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10393281-DS-12 | 10,393,281 | 24,484,269 | DS | 12 | 2161-10-27 00:00:00 | 2161-10-28 19:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RLE Pain
Major Surgical or Invasive Procedure:
Placement of Stomal Catheter (___)
Placement of Bilateral Percutaneous Nephrostomy Tubes (___)
History of Present Illness:
Ms. ___ is a ___ woman with HCV cirrhosis (s/p
Harvoni ___ w/ SVR, not active on Txpt list due to low MELD;
c/b
varices, thrombocytopenia, portal htn s/p TIPS), 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 severe RLE pain and is
admitted to the liver service for evidence of decompensated
cirrhosis.
The patient was in her usual state of health until 1 month prior
to admission when she developed sudden-onset RLE hip and
anterior
leg pain. The pain progressed from a ___ at onset to a ___
in severity and she presented to her PCP at ___
where she underwent MRI, which per the patient showed "something
the her leg compressing a nerve." She also reportedly underwent
___ which was reportedly negative for thrombus (records not
available to review). She was given percocet for pain relief
which slightly helped but mostly just sedated her. There was no
preceding trauma or activity changes. She denies associated
fevers, chills, leg swelling, erythema, or skin changes. Due to
her ongoing pain she presented to the ED.
In the ED, she was afebrile, BPs 130s/70s, and breathing 95% on
RA. She was noted to be AOx3, normal pulmonary exam, with a soft
non-distended and non-tender abdomen. Her labs were notable for
a
leukocytosis to 13.9, Hgb 15 (baseline 10), platelets 90
(baseline ___, INR of 1.8 (up from 1.4 on ___,
creatinine 4.6 (from 0.7 baseline), BUN 98 (baseline ___,
sodium 131, K 5.3, bicarb 17 w/ AnGap 21, phos 5.8, albumin 3.0
(b/s ___, lactate 2.7. Her LFTs were notable for normal
ALT/AST, alk phos 125 (down from 168), and Tbili 3.0 (up from
1.6
in ___. For her RLE pain, she had a hip Xray that showed NO
acute fracture or dislocation. There was mild degenerative
changes bilaterally w/ multiple embolization coils over the R
iliac bone. The patient was noted to be slightly confused so a
CXR was performed to r/o PNA and was unremarkable. A RUQUS was
also performed iso worsening cirrhosis labs that showed a patent
TIPS, minimal ascites, and mild splenomegaly. Of note, there was
moderate hydronephrosis involving the R collecting system.
Hepatology was consulted and recommended infectious workup,
paracenetesis (not preformed d/t no ascites), albumin for volume
resuscitation, and to hold home diuretics.
Patient received: Lidocaine patch and tramadol for pain, home
cipro SBP ppx, home rifaximin, and albumin 12.5 gm.
On arrival to the floor, the patient is in distress from pain
and
is unable to give a cohesive history due to the pain severity.
She corroborates the above story regarding her hip pain as best
as she can. She is not sure what the circumstances were around
the pain starting but denies any trauma. She endorses some mild
lower abdominal pain that is crampy in nature and relieved with
bowel movements. She denies melena or BRBPR but does endorse
intermittent diarrhea. She does not know when it started but
states it has been ongoing for at least a week. She denies any
abdominal distension, recent confusion, ___ swelling. She
denies any recent nausea or vomiting. No changes to the color or
odor of her ostomy output.
Of note, she was recently hospitalized at ___ for periostomal
variceal bleeding. She underwent successful TIPS there on
___.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
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: ___ 2211 Temp: 97.9 PO BP: 145/79 R Lying HR: 81 RR: 18
O2 sat: 92% O2 delivery: Ra
GENERAL: In acute distress from pain
HEENT: AT/NC, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, diffusely tender to palpation,
no
rebound/guarding, unable to palpate spleen d/t discomfort
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric, NO asterixis, unable to participate in serial 7s or
days of week backwards due to distress from pain
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Final Physical Exam:
Patient died from acute hypoxemic respiratory failure secondary
to decompensated cirrhosis on ___ at 1131 am while on
comfort measures only.
Pertinent Results:
ADMISSION LABS:
___ 05:41PM BLOOD WBC-13.9* RBC-4.91 Hgb-15.0 Hct-43.0
MCV-88 MCH-30.5 MCHC-34.9 RDW-20.2* RDWSD-63.1* Plt Ct-90*
___ 05:41PM BLOOD Neuts-83.3* Lymphs-6.7* Monos-8.6
Eos-0.6* Baso-0.2 Im ___ AbsNeut-11.59* AbsLymp-0.93*
AbsMono-1.20* AbsEos-0.08 AbsBaso-0.03
___ 06:02PM BLOOD ___ PTT-31.2 ___
___ 06:02PM BLOOD D-Dimer-7055*
___ 05:41PM BLOOD Glucose-100 UreaN-98* Creat-4.6*# Na-131*
K-5.3 Cl-93* HCO3-17* AnGap-21*
___ 05:41PM BLOOD ALT-12 AST-33 CK(CPK)-31 AlkPhos-125*
TotBili-3.0*
___ 05:41PM BLOOD Lipase-53
___ 08:50AM BLOOD CK-MB-4 cTropnT-0.03*
___ 03:45PM BLOOD CK-MB-4 cTropnT-0.03*
___ 05:41PM BLOOD Albumin-3.0* Calcium-9.2 Phos-5.8* Mg-2.0
___ 05:19AM BLOOD TSH-5.0*
___ 03:45PM BLOOD T4-5.0
___ 10:15AM BLOOD ASA-NEG Acetmnp-6* Tricycl-NEG
___ 10:30AM BLOOD ___ pO2-159* pCO2-28* pH-7.40
calTCO2-18* Base XS--5 Comment-GREEN TOP
___ 06:20PM BLOOD Lactate-2.7*
MICROBIOLOGY:
=================
___ 11:43 pm BLOOD CULTURE
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
Daptomycin MIC OF 2 MCG/ML test result performed by
Etest.
MICROCOCCUS/STOMATOCOCCUS SPECIES. PRESUMPTIVE
IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- 32 R
VANCOMYCIN------------ =>32 R
All other blood cultures were negative
___ 12:51 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 CFU/mL.
All other urine cultures were negative
___ 11:47 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___: NEGATIVE.
IMAGING:
==============
___ (UNILAT 2 VIEW) W/P
No acute fracture or dislocation.
___ (SINGLE VIEW)
No acute cardiopulmonary process.
___ OR GALLBLADDER US
1. Moderate hydronephrosis involving the right collecting
system, new compared
to prior study. Consider CT urogram to evaluate for an
obstructing lesion in
the ureter.
2. Patent TIPS extending from the left portal vein to the left
hepatic vein,
with similar velocities and direction of flow.
3. Cholelithiasis without evidence for cholecystitis.
4. Cirrhotic liver with sequela of portal hypertension,
including minimal
perihepatic ascites fluid and mild splenomegaly measuring up to
13.5 cm.
RECOMMENDATION(S): Consider CT urogram to evaluate for an
obstructing lesion
in the ureter.
___ SCAN
IMPRESSION: Low likelihood ratio for recent pulmonary embolism.
Patchy
perfusion images with more heterogeneity on the ventilation
images and no
mismatched defects is a pattern often seen with airways disease.
___ LOW EXT W/O C RIGHT
1. Within limitations of this noncontrast CT, no suspicious
mass or evidence
of nerve compression is identified. However this is better
evaluated on MRI.
2. No acute fracture, dislocation or significant degenerative
changes.
3. Please refer to the separate report from the concurrently
performed CT
abdomen and pelvis for assessment of the intraabdominal and
pelvic structures.
___ ABD & PELVIS W/O CON
1. Dilated ileal conduit, moderate right and mild left
hydroureter, and severe
right and moderate left hydronephrosis is new from prior CT.
Findings are
concerning for ileal conduit stricture and outflow obstruction.
2. Splenic and hepatic flexure bowel wall thickening and
pericolonic
stranding, which is concerning for colitis.
3. Cirrhotic liver with TIPS in place.
4. Cholelithiasis without evidence of cholecystitis.
___ LOWER EXT VEINS
No evidence of deep venous thrombosis in the right lower
extremity veins.
___ Echo Report
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. There is normal left ventricular
wall thickness with a normal cavity size. There is normal
regional and global left ventricular systolic function. The
visually estimated left ventricular ejection fraction is >=60%.
There is no resting left ventricular outflow tract gradient.
Dilated right ventricular cavity with depressed free wall
motion. There is abnormal interventricular septal motion c/w
right ventricular pressure overload. The aortic sinus diameter
is normal for
gender with normal ascending aorta diameter for gender. The
aortic arch diameter is normal with a normal descending aorta
diameter. There is no evidence for an aortic arch coarctation.
The aortic valve leaflets are moderately thickened. There is
mild aortic valve stenosis (valve area 1.5-1.9 cm2). There is no
aortic regurgitation. The mitral valve leaflets are mildly
thickened. There is no mitral regurgitation. The tricuspid valve
leaflets are mildly thickened. There is mild to moderate [___]
tricuspid regurgitation. There is SEVERE pulmonary artery
systolic hypertension. There is no pericardial effusion.
___ PLMT NEPHROSTOMY CATHETER
Successful placement of 8 ___ nephrostomy tube on both sides.
Bilateral distal ureter narrowing.
___ CT ABD & PELVIS W/O CON
1. Mild decrease in moderate bilateral hydronephrosisstatus post
placement of bilateral percutaneous nephrostomies. Minimal
interval decrease in dilation of ileal conduit just distal to
ureteral anastomosis with collapsed segment of ileum at the
stoma site and retraction of drainage tube, which remains in
place though terminates just beyond the peritoneum. Findings
remain concerning for ileal conduit stricture and outflow
obstruction.
2. Cirrhotic liver with TIPS in place.
___ PORTABLE ABDOMEN
Gas distention of the stomach with nonspecific paucity of small
and large bowel gas which may be secondary to fluid-filled loops
of bowel, as on prior.
___ U.S.
1. Unchanged severe right and moderate left hydronephrosis.
Assessment for subtle changes in hydronephrosis may be difficult
given severity of hydronephrosis. Correlation with PCN output
is recommended.
2. Small volume ascites.
___ NEPHROSTO
Technically successful upsizing to 10 ___ bilateral
nephrostomy tubes
___ L SPINE W/O CONTRAST
1. Mild canal narrowing at the T10-T11 level from partially
calcified disc protrusion.
2. Mild bilateral neural foraminal narrowing at the L4-5 level.
3. Large right-sided facet osteophyte causing mild neural
foraminal narrowing at L5-S1 level.
4. Right total cyst at S2 level.
___ ABDOMEN
Gaseous distension of the stomach. No abnormally dilated loops
of small or large bowel.
___ ABDOMEN
Normal gaseous distension of the stomach, decreased from
radiograph dated ___.
___ ABDOMEN
Persistent gaseous distention of the stomach. There are no
abnormally dilated
loops of large or small bowel. Osseous structures are
unremarkable. The Dobhoff tube courses past the left
hemidiaphragm and terminates in the gastric body. Bilateral
nephrostomy tubes, right lower quadrant embolization coils, and
bilateral pelvic surgical
clips are unchanged in position.
___ ABD & PELVIS W/O CON
1. No new acute abdominopelvic findings.
2. Interval resolution of bilateral hydronephrosis and ileal
conduit dilation. Percutaneous nephrostomy tubes appear
appropriately placed.
3. Interval placement of a ___ feeding tube terminating in
the first part of the duodenum.
4. Cirrhotic liver with TIPS in place. Moderate ascites
Brief Hospital Course:
Ms. ___ was a ___ year old woman with a history notable for
HCV c/b cirrhosis (s/p Harvoni, TIPS), transitional cell
carcinoma (s/p gem-cis chemotherapy, cystectomy w/ileal loop
urostomy), HTN and T2DM who presented to ___ with RLE pain and
was found to have severe hydronephrosis and associated acute
obstructive renal failure, bacteremia, decompensated cirrhosis,
and severe pulmonary hypertension.
ACTIVE MANAGEMENT:
=====================
#Goals of Care
#Death
Patient was made CMO following meeting on including HCP and
Palliative care on ___. Her care then focused on pain
management with IV dilaudid and ativan. She was pronounced dead
on ___ at 1131 am when the nurse called the primary team to
the bedside. Death was attributed to acute hypoxemic respiratory
failure secondary to decompensated cirrhosis.
#Decompensated Cirrhosis with portal hypertension
#Hyperbilirubinemia
MELD-Na 33 on admission, from 13 in ___ the sharp increase was
mostly attributabled to her severe ___ and ___ increase in Cr.
TIPS was confirmed to be patent on RUQUS from ___. Given the
patent had diffuse abdominal tenderness, SBP was suspected,
although there was minimal ascites and no tappable fluid pocket;
she was empirically treated with antibiotics. No evidence of
variceal bleeding. Patient initially received albumin for volume
resuscitation, and was continued on her home rifaximin and
pantoprazole. Home direutics were held i/s/o acute renal
failure. INR started increasing (up to 3.0) and total bili
ranged from 2.0 to 3.0
___
#Hydronephrosis
Pt admitted with a Cr > 5 with baseline 0.7 just one month
prior. Possibly multifactorial, with bilateral hydronephrosis
seen on US and CT c/f ileal conduit stricture causing acute
obstructive renal failure, as well as recent heavy NSAID use in
last month (which patient had been taking for her RLE pain). The
patient initially had a stomal catheter placed on ___, with
little improvement. Cr peaked at 6.1 on ___, but down-trended
after she had bilateral percutaneous nephrostomy tubes placed by
___ team on ___. By ___, Cr had normalized. On ___ Cr peaked
again at 1.6, nephrostomy tubes were upsized and Cr normalized.
On ___ there was a 48 hour rise up to 1.3 before normalizing,
likely ___ to poor PO intake.
#Bacteremia
#Leukocytosis
Blood culture from admission (___) grew GPCs in pairs and
chains, and eventually speciated to vancomycin-resistant
enterococcus, micrococcus, and stomatococcus. Possibly a
contaminant given only 1 tube, but patient had a persistent
white count for several days. She remained afebrile throughout
admission. Patient was initially broadly covered with vancomycin
+ ceftazidime, but vancomycin was converted to daptomycin on ___
when sensitivities resulted. ID followed the patient and
recommended treatment with ceftazidime (completed ___, to
treat for a likely GI source of SBP, and daptomycin (completed
on ___. Leukocytosis persisted until ___, although no clear
etiology was determined.
#Pulmonary HTN
#ST elevations on EKG
Shortly after admission, patient had an EKG c/f ST elevations in
leads V1-V3. Cardiology evaluated the patient and determined
that a STEMI was very unlikely. Troponins were elevated i/s/o
acute renal failure, but CK-MB was wnl. A TTE was performed, and
showed elevated PA pressure and dilated, hypokinetic RV
consistent with new onset pulmonary HTN. The likely etiology is
portopulmonary HTN, given her liver disease. Unlikely ___
pulmonary emboli given negative V/Q scan, and unlikely ___ left
heart failure given TTE w/o evidence of LV dysfunction. Right
heart catheterization was attempted on ___ following resolution
of the ___. However she could not tolerate lying on the
procedure table. Further work-up was deemed not necessary
following family meeting on ___.
