3* MCHC-34.7 RDW-18.4* Plt ___
___ 12:10AM BLOOD WBC-9.0 RBC-2.36* Hgb-7.6* Hct-21.7*
MCV-92 MCH-32.1* MCHC-34.8 RDW-18.3* Plt ___
___ 06:25AM BLOOD Glucose-94 UreaN-20 Creat-0.8 Na-131*
K-4.1 Cl-97 HCO3-28 AnGap-10
___ 12:10AM BLOOD Glucose-112* UreaN-20 Creat-0.7 Na-130*
K-4.0 Cl-98 HCO3-25 AnGap-11
___ 06:25AM BLOOD ALT-24 AST-47* LD(LDH)-195 AlkPhos-247*
TotBili-0.9
___ 12:10AM BLOOD ALT-16 AST-25 AlkPhos-201* Amylase-29
TotBili-0.6
___ 06:25AM BLOOD Albumin-2.3* Calcium-7.9* Phos-3.4 Mg-1.8
___ 01:36AM BLOOD Lactate-1.4
.
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 5:37 ___
1. Tubular fluid-filled structure in the right flank (300b:26,
2aA:35)
without definite sinus tract to the skin surface but extension
at least to the intra-abdominal cavity is improved from ___ at which time there was a sinus tract to the skin and
significantly improved from the prior CT of ___ at which
time there was a focal subcutaneous collection of air and fluid
with a sinus tract to the skin. Subcutaneous fluid and stranding
in the right lateral and anterior abdominal wall with shallow
but slightly rim enhancing fluid collection measuring 3.6 x 0.8
cm (2aA:35).
2. Interval development of peripheral ill-defined hypodense
lesion segment 6 measuring 17 x 15 mm (2aA:21) from ___
may represent early abscess formation, infarct or biloma given
its linear extension centrally (2aA:18). Stable biliary
dilatation compared to the most recent prior CT of ___.
3. Known cholangiocarcinoma with ascites and worsening
generalized anasarca from ___. Decreased distention of
small bowel with persistent bowel wall edema from ___.
Brief Hospital Course:
ASSESSMENT AND PLAN:
Ms. ___ is a ___ year old woman with a history of locally
advanced cholangiocarcinoma s/p resection which was not
complete. She has had multiple admissions for biliary
obstruction but more recently an abdominal infection for which
she was on cefepime, changed to doxycyline 6 days ago. Gram
stain of the abscess grew pseudomonas on ___. She presents
with fever and increased redness of the wound.
.
1. Fever: Initial sources of infection included pneumonia, UTI,
bacterial infection or skin infection. She has no evidence of
PNA on CXR and UA is clear. Urine culture was negative. She
has no clear evidence of active malignancy to be causing fever.
She does not have evidence of biliary obstruction based on
laboratory data or clinical symptoms. She was evaluated by the
hepatobiliary service in the ER who did not think that she had
any problems that would require surgical intervention. She was
initially changed from outpatient Doxycycline to Cefepime q24.
ID was consulted and recommended changing the dosing from q12 to
q24. They also recommended obtaining a CT scan of the abdomen
to see if there was an underlying fluid collection or abscess.
The CT revealed a small hypodensity in the liver that was
consistent with abscess. I had a thorough discussion with the
patient about the possibility of taking a biopsy of the lesion
and the potential risks involved vs. a more conservative line of
management such as continual IV ABX. She was clear that the
less invasive approach was preferred. I discussed this decision
with the ID consulting team who agreed. She should get a repeat
CT in approximately 4 weeks to assess for resolution.
.
Of note, the patient had a temperature of 100.6 the evening of
___. KUB was obtained as well as blood cultures though without
neutropenia, this is not a true fever. The ID consult team
suggested to add on Flagyl for better anerobic coverage in
addition to the oral Vancomycin. Her outpatient ID MD can
decide whether to taper the Vancomycin or wait until Cefepime
and Flagyl are complete.
.
2. Cholangiocarcinoma: The patient was followed by the oncology
consultant for medicine, Dr. ___. In discussions, she stated
that she was not intererested in chemotherapy as the risks
outweighed the benefits. She mentioned the possiblity of XRT,
but I am unsure if this option is viable. She will discuss with
Dr. ___ options 5 days after discharge. Considerations
should also given to palliative treatments only as the patient
made clear her disinterest in ___ medical procedures.
.
3. Anemia secondary to inflammation and blood loss. The patient
has a baseline anemia from inflammation caused by infection as
well as her malignancy. In addition, she had a guiac positive
brown stool. She had no episodes of bright red blood per rectum,
melena, coffee ground emesis, or other evidence of active
bleeding. Transplant surgery was aware of her decrease in Hct
and did not feel it was a result of her surgery. I called the
GI consult team who said preliminarily, she would not need a
repeat endoscopy from the one she had on ___ regardless, the
patient states she would not want an endscopy regardless. She
was given 2 units PRBCs for comfort and may require additional
transfusions as an outpatient to improve fatigue. Her PPI was
increased to BID and Carafate added per the recommendations of
GI after her last endoscopy.
.
4. Hx of C. Diff: No evidence of worsening infection. Normal
bowel movements daily.
Continued Vancomycin 125 mg PO BID
.
5. ___ Edema: Per patient this was from prior hospitalization and
IV fluids.
Lasix 20 mg PO daily was continued with the exception of the day
of ___. She maintained normal renal function and had chronic,
asymptomatic hyponatremia.
.
I spent > 90 minutes in discussion with patient, family, RNs,
consultants, case management, and in discharge planning
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Doxycycline Hyclate 100 mg PO Q12H
2. Levothyroxine Sodium 125 mcg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Ursodiol 300 mg PO BID
6. Vancomycin Oral Liquid ___ mg PO BID
Discharge Medications:
1. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth twice a day Disp #*60 Capsule Refills:*1
2. Ursodiol 300 mg PO BID
3. Vancomycin Oral Liquid ___ mg PO BID
4. Levothyroxine Sodium 125 mcg PO DAILY
5. CefePIME 2 g IV Q12H
RX *cefepime [Maxipime] 1 gram 1 gram IV twice a day Disp #*60
Vial Refills:*0
6. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*90 Tablet Refills:*0
7. Morphine Sulfate ___ ___ mg PO Q3H:PRN pain
RX *morphine 15 mg ___ tablet(s) by mouth q3 Disp #*60 Tablet
Refills:*0
8. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
9. Sucralfate 1 gm PO BID
RX *sucralfate [Carafate] 1 gram 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*1
10. Furosemide 20 mg PO DAILY
11. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Liver Abscess
Cholangiocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a fever likely caused by a liver abscess
and not a cellulitis
Followup Instructions:
___
|
10387100-DS-19 | 10,387,100 | 28,065,541 | DS | 19 | 2142-09-13 00:00:00 | 2142-09-14 22:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dark urine/light stool
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with history of hypertension,
hypercholesterolemia and diabetes who presents to the ___
with fatigue x ___s dark urine/light stools since
___. The patient notes that his health began to decline when
he was switched from crestor to lipitor on ___ due to impending
formulary change of his insurance. He noticed fatigue after the
switch, and on ___ he noted decreased appetite and the
aforementioned colour changes in his stool and urine. Other
symptoms he has noted has included some generalized
musculoskeletal pain in his neck, back and left thigh. He also
has noted some chills since ___, but denies frank fevers. His
last dose of lipitor was the night before admission on ___.
Review of systems was negative for any recent abnormal food
exposures. No history of hepatitis or IV drug use. No belly
pain, nausea, vomiting, brbpr or melena. No dysuria or history
of kidney problems. No chest pain, cough or shortness of breath.
He does endorse fairly significant EtOH intake, generally ___
beers a day but as much as 6 drinks occasionally on weekends.
.
In the ED, initial VS: 99.4 84 127/62 18 100% ra. The patient
underwent a RUQ ultrasound that showed no extra or intrahepatic
duct dilation. The gallbladder was collapsed, although
gallbladder wall thickening was apparent. Labs were notable for
moderate elevation in aminotransferases, alkaline phosphatase
and mild conjugated hyperbilirubinemia. The patient also had
elevation in creatinine to 1.8, although baseline was unknown.
Past Medical History:
Hypertension
Hypercholesterolemia
Diabetes - diet controlled.
Erectile dysfunction
Alcohol abuse
Social History:
___
Family History:
FAMILY HISTORY: Father deceased ___ from colon ca. Mother
deceased from complications of diabetes. No siblings. Children
are healthy.
No family history of inflammatory bowel disease or liver
disease.
Physical Exam:
Admission VS - 100.4 129/75 91 18 98% on RA
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, mild scleral and oral icterus, 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, Palpable spleen tip and liver edge,
no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - grossly non focal.
Pertinent Results:
___ 03:28PM BLOOD WBC-6.3 RBC-4.00* Hgb-11.7* Hct-33.7*
MCV-84 MCH-29.3 MCHC-34.8 RDW-14.8 Plt ___
___ 04:45AM BLOOD WBC-5.8 RBC-3.60* Hgb-10.5* Hct-30.2*
MCV-84 MCH-29.1 MCHC-34.7 RDW-14.9 Plt ___
___ 03:28PM BLOOD Neuts-68.8 Lymphs-12.6* Monos-4.3
Eos-14.0* Baso-0.3
___ 03:28PM BLOOD ___ PTT-28.8 ___
___ 04:45AM BLOOD ___ PTT-28.5 ___
___ 03:28PM BLOOD Glucose-122* UreaN-26* Creat-1.8* Na-135
K-3.9 Cl-101 HCO3-22 AnGap-16
___ 04:45AM BLOOD Glucose-77 UreaN-21* Creat-1.4* Na-135
K-3.6 Cl-105 HCO3-20* AnGap-14
___ 03:28PM BLOOD ALT-139* AST-98* CK(CPK)-132 AlkPhos-306*
TotBili-2.7* DirBili-2.1* IndBili-0.6
___ 04:45AM BLOOD ALT-111* AST-91* CK(CPK)-140 AlkPhos-277*
TotBili-2.5*
___ 03:28PM BLOOD Lipase-38
___ 03:28PM BLOOD Albumin-4.1
PENDING Labs
___ 04:45AM BLOOD IgM HAV-PND
___ 04:45AM BLOOD AMA-PND Smooth-PND
___ 04:45AM BLOOD ___
___ 5:21 am URINE Source: ___.
URINE CULTURE (Pending):
Urine studies
___ 05:21AM URINE Color-Yellow Appear-Clear Sp ___
___ 05:21AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 05:21AM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 05:21AM URINE Mucous-RARE
___ 05:21AM URINE Hemosid-NEGATIVE
___ 05:21AM URINE Hours-RANDOM Creat-81 Na-81 K-11 Cl-83
Imaging
RUQ u/s: Contracted/collapsed gallbladder. apparent GB wall
thickening/edema may in part relate to contracted state vs true
edema. Neg sonographic ___. No intra-extra hepatic biliary
dilatation. patent portal vein. liver nl in echotexture.
Brief Hospital Course:
___ y.o man with history of HTN, HL, and DM present with
myalgias, low grade fever, mild organomegaly and cholestatic
liver enzymes concerning for DILI.
.
#Liver injury - Most likely dx given LFT pattern is cholestatic
drug-induced liver injury. Would also consider autoimmune
hepatitis type 1 given low grade temps and eosinophilia. Both of
the above can present very similarly. Low concern for alcohol
hepatitis or statin myopathy given nontypical lab patterns. Low
suspicion for cholecystitis given exam and other findings. Labs
for autoimmune hep was sent including ___, ama and antismooth
muscle antibodies and his anti-mitochondrial antibody returned
positive with a ratio of 1:160 at time of discharge. LFTs
downtrending at time of discharge. Plan to continue to hold
statin and cholestyramine at time of discharge with f/u with PCP
in few days for repeat labs. The patient's PCP was notified of
the positive AMA and will decide whether to refer the patient to
hepatology to evaluate for PBC versus type I autoimmune
hepatitis.
.
# Eosinophilia: Likely ___ hypersensitivity component of DILI vs
autoimmune hepatitis. Would also consider parasitic infection
given loose stool although lower likelihood given lack of
travel. Ordered stool o/p which are pending at time of
discharge.
.
# Low grade fever - Less likely to be infectious or
cholecystitis esp given benign exam. Can see low grade/fever
with DILI and autoimmune hepatitis. Did not spike fever during
hospitalization. Urine culture was checked for low grade temp
and XXX at time of discharge.
.
#Acute kidney injury - Admission creatinine 1.8 now improving.
Fena 1% and appears to be improving w IVF. Baseline appears to
be ~1.3 per Atrius records. Home ACE and diuretic were held on
admission and restarted prior to discharge.
INACTIVE ISSUES
#Diabetes - QID fingersticks, will start insulin if these are
presistently high.
he did not require insulin administration. Home asa was
continued. Metformin was discontinued in the setting of
hepatitis (this was changed after discharge via telephone).
.
#Hypertension - Normotensive during hospitalization. On
admission team held ace-i, diuretic given acute renal failure
but these were restarted as above.
TRANSITIONAL ISSUES:
Liver: Work up of positive AMA, repeat LFTs, both communicated
to PCP.
# FEN: IVFs / replete lytes prn / heart healthy diabetic diet
# PPX: heparin SQ
# ACCESS: PIV
# CODE: Full
# CONTACT: ___, Wife ___ ___
___ on Admission:
Confirmed w ___ pharmacy
lisinopril 40mg daily
(hydrochlorothiazide not since ___
chlorthalidone 25mg daily
cholestyramine-aspartame powder 4g/1 scoop
Lipitor 80mg qhs
viagra 100mg
metformin 500mg ER daily, takes occasionally
aspirin 81mg
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
4. metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day: Takes sporadically.
5. Viagra 100 mg Tablet Sig: One (1) Tablet PO once a day as
needed: Take 1 hour prior to sex .
Discharge Disposition:
Home
Discharge Diagnosis:
Drug induced liver injury
Eosinophilia
Fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with elevated liver tests and
change in your urine/stool consistent with a drug induced liver
injury. This is likely due to the atorvastatin which has been
stopped. We checked blood tests to exclude autoimmune disease as
the cause of your symptoms and these were pending at time of
discharge. We will communicate these results with Dr. ___
PCP. Dr. ___ recheck your liver studies when he sees you on
___.
Please continue to stay off of the atorvastatin.
The following changes were made to your medications:
STOP atorvastatin (lipitor) and cholestyramine.
Continue other home medications including chlorthalidone,
lisinopril, viagra and metformin.
Please follow up with your doctors as listed below.
Followup Instructions:
___
|
10387377-DS-13 | 10,387,377 | 21,717,675 | DS | 13 | 2188-08-05 00:00:00 | 2188-08-06 14:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Penicillins / albuterol
Attending: ___
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catherization ___
History of Present Illness:
This is a ___ yo F with CAD s/p CABG (___) with recurrent
admissions due to chest pain with DES placed to LAD and POBA to
ostial ___ diagonal artery on ___ who was transfered here
from an outside hospital due to chest pain. The patient noted
mild, left sided chest pain 2 days prior to admission. The
patient has been compliant with her medications including
aspirin and plavix. Last night, the pain became worse and woke
the patient up from sleep around 1AM. The patient's pain starts
under her left breast and radiates above the breast and across
the chest. The pain also radiates to the left elbow. The patient
describes this pain as the same as her cardiac pain prior to the
stent placement. When the patient awaoke, she took 1 nitro with
some relief. She awoke again with the same pain and took ___
more nitros. When the pain did not resolve, the patient called
the ambulance. The patient says that she had mild nausea,
diaphoresis, and palpitations associated with these episodes.
She denied SOB. The patient says that the pain was worse with
deep breaths but was not positional. At the OSH, the patient was
given nitropaste, bloodwork did not reveal any abnormalities,
and the EKG was not concerning. The patient was started on a
heparin gtt and transfered here for further workup.
.
Initial VS: 99.2 72 118/48 12 100% 2L nc. On interview, the
patient was chest pain free.
.
REVIEW OF SYSTEMS
+ recent Stroke
On review of systems, no bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. She denies recent fevers, chills or rigors
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
Cardiac Risk Factors:
Diabetes(+),Dyslipidemia(+),Hypertension(+)
# CAD -- s/p MI in ___ (2v CAD on cardiac cath)
# CABG -- ___ with mitral valve repair and MAZE
# Chronic Diastolic Congestive Heart Failure
-- LVEF 50% on ___ with mild regional systolic dysfunction
# Paroxysmal atrial fibrillation
-- no episodes since MAZE
-- no longer on Coumadin
# WPW s/p ablation
# Pulmonary hypertension
# Hypertension
# Hyperlipidemia
# Diabetes Mellitus Type 2
# Hypothyroidism s/p thyroid irradiation
-- previously hyperthyroid many years ago
# COPD
# Carotid Stenosis
# Kidney Stones
# Tonsillectomy
# H/o viral gastroenteritis
# GERD
Social History:
___
Family History:
# Mother -- heart murmur
# Children -- two sons with arrhythmia, one died from MI at age
___, daughter with thyroid cancer
# Maternal Grandmother -- diabetes
Physical ___:
VS: T= 97.4 BP= 128/70 HR= 88 RR= 20 O2 sat= 98% RA
GENERAL: Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP not elevated.
CARDIAC: Normal sinus rhythm. Nl S1, S2, ___ systolic ejection
murmur at RUSB that does not obscure S2, radiation to carotids.
no S3, S4
LUNGS: Distant breath sounds. No crackles, wheezes, or
consolidations
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: trace ___ edema, left calf tenderness
NEURO: CN II-XII tested and intact, strength ___ throughout,
sensation grossly normal. Gait not tested.
Pertinent Results:
ADMISSION LABS:
___ 01:30PM BLOOD WBC-7.9 RBC-4.00* Hgb-12.2 Hct-37.8
MCV-94 MCH-30.4 MCHC-32.3 RDW-13.4 Plt ___
___ 01:30PM BLOOD Neuts-62.3 ___ Monos-4.2 Eos-1.3
Baso-1.2
___ 01:30PM BLOOD ___ PTT-31.4 ___
___ 01:30PM BLOOD Glucose-123* UreaN-24* Creat-1.0 Na-140
K-3.8 Cl-103 HCO3-26 AnGap-15
___ 01:30PM BLOOD Calcium-9.2 Phos-3.3 Mg-2.0
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-9.6 RBC-3.40* Hgb-10.7* Hct-33.3*
MCV-98 MCH-31.4 MCHC-32.2 RDW-13.9 Plt ___
___ 07:20AM BLOOD ___ PTT-25.1 ___
___ 07:20AM BLOOD Glucose-115* UreaN-22* Creat-0.9 Na-138
K-3.9 Cl-102 HCO3-30 AnGap-10
___ 07:20AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.9
Cardiac Enzymes:
___ 01:30PM BLOOD cTropnT-<0.01
___ 10:00PM BLOOD CK-MB-2 cTropnT-<0.01
___ 08:00AM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:48PM BLOOD CK-MB-10
___ 07:20AM BLOOD CK-MB-20*
___ 10:00PM BLOOD CK(CPK)-48
___ 08:00AM BLOOD CK(CPK)-33
LENIs: No clot ___
=============
Cardiac Cath:
See OMR for final report. Not dictated by time of discharge.
Brief Hospital Course:
___ yo F with CAD s/p CABG and recent cath with DES and POBA to
LAD, multivessel disease planned for staged intervention who
presents here with chest pain but negative CEs and no
significant EKG changes.
1. Chest Pain: This is likely cardiac chest pain given the
patient's risk factors, known CAD, and similar pain to previous.
This is not likely stent thrombosis due to compliance with
aspirin and plavix and negative enzymes, and quick resolution of
pain. The patient underwent a cardiac cath that showed LAD with
patent stent then 99% mid with distal filling from LIMA (no
change from previous. RCA 40% proximal, 80% mid, 80%
posterolateral. The patient underwent Rotoblator with 1.5 burr
followed by DES of mid-RCA with 2 overlapping DES, Balloon PTCA
of posterolateral with moderate residual stenosis but difficult
to advance larger balloons. The patient also complained of
bilateral leg tenderness, but LENIs were negative for any DVT.
The patient will continue aspirin and plavix indefinitely. She
will continue her metoprolol, lisinopril, nitro, and ranolazine
as needed.
CHRONIC DISEASES:
2. Chronic Diastolic Heart Failure: The patient looked euvolemic
on exam. Continued lasix 40mg Daily, lisinopril 2.5mg Qday,
Metoprolol 100mg Qday
3. Hyperlipidemia: On statin
4. DM2: On Glimepiride
5. COPD: on spiriva, supplemental O2
6. GERD: on protonix
7. Hypothyroidism: On levothyroxine
.
TRANSITIONAL ISSUES: None
Medications on Admission:
Plavix 75mg Qday
Atorvastatin 80mg Qday
Nitro SL PRN
Lisinopril 2.5mg Qday
Tylenol PRN
Glimepiride 1mg Qday
Levothyroxinw 88mcg Qday
Metoprolol XL 100mg Qday
Spiriva Qday
Colace
Ranolazine 500mg Qday
Lasix 40mg Qday
Protonix 40mg Qday
Aspirin 325mg Qday
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. ranolazine 500 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Qday ().
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
10. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. glimepiride 1 mg Tablet Sig: One (1) Tablet PO once a day.
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis
- Coronary artery disease
- Unstable Angina
Secondary diagnosis
- Pulmonary hypertension
- Hypertension
- Hyperlipidemia
- Diabetes Mellitus Type 2
- Hypothyroidism s/p thyroid irradiation
- COPD
- GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to our hospital for scheduled catheterization of your
coronary arteries. She tolerated the procedure very well.
During the procedure, we opened up with a right sided coronary
artery with a drug eluting stent. You also underwent an
ultrasound of your legs, which did not reveal any blood clots.
We continued all your home medications, and you should be able
to go home today.
.
No changes were made to your home medication list.
.
It has been a pleasure taking care of you here at ___. We
wish you a speedy recovery.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10387770-DS-17 | 10,387,770 | 25,294,592 | DS | 17 | 2197-02-04 00:00:00 | 2197-02-08 20:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Lipitor
Attending: ___.
Chief Complaint:
weakness and fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year old gentleman with a history of
chronic kidney disease (baseline creatinine 1.6), non-insulin
dependent diabetes (HA1c 6.9 ___, who presented with
weakness and fatigue. The patient was in his usual state of
health until 3 weeks ago when he noticed progressive fatigue
leading to sleeping 18 hours per day and decreased energy for
daily activities. He also reports weakness in both legs and a
new weakness leading to an inability to open water bottles. The
patient also reports decreased appetite and PO food intake due
to a new lump in his throat that was painless but provided
resistance to swallowing and occasionally made him gag. The lump
is intermittent and the patient reports that it went away
yesterday and has not returned. He has also noted a change to
the consistency of his bowel movements with more loosely formed
stool. The patient denies any abdominal pain, nausea,
vomitting, blood in his sputum, constipation, BRBPR, melena. He
endorses chills, but denies fever or night sweats.
The patient presented to his PCP ___ ___ and was found to
have hypotension 78/38 sitting and 82/40 lying down.
In the ED, vitals were: 97.6, 54, 76/47, 16, 92RA. A Chest Xray
revealed no focal consolidation or pleural effusion. A bedside
ultrasound showed no effusions; the IVC collapses easily. Labs
notable for BUN/Cr rise to 84/4.3 and potassium of 5.7. EKG
reported by ED: SR @ 62, no ST elevation. The patient was given
Kayexalate and and calcium gluconate in the ED.
On the floor at 9AM vitals were: 98.1 93/57 85 18 98RA.
Orthostatic blood pressure was 110/54 supine and 112/62 standing
after 3 minutes. The patient reported feeling 100% better, but
endorsed some weakness. He reported that the lump in his throat
was gone. His last bowel movement was the night of admission
and was very loose.
At 9:30 AM ___ the patient's heart rate spiked to 140-160
and a bed side EKG showed irregularly irregular rhythm
indicating atrial fibrillation. The patient received IV 5 mg
metoprolol and his BP decreased to 110-120 range. He denies
chest pain, palpitations, headache, dizziness, blurry vision,
nausea, vomitting. He received a second IV push of 5 mg
metoprolol.
Past Medical History:
1. Diabetes mellitus with peripheral neuropathy and chronic
renal failure (cre = 1.6 on ___ with estGFR = 42). %HbA1c =
6.9 on ___.
2. Emphysema.
3. Hypertension.
4. Posterior vitreous detachment.
5. Urolithiasis.
6. History of basal cell carcinomas.
7. Hypersensitivity reaction.
8. Allergic rhinitis.
9. Vitamin B12 deficiency with vitB12 = 154 on ___.
10. Hypogammaglobulinemia.
Social History:
___
Family History:
FAMILY HISTORY:
FH significant for mother with gastric ___ @ age ___ died age ___
Father emphysema died age ___.
Siblings: no hx of cancer
Maternal 3 aumts and MGM also with h/o CA in the abdomen,
unknown which types.
Physical Exam:
PHYSICAL EXAM:
VITALS: 98.7 129/66 56 18 100RA; Ins: 1230, Outs: 1375
GENERAL: Laying supine in bed, comfortable, in no acute
distress.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, moist mucous
membranes, OP clear.
NECK: Supple, no thyromegaly, no thyroid bruits, JVP at 7, no
carotid bruits. no palpable neck mass.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no ronchi/rales/wheezes, good air movement,
resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. No
CVAT.
EXTREMITIES: warm and well perfused, no cyanosis, clubbing. No
edema of the lower extremities, 1+ peripheral pulses.
SKIN: 1+ pitting edema on lower back. Echymoses on abdomen and
upper extremities and hands from telemetry stickers.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ in right hamstrings and ___ in right hipflexors. Otherwise,
muscle strength ___ throughout, sensation grossly intact
throughout. 2+ reflexes bilaterally in patella, achilles, bicep
and tricep.
Discharge Exam:
PHYSICAL EXAM:
Vitals: 98.5 (tmax 98.5) 114/78 (range: 114/78 - 150/80), 72, 18
100RA
ins 1710 mL; outs 1650 mL
Blood Glucose ___: AM: 132; Noon: 223; ___: 182; bedtime: 211
GENERAL: The patient is sitting up in bed; comfortable looking.
in no acute distress.
HEENT: normocephalic atraumatic; extraoccular movements intact,
moist mucus membranes, pupils equally round and reactive to
light
NECK: JVP at 6, no carotid bruits, no lymphadenopathy
CARDIO: normal S1 S2, no murmurs rubs or gallops, regular rate
and rhythm
LUNGS: clear to auscultation bilaterally
ABD: soft, nontender nondistended, normoactive bowel sounds, no
guarding / rebound
EXTREMITIES: 1+ sacral edema; no ankle edema; 1+ dorsal pedis
pulses, warm and well perfused. Strength ___ in right tricep;
___ throughout.
NEURO: CN II - XII intact; Awake and oriented x 3.
Pertinent Results:
ADMISSION LABS:
___ 08:30PM WBC-6.7 RBC-3.64* HGB-11.4* HCT-37.9*
MCV-104* MCH-31.3 MCHC-30.1* RDW-13.6 PLT COUNT-222
___ 08:30PM NEUTS-67.3 ___ MONOS-4.6 EOS-1.7
BASOS-0.3
___ 02:55PM GLUCOSE-143* UREA N-84* CREAT-4.3*#
SODIUM-137 POTASSIUM-5.7* CHLORIDE-111* TOTAL CO2-11* ANION
GAP-21*
___ 11:15PM TOT PROT-5.5* CALCIUM-10.1 PHOSPHATE-4.4
MAGNESIUM-1.7
___ 06:34PM LACTATE-2.2*
ADMISSION URINALYSIS
___ 02:55PM URINE HOURS-RANDOM CREAT-174 TOT PROT-35
PROT/CREA-0.2 albumin-11.3 alb/CREA-64.9*
___ 08:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 08:00PM URINE RBC-<1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 08:00PM URINE HYALINE-4*
___ 08:00PM URINE MUCOUS-RARE
BLOOD GASES:
___ 08:48AM BLOOD Type-VENOUS pO2-169* pCO2-29* pH-7.14*
calTCO2-10* Base XS--18 Comment-GREEN TOP
___ 05:08PM BLOOD Type-ARTERIAL pO2-107* pCO2-24* pH-7.39
calTCO2-15* Base XS--8
___ 05:20PM BLOOD Type-ARTERIAL pO2-122* pCO2-29* pH-7.38
calTCO2-18*
STUDIES:
EKG ___: Sinus rhythm at the lower limits of normal rate.
Borderline low limb lead voltage. Peaked precordial T waves -
consider hyperkalemia. Since the previous tracing of ___ T
waves may be more peaked. Rate 60.
CHEST XRAY ___: No acute cardiopulmonary process.
ECHO ___: "Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. No valvular pathology or pathologic flow
identified."
RENAL ULTRASOUND ___: "Renal cysts. Otherwise, normal
renal ultrasound. Possible focal hypoechoic liver lesion, seen
only on one image."
LIVER AND GALLBLADDER ULTRASOUND ___: Multiple simple
hepatic cysts. Dilated pancreatic duct with atrophic pancreatic
parenchyma. The etiology is indeterminate. This should be
further investigated with multiphasic CT/MRI or ERCP.
CT HEAD ___ "No evidence of intracranial mass nor acute
process. If there is continued clinical concern, an MRI, even
without contrast, is more sensitive for the detection of
intracranial mass or acute infarction. Fluid opacification of
the right sphenoid sinus which should be correlated with
clinical signs of sinusitis."
CT TORSO ___: 1. No evidence of solid pancreatic mass.
Coarse calcifications within the pancreatic duct in the head and
uncinate process is associated with chronic postobstructive loss
of parenchyma at the body and tail of pancreas with associated
ductal dilation.
2. Vascular calcifications of the origin of the coronary
arteries. Minimal vascular calcifications of the aortic arch
without aneurysmal change.
3. Multiple hepatic cysts. One cyst with calcifications is seen
at the liver dome, probably representing a slightly complicated
cyst but unlikely to be of clinical significance.
4. Atrophic appearance of both kidneys. Probable renal pelvic
cyst on the left, incompletely characterized.
5. Possible punctate stone dependently within the gallbladder.
6. Liver is borderline low-density, which may be related to mild
hepatic steatosis.
7. Slight fullness of the left adrenal gland without discrete
nodularity.
8. Colocolonic fistula in the rectum, which appears chronic in
nature.
MRI Head (___):
1. No acute intracranial abnormality.
2. Generalized cerebral volume loss with mild changes of chronic
small vessel ischemic disease.
TELEMETRY ___: Telemetry showed normal sinus rhytym with
no events but showed 4 beats of PVCs.
VIDEO OROPHARYNGEAL SWALLOW: ___: Barium passed freely
through the oropharynx without evidence of ostruction. There was
vallecular and pyriform sinus residue with all consistencies.
Anterior osteophytes are present at C4-C5 which may also be
contributing to patients symptoms. There was penetration with
thin liquids and no aspiration.
TELEMETRY ___: Telemetry showed normal sinus rhytym with
no events but showed 7 beats of PVCs which resolved
spontaneously.
Brief Hospital Course:
The patient is a ___ year old gentleman with a history of CKD
(baseline creatinine = 1.6), DM, and HTN who presents with
weakness, hypotension, fatigue, and dysphagia in the setting of
weight loss found to have a severe non gap metabolic acidosis
and acute on chronic kidney failure as well as new onset atrial
fibrillation.
# Dysphagia/decreased appetite/weight loss: Mr. ___
presented with a 3 week history of progressive dysphagia for
both solids and liquids. He endorsed the feeling of an
intermittent "lump in his throat," weight loss, and difficulty
swallowing. Past records indicated an 11 lb weight loss since
___. Pt stated his appetite decreased markedly and he began
eating and drinking much less over the past 3 weeks, with
typical fluid intake of only 2 cups of water. On admission, he
described improvement of the feeling and subsequent increase in
appetite. Due to fatigue, weight loss, weakness, and a family
history of GI cancer, concern for malignancy was high. GI was
consulted. A CT torso did not reveal malignancy, but
demonstrated coarse calcifications in the pancreatic duct in the
head and uncinate process with chronic postobstructive loss of
parenchyma at the body and tail of pancreas with associated
ductal dilation. No acute intervention was necessary for this
chronic process. Video swallow and speech and swallow consult
revealed mild oropharyngeal dysphgia most notable for pharyngeal
residue with all consistencies which is c/w pt's complaints of
feeling food, liquid, and pills stuck in his throat. The pt was
found to have anterior osteophytes at C4-C5 as well as reduced
UES opening which do appear to be contributing to the pharyngeal
residue. The patient was counseled to take smaller bites, to
chew well, and to drink a lot of fluid with meals.
# Dilated pancreatic duct seen on imaging - This was
incidentally found on workup for his fatigue and weight loss.
GI was consulted who discussed the pancreatic duct obstruction
with ERCP. As he was asymptomatic with normal LFTs, no
additional work-up was recommended. The patient was scheduled
for follow up with Dr.
___ GI.
#. Acute renal failure with metabolic acidosis/acidemia - The
patient has a history of CKD with a baseline creatinine of
1.6-2.0. This was found on admission here to be 4.3. Pt had
VBG showing pH of 7.14 and a non-anion gap acidosis. Renal US
was unremarkable and pt's SPEP, UPEP, and free light chain k/l
ratio revealed no evidence of monoclonal antibody disease. The
patient's acidosis was presumed to be diarrhea versus renal
tubular acidosis and was treated with sodium bicarbonate. The
patient's acidosis corrected. With fluids, the patient's
creatinine trended downward and stabilized at 2.6 to 2.8. He
was seen by nephrology here and will follow up with them as an
outpatient. He was discharged on sodium bicarbonate tabs BID.
His ACE-inhibitor and spironolactone were discontinued. His
medications became renally dosed including discontinuation of
metformin and lowering of januvia to 50 mg.
# Atrial fibrillation - The pt went into atrial fibrillation on
his first admission day and was completely asympomatic. He was
rate controlled with metoprolol and then converted back to NSR
within 18 hours. An echo was performed and demonstrated a
mildly dilated left atrium and mild LVH, but no other valvular
abnormalities and no pericardial effusion. This was his first
known episode of Atrial fibrillation and the patient remained on
telemetry for 5 more days without any further episodes of atrial
fibrillation; thus anticoagulation was not started. It was
presumed that the atrial fibrillation was due to the patient's
acidosis and volume depleted state. However, the patient does
have substrate for the disease given his enlarged LA and
recurrence of the disease would warrant anticoagulation given
his CHADS score of 3.
# Right sided weakness/Dysarthria: Physical exam revealed
right sided hamstring weakness of ___ and right sided bicep
weakness of ___. There was also question of 1 month history of
dysarthria reported by his family. Labs revealed normal morning
cortisol, CK and TSH levels. A CT of the head did not reveal a
hemorrhagic stroke. Given initial concern for malignancy as
well as atrial fibrillation, MRI was performed which showed no
evidence of recent stroke or other acute abnormality. The
patient's strength improved throughout his hospital stay. He
was not dysarthric.
# Hypotension: The patient presented to a medical appointment on
___ with BP of 78/38 sitting and 82/40 lying down. Pt's
blood pressures returned to within normal limits after
administration of fluids. Quinapril and spironolactone were
discontinued.
# Diabetes mellitus: The patient required about 8 units of
sliding scale humalog daily. Because of his new ___, his
sitagliptin was decreased from 100 to 50 mg. Metformin was also
discontinued due to ___. The patient was started on glipizide
and was told to measure his blood sugars TID and to report these
values to Dr. ___ further ___ of his medications.
# Macrocytic Anemia: The patient was guaiac negative here. He
was seen by Dr. ___ prior to admission who performed a workup
for the patient's anemia with blood smear revealing occasional
macro-ovalocytes. Because b12 and folate levels were normal and
patient not on any medications that cause megaloblastic
maturation, it was thought that patient likely has an element of
myelodysplasia. He had burr cells (due to renal failure).
TRANSITIONAL ISSUES:
1. Repeat basic metabolic panel within the next week. Notable
labs on last check: Hct 31.2, Cr 2.8, serum bicarbonate 23.
2. Determine whether sodium bicarbonate needs to be continued.
3. Outpatient follow-up with PCP, ___, and GI.
4. Per recommendation of Nephrology, ACE-inhibitor and
metformin were stopped.
5. Glipizide was started. Continuing Januvia. Patient wsa
instructed to check blood sugars frequently at home.
6. Monitor weight.
Code status: Full
Medications on Admission:
ASPIRIN - 81 MG TABLET - ONE EVERY DAY
FLUTICASONE - 50 mcg Spray, Suspension - 1 spray nasal twice a
day
METFORMIN - 850 mg Tablet - 1 Tablet(s) by mouth three times a
day
METOPROLOL TARTRATE - 25 mg Tablet - 1 Tablet(s) by mouth twice
a
day
QUINAPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
SITAGLIPTIN [JANUVIA] - 100 mg Tablet - 1 Tablet(s) by mouth
once
a day
SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth twice a day
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - 1,000 mcg Tablet
-
2 Tablet(s) by mouth once a day
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal twice a day.
3. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: Two (2)
Tablet PO once a day.
4. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Outpatient Lab Work
Please have a chem-7 drawn on ___ and faxed to Dr ___
at ___.
Diagnosis: Acute kidney injury
7. Januvia 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
acute on chronic kidney disease
atrial fibrillation with rapid ventricular reponse
non-anion gap metabolic acidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You came in for weakness, fatigue, difficulty
swallowing, low blood pressure, and weight loss. You were found
to have some functional swallowing difficulties, and some bone
spurs in your neck that may be contributing to your symptoms.
There is no acute intervention that needs to be done for this.
It is very important that you drink fluids despite these
symptoms. You were found to have injury to your kidneys and low
blood pressure because you were not drinking enough. With
fluids, your blood pressure and kidney function improved, but it
still has not returned to normal.
During your stay, you started to have an irregular and rapid
heart beat. This improved with correction of your metabolic
abnormalities.
Lastly, because of your worsened kidney function, you should not
take metformin for your diabetes. You should keep a close eye
on your blood glucoses, measuring them before every meal and
bedtime and record this. You can then show these numbers to
your primary care doctor, who can adjust your medications and
how to further proceed in managing your diabetes. If your blood
sugars are above 200 or less than 100, you should call Dr.
___ let him know. His phone number is ___.
Please have your blood drawn on ___, and the results faxed
to Dr. ___.
The following changes were made to your medications:
STOP Metformin
STOP Quinapril
STOP Spironolactone
DECREASE Januvia to 50mg
START Sodium bicarbonate
START GLIPIZIDE 5mg
DRINK at least 2L of fluid a day. This is very important to do.
Have your family help with this.
Followup Instructions:
___
|
10387770-DS-18 | 10,387,770 | 25,124,191 | DS | 18 | 2198-03-15 00:00:00 | 2198-03-17 13:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Lipitor
Attending: ___
Chief Complaint:
Generalized weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male w/ PMH of CKD (baseline cr 2.0-4.0 in recent
months), NIDDM (HA1c 6.9 ___, emphysema, hypertension, and
vitamin B12 deficiency, now presenting w/ generalized weakness x
3 months.
Pt states that he has been feeling fatigued over the last ___
months. He also states that he was taking metformin 850mg po tid
(2 qam and 1 qpm). Pt reports that he self-titrated down on his
metformin several months ago due to improved DM control. Once he
got down to one pill per day, he noticed rising sugars, so he
began taking 3 pills per day approximately ___ months ago. Over
the last two weeks, Pt reported severe weakness and occasional
shakiness, also slowed / slightly slurred speech. Pt then came
to the ED for evaluation.
Denies any fevers, chills, weight loss or night sweats. He
denies any chest pain, dyspnea. He denies any easy bruising, but
does report easy fatigability. His right sided
weakness/dysarthria appears unchanged since ___. and he
continues to have ___ weakness on the right side. CT and MRI
imaging have been unrevealing.
In the ED, initial vitals were: 98 80 95/57 18 98% RA. His labs
were significant for HCT 30.5, Cr 4.3, HCO3 13, lactate 3.9, and
pH 7.21, anion gap of 17. He received 1L NS, and renal was
consulted, who recommended sending urine lytes, stopping
metformin, may need to start PO bicarbonate, and to admit to
medicine for observation. There will be ongoing discussions
regarding RRT on the floor. Repeat lactate prior to transfer to
floor was 2.7.
On the floor, VS: 97.4, 116/65, 73, 18, 100% RA.
Pt's family reports that he has been intermittently somnolent
during the day, sleeping at odd times for hours and then waking
up. He also has not been eating or drinking much for the last
___ weeks.
Review of systems:
(+) Per HPI, reports extreme fatigue, slurred / slow speech,
intermittent somnolence as above.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
1. Diabetes mellitus with peripheral neuropathy and chronic
renal failure (cr = 2.1-4.0 from ___. %HbA1c =
6.7 on ___.
2. Emphysema.
3. Hypertension.
4. Posterior vitreous detachment.
5. Urolithiasis.
6. History of basal cell carcinomas.
7. Hypersensitivity reaction.
8. Allergic rhinitis.
9. Vitamin B12 deficiency
10. Hypogammaglobulinemia.
Social History:
___
Family History:
FAMILY HISTORY:
___ significant for mother with gastric ___ @ age ___ died age ___
Father emphysema died age ___.