#Abdominal pain
#Nausea/Vomiting
Pt had diffuse and significant abdominal pain on admission, with
associated nausea/vomiting. This was thought to be largely due
to her significant uremia, acute renal failure, and significant
hydronephrosis. Given cirrhosis, elevated WBC, and AMS there was
initial concern for SBP, but her US on arrival showed only trace
ascites. Her CT Abd/Pelvis from ___ CT demonstrated colitis,
which may also have contributed to her pain, although the
patient remained afebrile and had no diarrhea to cause concern
for C diff. As above, the patient was empirically treating for
intra-abdominal infections and SBP, and given aggressive pain
control with Dilaudid 0.25-0.5 mg IV Q3H:PRN. Tube feeds were
attempted though she began having intermittent projectile
vomiting. KUB on ___ showed a greatly distended stomach. She
was given reglan and bowel rest. The following day, KUB showed a
decrease in distension. Tube feeds were intermittently attempted
however she would then have recurrent abdominal pain and
vomiting. KUB on ___ showed stomach distension again. Tube
feeds were never run faster than 10cc/hr rate when they were
given. Feeding tube was withdrawn on ___.
#RLE pain
#Back Pain
Patient's presenting complaint was severe RLE pain. MRI from OSH
showed degenerative facet arthropathy with some impingement on
L3-L5 roots, which is the likeliest cause of her symptoms.
Severe hydronephrosis was also very likely contributed to her
back pain, although this is much less likely to have caused the
thigh/leg pain. No MRI findings were c/f metastatic tumors in
the patient's femur or lumbar spine. As above, patient's pain
was managed with Dilaudid.
#Suicidal Ideations
There was initial concern that patient may have been suicidal in
ED on presentation. This was discussed with the patient's
brother-in-law ___ on ___, who stated that she may
have had occasional passive suicidal ideations over the 2
weeks prior to her admission, likely attributable to her severe
RLE pain. He is not aware of her making any attempts to overdose
on NSAIDs. Over course of admission, patient denied suicidal
ideations, but endorsed depression and had a flat affect at
times.
#Anion-gap metabolic acidosis
#Lactic acidosis
Patient had AGMA and elevated lactate on admission, likely in
the setting of acute renal failure and lactic acidosis from
volume depletion and infection. Repeat lactate level the
following day was normal.
CHRONIC ISSUES:
===============
#T2DM - Not on medications at home, but was maintained on ISS
while hospitalized until placed on CMO.
#Hypothyroidism - Continued home levothyroxine until placed on
CMO
#Hypertension. Initially held home meds i/s/o acute infection,
c/f hypotension
#GERD. Continued home PPI
# CONTACT: ___ |Brother-in-Law| ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q24H
3. Furosemide 20 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Rifaximin 550 mg PO BID
7. Spironolactone 50 mg PO DAILY
8. biotin 5 mg oral DAILY
9. Senna 17.2 mg PO QHS
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
11. Lactulose 15 mL PO TID
12. Levothyroxine Sodium 50 mcg PO DAILY
13. Ferrous GLUCONATE 324 mg PO DAILY
14. Metoprolol Succinate XL 50 mg PO DAILY
15. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
Patient died from acute hypoxemic respiratory failure secondary
to decompensated cirrhosis on ___ at 1131 am while on
comfort measures only.
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient died from acute hypoxemic respiratory failure secondary
to decompensated cirrhosis on ___ at 1131 am while on
comfort measures only.
Discharge Condition:
Patient died from acute hypoxemic respiratory failure secondary
to decompensated cirrhosis on ___ at 1131 am while on
comfort measures only.
Discharge Instructions:
Patient died from acute hypoxemic respiratory failure secondary
to decompensated cirrhosis on ___ at 1131 am while on
comfort measures only.
Followup Instructions:
___
|
10393551-DS-5 | 10,393,551 | 24,556,198 | DS | 5 | 2163-08-13 00:00:00 | 2163-08-14 05:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right ankle pain
Major Surgical or Invasive Procedure:
Right ankle ORIF ___, ___
History of Present Illness:
___ male otherwise healthy who presents with the above
fracture s/p mechanical fall. He was at a concert 1.5 hours ago
when he sustained this injury and admits to heavy EtOH use (12
beers) and LSD use while at the concert. No HS or LOC.
Past Medical History:
none
Social History:
___
Family History:
non-contributory.
Physical Exam:
afebrile. hemodynamically stable
General: No acute distress
Right lower extremity: Dressing is clean, dry and intact.
extremity is neurovascularly intact.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right ankle fractureand was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for open reduction and internal fixation right ankle,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home was appropriate. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non-weight bearing in the right lower extremity, and will be
discharged on <<>> for DVT prophylaxis. The patient will follow
up with Dr. ___ routine. A thorough discussion was had
with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
RX *acetaminophen 650 mg 1 tablet(s) by mouth 5x per day Disp
#*70 Tablet Refills:*0
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*28 Capsule Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
wean as tolerated. dispose of excess tablets.
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours as
needed Disp #*28 Tablet Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp
#*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right ankle fracture dislocation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non-weight bearing right lower extremity until follow up.
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add *** as needed for increased pain. Aim to wean off
this medication in 1 week or sooner. This is an example on how
to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take aspirin 325 mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- 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
FOLLOW UP:
Please follow up with Dr. ___ in the ___ Trauma
Clinic ___ days post-operation for evaluation. Please call
___ to schedule appointment.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Followup Instructions:
___
|
10393736-DS-2 | 10,393,736 | 22,225,353 | DS | 2 | 2180-10-25 00:00:00 | 2180-10-25 14:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___ weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with a history of
hypertension
and previous DVT/PE (no longer on coumadin) who presents as a
transfer from ___ after receiving IV tPA
approximately 2 hours after the onset of left sided weakness.
She
was last seen normal at 1:45pm when she got into the bathtub
without difficulty. Shortly thereafter she called out for her
son
saying that she couldn't move. He came to find her with slurred
speech and left sided weakness. He called EMS and she was
brought
to ___, where a stat head CT was performed. By report
this showed no evidence of hemorrhage or acute infarct (images
currently being uploaded). Neurology was consulted and found her
to have an NIHSS of 8, with dysarthria, a mild left facial
droop,
a left visual field cut, left sided neglect, and drift of her
left ___ and ___ leg. She was given IV tPA starting at 3:35pm
and was subsequently transferred to ___ for further
management.
Upon arrival her repeat NIHSS was 10, with some confusion in
answering the LOC questions, a left facial droop, dysarthria,
mild drift of the left and leg, and left sided neglect. The
strength in her left arm and leg had improved significantly
however to the point that she was nearly full strength on formal
testing. Her speech also sounded much more clear according to
her
family. A repeat CT/A/P showed no acute abnormalities and no
vessel occlusions.
ROS negative except as above.
Past Medical History:
HTN
DVT/PE previously on coumadin - taken off within the last 6
months per her daughter
Social History:
___
Family History:
No known history of neurologic disorders
Physical Exam:
ADMISSION:
Physical Exam:
Vitals: 97.4 83 160/87 18 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Alert, oriented to self and hospital, does not
know date. Says she is ___ years old. Speech is significantly
dysarthric but her language is fluent with intact naming,
repetition, and comprehension. Able to follow both midline and
appendicular commands. She has visual and tactile neglect on the
left.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. Decreased response to visual
stimuli on the left.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: L lower facial droop
VIII: Hearing intact to voice.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. +L pronator drift.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 4+ ___ ___- 5 5- 4+ 5
R 5 ___ ___ 5 5 5 5
-Sensory: Difficulty complying with formal sensory testing but
no
obvious deficits to light touch or pinprick
-DTRs: slightly brisker throughout on the left, toes upgoing
bilaterally
-Coordination: FNF intact on the R but mildly ataxic on the L,
seemingly in proportion to her weakness
-Gait: Deferred
Discharge: Unchanged from above apart from increased
disorientation; patient was not oriented to place this morning.
Pertinent Results:
___ 06:51PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 06:51PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:51PM URINE BLOOD-SM NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 06:51PM URINE RBC-3* WBC-23* BACTERIA-MOD YEAST-NONE
EPI-<1
___ 05:48PM GLUCOSE-119* UREA N-22* CREAT-1.0 SODIUM-138
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-27 ANION GAP-10
___ 05:48PM cTropnT-<0.01
___ 05:48PM CALCIUM-8.9 PHOSPHATE-4.5 MAGNESIUM-2.1
___ 05:48PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 05:48PM WBC-8.3 RBC-3.60* HGB-11.0* HCT-34.8* MCV-97
MCH-30.5 MCHC-31.5 RDW-13.1
___ 05:48PM NEUTS-76.4* LYMPHS-16.6* MONOS-4.7 EOS-1.7
BASOS-0.6
___ 05:48PM PLT COUNT-249
___ 05:48PM ___ PTT-21.5* ___
CT/A/P:
IMPRESSION:
No vascular territorial infarct, hemorrhage or mass effect.
There are old
lacunar infarcts versus prominent perivascular spaces in the
left basal
ganglia and thalamus.
Head and neck CTA is unremarkable, without evidence of
significant stenosis, dissection or aneurysm larger than 2 mm.
10 x 11 mm right thyroid lobe hypodense nodule. Recommend
thyroid sonography for further evaluation, as clinically
warranted.
There is a patulous esophagus with layering debris, which may
place the
patient at-risk for aspiration.
MRI:
IMPRESSION:
1. Acute infarction in the right thalamus, and multiple small
acute
infarctions in bilateral superior parietal lobes, left occipital
pole, and posterior inferior left cerebellar hemisphere. The
distribution of the infarctions suggests a central embolic
source.
2. No evidence of intracranial hemorrhage.
Echo:
The left atrium is mildly dilated. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened. No
masses or vegetations are seen on the aortic valve. There is a
minimally increased gradient consistent with minimal aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Brief Hospital Course:
ICU Course:
___ is a ___ F with h/o HTN, DVT/PE (not on coumadin)
transferred from ___ where she received tPA for acute
onset left sided weakness. There was some improvement in left
sided motor function after tPA. She continues to have an ataxic
hemiparesis on the left, a left facial droop and dysarthria.
The patient was admitted to the neuro ICU for close monitoring
following treatment with IV tPA. She remained stable overnight.
Repeat head CT at 24 hours post tPA administration showed no
evidence of infarction. She was restarted on ASA 81mg daily and
subcutaneous heparin for DVT prophylaxis. She was transferred to
the neurology floor for continued care under the stroke team.
Floor Course:
Ms ___ was admitted to the Stroke Service at ___
___ after presenting with ___ weakness. She had an
MRI of her brain that showed multiple small infarcts. She had an
episode of atrial fibrillation during her admission. Her rhythm
normalized with IV metoprolol and her atrial fibrillation did
not recur. She likely has paroxysmal afib and this is likely
the underlying etiology of her infarcts. She was started on
heparin after her episode of atrial fibrillation; however, she
had frank blood in her stool the morning after starting heparin
so her heparin was discontinued and she was continued on aspirin
instead. her hematocrit remained stable. Consideration could
be given to an outpatient colonoscopy if her symptoms persist.
She was also noted to have a urinary tract infection which was
treated with 5 days of IV ceftriaxone.
Medications on Admission:
Lisinopril 2.5mg qday
Aspirin 81mg qday
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain / fever > 101.5
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Senna 17.2 mg PO HS
5. Lisinopril 2.5 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Multiple ischemic infarcts
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms ___,
You were admitted to the Stroke Service at ___
after presenting with ___ weakness. You had an MRI of
your brain that showed multiple small strokes. You had an
episode of abnormal heart beat called atrial fibrillation. This
likely also happened prior to your admission to the hospital and
was likely the cause of your strokes by causing small blood
clots to travel from your heart to your brain. You were
initially started on a blood thinner to try to prevent further
clots from forming in your heart and traveling to your brain;
however, you had an episode of bloody stool making it necessary
to stop the blood thinner. You were continued on a baby aspirin
in place of the blood thinner. Your blood counts remained
stable despite your bloody stool. You were also noted to have a
urinary tract infection which was treated with antibiotics.
Followup Instructions:
___
|
10393792-DS-9 | 10,393,792 | 20,977,284 | DS | 9 | 2126-11-18 00:00:00 | 2126-11-23 15:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___: Video-Assisted Thoracostomy with Pleural Fluid Drainage
and Decortication of Pleural Lining
History of Present Illness:
PCP:
Name: ___.
Location: ___
Address: ___
Phone: ___
Fax: ___
HPI:
___ yo transgender man->woman with HBV cirrhosis, eAg-negative,
eAb positive HBV on tenofovir, who presents with acute R
chest/abd/back pain x2 weeks. She states she developed acute
pain as above, sharp, radiating and made worse with
breathing/coughing/movement. She has never had this pain
before. She describes SOB with this pain and subjective fever.
She denies HA, productive cough, ST, lower abd pain, or n/v.
She denies change in bowel or bladder habits. She presented to
the ED on ___ and had essentially negative CTU. She was
treated supportively. She denies new swelling or rash.
in the ED, CXR noted new effusion, consolidation in RLL. ___
12. Hospitalized for further evaluation of pleural effusion.
RUQ US negative. She states ongoing pleuritic chest pain
flu shot 3 days prior but no URI sxs
10 point review of systems reviewed, otherwise negative except
as listed above
Past Medical History:
eAg-negative (precore mutation) HBV and cirrhosis.
Social History:
___
Family History:
1) Mother deceased; history of hepatitis B.
2) Brothers deceased; history of hepatitis B and alcohol excess.
3) Father with unknown health history.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.1, BP 115/76, HR 80, RR 14, 97%RA
GEN: well appearing in NAD
HEENT: MMM, OP clear, anicteric sclera
NECK: supple no LAD
HEART: RRR no mrg
LUNG: dullness to percussion and ausculatation at R base.
limited inspiration by pain noted on exam. No wheeze.
Concurrent R basilar crackles above dullness
ABD: soft NT /ND +BS no rebound. No fluid wave
EXT: warm well perfused no pitting edema
SKIN: no rashes noted
NEURO: no focal deficits noted
DISCHARGE PHYSICAL EXAM:
Vitals: 98.6, 106/62, 69, 18, 96% RA
I/O: 150/450 last shift
Weight: NR
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally; slightly diminished
breath sounds on left but improved from prior day
CV: RRR, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, NTTP, non-distended, bowel sounds present, no rebound
tenderness or guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: R chest tube c/d/I s/p CT being pulled; blanching, patchy
rash overlying R thoracolumbar back improving (has been present
since admission)
NEURO: A&O x3, moving extremities well grossly
Pertinent Results:
ADMISSION LABS:
-----------------
___ 03:54AM BLOOD WBC-12.6*# RBC-3.94 Hgb-13.1 Hct-38.3
MCV-97 MCH-33.2* MCHC-34.2 RDW-11.9 RDWSD-43.4 Plt ___
___ 03:54AM BLOOD Neuts-81.1* Lymphs-9.8* Monos-6.5 Eos-1.8
Baso-0.2 Im ___ AbsNeut-10.20*# AbsLymp-1.23 AbsMono-0.82*
AbsEos-0.22 AbsBaso-0.03
___ 03:54AM BLOOD ___ PTT-38.3* ___
___ 03:54AM BLOOD Glucose-105* UreaN-16 Creat-1.2* Na-142
K-3.7 Cl-110* HCO3-22 AnGap-14
___ 03:54AM BLOOD ALT-24 AST-26 AlkPhos-100 TotBili-0.8
___ 03:54AM BLOOD Lipase-30
___ 03:54AM BLOOD Albumin-3.2* Calcium-9.2 Phos-2.1* Mg-1.8
___ 03:54AM BLOOD D-Dimer-413
___ 03:54AM BLOOD HCG-<5
___ 04:01AM BLOOD Lactate-1.0
OTHER IMPORTANT LABS:
___ 11:05AM BLOOD HIV Ab-Negative
___ 09:50PM BLOOD Vanco-8.7*
___ 06:53AM BLOOD Vanco-16.3
___ 07:45AM BLOOD Vanco-9.9*
___ 08:13AM BLOOD Vanco-32.4*
___ 03:45PM BLOOD Vanco-19.9
___ 11:29AM BLOOD Vanco-6.7*
___ 05:33AM BLOOD Glucose-95 Lactate-2.4* Na-134 K-4.2
Cl-101
___ 05:33AM BLOOD Type-ART pO2-71* pCO2-32* pH-7.42
calTCO2-21 Base XS--2 Intubat-NOT INTUBA
___ 06:32AM URINE Hours-RANDOM UreaN-270 Creat-41 Na-14
K-17 Cl-10
___ 06:32AM URINE Osmolal-190
___ 03:54AM URINE UCG-NEG
___ 02:38PM PLEURAL WBC-1550* Hct,Fl-3* Polys-82*
Lymphs-13* Monos-5*
___ 02:38PM PLEURAL Hct,Fl-3*
___ 02:38PM PLEURAL TotProt-4.9 Glucose-32 LD(LDH)-662
Albumin-2.4 Cholest-51
MICROBIOLOGY:
---------------
___ Pleural fluid culture: GNR's most likely fusobacterium
per microlab and GPCs most likely peptostreptococcus
___ Blood Culture: Negative
___ Blood Cultures x2: Negative
___ Urine legionella: Negative
___ Blood cultures x2: Negative
___ Urine Culture: Negative
___ BAL: Negative for malignant cells; AFB smear negative;
No nocardia, fungus, or legionella; Acid Fast Culture pending
___ Pleural fluid culture: Negative; Acid Fast Culture
pending
___ Pleural tissue culture: Negative
___ Induced sputum: AFB smear negative; culture pending
___ Induced Sputum: AFB smear negative; culture pending
___ Quantiferon Gold Assay: Indeterminant
IMAGING AND OTHER STUDIES:
___ Liver U/S: Coarsened liver consistent with cirrhosis.
No focal hepatic lesions. A gallbladder polyp measures 4 mm.