Siblings: no hx of cancer
Maternal 3 aumts and MGM also with h/o CA in the abdomen,
unknown which types.
Physical Exam:
ADMISSION EXAM:
Vitals: 97.4, 116/65, 73, 18, 100% RA.
General: well appearing elderly man in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
moist mucosa
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength in left upper and both
lower extremities, ___ strength in right upper extremity,
grossly normal sensation throughout, 2+ reflexes bilaterally,
steady, normal gait w/ cane. No asterixis.
DISCHARGE EXAM:
Vitals: 98.1, 107-130/61-64, 75, 18, 100%RA, pain ___.
General: well appearing elderly man in no acute distress
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Pertinent Results:
ADMISSION LABS:
___ 01:55PM WBC-7.0 RBC-3.09* HGB-10.1* HCT-30.5* MCV-99*
MCH-32.7* MCHC-33.2 RDW-13.3
___ 01:55PM NEUTS-71.6* ___ MONOS-4.7 EOS-1.2
BASOS-0.4
___ 01:55PM PLT COUNT-222
___ 01:55PM ___ PTT-31.6 ___
___ 01:55PM GLUCOSE-138* UREA N-72* CREAT-4.3* SODIUM-140
POTASSIUM-4.6 CHLORIDE-108 TOTAL CO2-15* ANION GAP-22*
___ 01:55PM ALT(SGPT)-8 AST(SGOT)-11 ALK PHOS-64 TOT
BILI-0.2
___ 01:55PM LIPASE-15
___ 01:55PM ALBUMIN-4.3 CALCIUM-9.9 PHOSPHATE-4.6*
MAGNESIUM-1.9
___ 05:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 05:50PM URINE RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 05:50PM URINE MUCOUS-RARE
___ 05:50PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:50PM URINE HOURS-RANDOM CREAT-59 SODIUM-52
POTASSIUM-20 CHLORIDE-56
___ 08:32PM ___ PO2-26* PCO2-37 PH-7.21* TOTAL
CO2-16* BASE XS--13
___ 08:32PM LACTATE-2.7*
___ 08:32PM O2 SAT-42
___ 06:05PM ___ PO2-115* PCO2-29* PH-7.21* TOTAL
CO2-12* BASE XS--15
PERTINENT LABS:
___ 06:05PM LACTATE-3.9*
DISCHARGE LABS:
___ 09:02AM BLOOD Lactate-1.6
___ 06:25AM BLOOD WBC-5.6 RBC-2.73* Hgb-9.2* Hct-25.7*
MCV-94 MCH-33.6* MCHC-35.6* RDW-13.7 Plt ___
___ 06:25AM BLOOD Glucose-145* UreaN-57* Creat-3.4* Na-142
K-3.4 Cl-109* HCO3-22 AnGap-14
___ 06:25AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.9
PERTINENT IMAGING:
VENOUS MAPPING LEFT UPPER EXT (___):
1. Preserved phasicity of bilateral subclavian veins, indirect
sign of
central venous patency.
2. Patent left cephalic and basilic veins, with diameters as
described above.
3. Patent left brachial and radial arteries, with no
calcifications seen in the current study.
ADMISSION EKG:
Atrial fibrillation with rapid ventricular response. Consider
prior inferior wall myocardial infarction. Compared to the
previous tracing of ___ atrial fibrillation has appeared.
Brief Hospital Course:
Mr. ___ is an ___ male w/ PMH of CKD (baseline
creatinine ___ in recent months), NIDDM (HA1c 6.7%), emphysema,
hypertension, and vitamin B12 deficiency, now presenting w/
generalized weakness x 3 months found to be in metabolic
acidosis secondary to metformin toxicity.
ACTIVE DIAGNOSES:
# Metabolic acidosis: His initial labs at admission with AG 17,
HCO3 15, delta AG/delta HCO3 of ___ with elevated lactate are
consistent with diagnosis of anion gap plus non anion gap
metabolic acidosis, with appropriate respiratory compensation.
There is lactic acidosis related to metformin, along with non
anion gap metabolic acidosis related to inability to handle
obligatory proton intake. His metformin was stopped. He was
treated with IVF which helped to resolve the lactic acidosis
(lactate 1.6 on ___ and greatly improved the pt's symptoms,
but bicarb remained at 14 with a venous pH of 7.23 the following
day. Renal was consulted. He was treated with oral bicarb 1300mg
BID, without great benefit. He was given IV bicarb x1, which
resulted in a normal bicarb (22) on the day of discharge. The pt
was discharged with a prescription for oral bicarb 1300mg BID.
His electrolytes should be re-checked at his PCP ___ and
need for continued bicarb re-assessed.
# Chronic kidney disease stage IV: Mr. ___ had hx of stage
III-IV chronic kidney disease related to diabetes, hypertension
and prior episodes of ___. His renal failure has been worsening
over the past 6 months, and is now late stage IV-early stage V.
Renal was consulted and started preparation for RRT. Options
were discussed including HD, HHD and PD. He is leaning towards
HD, but wants to read about the subject. The pt has follow up
with the surgeons for arranging access. In the meantime, avoid
IVs, phlebotomies and BP checks in his left arm. He will follow
up with ___ (___) and Dr. ___ in
the ___ clinic.
# Type II Diabetes Mellitus: Pt has had good control with A1c
6.7% in ___. Pt was on ___ 50mg daily and metformin
850mg TID. Given his CRF, metformin must be discontinued
indefinitely. A ___ consult was obtained to assist in med
management. Januvia must be renally dosed, so the pt was
discharged on ___ 25mg daily. If further BG control needed,
glipizide 2.5mg daily could be added. The pt should call for a
___ at the ___ (seen by Dr. ___ as
___, and should also call for BG <80.
CHRONIC DIAGNOSES:
# Paroxysmal Atrial fibrillation: The pt was generally well
rate-controlled but had occasional asymptomatic nocturnal
bradycardia down to the ___ on his home dose of metoprolol (50mg
BID). He was discharged on Toprol XL 37.5mg PO daily. In
addition, anticoagulation was discussed with the patient, whose
CHADS score is 3. He was resistant to the idea of starting
Coumadin, despite being told the risks and benefits, and was
instructed to discuss the issue with his PCP and cardiologist.
# Vitamin B12 Deficiency: Most recent B12 shows pt is repleted.
His home B12 was continued on discharge.
# Hypertension: The pt was continued on his home dose of
tamsulosin. Beta-blocker dose changed (see above).
# Vitamin D deficiency: The pt was continued on his home dose of
calcitriol.
# Primary prevention: The pt was continued on aspirin 81 daily.
TRANSITIONAL ISSUES:
-The patient's DM regimen has changed to ___ 25mg daily.
Metformin was discontinued indefinitely. He needs close follow
up with his blood sugars and should be seen in the ___ clinic
(pt to call for appt).
-The patient's metoprolol was discontinued and replaced with
metoprolol XL 37.5mg daily.
-Anticoagulation is recommended for this pt with paroxysmal A.
fib and CHADS score 3. He refused to initiate treatment with
Coumadin. His PCP and cardiologist should discuss this issue
further with the pt.
-The pt is taking oral bicarbonate and should have his
electrolytes re-tested as part of his PCP follow up.
-___ arm precautions are new for this pt, who is planning for
fistula placement in the coming weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcitriol 0.25 mcg PO EVERY OTHER DAY
2. Calcitriol 0.5 mcg PO EVERY OTHER DAY
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. MetFORMIN (Glucophage) 850 mg PO 2 TABS IN AM AND 1 TAB IN ___
5. Metoprolol Tartrate 25 mg PO BID
hold for sbp < 90 or hr < 60
6. Januvia *NF* (sitaGLIPtin) 50 mg Oral daily
7. Tamsulosin 0.4 mg PO HS
8. Aspirin 81 mg PO DAILY
9. Cyanocobalamin ___ mcg PO DAILY
10. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
Discharge Medications:
1. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO EVERY OTHER DAY
4. Calcitriol 0.5 mcg PO EVERY OTHER DAY
5. Cyanocobalamin ___ mcg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. Januvia *NF* (sitaGLIPtin) 25 mg Oral daily
RX *sitagliptin [Januvia] 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
8. Tamsulosin 0.4 mg PO HS
9. Sodium Bicarbonate 1300 mg PO BID
RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth twice a day
Disp #*120 Tablet Refills:*0
10. Metoprolol Succinate XL 37.5 mg PO DAILY
RX *metoprolol succinate [Toprol XL] 25 mg 1.5 tablet extended
release 24 hr(s) by mouth once a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
# Metformin adverse effect
# metabolic acidosis
# Paroxysmal Atrial fibrillation
# Chronic kidney disease
SECONDARY DIAGNOSES:
# Type 2 diabetes mellitus with complications
# Hypertension
# Emphysema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you during your hospitalization at
___.
You were admitted because of a toxicity from metformin, called
metabolic acidosis. It caused you to be very sleepy and weak.
Your metformin was stopped permanently and you were treated with
IV fluids and bicarbonate, a medicine used to decrease acid in
the blood. In terms of your diabetes medications, you will be
discharged home on just Januvia 25mg daily. DO NOT TAKE
METFORMIN. You should call Dr. ___ office on ___ to
schedule a ___ appointment within the week. You will also
be sent home with a new prescription for bicarbonate pills, to
help counteract the acid in your blood.
You were also found to have worsening kidney function. The
kidney doctors saw ___ and suspect you will need dialysis in the
near future. You will need to follow up with them to plan for
fistula placement soon.
You have paroxysmal atrial fibrillation (originally thought to
be a new diagnosis for you, but upon further investigation into
the records, you have a history of it in the past). Because your
heart rate was low during the night, you will be discharged on
37.5mg metoprolol XL (a slightly lower dose than what you were
previously on, as well as a longer-acting medication). You will
need to discuss anticoagulation with Dr. ___ it is
indicated for your heart rhythm to prevent stroke, but you did
not want to start the medication in the hospital.
Followup Instructions:
___
|
10387770-DS-20 | 10,387,770 | 23,454,089 | DS | 20 | 2202-12-30 00:00:00 | 2202-12-31 22:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Lipitor
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a an ___ y.o. male with history of chronic a. fib on
coumadin, DM type II, HFpEF(EF >65% ___, and CKD stage V, with
a chronic right pleural effusion presents with progressive
decline in functional status (decreased appetite and mobility)
with fall from standing today. He presented to the emergency
department after reporting fall from standing with unknown head
strike. He endorsed unclear recollection of the event (thinks he
slipped on something in the bathroom), but is pretty certain he
had no loss of consciousness and wife reports he was aware when
she came into the room. No bowel or bladder incontinence.
Past Medical History:
1. Diabetes mellitus with peripheral neuropathy and chronic
renal failure (cr = 2.1-4.0 from ___. %HbA1c = 6.7
on ___.
2. Emphysema.
3. Hypertension.
4. Posterior vitreous detachment.
5. Urolithiasis.
6. History of basal cell carcinomas.
7. Hypersensitivity reaction.
8. Allergic rhinitis.
9. Vitamin B12 deficiency
10. Hypogammaglobulinemia.
11. Pleural effusion
12. CHF
13. Afib on warfarin, CHADS2Vasc 5
Social History:
___
Family History:
FAMILY HISTORY:
___ significant for mother with gastric ___ @ age ___ died age ___
Father emphysema died age ___.
Siblings: no hx of cancer
Maternal 3 aumts and MGM also with h/o CA in the abdomen,
unknown which types.
Physical Exam:
ADMISSION Physical Exam:
========================
VITALS: Temp 98.4 BP135/72 HR100 SpO295% RR 18
GENERAL: Comfortable, well-appearing.
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection. Moist mucous membranes, good
dentition. Oropharynx is clear.
NECK: No JVD visualized. Neck is supple with full range of
motion.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___
RUSB
systolic murmur
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally. There is no lower extremity edema. There is a
well-appearing wound with sutures in Left hand.
SKIN: Warm. Cap refill <2s. No rash. Diffuse bruising at arms
and
sites of insulin injections.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Alert and
oriented to person, place, but thought it was ___. Correctly
knew ___ was yesterday. Difficulty with weeks in reverse.
Left arm fistula: Bruit with palpable thrill present
DISCHARGE PHYSICAL EXAM
=======================
VS: ___ 1137 BP: 103/64 HR: 73 RR: 20 O2 sat: 99% O2
delivery: Ra
GENERAL: Resting comfortably in bed in no acute distress.
HEENT: Normocephalic, atraumatic. EOMI. Dry mucous membranes.
NECK: Supple. JVP flat while lying.
CARDIAC: Regular rhythm, normal rate. ___ RUSB systolic murmur
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. No edema.
SKIN: Scattered ecchymosis in upper extremities. distal
extremities warm and well perfused.
PSYCH/NEURO: Calm, A+O x1-2
Pertinent Results:
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-16.4* RBC-3.19* Hgb-10.4* Hct-32.8*
MCV-103* MCH-32.6* MCHC-31.7* RDW-13.0 RDWSD-48.9* Plt ___
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD ___ PTT-40.4* ___
___ 06:25AM BLOOD Glucose-162* UreaN-81* Creat-5.0* Na-138
K-4.2 Cl-95* HCO3-20* AnGap-23*
___ 06:25AM BLOOD Calcium-9.4 Phos-5.3* Mg-2.6
ADMISSION LABS:
___ 01:00PM BLOOD Neuts-82.6* Lymphs-9.9* Monos-7.0
Eos-0.0* Baso-0.1 Im ___ AbsNeut-9.19* AbsLymp-1.10*
AbsMono-0.78 AbsEos-0.00* AbsBaso-0.01
___ 01:00PM BLOOD Plt ___
___ 01:00PM BLOOD ___ PTT-40.1* ___
___ 01:00PM BLOOD Glucose-274* UreaN-42* Creat-4.5* Na-140
K-3.3* Cl-85* HCO3-30 AnGap-25*
___ 01:00PM BLOOD ALT-8 AST-11 CK(CPK)-42* AlkPhos-113
TotBili-1.0
___ 01:00PM BLOOD Lipase-38
___:00PM BLOOD ___
___ 07:50AM BLOOD CK-MB-3 cTropnT-0.12*
___ 08:50AM BLOOD CK-MB-2 cTropnT-0.09*
___ 09:40AM BLOOD CK-MB-1 cTropnT-0.10*
___ 03:39AM BLOOD CK-MB-2 cTropnT-0.11*
___ 01:00PM BLOOD Albumin-3.4* Calcium-9.9 Phos-4.4 Mg-1.5*
___ 01:09PM BLOOD Lactate-3.3*
___ 06:30PM BLOOD Lactate-2.3*
___ 10:52AM BLOOD Lactate-1.9 K-3.4
IMAGING/OTHER STUDIES
=====================
* ___ TTE:
The left atrial volume index is severely increased. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Diastolic function could not be assessed. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are mildly thickened (?#). No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no
mitral valve prolapse. Mild to moderate (___) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images unable to be reviewed) of
___, the degree of mitral regurgitation is greater.
Estimated pulmonary artery pressures are higher.
Brief Hospital Course:
This patient is a an ___ y.o. male with history of chronic a. fib
on Coumadin, DM type II, HFpEF(EF >65% ___, and CKD stage V,
with a chronic right pleural effusion and scarring who presented
with progressive decline in functional status (decreased
appetite and mobility)with fall from standing and multiple falls
recently. He was initially admitted for a ___ evaluation and
became unresponsive in the AM of ___ and found to have sustained
monomorphic VT. He was subsequently transferred to the CCU where
he was started on IV Amiodarone and then transferred back to the
medical ward.
#Monomorphic Ventricular Tachycardia:
The patient became unresponsive in the AM of ___ and found to
have sustained monomorphic VT on telemetry and EKG. A CODE BLUE
was called and the patient received two shocks, a 150mg IV and a
300 mg IV amiodarone bolus, and was then started on an
amiodarone drip before being transferred to the CCU. The patient
stabilized on the amiodarone drip in the CCU and was transferred
to the medical floor. He was subsequently started on Amiodarone
400mg PO BID to complete a 10g Amiodarone load (to end on
___. The patient will be transitioned to Amiodarone 400mg
PO QD on ___ (once 10g load is complete). He was continued
on warfarin for anticoagulation for his atrial fibrillation (as
discussed below). The source of his VT was thought to be
secondary to a reentry mechanism due to myocardial scarring as
the patient does have evidence of possible prior inferior MI
with Q waves in II, III and aVF.
#Goals of Care
#Declining Functional Status
#Fall
#Concern for Aspiration/ Dysphagia
The patient initially presented to the ED after sustaining
multiple falls and having increasing difficulty with ambulation
and preforming his ADLs at home. Initially his falls were
thought to be mechanical vs. possible orthostasis, however,
given his VT arrest (as above), it most likely arrhythmogenic
syncope. Following the patient's VT arrest and ICU stay, the
___ hospital course was complicate by delirium, concerns
for aspiration, and severe deconditioning. ___ saw the patient
and had recommended rehab. Speech and Swallow saw the patient
and determined the patient to be at high aspiration risk and had
initially recommended NPO. A goals of care discussion was held
with the family and patient made the patient DNR/DNI, and do not
hospitalize. It was established that the patient's main goal was
to be able to get home and he and the family were amenable to
rehab as bridge. Per family meeting wish to go ahead and allow
patient to eat and the patient was order modified aspiration
diet.
#UTI
The patient became acutely delirious on ___ and an infectious
work up was sent including a urine culture which was positive
for E. coli. He was treated with CTX starting on ___ with
plans for a 7 days course for a complicated UTI to end on
___. Converted to cefpodoxime on discharge.
#Encephalopathy
The patient acutely developed altered mental status in ___ of
___ which included vivid hallucinations and agitation. He
was A&O x0 at that time. Neuro exam was non-focal. The following
day his delirium had substantially improved, however, he
remained more somnolent and had not returned to his baseline.
Thought to be hospital delirium in the setting of recent arrest
and infection. We continued to treat his infection as above and
prescribed Seroquel QHS PRN.
#Chronic Afib on Coumadin
The patient has known A. fib with a CHADS2vasc 5: 7.5% annual
risk of CVA, 15% total event risk (including TIA). He presented
with an elevated INR to 6.8 and his Warfarin was initially held.
For rate and rhythm control the patient was initially continued
on his home Metoprolol which was discontinued after his VT
arrest when he was started on amiodarone. For anticoagulation
the patient's INR was initially supratherapeutic and trended
down. He continued to be intermittently supratherapeutic during
his hospitalization and his warfarin was dosed based on INR
levels.
#HFpEF
The patient has known HFpEF with his last TTE prior to admission
in ___ with EF 65%. BNP 26808 on arrival, though the patient
appeared dried on initial presentation and his weight was down.
This was thought to be secondary to over diuresis in the setting
of poor PO intake. The patient's home Torsemide and Metolazone
were initially held given his dry appearance on presentation.
Ultimately his home Torsemide 80mg QD was resumed. We continued
to hold his home metolazone 2.5mg PO QD as patient appeared
euvolemic or volume down throughout his hospitalization.
#CKD Stage V:
The patient had known CKD-V on presentation likely secondary to
HTN or DM. He has an intact left AV fistula intact with good
bruit though patient, however, he opted not to pursue HD moving
forward. His baseline Cr is ~3.5-4.5 since ___.
#BPH:
The patient was continued on Tamsulosin.
#Diabetes mellitus:
Complicated by peripheral neuropathy and chronic renal failure.
Most recent HbA1c = 6.7. The patient was continued on his home
Glargine 6U qAM and his home Lispro 3U with breakfast and 2 w/
dinner
TANSITIONAL ISSUES:
[] Patient will complete cefpodoxime for his UTI on ___
[] Patient's Amiodarone should be switched to from 400mg PO BID
to ___ PO QD starting on ___
[] INR remains labile and will require regular checks over the
next week to 2 weeks to maintain at a therapeutic level. Would
check next INR on ___ and if <3.0, would start 1.0mg PO QD
with a repeat INR in ___ days.
[] Patient requires ongoing work with ___ to be able to safely
transition home, which may include transition to acute rehab
once he recovers sufficiently. If patient ultimately does not
recover enough to transition home, will merit further goals of
care discussion and consideration of hospice (patient family
aware of this as a possible contingency but we and they are
hopeful he will mount enough recovery)
[] Ongoing work with swallow therapist.
[] Discharge Cr: 5.0. Patient not interested in dialysis based
on GOC. The patient may begin to develop symptoms from his
worsening kidney function (volume overload, uremia, further AMS)
and this should be a discussion with his family and him about
how they would like to proceed (i.e. if hospitalization is in
goals of care, if he would like to pursue hospice, etc.).
[] Patient has 8cm left hand wound. Sutures removed on ___.
Would re-examine hand wound intermittently and ensure that it
does not look infected and is not opening up/ dehiscing.
[] Patient's home metolazone is being held currently. Appears
euvolemic, but if appears to be volume overloaded may consider
restarting Metolazone.
[] CODE STATUS: DNR/DNI/No Dialysis/ No escalation of Care.
[] CONTACT:
***HCP: ___/ Relationship: Daughter/ Phone number:
___ phone: ___
***Alternate HCP: ___ ___
***Pt would also like wife ___ to be a contact:
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcitriol 0.5 mcg PO DAILY
2. Collagenase Ointment 1 Appl TP DAILY
3. Donepezil 5 mg PO QHS
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. Glargine 6 Units Breakfast
Humalog 3 Units Breakfast
Humalog 2 Units Dinner
6. Metolazone 2.5 mg PO PRN BEFORE TORSEMIDE WHEN THERE IS LEG
SWELLING Leg swelling
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Tamsulosin 0.4 mg PO QHS
10. Torsemide 80 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Cyanocobalamin ___ mcg PO BID
13. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
14. Sodium Bicarbonate 1300 mg PO BID
15. Warfarin 2.5 mg PO 5X/WEEK (___)
16. Warfarin 5 mg PO 2X/WEEK (MO,FR)
Discharge Medications:
1. Amiodarone 400 mg PO BID Duration: 4 Doses
2. Amiodarone 400 mg PO DAILY
PLEASE START FIRST DOSE IN AM of ___
3. Docusate Sodium 100 mg PO BID
4. Multivitamins W/minerals 1 TAB PO DAILY
5. QUEtiapine Fumarate 25 mg PO QHS:PRN agitation,
hallucinations
6. Ramelteon 8 mg PO QHS
7. Senna 17.2 mg PO BID
8. Glargine 6 Units Breakfast
Humalog 3 Units Breakfast
Humalog 2 Units Dinner
9. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
10. Aspirin 81 mg PO DAILY
11. Calcitriol 0.5 mcg PO DAILY
12. Collagenase Ointment 1 Appl TP DAILY
13. Cyanocobalamin ___ mcg PO BID
14. Donepezil 5 mg PO QHS
15. Fluticasone Propionate NASAL 1 SPRY NU BID
16. Metoprolol Succinate XL 25 mg PO DAILY
17. Omeprazole 40 mg PO DAILY
18. Tamsulosin 0.4 mg PO QHS
19. Torsemide 80 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Ventricular Tachycardia Arrest
HFpEF
CKD Stage V
Atrial Fibrillation
Type II Diabetes
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you had a fall at
home and had not been walking/moving as well at home.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While you were in the hospital you had an arrhythmia called
Ventricular Tachycardia for which you were given medications and
required an electrical shock.
- You were sent to the ICU and started on an IV medication to
help treat your arrhythmia
- Your medications were adjusted to help your heart function
better
- We had our physical therapists work with you to help you
rehabilitate.
- You were found to have a urinary tract infection for which you
were treated with IV antibiotics.
- We had multiple meetings with you and your family to discuss
what the best plan is going forward with your treatment
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please see the section below for a list of all of your
medications
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10387936-DS-20 | 10,387,936 | 20,326,543 | DS | 20 | 2143-12-15 00:00:00 | 2143-12-16 14:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, abdominal pain, nausea, emesis, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o M with no PMH who presented to the ED on ___ with fever,
diffuse abdominal pain, nausea, SOB and diarrhea.
He had been seen in the ED the day prior for one day of fatigue,
myalgias, fevers/chills, HA's and nausea. He reports starting to
feel poorly in the middle of the day after class. When his sxs
persisted that afternoon, he presented to the hospital. He had
normal labs and a negative flu swab in the ED, diagnosed with
viral syndrome and sent home.
The patient's symptoms worsened that night and he developed
severe abdominal pain. He says the pain was diffuse, severe
(___) and fluctuated in severity. He reports worse pain with
eating. His vomiting and diarrhea persisted and he reports that
both were non-bloody. He did not take his temperature at home.
He was unable to eat/drink at home. He continued to experience
nausea, vomiting, HA's and chills on ___ and represented
to the ED.
He says he has never had any prior issues with diarrhea and has
never experienced this constellation of sxs in the past. He
denies any chest pain or shortness of breath. No urinary
symptoms. He does not report any sick contacts, recent travel or
changes to eating habits. He endorses a rash on his knuckles
that developed over the last month. No family history of similar
presentations.
In the ED, initial vital signs were: T 102.4, HR 104, BP
116/53, RR 16, 100% RA
- Exam notable for: Normal cardiac and pulmonary exam. Right
lower quadrant tenderness without rebound or guarding.
- Labs were notable for CRP 140.4, WBC 3.7 (with 40% bands); Hct
34.0; Plt ct ___ Cr 1.0; C diff neg; Cal 7.7; Mag 1.2; lactate
2.7; stool studies, blood cx, ESR UA, lactate are pending.
- Studies performed include a bedside ultrasound which did not
show any definitive inflamed appendix. CT abdomen and pelvis
with contrast showed diffuse thickening of the right ascending
colon and terminal ileum concerning for IBD.
- Patient was given cipro/flagyl, IV fluids, Zofran and morphine
- Vitals on transfer: T:102.1 BP: 138/74 HR:93 RR:18 O2sat:97%RA
Upon arrival to the floor, the patient was stable with diffuse
abdominal pain, HA's, nausea. He was able to tolerate clear
liquids without vomiting, but still complained of nausea.
Review of Systems:
(+) per HPI
(-) vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
None
Social History:
___
Family History:
Reports diabetes on his father's side. No other medical
conditions that he is aware of.
Physical Exam:
Admission exam:
Vitals- T:102.1 BP: 138/74 HR:93 RR:18 O2sat:97%RA
GENERAL: In some discomfort but well-appearing; AOx3, NAD
HEENT: PERRL, EOMI, MMM
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
Resonant to percussion.
BACK: Skin. no spinous process tenderness. no CVA tenderness.
ABDOMEN: Guarding, tender diffusely and especially in RLQ, no
rebound tenderness, negative ___ sign
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN:Hyperpigmentation on knuckles bilaterally.
NEUROLOGIC: CN2-12 intact. ___ strength throughout.
Discharge exam:
Vitals- T:97.9 BP:105/63 P:52 RR:18 O2sat:98%ra
GENERAL: lying in bed, comfortable, AOx3, NAD
HEENT: PERRL, EOMI, MMM
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
ABDOMEN: bowel sounds present, non-distended, mildly tender to
palpation diffusely. No peritoneal signs, neg ___ sign.
EXTREMITIES: No edema.
SKIN:Hyperpigmentation on knuckles bilaterally.
Pertinent Results:
Admission labs:
___ 04:30PM BLOOD WBC-4.7# RBC-4.99 Hgb-12.6* Hct-38.6*
MCV-77* MCH-25.3* MCHC-32.6 RDW-13.2 RDWSD-37.1 Plt ___
___ 04:30PM BLOOD Neuts-80* Bands-13* Lymphs-3* Monos-3*
Eos-0 Baso-1 ___ Myelos-0 AbsNeut-4.37 AbsLymp-0.14*
AbsMono-0.14* AbsEos-0.00* AbsBaso-0.05
___ 04:30PM BLOOD Plt Smr-LOW Plt ___
___ 04:30PM BLOOD Glucose-161* UreaN-9 Creat-0.9 Na-136
K-3.4 Cl-102 HCO3-18* AnGap-19
___ 10:04AM BLOOD ALT-15 AST-16 AlkPhos-37* TotBili-0.3
___ 10:04AM BLOOD Calcium-7.7* Phos-2.7 Mg-1.2*
___ 01:00AM BLOOD calTIBC-226* Ferritn-229 TRF-174*
___ 10:04AM BLOOD CRP-140.4*
___ 04:50PM BLOOD Lactate-2.7*
Discharge labs:
___ 06:35AM BLOOD WBC-6.0 RBC-5.14 Hgb-12.8* Hct-39.4*
MCV-77* MCH-24.9* MCHC-32.5 RDW-13.9 RDWSD-38.6 Plt ___
___ 06:35AM BLOOD ___ PTT-32.0 ___
___ 06:35AM BLOOD Glucose-84 UreaN-4* Creat-0.7 Na-141
K-4.5 Cl-103 HCO3-24 AnGap-19
___ 06:35AM BLOOD ALT-209* AST-216* AlkPhos-67 TotBili-0.3
___ 06:35AM BLOOD Calcium-8.9 Phos-4.9* Mg-2.1
___ 02:12PM BLOOD calTIBC-235* Ferritn-581* TRF-181*
___ 06:35AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative HAV Ab-Negative
Imaging:
CT Abdomen/Pelvis with Contrast ___
1. Marked mural thickening involving the ascending colon and
terminal ileum concerning for inflammatory bowel disease. Small
volume ascites and reactive lymph nodes in the right lower
quadrant.
2. Normal appendix.
3. Left renal collecting system.
RUQ U/S ___
Normal abdominal ultrasound. No ultrasound findings correlating
to the
reported history of right upper quadrant pain.
MICROBIOLOGY:
___ 10:00 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___:
SALMONELLA SPECIES.
SALMONELLA ID CONFIRMED BY STATE LAB ON ___.
Reported to and read back by ___ ___ ___ @12:35
___.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
CANCELLED. PATIENT CREDITED.
Three separate stool specimens collected EVERY OTHER
DAY are
recommended for optimum sensitivity. Duplicate
specimens collected
on the same day will not be processed, since this does
not
increase diagnostic yield. Make sure to label date and
time of
collection on each stool specimen submitted to ensure
appropriate
processing.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Brief Hospital Course:
___ y/o M with no PMH who presented to the ED with 2 days of
fever/chills, vomiting, non-bloody diarrhea, and worsening
abdominal pain consistent with salmonella enterocolitis and
transaminitis.
#Salmonella enterocolitis
Patient presented with 2 days of fevers to 102.1, worsening
diffuse abdominal pain, vomiting and non-bloody diarrhea. CT
demonstrated thickening of ascending colon and terminal ileum,
numerous reactive lymph nodes in the right lower quadrant, and
normal appendix. Stool studies positive for salmonella
infection, possibly acquired from lab exposure at his school.
Initially treated with cipro/flagyl, now narrowed to cipro with
clinical improvement. Pt w/associated odynophagia, and was thus
tested for HIV and EBV, which were negative. His pain was
managed with IV morphine, nausea with Zofran, and he was given
IV maintenance fluids as needed. At the time of discharge, he
had much improved pain, no diarrhea, and was able to tolerate
PO.
# Abnormal liver function tests:
Patient's liver function tests were elevated, which is likely a
manifestation of
Salmonella enteritidis enterocolitis, which will likely
___: ___. ___,
___, et al. Abnormalities in liver enzyme levels during
Salmonella enteritidis enterocolitis. Rev ___.
___. He had no RUQ pain or tenderness, RUQ
ultrasound without acute process, and hepatitis serologies were
negative. Monospot and CMV were negative. His LFTs will be
checked ___ days after discharge, and he will follow-up with his
PCP ___ ___ weeks.
# Anemia: Hgb of 11.3 on admission which increased to 12.8 by
discharge. Unclear of his baseline. This is likely a function of
acute marrow suppression secondary to infection, which is
already self-resolving. His CBC will be checked ___ days after
discharge, and he will follow-up with his PCP ___ ___ weeks.
Transitional issues:
- LFTs on discharge: AST 216, ALT 209, Alk Phos 67, Tbili 0.3
- Hemoglobin on discharge: 12.8
- ___ meds: Ciprofloxacin 500 mg PO BID (Day 1 = ___, 7 day
course, last day = ___
-***Instructed Mr. ___ he should not handle or prepare food
for others for ___ weeks given asymptomatic shedding phase. This
phase will be prolonged in setting of antibiotics.
#Emergency Contact/HCP: Mom ___
Medications on Admission:
None
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*5 Tablet Refills:*0
2. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth q8H: prn Disp #*10
Tablet Refills:*0
3.Outpatient Lab Work
ICD-10: R94.5 Transaminitis
Labs: Hemoglobin, Liver Function Tests
Please fax results to: Attn: ___, MD (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Infectious colitis (salmonella)
Secondary diagnosis:
Transaminitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for severe abdominal pain, fevers, nausea, and
diarrhea. You were found to have an infection of your colon
caused by salmonella bacteria. This infection was likely
acquired from your recent handling of salmonella in school. We
treated you with broad antibiotics (ciprofloxacin and flagyl) to
treat your infection, and your condition improved. Once you
leave, you should continue taking the ciprofloxacin antibiotic
for 2 more days (until the end of the day on ___.
In the hospital, we also noticed that your Liver Function Tests
(LFTs) were increasing, which could be a sign of liver
inflammation. This may be related to your salmonella infection.
An ultrasound of your liver was normal. Please have your labs
checked at the ___ lab (___) on
___ or ___. For questions, their phone number
is ___. To be clear, this is just to get labs drawn to
minimize costs while you establish insurance in ___. The
results will be sent to us, and we will follow-up. Please also
see your PCP in ___ in the next ___ weeks.
If your condition worsens for any reason, or you develop ___ or
worsening pain, fever, yellowing of eyes or skin, confusion,
inability to tolerate food (nausea or vomiting) proceed straight
to the emergency department.
It was a pleasure to take care of you.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10388043-DS-11 | 10,388,043 | 22,871,741 | DS | 11 | 2142-10-06 00:00:00 | 2142-10-06 17:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with metastatic triple
negative breast cancer complicated by malignant urinary
obstruction requiring intermittent self-catherization who
presents with syncope.
Patient was recently admitted ___ to ___ with fevers and
urine retention found to have sepsis from pyelonephritis. She
was
treated with 7-day course of ciprofloxacin. She was seen in
___ clinic and started on capecitabine 2500mg daily.
Patient reports 5 days ago, she developed lightheadedness and
dizziness upon sitting up in bed and standing associated with
room spinning. She also note associated feeling warm and sweaty.
This lasted between 20 minutes to 1 hour and improved with lying
on a cold surface. Then 2 days ago, she was going to the
bathroom
to lie down on the cold floor when she had a syncopal event,
striking her head. Then on ___ night, patient had the same
episode in the early morning where she got up to go to the
bathroom and had a syncopal event in the bathroom where she hit
her head and lost consciousness. She was found on the ground by
her mother who noted that she was disoriented. She denies any
seizure activity or tongue biting. She denies associated chest
pain, palpitations, shortness of breath, headaches, slurred
speech, and weakness/numbness. She felt dizzy all day on ___
so presented for to see her oncologist who referred her into the
ED. She otherwise endorses new hoarseness for the past 1 week.
She notes increased right arm lymphedema with decreased strength
and intermittent numbness. She notes decreased appetite but has
been drinking plenty of fluids. Also some mild diarrhea since
starting capecitabine.
On arrival to the ED, initial vitals were 97.1 90 131/85 20 95%
RA. Exam was notable for normal neurological exam. Labs were
unremarkable. Blood and urine cultures were sent. CXR and head
CT
were negative. CT neck showed non-specific retropharyngeal edema
and persistent right neck mass. She was given morphine 2mg IV,
Tylenol 1g IV, Zofran 4mg IV, and 1L NS. Prior to transfer
vitals
were 98.1 85 114/79 16 97% RA.
On arrival to the floor, patient reports ___ right-sided neck
pain. She denies fevers/chills, headache, vision changes,
weakness/numbnesss, shortness of breath, cough, hemoptysis,
chest
pain, palpitations, abdominal pain, nausea/vomiting,
hematemesis,
hematochezia/melena, dysuria, hematuria, and new rashes.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-late ___: discovered to have a right upper outer quadrant
breast mass.
- Right partial mastectomy and sentinel node biopsy performed at
___ in ___ on
___ revealed an infiltrating ductal carcinoma with
2 of 4 positive sentinel nodes, ER positive, PR positive, and
HER-2 negative. Reexcision and axillary dissection were
performed
in ___, with negative margins and 6 negative nodes by
report
- She underwent radiation therapy, and chemotherapy (Adriamycin,
cyclophosphamide, Taxol, Avastin).
-___: she was found to have metastatic disease involving her
neck, ovaries, and bones.
- Not currently getting chemotherapy, getting XRT for bony
metastasis in neck. Had been enrolled in study investigating the
safety and efficacy of Eribulin Mesylate in Combination With
Pembrolizumab. Pembrolizumab permanently discontinued on ___, due to recurrent pneumonitis. Determined to have
progression
of her disease and therefore taken off study with Eribulin,
effective ___.
PAST MEDICAL HISTORY:
- breast cancer, as above
- pembrolizumab-induced cryptogenic organizing pneumonia
- hypothyroidism
- HLD
Social History:
___
Family History:
Father - multiple myeloma (___). No family history of breast or
ovarian cancer.
Physical Exam:
ADMISSION
VITALS: Afebrile and vital signs stable
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. TM
normal, cone of line intact bilaterally. Right neck with
thickened, course skin post-radiation, limited rotational ROM.
CV: Heart regular, no murmur, no S3, no S4. No JVD. No ___ edema
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE
VITALS: Afebrile and vital signs stable
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. TM
normal, cone of line intact bilaterally. Right neck with
thickened, course skin post-radiation, limited rotational ROM.
CV: Heart regular, no murmur, no S3, no S4. No JVD. No ___ edema
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION
___ 08:15PM BLOOD WBC-6.2 RBC-3.77* Hgb-10.5* Hct-32.1*
MCV-85 MCH-27.9 MCHC-32.7 RDW-17.1* RDWSD-50.8* Plt ___
___ 08:15PM BLOOD Neuts-69.5 Lymphs-17.7* Monos-9.7 Eos-2.3
Baso-0.5 Im ___ AbsNeut-4.28 AbsLymp-1.09* AbsMono-0.60
AbsEos-0.14 AbsBaso-0.03
___ 08:15PM BLOOD Glucose-119* UreaN-12 Creat-0.7 Na-140
K-3.9 Cl-102 HCO3-27 AnGap-11
___ 08:15PM BLOOD cTropnT-<0.01
___ 09:07PM BLOOD Lactate-1.4
DISCHARGE
___ 05:35AM BLOOD WBC-6.2 RBC-3.97 Hgb-10.8* Hct-33.9*
MCV-85 MCH-27.2 MCHC-31.9* RDW-17.4* RDWSD-52.3* Plt ___
___ 05:35AM BLOOD Glucose-95 UreaN-10 Creat-0.7 Na-137
K-4.2 Cl-100 HCO3-26 AnGap-11
___ 05:35AM BLOOD Albumin-3.7 Calcium-8.7 Phos-4.1 Mg-2.1
IMAGING
___ MRI
1. No acute intracranial abnormality. No evidence of
intracranial metastatic disease at this time.
2. Solitary punctate focus of FLAIR hyperintensity, right
external capsule, nonspecific. This could relate to sequelae of
migraines, prior trauma, or early changes of chronic white
matter microangiopathy.
3. Partially visualized enhancement and edema in the right
inferior mastoid soft tissues at the posterolateral skullbase,
without definitive apparent bony involvement. No focal fluid
collection. This can be previously seen on examination of ___, previously described as concerning for metastatic
disease.
Brief Hospital Course:
# Syncope: Patient with syncope in setting of dizziness.
Differential includes vasovagal (with significant edema, now
post-radiation changes and mass in the area, carotid sinus may
be involved), cancer-related (possible brain mets or from new
chemotherapy), med-related. Tele unremarkable throughout stay.
No recurrence of Sx inpatient and ambualting without difficulty.
Revealed that pt was taking Flexeril briefly around the time of
Sx starting, which may have been contributing; this was held.
Brain MRI showed no acute abnormality. Primary oncologist saw
the patient on the day of discharge and agreed that she was safe
for discharge with close outpatient follow up. Coached patient
on slowly transitioning from lying to sit to stand; will stay
out of work through the holiday week.
#UTI: E coli in urine, >100k patient reports having had subtle
UTI Sx in the past treated. Bactrim DS BID x3 days; last will be
___ am dose. Discharged with remaining doses.
# Metastatic Triple Negative Breast Cancer:
# Secondary Neoplasm of Bone:
# Secondary Neoplasm of Lymph Node:
# Secondary Neoplasm of Omentum: Recently started on
Capecitabine. Evidence of metastatic spread to retropharyngeal
area with edema probably ___ radiation, likely compression
likely of laryngeal nerve. Updated Dr. ___.
# Malignant Bladder Neck Obstruction: Extensive involvement by
the neoplasm in floor of pelvis with mass in vesico-uterine
pouch and extrinsic compression of ureters. Intermittent
straight catheterization, as at home.