___ CT CHEST W/CONTRAST: Large loculated nonhemorrhagic
right pleural effusion, a chest tube identified, its tip
superior in location. Suggest retracting chest tube fore better
drainage. There are notably no pleural implants or abnormal
enhancement identified. Multifocal consolidations within the
left upper lobe are nonspecific. Organizing pneumonia is
favored.
___ CXR: Comparison to ___. Increase in extent
of both the left and the right pleural effusion. The right chest
tube has been pulled back. Areas of consolidation at the lung
bases to also increase. Unchanged mild to moderate pulmonary
edema. The heart border can no longer be clearly visualized.
DISCHARGE LABS:
----------------
___ 06:47AM BLOOD WBC-10.5* RBC-3.62* Hgb-11.7 Hct-35.3
MCV-98 MCH-32.3* MCHC-33.1 RDW-12.3 RDWSD-44.2 Plt ___
___ 06:47AM BLOOD Glucose-96 UreaN-25* Creat-2.0* Na-135
K-4.2 Cl-100 HCO3-27 AnGap-12
___ 06:53AM BLOOD ALT-39 AST-80* LD(LDH)-233 AlkPhos-293*
TotBili-1.2
___ 06:47AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.4
Brief Hospital Course:
Ms. ___ is a ___ transgender woman (male to female) with a
history of hep B cirrhosis (well-compensated) c/b esophageal
varices and portal hypertensive gastropathy admitted for sepsis
most likely ___ aspiration pna and associated R-sided Empyema
s/p VATS with decortication and drainage.
# Aspiration PNA/Empyema/sepsis: The patient originally
presented with hypoxia, fevers, and leukocytosis i/s/o chest CT
showing multifocal consolidations and large R-sided pleural
effusion. She underwent thoracentesis with IP on ___ with
fluid analysis showing elevated LDH and pH 6.99, c/w empyema,
and was transferred to the ICU for further management of her
hypoxic respiratory distress. She was empirically treated with
Vancomycin/Zosyn/Levaquin and had a chest tube placed with
significant improvement in symptoms. She subsequently undrewent
VATS with decortication and drainage of empyema on ___,
which improved patient's symptoms significantly. Regarding abx
management, she was initially on Vanc/Zosyn/Levaquin (first dose
___ with levaquin changed to azithro on ___. With
guidance of ID and cultures from thoracentesis growing
peptostreptococcus and fusobacterium (c/w aspiration as etiology
of infection), the patient was changed to course of ceftriaxone
2g IV daily and flagyl 500mg PO TID, with first dose considered
as POD1 from VATS ___ for 14 day course). On discharge, the
patient had her chest tubes d/c'ed, was breathing well on RA,
and had a MIDD line placed for continued IV abx therapy at home.
She was set up for ___ with both her PCP as well as ID.
# ___: The patient presented with a baseline Cr of ___, which
peaked at 2.2 during this admission, most likely ___ CIN I/s/o
recent contrast exposure (during CT with contrast on ___. For
her ___, the patient was managed supportively and her Cr was
still downtrending at discharge. Her medications were renally
dosed throughout this hospitalization
CHRONIC/RESOLVED/STABLE ISSUES:
# Hypoxia: The patient developed rapidly worsening respiratory
status on admission and was managed for her PNA/empyema as
above, briefly in the ICU. In addition to management of her
infection, she was treated supportively with supplemental O2 as
needed and duonebs PRN. She was discharged saturating well on RA
and with follow up with thoracics for wound care
post-hospitalization.
# Cirrhosis ___ Hepatitis B: The patient had HBeAg-negative HBV
and stage 1 fibrosis (per LBX ___, c/b varices, and portal
gastropathy. She had no evidence of ascites on admission and was
continued on her home tenofovir (dosed renally I/s/o CIN)
throughout this admission. She is followed by liver clinic as an
outpatient and was instructed to ___ with them after
discharge.
# Nephrolithiasis: For her history of nephrolithiasis, she was
managed on her home tamsulosin during this admission.
TRANSITIONAL ISSUES:
-Patient was discharged on antibiotic therapy with Ceftriaxone
2g IV daily and Flagyl 500mg PO q8H for total 14 day course
(first dose ___ - last dose ___
-She was discharged with follow up with thoracics (suture
removal and post-op care), ID, and her PCP
-___ hospitalization was complicated by ___ likely due to
contrast induced nephropathy. Her Cr was improving on discharge
and she was instructed to have chem-7 drawn on ___ and have
results faxed to her PCP for ___ discharge, she had asymptomatic, mild elevation in LFTs and
was instructed to have repeat LFTs drawn on ___ and have
results faxed to her PCP for ___ suspicion for aspiration as the cause of her pneumonia
and empyema, she underwent and passed speech and swallow
evaluation.
-During this hospital stay, due to worsening kidney function in
the setting of CIN, the patient's tenofovir dosing was changed
from 300mg PO q24H to q48H. Please follow up with PCP regarding
future dosing of this medication once your kidney function
stabilizes.
Medications on Admission:
Tenofovir 300mg daily
Tylenol ___ MG TID
Ibuprofen 600mg QID prn
Vitamin D
Flomax 0.4mg daily/HS
Discharge Medications:
1. CeftriaXONE 2 gm IV Q24H
Last dose on ___
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams IV once
a day Disp #*9 Intravenous Bag Refills:*0
2. Tenofovir Disoproxil (Viread) 300 mg PO Q48H
3. Acetaminophen 500 mg PO Q6H pain
RX *acetaminophen 500 mg 1 tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*0
4. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
Last dose on ___
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8
hours Disp #*27 Tablet Refills:*0
5. Tamsulosin 0.4 mg PO QHS
6. Outpatient Lab Work
Please have LFTs (ICD 10: R74.0) and Chem 7 (ICD 10: N17.9)
drawn on ___ and have results faxed to Dr. ___
(___).
7. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
8. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
--------------------
-Aspiration Pneumonia with Empyema
SECONDARY DIAGNOSIS/ES:
-Acute Kidney Injury secondary to Contrast Induced Nephropathy
-Hypoxic Respiratory Failure
-Compensated Cirrhosis secondary to Hepatitis B
-Nephrolithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for chest pain, difficulty breathing,
and fevers. You were found on X-ray to have a pneumonia and
fluid in the sac around your lungs. Studies of this fluid showed
infection, for which you were given antibiotics intravenously
(through your veins). You were monitored closely in the
intensive care unit (ICU) and underwent a surgery to drain this
fluid. Following this surgery, you were monitored initially in
the ICU, then on the general medicine floor. You were changed
from intravenous to oral antibiotics and improved rapidly.
On discharge, you were breathing well with no more fevers. You
were sent home with instructions to continue taking antibiotics
and to follow up with your outpatient doctors ___ detailed
below).
Thank you for allowing us to be a part of your care,
Your ___ Team
Followup Instructions:
___
|
10393855-DS-15 | 10,393,855 | 23,109,643 | DS | 15 | 2179-06-20 00:00:00 | 2179-06-24 16:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___
___ Complaint:
EtOH intoxication
Major Surgical or Invasive Procedure:
___: Intubation
History of Present Illness:
Ms. ___ is a ___ yo F with a sig PMHx of sickle cell disease
who presents with acute alcohol intoxication. A limited history
was obtained given her altered mental status.
Briefly, the patient was at a party and consumed 8 servings of
hard alcohol. She was found to be altered and EMS was called.
When they arrived, she was vomiting in the bathroom and
unresponsive. She was arousable to sternal rub. She was brought
to ___ for further management. En route, she was de-satting to
88% and continuing to actively vomit.
On arrival, the patient was intubated (MAC 3, 7.0 ETT) for
airway
protection and transferred to the MICU.
In the ED:
- Initial vitals were:
T97.8 HR68 BP102/66 RR20 SPO2 100% intubated
- Exam notable for:
Patient was clearly intoxicated. She was actively vomiting and
was not clearing her secretions. Her head was needed to be held
up so she did aspirate
- Labs notable for:
VBG: pH 7.33 pCO2 45 pO2 92 HCO3 25
Lactate: 1.8
CBC: Hb 8.6 -> 9.7 WBC 4.1
BMP: Na 140 BUN/Cr ___
LFTs: AST 41 ALT 9
serum etoh: 215
serum acetamin: pos
serum asa 0.30
serum bzd, barb, tca: neg
- Imaging was notable for:
+CXR: pnd
- Patient was given:
IV DRIP Fentanyl Citrate
IV DRIP Midazolam
Upon arrival to the ICU, patient is intubated and sedated.
Review of systems was negative except as detailed above.
Past Medical History:
Sickle Cell Disease
Social History:
___
Family History:
Unable to obtain
Physical Exam:
ADMISSION EXAM:
VITALS: Reviewed in MetaVision.
GENERAL: intubated and sedated.
HEENT: Small amount of bloody secretions coming from OG tube, NG
tube in place, NC/NT
CARDIAC: RRR, no m/r/g
PULMONARY: CTA ___
ABDOMEN: Abdomen distended but not tense
EXTREMITIES: No clubbing, cyanosis or edema
SKIN: Warm and dry
NEURO: Pupils (3-->2 mm) equal and reactive
DISCHARGE EXAM:
VITALS: Reviewed in MetaVision.
GENERAL: Awake and conversant
HEENT: Small amount of bloody secretions coming from OG tube, NG
tube in place, NC/NT
CARDIAC: RRR, no m/r/g
PULMONARY: CTA ___
ABDOMEN: Non tender non distended abdomen
EXTREMITIES: No clubbing, cyanosis or edema
SKIN: Warm and dry
NEURO: Pupils (3-->2 mm) equal and reactive
Pertinent Results:
PERTINENT RESULTS:
___ 03:05AM BLOOD WBC-6.0 RBC-2.43* Hgb-8.6* Hct-24.8*
MCV-102* MCH-35.4* MCHC-34.7 RDW-16.3* RDWSD-59.4* Plt ___
___ 03:05AM BLOOD Glucose-147* UreaN-5* Creat-0.6 Na-139
K-3.1* Cl-104 HCO3-23 AnGap-12
___ 03:05AM BLOOD ASA-0.30* ___ Acetmnp-POS*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CXR:
"Interval placement of endotracheal tube ending 1.5 cm above the
carina.
1-2 cm retraction is recommended.
2. No evidence of consolidation, effusion, or pneumothorax."
Brief Hospital Course:
Key Information for Outpatient Providers:Ms. ___ is a ___ yo
F with a history of sickle cell disease
who presents with acute alcohol intoxication.
#Acute Hypoxic Respiratory Failure:
The patient presented after significant vomiting due to alcohol
consumption. She initially desaturated en route, and given her
altered mental status, she was intubated for airway protection.
Her mental status improved and she was able to be extubated
without issue.
#Toxic Metabolic Encephalopathy:
#ETOH Intoxication:
The patient presented after significant alcohol consumption and
intoxication that was likely accidental. On arrival, she
was obtunded and only arousal to sternal rub. Serum ETOH 215 was
likely the source of her altered mentation. Of note, the patient
had a positive toxicology screen for ASA and Acetaminophen as
well. She was given IV fluids and he repeat Tylenol level was
negative.
#Sickle cell disease:
The patient's hemoglobin was 9.2 on admission and she had a low
haptoglobin. Therefore, there was concern for a sickle crisis.
Her repeat hemoglobin was stable so she was discharged home
after getting IV fluids.
TRANSITIONAL ISSUES:
=================================
[ ] Please limit alcohol intake
[ ] monitor CBC to ensure anemia resolving
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Acute Hypoxic Respiratory Failure
Toxic Metabolic Encephalopathy
Alcohol Intoxication
Secondary Diagnosis:
Sickle Cell disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted because you were intoxicated and we were
worried about your safety.
WHAT WAS DONE WHILE I WAS HERE?
We put a breathing tube down your airway and connected you to a
breathing machine because we were worried about your breathing.
We gave you fluids and monitored you until you were safe to
breathe on your own and then we removed the tube. We monitored
your lab work closely.
WHAT SHOULD I DO NOW?
You should take your medications as instructed.
You should go to your doctors ___ as below.
We wish you the best!
-Your ___ Care Team
Followup Instructions:
___
|
10394561-DS-11 | 10,394,561 | 23,430,554 | DS | 11 | 2146-07-19 00:00:00 | 2146-07-19 20:45:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
tramadol / oxycodone / codeine
Attending: ___
Chief Complaint:
Mechanical fall
Major Surgical or Invasive Procedure:
___ - T11-T12 fusion and T11, T12, partial L1 laminectomy
for epidural hematoma evacuation
History of Present Illness:
___ female with newly diagnosed ALS presenting with L1
fracture. Patient had what she describes as a mechanical trip
and fall while at her independent living facility. She was able
to crawl in order to get help. She was taken to ___,
where she was found to have a negative CT head and CT C-spine,
but a CT L-spine showing an acute fracture of L1 with an
associated
epidural fluid collection and moderate central canal narrowing.
She was transferred here for spinal surgery consultation. She
states that she otherwise feels at her baseline. No fevers, no
headache, visual change, no chest pain. She denies numbness,
tingling or weakness in extremities. She denies new bowel or
bladder incontinence.
Past Medical History:
PMHx:
ALS
HYPERTENSION
LEFT BUNDLE BRANCH BLOCK
MITRAL REGURGITATION
CORONARY ARTERY DISEASE
FRACTURED BONE
MOHS SURGERY
TUBAL LIGATION
APPENDECTOMY
GERD
PROLAPSED BLADDER
GENITAL HERPES
BACK PAIN
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
T: 97.8 BP: 143/81 HR: 72 RR: 20 O2Sats: 92% 4L NC
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs Intact
Neck: Supple.
Lungs: Increased work of breathing, with new O2 requirement
Cardiac: RRR.