# Mispositioned Port: CXR with port tip likely in right
brachiocephalic vein. Now s/p repositioning this admission by ___
with no issues thereafter.
# Anemia: At baseline. No evidence of bleeding. Likely due to
chronic disease/malignancy.
# Hypothyroidism: Continue home levothyroxine
# Right Arm Lymphedema; chronic; continue supportive care
TRANSITIONAL ISSUES:
- f/u with oncologist
- f/u pain regimen following DC of flexeril
- consider further outpatient imaging to assess for effect of
radiation/mass on carotid sinus if symptoms do not resolve
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
2. Levothyroxine Sodium 175 mcg PO DAILY
3. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
5. Capecitabine 1000 mg PO QAM
6. Capecitabine 1500 mg PO QPM
7. Cyclobenzaprine ___ mg PO HS:PRN pain
8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily as
needed Disp #*30 Tablet Refills:*2
2. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily as
needed Disp #*30 Tablet Refills:*1
3. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice daily Disp #*2 Tablet Refills:*0
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
6. Capecitabine 1000 mg PO QAM
7. Capecitabine 1500 mg PO QPM
8. Ferrous Sulfate 325 mg PO DAILY
9. Levothyroxine Sodium 175 mcg PO DAILY
10. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
Discharge Disposition:
Home
Discharge Diagnosis:
syncope
retropharnygeal mass, edema, s/p radiation therapy
UTI
Discharge Condition:
stable
Discharge Instructions:
You were admitted due to dizziness and a fall. It is not
entirely clear what caused this but it may be due to your cancer
or cancer treatment. Fortunately the MRI of your brain showed no
acute changes. We also found that you may have a urinary tract
infection and you were started on antibiotics. Please take the
last two doses tonight and tomorrow morning.
Please take all medications as prescribed and make sure to see
your oncologist in follow up.
Followup Instructions:
___
|
10388177-DS-10 | 10,388,177 | 22,335,321 | DS | 10 | 2136-04-17 00:00:00 | 2136-04-17 20:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Endoscopic Gastroduodenoscopy, Colonoscopy
History of Present Illness:
___, status post whipple procedure for groove pancreatitis
complicated by wound infection, anastamotic leakage at the
pancreaticojejunal anastamosis, with four days of melena,
fatigue, and found at OSH ED to be in SVT up to 190 and have a
HCT of 15. Per the wife, the patient had four days of
increasingly melanic stools and the day of presentation to the
OSH ED, had an episode of shaking, chills, and light-headedness
followed by shortness of breath. It was after this that he
presented to the OSH ED and had the above listed findings. He
was transferred emergently to the ___ ED after receiving 2U
PRBC and several rounds of adenosine which eventually broke his
SVT. On initial evaluation in the ___, he was stable and
responding appropriately to questions though he did appear quite
pale.
Past Medical History:
Significant for a ___ history of
diabetes, which has recently become insulin-dependent. He has a
hypervascular lesion in the right kidney concerning for renal
cell carcinoma.
Social History:
___
Family History:
He has no family history of gastrointestinal malignancy.
Physical Exam:
Gen: Well appearing, no acute distress
CV: Regular rate and rhythm, no murmurs,rubs or gallops
Pulm: Clear to auscultation bilaterally
Abd: Soft, not distended, JP drain x2 in the R abdomen,
nontender,
no rebound or guarding, hypoactive bowel sounds, no palpable
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 08:36AM HCT-23.4*
___ 04:35AM WBC-23.4* RBC-2.34*# HGB-6.8*# HCT-20.9*#
MCV-90 MCH-29.2 MCHC-32.6 RDW-15.1
Brief Hospital Course:
On ___ the patient was admitted to the General Surgical
Service for evaluation and treatment of SOB revealed to be
secondary to anemia to a crit of 15 at an outside hospital, he
was transferred to the ___ ED where he was transfused 2 units
of blood and admitted to the ICU.
Neuro: The patient received Dilaudid with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications.
CV: Upon admission to the ICU, the patient's vitals were
monitored, closely, he received serial HCT checks, (Q4 hours)
and was transfused another unit of blood. After his hematocrit
stabilized his vitals were consistently stable and his labs were
drawn daily.
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: Upon admission he had a DRE with a positive GUAIAC.
The patient was made NPO with IV fluids. A CT scan of his
abdomen revealed no evidence of internal bleeding. He received
an EGD to identify the source of his bleed. A clean based ulcer
was identified at his gastro-jejunal anastomosis and was
clipped. He received a colonoscopy prep, and received a
colonoscopy, this revealed no source of bleeding. It was
determined that the source of bleeding must be the ulcer, and he
was started on IV PPI, and evaluated for H. pylori which was
negative. He was restarted on tube feeds, and his PO diet was
advanced when appropriate, which was well tolerated. Patient's
intake and output were closely monitored, and IV fluid was
adjusted when necessary. Electrolytes were routinely followed,
and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. His EGD revealed an
active esophageal candidiasis. He was started on and completed a
course of fluconazole.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly. A ___
consult was retained for the patients relatively new diagnosis
of diabetes.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; 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 regular
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. Of note, the patient is
declining to take pancreatic replacement enzymes at this time
due to lack of insurance coverage and prohibitive cost of the
medication.
Medications on Admission:
Amlodipine 5 mg PO daily, lantus 24- 26 in evening, metoprolol
25 mg tablet ER BID, percocet ___ mg ___ tablet(s) Q ___ hours
for pain, aspirin 81 mg ___ QD, omeprazole 20mg BID
Discharge Medications:
1. omeprazole 20mg PO BID -> (patient was given pantoprazole
prescription but his insurance did not cover it, and he already
had a standing prescription for omeprazole 20mg PO BID at home
which he was instructed to continue as part of his therapy until
told otherwise in ___ clinic)
2. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
3. Glargine 18 Units Bedtime
Insulin SC Sliding Scale using Insulin
RX *insulin glargine [Lantus] 100 unit/mL please take before
bedtime. 18 Units before BED; Disp #*1 Vial Refills:*2
RX *insulin syringe-needle U-100 [Insulin Syringe] 30 gauge x
___ per insulin teaching as needed Disp #*3 Box Refills:*2
Disp #*3 Box Refills:*2
4. Amoxicillin 1000 mg PO Q12H H. pylori Duration: 7 Days
RX *amoxicillin 500 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
5. Clarithromycin 500 mg PO Q12H H. pylori Duration: 7 Days
RX *clarithromycin [Biaxin] 500 mg 1 tablet(s) by mouth twice a
day Disp #*14 Tablet Refills:*0
6. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H pain
RX *oxycodone-acetaminophen [Percocet] 5 mg-325 mg 1 tablet(s)
by mouth every ___ hours Disp #*30 Tablet Refills:*0
7. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
RX *insulin lispro [Humalog KwikPen] 100 unit/mL Up to 10 Units
per sliding scale four times a day Disp #*2 Box Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
bleeding ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You may shower with your drains in place, but please keep them
covered while in shower and change dressings afterwards with
clean, dry dressings. Do not soak in a tub. Please call Dr.
___ or return to the emergency department if you have
any bright red blood per rectum or dark tarry stools, bloody
vomit, a fever greater than 100.5 degrees, significant increase
in redness or drainage from around your wounds, significant
increase or change in color of the drainage from your abdominal
drain, or for any other medical concerns related to your recent
surgery and post-operative course. Please take all prescribed
medications as instructed, and call Dr. ___ office with any
questions.
Followup Instructions:
___
|
10388429-DS-22 | 10,388,429 | 25,170,552 | DS | 22 | 2172-02-07 00:00:00 | 2172-02-08 19:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Tape ___ / Morphine / Atorvastatin / Zocor /
Tobramycin
Attending: ___
Chief Complaint:
Dyspnea and orthopnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with systolic CHF (EF40-45% on last formal TTE), CAD s/p
multiple MIs and PCI with BMSx2 to the RCA and DES x1 to the
RCA, Afib on warfarin, recent basilar stroke, PAD s/p stents who
presents from rehab with shortness of breath and orthopnea. The
patient is a somewhat poor historian, she is accompanied by her
husband who provides some history. She states that she was
feeling mildly SOB at the end of her recent hospitalization and
since arriving to rehab yesterday. However, she felt
significantly more SOB this AM when she was trying to get
dressed. She denies CP and cannot remember the last time she had
CP or chest discomfort. She does not remember having heart
attacks in the past or what she felt like at that time. She
reports ongoing dry cough with no fevers and no dysuria. She is
unable to be specific about her diet, but states that she tried
to avoid foods high in salt. She has been receiving all her
medications at the hospital and at rehab recently.
She normally sleeps on 2 pillows but states this is for comfort
and not related to her breathing, she denies any PND. She had
felt short of breath recently with walking, even short distances
while at rehab and in the hospital. Prior to her previous
admission, she lived independently at home with her husband. She
did not wear oxygen at home prior to her last admission.
In the ED, initial vitals were 97.9 96 135/95 16 98% 4L NC
Labs and imaging significant for BNP of 15,000 and trop of 0.04.
Patient given Lasix 40mg IV at OSH ED. Also reportedly had ED
echo which showed EF of 35%. She received ASA 325mg in the ED.
Vitals on transfer were ___, 130/91, 91, 26, 94%RA
On arrival to the floor, patient reports feeling comfortable at
rest with no SOB or chest pain. She has no complaints but
appears mildly confused. Her husband reports that she has been
intermittently confused lately, but is unable to specify how
long this has been going on for.
REVIEW OF SYSTEMS
On review of systems, s/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 chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: inferior STEMI with had
total occlusion of RCA s/p BMS x2 in ___. Also had DES placed
in mid-RCA in ___.
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-Afib on warfarin
-Cerebrovascular atherosclerosis
-Basilar aneurysm s/p multiple coiling (some failed attempts,
last ___
-H/o mesenteric ischemia s/p ex-lap
-H/o ruptured AAA s/p repair in ___
-S/p right common and external iliac stent in ___
-H/o hydrocephalus s/p VP shunt placement in ___
-Sp multiple abdominal surgeries ___
Social History:
___
Family History:
Father died of an MI in his ___, but no other family members
with CAD. No known history of strokes in her family.
Physical Exam:
Admission exam:
VS: T=98.3 BP 137/44 HR 100 RR 26 ___
Weight: 74kg
GENERAL: NAD. Oriented x1 (name only, knows "hospital"). Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP to the ear lobe
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. regular rate with occasional premature beats, normal S1,
S2. No m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB with no crackles,
but diminished lung sounds at the bases bilat.
ABDOMEN: Multiple well-healed incisions and well-healed
ileostomy. Mild tenderness to palp in all quardants. Normoactive
BS
EXTREMITIES: No c/c/e. Significant bruising over the right groin
int he area of her recent vascular access, small 1-2cm hematoma
with mild TTP int he right groin.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: CN II-XII intact, dysmetria with finger-to-nose
bilaterally, but worse on left. Only mild discoordination with
rapid alternating movements in ___. Strength ___ in all
extremities.
PULSES:
Right: DP 1+ ___ 1+
Left: DP 2+ ___ 2+
Discharge exam - unchanged from above except as below:
VS: O2sat >95% on RA
Weight: 68.2kg
Neck: JVP of approx 6cm
Lungs: slightly diminished breath sounds at the bases bilat
Neuro: A&Ox ___ (name and occasionally location)
Pertinent Results:
Admission labs:
___ 05:10AM BLOOD WBC-5.0 RBC-3.34* Hgb-10.6* Hct-33.3*
MCV-100* MCH-31.8 MCHC-32.0 RDW-13.5 Plt ___
___ 05:10AM BLOOD ___ PTT-26.2 ___
___ 05:10AM BLOOD Glucose-182* UreaN-12 Creat-1.0 Na-142
K-4.0 Cl-110* HCO3-23 AnGap-13
___ 05:10AM BLOOD Calcium-9.0 Phos-3.8 Mg-1.8
___ 04:00PM URINE Color-Straw Appear-Clear Sp ___
___ 04:00PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
___ 04:00PM URINE RBC-31* WBC-3 Bacteri-NONE Yeast-NONE
Epi-0
Discharge labs:
___ 07:15AM BLOOD WBC-6.1 RBC-3.53* Hgb-11.4* Hct-35.3*
MCV-100* MCH-32.4* MCHC-32.4 RDW-12.9 Plt ___
___ 07:15AM BLOOD ___
___ 07:15AM BLOOD Glucose-71 UreaN-18 Creat-1.2* Na-143
K-4.3 Cl-102 HCO3-32 AnGap-13
___ 07:15AM BLOOD Mg-2.1
Cardiac enzymes:
___ 04:15PM BLOOD cTropnT-0.04* ___
___ 11:53PM BLOOD CK-MB-3 cTropnT-0.04*
___ 07:17AM BLOOD CK-MB-3 cTropnT-0.04*
Imaging:
-CXR (___): Bilateral pleural effusions with overlying
atelectasis. Underlying consolidation not excluded.
Brief Hospital Course:
___ with systolic CHF (EF40-45% on last formal TTE), CAD s/p
multiple MIs and PCI with BMSx2 to the RCA and DES x1 to the
RCA, Afib on warfarin, recent basilar stroke, PAD s/p stents who
presents from rehab with shortness of breath and orthopnea.
# PUMP/Acute on chronic systolic heart failure: She appeared
volume overloaded on exam with JVP to the earlobe and worsening
pleural effusions on CXR with mild pulm edema. This in
combination with her symptoms of DOE and orthopnea suggested an
exacerbation of her systolic heart failure. Etiology of her
exacerbation is thought to be from fluids she received during
her recent admission to neurology where she had proedures
performed. She also received 2 units of PRBCs during this
admission. Her troponin was stable x3 at 0.04 and CK-MB was
negative.
She was given IV Lasix for diuresis, she initially
responded well to 20mg IV but subsequently required 40mg IV.
Her symptoms improved with diuresis and her weight decreased
approximately 6kg during this hospitalization. She was started
on torsemide 10mg PO daily at the time of discharge. She will
follow-up with Dr. ___ cardiology, who she has not seen
for many years. She was already on an ACEi at admission and her
beta blocker was converted to metoprolol succinate. She was
educated on adhering to a low sodium diet, we also discussed
these issues with her husband.
# CORONARIES: She has a history of multiple MIs and her reduced
ejection fraction with regional wall motion abnormalities are
thought to be secondary to these infarcts. She remained chest
pain free during this admission and did not report chest pain
prior to the onset of her dyspnea and orthopnea. She was
continued on ASA 325, metoprolol (converted to succinate at
discharge), and lisinopril 10mg.
# RHYTHM: She was occasionally tachycardic to the 100s during
this admission. Has a h/o Afib, although rhythm appeared to be
atrial tach vs Afib. Her metoprolol was increased from 50mg q8h
to 50mg q6h with improvement in her heart rate. At discharge,
she will continue metoprolol succinate 200mg daily. She was
continued on warfarin during this admission, dose was decreased
to 3mg. She will need a repeat INR checked on ___,
please fax results to Dr. ___ at ___.
--Chronic issues--
# T2DM: Blood sugar remained variable, she was as low as the ___
and as high as ~400. She was continued on her home dose of
Lantus and a regular insulin sliding scale.
# PAD s/p right CIA and CEA stents: Continued on ASA 325mg
daily
# HTN: BP remained relatively well controlled. She was
continued on lisinopril and metoprolol as above.
# Hyperlipidemia: Continued on rosuvastatin
# Recent cerebellar stroke: She continued to have deficits in
her neurologic exam, cerebellar signs including rapid
alternating movements and finger-to-nose were diminished L>R.
She was continued on warfarin and ASA as above.
# Code status this admission: DNR/ *OK to intubate*
# EMERGENCY CONTACT: ___ (husband): ___
# Transitional issues:
-Will follow-up with Dr. ___ her systolic heart
failure
-Metoprolol 50mg tid changed to metoprolol succinate 200mg daily
at discharge
-Started on torsemide 10mg PO daily at discharge
-Will need chem-10 and INR checked on ___, please fax
results to Dr. ___ at ___.
Medications on Admission:
1. warfarin 5 mg daily
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Q6PRN
3. aspirin 325 mg daily
4. lisinopril 10 mg daily
5. insulin glargine 15 units AM, 18 units ___ .
6. insulin regular human Insulin sliding scale (120-160 for
2U, 160-200 for 4U, etc.).
7. nicotine 14 mg/24 hr
8. rosuvastatin 20 mg daily
9. trazodone 25mg PRN insomnia
10. folic acid 1 mg daily
11. thiamine HCl 100 mg daily
12. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule
TID w/ meals
13. metoprolol tartrate 50 mg TID
14. bisacodyl 10mg daily PRN
15. docusate sodium 100 mg BID
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
5. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. insulin glargine 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous Each morning.
7. insulin glargine 100 unit/mL Solution Sig: Eighteen (18)
units Subcutaneous Each evening.
8. insulin regular human 100 unit/mL Solution Sig: sliding scale
units Injection three times a day.
9. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
13. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. torsemide 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
17. Outpatient Lab Work
Chem-10 and ___ on ___, fax results to Dr. ___
at ___
18. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: At
4PM daily.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Acute on chronic systolic heart failure
Secondary diagnoses:
Coronary artery disease
Hypertension
Type 2 diabetes
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your admission to
___ for shortness of breath. You had extra fluid in your
lungs which led to your shortness of breath, this likely
happened because you got fluids during your last admission. You
received IV Lasix to help get rid of the extra fluid. You will
go home with a diuretic pill ("water pill") to help keep the
fluid off. You will also follow-up with a cardiologist after
discharge
The following changes were made to your medications:
START torsemide 10mg PO daily
START metoprolol succinate 200mg by mouth daily
CHANGE warfarin to 3mg by mouth daily
STOP metoprolol tartate
Followup Instructions:
___
|
10388546-DS-18 | 10,388,546 | 26,923,676 | DS | 18 | 2204-08-16 00:00:00 | 2204-08-19 22:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Codeine
Attending: ___.
Chief Complaint:
CC: abdominal pain
Major Surgical or Invasive Procedure:
exploratory laparotomy
total abdominal hysterectomy
bilateral salpingo-oophorectomy
omentectomy
splenectomy
rectosigmoid resection and reanastomosis with protective
ileostomy
optimal primary cytoreduction
History of Present Illness:
Ms. ___ is a ___ woman who was called into the emergency
department by Dr. ___ concern for obstruction from what is
believed to be ovarian malignancy.
Ms. ___ reports that she has had several weeks of abdominal
discomfort and bloating. She was seen by her primary care doctor
and had an outpatient CT last ___ that demonstrated a 6cm
right adnexal mass adjacent to the sigmoid, omental caking, a
1.2cm splenic lesion, and mild-moderate ascites. The liver and
lung bases were unremarkable. She developed nausea/vomiting from
the PO contrast, and was then seen at the ___ emergency
room where she received IV hydration and antiemetics. As there
was no evidence of bowel obstruction or renal failure, she was
discharged home so that she could fly to ___ with plan for
work-up on her return. While in ___, she had increased pain
and was unable to have a bowel movement. She was admitted to a
hospital there, but deferred surgery at that time. She just
arrived back in ___ today.
She reports that her last normal bowel movement was on ___
(over a week ago). She has been taking colace and miralax with
minimal benefit. She has very little appetite, but otherwise
denies nausea or emesis. She continues to feel bloated. She
denies any difficulties with voiding. Denies fever/chills,
SOB/CP, palpitations, or dizziness.
Her CA-125 from ___ is 103.2
Past Medical History:
Obstetrical History: G3P3
-SVD x 3, uncomplicated per pt
Gynecologic History:
-Menarche: ___
-Reports regular menses. Denies h/o menorrhagia or dysmenorrhea
-Went through menopause in her early ___.
-Last Pap test in ___ was negative
-Denies history of abnormal Paps
-Denies h/o fibroids, cysts
-Last mammogram in ___ normal
-Denies history of breast disease
-Denies h/o pelvic infections or STIs
Past Medical History:
- hypothyroidism s/p thyroidectomy (Pathology was Oncocytic
(Hurthle cell) neoplasm with atypical features)
- colonic adenoma in ___. Last colonoscopy ___ with
diverticulosis but otherwise no abnormalities
- osteopenia
- lumbar spondylosis
Past Surgical History:
- left thyroid lobectomy and isthemectomy (___)
- completion thyroidectomy (___) performed because previous
pathology not clear if malignancy or not
Social History:
___
Family History:
-Brother died of colon cancer diagnosed in his ___
-Another brother died of brain cancer
-Niece diagnosed with breast cancer in her ___
-Denies a family history of ovarian, uterine, or cervical
malignancy
Physical Exam:
On Admission:
VS: 98.8 84 137/63 16 99% RA
Gen: comfortable appearing Caucasian woman, presents with her
husband and her sister
CV: rate ___, normal rhythma, no murmur
Resp: CTAB, good air movement throughout, no crackles or wheezes
Abd: hypoactive bowel sounds presents, softly distended,
nontender to palpation
Extremities: good perfusion, no edema, calves nontender
DISCHARGE EXAM:
AVSS, NAD
RRR, CTAB
Abdomen soft, NT, ND, nl BS
Ostomy site pink, putting out liquid brown stool and gas
Left JP drain site dry and healing with steristrips
Mild erythema on inferior third of vertical paramedian incision.
no induration or TTP. Incision otherwise c/d/i and healing well
with steristrips.
Extremities 1+ pitting edema overally improved, NT soft
bilaterally
Pertinent Results:
ADMISSION LABS:
___ 04:45PM BLOOD WBC-12.0*# RBC-4.74 Hgb-13.8 Hct-41.1
MCV-87 MCH-29.0 MCHC-33.5 RDW-13.9 Plt ___
___ 04:45PM BLOOD Neuts-76.4* Lymphs-17.6* Monos-5.1
Eos-0.6 Baso-0.3
___ 04:45PM BLOOD ___ PTT-26.3 ___
___ 04:25PM BLOOD ___
___ 04:45PM BLOOD Glucose-78 UreaN-11 Creat-0.6 Na-136
K-3.9 Cl-97 HCO3-24 AnGap-19
___ 11:00AM BLOOD Albumin-4.1 Calcium-8.3* Phos-3.4 Mg-1.9
___ 04:45PM BLOOD CEA-1.6
___ 08:25PM BLOOD CA ___ -Test
Day of discharge:
___ 05:29AM BLOOD WBC-14.1* RBC-2.66* Hgb-8.1* Hct-24.1*
MCV-91 MCH-30.3 MCHC-33.5 RDW-14.6 Plt ___
___ 05:29AM BLOOD Glucose-101* UreaN-6 Creat-0.4 Na-139
K-4.2 Cl-105 HCO3-27 AnGap-11
___ 05:29AM BLOOD Calcium-7.5* Phos-4.6* Mg-1.9
___ PATHOLOGY:
1. Omentum, biopsy (A-J):
Metastatic adenocarcinoma, see synoptic report.
2. Uterus and cervix (K-Q):
- Metastatic adenocarcinoma, present on anterior and posterior
uterine serosa.
- Leiomyoma, measuring up to 1.2 cm.
- Unremarkable cervix and atrophic endometrium.
3. Spleen (R):
No carcinoma seen. See addendum for microscopic description of
the splenic nodule.
4. Omentum (S-W):
Metastatic adenocarcinoma, see synoptic report.
5. Anastomotic donut (X):
Unremarkable colonic segment.
6. Rectosigmoid colon, bilateral fallopian tubes and ovaries
(Y-AL):
Ovarian adenocarcinoma extending into the colonic serosa
circumferentially with construction but not complete obstruction
of the bowel.
No colonic mucosal involvement.
Ovary Synopsis
Staging according to ___ Joint Committee on Cancer Staging
Manual -- ___ Edition, ___
MACROSCOPIC
Specimen Type: Right salpingo-oophorectomy, left
salpingo-oophorectomy, hysterectomy, omentectomy, rectosigmoid
colon.
Tumor Site
Dominant Side (2x larger): Bilateral.
Surface Involvement: Present.
Tumor Size
Greatest dimension: 7 cm.
Other organs/Tissues Received: Rectosigmoid colon, spleen.
MICROSCOPIC
Histologic Type: Serous, carcinoma.
Histologic Grade: G3: poorly differentiated.
Washings/cytology: Not applicable.
Fallopian tube
Serosal implant.
Uterus
Serosa: Implant.
Endometrium: Negative.
Omentum: Implant, macroscopic.
EXTENT OF INVASION
Primary Tumor TNM (FIGO): pT3c (IIIC): Peritoneal metastasis
beyond pelvis more than 2 cm in greatest dimension and/or
regional lymph node metastasis.
Regional Lymph Nodes: pNX: Cannot be assessed.
Lymph Nodes: None submitted.
Distant metastasis: pMX: Cannot be assessed.
Venous/lymphatic vessel invasion (V/L): Present.
Comments: The degree of parenchymal ovarian involvement is
limited; this may represent a primary peritoneal carcinoma.
Entire tubal fimbria has been examined microscopically
Brief Hospital Course:
Ms. ___ was admitted to the GYN oncology service for
further evaluation of her adnexal mass and symptoms of
obstruction, which were attributed to likely ovarian cancer.
The decision was made to continue her admission until planned
surgery due to a failure to thrive. She was begun on total
parenteral nutrition on hospital day #3. On (HD #7) ___
she underwent optimal cytoreduction with an exploratory
laparotomy, a total abdominal hysterectomy, bilateral
salpingo-oophorectomy, rectosigmoid resection with primary
anastomosis, omentectomy, splenectomy, and diverting ileostomy,
see operative report for details. Final pathology showed
metastatic ovarian adenocarcinoma, see pathology report for
details. She was admitted to the intensive care unit for close
postoperative monitoring due to intraoperative hypotension and
concern for fluid overload. She was extubated on postoperative
day #1, remained hemodynamically stable, and was transferred to
the floor on POD #2. Below is a summary of her course by
system:
# Postoperative care: postoperative pain was controlled with a
thoracic epidural and IV medications until she was ultimately
transitioned to oral medications without difficulty. She had
two ___ drains that put out decreasing amounts of
serosanguinous fluid and where removed on POD #7. Staples were
removed POD#9, and ___ erythema was noted. Keflex
was begun for presumed cellulitis. The tape from her JP drain
site caused skin blistering--these were monitored and showed no
signs of infection.
# Heme: She received 3 units of packed red cells
intraoperatively and remained hemodynamically stable throughout
her recovery. Her hematocrit slowly drifted to 24.1, and on the
day of discharge she received 2 units of packed red cells in
anticipation of undergoing chemotherapy. In total, she received
5 units of pRBC during her hospitalization.
# ID: Her WBC count was noted to peak at 17.5 during her
recovery, but she remained afebrile without focal complaints.
Urinalysis was negative, and culture contaminated. Her
leukocytosis improved without intervention. She was ultimately
treated for presumed incisional cellulitis for a planned 10 day
course.
#GU: Her creatinine remained normal. By POD#5 she was
ambulating well enough for the foley to be discontinued, and she
voided without difficulty.
# GI: NGT was removed POD#3, the ostomy began to discharge bowel
contents, and her diet was advanced to regular by POD#7. Her
TPN was weaned accordingly, and triglycerides and LFTs were
normal. The Ostomy nurse provided teaching and care.
Asymptomatic oral thrush was treated with nystatin swish with
noted improvement.
# Health maintenance: due to her splenectomy, she received
Menactra, Haemophilus B Conj, Pneumovax 23 vaccines prior to
discharge. She remained on prophyiclactic lovenox, pneumatic
compression boots, PPI and incentive spirometer throughout her
admission.
She was discharged on POD #10 ambulating with a cane, voiding,
on a regular diet, and passing some rectal flatus. She felt
confident in her ability to care for her ostomy, and she was set
up for home ___, Ostomy care, and home ___ visits (was was
prescribed a walker to use as needed). She has follow up
scheduled with Dr. ___ in medical oncology and Dr. ___
___ GYN oncology surgeon.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 137 mcg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 137 mcg PO DAILY
2. Ibuprofen 600 mg PO Q6H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*100 Tablet Refills:*1
3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every four (4) hours Disp #*60 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*100 Capsule Refills:*1
5. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours
Disp #*40 Capsule Refills:*0
6. Rolling Walker
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
stage IIIC peritoneal cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance
Discharge Instructions:
Dear ___ were admitted to the gynecologic oncology service after
undergoing the procedures listed below. ___ have recovered well
after your operation, and the team feels that ___ are safe to be
discharged home. 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 (APAP) in 24 hrs
* No strenuous activity until your post-op appointment
* Nothing in the vagina (no tampons, no douching, no sex) for 12
weeks.
* No heavy lifting of objects >10 lbs for 6 weeks.
* ___ may eat a regular diet.
* Continue to follow up with Ostomy nurses recommendations
.
Incision care:
* ___ 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:
___
|
10388675-DS-16 | 10,388,675 | 20,325,171 | DS | 16 | 2180-05-15 00:00:00 | 2180-05-16 23:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Encephalopathy
Major Surgical or Invasive Procedure:
EGD on ___ with APC of bleeding GAVE
History of Present Illness:
___ is a ___ male with a h/o hepatitis C and
cirrhosis taken to ___ with confusion, agitation,
elevated ammonia levels to 277, asterixis on OSH ED exam.
Per wife (pt currently intubated), pt at baseline has no
cognitive deficits, has never had hepatic encephalopathy that
she knows of. He was admitted to ___ 1.5 weeks ago for a
few days for SOB, and over the course of about 2 days had 9L of
ascites removed. He was d/c'd home on lactulose (new Rx). Over
the last 2 wks, she says he has lost about 40lbs total from the
lactulose and diuretics. He was at home this past week doing
well, but on ___ appeared sluggish, was slow to respond, was
very shaky and confused (trying to go to bathroom in closet).
EMS came and per notes the pt was AAOx2 upon exam. Per wife, pt
had not been taking lactulose daily.
20mg labetalol given at ___ as he had BP's 200s/ 120s.
Two 20G PIV's. OG tube placed prior to MICU admission. BID
___: Ammonia 277, K 4.7, lactate 1.1, Tn <0.01, CK-MB 1.1.
Patient was intubated for agitation/confusion and
combativeness/safety issue (not for medical reasons per ___
___ notes) and sedated with propofol. Per report intubation
was difficult, unclear why. He was transferred secondary to lack
of intensive care unit beds.
In the ___ ED, initial vitals: 36.8 104 176/95 20 97% Other
Patient presented to ED intubated and sedated. ED bedside
ultrasound did not reveal any tappable ascites. Hyperkalemia to
6.3 was treated with insulin, dextrose, calcium, started
kayexalate per OGT. Patient was hemodynamically stable and
afebrile. CT head obtained in ED; f/u CXR done b/c ETT seemed
misplaced. Ammonia: 130. Lactate:0.9. Glu:162. Given CeftriaXONE
1 g IV in ED. On ___ CXR did not show RUL collapse, but
0700 CXR does. OGT and ETT secretions noted to be
bloody/bilious.
On arrival to the MICU, pt was intubated and sedated. Hx
obtained with wife per above.
Review of systems:
(+) Per HPI
Past Medical History:
Hep C (per wife, ___ about ___, was on interferon x 8mo then
stopped)
Cirrhosis (per wife, ___ a few weeks ago)
Bipolar dz
HTN
Social History:
___
Family History:
___
Physical Exam:
ADMISSION EXAM:
===============
Afebrile, 88 131/81 18 100% VENT
GENERAL: intubated and sedated
HEENT: Sclera anicteric, dry mouth, OG and ETT in place
NECK: JVP not elevated, no LAD
LUNGS: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds hypoactive,
no organomegaly, no appreciable fluid wave or increased tympany
EXT: Warm, well perfused, 2+ pulses, no edema
SKIN: not jaundiced; face with several nondescript erythematous
papules
NEURO: sedated at moment
DISCHARGE EXAM:
===============
VS: Tm 98.6 Tc 97.7 F, BP 120/66, HR 82, RR 20, 99% RA
I/O: 240/60 + 2 bm
GEN: Alert and oriented, no distress
HEENT: NCAT, MMM, EOMI, sclerae anicteric
NECK: supple, no JVD or ___, no thyroid abnormality
CV: RRR, ___ systolic murmur loudest at RUSB
LUNGS:CTAB
ABD: +BS, mildly distended but soft, non-tender
RECTAL:
EXTR: Warm, no edema
SKIN: 4mm nevus on L middle back (family says has been there for
___ stable); no spider angiomata
GU: no foley
NEURO: A&O, conversing well, no asterixis, days of week
backwards correct
Pertinent Results:
ADMISSION LABS:
================
___ 06:50AM BLOOD WBC-5.4 RBC-3.53* Hgb-10.2* Hct-32.9*
MCV-93 MCH-28.8 MCHC-30.9* RDW-16.2* Plt Ct-66*
___ 06:50AM BLOOD ___ PTT-31.9 ___
___ 06:50AM BLOOD UreaN-27* Creat-2.2* Na-139 K-6.3*
Cl-110* HCO3-24 AnGap-11
___ 06:50AM BLOOD ALT-32 AST-49* AlkPhos-221* TotBili-1.5
___ 06:50AM BLOOD Lipase-149*
Micro:
___: blood/urine cx negative
___: no MRSA/VRE
IMAGING:
==========
___ TTE
The left atrial volume index is mildly increased. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is ___ mmHg. Normal left ventricular wall
thickness, cavity size, and global systolic function (biplane
LVEF = 59 %). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
There is no valvular aortic stenosis. The increased transaortic
and transpulmonic velocities are likely related to increased
stroke volume due to high stroke volume. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Physiologic mitral regurgitation is
seen. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function with increased transaortic and transpulmonic velocities
due to high stroke volume. No pathologic valvular flow.
___ EGD
Impression: Grade 3 varix at the lower third of the esophagus
Grade 2 varices at the lower third of the esophagus
Angioectasias in the antrum with active bleeding (thermal
therapy)
Erythema, congestion and mosaic appearance in the fundus
compatible with portal gastropathy
Question of a duodenal varix
Otherwise normal EGD to third part of the duodenum
___ Abdominal MRI
IMPRESSION:
1. Cirrhotic liver with numerous T1 hyperintense regenerative
nodules. 1.9 cm
arterial hyper enhancing lesion in segment IV B of the liver,
without delayed
washout or pseudocapsule, although highly suspicious, does not
meet OPTN
criteria for HCC at this time. Recommended short interval
followup MRI in 3
months. The sonographic abnormality in segment II corresponds to
an exophytic
regenerative nodule.
2. Marked splenomegaly with extensive perisplenic collaterals,
small amount of
upper abdominal ascites, consistent with portal hypertension.
CXR ___
FINDINGS:
Compared to the prior study, there appears to been interval
improvement in the previously seen subsegmental atelectasis of
the right upper lobe. Density in the right peritracheal position
on the current exam is thought to represent vascular structures,
within the range of normal for technique. The right minor
fissure is restored to normal position and thickness. There may
be minimal linear atelectasis at the left base, but no
consolidation or effusion is detected. There is mild upper zone
redistribution, but no overt CHF. No effusion. The NG tube tip
overlies the stomach. The side port may lie immediately distal
to the GE junction.
US ___
IMPRESSION:
1. Exophytic lmass in the left lobe of the liver measures 2.5
cm. Further characterization with multiphasic CT or MRI abdomen
is recommended.
2. Coarse liver parenchyma and a nodular contour are consistent
with the provided diagnosis of cirrhosis. Patent hepatic
vasculature.
3. Splenomegaly, gallbladder wall edema, varices and trace
ascites also consistent with the provided diagnosis of
cirrhosis.
4. Atrophic right kidney.
___ CT head
IMPRESSION:
1. No evidence of acute intracranial process.
2. Thickening of multiple ethmoid air cells. Correlate with
patient
symptoms.
Brief Hospital Course:
___ male with a h/o hepatitis C and cirrhosis taken to
___ with confusion, agitation, elevated ammonia
levels, asterixis on OSH ED exam.
ACTIVE ISSUES:
===============
# Hepatic encephalopathy: Pt presented to the ___ ICU from OSH
with acute hepatic encephalopathy that required intubation
secondary to agitation. The most likely etiology of this episode
of hepatic encephalopathy is non-adherence to lactulose. Per
report, pt had not been taking lactulose daily. Infectious
workup was negative. RUQ US showed patent hepatic vasculature
and a 2.5cm exophytic lesion. Head CT showed no evidence of
acute intracranial process. Pt was able to be extubated less
than 24 hours after arrival to ___. Pt was started on
lactulose q2H and rifaxamin and his mental status improved. No
clear source of infection and TEE normal. Pt was subsequently
transferred to the liver service, where he was changed to
lactulose TID in the setting of possible melena (discussed
below). Pt's mental status continued to improve, and he was
discharged on rifiaximin/lactulose.
# Esophageal varices/Melena: Pt presented with a recent EGD
from ___ ___ demonstrating 3 cords of grade I esophageal
varices, no gastric varices, portal hypertensive gastropathy,
and gastritis. On presentation to the ___ liver service from
the ICU, pt had a melenic stool. Pt's hgb was noted to have
dropped from 10.2 to 8.6. Pt was subsequently started on PPI IV
BID and octreotide gtt. Pt's hgb subsequently stabilized
without requiring transfusion. Pt subsequently underwent EGD
___ which demonstrated grade 2 and grade 3 varices. Also
underwent argon coagulation of bleeding gastric varices. He
completed a 5-day course of octreotide and was started on
pantoprazole and sucralfate. He was discharged on ciprofloxacin
to prevent infection.
# Exophytic liver mass: Pt was found to have a 2.5cm exophytic
mass in the left lobe of the liver on RUQ ultrasound. The MICU
team discussed this finding with the patient/family. AFP was
found to be elevated at 26.8. MRI liver was performed and
demonstrated the same mass with recommendations for f/u in 3
months.
# Neutropenia: During his hospital course, pt was noted to have
developed neutropenia to 880. Most likely due to portal
hypertension and splenic sequestration leading to pancytopenia.
# Hepatitis C Cirrhosis: Pt presented with decompensated
cirrhosis ___ class B and MELD 18 at time of transfer.
Pt's cirrhosis has been complicated by grade one esophageal
varices, ascites, and encephalopathy. Pt's home nadolol was
held in the setting of possible GI bleed, and pt's diuretics
were held in the setting of ___. Prior to discharge pt's home
nadolol and diuretics were restarted.
# Hypernatremia: He most likely accumulated his 3.1L free water
deficit (based on admission weight 98kg) from not eating while
intubated and not receiving feeds. He later became thirsty and
po intake was encouraged.
# New murmur: Unremarkable echo, most likely flow murmur from
high output state and anemia. Discussed with patient and wife.
CHRONIC ISSUES:
===================
# CKD: Pt presented with a Cr of 2.2 from Cr of 2.1 ___. Cr
1.77 last year and 2.0 this year per PCP ___. Wife says this
is from 10+ yrs ago lithium-induced injury. Trended down during
hospital stay.
# Bipolar dz: Continued on home seroquel.
TRANSITIONAL ISSUES:
=====================
- needs EGD in 2 weeks
- needs repeat MRI liver in 3 weeks
- electrolytes and CBC in 1 week (restarting diuretics,
borderline neutropenia at discharge)
- patient instructed not to drive
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Spironolactone 50 mg PO DAILY
2. QUEtiapine Fumarate 400 mg PO QHS
3. Lactulose 10 mL PO DAILY
4. Furosemide 20 mg PO EVERY OTHER DAY
5. Nadolol 20 mg PO DAILY
6. Methocarbamol ___ mg PO TID:PRN pain
Discharge Medications:
1. Lactulose 15 mL PO TID
Aim for 3 bowel movements per day. Increase to ___ stools/day if
signs of confusion
RX *lactulose 10 gram/15 mL 15 mL by mouth three times a day
Refills:*0
2. QUEtiapine Fumarate 400 mg PO QHS
3. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
5. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram 1 tablet(s) by mouth Four times a day Disp
#*120 Tablet Refills:*0
6. Furosemide 20 mg PO EVERY OTHER DAY
7. Spironolactone 50 mg PO DAILY
8. Nadolol 20 mg PO DAILY
9. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*6 Tablet Refills:*0
10. Outpatient Lab Work
Please check Na, K, Cl, HCO3, BUN, Cr, Mag, Phos, and
Hemoglobin, Hematocrit, WBC in ONE WEEK (around ___.
Fax results to ___
___, NP
ICD 9: 571.5 cirrhosis
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: acute hepatic encephalopathy; Bleeding GAVE (Gastric
Antral Vascular Ectasia); liver mass
Secondary: Hepatitis C cirrhosis; esophageal varices
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
No asterixis
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were transferred here from ___ for an
episode of confusion due to build up of toxins that your liver
is unable to clear because of your cirrhosis. You required
sedation and a breathing tube and ICU admission to give you
medicines to help you clear those toxins and your mental status
improved. You will need to continue these medications (LACTULOSE
and RIFAXIMIN) every day to decrease your risk of confusion, and
you should NOT DRIVE.
While you were here you were noted to have black stools and
endoscopy revealed some slow bleeding in your stomach that is
due to increased pressures created by your liver. The bleeding
was stopped with cautery, but you will need another EGD in 2
weeks for possible banding (treatment) of your varices (dilated
blood vessels) in your esophagus.