Extrem: Warm and well-perfused.
Discharge Physical Exam:
Exam:
Opens eyes: [x]spontaneous [x]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Comprehension intact [x]Yes [ ]No
Motor:
Deltoid BicepTricepGrip
IPQuadHamATEHLGast
[-]Clonus ___ [x]Sensation intact to light touch
[x]Propioception intact
Pertinent Results:
Please see OMR for pertinent lab/imaging studies.
Brief Hospital Course:
SUMMARY:
=========
Ms. ___ is a ___ yo woman with recently diagnosed ALS, HTN, MR,
and CAD, who presented to ___ after mechanical fall, found to
have L1 fracture and new O2 requirement. She was initially
admitted to the neurosurgery service for evaluation of her T12
compression fracture. Ultimately her fracture required surgical
intervention due to development of epidural hematoma, see below.
She had a persistent oxygen requirement for further evaluation.
Her hypoxia was felt multifactorial in the setting of pain
causing splinting, inability to fully expand her lungs while
wearing TLSO brace, neuromuscular weakness in the setting of her
newly diagnosed ALS, abdominal distention from constipation.
Hypoxia improved with pain control, recruitment of the lung and
improvement in atelectasis, improvement in constipation. She
remained hemodynamically and neurologically stable and was
discharged to rehab on ___.
TRANSITIONAL ISSUES:
====================
[]Patient has Formal PFTs as outpatient scheduled for end of
___, sleep study scheduled for ___ need earlier if
desaturations continue at nighttime and raise concern for
apnea/inadequate nocturnal ventilation
[]Medications to restart on an outpatient basis: Baby ASA
(although neurosurgery recommends discontinuation of aspirin if
only for primary prevention purposes).
[]She will need to follow up with Dr. ___ in ___
clinic with AP/Lateral thoraco-lumbar XR.
ACUTE/ACTIVE ISSUES:
====================
#T12/L1 fracture due to
#Unwitnessed fall complicated by
#Epidural hematoma:
Imaging revealing of associated ventral epidural fluid
collection T11-L1 with mod central canal narrowing. CT head with
no intracranial abnormalities. Transferred from ___ for
___ eval, who initially determined there was no need for acute
surgical intervention given stable fracture with no neuro
deficits. Fall felt to be mechanical in nature based on
patient's description. Pain control provided with acetaminophen
1000mg Q8H, ibuprofen prn.
On ___ patient noted to have bilateral thigh pain in the
context of persistent urinary retention and fecal retention.
Her rectal tone was decreased, with normal perianal sensation.
An MRI L-spine on ___ demonstrated an intrathecal hematoma
from T11-L1, consistent with a partially imaged fluid collection
on CT L-spine done at ___. This fluid collection was
noted to compress the spinal cord anteriorly. Aspirin and SQH
were stopped at this point. Given compression effect, Pt was
taken urgently to the operating room on ___ after a family
discussion and discussion with Pt regarding her goals after
surgery. Patient underwent a T11-T12 fusion, and
T11/T12/partial L1 laminectomy for evacuation of epidural
hematoma. It was an uncomplicated procedure. Please see OMR for
detailed operative report. The patient was extubated in the OR,
and transferred to PACU. She remained hemodynamically and
neurologically stable and was transferred to the floor for
ongoing monitoring. A subfascial JP drain was placed
intraoperatively and despite occlusive dressing reinforcement,
the bulb did not maintain adequate suction. It was removed on
POD2, post pull XRs showed intact hardware and no retained
drain. She remained hemodynamically and neurologically stable
and was discharged to rehab on ___.
Activity recommendations were as follows:
Patient is required to wear TLSO brace when out of bed, and ___
___ the brace at edge of bed. Will need follow up in ___ clinic
as outpatient
#Acute Hypoxemic Respiratory Failure
Most likely due to atelectasis ___ pain, TLSO brace, ?aspiration
(see below) and underlying NM weakness from ALS. Hypoxia
improved with improved pain control and encouraged use incentive
spirometer/mobilization.
-Patient should have her outpatient PFT's as scheduled at the
end of ___.
#Question of dysphagia and
#Question of aspiration:
Patient noted on ___ to have some gurgling with swallowing
concerning for possible dysphagia. She was initially kept on a
modified diet of nectar-thick liquids and pureed solids per
discussion with the patient. Video swallow on ___
demonstrated "intermittent trace aspiration with thin
liquids...[and] prolonged mastication." As such, SLP
recommended a diet of thin liquids and pureed solids, to which
the patient was amenable.
CHRONIC/STABLE ISSUES:
======================
#ALS
Neurology team followed during admission. Continued home
riluzole, cyclobenzaprine and dextromethorphan-quinidine.
#Hypertension
Continued home amlodipine
#HLD
Continued home atorvastatin
#Family history of premature CAD:
Patient has family history of premature CAD without any
documented CAD or percutaneous interventions/bypasses of her
own. Her aspirin was held as above in the setting of
intrathecal/epidural hematoma. Neurosurgery recommends
discontinuation of aspirin if administered only for primary
prevention.
#Depression
Continued home citalopram
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QMON
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Citalopram 20 mg PO QHS
6. Cyclobenzaprine 5 mg PO HS:PRN spasms
7. dextromethorphan-quinidine ___ mg oral BID
8. LORazepam 1 mg PO QHS
9. Metoprolol Tartrate 25 mg PO BID
10. riluzole 50 mg oral BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Bisacodyl ___AILY:PRN Constipation - Second Line
3. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain - Moderate
RX *hydromorphone 2 mg 1 - 2 tablet(s) by mouth q6hrs Disp #*40
Tablet Refills:*0
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
5. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Second Line
Reason for PRN duplicate override: Alternating agents for
similar severity
6. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - Second Line
7. Polyethylene Glycol 17 g PO DAILY
8. Senna 17.2 mg PO BID
9. Alendronate Sodium 70 mg PO QMON
10. amLODIPine 10 mg PO DAILY
11. Atorvastatin 20 mg PO QPM
12. Citalopram 20 mg PO QHS
13. Cyclobenzaprine 5 mg PO HS:PRN spasms
14. dextromethorphan-quinidine ___ mg oral BID
15. LORazepam 1 mg PO QHS
16. Metoprolol Tartrate 25 mg PO BID
17. riluzole 50 mg oral BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
L1 fracture after a fall
Intrathecal/epidural hematoma status post operative drainage via
Acute hypoxemic respiratory failure, improved
Dysphagia
SECONDARY DIAGNOSES:
History of amyotrophic lateral sclerosis
History of 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 from your Medical Team
------
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I SEEN IN THE HOSPITAL?
-You had a fall.
WHAT HAPPENED WHEN I WAS IN THE HOSPITAL?
-You had a fracture of the lower part of your spine (L1).
Initially this was managed without surgery and a brace to keep
you steady.
-You began to have trouble urinating and defecating; repeat
imaging showed a small bleed around your spinal cord. For this
the Neurosurgery team performed an operation to remove the bleed
around your spinal cord.
-Your oxygen levels were low, likely in the setting of pain and
decreased moving around. As you began to get up and walk your
low oxygen levels improved.
-You had some trouble swallowing. Our swallow therapists
evaluated your swallowing and recommended a modified diet to
reduce your risk of choking on food; this included pureed solid
foods and thin liquids.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
-Please continue to take all your medications prescribed here.
-Please follow up with your doctors at your ___
appointments.
-Please keep your appointment for pulmonary function tests at
the end of ___, to see how well your lungs are working.
We wish you all the best!
Sincerely,
Your ___ Care Team
--------
Discharge Instructions from your Surgical Team
--------
Discharge Instructions
Spinal Fusion
Surgery
Your dressing may come off on the second day after surgery.
Your incision is closed with staples or sutures. You will need
suture/staple removal.
Do not apply any lotions or creams to the site.
Please keep your incision dry until removal of your
sutures/staples.
Please avoid swimming for two weeks after suture/staple
removal.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
You must wear your brace at all times when out of bed. You may
apply your brace sitting at the edge of the bed. You do not need
to sleep with it on.
You must wear your brace while showering.
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc
until cleared by your
neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs.
Followup Instructions:
___
|
10394720-DS-7 | 10,394,720 | 26,977,907 | DS | 7 | 2165-11-19 00:00:00 | 2165-11-19 18:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o prior stroke, afib with pacer, on dabigatran,
who presented to ED s/p syncopal fall with CT findings of tSAH
and non displaced occipital bone fracture. In ED patient went
into afib with RVR, and found to have right LL pneumonia with
supplement O2 requirement. She was admitted to ___ under
neurosurgery primary for further management.
Past Medical History:
Osteoporosis
Lipids
tobacco use
Social History:
___
Family History:
No family history of heart disease
Physical Exam:
=====================
ADMISSION PHYSICAL EXAM
=====================
GCS
Airway: [ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[x]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
GCS Total: 15
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious [ ]None
Orientation: [x]Person [x]Place [x]Time [ ]None
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL 4-3mm briskly reactive
EOM: [x]Full [ ]Restricted [ ]Unable to Assess
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No
Comprehension intact [x]Yes [ ]No
Motor:
Trap Deltoid Bicep Tricep Grip
Right5 4+ 5 5 5
Left5 5 5 5 5
IPQuadHamATEHLGast
Right5 5 5 5 5 5
Left4+ 5 5 5 5 5
Slight R delt weakness and L IP weakness secondary to prior
fractures of R shoulder and L pelvis.
[x]Sensation intact to light touch
======================
DISCHARGE PHYSICAL EXAM
======================
VITALS
24 HR Data (last updated ___ @ 751)
Temp: 98.0 (Tm 98.2), BP: 116/72 (102-116/58-72), HR: 60
(60-61), RR: 18 (___), O2 sat: 90% (90-97), O2 delivery: Ra
(1L-2L)
GENERAL: Elderly ___ speaking lying comfortably in
bed in no acute distress on room air
HEENT: NC/AT, sclera anicteric
NECK: JVP at clavicle w/ no HJR
CARDIAC: regular rhythm, normal rate. Normal S1 and
S2. No m/r/g.
LUNGS: crackles improved bilaterally, no increased work of
breathing, transmitted upper airway sounds, no wheezing, no
accessory muscle use
ABDOMEN: soft, non-distended, non-tender
EXTREMITIES: warm, well-perfused, no ___ edema
NEUROLOGIC: A&Ox3. No facial asymmetry. Moving bilateral UEs
normally.
Pertinent Results:
=============
ADMISSION LABS
=============
___ 10:57AM PLT COUNT-184
___ 10:57AM NEUTS-88.9* LYMPHS-2.9* MONOS-6.9 EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-13.46* AbsLymp-0.44*
AbsMono-1.05* AbsEos-0.00* AbsBaso-0.03
___ 10:57AM WBC-15.2* RBC-4.50 HGB-13.8 HCT-41.6 MCV-92
MCH-30.7 MCHC-33.2 RDW-14.6 RDWSD-49.9*
___ 10:57AM CK-MB-1 cTropnT-<0.01
___ 10:57AM GLUCOSE-142* UREA N-16 CREAT-1.0 SODIUM-134*
POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-21* ANION GAP-15
___ 11:02AM ___ PTT-32.9 ___
___ 11:03AM LACTATE-2.6*
===============
PERTINENT STUDIES
===============
___ CT spine w/o contrast:
1. 1.4 cm right thyroid nodule has significantly increased,
thyroid ultrasound
recommended to exclude neoplasm.
2. No acute fracture.
3. Degenerative changes.
4. Bilateral parotid masses, stable since ___.
___ NCHCT:
1. Anterior bifrontal, bitemporal, right vertex subarachnoid
hemorrhage.
2. There may be trace left frontal, right temporal subdural
hematoma.
3. Nondisplaced occipital bone fracture. Soft tissue swelling
scalp.
___ CTA chest:
1. No evidence of pulmonary embolism to the segmental level.
2. Mild pulmonary edema with moderate bilateral pleural
effusions, right
greater than left, and associated compressive atelectasis.
Moderate
centrilobular emphysema also noted.
___ TTE
The left atrium is elongated. The right atrium is mildly
enlarged. There is no evidence for an atrial septal defect by
2D/color Doppler. The estimated right atrial pressure is ___
mmHg. There is mild symmetric left ventricular hypertrophy with
a normal cavity size. There is normal regional and global left
ventricular systolic function. Quantitative biplane left
ventricular ejection fraction is 59 %. There is no left
ventricular outflow tract gradient at rest or with Valsalva.
Mildly dilated right ventricular cavity with normal free wall
motion. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch
diameter is normal. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. There is trace
aortic regurgitation. The mitral valve leaflets are mildly
thickened with no mitral valve prolapse. There is moderate
mitral annular calcification. There is mild [1+] mitral
regurgitation. There is mild pulmonic regurgitation. The
tricuspid valve leaflets appear structurally normal. There is
mild [1+] tricuspid regurgitation. There is mild pulmonary
artery systolic hypertension. The end-diastolic PR velocity is
elevated suggesting pulmonary artery diastolic hypertension.
There is no pericardial effusion.
Compared with the prior TTE (images reviewed) of ___ , a
wire/catheter is noted in the right ventricle, other findings
are similar. Left ventricular hypertrophy was previously
present. Atrial fibrillation is suggested in the current study.
___ ___
1. Interval decrease in previously seen bifrontal, right greater
than left,
subarachnoid hemorrhage, with near resolution. Previously seen
subarachnoid
blood along the floors of the bilateral middle cranial fossa is
also decreased
with minimal residual blood product.
2. Probable small right frontal intraparenchymal hemorrhage
shows minimal
residual density, improved compared to prior.
3. No definite residual subdural blood products are identified.
4. Unchanged nondisplaced occipital skull base fracture, as
above.
5. No new hemorrhage or large territorial infarction. No new
fracture.
Ventricles and sulci are age-appropriate.
6. Old right frontal and right occipital infarcts are again
seen, unchanged.
============
MICROBIOLOGY
============
Bloods cultures ___: No growth
=============
DISCHARGE LABS
=============
___ 07:20AM BLOOD WBC-11.5* RBC-4.66 Hgb-13.7 Hct-42.1
MCV-90 MCH-29.4 MCHC-32.5 RDW-14.2 RDWSD-47.2* Plt ___
___ 07:20AM BLOOD Plt ___
___ 07:20AM BLOOD Calcium-9.4 Phos-3.0 Mg-2.0
Brief Hospital Course:
Ms. ___ is an ___ female with a history of atrial
fibrillation/sick sinus syndrome/tachy-brady syndrome
status-post recent PPM placement ___ on dabigatran and
CVA without residual deficit admitted after mechanical fall with
head strike that resulted in SAH, SDH, and nondisplaced
occipital bone fracture. Course complicated by afib with RVR,
CAP and subsequent acute hypoxic respiratory failure, which
improved prior to admission.
====================
TRANSITIONAL ISSUES
====================
[] Follow up in ___ clinic, repeat head CT after 7 days revealed
improving ___/SDH
[] Patient completed 7 day course of Keppra for seizure
prophylaxis
[] Dabigatran was held for 7 days, and re-started when repeat
head CT showed improving ___
[] Pt's rates responded to diltiazem while inpatient (a-paced),
consider continuing to wean off metop as outpatient
[] Pt will need re-scheduling of cataract surgery
[] ACEi held on admission for hypotension, was not restarted
given normotension
[] FYI patient received additional 500cc IV fluids on day of
discharge due to over-diuresis on the prior day with evidence of
hemoconcentration on labs
NEW MEDICATIONS
Diltiazem 360mg XR
MEDICATIONS WE CHANGED
Increased Metoprolol Succinate to 75mg daily
MEDICATIONS WE STOPPED
Benazepril
=============
ACTIVE ISSUES
=============
#Acute hypoxic respiratory failure, resolved
Thought to be due to fluid overload secondary to recent afib
with RVR. CTA showed pulmonary edema and bilateral pleural
effusions. Respiratory status improved with return to a-paced
rhythm and diuresis, now breathing comfortably on room air w/
ambulation. Her TTE was stable from ___. Patient also was
treated for a presumed CAP with a 7 day course of ceftriaxone
given her initial leukocytosis and consolidation on CXR.
- Not discharged on any diuretic as volume overload thought to
be only in context of uncontrolled rates and pt was euvolemic at
discharge
#Atrial fibrillation with rapid ventricular response, resolved
Pt was found to be in afib w/ RVR while in the ICU, converted to
atrial paced rhythm s/p initiation of metoprolol and diltiazem.
Has been a-paced and rate controlled since ___. Her
anticoagulation was held during this admission given recent
___/SDH.
-Continue amiodarone 200mg daily
-Continue diltiazem 360mg daily
-Continue metoprolol succinate 75mg daily, can be downtitrated
as outpatient
#bifrontal, bitemporal, right vertex SAH
#left frontal, right temporal SDH
#non-displaced occipital bone fracture
Secondary to mechanical fall with head strike, and improving on
repeat imaging ___. Finished course of Keppra ___. No
focal neurological deficits on exam.
-Follow-up in ___ clinic
-*** Dabigatran
Chronic issues
===============
#HTN
ACEI held this admission given initial hypotension. Was not
restarted at discharge.
#HLD
Continued home atorvastatin
Medications on Admission:
1. Amiodarone 200 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. benazepril 10 mg oral DAILY
4. Dabigatran Etexilate 150 mg PO BID
5. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Diltiazem Extended-Release 360 mg PO DAILY
2. Metoprolol Succinate XL 75 mg PO DAILY
3. Amiodarone 200 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Dabigatran Etexilate 150 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Non-displaced occipital bone fracture
Subarachnoid hemorrhage
Subdural hematoma
Atrial fibrillation with rapid ventricular response
Acute hypoxic respiratory failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You fell and hit your head
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a CT scan that showed bleeding in your head
- You were given a medication (levetiracetam, or Keppra) to
prevent you from having a seizure
- You were given medications (metoprolol and diltiazem) to slow
you heart rate when it was going too fast
- You were given supplemental oxygen when you were having
difficulty breathing
- You had a CT scan that showed fluid in and around your lungs
- You were given a medication (furosemide, or Lasix) to help you
get rid of the fluid in and around your lungs
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:
___
|
10394761-DS-5 | 10,394,761 | 23,737,808 | DS | 5 | 2190-04-23 00:00:00 | 2190-05-03 15:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Aspirin
Attending: ___.
Chief Complaint:
weakness, dyspnea on exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with severe AS, CKD and pneumonia, treated with azithromycin
___ for CAP PNA referred by PCP for PNA, leukocytosis,
elevated creatinine and elevated BNP.
According to the patient, she first began to feel unwell in mid
___, when she began to feel weak with intermittent "hot
flashes" with sweating and chills. Never took her temperature
but believes she has fevers. In early ___ she developed
persistent cough, productive of clear sputum, with occasional
streaks of blood. She also reports worsening dyspnea on
exertion. At baseline, she is able to walk up ___ stairs before
becoming SOB and needing a break. In the past month, she reports
having to stop at each consecutive step for a break. She also
reports sleeping on 3 pillows at night (stable for over a year
now), but denies PND. Patient has leg swelling at baseline, but
reports no recent worsening. Saw her PCP ___, who was concerned
for PNA vs CHF ___ worsening AS. CXR showed Patchy opacity in R
lower lobe and WBC 14, so patient was given 5 day course of
Azithromycin. BNP also elevated at this time, so HTCZ d/c'd and
patient started on Furosemide 20mg daily. According to patient,
her symptoms did not improve with antibiotics, furosemide. Of
note, patient's creatinine bumped with addition of furosemide
(b/l 1.5->1.7) and sodium fell to 128.
Patient returned to her PCP ___ ___, reported symptoms not
resolved. Also noted poor appetitie and decreased PO intake over
past 3 days. PCP noted her WBC increased to 17, Creatinine 2.5
and worsening anemia (Hb 9.3), so directed her to ED.
In the ED, initial vitals were: T 98 P 89 Bp 139/64 RR 17 O299%
RA
Exam was notable for diffusely coarse breath sounds in all
fields and 1+ pitting edema in BLE.
Labs were notable for: WBC 21.3, Hb 9.0, Na 131, Bicarb 20, AG
21, Cr 2.1, BNP 2356, Ca 7.0, Mg 0.7, Albumin 3.0. UA positive
for WBC, CXR showed persistent R patchy basilar opacity. Patient
given 3L NS, 2mg IV Mg x 2, 1g CTX, 500mg Azithromycin (plus
home medications, including ASA, Metop, Omeprazole, Calcium,
Vitamin D).
On the floor, patient still complaing of dry cough, but overall
feels well. Denies fevers, chills, abdominal pain, nausea,
vomiting, diarrhea or dysuria. No exertional CP or dizziness.
She reports poor appetite, because "food doesn't taste the
same". Talks about her husband who passed away ___ years ago and
becomes very tearful. Reports that she lives alone in a two
story house and has no help with housework or groceries. She
reports being able to manage her ADL's, but has been struggling
since becoming ill. Her nephew ___ is her proxy and checks
in on her occasionally, also takes her to appointments.
Past Medical History:
1. Severe aortic stenosis
2. Mild aortic regurgitation
2. Arthritis
3. Fibromyalgia
4. Hypertension
5. Hyperlipidemia
6. Deviated septum
7. Hiatal hernia with GERD
8. Chronic renal insufficiency (baseline Cr ~ 1.5 mg/dl)
Social History:
___
Family History:
Parents are both deceased. Father ___ years; lung cancer);
Mother ___ years; heart attack). She has siblings (sister died
suddenly at ___, sister died of cancer at ___, sister died at ___,
brother with MI in ___. She has no children.
Physical Exam:
Admission Exam
================
Vital Signs: T 97.7, BP 127/53, P 73, RR 18, O2 100% RA.
General: Alert, oriented, no acute distress, breathing
comfortably.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, loud systolic murmur best heard at
___. No radation to carotids.
Lungs: Good air movement throughout, bibasilar crackles. No
expiratory wheezes or 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, 2+ pitting edema b/l
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
Discharge Exam
================
Vitals: T:98.0 BP:116/46 P:87 R:24 O2:97% RA,
General: Sitting up in her chair, well appearing; 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, late peaking systolic murmur heard
throughout precordium but strongest at RUSB and LUSBD.
Lungs: Course breath sounds throughout. Few bibasilar crackles.
No expiratory wheezes. Breathing comfortably on room air.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, 2+ pitting edema b/l
Pertinent Results:
Admission Labs
================
___ 11:08AM BLOOD WBC-17.4* RBC-3.22* Hgb-9.3* Hct-28.5*
MCV-89 MCH-28.9 MCHC-32.6 RDW-13.2 RDWSD-43.0 Plt ___
___ 11:08AM BLOOD Neuts-83.0* Lymphs-9.8* Monos-5.4
Eos-0.7* Baso-0.4 Im ___ AbsNeut-14.45* AbsLymp-1.71
AbsMono-0.94* AbsEos-0.13 AbsBaso-0.07
___ 11:08AM BLOOD Plt ___
___ 02:15PM BLOOD Ret Aut-1.8 Abs Ret-0.06
___ 11:08AM BLOOD UreaN-50* Creat-2.5* Na-132* K-3.9 Cl-91*
HCO3-24 AnGap-21*
___ 06:15AM BLOOD ALT-20 AST-41* AlkPhos-59 TotBili-0.4
___ 11:08AM BLOOD proBNP-___*
___ 06:15AM BLOOD Albumin-3.0* Calcium-7.0* Phos-4.0
Mg-0.7*
___ 02:15PM BLOOD Calcium-6.9* Mg-2.1
___ 07:48PM BLOOD calTIBC-186* VitB12-GREATER TH
Folate-GREATER TH Ferritn-363* TRF-143*
___ 02:15PM BLOOD Osmolal-285
___ 12:04AM BLOOD Lactate-1.1
Microbiology
===============
Urine culture ___:
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. 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
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Blood cultures ___: negative
Blood cultures ___: pending
Sputum culture ___:
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
Imaging
==========
CXR ___
IMPRESSION:
Persistent patchy right basilar opacity is worrisome for
pneumonia. Recommend follow up ___ weeks after completion of
antibiotic therapy, if findings persists, recommend chest CT.
Chest CT ___
IMPRESSION:
Scattered ground-glass and nodular opacities with basilar
predominance
superimposed upon background chronic interstitial changes. The
appearance suggests an infectious process including atypical
infections. A short-term follow-up chest CT is recommended to
ensure resolution.
Echo ___
IMPRESSION: Severe aortic valve stenosis. Mild symmetric left
ventricular hypertrophy with preserved regional and global
biventricular systolic function. Mild pulmonary artery
hypertension. Mild mitral regurgitation. Increased PCWP.
Discharge Labs
================
___ 06:05AM BLOOD WBC-18.6* RBC-2.73* Hgb-7.7* Hct-24.4*
MCV-89 MCH-28.2 MCHC-31.6* RDW-13.7 RDWSD-44.8 Plt ___
___ 06:05AM BLOOD Plt ___
___ 06:05AM BLOOD Glucose-109* UreaN-37* Creat-1.5* Na-131*
K-4.8 Cl-96 HCO3-25 AnGap-15
___ 05:45AM BLOOD proBNP-3259*
___ 06:05AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.7
___ 05:45AM BLOOD VitB12-___* Folate-GREATER TH
___ 06:05AM BLOOD RheuFac-99*
___ 06:05AM BLOOD RheuFac-99*
Brief Hospital Course:
Ms. ___ is an ___ year old woman with severe AS and CKD,
treated with azithromycin ___ for CAP PNA, admitted for
persistent DOE, leukocytosis, and elevated BNP, concerning for
CHF versus persistent PNA.
#Cough/SOB: Original concern for persistent CAP vs CHF. Patient
did not appear significantly volume up on exam, no evidence of
effusion on CXR or chest CT. BNP 2512, down from PCP visit on
___. Home furosemide stopped in setting of ___. Patient
afebrile, but with persistent cough and leukocytosis. Repeat
chest CT showed scattered nodular and ground glass opacities
with basilar predominance, superimposed on background of chronic
interstitial changes, most concerning for infection,
particularly atypicals. Urine legionella negative. Patient
completed five day course of renally dosed Levofloxacin, with no
improvement in symptoms or leukocytosis. Pulmonology consulted
on ___, recommended laboratory work up and PFT's to evaluated
for ILD. ___ returned weakly positive (1:40) and pANCA returned
positive (1:160) post discharge. PFT's normal. Per Pulm, patient
required no treatment and can be followed as outpatient, as she
exhibited no systemic manifestations of vasculitis and had
normal lung function by PFT's. Dr. ___
cardiologist) saw patient and expressed concern that AS
contributing significantly to both cough and SOB. He recommended
Cardiac Surgery consult for evaluation of TAVR versus open valve
replacement surgery. Cardiac surgery consulted on ___ and
patient began pre-operative work up. Patient seen by ___ on ___,
ambulatory saturations 97-98% , 94% with stairs. Cleared for
home with home physical therapy. Patient discharged to home with
close outpatient follow up with Cardiology, Cardiac Surgery and
Pulmonology.
#Leukocytosis: Patient with neutrophilic leukocytosis (no left
shift), present since early ___. Most likely cause thought to
be infection, in setting of fevers, CXR and CT findings
concerning for PNA. UA + ___, WBC, few bacteria and UCx gram
negative rods, but patient asymptomatic. Urine culture grew
___ Klebsiella, pan sensitive, and patient completed 5 day
course of Levofloxacin. One episode of diarrhea in days prior to
admission, but patient reported history of IBS and noted that
intermittent diarrhea is her baseline. Patient also presented
with anemia, slowly developing over past year, so primary
hematologic process, such as CML, MDS were considered. However,
given acute onset, lack of thrombocytopenia or immature forms on
differential, this is unlikely. Patient not on corticosteroids
or other medications that would contribute to elevated WBC. Per
pulm and cardiology, leukocytosis may be secondary to severe AS,
resultant CHF. Leukocytosis stable throughout admission. Patient
to follow up with Heme/Onc as outpatient.
#Anemia: Patient's Hb 9.0 on presentation, down from 10.1 on
___. MCV 89. Patient has known anemia, work up in ___
revealed normal iron, ferritin and TIBC. Patient reported no
black or bloody stools. Did report occasional streaks of blood
in her sputum, but no frank hemoptysis. Repeat iron studies
revealed pattern consistent with anemia of chronic disease/iron
deficiency anemia. Reticulocyte index 0.5%, suggesting patient's
marrow not responding appropriately, could be secondary to
chronic disease, age, or hematologic process. Haptoglobin
elevated, LDH normal, so patient not hemolyzing due to AS.
Patient never had colonoscopy and refused rectal exam during
admission. H/H remained stable and patient required no
transfusions. Discharged with instructions to follow up with
PCP. ___ consider GI follow up as outpatient.
#Acute on Chronic Kidney InjuryI: Patient's creatinine 2.5 at
PCP ___ ___, up from baseline of 1.5. Likely pre-renal in
setting of poor PO intake, furosemide 20mg daily started in
early ___. Returned to baseline with IVF. Patient's
furosemide held during admission in setting of ___.
#Hyponatremia: Asymptomatic. Patient's sodium 131 on admission
and patient appeared volume down. Improved to 133 w/IVF, so
thought to be hypovolemic hyponatremia in setting of poor PO
intake. Not on any medications associated with SIADH. Urine
lytes showed normal osm, sodium 36. Feurea 33. Unclear if drawn
before IVF. Hyponatremia persisted and repeat urine lytes
reveaed urine sodium 23, elevated urine osmolality, concerning
for element of SIADH in setting of either volume depletion or
low solute intake. Sodium improved with volume restriction and
increased PO intake.
#Hypomagnesia: Mg 0.7 on admission, improved with IV Mg x 2.
Magnesium has been low in past (1.1 in ___ Patient reported
intermittent diarrhea ___ IBS for several years and is also on
PPI, which is associated with hypomagnesia. In addition, patient
recently started on furosemide, which may be contributing.
Magnesium repleted as needed and normalized prior to discharge.
#Severe AS: recent echo in ___. Per cardiolgy notes, patient
considering TAVI. Did not endorse CP or lightheadedness on
exertion. No episodes of syncope. Outpatient cardiologist Dr.
___ patient requires semi-urgent valve replacement,
recommended surgeons see her as inpatient. Cardiac surgery
officially consulted ___ for evaluation for TAVR vs surgery for
valve replacement. Patient completed part of pre-op evaluation
during admission. Will follow up with Cardiology, Cardiac
Surgery as outpatient.
#FTT: patient with malaise, significant weight loss in past
several months. ___ be secondary to AS or depression, but given
age, malignancy a possibility. CT did no show any evidence of
primary or metastatic malignancy. Patient presented with anemia
with and reportedly has never had colonoscopy. Patient declined
rectal exam for stool guaiac. Mammograms done years ago were
normal and patient reported no breast masses. Patient to follow
up with PCP, who may consider referral to GI if symptoms do not
improve with valve replacement.
Chronic Issues:
#HTN: Normotensive during hospitalization. Held Furosemide in
setting of ___, but continued home Metoprolol. Furosemide
re-started upon discharge.