Imaging of your liver showed a small 1.9cm mass, which should be
looked at again with MRI in 3 months to make sure it is not
cancerous.
Please weigh yourself daily and call your doctor if your weight
increases by more than 3 pounds or if your abdomen gets very
distended.
Followup Instructions:
___
|
10388675-DS-18 | 10,388,675 | 28,991,398 | DS | 18 | 2180-07-05 00:00:00 | 2180-07-07 16:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
In brief,
Mr. ___ is a ___ with history of decompensated HCV
cirrhosis (Childs ___ Class B), complicated by encephalopathy,
portal hypertension with esophageal varices and gastropathy,
GAVE, being worked up for transplant who presents with abdominal
pain.
___ has a recent admission ___ for lightheadedness, found
to have hgb 6.5, no overt bleeding but underwent EGD, GAVE
treated with APC, started on iron supplementation. ___ underwent
repeat EGD on ___ which showed medium sized varices without
high risk features, esophageal candidiasis, and angioectasias
treated with thermal therapy. ___ has not started fluconazole
because his instructions were to decrease nightly seroquel to 50
(from 400mg) while on fluconazole and ___ did not have any 50mg
tablets.
On ___ ___ started to have some lower abdominal discomfort rated
___ that ___ attributed to constipation, took some extra
lactulose and stooled (not black or bloody) and passed a lot of
gas which relieved the pain. The following day ___ developed ___
RUQ pain only noticeable when ___ presses on the RUQ, coughs, or
moves around. No changes in bowel movements, no fevers, nausea,
vomiting, or changes in color of stools or urine. Wife called
the liver clinic and ___ was referred to the ED for admission.
Of note, ___ had an abdominal MRI ___ which showed 4 lesions
that meet criteria for diagnosis of HCC (the largest is 2x2cm),
and one smaller lesion that does not (8mm). These findings have
not yet been discussed with the patient.
In the ED initial vitals were: 99.6 72 131/68 18 100% RA
- Labs were significant for Hgb 10.2 (10.4 2d prior), plt 35
(below baseline, INR 1.3, Cr 2.4 (about baseline), tbil 2.4,
(from 1.3 2 days ago), UA negative for infection. US showed
patent vasculature, no fluid to tap.
- Patient was given no medications.
Vitals prior to transfer were:98.5 64 118/73 16 100% RA
On the floor, patient has ___ RUQ pain only with palpation of
his upper abdomen. ___ is otherwise comfortable.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
- HCV cirrhosis diagnosed in ___, complicated by hepatic
encephalopathy, portal hypertension, varices, portal
hypertensive gastropathy, hypernatremia
- history of melena in setting of multiple esophageal varices
(grades I to 3) and possible duodenal varix, as well as portal
hypertensive gastropathy and GAVE
- HCV genotype 1b s/p relapse after interferon/Ribavirin x8-9
months years ago
- Exophytic liver mass found during ___ admission, due for 3
month f/u ___
- Neutropenia attributed to splenic sequestration
- Bipolar Disorder
- Chronic Kidney Disease secondary to lithium
- Hypertension
Social History:
___
Family History:
No family history of malignancy
Physical Exam:
Admission physical exam:
VS - Tc 97.7 HR 67 BP 113/75 RR 20 99% 02 sat on RA
GENERAL: well appearing middle aged gentleman, well-groomed, in
no distress
HEENT: AT/NC, EOMI, icteric sclera, pink conjunctiva, patent
nares, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: regular rate, rhythm, S1/S2, ___ systolic murmur, no
gallops, or rubs
LUNG: clear to auscultation bilaterally, no wheezes, rales,
rhonchi, breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, tenderness to palpation in RUQ. Pain
localizes to liver edge on inspiration as palpate. No
rebound/guarding, +splenomegaly.
EXTREMITIES: no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, no asterixis
SKIN: warm without rashes, has scattered spider angiomata and
palmar erythema
Discharge physical exam:
VS - Tc 97.7 HR 67 BP 113/75 RR 20 99% 02 sat on RA
GENERAL: well appearing middle aged gentleman, well-groomed, in
no distress
HEENT: AT/NC, EOMI, icteric sclera, pink conjunctiva, patent
nares, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: regular rate, rhythm, S1/S2, ___ systolic murmur, no
gallops, or rubs
LUNG: clear to auscultation bilaterally, no wheezes, rales,
rhonchi, breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, tenderness to palpation in RUQ. Pain
localizes to liver edge on inspiration as palpate. No
rebound/guarding, +splenomegaly.
EXTREMITIES: no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, no asterixis
SKIN: warm without rashes, has scattered spider angiomata and
palmar erythema
Pertinent Results:
Admission labs:
___ 07:41PM BLOOD WBC-4.4# RBC-3.28* Hgb-10.2* Hct-32.5*
MCV-99* MCH-31.1 MCHC-31.3 RDW-20.5* Plt Ct-35*
___ 07:41PM BLOOD Neuts-68.1 ___ Monos-9.3 Eos-2.1
Baso-0.5
___ 08:01PM BLOOD ___ PTT-31.8 ___
___ 07:41PM BLOOD Glucose-93 UreaN-30* Creat-2.4* Na-138
K-4.7 Cl-110* HCO3-23 AnGap-10
___ 07:41PM BLOOD ALT-42* AST-68* AlkPhos-215* TotBili-2.4*
___ 07:41PM BLOOD Albumin-3.2*
___ 07:49PM BLOOD Lactate-2.2*
Discharge labs:
___ 08:28AM BLOOD WBC-3.2* RBC-3.18* Hgb-9.4* Hct-31.2*
MCV-98 MCH-29.7 MCHC-30.2* RDW-20.5* Plt Ct-36*
___ 08:28AM BLOOD Plt Ct-36*
___ 08:28AM BLOOD Glucose-146* UreaN-29* Creat-2.3* Na-138
K-4.1 Cl-109* HCO3-22 AnGap-11
___ 08:28AM BLOOD ALT-40 AST-61* AlkPhos-185* TotBili-2.1*
___ 08:28AM BLOOD Calcium-8.6 Phos-3.7 ___ EGD
Medium sized varices without high risk features at the distal
esophagus
Esophageal candidiasis
Angioectasias in the antrum (thermal therapy)
Otherwise normal EGD to third part of the duodenum
___ Liver US wet read
RUQ US: nothing acute (vasculature patent, gallbladder
decompressed, tumors not seen due to coarse echotexture, no
fluid to tap, some gallbladder thickening explained by
cirrhosis)
___ CT chest
1. Assessment of the chest demonstrated no definitive evidence
of metastatic disease. Mild emphysema and centrilobular nodules
are most likely consistent with respiratory bronchiolitis,
please correlate clinically.
2. Several mediastinal lymph nodes, some of them borderline that
should be reassessed in three months for documentation of
stability.
3. Potential anemia.
4. Paracardiac lymph nodes, borderline as well and should be
reassessed at the same time.
5. Stigmata of cirrhosis, partially imaged, will be assessed in
details as part of the MRI of the abdomen and the corresponding
report will be issued.
___ MRI abdomen
IMPRESSION:
1. Three OPTN-5a lesions within segments II and VI, and one
OPTN-5b lesion within segment IVb.
2. 8 mm arterially enhancing lesion within segment VII, not
meeting OPTN-5 criteria.
3. Hepatic cirrhosis with multiple regenerative nodules.
4. Massive splenomegaly with perisplenic and perigastric varices
reflecting chronic portal hypertension.
5. Small amount of perihepatic and perisplenic ascites.
Brief Hospital Course:
___ with history of decompensated HCV cirrhosis (___
Class B), complicated by encephalopathy, portal hypertension
with esophageal varices and gastropathy, GAVE, being worked up
for transplant who presents with abdominal pain. His abdominal
resolved quickly on the floor and ___ was anxious for same day
discharge home.
# Abdominal pain: Patient appears to have a tender liver edge,
which may have bene related to a more inferior liver lesion. ___
had no signs or symptoms of cholecystitis, no rebound tenderness
or peritoneal signs. Not constipated. US was negative for clot.
Discussed with liver team, did serial abdominal exams, trended
MELD labs, and followe up blood and urine cultures.
# Esophageal candidiasis:
Was prescribed fluconazole previously but never started course
because ___ was concerned about decreasing his seroquel dosing
and risk of a manic episode. ___ was switched to nystatin swish
and swallow for 10 day course, with GI followup.
# liver lesions: New MRI findings (liver lesions) discussed with
patient. Did not yet discuss with him whether this will impact
his transplant. Tumor board meets ___. After this will be
discussed with patient, wife, and hepatology.
# HCV cirrhosis: undergoing transplant work up, patient of Dr.
___ is Childs B, with diuretic-controlled ascites,
varices, and history of encephalopathy. TrendED MELD labs daily,
continueD furosemide and spironolactone for ascites. Continue
lactulose and rifaxamin for h/o encephalopathy.
# GAVE/Varices: No signs of active bleeding. Continued
sucralfate, nadolol and PPI, and iron supplementation.
# Thrombocytopenia: Worse than baseline possibly related to
massive splenomegaly (sequestration) and decreased thrombopoetin
production. Trended daily. Held heparin, used pneumoboots while
platelets <50K .
# Bipolar disorder: Continued seroquel.
TRANSITIONAL ISSUES:
# Will need to have discussion with patient and wife about 4
liver lesions and how will impact transplant.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO EVERY OTHER DAY
2. Lactulose 30 mL PO TID
3. Nadolol 20 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. QUEtiapine Fumarate 400 mg PO QHS
6. Rifaximin 550 mg PO BID
7. Spironolactone 50 mg PO DAILY
8. Sucralfate 1 gm PO QID
9. Ferrous Sulfate 325 mg PO BID
10. Fluconazole 200 mg PO Q24H
Discharge Medications:
1. Ferrous Sulfate 325 mg PO BID
2. Furosemide 20 mg PO EVERY OTHER DAY
3. Lactulose 30 mL PO TID
4. Nadolol 20 mg PO DAILY
5. Pantoprazole 40 mg PO Q12H
6. QUEtiapine Fumarate 400 mg PO QHS
7. Rifaximin 550 mg PO BID
8. Spironolactone 50 mg PO DAILY
9. Sucralfate 1 gm PO QID
10. Nystatin Oral Suspension 5 mL PO QID Duration: 10 Days
RX *nystatin 100,000 unit/mL 5 ml by mouth four times a day Disp
#*1 Bottle Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
HCV cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain that resolved without
intervention. Your labs and workup was all reassuring. Liver
team discussed your MRI and will continue to follow you as an
outpatient.
Followup Instructions:
___
|
10388675-DS-21 | 10,388,675 | 25,596,778 | DS | 21 | 2180-10-26 00:00:00 | 2180-11-04 15:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
epigastric pain
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ year old male with HCV cirrhosis, ___ s/p RFA ablation x2,
most recently on ___, CKD and GAVE with prior GI bleed s/p EGD
on ___ with ___ who presented to ___ ED on ___ for sudden
onset severe epigastric pain.
Of note, patient was recently admitted to ___ ___ for
radiofrequency ablation of HCC without complications.
Surveillance EGD on ___ showed 1 cord of grade II varices in
the distal esophagus, findings consistent with GAVE, and mucosa
with a mosaic pattern consistent with mild portal hypertensive
gastropathy. An Argon-Plasma Coagulator was applied
successfully.
Admitted to ___, Liver US showed acute left portal vein
thrombus, for which he was treated with a heparin drip on
___. Early morning of ___ patient found hypotensive
70/40 with a fever ___. Patient was AOx3 but felt "foggy". Stat
labs showed Hct 24.6 (down from 28.5 on admit) with lactate 3.2.
300cc melanotic stool. CTX given. Transfer to MICU initiated at
2AM.
Past Medical History:
- HCV cirrhosis diagnosed in ___, complicated by hepatic
encephalopathy, portal hypertension, varices, portal
hypertensive gastropathy, hypernatremia
- ___ with 4 discrete lesions s/p RFA ablation ___ with
complete resolution of ___ lesions. Had RFA of final lesion
___
- history of melena in setting of multiple esophageal varices
(grades I to 3) and possible duodenal varix, as well as portal
hypertensive gastropathy and GAVE
- HCV genotype 1b s/p relapse after interferon/Ribavirin x8-9
months years ago
- Neutropenia attributed to splenic sequestration
- Bipolar Disorder
- Chronic Kidney Disease secondary to lithium
- Hypertension
Social History:
___
Family History:
No family history of malignancy or liver disease
Physical Exam:
Admission Physical Exam:
Vitals- ___ BP:100/70 P:70 R: 18 O2: 96% RA
GENERAL: AOx3, NAD, mentating at baseline
HEENT: OP w/o blood, no scleral icterus
LUNGS: Diffuse mild wheezes
CV: rrr, no murmur
ABD: soft, moderately distended, epigastric ttp w/o guarding
EXT: warm, peripheral pulses intact, no ___ edema
SKIN: no rash or skin breakdown
Discharge Physical Exam:
VS:T 98.2, Tmax 98.4, HR 67 BP 128/66 RR 18 O2 96RA
I/O: 50/550 (since midnight), 1140/550+ last 24 hours, 3 BM
GENERAL: AOx3, NAD, mentating at baseline
HEENT: clear oropharynx, scleral icterus
LUNGS: CTAB, no w/r/r
CV: rrr, no murmur/gallops/rups
ABD: soft, distended, nontender
EXT: warm, peripheral pulses intact, trace ___ edema
SKIN: no rash or skin breakdown, (+) Jaundice
Pertinent Results:
ON ADMISSION
___ 06:59PM WBC-3.3* RBC-3.21* HGB-10.5* HCT-32.7*
MCV-102* MCH-32.6* MCHC-32.0 RDW-16.1*
___ 06:59PM NEUTS-69.6 ___ MONOS-7.2 EOS-2.1
BASOS-0.7
___ 07:05PM LACTATE-2.1*
___ 06:59PM PLT COUNT-56*
___ 06:59PM LIPASE-116*
___ 06:59PM ALT(SGPT)-59* AST(SGOT)-114* ALK PHOS-317*
TOT BILI-1.8*
ON DISCHARGE
___ 05:45AM BLOOD WBC-3.1* RBC-2.76* Hgb-9.0* Hct-28.0*
MCV-101* MCH-32.5* MCHC-32.1 RDW-16.5* Plt Ct-44*
___ 05:45AM BLOOD ___ PTT-32.7 ___
___ 05:45AM BLOOD Glucose-79 UreaN-32* Creat-2.1* Na-133
K-4.7 Cl-106 HCO3-17* AnGap-15
___ 05:45AM BLOOD ALT-57* AST-120* LD(LDH)-179 AlkPhos-313*
TotBili-9.7*
___ 05:45AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.2
MICRO
___ 1:04 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
___ 1:41 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
___ 9:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 3:32 am MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Pending):
___ 12:22 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S). PRELIMINARY SENSITIVITY.
These preliminary susceptibility results are offered to
help guide
treatment; interpret with caution as final
susceptibilities may
change. Check for final susceptibility results in 24
hours.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
GRAM NEGATIVE ROD(S)
|
AMPICILLIN------------ R
CEFEPIME-------------- S
CEFTAZIDIME----------- S
CEFTRIAXONE----------- S
CIPROFLOXACIN--------- S
GENTAMICIN------------ S
MEROPENEM------------- S
TOBRAMYCIN------------ S
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
___ 7:51 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
___ 7:05 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 4:00 pm SWAB Source: Rectal swab.
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Pending):
___ 6:59 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING:
CHEST (PORTABLE AP) ___ 9:59 ___
Normal heart, lungs, hila, mediastinum, and pleural surfaces. No
evidence of intrathoracic malignancy or infection.
CHEST (PA & LAT) ___ 7:08 ___
Normal heart, lungs, hila, mediastinum, and pleural surfaces. No
evidence of intrathoracic malignancy or infection.
MRI ABDOMEN W/O & W/CONTRAST (___):
IMPRESSION:
1. Hepatic cirrhosis with trace perihepatic ascites. Multiple
regenerative nodules and two arterially enhancing lesions,
unchanged, which likely are perfusional but attention to these
areas are recommended on subsequent exams. No lesion identified
concerning for hepatocellular carcinoma.
2. Radiofrequency ablation defects in segments II, IV, VI, and
VII with
coagulative necrosis. Smooth hyperenhancement is identified
around the
segment IV ablation zone likely reflective of altered perfusion
related to treatment.
3. Occlusive thrombus in the left portal vein.
4. Heterogeneous material is identified within the gallbladder.
This may
represent gallbladder sludge however hemorrhage cannot be
entirely excluded.
5. Splenomegaly with venous varices compatible with portal
hypertension.
6. Bibasilar atelectasis.
___ Liver ultrasound:
1. Acute left portal vein thrombus. Patent main and right
portal veins.
2. 1.9 and 2.9 cm left and right hepatic lobe lesions most
consistent with RF ablation sites. No focal fluid collection.
Treatment sites better assessed on prior MR dated ___.
3. Coarse nodular hepatic parenchyma consistent with known
history of
cirrhosis. Splenomegaly and trace ascites noted.
4. Persistent gallbladder sludge with gallbladder wall
thickening likely
related to chronic cirrhosis.
___ Chest xray:
No evidence of acute cardiopulmonary disease.
Brief Hospital Course:
___ with HCV and HCC, recent RFA on ___ and EGD with APC
___, admitted on ___ for severe epigastric pain, found to
have new L portal vein thrombus, treated with a heparin drip and
1 dose coumadin. Morning of ___ found hypotensive and febrile
with 24hr Hct drop from 28 to 24, and subsequently transferred
to MICU for stabilization. Heparin drip stopped, given 1 dose
VitK. EGD on ___ showed slow ooze from GAVE, no active variceal
bleeding, no intervention. Subsequently HD stable. Received
total 2U RBC, 1U FFP, 1U Plts, last RBC transfusion on ___ at
1AM. Pt remained HD stable with no further melena/bleeding. He
was found to have E coli bacteremia and enterococcus UTI.
# E coli bacteremia: Grew on ___ blood cx. Was hypotensive
previously, but now hemodynamically stable (SBP>100 over last
24h). No ascites to tap. Urine culture did not grow E.coli.
Likely bacterial translocation during GIB. Previously on CTX and
switched to cipro on ___ given sensitivities. Patient remained
afebrile and HD stable. He was switched to cipro for 2 week
course to end ___. Qtc was monitored and was 420 on day of
discharge.
- cipro x2 weeks until ___
- monitor QTc with EKG today as patient is also on high dose
seroquel
#Acute blood loss in the setting of anticoagulation with
heparin gtt. Heparin was stopped. EGD showed GAVE and grade 3
varices with red ___ sign. No banding performed as patient is
s/p APC for GAVE. H/H has been stable. H/H stable prior to DC.-
continue to trend h/h, transfuse goal Hb > 7. Continued PPI
- anticoagulation has been discontinued
- continue nadolol 40mg daily
# UTI: Enterococcus as per ___ Urine Cx. Was on vancomycin but
sensitive to ampicillin and switched to augmentin on ___.
- augmentin until ___ for 10 day course
#Hypotension: originally thought to be sepsis vs acute blood
loss. Hct 28 to 24, source would likely be UGIB given recent EGD
findings and melena. Recent UA and CXR unremarkable, but SBP was
on differential. There were no ascites to tap. Patient remained
HD stable on the floor.
#Hepatic Vein Thrombosis - L hepatic vein thrombosis in the
setting of known HCC. Initially treated with heparin gtt on
___, which was d/c'ed on ___ in setting of bleed.
- Discontinued anticoagulation due to bleed
# Thrombocytopenia: Likely from splenic sequestration vs
consumption.
# HCV cirrhosis: Patient is not a transplant candidate due to
___ not meeting ___ criteria for transplant consideration. He
is ___ Score 13 (class C), with diuretic-controlled
ascites, grade II-III varices and GAVE and history of
encephalopathy, MELD 31. s/p recent RFA x2 most recently ___.
No current e/o encephalopathy or decompensation of liver disease
on exam. Tbili trending up. Diuretics were held in setting of
UGIB, no accumulation of ascites, will restart at discharge.
Continued with rifaximin/lactulose and nadolol for grade 3
varices.
-MRI will be discussed at next tumor meeting to determine if
candidate for live liver donor pending if mass at PVT is
determined to be tumor vs. bland
- restarted 20mg lasix and 50mg spironolactone on discharge
# CKD: Patient with history of CKD from lithium with baseline
creatinine 2.3. Currently stable. Trending down 3.1 (___) to
2.5 (___).
# Bipolar disorder: Continued home seroquel
#___ s/p RFA: Patient s/p repeat RFA of single remaining liver
lesion without complications
TRANSITIONAL ISSUES
-will need to complete 14 days of antibiotics for E. coli
bacteremia from last negative blood culture (___). Last day of
ciprofloxacin is ___
-please follow up pending blood cultures
-will need to complete 10 day course of antibiotics for UTI.
Last day of augmentin is ___
-will have chem7, LFTs, coags drawn on ___ with results to be
faxed to Dr. ___ follow up with results
-nadolol uptitrated from 20mg to 40mg daily. please adjust dose
as needed.
# Communication: Patient; ___ (wife) ___
# Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO EVERY OTHER DAY
2. Lactulose 15 mL PO TID
3. Nadolol 20 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. QUEtiapine Fumarate 400 mg PO QHS
6. Rifaximin 550 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. Spironolactone 50 mg PO DAILY
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
2. Lactulose ___ mL PO TID encephalopathy
3. Nadolol 40 mg PO DAILY
RX *nadolol 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. QUEtiapine Fumarate 400 mg PO QHS
5. Rifaximin 550 mg PO BID
6. Amoxicillin-Clavulanic Acid ___ mg PO Q8H
please take until ___. please take it at least 2 hour apart
from iron
RX *amoxicillin-pot clavulanate [Augmentin] 500 mg-125 mg 1
tablet(s) by mouth every 8 hours Disp #*18 Tablet Refills:*0
7. Ciprofloxacin HCl 750 mg PO Q12H
please take until ___. please take it at least 2 hour apart
from iron
RX *ciprofloxacin 750 mg 1 tablet(s) by mouth every 12 hours
Disp #*20 Tablet Refills:*0
8. Furosemide 20 mg PO EVERY OTHER DAY
9. Pantoprazole 40 mg PO Q12H
10. Spironolactone 50 mg PO DAILY
11. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
dyspepsia
please take only as needed
RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL ___ mL
by mouth four times a day as needed Refills:*0
12. Outpatient Lab Work
please check chem7, coags, AST, ALT, alk phos, tbili and fax
results to Dr. ___. Phone: ___
Fax: ___
ICD-9 code: ___.5, ___.4
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: portal vein thrombosis, E. coli bacteremia, urinary
tract infection, GI bleed in setting of anticoagulation
SECONDARY: HCV cirrhosis, HCC
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___
___. You came in to the hospital
because of abdominal pain and we found a clot in the large vein
that goes to your liver. As a result, we started you on a blood
thinner, but this caused you to bleed. The blood thinner was
therefore discontinued and you stopped bleeding. You also have
an infection in your bloodstream likely due to bacteria from
your gut that travelled to your bloodstream when you were
bleeding. As a result you will need to take antibiotics
(ciprofloxacin) for a total of 14 days (last day ___. You
also have an infection in your urine and will need to take
antibiotics (augmentin) for a total of 10 days.
Please make sure you follow up with your appointments. Your case
will be discussed at the tumor board next week. Please have your
blood drawn on ___.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
10388767-DS-10 | 10,388,767 | 24,446,997 | DS | 10 | 2185-12-10 00:00:00 | 2185-12-12 07:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___, BRBPR
Major Surgical or Invasive Procedure:
___ EGD/Colonoscopy
History of Present Illness:
___ with multiple medical comorbidities (although no h/o liver
dz or other condition requiring anticoagulation) significant for
diverticulosis and hemorrhoids (last screening ___ ___, who
presents from PCP ___/ c/o episodic rectal bleeding for 1 week.
Patient reports that she started to notice intermittent
dark-black stools or blood in toilet bowl; she has also noticed
some mild epigastric and lower abdominal discomfort.
In the ED, patient was initially noted to be afebrile with T97.4
HR92 BP124/79 RR18 98RA. Patient was T&S'd, received 2 pIVs,
and initiated on pantoprazole IV drip. Labs were notable for
lactate WNL, hgb 9.6, LFTs WNL, chemistries WNL. Exam was
notable for black stools on DRE with +guaiac. GI was consulted
from the ED; will take
On the floor, AVSS. Over the past 2 days, patient reports the
episodes have increased in severity and frequency, and have been
accompanied with worsening fatigue. Also reporting some
lightheadedness upon standing. Patient denies recent f/c/n/v/d.
No CP/SOB. No She denies recent alcohol abuse or extensive use
of NSAIDs.
Past Medical History:
1. CAD s/p cardiac cath @ BWH-hx coronary endothelial
dysfunction
no obstructive disease ___
2. HTN
3. Hyperlipidemia
4. Diabetes mellitus, borderline
5. Hx DVT in ___
6. Morbid obesity
7. Asthma
8. Anxiety
9. Dementia, on donepezil
10. Lumbar spinal stenosis
11. Hx of depression
12. Panic disorder w/ agoraphobia
13. Migraines
14. Empty sella syndrome
15. Hx fatty liver
16. Esophageal reflux
17. Insomnia
18. Vitamin B12 deficiency
19. Nephrolithiasis
20. h/o thrombophlebitis (deep femoral v)
21. internal hemorrhoids
22. diverticulosis
22. b/l pseudophakia
Social History:
___
Family History:
No known GI malignancy
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.7 144/73 84 18 100RA
GENERAL: Alert, oriented, obese woman in no acute distress, very
pleasant woman
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-distended, mildly tender over epigastric region
with deeper palpation, +BS, no rebound tenderness or guarding,
no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes
NEURO: AOx3, grossly intact
DISCHARGE PHYSICAL EXAM:
VS: 98.1 ___ 110s-120s/40s-80s ___ 96-100RA
GENERAL: Alert, oriented, obese woman in no acute distress, very
pleasant
HEENT: no JVD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-distended, non-tender, +BS, no rebound tenderness
or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes
NEURO: AOx3, grossly intact
Pertinent Results:
ADMISSION LABS
==============
___ 03:09PM BLOOD WBC-9.8 RBC-3.27* Hgb-9.6* Hct-30.4*
MCV-93 MCH-29.4 MCHC-31.6* RDW-14.5 RDWSD-49.1* Plt ___
___ 03:09PM BLOOD Neuts-61.8 ___ Monos-9.0 Eos-2.4
Baso-0.8 Im ___ AbsNeut-6.04 AbsLymp-2.48 AbsMono-0.88*
AbsEos-0.23 AbsBaso-0.08
___ 03:09PM BLOOD ___ PTT-31.3 ___
___ 03:09PM BLOOD Glucose-128* UreaN-19 Creat-0.7 Na-140
K-3.7 Cl-101 HCO3-25 AnGap-18
___ 03:09PM BLOOD ALT-23 AST-19 AlkPhos-72 TotBili-0.5
___ 03:09PM BLOOD Albumin-4.2
___ 03:17PM BLOOD Lactate-1.7
DISCHARGE LABS
===============
___ 01:10PM BLOOD WBC-8.6 RBC-3.06* Hgb-9.0* Hct-28.3*
MCV-93 MCH-29.4 MCHC-31.8* RDW-14.7 RDWSD-49.3* Plt ___
___ 06:15AM BLOOD Glucose-101* UreaN-6 Creat-0.6 Na-142
K-3.9 Cl-106 HCO3-27 AnGap-13
___ 06:15AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.2
IMAGING/STUDIES:
=================
___ GI Bleed Embo/Angiogram
FINDINGS:
1. Right common femoral arteriogram showing normal anatomy with
low common femoral artery bifurcation.
2. No active extravasation identified on ___, selective sigmoid
branch (adjacent to endoscopically placed clips), or SMA
arteriograms. No embolization perform.
IMPRESSION:
No active extravasation identified. No embolization performed.
EGD ___
Findings:
Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Recommendations: No source of bleeding identified.
Proceed to colonoscopy. OK to discontinue IV PPI.
Additional notes: The attending was present for the entire
procedure. The patient's home medication list is appended to
this report. FINAL DIAGNOSIS: Normal examination. Estimated
blood loss = zero. No specimens were taken for pathology.
___ Colonoscopy
Impression: Fresh blood and clots were seen throughout the whole
colon. Severe diverticulosis was seen throughout the whole
colon. An actively bleeding diverticulum was identified at 35 cm
in the sigmoid colon. 2cc of epinephrine were injected into the
diverticulum in attempts at hemostasis, but unsuccessful. An
endoclip was placed adjacent to the bleeding diverticulum for ___
localization. ___ was consulted for embolization. Large
nonbleeding internal hemorrhoids were seen on retroflexion in
the rectum. A 4mm polyp was seen in the left colon, but not
removed in the setting of active bleeding.
Otherwise normal colonoscopy to cecum
Recommendations: ___ consult for embolization.
Transfuse 1u PRBC now for active bleeding.
Maintain active type and cross and large bore IV access.
After the acute episode has resolved, recommend repeat
colonoscopy for polypectomy.
Additional notes: The procedure was performed by the fellow and
the attending. The attending was present for the entire
procedure. The patient's reconciled home medication list is
appended to this report. FINAL DIAGNOSES are listed in the
impression section above. Estimated blood loss = zero. No
specimens were taken for pathology
Brief Hospital Course:
___ p/w one week h/o dark-black stools c/f melena and UGIB vs
R-sided colonic bleed perhaps in setting of diverticulosis.
# GIB: H/o hemorrhoids and diverticulosis, both which would
cause more BRBPR; however could be R-sided. Most likely UGIB
given h/o GERD, report of dark stools and recent abdominal
discomfort; last colonoscopy over ___ years ago. HD stable, but
complaining of some lightheadedness, c/f orthostasis,
symptomatic anemia. Patient received 2 pIVs on admission and IV
pantoprazole, consented for blood products, made NPO at ___ for
___, and written for moviprep. Underwent ___
___ which showed diverticular bleed which was clipped and
injected with epi for attempt at hemostasis; hemostasis
unsuccessful so, patient underwent ___ guided embolization
procedure; however, ___ was unable to identify the bleed. Patient
remained HD stable with stable hgb and so was discharged the
following day. Hgb 9.0 at discharge.
# CAD: s/p cardiac cath @ ___. No CP currently. Continued home
ASA 81mg.
# HTN: Stable. Held home ACEI and HCTZ in setting of acute GIB
and while NPO.
# dementia: Stable. Continued home donepezil (ARICEPT) 5 mg QHS.
# HL: Stable. Continued home ATORVASTATIN 80 MG qd.
# anxiety/depression: Continued home venlafaxine 100 mg QD.
# Asthma/RAD: no respiratory complaints at this time. Continued
home albuterol, fluticasone, loratidine.
TRANSITIONAL ISSUES
===================
-H/H on discharge 9.0/28.3
-EGD/Colonoscopy showed bleeding diverticula
-Lisinopril restarted, but HCTZ held. Please reassess and
consider restarting HCTZ.
-Pt should have CBC within a week to ensure stable H/H
-FULL code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Venlafaxine 100 mg PO BID
3. Donepezil 5 mg PO QHS
4. Loratadine 10 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Lisinopril 5 mg PO DAILY
8. Hydrochlorothiazide 12.5 mg PO DAILY
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
11. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Donepezil 5 mg PO QHS
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Loratadine 10 mg PO DAILY
7. Venlafaxine 100 mg PO BID
8. Lisinopril 5 mg PO DAILY
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-gastrointestinal bleed
SECONDARY:
-diverticulosis
-diabetes mellitus (type II)
-CAD
-HTN
-HLD
-anxiety/depression
-asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the ___ because of bloody stools. This
was concerning for bleeding in your stomach and/or your colon.
Because you had not had any imaging in several years, you
underwent an upper endoscopy (camera from above) and a
colonoscopy (camera from below) to see your stomach and colon,
respectively. We found a bleeding diverticula, or pouch of your
intestine.
Please continue to follow up with your primary care doctor on
___ at 11:00 am. Please do not take your
hydrochlorothiazide for now.
It was a pleasure taking part in your care,
Your ___ Medicine Team
Followup Instructions:
___
|
10388863-DS-19 | 10,388,863 | 25,782,468 | DS | 19 | 2112-03-28 00:00:00 | 2112-03-28 16:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Oxycodone / Aquaphor / Lamictal XR
Attending: ___.
Chief Complaint:
diplopia
Major Surgical or Invasive Procedure:
Right-sided ventriculoperitoneal shunt placement.
History of Present Illness:
Mr. ___ is a ___ year old man with a history of atypical
carcinoid tumor of the lung and brain who presents to the ER
with gait unsteadiness and diplopia in the past 2 weeks. He
states he has never had trouble with his vision in the past but
his right eye became blurred/double vision, now his left eye is
affected. He has noticed more discoordination when walking,
tripping over things. He denies falls. His headaches have been
worse in the past 2 weeks. he has been taking dilaudid 2mg
tablets ___ times per day. He denies changes in speech,
swallowing, falls, focal weakness or numbness. He saw his PCP
today who referred him to the ER.
He recently started Temodar (240 mg daily) and took this for 1
week on, completing this week yesterday.
In the emergency department, initial vitals: 97.7 83 129/77 16
100%. Head CT showed numerous supratentorial and infratentorial
metastatic lesions which were unchanged since ___. He
received 10 mg of IV dexamethasone and 2mg IV dilaudid.
On the floor, he complains of a headache all over his head. The
dilaudid he received in the ER lasted for a few hours. He
denies cough, shortness of breath, nausea, vomiting, diarrhea.
REVIEW OF SYSTEMS:
(+) Per HPI + constipation
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denied arthralgias or myalgias.
Past Medical History:
PAST ONCOLOGIC HISTORY (summarized from ___ clinic notes):
- presented in ___ with personality changes, disinhibition
and headache. Head CT at OS___ showed R frontal hemorrhage.
Repeat head CTA ___ showed a 3.6 x 3.2cm hyperdense
subependymal mass in R inferior frontal lobe, most c/w a
subependymal astrocytoma. There was a 6mm hyperdense nodule in L
lateral ventricle & several hyperdense areas in supratentorium.
He started phenytoin/decadron. Brain MRI ___ showed mult.
intra-parenchymal brain lesions.
- ___: CT Torso showed RUL mass, 5.3 cm w/ adjacent nodules,
up to 7mm. Mediastinal & R hilar lymphadenopathy present, up to
2.5cm
- ___: bronchoscopy w/ FNA of 4L LN was (+) for
neuroendocrine tumor.
- ___: pt had stereotactic brain bx intraparenchymal lesion
was non-diagnostic.
- ___: repeat brain bx. Path was (+) for metastatic
carcinoid, w/ proliferative index (Ki-67 or MIB) 50%, c/w
atypical carcinoid.
- ___: WBRT
He was admitted
- ___: Cisplatin Etoposide x 4 cycles with concomittent
chest RT
- ___: completed chest XRT
- ___: brain MRI showed 2 new brain lesions w/ significant
growth of L parieto-occipital lesion.
- ___: Cyberknife
PAST MEDICAL HISTORY:
ADHD previously on Adderall
Cervical disk fusion by anterior approach ___ years ago
Multiple lipomas removed
Social History:
___
Family History:
Father died at ___ of colon CA. His mother is ___, she had surgery
for benign thyroid nodules. There is otherwise no known history
of cancer in his family.
Physical Exam:
Admission Physical Exam:
VS: T97.3 BP 123/76 HR 65 RR 16 96% RA
GENERAL: alert and oriented, NAD
HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, No LAD. Report blurred vision in the left on lateral
gaze.
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.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout. Tandem gait
slightly unsteady.
.
Discharge Physical Exam:
VS: T98.1 BP 100s-120s/60s-80s HR ___ RR 18 98% RA
GENERAL: alert and oriented, NAD, right side of head shaved from
surgery
HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, No LAD. Report blurred vision in the left on lateral
gaze.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: CTAB, good air movement bilaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial
pulses.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout. Tandem gait
slightly unsteady.
Pertinent Results:
Admission Labs:
___ 02:50PM BLOOD WBC-13.7* RBC-4.61 Hgb-12.8* Hct-36.5*
MCV-79* MCH-27.8 MCHC-35.0 RDW-14.8 Plt ___
___ 02:50PM BLOOD Neuts-88.8* Lymphs-6.4* Monos-4.0 Eos-0.4
Baso-0.4
___ 02:50PM BLOOD ___ PTT-23.6* ___
___ 02:50PM BLOOD Glucose-161* UreaN-27* Creat-1.0 Na-139
K-3.8 Cl-104 HCO3-21* AnGap-18
___ 02:50PM BLOOD Calcium-9.1 Phos-3.2 Mg-2.2
.
Pertinent Labs:
___ 06:20AM BLOOD WBC-14.2* RBC-4.25* Hgb-11.9* Hct-35.9*
MCV-85 MCH-28.0 MCHC-33.0 RDW-15.1 Plt ___
___ 07:00AM BLOOD ___ PTT-23.9* ___
___ 06:20AM BLOOD Glucose-122* UreaN-19 Creat-0.9 Na-139
K-4.4 Cl-100 HCO3-29 AnGap-14
___ 06:20AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.3
___ 06:57AM BLOOD Valproa-31*
___ 06:25AM BLOOD Valproa-80
.
CT HEAD W/O CONTRAST Study Date of ___ 3:00 ___
IMPRESSION:
Numerous infratentorial and supratentorial metastatic lesions,
as detailed
above, appear largely stable in size and distribution since
___ MR exam but significantly progressed since ___ CT
study. Hyperdense components in the bifrontal lesions may
represent foci of hemorrhage.
Lesion in the midbrain is in close proximity to left oculomotor
nerve nucleus could explain patient's diplopia.
MR HEAD W & W/O CONTRAST Study Date of ___ 12:27 ___
IMPRESSION: Numerous supra- and infra-tentorial metastatic
lesions. Some
lesions are stable, some are new and most have increased in size
as compared to the prior study.
CHEST (PRE-OP PA & LAT) Study Date of ___ 7:52 ___
IMPRESSION: No acute intrathoracic process.
CT HEAD W/O CONTRAST Study Date of ___ 6:03 ___
IMPRESSION: Interval placement of right transfrontal
ventriculostomy
catheter, without acute intracranial hemorrhage or other
short-interval
change.
Brief Hospital Course:
ASSESSMENT AND PLAN:
Mr. ___ is a ___ year old man with atypical carcinoid tumor
involving the brain and lungs who is admitted with diplopia and
gait unsteadiness.
1. Metastatic Carcinoid Tumor: On arrival an MRI of the head was
performed which showed multiple metastatic lesions. This imaging
was reviewed by neuro-oncology and neurosurgery and there was
significant concern for hydrocephalus from a metastatic lesion
compressing the aqueduct. The decision was made to take the pt
for a shunt placement. He was given Dexamethasone 4mg QID prior
to surgery. A VP shunt was placed without complication. He had
received some symptom improvement following shunt placement. We
also added Valproic acid to his regimen as well for headache and
seizure prophylaxis.
2. Headache: Most likely from metastatic disease and multiple
lesions in the pts brain. We controlled his headaches with
Dilaudid prn for pain and added Valproic acid to his regimen.
His Valproic acid level was therapeutic at time of discharge.
3. Transitional-The pt has follow up appointments with
hematology oncology following discharge. He was instructed to
make a follow up appointment with Neurosurgery in 4 wks.
Medications on Admission:
dexamethasone 4 mg PO BID
hydromorphone 2 mg tab PO BID PRN pain
lorazepam 1mg PO daily PRN anxiety, sleep
ondansetron HCl 8 mg PRN nausea
temozolomide [Temodar] 100 mg once daily 7 days on 7 days off
temozolomide [Temodar] 140 mg Capsule once daily 7 days on 7
days off
Topiramate 100 mg Tablet PO BID
Discharge Medications:
1. hydromorphone 2 mg Tablet Sig: ___ Tablets PO every ___ hours
as needed for pain, headache.
Disp:*30 Tablet(s)* Refills:*0*
2. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
3. ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for nausea.
4. divalproex ___ mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
7. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO twice a day.
8. temozolomide 100 mg Capsule Sig: One (1) Capsule PO once a
day: 7 days on and 7 days off.
9. temozolomide 140 mg Capsule Sig: One (1) Capsule PO once a
day: 7 days on 7 days off .
10. famotidine 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Carcinoid Tumor with Mets to the Brain
occlusive hydrocephalus
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 blurry vision and
difficulty walking. An MRI of your brain showed that there was
an increased amount of fluid present. Neurosurgery placed a
shunt to help drain this excess fluid.
The following changes have been made to your medications:
STOP:
Topiramate
CHANGE:
Hydromorphone 2mg every ___ for pain
START:
Divalproex for headaches
Famotidine to prevent ulcers
Docusate Sodium to soften stool
Senna for constipation
**Your scalp sutures are dissolvable and you have steri strips
at your abdominal incision. Both these areas can get wet on
___. Do not scrub the wounds, pat dry.
Followup Instructions:
___
|
10389189-DS-17 | 10,389,189 | 25,606,796 | DS | 17 | 2119-10-25 00:00:00 | 2119-10-26 13:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Priapism
Major Surgical or Invasive Procedure:
Distal T shunt for treatment of priapism
History of Present Illness:
___ year old who developed priapism 36hrs prior and failed
aspiration and PE irrigation at an OSH. Transferred to ___,
later taken to OR for T shunt.
Past Medical History:
None
Social History:
___
Family History:
None
Physical Exam:
NAD
Perfused
Nonlabored breathing
Abd SND
Ext WWP
Priapism improved although still firm, glans soft, doppler with
good flow
Pertinent Results:
___ 10:20PM GLUCOSE-96 UREA N-15 CREAT-0.8 SODIUM-138
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-22 ANION GAP-18
___ 10:20PM estGFR-Using this
Brief Hospital Course:
Presented to the ED from OSH with persistent priapism s/p failed
failed aspiration and PE irrigation.
Transferred to ___ and taken to OR for T shunt.
Postoperatively pain dramatically improved in AM. However,
appearance of phallus is still quite firm. Aspiration of
corporeal bodies with 19G needle did not produce
any blood flow. Doppler US revealed likely clot in bilateral
corporeal bodies with antegrade venous flow. There was normal
flow in superficial arteries and a question of a possible AV
fistula.
Given risk of further intervention, good flow on doppler,
improved pain, sent home without further intervention. The
patient was discharged in stable condition, eating well,
ambulating independently, voiding without difficulty, and with
pain control on oral analgesics. On exam, incision was clean,
dry, and intact, with no evidence of hematoma collection or
infection. The patient was given explicit instructions to
follow-up in clinic in one week.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*40 Capsule Refills:*0
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Priapism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-Resume your pre-admission/home medications except as noted.
ALWAYS call to inform, review and discuss any medication changes
and your post-operative course with your primary care doctor.
-___ OTHERWISE NOTED; AVOID aspirin or aspirin containing
products and supplements that may have blood-thinning effects
(like Fish Oil, Vitamin E, etc.). This will be noted in your
medication reconciliation.
IF PRESCRIBED (see the MEDICATION RECONCILIATION):
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control.
For pain control, try TYLENOL FIRST, then ibuprofen, and then
take the narcotic pain medication as prescribed if additional
pain relief is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-Call your Urologist's office to schedule/confirm your follow-up
appointment in 2 weeks AND if you have any questions.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks or until
otherwise advised. Light household chores/activity and leisurely
walking/activity is OK and should be continued. Do NOT be a
couch potato
-Tylenol should be your first-line pain medication. A narcotic
pain medication has been prescribed for breakthrough pain ___.
-Max daily Tylenol (acetaminophen) dose is THREE to FOUR grams
from ALL sources
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up and/or
as directed in the handout
-You may shower normally but do NOT immerse your incisions or
bathe
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool-softener, NOT a laxative
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest emergency room.
Followup Instructions:
___
|
10389768-DS-10 | 10,389,768 | 21,411,295 | DS | 10 | 2148-07-29 00:00:00 | 2148-07-30 13:39:00 |
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:
Coronary cath ___ s/p 2x DES to RCA
History of Present Illness:
This is a ___ with no past medical history who presented to an
OSH with chest pain and transferred to the ___
___ yo male with no pmh who present from an osh as an NSTEMI.
Endorsing substernal cp since 5p. Presented to OSH where found
to have dynamic ECG changes in an inferior lateral distribution.
Constant chest pressure with right arm pain. OSH where CTA
without dissection and troponin positive to 0.3.
In the ED initial vitals were:
97.9 68 106/68 19 97% NC
EKG: inferioapical q-waves and TWI
Labs/studies notable for:
WBC=11.3 Plt 144, proBNP=167, trop 0.68, MB=138
lactate.
Patient was given: full dose aspirin, loaded with clopidogrel,
IV heparin, Atrovastatin, nitro ggt for chest pain.
The patient continued to have chest pain despite nitro drip and
was send to the CCU for further monitoring pending further eval
for cath.
On arrival to the CCU: 98.4 89/68 72 94% on RA. patient
complains of ___ chest pain. was given 1L NS
Past Medical History:
no past medical history.
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
==========================
ADMISSION PHYSICAL EXAM
==========================
VS: 98.4 89/68 72 94% on RA
general: look in pain
chest: good air entry bilat with no wheeze or crackles.
heart: normal S1 and S2 with no murmur.
abdomen: soft and non-tender.
ext: warm and well perfused.
========================
DISCHARGE PHYSICAL EXAM
========================
VS: Tc 99.3 106-118/65-74, 74-83, 98% on RA
general: Adult male in NAD
chest: good air entry bilat with no wheeze or crackles.
heart: normal S1 and S2 with no murmur.
abdomen: soft and non-tender.
ext: warm and well perfused.
Pertinent Results:
========================
ADMISSION LABS
========================
___ 02:10AM BLOOD WBC-11.3* RBC-4.55* Hgb-14.4 Hct-42.9
MCV-94 MCH-31.6 MCHC-33.6 RDW-13.0 RDWSD-44.7 Plt ___
___ 02:10AM BLOOD Neuts-75.2* Lymphs-15.5* Monos-6.3
Eos-1.6 Baso-0.4 Im ___ AbsNeut-8.53* AbsLymp-1.76
AbsMono-0.71 AbsEos-0.18 AbsBaso-0.04
___ 02:10AM BLOOD ___ PTT-85.1* ___
___ 02:10AM BLOOD Glucose-123* UreaN-15 Creat-0.9 Na-139
K-3.8 Cl-105 HCO3-24 AnGap-14
___ 02:10AM BLOOD CK(CPK)-869*
___ 02:10AM BLOOD CK-MB-138* MB Indx-15.9* proBNP-167*
___ 02:10AM BLOOD cTropnT-0.68*
___ 02:10AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.1
___ 04:19PM BLOOD %HbA1c-5.0 eAG-97
___ 08:13AM BLOOD Triglyc-175* HDL-32 CHOL/HD-4.7
LDLcalc-83 LDLmeas-109
___ 02:10AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 02:23AM BLOOD Lactate-1.3
===========
MICRO
===========
None
==============
IMAGING
==============
___ CXR
There is moderate interstitial pulmonary edema. No focal
infiltrates to
suggest pneumonia. Borderline enlargement of the
cardiomediastinal
silhouette. No pleural effusion. No pneumothorax.
___ Cardiovascular Cath Physician ___
___
Right dominant
LM: No disease.
LAD: No disease. Gives collaterals to the RCA.
LCx: No disease.
RCA: Mid vessel diffuse 50% disease. Distal thrombotic
occlusion.
Impressions:
Occluded RCA, successfully stented with 2 overlapping DES.
Ticagrelor 180 loaded on table.
TR band to right wrist.
Recommendations
ASA for life, Ticagrelor 90 BID x ___ year, then switch to 60 BID
thereafter.
___ Cardiovascular ECHO
Conclusions
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with mild focal
basal inferior and inferoseptal hypokinesis (PDA distribution).
The remaining segments contract normally (LVEF = 50%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic
dysfunction, c/w CAD.
========================
DISCHARGE LABS
========================
___ 06:50AM BLOOD WBC-9.0 RBC-4.41* Hgb-14.1 Hct-42.4
MCV-96 MCH-32.0 MCHC-33.3 RDW-13.0 RDWSD-46.5* Plt ___
___ 06:50AM BLOOD Glucose-100 UreaN-11 Creat-0.9 Na-142
K-4.0 Cl-105 HCO3-23 AnGap-18
___ 06:50AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.0
___ 04:19PM BLOOD %HbA1c-5.0 eAG-97
___ 08:13AM BLOOD Triglyc-175* HDL-32 CHOL/HD-4.7
LDLcalc-83 LDLmeas-109
___ 02:10AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 02:23AM BLOOD Lactate-1.3
Brief Hospital Course:
Summary
___ with no PMH presented with new onset of central chest pain
with q-waves and elevation in trops consistent with acute MI. He
underwent cardiac cath ___ with 2 DES to RCA and did well post
procedure without complications.
# Non-ST elevation myocardial infarction: Presented with
increasing trops and ST changes on the EKG. He underwent cardiac
cath ___ with 2 DES to RCA and did well post procedure without
complications. He was discharged on Aspirin 81mg daily,
Atorvastatin 80mg Daily, Metoprolol succinate 25mg daily and
ticagrelor 90mg BID.
# R ear fullness and hearing loss: During admission, patient
developed fullness and diminished hearing in his R ear. Was not
associated with dizziness, vision changes, nasal discharge or
pain. Exam was unrevealing. He was given Flonase prescription to
help with any Eustachian tube dysfunction. We also set up
outpatient ENT referral.
Transitional Issues
- Followup appointments were made with PCP, ENT and cardiology.
- He was prescribed aspirin, atorvastatin, metoprolol and
ticagrelor for post-MI care. He should take the aspirin and
ticagrelor for at least ___ year post ___.
- Given Flonase for ear fullness and hearing loss and will
follow with ENT as above.
# CODE: Full
# Contact: ___
Relationship: OTHER
Phone: ___
Medications on Admission:
None
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
RX *fluticasone 50 mcg/actuation 1 spray daily Disp #*30 Spray
Refills:*0
4. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
take and call ___
RX *nitroglycerin 0.3 mg 1 tablet(s) sublingually prn chest pain
Disp #*100 Tablet Refills:*0
6. TiCAGRELOR 90 mg PO BID
RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: NSTEMI
Secondary diagnosis: R sided hearing loss
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to ___ with chest pain and were found to have a heart
attack. We placed a stent to keep your artery open. Please take
the medications we have prescribed and keep the appointments we
have made.
It was a pleasure taking care of you, best of luck.
Your ___ medical team
Followup Instructions:
___
|
10390100-DS-11 | 10,390,100 | 26,330,031 | DS | 11 | 2145-06-22 00:00:00 | 2145-06-24 11:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Norvasc / Keflex / latex / metoprolol
Attending: ___.
Chief Complaint:
R distal femur fracture
Major Surgical or Invasive Procedure:
Fixation, distal femoral fracture, with retrograde
intramedullary nail ___
History of Present Illness:
This is a ___ with a history of afib on Coumadin, s/p right knee
replacement (___) complicated by incisional wound infection
s/p IV vanco and po Bactrim (___) presenting after
mechanical fall at home with right distal femoral metaphyseal
oblique fracture with displacement, near but not communicating
with recent TK. She underwent fixation on ___ complicated by
bleeding requiring 4 uPRB. She became more delirious after her
surgery and transferred to the medical service. Her course has
been complicated by supratherapeutic INR (3.5 despite 2 uFFP),
___ (Cr 2.6, baseline 1.6) thought ___ Bactrim and
chlorthalidone and fevers to 103.
Per report, she was previously A&Ox3 and appropriate. At the
time, she was in severe pain and was using her dilaudid PCA. On
the medical service, her Hct was 24.1 but no further blood
products could be given as she was persistently febrile for > 6
hours. At 22:30, she developed new hypotension to 78, although
asymptomatic (other than ongoing delirium). She was given 1L NS
and 2 uPRBC without improvement in blood pressure. Given
hypotension and nursing concern, she was transferred to the
MICU.
Past Medical History:
- A fib on Coumadin
- HTN
- R TKR (___) c/b incisional infection s/p ___
- Sepsis ___ pyelonephritis (___)
- Diastolic CHF
- COPD
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 100.8, HR 92, 95/38, 100% on 2L
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
NECK: supple
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, III/VI early systolic
murmur, no rubs/gallops
ABD: soft, non-tender, non-distended, no rebound tenderness or
guarding
EXT: R knee larger than left with surgical staples in place,
tender to touch but no erythema/warmth/oozing w/ healing edges.
Both legs Warm, well perfused, 1+ pulses b/l ___, 2+ pulses
radially, no clubbing, cyanosis or edema.
SKIN: R Achilles skin abrasion 2x2cm
NEURO: AOX3, alert and attentive, CNII-XII intact, moving all
extremities, normal strength UE
DISCHARGE PHYSICAL EXAM:
VS: 98.9 141/66 70 20 94%RA
Gen: AAOx3
HEENT: AT/NC, eyes anicteric, PERRL, MMM
CV: RRR, (+)S1, S2, SEM at RUSB
Pulm: CTAB
Abd: soft, ND/NT, no rebound/guarding
GU: no foley in place
Ext: RLE significantly larger than left, wrapped in ace-bandage
from foot to upper thigh, (+) edema in ankle, (+) palpable DP.
LLE edematous to calf.
Skin: no evidence of ecchymosis, rash. PLE wrapped as above
Neuro: AAOx3
Pertinent Results:
ADMISSION LAB VALUES:
___ 01:00AM PLT COUNT-205
___ 01:00AM NEUTS-71.5* LYMPHS-17.1* MONOS-6.0 EOS-4.8
BASOS-0.2 IM ___ AbsNeut-8.65* AbsLymp-2.07 AbsMono-0.73
AbsEos-0.58* AbsBaso-0.03
___ 01:00AM WBC-12.1* RBC-2.69* HGB-8.6* HCT-26.5*
MCV-99* MCH-32.0 MCHC-32.5 RDW-12.5 RDWSD-44.9
___ 01:00AM estGFR-Using this
___ 01:00AM GLUCOSE-138* UREA N-35* CREAT-2.6*#
SODIUM-136 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-21* ANION GAP-18
___ 03:38AM ___ PTT-44.9* ___
___ 03:30PM ___
___ 05:55PM ___ PTT-37.1* ___
___ 05:55PM HCT-19.5*#
___ 05:55PM GLUCOSE-151* UREA N-34* CREAT-2.6* SODIUM-136
POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-23 ANION GAP-13
___ 08:37PM URINE HOURS-RANDOM UREA N-324 CREAT-149
SODIUM-34 POTASSIUM-50 CHLORIDE-17
DISCHARGE LAB VALUES:
PERTINENT IMAGING/STUDIES:
CT RLE: IMPRESSION:
1. Spiral fracture through the mid and distal diaphysis of the
right femur
with half shaft width posteromedial displacement and 90 degree
external
rotation of the distal fragment. No intra-articular extension.
2. Small intramuscular hematoma.
3. Gastrocnemius muscle lipoma.
CT HEAD: No acute intracranial process.
CT CSPINE: IMPRESSION:
1. No fracture or prevertebral fluid.
2. Mild C3 on CT retrolisthesis is likely chronic and
degenerative in nature.
3. Mild to moderate multilevel cervical spine degenerative
change, with severe neural foraminal narrowing worst bilaterally
at C5-6.
Brief Hospital Course:
Ms. ___ is a ___ lady w/ Afib on Coumadin, s/p R knee
replacement (___) c/b incisional wound infection (___)
presenting after mech fall w/ femur fx s/p fixation c/b ___ and
supratherapeutic INR now w/ persistent fever, leukocytosis,
unstable Hct concerning for infection and continued bleed
transferred to MICU for hypotension. Stabilized w/fluid
resuscitation and additional PRBCs. Transferred back to ___ med
floor where she remained stable and was discharged to rehab.
# Hypotension: Combination of possible sepsis with fever and
leukocytosis and blood loss in setting of
operation/supratherapeutic INR. Urine cx, blood cx, CXR
negative. Started on vanc and zosyn and continued on vanc given
c/f soft tissue infection in the setting of recent
instrumentation. Pt also required additional 1 unit pRBC and 2
units FFP in MICU although no source of bleeding identified
except for intra-operative/hematoma. Pressor requirement ended
after transfusions and patient was transferred back to ___ med
floor. She remained HDS, afebrile. She was evaluated by ID and
given no identified source of infection in the setting of
stability, her antibiotics were discontinued.
#Fever/leukocytosis: Presumed sepsis with no pneumonia on CXR
and no UA abnormalities. Given persistently high fever in the
setting of post-operative, other possible etiologies included
atelectasis possible although febrile to 103 w/o improvement
w/Tylenol vs transfusion reaction although also unlikely given
time separation from last transfusion vs malignant hyperthermia
although time course also unlikely and no rigidity on exam vs
possible allergic rxn given known allergy to tape and possibly
received something in OR that was a trigger vs per ortho c/f
inoculation of overlying cellulitis into wound. Patient received
2 days of Zosyn which was stopped and she was continued on
Vancomycin on transfer to the floor. Her thigh and knee were
monitored closely by Orthopedics and medical team with no
external signs of cellulitis identified. She remained afebrile
for >48hours prior to discharge and was not discharged on
antibiotics.
# Anemia: Initially incomplete response to transfusions after
2uFFP, 1uPRBC following surgery. Serial thigh measurements for
concern for hematoma/compartment syndrome were unchanged. H&H
stable when transferred to the floor and remained stable through
discharge.
# Altered mental status: Acute episode of AMS in the ICU in
setting of history of delirium with hospitalization. Much
improved on discharge to the floor. Narcotics were avoided and
delirium precautions were put in place. She was AAOx3 on
discharge.
# Elevated INR: on Coumadin for a fib. Elevated to 3.0 on
admission, increased to ___ s/p 2uFFP. Possible etiology for
elevation is recent antibiotic use. Received 2 unit FFP and 5mg
Iv vit K with complete correction to INR of 1.0. She was
restarted on 2.5mg of Coumadin on ___ and subcut heparin. On
discharge, her INR was 1.0 and she received a 2nd dose of 2.5mg
Coumadin.
# ___: admission Cr 2.0 with high of 2.5 in MICU (baseline 1.6).
Likely pre-renal from blood loss, dehydration, sepsis. FeNa of
0.41%. Held lisinopril and chlorthalidone pending renal
recovery. Following fluid resuscitation Cr improved to below
baseline (1.2 on discharge) and her home medications were
restarted
# R femur fx: s/p fixation (___): R distal metaphyseal
femoral fracture adjacent to, but not communicating with recent
R TKR in the setting of a mechanical fall. S/p OR on ___
for fixation c/b bleeding. Ortho managed wound care during
admission. Required PCA for pain control which was able to be
downtitrated to standing Tylenol, tramadol PRN for pain. She was
evaluated by physical therapy who felt she required rehab.
# HTN: Home meds held in MICU in setting of c/f sepsis.
Following transfer to the floor, patient's home medications were
restarted.
TRANSITIONAL ISSUES:
[] d/c on 2.5mg Coumadin, INR at d/c 1.0 -> continue to monitor
[] d/c w/o antibiotics -> if becomes febrile, consider
thigh/knee as likely source
[] avoiding narcotics for pain control -> standing Tylenol,
tramadol 50mg PRN for breakthrough
# CODE: Full
# CONTACT: ___ (husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atorvastatin 20 mg PO QPM
3. Carvedilol 12.5 mg PO BID
4. Cetirizine 10 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
8. Docusate Sodium 100 mg PO BID
9. Senna 8.6 mg PO HS
10. Warfarin 3.75 mg PO 4X/WEEK (___)
11. Sulfameth/Trimethoprim DS 1 TAB PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atorvastatin 20 mg PO QPM
3. Carvedilol 12.5 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Lisinopril 40 mg PO DAILY
6. Senna 8.6 mg PO HS
7. Warfarin 2.5 mg PO DAILY16 Duration: 1 Dose
8. Chlorthalidone 25 mg PO DAILY
9. Heparin 5000 UNIT SC BID
10. Vitamin D ___ UNIT PO DAILY
11. Cetirizine 10 mg PO DAILY
12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*56
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary Diagnoses
-Distal right femur fracture
-Hypotension
-Fever
-___
Secondary Diagnoses
-HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the ___
for management of your right femur fracture. The repair of your
femur was successful. However, after your procedure, you became
very sick requiring transfer to the medical intensive care unit.
You were admitted to our intensive care unit where you
received fluids and blood, along with antibiotics. At this point
you were stable enough for general medical care on the medicine
floor where you were evaluated by the Infectious Disease team.
Given your normal temperature and no signs of infection, your
antibiotics were stopped. You should follow-up with your primary
care doctor. You should also follow the orthopedic instructions
below.
Thank you for letting us be a part of your care!
Your ___ Team
SPECIFIC 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:
- Touchdown weight bearing right lower exremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
Followup Instructions:
___
|
10390112-DS-13 | 10,390,112 | 20,837,301 | DS | 13 | 2148-07-29 00:00:00 | 2148-07-31 14:25:00 |
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:
TEE Cardioversion
History of Present Illness:
___ with PMH of cardiomyopathy (unknown details), HTN, HLD,
recently diagnosed atrial fibrillation not on anticoagulation
presenting with dyspnea.
Patient reports worsening dyspnea over the past 5 days. He was
recently traveling to a wedding in ___ - denied any change in
diet, continued to exercise but noted progressively worsening
SOB with exertion. This is associated with 2 pillow orthopnea
and cough x 2 weeks. He notes mild abdominal bloating. He denies
chest pain. Denies fevers, chills, abdominal pain, nausea,
vomiting constipation. The patient initially presented to
outpatient NP for evaluation. There, he was found to have O2 sat
91% on RA and HR 128 on office ECG. He was suspected to have CHF
exacerbation and was referred to the ___ ED for further
evaluation.
Of note, per NP ED referral, patient has been followed by
cardiology for CAD, cardiomyopathy and AF. He was prescribed
xarelto in ___ for anticoagulation, but deferred starting the
medication until after his scheduled cataract surgery (scheduled
for tomorrow ___. The patient otherwise reported compliance
with his metoprolol.
In the ED initial vitals were: T97.6, HR 166, BP 133/103, RR
22, O2 93% on RA
Exam notable for: diminished breath sounds in b/l bases.
Cardiac exam tachycardic. Abdomen soft, NT/ND, no ___ edema
Labs/studies notable for:
- Na 141, K 4.4, Cl 104, HCO3 21, BUN 19, Cr 1.0, Glucose 122
- WBC 9.1, PMNs 71.3%, Leuks 17.4%, Hgb 14.4, HCT 43.0, Plt 243
- trop < 0.01, proBNP 3252
- UA negative, TSH pending
- EKG: (reportedly) afib RVR with intermittent runs of VT, ___
beats
- CXR: Bibasilar opacities, right greater than left may reflect
atelectasis or infection in the appropriate setting. Pulmonary
vascular engorgement without overt signs of pulmonary edema.
Patient was given:
- metoprolol 5mg IV x1, metoprolol 12.5mg PO x1 with
improvement in HR to ___
Vitals on transfer: T97.7, HR 109, BP 121/89, RR 25, O2 92% on
NC
On the floor, patient endorses mild ongoing dyspnea with
occasional dry cough and no other symptoms.
ROS:
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope. Denies exertional buttock
or calf pain.
On further review of systems, denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains,
hemoptysis, black stools or red stools. Denies recent fevers,
chills or rigors. All of the other review of systems were
negative.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, no
diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
? CAD (patient unsure on details, no prior cath)
H/o cardiomyopathy in ___
H/o Duodenal ulcer
Prostate cancer with biopsy in ___ showing low risk cancer
BPH
Pseudoexfoliation glaucoma
Afib with RVR diagnosed in ___
Social History:
___
Family History:
Brother with history of MIs in his ___, now deceased. Father
with ? anxiety. No other known family cardiac history.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: 98 124/94 138 20 97%RA
GENERAL: Comfortable appearing gentleman in NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink. No xanthelasma.
NECK: Supple with JVP of 10 cm.
CARDIAC: Irregular, normal S1, S2. No murmurs/rubs/gallops. No
thrills, lifts.
LUNGS: No chest wall deformities, respirations unlabored,
bibasilar crackles
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ pitting edema to ankles bilaterally with sock
lines notable on exam
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: T 97.5 BP 116/85 (99-118/68-85) HR 95 (73-95) RR ___
O2 95-99% RA
I/O: 8h ___, 24h ___
Weight: 88.1 <- 88.2 <- 89.6
Telemetry: Afib with intermittent runs of nonsustained vtach,
also with PVCs.
GENERAL: Comfortable appearing gentleman in NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink. No xanthelasma.
NECK: Supple with no appreciable JVP.
CARDIAC: Irregularly irregular, tachycardia, normal S1, S2. No
murmurs/rubs/gallops. No thrills, lifts.
LUNGS: No chest wall deformities, respirations unlabored, no
crackles.
ABDOMEN: Soft, distention improved from yesterday, nontender to
palpation. No HSM.
EXTREMITIES: 2+ pitting edema to ankles bilaterally with sock
lines notable on exam
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS:
================
___ 02:30PM NEUTS-71.3* LYMPHS-17.4* MONOS-9.4 EOS-1.1
BASOS-0.6 IM ___ AbsNeut-6.47* AbsLymp-1.58 AbsMono-0.85*
AbsEos-0.10 AbsBaso-0.05
___ 02:30PM WBC-9.1 RBC-4.98 HGB-14.4 HCT-43.0 MCV-86
MCH-28.9 MCHC-33.5 RDW-14.4 RDWSD-44.9
___ 02:30PM TSH-3.6
___ 02:30PM cTropnT-<0.01
___ 02:30PM proBNP-3252*
___ 02:30PM GLUCOSE-122* UREA N-19 CREAT-1.0 SODIUM-141
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-21* ANION GAP-20
___ 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 03:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:00PM URINE UHOLD-HOLD
___ 03:00PM URINE GR HOLD-HOLD
___ 03:00PM URINE HOURS-RANDOM
___ 03:00PM URINE HOURS-RANDOM
___ 11:35PM MAGNESIUM-1.8
___ 11:35PM cTropnT-<0.01
___ 11:57PM LACTATE-1.5
DISCHARGE LABS:
================
___ 03:40AM BLOOD WBC-5.7 RBC-4.93 Hgb-14.0 Hct-42.8 MCV-87
MCH-28.4 MCHC-32.7 RDW-14.2 RDWSD-44.5 Plt ___
___ 03:40AM BLOOD Plt ___
___ 03:40AM BLOOD Glucose-94 UreaN-24* Creat-1.0 Na-138
K-4.4 Cl-101 HCO3-24 AnGap-17
___ 03:40AM BLOOD ALT-28 AST-19
___ 03:40AM BLOOD Calcium-8.9 Phos-4.5 Mg-2.0
RADIOLOGY:
===========
CHEST (PORTABLE AP) ___
IMPRESSION:
Bibasilar opacities, right greater than left may reflect
atelectasis or
infection in the appropriate setting. Pulmonary vascular
engorgement without overt signs of pulmonary edema.
CARDIAC STUDIES:
=================
CARDIOVASCULAR ECHO ___
CONCLUSIONS
The left atrial volume index is moderately increased. No left
atrial mass/thrombus seen (best excluded by transesophageal
echocardiography). The estimated right atrial pressure is ___
mmHg. There is mild symmetric left ventricular hypertrophy with
normal cavity size. There is severe global left ventricular
hypokinesis (biplane LVEF = 25 %). Systolic function of apical
segments is relatively preserved. [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
mitral regurgitation.] The estimated cardiac index is depressed
(<2.0L/min/m2). No masses or thrombi are seen in the left
ventricle. The right ventricular cavity is mildly dilated with
moderate global free wall hypokinesis. The aortic root is mildly
dilated at the sinus level. 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. Moderate to severe (3+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
severe global hypokinesis in a pattern most c/w a non-ischemic
cardiomyopathy. Moderate to severe mitral regurgitation.
Moderate pulmonary artery systolic hypertension. Right
ventricular cavity dilation with free wall hypokinesis. Mildly
dilated aortic root.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or ___.
Brief Hospital Course:
Mr. ___ is a ___ year old male with history of cardiomyopathy
who presented with dyspnea found to atrial fibrillation with RVR
and new systolic heart failure exacerbation.
# Systolic CHF exacerbation EF 25%
Echocardiogram prior to cardioversion showed an ejection
fraction of 25% and patient presented with dyspnea on exertion.
Patient was diuresed with IV Lasix and transitioned to 40 mg PO
Lasix prior to discharge. Patient continued on lisinopril 40 mg
daily. Weight on discharge was: 88.1kg (194.2lbs)
# Atrial Fibrillation:
Patient presented with atrial fibrillation with RVR. He was
stared on xarelto 20 mg daily. TSH 3.6, ALT 28, AST 19 prior to
starting amiodarone. He was discharged on metoprolol succinate
75 mg BID, amiodarone 400 mg BID, and xarelto 20 mg daily.
Patient was cardioverted to sinus rhythm on ___. Amiodarone
dose should be down-titrated upon follow up with Dr. ___.
# Cataracts:
He was scheduled for upcoming cataracts surgery that was
cancelled as patient would have to hold xarelto prior to this
procedure. Patient instructed to take xarelto every day
especially in the month after cardioversion. As such he was
instructed to reschedule his cataract surgery in 1 month. This
was relayed to his eye doctor Dr. ___.
# Hypertension:
Patient remained normotensive throughout hospitalization.
Lisinopril 40 mg daily continued. Metoprolol succinate 75 mg BID
continued as above.
# BPH:
-Continued tamsulosin
# H/o duodenal ulcer:
Continued omeprazole. H/H remained stable.
TRANSTIONAL ISSUES:
=====================
-weight on discharge: 88.1kg (194.2lbs)
-Lasix 40 mg daily started
-metoprolol succinate 75 mg BID started
-xarelto 20 mg daily started
-amiodarone 400 mg BID started, dose to be down-titrated on
follow up with Dr. ___ 3.6, ALT 28, AST 19 prior to starting amiodarone
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.8 mg PO QHS
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Desonide 0.05% Cream 1 Appl TP BID
6. amLODIPine 5 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Pravastatin 40 mg PO QPM
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Medications:
1. Rivaroxaban 20 mg PO DINNER
Daily with the evening meal.
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth daily with
dinner Disp #*30 Tablet Refills:*3
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Omeprazole 20 mg PO DAILY
5. Tamsulosin 0.8 mg PO QHS
6. Desonide 0.05% Cream 1 Appl TP BID
7. Lisinopril 40 mg PO DAILY
8. Pravastatin 40 mg PO QPM
9. amLODIPine 5 mg PO DAILY
10. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
11. Metoprolol Succinate XL 75 mg PO BID
RX *metoprolol succinate 50 mg 1.5 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
12. Amiodarone 400 mg PO BID
Please do not take if lightheaded, fatigued, or if HR < 50 beats
per minute
RX *amiodarone 400 mg 1 tablet(s) by mouth Twice per day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial Fibrillation
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 ___
because you had difficulty breathing. You were found to have an
abnormal heart rhythm called atrial fibrillation, that caused
the fluid to back up to the rest of your body. This caused you
to have difficulty breathing.
For your abnormal heart rhythm, we started you on an
anticoagulant called xarelto. This is a blood thinner that helps
to prevent blood clots in your heart, and also helps to prevent
these clots from traveling to the rest of your body and causing
a stroke. It is very important that you take this medication
every day and do not miss ___ dose.
We also started you on a new medication to control your heart
rate so that your heart could better work to pump blood forward
to the rest of your body. You also underwent a procedure called
cardioversion. This helped to shock your heart into a regular
heart rate. You were then started on a new medication to help to
keep your heart beating in this regular rhythm.
For your difficulty breathing and fluid overload, we started you
on some diuretic medications to help take some extra fluid off.
This helped to control the swelling of your legs, improved the
bloating sensation you experienced, and helped with your
shortness of breath.
We have made changes to your medication list, so please make
sure to take your medications as directed. You will also need to
have close follow up with your heart doctor and your primary
care doctor. Please call your cardiology doctor at ___
if you feel lightheaded, fatigued, or have a slow heart rate
that is less than 50 beats per minute.
Please weigh yourself every day and call your doctor if your
weight increases by more than 3lbs over 2 days. Your weight at
time of discharge was 88.1kg (194.2lbs).
It was a pleasure to take care of you. We wish you the best with
your health!
Your ___ Cardiac Care Team
Followup Instructions:
___
|
10390714-DS-12 | 10,390,714 | 29,932,079 | DS | 12 | 2172-01-16 00:00:00 | 2172-01-16 17:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ciprofloxacin / Iodinated Contrast- Oral and IV Dye / morphine /
Penicillins / Quinolones
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___ Cath with DES to LAD
History of Present Illness:
___ year old female with no prior PMH and on no meds at home.
One month history of shortness of breath. Thought it would go
away. Progressively worsened to the point where she would get
short of breath even making her bed. She states it was a fairly
sudden onset of shortness of breath a month ago. No chest pain,
no fainting spells. Only significant thing she mentioned was
that
she had a cold a couple weeks before the onset of shortness of
breath. Usually lays on 2 pillows but since a month ago, gets
short of breath on 2 pillows and sometimes have to sit in a
chair
to catch her breath. No PND. No prior heart attacks. No prior
heart disease. No prior h/o arrhthymia or valvular disease.
Smoked 2 packs a day for ___ years but started smoking when she
was
___ years old. Quit smoking in ___ when she was ___ years old
around. No alcohol use. No recreational drug use.
At baseline, could walk for miles with no significant shortness
of breath. Now, can barely make it to the car without feeling
very short of breath.
Denies: vision changes, headaches, sore throat, cough, chest
pain, no palpitations aside from when she moves around a lot,
abdominal pain, diarrhea, constipation, swelling in the legs,
Went to ___ for worsening DOE. Was transferred to ___
for further evaluation for ACS vs PE. Was given full dose
aspirin
in ___ prior to transfer to ___.
At, ___, labs/studies:
-Na 143 K 4.1 Cl 112 HCO3 14 Glc 129 BUN 25 Cr 1.2 Ca 9.1
-Trop T <0.01 x2 D-dimer 1852
-CBC 6.9 H/H ___ Plt 244
-___ 13.3 PTT 29.1 INR 1.19
-VBG pH 7.39 PCO2 25 PO2 82 HCO3 16
-CXR: Mild cardiomegaly. No CHF. No focal infiltrates or pleural
effusions. Mediastinal contour grossly unremarkable.
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
DVT in unknown leg in the 1990s
Cholecystectomy
Thumb surgery
Humerus and scapular surgery for surgery
Social History:
___
Family History:
-Father: had a pacemaker - unclear reason why
-Mother: passed away, had DM
-Sister: none
-1 cousin passed away from MI in the ___
Physical Exam:
Admission Exam:
===================
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple, difficult to assess JVP given body habitus
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No
thrills,
lifts.
LUNGS: unlabored breathing, clear to auscultation bilaterally,
no
wheezes, no crackles
ABDOMEN: Soft, NTND. No tenderness to palpation
EXTREMITIES: 1+ pitting edema bilaterally
SKIN: No stasis dermatitis, ulcers, scars.
PULSES: Distal pulses palpable and symmetric
Discharge Exam:
====================
T 98.6PO BP 144 / 81R SittingHR67RR18Sat 96%Ra
GENERAL: NAD, pleasant
HEENT: Sclera anicteric, AC/NT
LUNGS: no crackles, normal WOB
HEART: RRR, no murmurs, no JVD
ABDOMEN: +BS, soft, NTND
EXTREMITIES: WWP, trace bilateral ___ edema up to knees
Pertinent Results:
Admission Labs:
=================
___ 07:00PM BLOOD WBC-7.2 RBC-4.60 Hgb-13.7 Hct-45.3*
MCV-99* MCH-29.8 MCHC-30.2* RDW-17.8* RDWSD-64.4* Plt ___
___ 07:00PM BLOOD Neuts-73.4* Lymphs-17.5* Monos-6.9
Eos-1.1 Baso-0.7 Im ___ AbsNeut-5.29 AbsLymp-1.26
AbsMono-0.50 AbsEos-0.08 AbsBaso-0.05
___ 07:00PM BLOOD ___ PTT-22.3* ___
___ 07:00PM BLOOD Glucose-125* UreaN-25* Creat-1.4* Na-144
K-4.3 Cl-111* HCO3-12* AnGap-21*
___ 07:00PM BLOOD ALT-13 AST-21 AlkPhos-86 TotBili-0.8
___ 07:00PM BLOOD ___
___ 07:00PM BLOOD Albumin-3.7 Cholest-239*
___ 11:39AM BLOOD %HbA1c-5.8 eAG-120
___ 07:00PM BLOOD Triglyc-152* HDL-42 CHOL/HD-5.7
LDLcalc-167* LDLmeas-178*
___ 01:45PM BLOOD TSH-1.1
___ 01:08AM BLOOD Type-ART pO2-73* pCO2-21* pH-7.38
calTCO2-13* Base XS--10
___ 01:08AM BLOOD Lactate-1.7
Pertinent Studies:
======================
___ LHC
Single vessel CAD with 50% pLAD and positive iFR succesfully
treated with 1 DES.
IVUS of stent showing good result and LMCA MLA >9 mm.
Mildly elevated left-side filling pressures.(17)
___ TTE:
The left atrial volume index is moderately increased. The right
atrium is moderately dilated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity is mildly dilated. There is
severe regional left ventricular systolic dysfunction with
hypokinesis of the anterior and septal segments; the lateral
segments contract best. No masses or thrombi are seen in the
left ventricle. Right ventricular chamber size is normal with
mild global free wall hypokinesis. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. An eccentric, posteriorly
directed jet of moderate to severe (3+) mitral regurgitation is
seen. Due to the eccentric nature of the regurgitant jet, its
severity may be significantly underestimated (Coanda effect).
Moderate [2+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: Severely depressed left ventricular systolic
dysfunction consistent with proximal left anterior descending
coronary artery disease. At least moderate to severe mitral
regurgitation. Moderate tricuspid regurgitation. Severe
pulmonary hypertension.
___ CTA Chest:
1. Moderately limited examination due to respiratory motion
artifact at the lung bases. Within these limitations, no
evidence of pulmonary embolism.
2. Moderate cardiomegaly. Diffuse mosaic attenuation of the
lung parenchyma with mild septal thickening at the lung bases,
likely reflecting a combination
of air-trapping and pulmonary edema. Trace left pleural
effusion.
3. Diffuse bronchial wall thickening may reflect chronic airways
disease
and/or fluid overload.
4. Multiple enlarged mediastinal lymph nodes measuring up to 1.7
cm in short axis, nonspecific, but may be reactive.
Discharge Labs:
==================
___ 06:35AM BLOOD WBC-6.9 RBC-4.70 Hgb-13.9 Hct-44.1 MCV-94
MCH-29.6 MCHC-31.5* RDW-16.3* RDWSD-56.5* Plt ___
___ 06:35AM BLOOD Plt ___
___ 06:20AM BLOOD Glucose-102* UreaN-30* Creat-1.5* Na-142
K-4.1 Cl-103 HCO3-24 AnGap-15
___ 06:20AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.0
Brief Hospital Course:
Patient Summary:
==================
___ with h/o DVT in the ___, who presented with subacute
progressive dyspnea on exertion, as well as EKG changes at OSH.
Diagnosed with acute HFrEF (EF 30%). Coronary angiogram with
single vessel CAD with 50% pLAD, successfully treated with 1
DES. Started on DAPT and diuresed to dry weight of 91.5kg on
discharge.
Active Issues:
==================
#Acute HFrEF (EF 30%)
#CAD w/ DES to pLAD
Patient presented with volume overload with elevated BNP and TTE
with newly reduced EF of 30% and regional WMA. LHC with single
vessel CAD and 50% stenosis of pLAD treated with 1 DES. LVED
mildly elevated at 17. Started on DAPT. Diuresed well with IV
Lasix boluses and discharged on PO Lasix 20mg ___. Medications
optimized with lisinopril 10mg, Metop succinate 50mg,
Atorvastatin 80mg, Plavix 75mg, and ASA 81mg. Will need a repeat
TTE in 6 weeks following discharge for evaluation of EF post
stent placement.
Discharge weight: 91.5kg
Discharge diuretic: 20mg PO Lasix MWF
Discharge Cr: 1.5
#CKD
Unclear baseline Cr, with admission Cr of 1.4. Spot total
protein/Cr ratio of 2.8, though in the setting of UTI,
concerning for CKD due to poorly controlled hypertension.
Started on lisinopril 10mg daily. Will need a repeat UA and
total protein/Cr ratio in follow up to assess for CKD..
#UTI
Dysuria, with urine culture growing pan sensitive E.coli. No
recent hospitalization, history of recurrent UTI, CVA
tenderness, fever, chills or leukocytosis. Completed
Nitrofurantoin 100mg x5 days while in ___.
# HLD: Lipid panel this admission notable for LDL 178, TC 239,
HDL 42, ___ 152. Basline CK 108. Started on Atorvastatin 80mg.
# Hyperglycemia: Pre-diabetic based on an A1C of 5.8%. Educated
on diet to prevent diabetes.
# Non-anion gap metabolic acidosis: On presentation with anion
gap acidosis likely ___ starvation ketoacidosis in the setting
of being NPO for a cath for a very long period of time. Acidosis
resolved spontaneously without treatment other than PO intake.
Transitional Issues:
========================
[] Follow up Chem 7 in 1 week and assess volume status for
adequacy of Lasix regimen
[] Elevated pulmonary artery pressure, recommend outpatient
sleep study for OSA
[] Repeat TTE in 6 weeks following discharge for re-evaluation
of EF and potential consideration of referral to
electrophysiology for possible ICD evaluation if LVEF remains
severely depressed
[] Repeat Total protein/Cr ratio in follow up to assess for CKD
[] Prescribed outpatient cardiac rehab
[] Follow up with PCP ___ non-specific mediastinal lymph nodes
measuring up to 1.7 cm in greatest dimension in the event
follow-up imaging should be considered.