#HLD: continued home Atorvastatin.
Transitional Issues:
-Patient should be good candidate for lifeline as outpatient
given comorbidities. If patient amenable, would arrange as
outpatient.
-Patient completed 5 day course of Levofloxacin for CAP. HD
stable, afebrile at discharge.
-Patient requires outpatient carotid US as part of pre-op
evaluation for TAVR vs surgical valve repair.
-Patient has likely diagnosis of ILD, will follow up with Pulm.
-Patient has anemia, with labs suggestive of anemia chronic dz
and iron deficiency. Patient declined rectal, has never had
colonoscopy. ___ consider rectal exam w/stool guaiac as
outpatient.
-Leukocytosis of unknown etiology, Infectious w/u negative.
Please monitor CBC as outpatient. Patient to follow up with
heme/onc.
-Please monitor electrolytes as outpatient. Patient had severely
low magnesium on presentation.
-Held patient's Lisinopril on discharge ___ ___. PCP may
___ at her discretion.
CODE: Full code (confirmed)
CONTACT: ___ (nephew) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Fluocinonide 0.05% Cream 1 Appl TP DAILY:PRN scalp itching
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Furosemide 20 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Nystatin Cream 1 Appl TP DAILY:PRN itching
8. Omeprazole 20 mg PO BID
9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY
10. Ascorbic Acid ___ mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Calcium Carbonate 1500 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Ferrous Sulfate 325 mg PO DAILY
15. Glucosamine-Chondroitin DS
___
2KCl-chondroit) unknown oral DAILY
16. Multivitamins 1 TAB PO DAILY
17. Zinc Sulfate 100 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Calcium Carbonate 1500 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO BID
9. Vitamin D 1000 UNIT PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Fluocinonide 0.05% Cream 1 Appl TP DAILY:PRN scalp itching
12. Furosemide 20 mg PO DAILY
13. Glucosamine-Chondroitin DS
___
2KCl-chondroit) 0 mg ORAL DAILY
14. Nystatin Cream 1 Appl TP DAILY:PRN itching
15. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY
16. Zinc Sulfate 100 mg PO DAILY
17. walker one walker miscellaneous ONCE Duration: 13 Months
Diagnosis: severe AS, deconditioning
Prognosis: Good
RX *___ [Ultra-Light Rollator] one walker once Disp #*1 Each
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Aortic Stenosis
CAP
Secondary:
Acute on chronic kidney injury
Leukocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted with cough and shortness of
breath. you had a chest CT concerning for pneumonia, so you
completed a course of antibiotics. You were seen by Pulmonology
(lung doctors) and Cardiology (heart doctors) who determined
that your symptoms are likely due to your heart valve. You will
follow up with Cardiology as outpatient in preparation for valve
surgery in the near future.
Also during this visit, you were found to have elevated white
blood cells (cells that fight infection). This was originally
thought to be due to your pneumonia, but it did not resolve with
antibiotics. You should follow up as outpatient with
hematology/oncology (blood doctors). The appointment is listed
below.
It was wonderful meeting you and we wish you all the best in
your recovery.
Sincerely,
Your Medical Team
Followup Instructions:
___
|
10394761-DS-9 | 10,394,761 | 27,780,658 | DS | 9 | 2192-05-24 00:00:00 | 2192-05-27 00:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Lipitor
Attending: ___.
Chief Complaint:
Dysphagia; Esophageal Dysmotility
Major Surgical or Invasive Procedure:
None
History of Present Illness:
In brief, this patient is a ___ y/o woman w/ a complicated PMHx
that includes Stage IIIb CKD, hiatal hernia c/b GERD and TAVR
last year who presents with worsening epigastric pain and
dysphagia. She reports that her dysphagia started a few months
ago, approximately ___. She develops the dysphagia in response
to both solids and liquids, and characterizes the pattern as
intermittent rather than progressive. Ms. ___ reports that
after eating, she feels like there is "something sitting in her
chest". Denies weight loss, odynophagia, drooling or any
difficulty initiating swallowing. Her dysphagia is also a/w a
epigastric pain that she describes as "burning" in quality.
After she shared these complaints with her PCP, ___
was offered a EGD but declined because she thought her symptoms
were improving. However, she is now amenable to a comprehensive
workup.
She also presented with a leukocytosis (18.9) with neutrophilic
predominance (89.5) and a U/A revealing bacteriuria and pyuria,
leading to concern for possible UTI and ceftriaxone
administration. Endorses intermittent "chills" that have
persisted since ___, but continues to deny fever, hematuria,
dysuria, abdominal pain and flank pain.
Of note, a CT of her Abdomen & Pelvis (___) was performed
to assess the possibility of abdominal pathology as the etiology
of her epigastric pain. CT revealed a right renal upper pole
mass that is concerning for renal cell carcinoma.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
- Severe Aortic Stenosis s/p TAVR (___)
3. OTHER PAST MEDICAL HISTORY:
1. Arthritis
2. Fibromyalgia
3. Hypertension
4. Hyperlipidemia
5. Deviated septum
6. Hiatal hernia with GERD
7. Chronic renal insufficiency (baseline Cr ~ 1.5 mg/dl)
Social History:
___
Family History:
Mother ___ ___ CORONARY ARTERY DISEASE
Father ___ ___ LUNG CANCER Smoker
Brother ___ ___ MYOCARDIAL INFARCTION
Brother ___ CANCER Unknown primary
Brother Living ___ CAROTID s/p bypass
PANCREATIC CANCER
Sister ___ ___ CANCER
ABDOMINAL AORTIC ANEURYSM
Physical Exam:
==================
ADMISSION EXAM
==================
VITALS: 98.9 PO 174 / 74 R Lying 94 18 94 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, pale conjunctiva, MMM, EOMI,
PERRL,neck supple,
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops , no edema
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
==================
DISCHARGE EXAM
==================
Vitals: T 98 , BP 135/75 , HR 72 , RR 18, O2 96% RA
General: alert, oriented, no acute distress
Eyes: Sclera anicteric, PERRLA
HEENT: MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Resp: CTAB, no wheezes, rales, ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
GI: soft, NT/ND, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
MSK: No sclerosis, calcinosis or telangiectasias evident. Warm,
well perfused, 2+ pulses, no clubbing, cyanosis or edema
Neuro: CNs2-12 intact, ___ motor strength x 4 extremities
Pertinent Results:
====================
ADMISSION LABS
====================
___ 11:15AM BLOOD WBC-18.3*# RBC-3.43* Hgb-9.7* Hct-30.5*
MCV-89 MCH-28.3 MCHC-31.8* RDW-13.4 RDWSD-43.5 Plt ___
___ 11:15AM BLOOD Neuts-85.9* Lymphs-6.7* Monos-5.2 Eos-1.0
Baso-0.3 Im ___ AbsNeut-15.69* AbsLymp-1.23 AbsMono-0.95*
AbsEos-0.19 AbsBaso-0.05
___ 11:15AM BLOOD Glucose-96 UreaN-39* Creat-1.7* Na-135
K-5.8* Cl-93* HCO3-23 AnGap-19*
___ 11:15AM BLOOD ALT-10 AST-35 AlkPhos-73 TotBili-0.4
___ 11:15AM BLOOD Albumin-3.4* Calcium-9.8 Phos-3.5 Mg-1.7
====================
PERTINENT RESULTS
====================
MICROBIOLOGY
====================
___ 05:11PM URINE Blood-TR* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 05:11PM URINE RBC-4* WBC-73* Bacteri-FEW* Yeast-NONE
Epi-<1
===
___ 5:11 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
====================
IMAGING/STUDIES
====================
CXR (___): Unchanged radiographic appearance of diffuse,
peripheral and basilar
predominant chronic interstitial abnormality without evidence of
definite new
superimposed acute cardiopulmonary process, with chest
morphology suggestive
of COPD. Findings may reflect sequelae of chronic aspiration.
===
CT Abdomen/Pelvis (___):
1. Right renal upper pole mass measuring 5.3 x 5.2 x 5.5 cm, new
from prior is
concerning for renal cell carcinoma.
2. No acute findings to account for epigastric pain. Incidental
findings as
described above.
===
Barium esophagram (___):
1. Limited study due to patient mobility. Given the
limitation, no stricture or obstructing mass. Mild esophageal
dysmotility.
2. No acute cardiopulmonary process seen on the scout
radiograph.
====================
DISCHARGE LABS
====================
___ 08:05AM BLOOD WBC-15.1* RBC-3.10* Hgb-8.6* Hct-27.4*
MCV-88 MCH-27.7 MCHC-31.4* RDW-13.3 RDWSD-43.1 Plt ___
___ 08:05AM BLOOD Glucose-83 UreaN-30* Creat-1.3* Na-140
K-4.5 Cl-99 HCO3-26 AnGap-15
___ 08:05AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.6
Brief Hospital Course:
Ms. ___ is a ___ year-old woman w/ a complex PMHx that
includes Stage III CKD, hiatal hernia c/b GERD and TAVR
presenting with epigastric pain and worsening dysphagia
concerning for dysmotility.
=======================
ACTIVE ISSUES:
=======================
# Epigastric Pain:
# Dysphagia: Ms. ___ has a h/o hiatal hernia c/b GERD and
presented with complaints of intermittent dysphagia to both
solids and liquids that has persisted for the past few months.
She previously met with her PCP for similar complaints but
declined an EGD because she felt the symptoms had improved.
While admitted, she had a CT abdomen/pelvis that did not show
any acute pathology to explain her symptoms. She underwent a
barium esophagram that demonstrated mild esophageal dsymotility
and no stricture or mass to explain her symptoms. She was
started on omeprazole.
# Leukocytosis: On admission she was noted to have a
leukocytosis (18.9) with neutrophilic predominance (89.5).
Urinalysis showed pyuria and bacteriuria, however the patient
was asymptomatic. She had no other signs or symptoms of
infection. Ultimately, this was thought to be inflammatory and
had downtrended to 15 by time of discharge.
# Asymptomatic bacteriuria/pyuria: Urinalysis revealed pyuria
and bacteriuria. The patient was asymptomatic.
# Acute on chronic kidney disease: Admission Cr was 1.7,
slightly higher than her baseline of 1.5. Thought to be
pre-renal in setting of decreased oral intake. Her creatinine
improved to 1.3 by time of discharge.
# Constipation: Patient reported constipation that developed
over week prior to admission and improved with home senna and
Colace.
=======================
CHRONIC ISSUES:
=======================
# AS sp TAVR: Patient underwent TAVR last year for severe aortic
stenosis.
# Hyperlipidemia: Continued statin.
# CAD: Continue aspirin, statin, beta blocker.
# HTN: Continued metoprolol.
# Hypothyroidism: Continued levothyroxine.
=======================
TRANSITIONAL ISSUES:
=======================
- Patient started on omeprazole 20 mg daily.
- Patient incidentally found on imaging to have renal mass
suspicious for renal cell carcinoma. This was discussed with the
patient, and she should follow up with her PCP regarding this.
- Communication: ___, ___
I certify that >31 minutes were spent on coordination of care &
discharge planning.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Acetaminophen 325 mg PO DAILY
5. Furosemide 40 mg PO 3X/WEEK (___)
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Senna 8.6 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Furosemide 20 mg PO 4X/WEEK (___)
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*1
2. Acetaminophen 325 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Furosemide 40 mg PO 3X/WEEK (___)
7. Furosemide 20 mg PO 4X/WEEK (___)
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- Dysphagia
- Asymptomatic pyuria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. Please see below
for information on your time in the hospital.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital because you were having trouble
swallowing
WHAT HAPPENED IN THE HOSPITAL?
- We took a picture of you while you were swallowing, and
fortunately this was normal and did not show anything to explain
your trouble swalloing
WHAT SHOULD I DO WHEN I GO HOME?
- You should take a new medicine to help with stomach acid
- You should follow up with your regular doctor
___ wish you the best!
-Your Care Team at ___
Followup Instructions:
___
|
10394817-DS-17 | 10,394,817 | 21,026,693 | DS | 17 | 2186-07-29 00:00:00 | 2186-07-29 17:29:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ hx of morbid obesity, bipolar disorder, who presented to
___ as transfer from OSH for back pain.
Per history obtained in the ED, she was found at home covered in
feces. She reportedly had back pain that was too severe for her
to walk to the bathroom and thus stooled herself. Regarding her
hx of BPD, lithium level was negative at OSH. She endorsed
insomnia and sleeping on the cough d/t 4-month hx of pain. She
states that she did not take lithium for past 4 months d/t
inability to stand/get medication from her pharmacy.
Regarding her pain: in the ED she was c/o lower back pain, lower
extremity weakness. Denied ___ anesthesias. No loss of
control of her bowel/bladder. She was able to ambulate with a
walker. Denied cardiac or respiratory symptoms.
In the ED, initial vitals were: 98.2 | 104 | 146/79 | 18 | 94%
RA
Exam was notable for:
HEENT: Normocephalic, atraumatic, PERRLA, EOMI, IMMM.
Skin: erythema to BLLE
Neck: no thyromegaly, no cervical lymphadenopathy, no c-spine
tenderness.
Resp: Normal work of breathing, symmetric chest expansion, CTAB
CV: Regular rate and rhythm, normal S1/s2, no m/g/r.
Abd: Obese, soft, non-tender.
GU: normal rectal tone
Ext: no edema, no evidence of trauma, no joint swelling or
effusion.
Neuro: CN2-12 grossly intact, Sensation intact to light touch
in
all extremities, moving all extremities spontaneously, FNF
intact, unable to assess gait.
Psych: Normal mood, normal mentation, linear thought process
Labs were notable for: Hb 11.2, WBC 10.4, -ve serum tox, lithium
< 0.06. UA was +ve for >182 WBC, mod bacteria, +ve Nitr, Lg
leuk.
Studies were notable for:
- CT L-spine w/o contrast: No evidence of fracture in the
lumbar
spine.
The patient was given: CTX 1g, ibuprofen and acetaminophen
Consults:
- Pt was seen in the ED by psych, noted to not meet ___
criteria; no recommendation to restart lithium. Psych to follow
w/ note that if she wants to leave AMA call psych to evaluate
capacity.
- Pt was evaluated by ___: Pt requires 1 assist for all mobility
and is severely deconditioned. Unable to return home at this
time
as she lives alone and does not have anyone available to assist
her. ___ rehab, pt agreeable.
On arrival to the floor, she endorses hx above.
Past Medical History:
PCOS
Super-super obese
Bipolar affective disorder
OSA, moderate
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL
==================
VITALS: ___ 0011 Temp: 98.4 PO BP: 162/51 HR: 110 RR: 18 O2
sat: 92% O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. Soft expiratory
wheeze,
no rhonchi or rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis. Pulses DP/Radial 2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL
==================
General: appears comfortable, NAD, morbidly obese, sitting
upright in chair on room air
HEENT: NC/AT
Lungs: symmetric expansion, no increased WOB, CTAB
Heart: RRR, no M/R/G, 2+ radial pulses bilaterally
Extremities:
- bilateral non-pitting lower extremity edema with chronic
changes, no brawny induration
- well-perfused, no bruising or bleeding
Neuro:
- alert, oriented ___, appropriate, pleasant, +fluent
- ambulatory, moves ___ extremities
Psych: appropriate
Pertinent Results:
INITIAL LABS
============
___ 09:34AM BLOOD WBC-9.4 RBC-4.35 Hgb-11.1* Hct-38.7
MCV-89 MCH-25.5* MCHC-28.7* RDW-17.6* RDWSD-57.1* Plt ___
___ 09:34AM BLOOD Plt ___
___ 09:34AM BLOOD Glucose-113* UreaN-14 Creat-0.6 Na-142
K-4.5 Cl-100 HCO3-27 AnGap-15
___ 09:34AM BLOOD CK(CPK)-113
___ 09:34AM BLOOD Calcium-9.3 Phos-4.6* Mg-1.9
___ 09:34AM BLOOD TSH-6.1*
___ 09:34AM BLOOD Free T4-1.3
___ 09:34AM BLOOD ___ CRP-44.0*
___ 10:43PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 10:43PM URINE Blood-SM* Nitrite-POS* Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 10:43PM URINE RBC-4* WBC->182* Bacteri-MOD* Yeast-NONE
Epi-<1
___ 10:43PM URINE Mucous-OCC*
___ 10:43PM URINE UCG-NEGATIVE
___ 10:43PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
MICROBIOLOGY
============
___ 10:43 pm URINE
**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.
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING
=======
CT L-SPINE W/O CONTRAST (___):
No acute displaced fractures are identified. There are mild
degenerative
changes of the lumbar spine with vertebral body osteophytosis
and intervertebral disc space narrowing, most prominent at
L1-L2. There is mild retrolisthesis of L5 relative to S1,
likely degenerative (602:60). There is angulation of the
coccyx, without definitive evidence for acute fracture.