Discharge weight: 91.5kg
Discharge diuretic: 20mg PO Lasix MWF
Discharge Cr: 1.5
#CODE STATUS: Full
#CONTACT:
Name of health care proxy: ___
Relationship: husband
Phone number: ___
>30 minutes spent on discharge planning/coordination of care.
Medications on Admission:
None
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*2
3. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
4. Furosemide 20 mg PO 3X/WEEK (___)
RX *furosemide 20 mg 1 tablet(s) by mouth three times per week,
___ Disp #*30 Tablet Refills:*0
5. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
6. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Acute systolic heart failure, ischemic
Coronary artery disease
Secondary diagnosis:
Acute kidney injury
Urinary tract infection
Hyperlipidemia
Pre-diabetes
Metabolic acidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you were feeling short
of breath.
What happened while you were in the hospital?
- You had ultrasound of your heart that showed you have
congestive heart failure
- Your shortness of breath was caused from extra fluid
accumulation in your body
- You were started on a medication called Lasix that helped take
fluid off of your body and improve your breathing
- You had coronary angiogram done that showed blockage of one of
the arteries to the heart. You got a stent placed in this
artery. This blockage is likely the cause of your heart failure.
- You were started on new medications to help with this
- You were improved significantly and were ready to leave the
hospital.
What should you do after leaving the hospital?
-Your weight at discharge is 201.72 lbs. Please weigh yourself
today at home and use this as your new baseline
-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.
-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. Please do not stop taking either
medication without taking to your heart doctor.
-___ take your medications as listed in discharge papers and
follow up at the listed appointments.
We wish you the best!
- Your ___ Healthcare Team
Followup Instructions:
___
|
10390732-DS-20 | 10,390,732 | 22,177,535 | DS | 20 | 2147-07-01 00:00:00 | 2147-07-01 13:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Iron / lisinopril / Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Transplant kidney hematoma
Major Surgical or Invasive Procedure:
___: Evacuation of subcapsular hematoma
___: Temporary triple lumen catheter via the left internal
jugular venous collateral approach
___: Placement of left portacath
History of Present Illness:
HPI: ___ w/ mechanical MVR/AVR, ESRD, complex dialysis access
history with bilateral UE AVGs, left fem-fem AVG, s/p DDRT
___, who presents with RLQ pain and worsening kidney function
(baseline Cr 2.2, up to 2.8 on check today). His K was note to
be
6.2. Mr ___ underwent a transplant kidney biopsy on ___ due to
proteinuria for which he had to be admitted and placed on a
heparin gtt due to his mechanical valves. Post biopsy his Cr
remained stable at 2.2 for several days until he was discharged
on ___. He states that his pain over the allograft began
suddenly today while watching the TV. He denies any trauma to
the
area. He thinks that he may have had some decreased urine output
over the last several days but this has not been recorded. He
was
given insulin/dextrose/lasix in the ED for his hyperkalemia with
repeat K of 5.6.
ROS:
(+) per HPI
(-) Denies fevers, chills, night sweats, unexplained weight
loss, changes in appetite, trouble with sleep, pruritis,
jaundice, rashes, bleeding, easy bruising, headache, dizziness,
vertigo, syncope, weakness, paresthesias, nausea, vomiting,
hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest
pain, shortness of breath, cough, edema, urinary frequency,
urgency
Past Medical History:
ESRD, HTN, dCHF, multiple line infections, restless leg
syndrome, asthma, VRE, Mitral valve endocarditis with
aortic valve annular abscess, MRSA, edema, anemia, afib, chronic
peridontitis, GERD, vitamin D deficiency, osteoporosis,
pericardial effusion w/ tamponade
PSH:
-AVR & MVR (mitral valve endocarditis w/ aortic valve annular
abscess) (___)
-pericardiocentesis (pericardial effusion w/ tamponade) ___,
___
-placement of PD catheter ___, ___
-L forearm graft excision (infected graft) ___, ___
-Removal of PD cathether (infected) ___, ___
-L femoral AV graft ___, ___
-DDRT c/b DGF ___, ___
-bilateral nephrectomies
-___ venogram left thigh AVG ballon angioplasty
-multiple UE AVG/fistulas now non-functional
-transjugular liver biopsy ___
Social History:
___
Family History:
mother with HTN
Physical Exam:
Vitals: 98.3 66 144/91 16 96%
GENERAL: Awake, mild distress from pain
HEENT: MMM
CARDS: RRR, mechanical S1/S2
PULM: CTAB, no w/r/r
ABDOMEN: RLQ allograft is swollen, tense and tender to
palpation.
No bruit. No suprapubic pain. GU exam is WNL
EXTREMITIES: 1+ edema. Multiple thrombosed AVG/AVF in the upper
arms.
NEURO: no asterixis, moving all exremities, alert and oriented
Pertinent Results:
Labs on Admission: ___
WBC-8.2 RBC-3.40* Hgb-9.1* Hct-31.6* MCV-93 MCH-26.7* MCHC-28.7*
RDW-15.6* Plt ___ PTT-46.8* ___
Glucose-189* UreaN-43* Creat-2.9* Na-138 K-5.8* Cl-110* HCO3-19*
AnGap-15
Calcium-8.6 Phos-3.7 Mg-1.7
___ HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE
___ tacroFK-10.9
.
Cardiac Perfusion Study:
1. Normal cardiac perfusion with moderate left ventricular
enlargement.
2. Normal ___ motion with an ejection fraction of 54%.
Brief Hospital Course:
___ y/o male well known to transplant service who was admitted
with pain over the transplant kidney three weeks post transplant
kidney biopsy.
Ultrasound showed a large subcapsular hematoma. He underwent
evacuation of the hematoma on ___. Surgeon was Dr. ___
___ who noted a large amount of relatively fresh appearing
hematoma upon opening the renal capsule. Also of note when the
capsule was opened there was no evidence of high pressure within
the kidney itself. Renal parenchyma was boggy, but pink and did
exhibit bleeding. Approximately 100 cc of clot was removed. He
was transferred to the ICU for further management. Heparin drip
was started following surgery. INR was subtherapeutic on
admission at 1.9
Baseline creatinine of 2.0 was increased to 2.9 that further
increased to 3.4. He also had hyperkalemia with K of 5.8 which
was initially treated with insulin, dextrose and calcium
gluconate. A temprorary dialysis line with VIP port was placed
in anticipation of need for dialysis as well as very poor access
history.
Potassium was 7.2 post op, and he underwent a single
hemodialysis session. Urine output on admisison was less than
400 cc. Urine output improved after hematoma evacuation(~1000 -
1500cc/day). Creatinine decreased from a peak of 4.3 post
operatively to 2.5 by POD 12.
On POD 2, he was having complaint of chest pain. Cardiology was
called and troponins were cycled and negative. A cardiac echo
was done showing mildly dilated and hypokinetic right ventricle
with moderate to severe tricuspid regurgitation and at least
moderate pulmonary hypertension. Well seated AVR and MVR with
elevated
gradient across the mitral valve. Mildly dilated thoracic aorta.
He then underwent a cardiac perfusion study which showed normal
cardiac perfusion with moderate left ventricular enlargement and
normal ___ motion with an ejection fraction of 54%.
He was stable and was able to transfer to the regular transplant
floor. Heparin drip and warfarin were resumed on POD 2. He
required 7 days on the heparin drip before the INR was at a
therapeutic level.
On ___, he went to the OR for a PORT placement in a small
vessel noted on chest CT. Surgeon was Dr. ___.
Interventional radiology was contacted and after premed with
steroid and benadryl prep (3 doses of 50mg of prednisone)he
underwent removal of the OR placed port and revision of the left
chest ___ Port-A-Cath, with 28 cm length of tubing terminating
in the right atrium. Also noted was distally occluded or tightly
stenosed Left internal jugular vein at junction with
rachiocephalic vein. Small contrast injection beyond this
demonstrated entral patency of the brachiocephalic vein into the
superior vena cava and right atrium. At end of case he
developed hives and shortness of breath and required emergent
treatment for anaphylaxis. He was transferred to the ICU for
management and did well eventually transferring back to the
med-surg unit.
Facial swelling and generalized edema was treated with IV doses
of Lasix then he was transitioned back to torsemide with
improved edema. He did complain of shortness of breath/cough and
was evaluated by a pulmonary consult. Repeat CXR was concerning
for worsened loculated right pleural effusion. TTE revealed
65-70%EF with moderate TR and severe systolic pulmonary
hypertension. Pulmonary Consult recommendations were to continue
diuresis as volume overload may have exacerbated severity of
pulmonary hypertension. Inhalers were continued. He was also
given 1 unit of PRBC for hct of 23 and epogen was increased to
3000units 3x per week in attempt to improve anemia. No
intervention was planned to intervene on the loculated effusion
given that he remained afebrile and wbc was wnl.
Overal edema decreased with weight dropping to 74kg by ___ on
torsemide 40mg daily. Baseline weight pre-hospitalization was
74kg.
Overall, he was feeling well and ready for discharge back to ___
___. RLQ incision staples were removed. Incision was inctact
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 12.5 mg PO BID
2. Dapsone 100 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Mycophenolate Mofetil 500 mg PO BID
5. Omeprazole 40 mg PO DAILY
6. PredniSONE 5 mg PO DAILY
7. Tiotropium Bromide 1 CAP IH DAILY
8. Torsemide 10 mg PO DAILY
9. Albuterol Inhaler 2 PUFF IH Q8H:PRN SOB
10. Alendronate Sodium 70 mg PO QSUN
11. Epoetin Alfa 3800 units SC WEEKLY
12. mometasone 220 mcg (120 doses) inhalation BID
13. Vitamin D 50,000 UNIT PO QMONTH
14. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral DAILY
15. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal congestion
16. Warfarin 7.5 mg PO DAILY16
17. Guaifenesin 5 mL PO Q6H:PRN congestion x 5 days
18. Tacrolimus 7.5 mg PO Q12H
Discharge Medications:
1. Carvedilol 12.5 mg PO BID
2. Dapsone 100 mg PO DAILY
3. Epoetin Alfa 3000 UNIT SC QMOWEFR
4. FoLIC Acid 1 mg PO DAILY
5. Mycophenolate Mofetil 500 mg PO BID
6. Omeprazole 40 mg PO DAILY
7. PredniSONE 5 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Torsemide 40 mg PO DAILY
10. Warfarin 5.5 mg PO DAILY16
11. Acetaminophen 325-650 mg PO Q6H:PRN pain
12. Albuterol Inhaler 2 PUFF IH Q8H:PRN SOB
13. Alendronate Sodium 70 mg PO QSUN
14. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral DAILY
15. Guaifenesin 5 mL PO Q6H:PRN congestion x 5 days
16. mometasone 220 mcg (120 doses) inhalation BID
17. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal congestion
18. Tacrolimus 11 mg PO Q12H
19. Vitamin D 50,000 UNIT PO QMONTH
20. Senna 8.6 mg PO BID constipation
21. Sarna Lotion 1 Appl TP BID
22. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN pain
23. Fluticasone Propionate 110mcg 2 PUFF IH BID
24. Docusate Sodium 100 mg PO BID
25. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheeze
26. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Kidney transplant subcapsular hematoma
Left IJ vein stenosis
Need for long term IV access, portacath placed
Loculated R pleural effusion
Pulmonary hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call the transplant clinic at ___ for fever >
101, chills, nausea, vomiting, diarrhea, constipation, inability
to tolerate food, fluids or medications, increased abdominal
pain, pain at the new port site, incisional redness, drainage or
bleeding, dizziness or weakness, decreased urine output or dark,
cloudy urine, swelling of abdomen or ankles, weight gain or loss
of more than 3 pounds in a day, monitor for signs of elevated
INR to include nosebleed, rectal bleeding, dark tarry stools or
easy bruising or any other concerning symptoms.
You will have labwork drawn twice weekly every ___ and
___ as arranged by the transplant clinic, with results to
the transplant clinic (Fax ___ . CBC, ___ Chem 10,
AST, T Bili, Trough Tacro level, urinalysis.
Transition to Belatacept is under discussion and will be
implemented in conjunction with the transplant clinic.
Follow your medication card, keep it updated with any dosage
changes, and always bring your card with you to any clinic or
hospital visits.
You may shower.Drink enough fluids to keep your urine light in
color.
Have your blood sugars and blood pressure checked.
Report consistently elevated values to the transplant clinic
Check your weight daily. If weight decreases 3 pounds in a day,
hold the torsemide
Do not increase, decrease, stop or start medications without
consultation with the transplant clinic at ___. There
are significant drug interactions with anti-rejection
medications which must be considered in medication management
following transplant
Consult transplant binder, and there is always someone on call
at the transplant clinic with any questions that may arise
Followup Instructions:
___
|
10390810-DS-3 | 10,390,810 | 26,871,911 | DS | 3 | 2139-05-07 00:00:00 | 2139-05-08 21:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex
Attending: ___
Chief Complaint:
Nausea/ vomiting
Major Surgical or Invasive Procedure:
Transjugular liver biopsy
History of Present Illness:
___ F with no PMH presenting as a transfer from ___ with
transaminitis and hyperbilirubinemia. Patient reports she has
had vomiting 2 hours after dinner every other day for the past
two weeks. Her sx started ___ when she ate 1.5lbs cherries
and felt lightheaded for 10 minutes afterwards. The next day she
ate fish and ___ greens and vomited. She has had vomiting
around 7:30pm qOD regardless of food ingested since then. She
never has nausea in the morning. There is no blood in her vomit,
just the food she ate. She has also had fatigue for this amount
of time and noted amber urine for about 1 week. She finally went
in yesterday because she felt she was not getting better.
The patient is a CNA who works outpatient. She denies known
biohazardous exposures. She was once told she has had hepatitis
but does not remember active disease. She most recently traveled
to the ___ in ___ but otherwise no recent foreign
travel. She also goes to ___ weekly. She takes no
medications, vitamins, or supplements. She has no sick contacts.
She denies drugs or etoh. She does smoke cigarettes and has DOE
for many years. She has not been sexually active in ___ years.
The patient also had a breast abscess in ___ for which she was
treated x 10 days with abx. She took ibuprofen for pain, has no
recent Tylenol use. She cant remember the antibiotic taken.
In the Emergency Department:
Initial Vitals: 97.7 78 111/62 19 100% RA. Also had an episode
of hypotension to 83/60 at 1000 ___
Labs: Notable for ALT: 1855 AP: 222 Tbili: 10.8 Alb: 3.6 AST:
___ INR:1.4 Plts:123. Tox screen negative
Studies: EKG QTC:___/___
Consults: None
Pt was given: 2L NS
Vitals on transfer: 98.2 70 115/45 24 97% RA
ROS: per HPI, denies fever, chills, night sweats, headache,
vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
None
Social History:
___
Family History:
Parents died of "old age" in the ___. Sister has DM.
Physical Exam:
ADMISSION EXAM:
VS: 98.4 126/89 71 18 99%RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT: normocephalic, atraumatic, + scleral icterus, PERRLA,
EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: obese, soft, non-tender, non-distended, no
organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash. Sub-cm scar on R breast at previous site of
abscess, well-healed
NEUROLOGIC: A&Ox3, No asterixis
DISCHARGE EXAM:
PHYSICAL EXAMINATION:
VS:98 99-109/53-57 ___ 18 97%RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT: normocephalic, atraumatic, + scleral icterus
NECK: Supple
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: CTAB
ABDOMEN: obese, soft, non-tender, non-distended, no
organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, No asterixis
Pertinent Results:
ADMISSION LABS:
___ 09:15AM BLOOD WBC-7.6 RBC-4.49 Hgb-13.9 Hct-40.8 MCV-91
MCH-31.0 MCHC-34.1 RDW-16.7* RDWSD-54.7* Plt ___
___ 09:15AM BLOOD WBC-7.6 RBC-4.49 Hgb-13.9 Hct-40.8 MCV-91
MCH-31.0 MCHC-34.1 RDW-16.7* RDWSD-54.7* Plt ___
___ 09:15AM BLOOD Neuts-53.1 ___ Monos-10.1 Eos-1.6
Baso-0.7 Im ___ AbsNeut-4.07 AbsLymp-2.61 AbsMono-0.77
AbsEos-0.12 AbsBaso-0.05
___ 09:15AM BLOOD ___ PTT-30.6 ___
___ 09:15AM BLOOD Glucose-86 UreaN-7 Creat-0.7 Na-140 K-4.1
Cl-105 HCO3-25 AnGap-14
___ 09:15AM BLOOD ALT-1855* ___ AlkPhos-222*
TotBili-10.8* DirBili-7.3* IndBili-3.5
___ 09:15AM BLOOD Lipase-60
___ 05:00PM BLOOD Albumin-3.3* Calcium-8.6 Phos-1.9* Mg-2.0
___ 09:15AM BLOOD HBsAg-Negative HBsAb-Positive
HBcAb-Positive* IgM HAV-Negative
___ 05:00PM BLOOD AMA-NEGATIVE Smooth-POSITIVE *
___ 05:00PM BLOOD ___
___ 05:00PM BLOOD IgG-1602* IgA-208 IgM-54
___ 06:40AM BLOOD HIV Ab-Negative
___ 09:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:15AM BLOOD HCV Ab-Negative
___ 06:22
Notable Infectious:
HERPES SIMPLEX VIRUS 1 AND 2 (IGG)
Test Result Reference
Range/Units
HSV 1 IGG TYPE SPECIFIC AB >5.00 H
HSV 2 IGG TYPE SPECIFIC AB >5.00 H
Value Interpretation
----- --------------
<0.90 Negative
0.90-1.10 Equivocal
>1.10 Positive
___ 07:20
HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY IGM
Test Result Reference
Range/Units
HSV 1 IGM SCREEN Negative Negative
HSV 2 IGM SCREEN Negative Negative
___ 17:00
LYME DISEASE ANTIBODY, IMMUNOBLOT
Test Name Flag Results Unit
Reference Value
--------- ---- ------- ----
---------------
Lyme Disease Ab, Immunoblot, S
IgG Immunoblot AB Positive kDa
Negative
IgG Band(s): p93, p66, p41, p39, p30, p18
IgM Immunoblot Negative kDa
Negative
IgM Band(s): No bands detected
___ 10:40 am TISSUE Source: Liver biopsy.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
Reported to and read back by ___ ___
___ 11:10AM.
ENTEROCOCCUS SP..
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 5:00 pm SEROLOGY/BLOOD CHEM S# ___ ADDED 06.02.
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
REACTIVE.
Reference Range: Non-Reactive.
QUANTITATIVE RPR (Final ___:
REACTIVE AT A TITER OF 1:4.
Reference Range: Non-Reactive.
TREPONEMAL ANTIBODY TEST (Final ___:
TP-PA REACTIVE.
TEST PERFORMED BY ___ LAB.
LFT TREND:
___ 09:15AM BLOOD ALT-1855* ___ AlkPhos-222*
TotBili-10.8* DirBili-7.3* IndBili-3.5
___ 06:40AM BLOOD ALT-1871* AST-2297* LD(LDH)-765*
AlkPhos-226* TotBili-14.4*
___ 05:35AM BLOOD ALT-1735* AST-2163* AlkPhos-220*
TotBili-18.5*
___ 05:40AM BLOOD ALT-1605* AST-1805* AlkPhos-217*
TotBili-19.2*
___ 06:20AM BLOOD ALT-1433* AST-1696* AlkPhos-204*
TotBili-20.6*
___ 01:29PM BLOOD ALT-1227* AST-1313* AlkPhos-202*
TotBili-21.9*
___ 05:35AM BLOOD ALT-968* AST-772* AlkPhos-219*
TotBili-23.1*
___ 06:00AM BLOOD ALT-658* AST-309* AlkPhos-226*
TotBili-19.9*
___ 12:56PM BLOOD ALT-630* AST-275* AlkPhos-226*
TotBili-20.0*
___ 05:25AM BLOOD ALT-501* AST-235* AlkPhos-249*
TotBili-16.5*
___ 05:35AM BLOOD ALT-401* AST-243* AlkPhos-217*
TotBili-14.5*
DISCHARGE LABS:
___ 05:35AM BLOOD WBC-12.5* RBC-4.06 Hgb-13.1 Hct-36.0
MCV-89 MCH-32.3* MCHC-36.4 RDW-21.4* RDWSD-65.4* Plt ___
___ 05:35AM BLOOD ___ PTT-27.9 ___
___ 05:35AM BLOOD Glucose-64* UreaN-13 Creat-0.7 Na-135
K-3.5 Cl-100 HCO3-27 AnGap-12
___ 05:35AM BLOOD ALT-401* AST-243* AlkPhos-217*
TotBili-14.5*
___ 05:35AM BLOOD Calcium-8.1* Phos-3.0 Mg-2.1
STUDIES:
Liver needle core biopsy ___:
2. Severely active hepatitis with zones of collapse amounting to
30% of the liver parenchyma.
3. Marked portal, periportal and lobular mixed inflammation
comprised of lymphocytes, focally
prominent plasma cells, neutrophils and rare eosinophils lobular
apoptotic hepatocytes.
4. Diffuse bile duct damage and proliferation.
5. No viral cytopathic effect identified.
6. Trichrome stain shows no advanced fibrosis.
7. Reticulin stain confirms areas of collapse.
8. Iron stain demonstrates no stainable iron.
9. CMV, HSV and Treponema immunostains are negative.
Note: The differential diagnosis include viral, autoimmune or
drug induced injury.
IMAGING:
Liver US ___:
IMPRESSION:
1. Contracted gallbladder, without sonographic evidence of acute
cholecystitis.
2. Probable extrarenal pelvis on the right.
___ CT Abd:
1. No intrahepatic or intra-abdominal fluid collections.
2. Heterogeneous hepatic parenchymal density may reflect
underlying steatosis or heterogenous enhancement relating to
history of acute hepatitis.
3. Subcentimeter hypodense lesions within hepatic segments V and
III are incompletely characterized on this single phase
examination, and are not seen on the recent ultrasound from ___. These are statistically likely benign, such as cysts
or biliary hamartomas, but if follow-up is desired, ultrasound
could be repeated in 6 months.
4. Intermediate-density hypodense renal lesion arising from the
upper pole of the left kidney was not included on the recent
ultrasound. This could be reassessed with a focused ultrasound
examination.
RECOMMENDATION(S): 6 month followup US to reassess liver
hypodensities. Focused ultrasound examination of the left upper
pole renal lesion to exclude solid mass; this can also be
performed at the same time as the assessment of the liver.
___ CT Chest:
1. No segmental lung consolidation or fluid collection.
2. Multiple pulmonary nodules, up to 4 mm, are statistically
likely benign but warrant follow-up chest CT in 12 months.
3. Irregular 3.0 cm hypodense left thyroid nodule warrants
dedicated thyroid ultrasound.
RECOMMENDATION(S): 1. Follow-up chest CT in 12 months.
2. Dedicated thyroid ultrasound.
Brief Hospital Course:
Ms. ___ is a ___ with no PMHx who presents with
transaminitis and hyperbilirubinemia.
#Acute hepatitis: Patient presented with ALT 1855; AP 222; Tbili
10.8; Alb 3.6; AST ___. Hepatitis antibody tests from ___ show
previous Hep A infection and immunity to Hep B from natural
infection. Denies any recent EtOH use and ALT:AST ratio not
consistent. No history of syncope or hypotension except briefly
BP to 83 systolic in ED. Tylenol level negative at ___.
___ be due to Keflex use in ___, which can cause
cholestatic jaudice, hepatitis, and transaminitis. No thrombosis
on RUQ. ___ and Anti-mitochondrial Abs negative. HBsAg negative,
Hep B Abs positive. IgG CMV positive but IgM negative.
Anti-smooth positive. Pathology significant for severely active
hepatitis with zones of collapse amounting to 30% of the liver
parenchyma. Steroids were started ___. Found to have
ENTEROCOCCUS in broth of liver bx and was prophylactically
treated with vancomycin while on IV steroids.
#Reactive RPR: per pt she has a hx of syphilis and got an
antibiotic for it. Per patient had tx in ___. Had positive
treponemal Ab. Per ___ public health department: original
titer 1:2 in ___, ___ w/ 3 doses PCN. Would not repeat
treatment unless plan for transplant
TRANSITIONAL ISSUES:
=================
- Avoid Keflex in the future
- Discharged on 2 weeks of 40 PO prednisone through ___, then
will need repeat LFTs to determine additional course
- Weekly labs
- Noted to have lung nodules on CT. Recommend repeat CT in ___
year
- Noted to have hypodensity on L kidney. Recommend outpatient
follow-up
- Noted to have two discreet hypodensities on Liver, recommend
outpatient RUQ US in 2 months.
- 30 x 17 mm hypodense nodule in the left lobe of the thyroid
warrants further evaluation with dedicated thyroid ultrasound
non urgently
#CODE: DNR, Ok to intubate
#CONTACT: ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. PredniSONE 40 mg PO DAILY
RX *prednisone [Deltasone] 20 mg 2 tablet(s) by mouth daily Disp
#*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Acute hepatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ because your liver tests were very
abnormal. You were found to have acute hepatitis, which we think
was caused by the Keflex you took, which may have triggered an
autoimmune reaction. Please avoid Keflex (cephalexin) in the
future.
Once an infectious case was excluded, you were treated with
steroids. You will need to continue steroids with close
monitoring of your liver tests as an outpatient. It would be
very dangerous to stop the steroids without consulting with your
doctor, not only because you could harm your liver but also
because stopping steroids abruptly can cause withdrawal (they
need to be tapered off).
Please continue to take your medications as prescribed and
follow up at your outpatient appointments. You will need weekly
labs while you are being monitored.
We wish you the best in your health,
Your ___ team
Followup Instructions:
___
|
10390866-DS-21 | 10,390,866 | 26,714,008 | DS | 21 | 2191-12-06 00:00:00 | 2191-12-07 11:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending: ___.
Chief Complaint:
shortness of breath and bleeding into right leg
Major Surgical or Invasive Procedure:
blood transfusion ___
History of Present Illness:
___ with history of hepatitis C, thrombocytopenia, leukopenia,
hyponatremia, prior IVDU and heavy alcohol use who presents with
SOB x 6 days. States he is now short of breath when walking a
few feet. Prior to 6 days ago he was very active, able to run up
a flight of steps. No cough, fever, chills, recent travel.
Denies any bloody/black stools, not vomiting blood. The patient
also has developed diffuse ecchymoses on both of his legs with
painful swelling of his right thigh and ankle with bilateral
lower extremity rash. He noticed this starting about 6 weeks
ago. He had the same thing a year ago which resolved on its own.
The patient attributes his leg swelling and bruising to sitting
in his car for 14 hrs a day for months on end as part of his job
as a ___. He denies any recent trauma. He saw his PCP
for this issue last month without a diagnosis. At baseline, he
denies easy bleeding or bruising. No family history of bleeding
disorders or heme malignancies that he knows of.
Of note, patient has a history of mild thrombocytopenia since
___ (120-140K), was seen by hematologist a month ago without a
denfinitive diagnosis. Since ___, plt improved to low normal
range. In addition, the patient has a history of mild
leukocytopenia since ___. His WBC counts have been in the
2.7-3.6K range, with relatively normal differential; his
eosinophil percentage is slightly elevated at 5.5-6%, however in
the setting of leukocytopenia his absolute eosinophilic count
remains well within normal range. Furthermore, review of his
labwork in ___ is also notable for macrocytic RBC indices in
recent years, however the patient has not been anemic prior to
today. He has not had any manifestations of liver failure,
coagulopathy or impaired hepatic synthetic function. A CT of the
abdomen and pelvis from ___ showed no evidence of splenomegaly
or hepatomegaly.
In the ED, initial vs were: 99.0 80 168/86 16 100% RA. Labs were
remarkable for Hct 45 -> 24, Na 122, elevated d-dimer. Guaiac
negative. CTA negative for PE, RLE doppler negative for DVT.
Vitals on Transfer: 76 142/70 16 98% RA.
On the floor, patient denies SOB while at rest, but quickly
becomes dyspneic when walking out of his room down the hall. He
reports severe pain in his right thigh.
Past Medical History:
- Obsessive compulsive disorder
- Hyperlipidemia
- Hypertension
- GERD
- Glaucoma
- Diverticulitis s/p partial colectomy
- Hyponatremia
- Thrombocytopenia
- Leukopenia
- Hepatitis C, reportedly with undetectable viral load
- Gout
- Hammertoe
Social History:
___
Family History:
There is no known family history of hemoglobinopathies, bleeding
diathesis, thrombophilias, hematologic malignancies. Mother had
an MI, father passed when patient was ___ years old. Cancer runs
in his mother's side of the family, but he is unsure of what
type, thinks related to brain.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 98.2, 144/81, 78, 16, 100% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Subumbilical
surgical scar
GU- no foley
Ext- Large hematoma circumferentially involving right thigh that
is painful to light palpation. Hematoma over lateral right
ankle. Large ecchymoses with palpable purpura and petechiae
scattered over bilateral lower extremities. 2+ DP and ___ pulse
on left foot, 1+ DP pulse on right foot. Right leg with 2+ edema
extending up to knee. Extremities are both warm and well
perfused.
DISCHARGE PHYSICAL EXAM:
Vitals- T 98 BP 132/78 HR 67 RR 67 O2 sat 100% RA
General- Alert, oriented, no acute distress.
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- Tender ecchymoses/hematoma circumferentially over proximal
right thigh with swelling, warmth and yellowish discoloration of
entire right leg. R leg flexion limited to 30 degrees. Large
ecchymosis over left posterior thigh. Petechiae over bilateral
distal ___. Dorsal pedal pulses 1+ bilaterally.
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ WBC-3.3* RBC-2.51*# Hgb-8.9*# Hct-24.7*# MCV-99*
MCH-35.3* MCHC-35.9* RDW-13.2 Plt ___
___ Neuts-61.4 ___ Monos-8.7 Eos-2.2 Baso-0.3
___ ___ PTT-27.3 ___
___ ___
___ Ret Aut-4.9*
___ Glucose-100 UreaN-10 Creat-0.9 Na-122* K-4.7 Cl-90*
HCO3-21* AnGap-16
___ ALT-29 AST-37 LD(LDH)-143 AlkPhos-59 TotBili-1.2
DirBili-0.4* IndBili-0.8
___ D-Dimer-4258*
___ calTIBC-325 VitB12-448 Folate-18.2 Hapto-245*
Ferritn-933* TRF-250
OTHER PERTINENT LABS:
___ Thrombn-12.8
___ ESR-86*
___ FacVIII-248
___ VWF AG-218 VWF ___
___ RheuFac-10 CRP-38.0*
___ C3-132 C4-17
___ HIV Ab-NEGATIVE
HCV viral load - no RNA detected
DISCHARGE LABS:
___ WBC-3.1* RBC-2.61* Hgb-9.1* Hct-25.8* MCV-99*
MCH-35.0* MCHC-35.5* RDW-14.3 Plt ___
___ Hct-27.7*
___ Cryoglb-NO CRYOGLO
Brief Hospital Course:
___ with history of HTN, HLD, GERD and hepatitis C s/p treatment
with ribavirin, prior IVDU who presents with SOB x 6 days.
# SOB: Likely secondary to symptomatic anemia. CTA negative for
PE. No clinical signs of pneumonia. No chest pain to suggest
cardiac etiology. With history of hep C, pulmonary manifestation
of cryoglobulinemia is possible but probably less likely.
Cryoglobulins pending at time of discharge. Pt was transfused 1
unit PRBC. Had symptomatic improvement in SOB and did not
require supplemental O2 at any time.
# Anemia: Hct dropped from 45 -> 24 within 2 months. Likely
secondary to blood loss into his leg, but unclear as to why
patient would have a spontaneous bleed. His coags and plt count
are normal. With concominant leukopenia and history of
thrombocytopenia, production defect from myelosuppression from
ethanol toxicity, nutrition deficiency, MDS, leukemia, viral
process (HIV, parvovirus), drug toxicity were considered.
However, elevated retic count suggests that the bone marrow is
responding and his LFTs are normal. Hematology evaluated the
patient and did not feel that this was a bone marrow or
hematologic problem. Recent ultrasound did not show splenomegaly
to support splenic sequestration. B12, folate and iron studies
do no suggest deficiency. HIV is negative. CT angiogram showed
no evidence of active bleeding.
# Rash: Purpuric and ecchymotic with scattered petechiae on
lower extremities. Not pruritic or painful. History of hep C
raised concern for mixed cryoglobulinemia or other vasculitis,
however dermatology did not feel the rash looked vasculitic and
they thought it was simply a manifestation of bleeding.
Associated ecchymoses and hematoma also is concerning for
platelet dysfunction, but plt function normal as detailed above.
Elevated ESR and CRP raise concern for rheumatologic process.
This can be further evaluated in the outpatient setting. C3 and
C4 are normal. ANCA and cryoglobulins were negative.
# Hyponatremia: Chronic, Na has been in 125-130 range since
___. Prerenal v SIADH. Chronic nature more suggestive of SIADH,
however urine electrolytes are more suggestive of potomania.
Given chronic nature, we did not attempt to aggresively correct.
# Leukopenia: WBC has been stably low since ___. Differential
is normal. Prior thrombocytopenia raised concern for chronic
smouldering myelosuppressive process such as MDS, leukemia,
ethanol toxicity, however hematology did not feel there was a
bone marrow problem. A rheumatologic problem is still a
possibility.
# H/O Hepatitis C: Reportedly undetectable viral load. Patient
has no clinical signs of hepatic decompensation. LFTs, coags,
and albumin are normal. Purpuric rash is concerning for mixed
cryoglobulinemia. HCV viral load is negative.
# HTN: Continued amlodipine and atenolol
# GERD: Continued omeprazole
- TRANSITIONAL ISSUES:
Will need re-check of CBC, electrolytes at PCP ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.25 mg PO BID:PRN anxiety
2. Amlodipine 5 mg PO DAILY
3. Atenolol 100 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. travoprost 0.004 % ___ daily
Discharge Medications:
1. ALPRAZolam 0.25 mg PO BID:PRN anxiety
2. Amlodipine 5 mg PO DAILY
3. Atenolol 100 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. travoprost 0.004 % ___ daily
Discharge Disposition:
Home
Discharge Diagnosis:
Right Lower Extremity Hematoma
Blood loss anemia
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to ___ for shortness of breath, a rash and a
hematoma in your right leg. A chest CT was obtained and was
negative for a pulmonary embolism (blood clot in your lung).
Hematology was consulted for your low white blood cell count,
history of low platelet count and spontaneous bleeding into your
right leg. They do not think this is a hematologic or bone
marrow problem. Dermatology was consulted to evaluate the rash
but they did not think a biopsy would provide additional
information.
Your work-up failed to reveal the underlying cause of bleeding.
You were transfused to treat your blood loss. A CT angiogram of
your right leg showed old evidence of bleeding but nothing
active.
Followup Instructions:
___
|
10390866-DS-22 | 10,390,866 | 21,727,001 | DS | 22 | 2195-11-16 00:00:00 | 2195-11-16 20:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending: ___
Chief Complaint:
sudden dizziness, gait unsteadiness, nausea/vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old man with history of
HTN, HLD, alcoholic hepatitis, chronic leukopenia and
thrombocytopenia, hepatitis C, gout, GERD, chronic low back pain
on Percocet who presents with several hour history of acute
onset
dizziness. History obtained from patient.
Patient reports he was in his usual state of health until 9AM
this morning. He had previously woken up at 0700 and felt in his
usual state of health. He was laying in bed watching TV when he
developed acute onset of dizziness, which came on suddenly,
"like
a switch." He describes the sensation as a lightheaded
sensation. Since onset at 0900 it has been constant, always
present at some level. It is exacerbated with head position
changes and with standing. It is associated with nausea and
vomiting; he had three episodes of vomiting at home. No
associated hearing loss, no tinnitus, no room-spinning vertigo,
no diplopia or visual changes, no focal weakness, no sensory
changes, no headache until arriving in the ED when he has a low
grade right frontal headache. He has never had this sensation
before. After it began, he was able to walk downstairs and
notes
that he felt generally unsteady. He had to hold onto the walls
and railing on the stairs very tightly, which is a change for
him.
He denies any preceding falls, denies LOC. Denies any preceding
confusion, difficulty speaking or understanding speech, chest
pain, and shortness of breath. Denies recent medication changes.
Denies recent illness. Denies fevers/chills.
Since being in the ED, vitals have been within normal limits.
After receiving Zofran his nausea has been improved.
Of note, the patient drinks 3 to 4 alcoholic beverages per day.
He tells me that he has been consistent with his alcohol use and
denies any changes in consumption. However, family pulled me
aside after completing the evaluation with concern that he may
be
drinking more than 3 to 4 beverages per day, as he seems
somewhat
tremulous this morning. He does not discuss these details with
them.
Of note, patient has a longstanding history of leukopenia and
thrombocytopenia, for which he has seen Hematology and Oncology
in the past, thought to be multifactorial including liver
disease
and underlying HCV.
Past Medical History:
HTN
HLD
GERD
Alcoholic hepatitis
Hepatitis C attributed to remote IV drug use
Chronic thrombocytopenia and leukopenia
Chronic low back pain on Percocet
History of diverticulitis
Chronic hyponatremia
Anxiety, OCD
Social History:
___
Family History:
There is no known family history of hemoglobinopathies, bleeding
diathesis, thrombophilias, hematologic malignancies. Mother had
an MI, father passed when patient was ___ years old. Cancer runs
in his mother's side of the family, but he is unsure of what
type, thinks related to brain.
Denies family history of stroke.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
===============================
Vitals: T 98.7F, BP 144/78, HR 83, RR 18, O2 100% RA
Orthostatic Vital Signs
Supine HR 68, BP 145/81
Seated HR 73, BP 129/84
Standing HR 84, BP 120/73
General: Awake, alert, in no acute distress
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: warm, well perfused; regular on telemetry
Pulmonary: breathing non labored on room air
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema
___ test negative (did not provoke nystagmus; reports
constant dizziness regardless)
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. He is irritable.
Able to relate history without difficulty. Attentive, able to
name ___ backward without difficulty. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Naming intact. No paraphasias. No dysarthria. Normal prosody.
No apraxia. No evidence of hemineglect. No left-right confusion.
Able to follow both midline and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. no skew. Head impulse test
indeterminate. Gaze conjugate. VF full to number counting. EOMI,
no nystagmus. V1-V3 without deficits to light touch bilaterally.
No facial movement asymmetry. Hearing intact to finger rub
bilaterally. Normal Rhinne and Weber test. Palate elevation
symmetric. SCM/Trapezius strength ___ bilaterally. Tongue
midline.
- Motor: Normal bulk and tone. No drift. He has bilateral
action
tremor, L>R arm, but no intention tremor.
[___]
L 5 5 5 5 ___ 5 5 5 5 5
R 5 5 5 5 ___ 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Normal cerebellar mirroring test. No
dysdiadokinesia. Normal heel to shin test. No truncal ataxia.
Good speed and intact cadence with rapid alternating movements.
- Gait: Able to stand without assistance though takes several
minutes to do so due to ongoing dizziness. Delayed initiation.
Narrow base. He is very unsteady and begins to fall when taking
steps. No sway in one direction or other. Unable to talk in
tandem. Romberg negative.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: T 98.2, BP 160s-180s/80s-90s, HR ___, RR 18, O2 97% RA
General: Awake, alert, in no acute distress
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: warm, well perfused; regular on telemetry
Pulmonary: breathing non labored on room air
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Speech is fluent
with full sentences, intact repetition, and intact verbal
comprehension. No dysarthria. No apraxia. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. no skew. Head impulse test
normal. Gaze conjugate. VF full to number counting. EOMI,
several beats nystagmus on right gaze. V1-V3 without deficits to
light touch bilaterally. No facial movement asymmetry. Hearing
intact to finger rub bilaterally. Normal Rhinne and Weber test.
Palate elevation symmetric. SCM/Trapezius strength ___
bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. He has bilateral
action tremor, R>L arm, improved from yesterday, but no
intention tremor.
[___]
L 5 5 5 5 ___ 5 5 5 5 5
R 5 5 5 5 ___ 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Right action tremor>left action tremor, improved
from yesterday. Normal cerebellar mirroring test. No
dysdiadokinesia. Normal heel to shin test.
- Gait: Able to stand and walk without assistance and without
difficulty. No sway in one direction or other. Romberg negative.
PHYSICAL EXAM:
VS: T 98.1, BP 160s-180s/80s-90s, HR 60-70s, RR 18, O2 98-100%
RA
General: Awake, alert, in no acute distress
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: warm, well perfused; regular on telemetry
Pulmonary: breathing non labored on room air
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
No dysarthria. No apraxia. No evidence of hemineglect. No
left-right confusion. Able to follow both midline and
appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. no skew. Gaze conjugate. VF
full to finger movement. EOMI, several beats nystagmus on right
gaze. V1-V3 without deficits to light touch bilaterally. No
facial movement asymmetry. Hearing intact to finger rub
bilaterally. Normal Rhinne and Weber test. Palate elevation
symmetric. SCM/Trapezius strength ___ bilaterally. Tongue
midline.
- Motor: Normal bulk and tone. No drift. He has bilateral action
tremor, R>L arm, improved from yesterday, but no intention
tremor.