There is no evidence of high-grade spinal canal or neural
foraminal stenosis.
There is no prevertebral soft tissue swelling.
Limited visualization of the intra-abdominal structures are
unremarkable.
CXR (___):
Heart is borderline in size. Mediastinal and hilar contours are
unremarkable.
There is no pleural effusion or pneumothorax. Moderate
interstitial process including prominent perihilar opacities
suggests mild to moderate interstitial pulmonary edema.
Thoracic spine has mild to moderate rightward convex curvature.
TTE (___):
The left atrium is normal in size. There is normal left
ventricular wall thickness with a normal cavity size. There is
suboptimal image quality to assess regional left ventricular
function. Overall left ventricular systolic function is normal.
The visually estimated left ventricular ejection fraction is
>=55%. There is no resting left ventricular outflow tract
gradient. The right ventricle was not well seen with normal free
wall motion. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic valve is
not well seen. The mitral valve leaflets appear structurally
normal with no mitral valve prolapse.
There is trivial mitral regurgitation. The pulmonic valve
leaflets are not well seen. The tricuspid valve is not well
seen. The pulmonary artery systolic pressure could not be
estimated. There is no pericardial effusion.
IMPRESSION: Poor image quality. Grossly normal biventricular
systolic function. Unable to quantify pulmonary artery systolic
pressure.
TTE (___):
The left atrium is normal in size. 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
55-60%. Left ventricular cardiac index is normal (>2.5
L/min/m2).
Diastolic function could not be assessed. Mildly dilated right
ventricular cavity with mild global free wall hypokinesis. The
aortic sinus diameter is normal for gender with normal ascending
aorta diameter for gender.
There is a normal descending aorta diameter. The aortic valve is
not well seen. There is no aortic valve stenosis. There is no
aortic regurgitation. The mitral valve leaflets appear
structurally normal with no mitral
valve prolapse. There is trivial mitral regurgitation. The
pulmonic valve leaflets are not well seen. The tricuspid valve
is not well seen. There is trivial tricuspid regurgitation. The
pulmonary artery systolic pressure could not be estimated. There
is no pericardial effusion.
IMPRESSION: Poor image quality despite use of IV ultrasound
contrast. Normal left ventricular wall thickness and
biventricular cavity sizes and regional/global biventricular
systolic function.
OTHER RESULTS
=============
___ 05:22AM BLOOD ALT-27 AST-21
___ 03:35PM BLOOD cTropnT-<0.01 proBNP-93
___ 01:20PM BLOOD TotProt-6.3* Cholest-172
___ 01:20PM BLOOD Ferritn-34
___ 12:06PM BLOOD %HbA1c-6.2* eAG-131*
___ 01:20PM BLOOD Triglyc-189* HDL-47 CHOL/HD-3.7
LDLcalc-87
___ 01:26PM BLOOD ___ pO2-113* pCO2-71* pH-7.35
calTCO2-41* Base XS-10 Comment-GREEN TOP
DISCHARGE LABS
==============
___ 07:54AM BLOOD Glucose-122* UreaN-24* Creat-0.7 Na-143
K-4.2 Cl-88* HCO3-33* AnGap-22*
___ 07:54AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.2
Brief Hospital Course:
Transitional issues:
====================
[] DIURESIS: repeat complete metabolic panel on ___ to
assess potassium and magnesium levels after starting torsemide
80mg daily.
[] NEW HEART FAILURE: follow up with cardiologist and obtain
stress test
[] PRE-DIABETES: HgA1c 6.2, follow up closely with primary care
physician
[] LIKELY OSA/OHS: polysomnogram as outpatient
[] PALIPERIDONE DOSING: next dose due on ___
[] PCP: please refer pt. to ___ within one month
and please call ___ Psychiatry @ ___ for
an Intake.
Any questions, please call ___ @ ___.
Ms. ___ is a ___ year old woman with history of morbid obesity
complicated by likely obstructive sleep apnea, and bipolar
disorder who originally presented with failure to thrive and
lower back pain, and was subsequently found to decompensated
heart failure and likely obstructive sleep apnea. Her hospital
course was notable for significant diuresis (50lbs) and
initiation of long-acting paliperidone.
ACTIVE ISSUES:
==============
# HFpEF
Ms. ___ presented with around one year of progressive lower
extremity edema with evidence of chronic changes. EKG notable
for inferior Q waves with poor R-wave progression, indicating
prior ischemic disease. TTE (___) demonstrated grossly normal
biventricular function, but was of low quality. Repeat TTE (___)
redemonstrated preserved ejection fraction, but was also limited
by body habitus. Cardiology was consulted and agreed that
presentation was consistent with HFpEF due to likely obesity.
She was diursed 50lbs using intravenous diuretics and discharged
at a weight of 463lbs. She was discharged on the medications
specified below.
# Failure to thrive
# Bipolar disorder
Upon presentation, there was concern that Ms. ___ was unable
to take care of herself at home. Per conversation with her local
police and board of health, her home was declared unlivable and
required professional cleaning and re-inspection. She was placed
on a ___ and Guardianship and ___ were obtained. She
was seen by psychiatry and started on paliperidone. She was
transitioned to long-acting paliperidone IM on ___.
# Bilateral lumbar pain
Her presenting complaint was lower back pain. CT-SPINE (___)
found no evidence of fracture or high-grade stenosis. Improved
with diruesis and non-opioid pain management.
# Urinary tract infection
On admission, Ms. ___ had a positive urinalysis with a urine
culture that eventually grew E. coli sensitive to ceftriaxone.
She was treated with three-doses of ceftriaxone (last ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. PALIperidone Palmitate 156 mg IM Q1MO (___)
RX *paliperidone palmitate [Invega Sustenna] 156 mg/mL 156 mg IM
q1MO Disp #*1 Syringe Refills:*0
3. Torsemide 80 mg PO DAILY
RX *torsemide 20 mg 4 tablet(s) by mouth once a day Disp #*120
Tablet Refills:*0
4.Outpatient Lab Work
Complete metabolic panel on ___
ICD 428.0
___
Address:___,
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
======================
- Heart failure
- Failure to thrive
SECONDARY DIAGNOSIS
======================
- Schizoaffective disorder
- Lower back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You are admitted with pain in your back and your legs.
- There was concern that you are not able to care for yourself
adequately at home.
- You had swelling in your legs that was caused by a condition
called heart failure, which is when your heart isn't as strong
as it used to be.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- You were given water pills to decrease the swelling in your
legs, and started on medications to help your heart
- You were started on paliperidone, a medication to help you
take care of yourself.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___. We
wish you all the best,
- Your ___ Care Team
Followup Instructions:
___
|
10394897-DS-10 | 10,394,897 | 26,929,808 | DS | 10 | 2162-11-10 00:00:00 | 2162-11-10 21:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Discomfort
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old female with multiple medical
problems including coronary artery disease, atrial fibrillation
with pacemaker, hypertension, diabetes, presenting with
abdominal
pain who was referred to ___ with concern for ACS.
Patient describes a "beating and pounding sensation in my
stomach" and is clear to say there is no pain. This has been
going on for about 5 days, and these episodes can last for hours
and occur randomly multiple times per day. The beating and
pounding sensations do not radiate anywhere into the back or
shoulder. She sometimes feels like her entire body is shaking,
and notes that a nurse "saw her shaking". There is no
correlation
with food, no nausea, vomiting, diarrhea.
She has also been having nocturnal urination with urgency, which
is unusual for her. Reports ___ times per night she is having to
go to the bathroom and sometimes doesn't make it, from a
baseline
of just once nightly without issue of incontinence. No fevers,
chills. It is unclear if her "shaking and pounding" sensation
described above is rigors, but she denies frank shaking chills.
Never had a UTI before, no recent abx. Her appetite is good, but
she has been more tired than usual this last week.
Additionally, she describes swelling in both legs, L > R.
Doesn't
take diuretic besides HCTZ, weight went from 140 to 168 over
several months, 10 pounds in last month. Getting more tired when
she walks around from bus stop. Denies chest pressure with
walking, shortness of breath, orthopnea, PND.
On review of systems she has a "funny feeling" in shoulder that
goes down her arm - but this is not a new issue, thinks it is
related to her known pseudogout.
In the ED:
-Initial vitals: 98.3 91 137/82 16 98% RA
-Labs notable for WBC 4.8, Hgb 9.9 (baseline ___, PLTs 116
(baseline 150s-170s), AST 43, ALT 43, AlkPhos 193, T bili 0.5,
Lipase 23, Trop 0.03 x 2, MB 2, proBNP 3085, Lac 1.6, Urine with
47 WBCs, 27 RBCs, 7 Epis)
-Imaging notable for CTA torso suggestive of volume overload,
gallstones with slightly distended gallbladder, pulmonary and
thyroid nodules, extensive coronary disease and moderate disease
at origin of celiac and SMA. No DVT on ___.
-EKG with paced rhythm, otherwise AF
-Consults: none
-Patient received: ASA 324, Ceftriaxone, Home meds, Lasix 40mg
PO
ROS: Per HPI, otherwise a 10 point review was negative.
Past Medical History:
- Hypertension
- hypercholesterolemia
- diabetes type 2 uncontrolled
- neuropathy
- hypothyroidism
- iron deficiency anemia
- bilateral rotator cuff disease
- GERD
- status post back surgery as above
- left tka ___
- right knee djd
- bilateral carpal tunnel syndrome
- colonic adenoma
Social History:
___
Family History:
Mother - alive, lives in ___, HTN and Alzheimers
Father - deceased from unclear cause
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.3 108/70 75 18 95 Ra
General: Tearful at times, no acute distress
Neck: EJ is distended, but clearly fills from above, tough JVP
exam overall
Chest: lungs clear
CV: irreg irreg, murmur
Abd: SP tender the most, but diffuse discomfort, vol guarding
Ext: warm, pitting to knees L>R
DISCHARGE PHYSICAL EXAM
General: alert, oriented, tearful when discussing past trauma
Eyes: Sclera anicteric
HEENT: MMM, oropharynx clear
Neck: supple
Resp: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops
GI: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
MSK: No CVA tenderness; deformed hand joints proximal > distal
___: surgical scars on both knees, L ankle effusion, no calf
tenderness with passive motion, no pitting edema
Neuro: motor function grossly normal
Pertinent Results:
ADMISSION LABS
==============
___ 08:40PM BLOOD WBC-4.8 RBC-3.23* Hgb-9.9* Hct-30.9*
MCV-96 MCH-30.7 MCHC-32.0 RDW-14.2 RDWSD-49.5* Plt ___
___ 08:40PM BLOOD Neuts-45.8 ___ Monos-11.2 Eos-1.0
Baso-0.6 Im ___ AbsNeut-2.21 AbsLymp-1.99 AbsMono-0.54
AbsEos-0.05 AbsBaso-0.03
___ 08:40PM BLOOD Glucose-113* UreaN-18 Creat-0.9 Na-141
K-3.8 Cl-104 HCO3-25 AnGap-12
___ 08:40PM BLOOD ALT-43* AST-43* CK(CPK)-196 AlkPhos-193*
TotBili-0.5
___ 06:36AM BLOOD ALT-35 AST-29 AlkPhos-181* TotBili-0.7
___ 08:40PM BLOOD Lipase-23
___ 08:40PM BLOOD CK-MB-2 proBNP-3085*
___ 08:40PM BLOOD cTropnT-0.03*
___ 02:33AM BLOOD cTropnT-0.03*
___ 08:40PM BLOOD Albumin-3.7 Calcium-9.5 Phos-3.2 Mg-1.7
___ 06:36AM BLOOD VitB12-___ Folate->20
___ 06:36AM BLOOD TSH-1.1
___ 12:50PM BLOOD Lactate-1.6
IMAGING
=======
LLE US:
IMPRESSION:
1. Slightly limited assessment of calf veins but otherwise no
evidence of
deep venous thrombosis in the left lower extremity veins.
2. Moderate left calf soft tissue edema.
CTA TORSO:
IMPRESSION:
1. This exam is a CTA and does not optimally assess solid
organs.
2. No acute pulmonary embolus.
3. Findings suggestive of heart failure/volume overload
including
cardiomegaly, mild pulmonary edema, trace bilateral pleural
effusions,
prominent hepatic vein and IVC, and small volume ascites.
4. Cholelithiasis with slightly distended gallbladder and
gallbladder edema. This could be secondary to third spacing in
the setting of volume overload and ascites; however, given
epigastric pain acute cholecystitis is not excluded. Recommend
further evaluation with dedicated right upper quadrant
ultrasound.
5. Small hiatal hernia.
6. Bilateral pulmonary nodules, largest measuring up to 5 mm in
the right
lower lobe. Follow-up as per ___ guidelines
below.
7. Mildly dilated main pulmonary artery can be seen as sequelae
of chronic
pulmonary hypertension.
8. Extensive coronary artery atherosclerosis.
9. Incidental replaced left hepatic artery.
RECOMMENDATION(S): 1. For incidentally detected multiple solid
pulmonary
nodules smaller than 6mm, no CT follow-up is recommended in a
low-risk
patient, and an optional CT follow-up in 12 months is
recommended in a
high-risk patient.
Brief Hospital Course:
___ yo F CAD (stent to LAD ___, SSS (s/p PPM ___, HFpEF, DM,
HTN, dyslipidemia and depression iso interpersonal trauma who
presented with an abdominal "jumping" sensation.
ACUTE:
======
#Abdominal "jumping sensation": Patient clear that she was not
experiencing abdominal pain. CTA done in ED ruled out PE or or
aortic aneurysm. Low concern for ACS given Trop of 0.03x2 and
EKG with no ischemic changes. Lower concern for hepatitis or
hepatic pathology given normal liver function labs. Could be
attributed
to patient's known cardiac conduction abnormalities though
unlikely in the setting of patient's functioning PPM, especially
in light of recent unremarkable pacer interrogation (per atrius
records). Patient's abdominal symptoms could be connected to
concern for infiltrative process (i.e. amyloid) connected to
HFpEF; however no clear association between jumping sensation,
absence of GI symptoms and
bland abdominal exam. Her abdominal discomfort improved without
intervention.
#HFpEF: Last with TTE in ___. Per chart concern for
infiltrative process contributing to hypertrophy. Patient with
CT findings concerning for volume overload though with no
clinical symptoms or signs consistent with volume overload or HF
exacerbation. IV diuresis was deferred. Continued home HCTZ,
losartan, pantoprazole, rosuvastatin,
amlodipine.