[___]
L ___
R ___
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Right action tremor>left action tremor, stable
since yesterday. Normal cerebellar mirroring test. No
dysdiadokinesia. Normal heel to shin test.
- Gait: Able to stand and walk without assistance. No sway in
one direction or other. Romberg negative.
Pertinent Results:
ADMISSION LABS:
==============
___ 08:50PM %HbA1c-5.5 eAG-111
___ 04:17PM URINE HOURS-RANDOM
___ 04:17PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-POS* mthdone-NEG
___ 04:17PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:17PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-150* KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.0
LEUK-NEG
___ 04:17PM URINE RBC-3* WBC-1 BACTERIA-FEW* YEAST-NONE
EPI-0
___ 03:52PM ___ PTT-25.5 ___
___ 03:30PM GLUCOSE-164* UREA N-13 CREAT-0.7 SODIUM-134
POTASSIUM-4.3 CHLORIDE-92* TOTAL CO2-24 ANION GAP-18*
___ 03:30PM estGFR-Using this
___ 03:30PM cTropnT-<0.01
___ 03:30PM ALBUMIN-4.2 CALCIUM-9.0 PHOSPHATE-3.2
MAGNESIUM-1.1* CHOLEST-163
___ 03:30PM TRIGLYCER-92 HDL CHOL-47 CHOL/HDL-3.5
LDL(CALC)-98
___ 03:30PM WBC-3.2* RBC-3.61* HGB-12.8* HCT-34.7* MCV-96
MCH-35.5* MCHC-36.9 RDW-11.1 RDWSD-39.4
___ 03:30PM NEUTS-77.4* LYMPHS-6.9* MONOS-14.4* EOS-0.0*
BASOS-0.0 IM ___ AbsNeut-2.47 AbsLymp-0.22* AbsMono-0.46
AbsEos-0.00* AbsBaso-0.00*
___ 03:30PM PLT COUNT-129*
IMAGING:
========
___ CTA Head & Neck:
Hyperdense changes in the cerebellar vermis immediately
posterior to the
fourth ventricle most likely represents blood products. This may
represent a subacute infarct with hemorrhagic transformation or
an intracranial
hemorrhage.
Mild to moderate atherosclerotic changes, but no significant
assess stenosis by NASCET criteria.
Mild to moderate atherosclerotic changes involving the
intracranial vessels as described above. No aneurysm formation
or complete stenosis.
___ MRI Head:
1. Subacute infarct or blood products involving the cerebellar
vermis
immediately posterior to the fourth ventricle. If concern for
aneurysm,
consider CTA head.
2. Chronic right cerebellar infarcts.
3. Probable small vessel ischemic changes, as described.
4. Paranasal sinus disease and nonspecific bilateral mastoid
fluid, as
described.
___ TTE: PFO. Normal biventricular systolic function. No
pathologic valvular flow.
___ LENIs: No evidence of deep venous thrombosis in the right or
left lower extremity veins.
___ MRI/MRA Brain:
1. T2/FLAIR hyperintensity with associated blooming artifact and
mild vascularity within the cerebellar nodulus a similar to the
previous
examination. 2D time-of-flight MRA imaging demonstrates a
probable connection between this finding and the distal left
___. An occult vascular malformation such as an AVM or
cavernoma is felt most likely, and could be further evaluated by
cerebral angiography.
2. Mild associated restricted diffusion within the cerebellar
vermis in the vicinity of the lesion as described above, which
may represent underlying subacute ischemic changes.
3. Frontal lobe predominant global cerebral atrophy and evidence
of chronic microangiopathy.
4. Chronic infarctions within the right cerebellar hemisphere.
INTERVAL LABS:
==============
___ 04:35AM BLOOD VitB12-709
___ 04:35AM BLOOD TSH-0.58
___ 05:00AM BLOOD WBC-3.3* RBC-3.61* Hgb-12.7* Hct-35.5*
MCV-98 MCH-35.2* MCHC-35.8 RDW-11.3 RDWSD-40.8 Plt ___
___ 05:00AM BLOOD Glucose-77 UreaN-9 Creat-0.7 Na-133 K-3.8
Cl-89* HCO3-27 AnGap-17*
___ 05:00AM BLOOD ALT-219* AST-216* AlkPhos-84 TotBili-1.4
___ 05:00AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.4*
Brief Hospital Course:
___ year old man with history of HTN, HLD, alcoholic hepatitis,
chronic leukopenia and thrombocytopenia, hepatitis C, gout,
GERD, chronic low back pain on Percocet who presented with acute
onset dizziness and gait unsteadiness, physical exam findings of
+Romberg, bilateral action tremor and MRI findings c/w possible
subacute vermis infarct d/t vertebral artery calcifications. MRA
with findings concerning for cerebellar AVM vs cavernoma,
radiology recommending cerebral angiography.
# Subacute cerebellar infarct
# TIA
He developed acute onset dizziness and unsteadiness associated
with nausea and vomiting. He had MRI which showed subacute
infarct or blood products involving the cerebellar vermis
immediately posterior to the fourth ventricle as well as right
cerebellar infarcts. His acute onset of symptoms are not
entirely explained by a subacute infarct, but could be related
to possible TIA (artery-artery vs. cardioembolic) or component
of EtOH w/d (scoring on CIWA) vs. chronic EtOH use. TTE showed
PFO. LENIS were negative. His risk factors were assessed: A1c
5.5, LDL 98. TSH .58. For his HTN, we resumed home atenolol 100
mg daily and amlodipine 10 mg daily. We started Plavix 75 mg
daily (he had prior history of GI distress and hematoma on ASA
81 mg), but on further discussion, he would like to re-try
Aspirin 81 mg daily (and if he does not tolerate, then he will
take Plavix 75 mg in place of Aspirin 81 mg). We also started
Atorvastatin 10mg daily (low dose given chronic elevation in
LFTs). LFTs will need to be checked w/ in one week of discharge.
___ recommended home with outpatient physical therapy
services. He was counseled on smoking cessation.
#Cerebellar vermis vascular malformation c/f AVM vs Cavernoma
Abnormal GRE signal first seen on ___ MRI. Subsequently followed
up with MRA of the brain which revealed increased vascularity at
the site of the nodule, suspicious for a small AVM vs. a
Cavernoma. Radiology recommended f/u with cerebral angiography.
Discussed this with ___, who recommended outpatient
follow up. This was discussed with the patient and his family;
Neurosurgery will contact him to schedule this as an outpatient.
# ETOH Use Disorder
# ETOH Withdrawal
No history of w/d seizures, but did have alcohol hepatitis in
the past. Patient adamant he does not have a problem with EtOH.
He reports he measures out how much he drinks, to the point of
compulsion. His family expressed concerns that he does drink
more than he says. He was monitored on CIWA and did require
diazapam 10 mg x2 initially but did not score after that. He was
started on thiamine and folic acid. Recommend ongoing counseling
post-discharge. SW had seen patient inpatient.
# Tranasminitis
# Hep C
AST/ALT at recent baseline (200s), no synthetic dysfx. He was
scheduled to see Dr. ___ in ___, but there is no indication
that he actually had that appointment. Recommend follow-up as
outpatient.
# Chronic back pain
Continued home regimen of oxycodone.
# Chronic pancytopenia
Prior eval by hematology and felt to be related to chronic EtOH.
His labs were within normal. Recommend EtOH cessation and
continued follow-up with heme-onc.
TRANSITIONAL ISSUES:
====================
# MEDICATIONS: Please see discharge medications.
[] Please continue to trend blood pressure, goal normotensive.
[] Please follow-up CBC (chronic pancytopenia). recommend f/u
with heme.
[] Recommend f/u with liver given hepatitis C.
[] Please follow-up LFTs given stable transaminitis and starting
atorvastatin 10 mg.
[] Please refer to social work if patient desires for ongoing
alcohol cessation.
[] Neurosurgery will contact him to arrange for outpatient
cerebral angiography.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. amLODIPine 10 mg PO DAILY
4. ALPRAZolam 0.25 mg PO BID:PRN Anxiety, insomnia
5. OxyCODONE--Acetaminophen (5mg-325mg) 2 TAB PO Q8H:PRN Pain -
Moderate
Discharge Medications:
1. Atorvastatin 10 mg PO QPM
2. Clopidogrel 75 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Thiamine 100 mg PO DAILY
6. ALPRAZolam 0.25 mg PO BID:PRN Anxiety, insomnia
7. amLODIPine 10 mg PO DAILY
8. Atenolol 100 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. OxyCODONE--Acetaminophen (5mg-325mg) 2 TAB PO Q8H:PRN Pain
- Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Subacute cerebellar infarct
Transient Ischemic Attack
Cerebellar AVM
Alcohol withdrawal
Patent foramen ovale
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of dizziness and
difficulty walking. This was likely caused by a TIA (Transient
Ischemic Attack), which is considered a warning. Your brain
imaging did not reveal an acute stroke, but did show that you
have had prior strokes. Strokes are a condition where a blood
vessel providing oxygen and nutrients to the brain is blocked by
a clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
*High blood pressure
*High Cholesterol
*Alcohol use
*Tobacco use
We imaged your brain as part of your stroke work-up and
incidentally, we found that some of the blood vessels in part of
your brain may have a unique shape ("vascular malformation").
We recommend that you follow up with neuroradiology. We do not
think that the symptoms that you presented with were caused by
this finding.
Your Medications have been changed as follows:
START Atorvastatin 10 mg qHS. This may affect your liver levels
and you can follow up with your pcp about this
START Aspirin 81 mg daily. If you are unable to tolerate
aspirin, you can start Plavix 75 mg instead.
Please take your other medications as prescribed. Please see
discharge medication list for details.
Please follow up with Neurosurgery as well as with Neurology and
your primary care physician as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10390866-DS-23 | 10,390,866 | 21,475,379 | DS | 23 | 2196-09-19 00:00:00 | 2196-09-19 18:04:00 |
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, Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with history of CVA, HTN, HLD,
alcoholic hepatitis, chronic leukopenia and thrombocytopenia,
hepatitis C, gout, GERD, chronic low back pain who presents with
syncopal episode and right facial droop.
Patient states that he has been working non stop for the past 2
days and has essentially not been eating, only drinking "a few
beers." He went home today after working and went to urinate. He
began feeling light-headed, lowered himself to the ground, and
lost consciousness. He thinks he came to within seconds, and he
felt dizzy. He did strike his head. His wife saw him and felt he
had a facial droop, so she encouraged him to come to the ED.
He denies cp, sob, n/v. Denies recent illnesses. Denies history
of alcohol withdrawal. He states he drinks "a few drinks per
day"
and says he has done this for his whole life.
Of note, the patient had a recent hospitalization in ___ for
dizziness and gait unsteadiness and was found to have a subacute
infarct vs AVM vs cavernoma in the cerebellar vermis as well as
right cerebellar infarcts. Given the severity of his symptoms,
he
was also thought to have TIA with potentially a component of
alcohol withdrawal/chronic alcohol use. TTE showed a PFO at that
time.
In the ED, initial VS were:
97.2 71 117/74 18 100% RA
Exam notable for:
unsteady and lightheaded during gait testing. NIHSS 0.
ECG:
Labs showed:
122 | 84 | 9
--------------<141
4.3 | 21 | 0.8
WBC 1.5, hgb 11.3 (MCV 100), plt 59
coags WNL
ALT 136, AST 255, tbili 1.0, ALP 117
trop <0.01, BNP 294
Lactate 1.8
Serum ETOH: 11
serum ASA, acetaminophen, TCA negative
Utox negative
Ucr 15, UNa 76, Uosm 206
UA negative
Imaging showed:
CT C spine without contrast: No cervical spine fracture or
malalignment.
CT Head without contrast:
No acute intracranial process. No acute hemorrhage.
CXR
No acute cardiopulmonary process.
Patient received:
IVFNS 1000 mL
IVMetoclopramide 10 mg
Positive orthostatic VS
Transfer VS were:
67 108/67 12 100% RA
On arrival to the floor, patient reports feeling weak and
light-headed. He has no other complaints.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
HTN
HLD
GERD
Alcoholic hepatitis
Hepatitis C attributed to remote IV drug use
Chronic thrombocytopenia and leukopenia
Chronic low back pain on Percocet
History of diverticulitis
Chronic hyponatremia
Anxiety, OCD
Social History:
___
Family History:
There is no known family history of hemoglobinopathies, bleeding
diathesis, thrombophilias, hematologic malignancies. Mother had
an MI, father passed when patient was ___ years old. Cancer runs
in his mother's side of the family, but he is unsure of what
type, thinks related to brain.
Denies family history of stroke.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
GENERAL: NAD
HEENT: EOMI, PERRL, anicteric sclera, dry MM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Nondistended, nontender in all quadrants, no
rebound/guarding. Refuses deep palpation.
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose, no facial
droop. CN II-XII grossly intact.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=======================
VS: 98.3 PO 162 / 86 93 18 99 Ra
GENERAL: thin older gentleman, no acute distress, conversant
HEENT: EOMI, PERRL, anicteric sclera, dry MM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Nondistended, nontender in all quadrants, no
rebound/guarding.
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, CN2-12 intact, moving all four extremitis
Pertinent Results:
ADMISSION LABS
==============
___ 08:25PM BLOOD WBC-1.5* RBC-3.09* Hgb-11.3* Hct-30.9*
MCV-100* MCH-36.6* MCHC-36.6 RDW-12.7 RDWSD-46.5* Plt Ct-59*
___ 08:25PM BLOOD Neuts-70.0 Lymphs-15.0* Monos-12.4
Eos-1.3 Baso-0.0 Im ___ AbsNeut-1.07* AbsLymp-0.23*
AbsMono-0.19* AbsEos-0.02* AbsBaso-0.00*
___ 08:25PM BLOOD ___ PTT-26.3 ___
___ 08:25PM BLOOD Plt Smr-VERY LOW* Plt Ct-59*
___ 08:25PM BLOOD Glucose-141* UreaN-9 Creat-0.8 Na-122*
K-4.3 Cl-84* HCO3-21* AnGap-17
___ 08:25PM BLOOD ALT-136* AST-255* AlkPhos-117 TotBili-1.0
___ 08:25PM BLOOD cTropnT-<0.01
___ 08:25PM BLOOD proBNP-294*
___ 08:25PM BLOOD Albumin-4.0 Calcium-9.3 Phos-3.2
___ 08:25PM BLOOD ASA-NEG Ethanol-11* Acetmnp-NEG
Tricycl-NEG
___ 09:52PM BLOOD Lactate-1.8
IMAGING
=======
CXR ___
IMPRESSION:
No acute cardiopulmonary process.
CT Head ___
FINDINGS:
Hyperdensity on prior CT centered at the cerebellar vermis is
not seen on the
current exam. There is no acute intra-axial or extra-axial
hemorrhage, mass
effect, midline shift, or acute major vascular territorial
infarct.
Hypodensity in the right thalamus is likely from a prior lacunar
infarct.
Ventricles and sulci are prominent compatible with global volume
loss. Dense
atherosclerotic calcifications are noted within the intracranial
ICAs and
vertebral arteries
Included paranasal sinuses and mastoids are clear. Skull and
extracranial soft
tissues are unremarkable. Chronic deformity of the left lamina
papyracea may
be from remote prior trauma.
IMPRESSION:
No acute intracranial process. No acute hemorrhage.
CT C Spine ___
FINDINGS:
Alignment is normal. No fractures are identified.Degenerative
changes are
most notable at C5-6 with intervertebral disc height loss and
uncovertebral
joint hypertrophy. There is secondary moderate right foraminal
narrowing at
this level. No significant canal narrowing. Apparent widening
of the
intervertebral disc anteriorly at C6-7 is unchanged from prior
CTA neck.There
is no prevertebral edema.
The thyroid and included lung apices are unremarkable. Dense
atherosclerotic
calcifications noted at the carotid bulbs.
IMPRESSION:
No cervical spine fracture or malalignment.
DISCHARGE LABS
===============
___ 08:35AM BLOOD WBC-4.0 RBC-3.04* Hgb-10.9* Hct-30.6*
MCV-101* MCH-35.9* MCHC-35.6 RDW-12.6 RDWSD-46.5* Plt Ct-61*
___ 05:25AM BLOOD Neuts-70.8 Lymphs-14.6* Monos-12.0
Eos-0.5* Baso-0.5 Im ___ AbsNeut-1.36* AbsLymp-0.28*
AbsMono-0.23 AbsEos-0.01* AbsBaso-0.01
___ 06:15AM BLOOD ___ PTT-26.3 ___
___ 08:35AM BLOOD Glucose-148* UreaN-9 Creat-0.8 Na-125*
K-3.0* Cl-86* HCO3-23 AnGap-16
___ 06:15AM BLOOD ALT-119* AST-207* LD(LDH)-188 AlkPhos-111
TotBili-1.4
___ 08:35AM BLOOD Calcium-8.6 Phos-2.4* Mg-1.1*
Brief Hospital Course:
SUMMARY STATEMENT
===================
Mr. ___ is a ___ year old man with history of CVA, alcohol
use disorder, hepatitis c, chronic pancytopenia who presented
with a syncopal episode at home. Problems addressed during his
hospitalization are as follows:
ACUTE ISSUES:
===============
#Syncope:
Patient presented after a fall at home. He was sitting on his
couch drinking beer, got up to use restroom, began urinating,
then fell and hit the left side of his head. No prodromal
symptoms. There was concern for a facial droop when he was in
the ED after a physician asked his wife whether he had a facial
droop and she reported "maybe". He had no neurologic deficits,
CT spine/head unremarkable. Orthostatics positive. Etiology most
likely orthostatic/micturition syncope. Likely hypovolemic from
working outdoors for long periods of time coupled with poor PO
intake. Also used diazepam prior to his fall prescribed for back
pain. This, in conjunction with alcohol use also contributory.
His home alprazolam was held. He was evaluated by neurology who
agreed this was unlikely stroke or seizure and more consistent
with micturition/orthostatic syncope . He did not get additional
neurologic workup. There was a low suspicion for cardiogenic
etiology, as previous TTE without valvular disease, telemetry
unremarkable. On discharge, he did have small degree of ongoing
orthostasis but was no longer symptomatic and blood pressure
~130s upon standing, so felt it was safe to discharge with plans
for outpatient follow up with PCP and consideration of further
testing.
#Pancytopenia:
Presented with WBC to 1.5 (ANC 1.07k), previously lowest of 2.7.
Thrombocytopenia to ___, previously lowest of 98. Given chronic
alcohol use, as well as associated transaminitis with AST/ALT of
2:1, suspect alcohol use is primary driver of pancytopenia. No
evidence of splenomegaly on ultrasound to suggest sequestration.
No obvious drug contributions or liver synthetic dysfunction.
Viral studies including HIV and Hep C viral load negative.
Hemolysis labs negative. Needs to have outpatient follow up.
#ETOH Use Disorder:
No history of withdrawal seizures, but daily drinker, reporting
___ beers per day, however suspect he drinks more than he states
after discussions with family. ETOH serum tox mildly elevated on
admission, briefly placed on CIWA scoring up to 3, not requiring
diazepam, no additional evidence of withdrawal. Seen by social
work team and appeared to be in pre-contemplative stage. Refused
resources to aid in alcohol cessation. Initiated thiamine, folic
acid, multivitamin supplementation.
#Hyponatremia:
Most likely hypovolemic hyponatremia. Presented with Na 122. Of
note, he is chronically hyponatremic, Na 122-130 range since
approximately ___. His sodium returned to baseline after
receiving IV fluids.
#Cerebellar stroke/AVM:
No evidence of stroke and evaluated by neurology as above in
#syncope. Continued aspirin and atorvastatin.
#Chronic back pain
Oxycodone PRN.
#Malnutrition (severity unknown):
Reports approximately 20 lb weight loss over the last year
secondary to poor appetite. Seen by nutrition. Refused PO
supplements. Encouraged to eat 3 meals per day.
#Tranasminitis
#Hep C
Patient was planned to follow up with Dr. ___ further
management of hepatitis C but patient never went to appointment.
Repeat Hep C viral load negative. Transaminase elevation likely
also due to alcohol use, evidenced by 2:1 AST/ALT ratio.
#Hypertension:
Held amlodipine, atenolol in setting of orthostatics as above.
#insomnia:
Discontinued alprazolam in setting of syncope as above.
#GERD:
Continued omeprazole
TRANSITIONAL ISSUES:
===================
[] consider outpatient referral for autonomic testing. Consider
initiating salt tabs or midodrine if ongoing orthostasis
[] ongoing alcohol cessation counseling
[] needs further outpatient workup of pancytopenia
[] needs outpatient follow up for chronic back pain. Provided a
short script of oxycodone
[] discharge weight: 62.78 kg (138.4 lb)
[] please check CBC, BMP at next PCP ___
[] consider holding aspirin if thrombocytopenia worsens
[] remained normotensive off amlodipine and atenolol, consider
discontinuing indefinitely
[] held alprazolam, would avoid prescribing any sedative
medications given daily alcohol use and syncope
[] consider salt tablets for chronic hyponatremia
[] continue to monitor weight loss
[] continue to encourage alcohol cessation
>30 minutes spent coordinating discharge home
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 10 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Thiamine 100 mg PO DAILY
7. ALPRAZolam 0.25 mg PO BID:PRN Anxiety, insomnia
8. Atorvastatin 10 mg PO QPM
9. Aspirin 81 mg PO DAILY
Discharge Medications:
1. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe
may cause sedation. Avoid driving
RX *oxycodone 5 mg 1 tablet(s) by mouth Q8H:PRN Disp #*15 Tablet
Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. FoLIC Acid 1 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#syncope
#hyponatremia
#pancytopenia
#etoh use disorder
#Cerebellar stroke/AVM
#chronic back pain
#malnutrition (severity unknown)
#transaminitis
#HTN
#GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at the ___
___.
WHY DID I COME TO THE HOSPITAL?
--You came to the hospital because you fell at home and hit your
head.
WHAT HAPPENED WHEN I WAS IN THE HOSPITAL?
--We evaluated you and found that you did not have a stroke. You
also did not have any damage to your brain or skull.
--Your blood pressure became low with standing. We gave you lots
of fluids and stopped some of your home medications including
alprazolam, which can make you more likely to fall. We believe
you likely fell because you were dehydrated and also because you
used a medication that makes you very tired when used with
alcohol ("diazepam" which you took for back pain).
--The level of salt in your body was low. We believe this was
from dehydration. Your salt levels improved with fluids.
--Your blood counts were low. We believe this is related to your
alcohol use.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
--Please continue to take your medications as prescribed and
follow-up with your doctors as ___.
We wish you all the ___!
Your ___ care team
Followup Instructions:
___
|
10390877-DS-2 | 10,390,877 | 28,589,927 | DS | 2 | 2143-04-19 00:00:00 | 2143-04-19 14:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right sided weakness and difficulty speaking
Major Surgical or Invasive Procedure:
___ placed, but removed prior to discharge.
History of Present Illness:
___ is a ___ year old man with history of MI, HTN, HL,
multiple prior CVAs thought to be cardioembolic on Coumadin, who
presents with right sided weakness and aphasia.
History is limited as patient is unable to answer questions. Of
note, he gets most of his care including admissions for prior
CVAs at ___. According to the family members, ___ was
otherwise in his usual state of health until 9PM the evening
prior to presentation. This morning around ___, his wife found
him lying in bed, staring up and not able to speak, as well as
right sided facial droop and weakness. He was emergently taken
to
___, where the initial NIHSS was 15. He did not receive
tPA due to being outside the window, on Coumadin with
therapeutic
INR. ___ showed chronic right MCA territory infarct, no
hemorrhage, and no acute findings. INR was 2.82.
Past Medical History:
MI, GI BLEED/DUODENAL ULCER, Hyperlipidemia, Hypertension, CVAs,
triple AAA repair, prior cardiac arrest
Social History:
___
Family History:
MVI
omeprazole 20mg PO
Simvastatin 40mg qHS
ASA ___
Metoprolol 50mg daily
HCTZ 25mg daily
Coumadin 2.5mg PO daily
Physical Exam:
Discharge Physical Exam:
Vitals:
Temp: 97.5-98.5
HR: ___
BP: 117-138/70-87.
RR: ___
O2 sats: 93-97%
Neurologic Examination:
- Mental status: Sitting up in bed, eating, in good spirits.
Cracks jokes. Dysarthric, but improving. Dobhoff tube removed.
- Cranial Nerves: Pupils are equal and reactive. EOMI without
nystagmus. Right hemianopia on BTT. Right facial droop.
- Sensorimotor: left arm/leg, right leg are full strength.
Right
arm able to offer some resistance to antigravity. Tricep 4-.
Bicep 4+. Wrist extensor 2. Finger extensor 1. Nods to tactile
stimulation.
- Coordination: No dysmetria on left, unable to test on right.
HTS intact.
- Gait: deferred
Admission Physical Exam:
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Eyes open, alert, tracks examiner. Effortful
but
able to produce name, very dysarthric. Unable to repeat or name
objects. Follows commands.
- Cranial Nerves: Pupils are equal and reactive. EOMI without
nystagmus. Right hemianopia on BTT. Right facial droop. Tongue
protrudes to left.
- Sensorimotor: left arm/leg, right leg are full strength.
Right
arm able to offer some resistance to antigravity. Tricep 4-.
Bicep 4+. Wrist extensor 2. Finger extensor 1. Nods to tactile
stimulation.
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response mute bilaterally
- Coordination: No dysmetria on left, unable to test on right.
HTS intact.
- Gait: deferred
Pertinent Results:
___ 02:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:30PM BLOOD TSH-0.62
___ 09:30PM BLOOD Triglyc-221* HDL-31 CHOL/HD-4.1
LDLcalc-53
___ 09:30PM BLOOD %HbA1c-6.6* eAG-143*
___ 09:30PM BLOOD Albumin-3.7 Calcium-8.4 Mg-2.0
Cholest-128
___ 02:40PM BLOOD cTropnT-<0.01
___ 09:30PM BLOOD CK-MB-2 cTropnT-<0.01
___ 02:40PM BLOOD ALT-24 AST-37 AlkPhos-60 TotBili-0.6
___ 02:40PM BLOOD Glucose-99 UreaN-15 Creat-1.4* Na-142
K-5.1 Cl-108 HCO3-22 AnGap-17
___ 02:40PM BLOOD WBC-8.2 RBC-5.17 Hgb-11.4* Hct-38.7*
MCV-75* MCH-22.1* MCHC-29.5* RDW-20.1* RDWSD-51.4* Plt ___
___ 02:40PM BLOOD Neuts-57.8 ___ Monos-13.1*
Eos-5.5 Baso-0.7 Im ___ AbsNeut-4.76 AbsLymp-1.88
AbsMono-1.08* AbsEos-0.45 AbsBaso-0.06
MRI on ___:
1. Acute to late sub-acute infarction in the distribution of the
left MCA and PCA territories. Findings may be embolic in origin.
2. No evidence of intracranial hemorrhage. Multiple chronic
infarctions as described above.
3. Diminutive flow voids of the left M2 segments of the middle
cerebral
artery. Please refer to recently performed CTA report for
additional details.
Brief Hospital Course:
___ is a ___ year old man with history of MI, HTN, HLD,
multiple prior CVAs thought to be cardioembolic on Coumadin, who
presented with right sided weakness and difficulty speaking.
Exam notable for
right hemianopia, right facial droop, pseudobulbar palsy with
dysarthria --- right arm > leg weakness. Taken together, likely
superior division left MCA syndrome. He was out of the window
for both tPA and endovascular intervention. Given that he was
therapeutic on warfarin, one could suspect failure of Coumadin
vs artery to artery embolism. He also was found to have heart
failure and a dyskinetic cardiac apex on echo, which could be a
source of clot, even while on warfarin. Another likely etiology,
based on the appearance of the strokes on MRI, is watershed. He
could have had an embolism in the left ICA that then broke off
to other vessels, causing a combined watershed + embolic stroke
syndrome.
Echo: Suboptimal image quality. Mild symmetric left ventricular
hypertrophy with global systolic dysfunction c/w multivessel CAD
or other diffuse process. Dialted ascending aorta. No definite
structural cardiac source of embolism identified.
Carotid ultrasounds showed: on the left moderate plaque with a
40-59% carotid stenosis. On the right there is a less than 40%
stenosis.
Mr. ___ biggest issue during his hospitalization was his
ability to swallow. On ___, he had a dobhoff tube placed, which
he tolerated well, and received formula feeds through for
several days. On ___, he had a video swallow study performed,
and was allowed to begin taking a modified dysphagia diet.
His dobhoff ___ tube was removed on ___, and he was
able to eat his modified diet all by mouth prior to discharge.
Nutrition was consulted, and agreed with plans for all oral
feeds moving forward.
Because Mr. ___ had a stroke even on warfarin, we discussed
with hematology the possibility of hyper coagulability. It was
decided to change him to apixaban 5mg BID on ___ & to
follow-up with hematology as an outpatient to discuss workup for
a hyper-coagulable state, since he had a stroke even though he
was therapeutic on warfarin.
============================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 53) - () 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? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
() 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 - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 2.5 mg PO DAILY16
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Simvastatin 40 mg PO QPM
4. Centrum (multivit-iron-min-folic
acid;<br>multivit-mins-ferrous gluconat) 3,500-18-0.4 unit-mg-mg
oral DAILY
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Metoprolol Succinate XL 25 mg PO DAILY
Take half of your original dose, take 12.5mg daily, and follow
your blood pressures.
3. Aspirin 81 mg PO DAILY
4. Centrum (multivit-iron-min-folic
acid;<br>multivit-mins-ferrous gluconat) 3,500-18-0.4 unit-mg-mg
oral DAILY
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Simvastatin 40 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
___)
Discharge Diagnosis:
Acute ischemic stroke.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of right-sided weakness
and difficulty talking 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:
- Prior strokes
- Heart disease
- Diabetes
- Hypertension
We are changing your medications as follows:
- Replacing warfarin with apixaban.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10391232-DS-14 | 10,391,232 | 21,818,897 | DS | 14 | 2165-11-25 00:00:00 | 2165-11-25 20:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left fistula swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o male with history of Hep C, HTN, HLD, ESRD on dialysis
maturing fistula in left arm, who presented from dialysis with
hematoma over fistula.
He currently gets dialysis through right upper chest tunneled
catheter. His fistula was placed on ___. He started regular
exercise on ___ and since then has had progressive swelling
over the fistula with tightness and moderate pain. Stopped
dialysis hour and a half early today.
In the ED, initial vitals were: 97.8 70 124/75 18 99% RA
Exam notable for thrill and bruit over the left arm fistula.
Minimal swelling overlying on the medial side. No overlying
erythema. Pulses intact distally
Imaging notable for 7.9 cm complex multiloculated fluid
collection adjacent to the left upper extremity fistula
compatible with a hematoma.
Transplant surgery was consulted and recommended: no need for
surgical intervention, admission to medicine
Patient was not given anything in the ED
On the floor, initial vitals were 97.8 134/77 77 18 96 RA.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
ESRD on TThS HD
HCV, untreated - diagnosed recently
HTN
HLD
Social History:
___
Family History:
Mother passed away from cancer in her ___ but spent time HD
Father alive, has diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: 97.8 134/77 77 18 96 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. L fistula with bruit and palpable thrill
Neuro: CNII-XII grossly intact
Access: tunneled HD line, peripherals
DISCHARGE PHYSICAL EXAM
=======================
VITALS: 97.2 | 126/74 | 67 | 18 | 95%ra
GENERAL: Well-appearing, no acute distress, alert and oriented.
HEENT: Sclera anicteric, MMM, oropharynx clear, no appreciable
lymphadenopathy
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. Palpable left radial and ulnar pulses.
LUNGS: Clear to auscultation bilaterally without wheezes, rales,
rhonchi
ABDOMEN: Soft, non-tender, non-distended. +Bowel sounds present.
Small (<3cm) reducible umbilical hernia with superior
semicircular scar. No organomegaly appreciated. No rebound or
guarding.
GU: No foley, otherwise deferred
EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema. L fistula with bruit and palpable thrill.
Incision healed, but soft 6-8cm hematoma. Otherwise warm with
brisk capillary refill, normal motor exam. Upper extremity
strength exam intact ___ shoulder abduction, elbow
flexion/extension, wrist flexion/extension, grip strength). Some
numbness to light palpation of medial distribution.
NEURO: Face grossly symmetric, moving all limbs with purpose
against gravity.
Pertinent Results:
ADMISSION LABS
==============
___ 09:00PM BLOOD WBC-3.4* RBC-3.51* Hgb-10.7* Hct-31.8*
MCV-91 MCH-30.5 MCHC-33.6 RDW-13.5 RDWSD-43.3 Plt ___
___ 09:00PM BLOOD Glucose-84 UreaN-36* Creat-11.5* Na-139
K-4.7 Cl-97 HCO3-29 AnGap-18
DISCHARGE LABS
===============
___ 07:10AM BLOOD WBC-3.7* RBC-3.58* Hgb-10.8* Hct-32.5*
MCV-91 MCH-30.2 MCHC-33.2 RDW-13.2 RDWSD-42.8 Plt ___
___ 07:10AM BLOOD ___ PTT-31.2 ___
___ 07:10AM BLOOD Glucose-79 UreaN-43* Creat-12.0* Na-137
K-5.1 Cl-95* HCO3-26 AnGap-21*
IMAGING
========
___ ULTRASOUND UPPER EXTREMITY
FINDINGS: Targeted grayscale and color Doppler ultrasound
images were obtained of the patient's symptomatic site along the
left upper extremity fistula. There is a complex multiloculated
fluid collection lateral to the left upper extremity fistula.
This measures 7.9 x 1.7 x 5.8 cm. This is approximately 0.5 cm
deep to the skin. No internal vascularity is noted within this
collection on color Doppler imaging. Normal color wall to wall
flow is noted in the partially imaged portions of the left upper
extremity fistula.
IMPRESSION: 7.9 cm complex multiloculated fluid collection
adjacent to the left upper extremity fistula compatible with a
hematoma.
Brief Hospital Course:
___ y/o male with history of Hep C, HTN, HLD, ESRD ___ ?FSGS vs.
HTN) on dialysis via tunneled right chest catheter with maturing
fistula in left arm, who presented from dialysis with new
swelling beneath fistula.
#FISTULA HEMATOMA: Evaluated by transplant surgery in the ED.
Imaging and exam consistent with hematoma. Felt to be no need
for acute intervention. No flow through fluid collection.
Currently dialyzed through tunneled line. Will be seen by Dr.
___ on ___ when she rotates through ___ and there is a
plan in the next few months for superficialization of the
fistula, which is currently too deep to use in dialysis.
#UMBILICAL HERNIA: Reportedly repaired at ___ in
___ on ___. Patient reports intermittent discomfort
from it, sometimes while stooling, sometimes while standing,
sometimes at rest. The hernia is <3cm, reducible, and the
patient tolerates POs well and is having normal bowel movements.
No evidence of infection, incarceration.
#ESRD on HD: Per prison nursing provider, records state this is
from hypertension. TThS HD. Missed part of most recent HD
session, no urgent need for HD while in-house given stable
electrolytes per nephrology and he will resume usual schedule at
discharge. Continued calcitriol, sevelamer.
#HTN: Continued home amlodipine, atenolol.
#ANEMIA: Normocytic, likely secondary to ESRD. On epogen, IV
iron as an outpatient
#HCV: Untreated; reportedly a recent diagnosis due to prison
tattoo. No known viral load or genotype available, but these
should be assessed in the outpatient setting.
# CODE: Full code presumed
# CONTACT: ___ ___
TRANSITIONAL ISSUES
===================
- FISTULA: Patient should be seen by Dr. ___ at ___ on ___
for follow up of fistula. Dr. ___. As previously
established, the fistula will likely require a revision
unrelated to the current hematoma, and this should be
coordinated between Dr. ___ nephrology, and Mr. ___
general practitioner team.
- HERNIA: Umbilical hernia, reportedly repaired ___ at ___
___ in ___ with other procedures, causing patient some
discomfort. Reducible, and patient still eating well and passing
flatus. No intervention needed at this time. Recommend
intermittent monitoring.
- HCV: Consider viral load and genotyping in outpatient setting.
- HYPERTENSION: Consider switch to labetalol from atenolol as
the latter is renally cleared.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Calcitriol 0.25 mcg PO DAILY
5. Ferric Gluconate 125 mg IV 1X/WEEK (WE)
6. sevelamer CARBONATE 1600 mg PO TID W/MEALS
7. Nephro-Vite (B complex-vitamin C-folic acid) 0.8 mg oral
DAILY
8. Vitamin D ___ UNIT PO ONCE A MONTH
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Calcitriol 0.25 mcg PO DAILY
5. Ferric Gluconate 125 mg IV 1X/WEEK (WE)
6. Nephro-Vite (B complex-vitamin C-folic acid) 0.8 mg oral
DAILY
7. sevelamer CARBONATE 1600 mg PO TID W/MEALS
8. Vitamin D ___ UNIT PO ONCE A MONTH
Discharge Disposition:
Extended Care
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
LEFT FISTULA HEMATOMA
SMALL REDUCIBLE UMBILICAL HERNIA
SECONDARY DIAGNOSES
===================
HCV
HYPERTENSION
HYPERLIPIDEMIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
WHY WAS I IN THE HOSPIAL?
*You were admitted because of swelling over fistula
WHAT HAPPENED IN THE HOSPITAL?
*An ultrasound revealed the swelling to be a hematoma (blood
collection)
*Transplant surgery saw you and determined that it was not safe
or necessary to drain the collection at this time.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
*Keep your left arm elevated above the level of your heart
whenever possible. This will help the swelling.
*Take Tylenol for pain.
*Tell your doctor if you have worsening weakness or numbness in
your hand
*Tell your doctor if you have vomiting or worsening abdominal
pain, or if the hernia in your abdomen cannot be pushed back in
anymore.
We wish you the best!
-Your care team at ___
Followup Instructions:
___
|
10391698-DS-13 | 10,391,698 | 25,190,401 | DS | 13 | 2120-10-03 00:00:00 | 2120-10-04 07:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Augmentin / Omnicef
Attending: ___.
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with T1DM on an insulin pump p/w hyperglycemia, nausea, and
vomiting for 10 hours. Her insulin pump ran out of insulin
overnight because she accidentally had a vial with less insulin
than usual and was unable to obtain a refill from the pharmacy
in
the evening. She woke up this morning feeling poorly and has
been
nauseous and vomiting since. She has had about 5 episodes of
NBNB
vomiting since onset. Prior to this morning, she was feeling in
her usual state of good health. No fevers or chills. No
abdominal
pain or diarrhea. No CP/SOB, no dysuria. She tested her ketones
at home, which were positive, prompting her visit to the
emergency department.
Of note, patient recently moved to ___ from ___ for
school and so she has not yet established a PCP or
endocrinologist. She does not know her insulin pump settings at
the moment.
In the ED,
- Initial Vitals: 98.0, 128, 114/50, 20 99%RA
- Exam: Generally uncomfortable appearing, otherwise
unremarkable
- Labs:
CBC: 21 > 13.1/42.1 < 288
BMP: 132/6.8/100/___/1.0 <449 AG 25
LA 3.7
VBG: ___ --> ___ LA 1.7
UA: +ketones, +1000 gluc
- Imaging: CXR wnl
- Consults: None
- Interventions: 4L LR + ___ @250cc/hr, insulin gtt, Mg 4g,
Zofran
Past Medical History:
DM1 on insulin pump
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
Admission exam:
================
VS: 98.9, 114, 128/66, 27, 99%
Gen: NAD
HEENT: NCAT, PERRL, EOMI
Resp: CTA B/L
CV: Regular tachycardia, +S1/S2, no m/r/g, no JVD, no pedal
edema, 2+ distal upper extremity and lower extremity pulses.
Capillary refill <2 sec.
Abd: Soft, Nontender, Nondistended, no rigidity or guarding
MSK: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry, No petechiae
Neuro: Alert and following commands, moving all extremities
spontaneously, sensation intact to light touch, speech fluent
Psych: Normal mood/mentation
.
.
Discharge exam:
===============
NAD
MMM, OP clear
RR, no m/r/g
CTAB
Abd soft, NT, BS+
No joint swelling/erythema/tenderness
No large rashes or skin lesions
Awake, alert, conversant w/ clear speech, stable gait
Calm, cooperative, pleasant
Pertinent Results:
Admission labs:
===============
___ 04:20PM BLOOD Glucose-454* Lactate-3.9*
___ 05:02PM BLOOD ___ pO2-74* pCO2-29* pH-7.05*
calTCO2-9* Base XS--21
___ 04:42PM BLOOD WBC-21.0* RBC-4.60 Hgb-13.1 Hct-42.1
MCV-92 MCH-28.5 MCHC-31.1* RDW-12.4 RDWSD-41.0 Plt ___
___ 04:42PM BLOOD Neuts-89.9* Lymphs-5.5* Monos-2.9*
Eos-0.1* Baso-0.4 Im ___ AbsNeut-18.90* AbsLymp-1.16*
AbsMono-0.62 AbsEos-0.02* AbsBaso-0.08
___ 04:42PM BLOOD Glucose-449* UreaN-22* Creat-1.0 Na-132*
K-6.8* Cl-100 HCO3-6* AnGap-25*
___ 04:42PM BLOOD Albumin-4.6 Calcium-9.8 Phos-5.6* Mg-2.1
___ 04:42PM BLOOD ALT-16 AST-23 AlkPhos-156* TotBili-1.0
___ 04:42PM BLOOD Lipase-6
___ 07:18PM BLOOD Beta-OH-5.3*
___ 07:18PM BLOOD HCG-<5
.
.
Notable labs:
=============
___ 01:25AM BLOOD %HbA1c-8.7* eAG-203*
___ 05:15AM BLOOD calTIBC-272 Ferritn-72 TRF-209
___ 01:25AM BLOOD Triglyc-62 HDL-44 CHOL/HD-2.8 LDLcalc-65
.
.
Micro:
======
-___ UCx: NGTD
***Interpret any positive result w/ caution given associated UA
was negative for inflammation/infection.
-___ BCx: NGTD
-___ BCx: NGTD
.
.
Imaging:
========
-___ CXR:
FINDINGS: Heart size is normal. The mediastinal and hilar
contours are normal. The pulmonary vasculature is normal. Lungs
are clear. No pleural effusion or pneumothorax is seen. There
are no acute osseous abnormalities.
IMPRESSION: No acute cardiopulmonary abnormality.
.
.
Discharge labs:
================
___ 05:15AM BLOOD WBC-10.3* RBC-3.54* Hgb-10.1* Hct-30.6*
MCV-86 MCH-28.5 MCHC-33.0 RDW-13.0 RDWSD-40.5 Plt ___
___ 05:15AM BLOOD ___ PTT-29.1 ___
___ 09:00AM BLOOD Glucose-97 UreaN-5* Creat-0.6 Na-143
K-4.0 Cl-109* HCO3-18* AnGap-16
___ 05:15AM BLOOD Calcium-8.2* Phos-1.9* Mg-2.1
.
.
Brief Hospital Course:
# DKA: presented w/ DKA due to running out of insulin and having
issues with insurance refilling. Treated in ICU w/ insulin gtt &
IVF resuscitation with resolution of anion gap. Feeling well
without any localizing signs/symptoms of infection, pan-negative
ROS, and she was tolerating a regular diet on the day of
discharge.
.
# Type I DM: Evaluated by ___ Diabetes team. Insulin pump
education performed by the diabetes educator. Filled Rx for
insulin and delivered to bedside prior to discharge. Patient to
follow up in ___ clinic in next 1 week to
establish care with ___ diabetologist (is student
living in ___, is originally from ___.
.
.
.
.
.
Time in care: >45 minutes in discharge-related activities today.
.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 50 mg PO DAILY
2. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Target glucose: 80-180
3. Tri-Sprintec (28) (norgestimate-ethinyl estradiol)
0.18/0.215/0.25 mg-35 mcg (28) oral DAILY
Discharge Medications:
1. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Basal Rates:
Midnight - 23:59: 1.25 Units/Hr
Meal Bolus Rates:
Breakfast = 1:4.8
Lunch = 1:4.8
Dinner = 1:4.8
Snacks = 1:4.8
High Bolus:
Correction Factor = 1:24
Correct To ___ mg/dL
MD has ordered ___ consult
Use of ___ medical equipment: Insulin pump
Reason for use: medically necessary and justified as ___
cannot provide this type of equipment or suitable alternative
not appropriate.
Provider acknowledges patient competent
RX *insulin lispro [Humalog U-100 Insulin] 100 unit/mL 100 units
SC ASDIR Disp #*4 Vial Refills:*12
2. Sertraline 50 mg PO DAILY
3. Tri-Sprintec (28) (norgestimate-ethinyl estradiol)
0.18/0.215/0.25 mg-35 mcg (28) oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# DKA
# Type I DM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to the hospital with diabetic ketoacidosis, a
diabetic emergency, due to running out of insulin for your
insulin pump. You were treated with an insulin drip in the ICU
and improved rapidly. You were evaluated by our ___ Diabetes
team who would like to see you in clinic within the next 1 week
to establish care with a ___ primary Diabetologist.
They are working on scheduling an appointment for you and will
contact you. If you have not heard from them within the next 2
days, please call their clinic at ___ and let them
know you were seen here at ___ and need an appointment within
the next 1 week.
It was a pleasure caring for you and we wish you the best!
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10392116-DS-20 | 10,392,116 | 25,173,613 | DS | 20 | 2190-12-09 00:00:00 | 2190-12-12 09:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Throat discomfort
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMHx GERD, esophageal spasm, and anxiety presenting with
throat andchest burning. Patient has long history of issues with
GERD and is followed by GI as an outpatient. She said that she
intermittently has issues at home and yesterday had quite severe
symptoms which seemed to pop up after she experienced the
emotional stressor of her washer leaking just after being
installed in her home. She tried nexium/zantac with incomplete
relief of her symptoms. She was also being bothered by a bit of
a cough and runny nose though says that these symptoms have been
present for quite some time. She denied any frank chest pain,
SOB, abdominal pain, n/v/d, constipation, dysuria, or frequency.
In the ED, initial VS were: 101.3 80 130/54 12 98% RA
Labs notable for: Na 131, trop neg x2, LFTs wnl
UA: Hazy, 30 prot, 40 ket, 7 RBC, few bacteria
Imaging showed:
CXR: PA and lateral views of the chest provided. The lungs are
hyperinflated with biapical pleuroparenchymal scarring again
noted. No focal consolidation, large effusion or pneumothorax is
seen. No signs of pneumothorax or pneumomediastinum. The
cardiomediastinal silhouette is stable. Bony structures are
intact. No free air below the right hemidiaphragm.
CT Torso:
1. No evidence of pancreatitis. Please note that CT findings of
pancreatitis may lack clinical findings by 48 hours.
2. No evidence of small-bowel obstruction colitis or
diverticulitis.
3. Large quantity of gas and stool throughout the bowel.
Patient received:
___ 19:56 PO Aluminum-Magnesium Hydrox.-Simethicone 30 mL
___ 19:56 PO Lidocaine Viscous 2% 10 mL
Transfer VS were: 99.3 93 143/55 16 99% RA
On arrival to the floor, patient reports that her reflux
symptoms have resolved but that she is having significant dry
mouth. She is otherwise well and without any acute complaint.
10 point ROS reviewed and negative except as per HPI
Past Medical History:
1. Coronary vasospams - ___ the pt was admitted to ___
___ due to CP unrelieved by NTG and was found to
have TWIs ___. Her first troponin and CK were normal
but the second troponin was elevated. Due to weather conditions,
pt was transferred to ___ (Dr. ___ ___ rather
than BI, where she underwent diagnostic cath. The angiogram
revealed focal ___ LAD dx (pt has a copy of the CD) which
responded to NTG. Subsequent intra- vascular US revealed no sig.
plaque in quite a nl appearing segment where the angiographic
stenosis had been, c/w vasospasm.
2. GERD
3. Depression.
Social History:
___
Family History:
M: Breast CA and silent MI
F: Parkinsons
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
=========================
VS: 99.3 138/64 89 19 99% Ra
GENERAL: Pleasant elderly F in NAD
HEENT: NCAT, dry mucous membranes
NECK: Supple, neck veins flat sitting upright
HEART: RRR, no m/r/g
LUNGS: CTAB anteriorly
ABDOMEN: Soft, NT/ND, BS+
EXTREMITIES: WWP, no c/c/e
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
PHYSICAL EXAM ON DISCHARGE:
=========================
VS: 99.6 PO 132 / 54 90 12 98 RA
GENERAL: Pleasant elderly F in NAD, runny nose
HEENT: NCAT, dry mucous membranes
NECK: Supple, neck veins flat sitting upright
HEART: RRR, no m/r/g
LUNGS: CTAB anteriorly
ABDOMEN: Soft, NT/ND, BS+
EXTREMITIES: WWP, no c/c/e
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS ON ADMISSION:
================
___ 06:42PM BLOOD WBC-6.0# RBC-3.77* Hgb-11.2 Hct-33.6*
MCV-89 MCH-29.7 MCHC-33.3 RDW-13.1 RDWSD-42.5 Plt ___
___ 06:42PM BLOOD Neuts-89.7* Lymphs-4.8* Monos-5.0
Eos-0.0* Baso-0.2 Im ___ AbsNeut-5.39# AbsLymp-0.29*
AbsMono-0.30 AbsEos-0.00* AbsBaso-0.01
___ 06:42PM BLOOD Glucose-150* UreaN-14 Creat-0.7 Na-131*
K-4.5 Cl-92* HCO3-23 AnGap-16
___ 09:35PM BLOOD ALT-18 AST-33 AlkPhos-64 TotBili-0.5
___ 09:35PM BLOOD Lipase-18
___ 06:42PM BLOOD cTropnT-<0.01
___ 09:35PM BLOOD cTropnT-<0.01
___ 09:35PM BLOOD Albumin-3.9
LABS ON DISCHARGE:
================
___ 08:35AM BLOOD WBC-6.5 RBC-3.43* Hgb-10.2* Hct-30.4*
MCV-89 MCH-29.7 MCHC-33.6 RDW-13.3 RDWSD-43.5 Plt ___
___ 08:35AM BLOOD Glucose-95 UreaN-13 Creat-0.6 Na-131*
K-4.0 Cl-92* HCO3-25 AnGap-14
___ 08:35AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.9
MICRO:
======
IMAGING:
=======
CXR:
PA and lateral views of the chest provided. The lungs are
hyperinflated with biapical pleuroparenchymal scarring again
noted. No focal consolidation, large effusion or pneumothorax
is seen. No signs of pneumothorax or pneumomediastinum. The
cardiomediastinal silhouette is stable. Bony structures are
intact. No free air below the right hemidiaphragm.
CT Abdomen and pelvis:
1. No evidence of pancreatitis. Please note that CT findings of
pancreatitis may lack clinical findings by 48 hours.
2. No evidence of small-bowel obstruction, colitis or
diverticulitis.
3. Large quantity of gas and stool throughout the bowel.
Brief Hospital Course:
Mrs. ___ is a ___ yo female with past medical history of
chronic watery rhinorrea, esophagitis, and GERD, who presented
with throat pain in the setting of fever, worsening runny nose,
and cough, suggestive of viral upper respiratory infection.
ACUTE ISSUES:
=============
#Throat pain:
Initially, the patient reported chest pain, which raised concern
for cardiac pain or severe esophagitis. Trops were negative and
ECG showed no ischemic changed. Upon further questioning, she
clarified that she had no chest pain but rather throat pain. Her
symptoms were likely due to upper respiratory viral infection.
Per review of records, she saw ENT on ___ for throat chronic
rhinorrhea. At that time, an endoscopy was performed and showed
normal hypopharynx and larynx, mild reflux changes, and no
glottic abnormality. She was able to tolerate PO intake and her
throat pain has improved. She had symptomatic relief with
lozenges PRN.
#Fevers: She was febrile in ED to 101.3 with cough and sore
throat. Exam was benign and there was no leukocytosis on labs.
UA bland. CXR with biapical scarring though no definitive
consolidation. CT chest without any findings which would explain
fevers. Her symptoms are likely due to upper respiratory viral
infection. She received conservative treatment.
#GERD: Patient with long-standing and significant issues with
GERD. Initially her symptoms were thought to be due to severe
GERD, though patient clarified that had throat pain and not
chest/epigastric pain. She was treated with BID PPI and
ranitidine.
#Hyponatremia: Likely in the setting of poor PO intake.
Encouraged PO intake.
CHRONIC ISSUES:
===============
#Esophageal spasm
#Atypical chest pain: Continued verapamil.
#Anxiety: Continued PRN ativan.
#Allergic rhinitis: Fluticasone while in house as home
azelastine not on formulary.
***TRANSITIONAL ISSUES:***
- Ensure resolution of symptoms
- Continue PPI BID, make sure patient takes it 30 minutes before
her meals
- Consider follow-up with ENT in case her symptoms persist
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. azelastine 0.15 % (205.5 mcg) nasal BID
2. esomeprazole magnesium 40 mg oral BID
3. LORazepam 0.5-1 mg PO Q6H:PRN Anxiety
4. Ranitidine 150 mg PO BID
5. Verapamil SR 120 mg PO Q24H
6. Vitamin D 1000 UNIT PO DAILY
7. Calcium Carbonate Suspension Dose is Unknown PO TID
8. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. azelastine 0.15 % (205.5 mcg) nasal BID
2. Calcium Carbonate Suspension Dose is Unknown PO TID
5 mL (1 tsp) = 1250 mg Calcium Carbonate = 500 mg of Elemental
Calcium
3. esomeprazole magnesium 40 mg oral BID
4. LORazepam 0.5-1 mg PO Q6H:PRN Anxiety
5. Multivitamins 1 TAB PO DAILY
6. Ranitidine 150 mg PO BID
7. Verapamil SR 120 mg PO Q24H
8. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Upper respiratory tract infection
SECONDARY DIAGNOSIS:
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at ___
___. You came to the hospital because you were
experiencing severe throat pain. You also had a runny nose,
fever, and a cough. These symptoms are likely due to a viral
infection and will get better within a few days.
There was an initial concern that you had a bad stomach reflux.
Upon further clarification, you clarified that the pain is in
your throat and not in the stomach. You do not need a scope to
look at the esophagus and stomach at this time.
Please make sure to follow-up with your doctors as ___.
Also, you should continue taking your acid reflux medications 30
minutes before your meals twcice a day. You can take other the
counter lozenges to relieve the throat pain.
We wish you all the best in health.
Your ___ team
Followup Instructions:
___
|
10392429-DS-16 | 10,392,429 | 20,402,482 | DS | 16 | 2125-12-29 00:00:00 | 2126-01-26 15:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: ERCP with sphincterotomy and stone extraction
___: Laparoscopic cholecystectomy
History of Present Illness:
___ man with atrial fibrillation on Eliquis, coronary
artery disease s/p 2 stents several years ago, diabetes, OSA,
presents with 24 hours of severe epigastric pain, Rigors,
vomiting transferred from OSH emergency room after found to have
gallstone pancreatitis.
He lives in ___ but is in ___ visiting for his
birthday. His wife and him normally go to ___ and ___. He was in his normal state of health until 24 hours ago
when he had sudden onset of abdominal pain after eating pizza.
He tried taking Tums and Pepto-Bismol with no relief. The pain
continued to get worse and he subsequently had nausea and
vomiting.
Later this afternoon he started to notice rigoring so he went to
urgent care where he was found to have obstructive pancreatitis
and a possible NSTEMI he was transferred to ___
emergency room. Per report in the emergency room there he was
found to have elevated liver function tests AST 147 ALT 150 T
bili of 3.7 and a lipase of 2200. Per report troponin was 0.21.
A right upper quadrant ultrasound was done which showed a
markedly distended gallbladder with thickened wall, nonmobile
gallstone within the neck of the gallbladder suspicious for
acute cholecystitis. He was given Zosyn and transferred to our
emergency room.
Past Medical History:
Atrial fibrillation
CAD
Diabetes
OSA
Hyperlipidemia
Hypertension
Social History:
___
Family History:
His father died of an MI, his uncle died of an MI
his mom died of old age in her late ___ she lived at a nursing
home.
He states numerous family members have had gallstones or had
their gallbladder removed
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
VS: 99.0 PO 156 / 75 85 20 95 2L NC
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERLL, EOMI, no conjuctival injection, +icteric
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, tender to palpation in the mid
epigastric and right upper quadrant area, 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, time, date, reason for
hospitalization. fluent speech.
Psychiatric: pleasant, appropriate affect
GU: no catheter in place
Discharge Physical Exam:
Temp: 98.5, BP: 169/90, HR: 71 RR: 18, O2 sat: 95%
Gen: A&O x3. In NAD. Sitting up in chair
CV: HR irregular, rate controlled
Pulm: LS ctab
Abd: soft, appropriately TTP incisionally. Lap sites CDI, OTA.
Ext: WWP no edema
Pertinent Results:
ADMISSION LABS
--------------
___ 08:00PM BLOOD WBC-16.0* RBC-4.33* Hgb-12.2* Hct-38.7*
MCV-89 MCH-28.2 MCHC-31.5* RDW-14.6 RDWSD-47.7* Plt ___
___ 01:46AM BLOOD ___
___ 08:00PM BLOOD Glucose-227* UreaN-18 Creat-0.9 Na-141
K-4.0 Cl-107 HCO3-23 AnGap-11
___ 08:00PM BLOOD ALT-142* AST-126* AlkPhos-117
TotBili-3.9*
___ 08:00PM BLOOD Lipase-1016*
___ 08:00PM BLOOD cTropnT-0.01
___ 08:00PM BLOOD Albumin-3.3* Calcium-8.9 Phos-3.7 Mg-1.7
IMAGING
-------
CXR ___
IMPRESSION:
Low lung volumes with possible mild pulmonary vascular
congestion and small bilateral pleural effusions. Bibasilar
airspace opacities likely reflect atelectasis in the setting of
low lung volumes, with aspiration or infection difficult to
exclude in the correct clinical setting.
CT ABD/PELVIS ___
IMPRESSION:
1. Dilated common bile duct due to choledocholithiasis in the
distal common bile duct with evidence of cholangitis involving
the distal common bile duct. ERCP is recommended for further
evaluation and management.
2. Cholelithiasis with evidence of acute cholecystitis.
3. Gallstone-associated mild interstitial edematous
pancreatitis. No
peripancreatic fluid collections.
4. 5.3 x 4.0 cm minimally complex hypodense rim calcific
structure in the
right lateral aspect of the pericardium, likely a calcified
pericardial cyst.
ERCP ___
- Ampulla normal
- pancreatogram: normal without evidence of filling defects
- cholangiogram: CBD 8mm. left and right hepatic ducts and
intrahepatic branches dilated. large filling defects suggestive
of stones
- sphincterotomy performed
- multiple balloon sweeps with the removal of multiple stones
- final cholangiogram with no evidence of filling defects
RUQUS ___
IMPRESSION:
1. Mildly distended gallbladder with cholelithiasis and small
amount of
pericholecystic fluid, compatible with known cholecystitis.
2. No evidence of intrahepatic or extrahepatic biliary
dilatation.
Brief Hospital Course:
___ yo man with AFib on Eliquis, CAD s/p 2 stents several years
ago, NIDDM, OSA, presenting with abdominal pain, found to have
gallstone pancreatitis, cholecystitis, and cholangitis. Patient
presented with lab and imaging consistent with gallstone
pancreatitis, with lipase > ___ and elevated LFTs. His Eliquis
was held in the setting of multiple procedures during this
hospitalization. He underwent successful ERCP on ___, with
sphincterotomy, stent placement and multiple stones. ACS was
consulted, and the patient underwent laparoscopic
cholecystectomy on ___ , which went well without complication
(reader referred to the Operative Note for details). After a
brief, uneventful stay in the PACU, the patient arrived on the
floor tolerating clears, on IV fluids, and oral analgesia for
pain control. The patient was hemodynamically stable.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. 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. Home Eliquis was
restarted on POD2.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Apixaban 5 mg PO BID
3. Atorvastatin 80 mg PO QPM
4. Metoprolol Succinate XL 12.5 mg PO BID
5. Januvia (SITagliptin) 100 mg oral DAILY
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H
2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*5 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 packet(s) by mouth once a
day Disp #*10 Packet Refills:*0
4. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Januvia (SITagliptin) 100 mg oral DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Metoprolol Succinate XL 12.5 mg PO BID
10. HELD- Apixaban 5 mg PO BID This medication was held. Do not
restart Apixaban until ___
Discharge Disposition:
Home
Discharge Diagnosis:
Gallstone pancreatitis
Choledocholithiasis
Chronic cholecystitis
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 were found to
have gallstone pancreatitis. You underwent an ERCP to remove
stones from your common bile duct. Once your pain and liver
function lab values improved, you were taken to the operating
room and had your gallbladder removed laparoscopically. You
tolerated this well. You are now eating and your pain is under
control on oral medications. Your lab tests postoperatively look
good. You can restart your eliquis tomorrow ___. You will need
to call the Acute Care Surgery clinic to schedule a follow-up
appointment.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10392686-DS-15 | 10,392,686 | 21,527,402 | DS | 15 | 2124-11-06 00:00:00 | 2124-11-28 09:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
codeine
Attending: ___.
Chief Complaint:
Chest pain and dyspnea on exertion
Major Surgical or Invasive Procedure:
___ - 1. Coronary artery bypass grafting x3 with the
left internal mammary artery to the left anterior descending
artery and reverse saphenous vein graft to the posterior
descending artery and obtuse marginal artery. 2. Patch repair
of atrial septal defect.
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of coronary
artery disease, diabetes mellitus, hyperlipidemia, hypertension
and prior non-ST elevation myocardial infarction in ___. A
cardiac catheterization in ___ demonstrated two vessel
coronary artery disease with 99% proximal OM1 which was
successfully treated with a 3.5 x 13 mm BX Velocity stent. She
was also noted to have a 60-70% mid RCA lesion.
She reports being under significant emotional stress as her ___
year old son was hospitalized for Encephalitis for over a month
and her mother-in-law passed away. Over the past two months she
has been experiencing intermittent chest discomfort/tightness
and dyspnea with climbing stairs. Symptoms improve with rest.
She underwent a cardiac catheterization which revealed coronary
artery disease. She was scheduled for surgery however she has
developed worsening chest pain over the last few days. She
states that previously she could walk up a flight of stairs
without SOB but now cannot. She states that her chest pain
(described as pressure radiating across her chest) has been
occurring more frequently in the last few days. She also states
she experienced an episode of L hand pain similar to her prior
MI. She then awoke overnight with chest pain, which is the first
time she has experienced this. She presented to the ED for
evaluation. Her EKG was without ischemia and troponin assays
were negative. She is now admitted for expedited CABG work up.
Past Medical History:
Coronary artery disease s/p stent in ___
Diabetes mellitus type 2
Hyperlipidemia
Hypertension
Non-ST Elevation Myocardial Infarction, ___
Surgical History:
Cholecystectomy
Partial hysterectomy
Social History:
___
Family History:
Mother had MI in her ___ and "enlarged" heart.
Physical Exam:
Admission exam
97.6, 72 NSR, 170/84, RR 10, 97% RA
General: NAD, lying in bed
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema [] no edema
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
___ Right:2+ Left:2+
Radial Right:2+ Left: 2+
Carotid Bruit: Right: absent Left: absent
Discharge Physical Exam
VS: T 98.0 HR: 60-70's SR BP: 118-137/70's RR: 18 Sats: 98% RA
Wt: 69.7 kg pre-op 66 kg
General: NAD
Cardiac: RRR
Resp: clear breath sounds
GI: benign
Extr: warm no edema
Wound: sternal & Right lower extremity clean dry intact. sternum
stable
Neuro: awake, alert walks independently
Pertinent Results:
Echo ___:
PRE BYPASS The left atrium is dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage. The right atrium is dilated. A left-to-right shunt
across the interatrial septum is seen at rest. A secundum type
atrial septal defect, about 0.8 cm in width, is present.
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. There are simple atheroma in the ascending aorta.
There are simple atheroma in the aortic arch. There are complex
(mobile) atheroma in the descending aorta. 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. Physiologic mitral regurgitation
is seen (within normal limits). The tricuspid valve leaflets are
mildly thickened. There is no pericardial effusion. Dr. ___ was
notified in person of the results in the operating room at the
time of the study.
POST BYPASS The patient is atrially paced. There is low normal
right ventricular systolic function. There is normal left
ventricular systolic function. Valvular function is unchanged
from the prebypass study. The thoracic aorta is intact after
decannulation.
CXR: ___ilateral pleural effusions and bibasilar atelectasis.
No
pneumothorax is identified. The size and appearance of the
cardiomediastinal silhouette is unchanged. Again noted is a
right internal jugular central venous catheter whose tip
projects over the cavoatrial junction.
IMPRESSION:
No significant interval change since the prior study with small
bilateral
pleural effusions and bibasilar atelectasis.
Admission Labs:
___ WBC-9.1 RBC-3.93 Hgb-10.7* Hct-33.3* MCV-85 MCH-27.2
MCHC-32.1 RDW-12.4 RDWSD-37.9 Plt ___
___ Glucose-110* UreaN-20 Creat-0.8 Na-144 K-4.1 Cl-107
HCO3-23
___ ALT-41* AST-64* LD(LDH)-273* AlkPhos-50 Amylase-36
TotBili-<0.2
Discharge Labs:
___ WBC-11.7* RBC-3.20* Hgb-8.9* Hct-27.2* MCV-85 MCH-27.8
MCHC-32.7 RDW-13.1 RDWSD-40.4 Plt ___
___ Glucose-120* UreaN-14 Creat-0.8 Na-140 K-4.1 Mg-2.0
Discharge Labs:
___ 04:53AM BLOOD WBC-11.7* RBC-3.20* Hgb-8.9* Hct-27.2*
MCV-85 MCH-27.8 MCHC-32.7 RDW-13.1 RDWSD-40.4 Plt ___
___ 04:53AM BLOOD Plt ___
___ 03:14PM BLOOD ___ PTT-25.8 ___
___ 05:11AM BLOOD Glucose-120* UreaN-14 Creat-0.8 Na-140
K-4.1
___ 05:11AM BLOOD Mg-2.0
Radiology Report CHEST (PA & LAT) Study Date of ___ 4:22
___
Final Report:
There are trace bilateral pleural effusions and bibasilar
atelectasis. No
pneumothorax is identified. The size and appearance of the
cardiomediastinal silhouette is unchanged. Again noted is a
right internal jugular central venous catheter whose tip
projects over the cavoatrial junction.
IMPRESSION:
No significant interval change since the prior study with small
bilateral
pleural effusions and bibasilar atelectasis.
___, MD electronically signed on SAT ___
4:43 ___
Brief Hospital Course:
___ was admitted following presenting with unstable
chest pain. Her original planned surgical date was ___ but due
to her unstable chest pain, she was admitted for medical
management with surgery sooner. EKG and enzymes were negative
and underwent usual pre-operative work-up. On ___ she was taken
to the operating where she underwent a coronary artery bypass
graft x 3 and ASD closure. Please see operative report for
surgical details. Following surgery she was transferred to the
CVICU for invasive monitoring in stable condition. Later this
day he was weaned from sedation, awoke neurologically intact and
extubated. Patient remained hemodynamically stable, she was
weaned from pressor therpy, required Atrial pacing for Sinus
bradycardia. Patient was started on Lopressor and Lasix. She had
post-op nausea that resolved with scopolamine patch, and
avoiding narcotics. Patient was transferred to the floor POD1.
Pacing wires and chest tubes were removed in timely fashion. She
was transfused 1PRBC on POD2 for acute blood loss anemia, Hct
22 bumped to 27 appropriately. Patient was seen by the physical
therapy department strengthening and mobility. She continue to
progress well and was ready for discharge to home on POD 4. All
follow-up appointment arranged.
Medications on Admission:
ATENOLOL - atenolol 50 mg tablet. tablet(s) by mouth -
(Prescribed by Other Provider; one po qd)
ATORVASTATIN - atorvastatin 80 mg tablet. 1 tablet(s) by mouth
daily - (Prescribed by Other Provider)
METFORMIN - metformin ER 500 mg tablet,extended release 24 hr. 1
tablet(s) by mouth twice a day - (Prescribed by Other Provider;
bid)
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release.
capsule(s) by mouth - (Prescribed by Other Provider; one po
qd)
SITAGLIPTIN [JANUVIA] - Januvia 100 mg tablet. 1 tablet(s) by
mouth daily - (Prescribed by Other Provider; )
Medications - OTC
ASPIRIN - aspirin 325 mg tablet,delayed release. tablet(s) by
mouth - (Prescribed by Other Provider; one po qd)
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
1,000 unit capsule. capsule(s) by mouth - (Prescribed by Other
Provider; one po qd)
CINNAMON BARK [CINNAMON] - Cinnamon 500 mg capsule. 4 capsule(s)
by mouth daily - (Prescribed by Other Provider; )
IBUPROFEN - ibuprofen 200 mg tablet. ___ tablet(s) by mouth
tabets daily over course day - (Prescribed by Other Provider)
OMEGA-3 FATTY ACIDS-FISH OIL [FISH OIL] - Fish Oil 360 mg-1,200
mg capsule. 1 capsule(s) by mouth twice a day - (Prescribed by
Other Provider)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Furosemide 20 mg PO DAILY Duration: 7 Days
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*1
5. Januvia (SITagliptin) 100 mg oral DAILY
6. MetFORMIN XR (Glucophage XR) 500 mg PO BID
Do Not Crush
7. Metoprolol Tartrate 50 mg PO BID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*180 Tablet Refills:*1
8. Omeprazole 20 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 17.2 mg PO DAILY
RX *sennosides [Senna Concentrate] 8.6 mg 1 by mouth at bedtime
Disp #*30 Tablet Refills:*0
11. Vitamin D 1000 UNIT PO DAILY
12. HELD- Fish Oil (Omega 3) 1000 mg PO BID This medication was
held. Do not restart Fish Oil (Omega 3) until seen by your PCP
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
ASD s/p closure
Past medical history:
Hypertension
Hyperlipidemia
s/p stent in ___
Diabetes mellitus type 2
Cholecystectomy
Partial hysterectomy
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: none
Discharge Instructions:
1. Shower daily -wash incisions gently with mild soap
2. No baths or swimming, look at your incisions daily
3. NO lotion, cream, powder or ointment to incisions
4. Daily weights. keep a log. Call with weight gain of ___
pounds over several days
5. Monitor sternal incision for signs of infection: fevers >
101, redness, drainage or increased pain. Should any of these
symptoms occur please call the office immediately. ___
6. No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
7. No lifting more than 10 pounds for 10 weeks
8. Encourage full shoulder range of motion, unless otherwise
specified
9. 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:
___
|
10393281-DS-11 | 10,393,281 | 26,073,810 | DS | 11 | 2161-07-25 00:00:00 | 2161-07-26 23:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Bleeding in urostomy bag
Major Surgical or Invasive Procedure:
TIPs and ___ embolization ___
History of Present Illness:
Ms. ___ is a ___ year-old woman with PMH of HCV cirrhosis
(s/p Harvoni ___ with SVR, currently inactive on transplant
list due to low MELD) c/b thrombocytopenia, portal hypertension,
and varices, transitional cell carcinoma (s/p neo-adjuvant
cisplatin/gemcitabine, radical cystectomy, urethrectomy,
TAH/BSO, and ileal conduit diversion in ___ who presented to
the ED with bleeding in her urostomy bag that began the
afternoon of admission. Around 2pm day of admission she noted
frank blood draining into her urostomy bag. She presented to
___ where 400 cc of blood were reportedly
emptied from her ostomy and she received 2 units pRBCs. Her
hemoglobin on presentation was 9.1 and she received 1 L LR. The
ED physician who examined her visualized a parastomal varix at
6:00 without signs of active bleeding. She was transferred to
___ for further management.
She presented to ___ ___ with blood in her
ostomy bag after increasing her aspirin usage reportedly to 4
325mg pills daily for weeks to treat left shoulder pain from her
humeral fracture ___. CT A&P at ___ showed
engorged varices. She was transferred to ___, Dr. ___
recommended transfer to ___ for embolization or expedited TIPS
workup but
she ended up signing out AMA. Spironolactone and propranolol
were held on discharge but resumed by Dr. ___ on ___. No
bleeding in between discharge and now. Urine cytology sent
during that visit to evaluate for recurrent urothelial
malignancy was negative. She denies recent fevers, dyspnea,
chest pain, abdominal pain, diarrhea, constipation, or worsening
leg
swelling.
Past Medical History:
- Bladder cancer s/p cystectomy with ileal loop urostomy at ___
about ___ years ago
- Hepatitic C Cirrhosis
- Hypertension
- Type II Diabetes
- GERD
Social History:
___
Family History:
She has a father and mother with cirrhosis thought to be due to
alcohol. Her mother had breast cancer and her sister has lung
cancer that is metastatic to the liver and spleen.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: ___ 2316 Temp: 98.9 PO BP: 107/65 L Sitting HR: 65 RR:
16 O2 sat: 96% O2 delivery: Ra
GENERAL: Pleasant, NAD
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM
NECK: supple, no JVD
HEART: RRR, S1/S2, ___ systolic mumur at apex
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. No fluid wave Ostomy
RLQ
pink, bag draining clear yellow urine
EXTREMITIES: Trace edema left ankle, no cyanosis, clubbing
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
Temp 98.4 BP106 / 68 HR 57 RR 18SaO2 96%Ra
GENERAL: Pleasant, NAD
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM
NECK: supple, no JVD
HEART: RRR, S1/S2, ___ systolic mumur at apex
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants except around
ostomy bag, no rebound/guarding, no hepatosplenomegaly. No fluid
wave Ostomy RLQ pink, bag draining clear yellow urine
EXTREMITIES: Trace edema left ankle, no cyanosis, clubbing
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
___ 07:45PM BLOOD WBC-5.4 RBC-3.06* Hgb-9.0* Hct-26.7*
MCV-87 MCH-29.4 MCHC-33.7 RDW-16.3* RDWSD-51.3* Plt Ct-86*
___ 07:45PM BLOOD Glucose-124* UreaN-11 Creat-0.8 Na-139
K-4.4 Cl-106 HCO3-22 AnGap-11
___ 07:45PM BLOOD ALT-11 AST-33 AlkPhos-107* TotBili-0.8
___ 03:30AM BLOOD Calcium-8.1* Phos-3.7 Mg-1.2*
NOTABLE LABS
___ 07:45PM BLOOD Lipase-98*
___ 05:34AM BLOOD %HbA1c-5.7 eAG-117
___ 08:02PM BLOOD Lactate-1.6
___ 08:11PM URINE RBC-4* WBC-25* Bacteri-FEW* Yeast-NONE
Epi-0
DISCHARGE LABS
___ 06:03AM BLOOD WBC-6.8 RBC-2.94* Hgb-8.6* Hct-26.4*
MCV-90 MCH-29.3 MCHC-32.6 RDW-15.9* RDWSD-52.2* Plt Ct-57*
___ 06:03AM BLOOD Glucose-93 UreaN-9 Creat-0.8 Na-139 K-3.5
Cl-105 HCO3-22 AnGap-12
___ 06:03AM BLOOD ALT-21 AST-44* AlkPhos-95 TotBili-1.6*
___ 06:03AM BLOOD Albumin-3.1* Calcium-7.6* Phos-2.4*
Mg-1.8
MICROBIOLOGY
__________________________________________________________
___ 5:01 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 12:50 pm BLOOD CULTURE #1.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 8:12 pm
URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 7:55 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 7:45 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING & PROCEDURES
KUB ___
Diffuse gaseous distension, predominantly of the colon, without
evidence of
obstruction.
CXR ___
Lungs are low volume with bibasilar atelectasis.
Cardiomediastinal silhouette
is stable. There is no pleural effusion. No pneumothorax is
seen.
Subsegmental atelectasis in the right lower lobe has resolved
TIPS
1. Pre-TIPS right atrial pressure of 18 and balloon-occluded
portal pressure
measurement of 36 resulting in portosystemic gradient of 18
mmHg.
2. Left hepatic venogram in the AP and ___ positions confirmed
appropriate
position of the TIPS cannula.
3. Initial portal venogram demonstrates a large esophageal
varix. Additional
venogram of the distal SMV/stomal varix demonstrate a an
enlarged varix in the
right lower quadrant adjacent to the patient's urostomy.
4. Post embolization venogram of the stoma varix demonstrate
complete stasis
of the vessel.
5. Post embolization portal venogram demonstrates absence of
flow within the
embolized esophageal varix as well as brisk flow through the
left hepatic vein
to left portal vein TIPS.
6. Post-TIPS right atrial pressure of 23 and portal pressure of
30 resulting
in portosystemic gradient of 7 mmHg.
IMPRESSION:
Successful right internal jugular access with transjugular
intrahepatic
portosystemic shunt placement (left hepatic vein to left portal
vein) with
decrease in porto-systemic pressure gradient (18 mmHg to 7
mmHg).
Successful sclerosis and embolization of a large right lower
quadrant stomal
varix adjacent to the patient's urostomy and successful
sclerosis and
embolization of an esophageal varix.
CTA A/P ___
1. Cirrhotic liver with stigmata of portal hypertension. No
lesions meeting
optn criteria for ___.
2. Rim enhancing segment 7 hepatic lesion is stable and remains
indeterminate.
3. Enlarged right inguinal lymph nodes, probably reactive.
4. Sigmoid colonic wall thickening can be secondary to chronic
fibromuscular
hyperplasia due to chronic diverticulitis. However, underlying
mass lesion
cannot be excluded. Correlation with colonoscopy results is
recommended.
RECOMMENDATION(S): Recommend ultrasound-guided biopsy of the
new enlarged
right inguinal lymph nodes given history of bladder carcinoma.
Brief Hospital Course:
Ms. ___ is a ___ year-old woman with PMHx of HCV cirrhosis
(s/p Harvoni ___ with SVR) c/b thrombocytopenia, portal
hypertension, and varices, transitional cell carcinoma (s/p
neo-adjuvant cisplatin/gemcitabine, radical cystectomy,
urethrectomy, TAH/BSO, and ileal conduit diversion in ___ who
presented to the ED with recurrent bleeding from her urostomy in
the setting of known
parastomal varices. She underwent TIPs and embolization of
stomal varix on ___ without issue.
#RECURRENT PARASTOMAL VARICEAL BLEEDING:
#ACUTE BLOOD LOSS ANEMIA. Patient presented with blood in her
ostomy bag in setting of known parastomal varices. Previously in
setting of excess aspirin use, but she reported no NSAID use
recently. Hgb 9.1 at ___, reportedly received 2 units prior to
transfer with inappropriate bump in hemoglobin. Patient had bag
exchange at OSH with no hematuria noted since exchange. No
hematemesis, melena, or hematochezia. ___ consulted who agreed
that Ms. ___ was a suitable candidate for TIPs and
embolization. CT scan (___) showed extensive intra-abdominal
varices, some of which herniated into the subcutaneous tissues
through the right lower quadrant ileostomy. CT scan also noted
enlarged right inguinal lymph nodes. Patient is now s/p TIPs and
embolization of stomal varix (___).
# Nausea. Patient was found to have significant nausea during
her hospital course. Etiology was unclear; KUB did not show SBO
or ileus, on Zofran. Hba1c 5.7, low concern for gastroparesis.
Patient started on MiraLAX and senna given KUB with no
obstruction but distension and gas. Relief of nausea by morning
of ___ after several bowel movements. She ate a bagel that
morning with no issue.
#HCV CIRRHOSIS. MELD-Na 11, previously on transplant list but
inactivated ___. Hx of varices, SBP. and hepatic
encephalopathy. EGD ___ with medium sized varices in lower
third of esophagus not banded. No ascites on clinical exam.
-Continued lactulose titrated to ___ BMs daily at first and then
replaced with senna, miralax as above. Patient reports that she
is not fully compliant with lactulose at home. Lactulose changed
to 15 mg QAM.
-Continued home rifaximin
-Continued home propranolol for known varices and then
discontinued post-TIPs
-Continued home lasix/spironolactone
-Continued home ciprofloxacin for SBP prophylaxis. Consider
discontinuing in the outpatient setting as below.
# Leukocytosis. Patient with WBC spike of 10.1 on ___ from ___.
Deemed likely leukemoid in setting of recent TIPs. Patiently
also briefly hypoxic w/ O2 requirement of 2 L. CXR ___ with
subsegmental atelectasis but no evidence of PNA. Hypoxia and WBC
count resolved without intervention.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 500 mg PO Q24H
2. Furosemide 20 mg PO BID
3. Pantoprazole 20 mg PO Q24H
4. Propranolol 10 mg PO BID
5. Rifaximin 550 mg PO BID
6. Lactulose 30 mL PO QID
7. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
8. Spironolactone 50 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. biotin 5 mg oral DAILY
Discharge Medications:
1. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth Daily Disp #*30 Packet Refills:*0
2. Senna 17.2 mg PO QHS
RX *sennosides [senna] 8.6 mg 2 tabs by mouth at bedtime Disp
#*60 Tablet Refills:*0
3. Lactulose 15 mL PO QAM
RX *lactulose 10 gram/15 mL 15 mL by mouth QAM Refills:*0
4. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
5. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
6. biotin 5 mg oral DAILY
7. Ciprofloxacin HCl 500 mg PO Q24H
8. Furosemide 20 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Rifaximin 550 mg PO BID
11. Spironolactone 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
======
Acute blood loss anemia
Recurrent parastomal variceal bleed
Secondary
========
HCV cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear,
You were admitted to the hospital because of concern for
bleeding.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were admitted to the hospital and underwent a procedure
called TIPS (transjugular Intrahepatic Portosystemic Shunt) to
relieve pressure from a known dilated blood vessel around your
ostomy.
- You had nausea and abdominal bloating while here. You were
found to have significant gas on x-ray and on exam. You were
started on medications to help you move your bowels and your
symptoms improved.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Please take all of your medications as prescribed (listed
below)
- Keep your follow up appointments with your doctors
- Please call your doctor or present to the emergency department
if you experience any of the danger signs listed below.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
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