#SSS s/p PPM: Patient with bi-chamber pacer last interrogated in
___ ___. Telemetry showed pacing followed by
irregular
rhythm with correction by pacing. Deferred EP consult for device
interrogation at this time given recent outpatient interrogation
was unremarkable
#Urinary symtpoms: Pt endorsed some urinary frequency and urge,
but on further review of her history this has been longstanding
for several months and seems to be related to the fact that she
has trouble sleeping at night I/s/o anxiety. She was afebrile,
non-elevated WBC and had a contaminated UA on admission. Patient
received 1g CTX on admission, but further treatment was deferred
given clarification of long-standing nature of urinary symptoms
and contaminated UA.
#Depression iso of significant interpersonal trauma/violence: Pt
suffered a serious attack by husband several years ago (he is
now in jail), and still suffers from anxiety and flashbacks
related to this.
Social work was consulted for support and met with patient. She
#Left lower leg swelling: Exam notable for left ankle effusion.
Low concern for DVT given negative ___. Most likely joint
process related to known history of pseudogout and
osteoarthritis. Continued home gabapentin.
CHRONIC:
#Hypothyroidism: continue home levo 125mcg
#HTN:
-substitute losartan for home irbestartan
-continue home HCTZ
#DMII: Hold home Metformin on admission
-sliding scale
#Anemia: Hb/Hct 9.9/20.7. Chronic per Atrius records
TRANSITIONAL ISSUES
===================
[ ] Please ensure patient has adequate social support and/or
therapy with respect to her previous attack and resultant
anxiety/depression/?PTSD
[ ] Consider repeat TTE for possible interval change in cardiac
function given evidence of volume overload on CTA (despite lack
of clinical signs or symptoms)
[ ] If patient continues to have urinary symptoms, consider
workup for urge incontinence vs recurrence of her bladder cancer
[ ] Numerous incidental findings on CTA that require further
workup:
- Bilateral pulmonary nodules, largest measuring up to 5 mm in
the right lower lobe. Follow-up as per ___
guidelines below.
- Mildly dilated main pulmonary artery can be seen as sequelae
of chronic pulmonary hypertension.
- Extensive coronary artery atherosclerosis.
RECOMMENDATION(S): 1. For incidentally detected multiple solid
pulmonary nodules smaller than 6mm, no CT follow-up is
recommended in a low-risk patient, and an optional CT follow-up
in 12 months is recommended in a high-risk patient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. irbesartan-hydrochlorothiazide 300-12.5 mg oral DAILY
2. Levothyroxine Sodium 125 mcg PO DAILY
3. Rosuvastatin Calcium 40 mg PO QPM
4. Gabapentin 300 mg PO BID
5. Celecoxib 100 mg oral BID
6. MetFORMIN XR (Glucophage XR) 1500 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H GERD
8. amLODIPine 5 mg PO DAILY HTN
Discharge Medications:
1. amLODIPine 5 mg PO DAILY HTN
2. Celecoxib 100 mg oral BID
3. Gabapentin 300 mg PO BID
4. irbesartan-hydrochlorothiazide 300-12.5 mg oral DAILY
5. Levothyroxine Sodium 125 mcg PO DAILY
6. MetFORMIN XR (Glucophage XR) 1500 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H GERD
8. Rosuvastatin Calcium 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were having abdominal discomfort and pain.
What was done for me while I was in the hospital?
We did several tests to make sure there were no emergencies like
a blood clot, a heart attack, or an infection that were causing
your discomfort. Everything was normal, and your discomfort
improved.
What should I do when I leave the hospital?
Please follow up with your primary doctor and cardiologist, and
continue to take all of your medications.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10395166-DS-15 | 10,395,166 | 20,916,094 | DS | 15 | 2175-12-07 00:00:00 | 2175-12-09 22:10:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / Morphine / Cipro / Reglan / Carafate / Protonix /
Flagyl / Miralax
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
___ F PMHx CAD s/p DES to RCA, recent admission ___ for DES to
midLcx p/w worsening LSCP, ___, sharp, +radiation to LUE, +
exertional, associated w some pleuritic discomfort as well,
improved w rest. Overall, she tells me that she has not felt
right since she was cathed last time. She feels that her chest
pain is exacerbated with any movement. Taking a deep breath
makes it worse. Nothing makes it better. When I asked when the
pain has started, she tells me that she is not sure, and repeats
taht she has not felt well ever since she left. She is very
worried that there is a blockage in her heart again.
Past Medical History:
Coronary artery disease: In ___, the patient had an elective
cardiac catheterization resulting in three drug eluting stents
in the right coronary artery, spanning from the mid vessel to
the ostium. She had a repeat catheterization in ___,
demonstrating 99% restenosis versus plaque collapse, which was
treated with an additional DES in the RCA.
GERD
Diverticulitis
IBS
Hemorrhoids
Back disc(?laminectomy)
Hysterectomy
Social History:
___
Family History:
DM, CAD, stroke, HTN
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals:98.5 - 157/57 - 53- 18- 95% RA
General Pleasant elderly woman standing next to bed, no
distress.
HEENT Sclera anicteric, Neck no JVD
Pulm not done due to pain with movement
CV regular but slow s1 s2 no m/r/g
Abd soft obese +bowel sounds nontender
Extrem warm no edema palpable distal ___ bilaterally
Neuro alert awake, CN II-XII intact, ___ strength, gait without
deficit.
.
DISCHARGE PHYSICAL EXAM
VS: TEMP 97.8, HR 54, BP 115/50, RR 18, O2 sat 98% on RA
GEN: NAD, A & O X3
HEENT: PERRL, no LAD, JVD ~7cm
HEART: RRR, good S1, S2, no m/r/g
LUNG: CTA bilaterally
ABD: soft, NT/ND, no HSM, +BS
EXT: no pitting edema
Pertinent Results:
ADMISSION LABS
___ 12:35AM BLOOD WBC-8.0 RBC-5.20 Hgb-13.6 Hct-43.6 MCV-84
MCH-26.2* MCHC-31.3 RDW-14.5 Plt ___
___ 12:35AM BLOOD Neuts-60.6 ___ Monos-4.8 Eos-4.0
Baso-1.0
___ 12:35AM BLOOD Glucose-120* UreaN-10 Creat-0.7 Na-130*
K-5.4* Cl-98 HCO3-24 AnGap-13
___ 08:50AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.4
.
CARDIAC LABS
___ 12:35AM BLOOD cTropnT-<0.01
___ 08:50AM BLOOD CK-MB-1 cTropnT-<0.01
___ 08:50AM BLOOD CK(CPK)-43
.
PERTINENT STUDIES
CXR ___
IMPRESSION: Low lung volumes accentuate the pulmonary
vasculature and
bibasilar dependent atelectasis.
.
CARDIAC CATHETERIZATION ___
Pending...
Brief Hospital Course:
This is a ___ year old woman with extensive CAD history, coming
in because she has not felt "well" since her last cath, and now
with chest pain, that is unresolving despite nitroglycerin.
.
ACTIVE ISSUES
#Chest Pain - Pt presented with chest pain, that was partially
reproducible on the exam. Of note, the chest pain did not
appear to be exertion, nor did it respond to nitroglycerin. Her
EKG was unchanged, and her cardiac enzymes were negative since
admission. Given pt recently underwent stent placement, she was
expedited to get cardiac catheterization. During the
catheterization, there were no evidence of low limiting lesion.
Pt was subsequently returned to medicine floor and discharged
the secondary day. Pt has imdur on her medication list, but she
is not actively taking this medication. We agreed that it is OK
to stop imdur if she has been asymptomatic without it.
.
CHRONIC ISSUES
# GERD: We continue home PPI
.
# Hyperlipidemia: We continued home statin
.
# Anxiety: We continued home esctalopram, lorazepam, and
zopidem.
.
TRANSITIONAL ISSUES
# CODE STATUS: Full
# PENDING STUDIES AT DISCHARGE: none
# MEDICATION CHANGES
- STOPPED Imdur per pt request
# FOLLOWUP PLAN
- Pt will be followed by her PCP, and cardiologist
Medications on Admission:
atorvastatin 20 mg qd
carvedilol 3.125 mg bid
aspirin 325 mg qd
prasguel 10 mg qd
lorazepam 0.5 mg bid
escitalopram 5 mg bid
ambien 10 mg qhs prn
lidocaine patch upto three patches for back pain
hydrocortisone 1% cream under breast
hydrocortisone 25 mg suppository prn
naftifine dose unknown
protonix 20mg bid
maalox tid prn
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. escitalopram 5 mg Tablet Sig: One (1) Tablet PO twice a day.
3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
6. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia .
8. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD PRN () as needed
for pain.
10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO every eight (8) hours as needed for constipation.
11. naftifine Topical
12. hydrocortisone 1 % Cream Sig: One (1) Topical once a day as
needed for itching.
13. hydrocortisone acetate 25 mg Suppository Sig: One (1)
Rectal once a day as needed for hemorrhoid.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
- coronary artery disease
Secondary diagnosis
- hyperlipidemia
- anxiety
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 chest pain. Your EKG was unchanged
and your blood test did not show evidence of heart attack.
Given your recent stent placement, you underwent a cardiac
catheterization. The study did not show evidence of flow
limiting lesions. You otherwise recovered well. We are happy
to let you go home to continue treatment.
.
You told us that you are not taking imdur. We will remove this
medication from your medication list. Please continue to take
the rest of your medication.
.
We also arranged the following appointments for you (see below).
.
It has been a pleasure taking care of you here at ___. We
wish you a speedy recovery.
Followup Instructions:
___
|
10395166-DS-17 | 10,395,166 | 27,282,209 | DS | 17 | 2177-10-30 00:00:00 | 2177-10-30 15:36:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Cipro
Attending: ___.
Chief Complaint:
AFib
Major Surgical or Invasive Procedure:
___ Permanent ___ ___ RF ___, ___ #
___ with Dr. ___
___ of Present Illness:
Ms. ___ is a splendid
___ woman known to the Cardiac surgery service. She
underwent Coronary Artery Bypass Graft x 3 (LIMA-LAD, SVG-OM,
SVG-RCA)on ___. Her post-op course was without event and she
was discharged to rehab on POD 4( ___ this morning
she
had a witnessed fall at rehab. She was transferred to ___ ED
and found to be in Afib with a stable BP. She will be admitted
to
the Cardiac Surgery service for further work-up.
Past Medical History:
Coronary Artery Disease
Depression
Gastroesophageal Reflux Disease
Hemorrhoids
Hyperlipidemia
Irritable Bowel Syndrome (Constipation)
Left Leg Weakness following Spine Surgery
Low Back Pain
Sciatica
Past Surgical History:
Hemorrhoidectomy ___
Laminectomy L4-L5 ___
Total Abdominal Hysterectomy ___
Cholecystectomy ___
Bladder Sling ___
Past Cardiac Procedures:
Stents (3) to RCA ___
Stent to RCA ___
POBA PDA and stent to LCX ___
Stent to RCA ___
Social History:
___
Family History:
Mother - died of myocardial infarction, age ___
Father - died of stroke, age uncertain
Brother - died of complications from Diabetes, history of CABG x
3, age ___
Physical Exam:
Pulse:125 Resp:12 O2 sat:100
B/P: 115/52
General:NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x, small laceration on the right occiput
Neck: C-collar on
Chest: Lungs clear diminished bilaterally
Heart: RRR [] Irregular [x] Murmur [] grade ______
Abdomen:Soft[x] non-distended [x] non-tender [x]bowel sounds +
[x]
Extremities: Warm [x], well-perfused [x] 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
Pertinent Results:
Echo ___
Conclusions
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. Trace aortic regurgitation is seen. Physiologic mitral
regurgitation is seen (within normal limits). There is no
pericardial effusion.
IMPRESSION: No pericardial effusion. Grossly preserved
biventricular systolic function.
.
___ 09:30AM BLOOD WBC-13.2* RBC-4.55 Hgb-10.8* Hct-34.7*
MCV-76* MCH-23.8* MCHC-31.2 RDW-22.3* Plt ___
___ 12:58AM BLOOD WBC-11.7* RBC-4.17* Hgb-9.8* Hct-32.6*
MCV-78* MCH-23.6* MCHC-30.1* RDW-22.5* Plt ___
___ 09:30AM BLOOD ___
___ 12:50PM BLOOD ___
___ 04:24AM BLOOD ___ PTT-27.3 ___
___ 10:00AM BLOOD ___ PTT-79.7* ___
___ 12:58AM BLOOD ___ PTT-81.2* ___
___ 08:40AM BLOOD ___ PTT-27.7 ___
___ 09:30AM BLOOD Glucose-130* UreaN-7 Creat-0.6 Na-130*
K-4.3 Cl-98 HCO3-24 AnGap-12
___ 04:24AM BLOOD Glucose-113* UreaN-6 Creat-0.6 Na-131*
K-4.3 Cl-101 HCO3-21* AnGap-13
Brief Hospital Course:
The patient was admitted for further management of her AFib.
She developed long pauses and was transferred to ___.
Coumadin was initiated for AFib. Ceftriaxone given for UTI. She
was evaluated by the Electrophysiology service and deemed to be
a candidate for permanent pacemaker. She underwent this
procedure with Dr. ___ on ___. She received a ___
pacemaker. Overall she tolerated this procedure well and was
transferred to ___ 6 post-procedure. She was evaluated by the
___ service and it was determined she would benefit for a short
stay at rehab. Expected length of stay at rehab is less than 30
days. She will follow-up in the device clinic next week. She
also has staples in the posterior head that should be
discontinued on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Cyclobenzaprine 5 mg PO TID:PRN back pain
4. Dexilant (dexlansoprazole) 60 mg oral bid
5. Escitalopram Oxalate 5 mg PO BID
6. Lidocaine 5% Patch 2 PTCH TD QAM
7. Lorazepam 0.5 mg PO BID:PRN anxiety
8. Milk of Magnesia 30 mL PO Q6H:PRN constipation
9. Mylanta 2 tsp oral tid prn prn
10. Acetaminophen 650 mg PO Q4H:PRN pain, fever
11. Docusate Sodium 100 mg PO BID
12. Metoprolol Tartrate 75 mg PO TID
13. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
14. Anucort-HC (hydrocorTISone Acetate) 25 mg rectal prn
constipation
15. lidocaine HCl-hydrocortison ac ___ % rectal bid
16. salt moisturizing solution ___ gtt NASAL PRN prn
17. Thera Tears (carboxymethylcellulose sodium) 0.25 %
ophthalmic tid
18. Vitamin D ___ UNIT PO DAILY
19. Furosemide 40 mg PO DAILY
20. Lisinopril 5 mg PO DAILY
21. Potassium Chloride 20 mEq PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q4H:PRN pain/fever
2. Aspirin EC 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Escitalopram Oxalate 5 mg PO BID
5. Lorazepam 0.5 mg PO TID
RX *lorazepam 0.5 mg 1 tablet by mouth three times a day Disp
#*90 Tablet Refills:*0
6. Metoprolol Tartrate 50 mg PO TID
7. Amiodarone 400 mg PO BID
___ bid x 1 week, then 400mg daily x 1 week, then 200mg daily
8. HYDROmorphone (Dilaudid) 2 mg PO BID
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
___ MD to order daily dose PO DAILY16
dose to change daily for goal INR ___. Zolpidem Tartrate 10 mg PO HS
11. Anucort-HC (hydrocorTISone Acetate) 25 mg rectal prn
constipation
12. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth q3h Disp
#*40 Tablet Refills:*0
13. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 2 Days
14. Thera Tears (carboxymethylcellulose sodium) 0.25 %
ophthalmic tid
15. Vitamin D ___ UNIT PO DAILY
16. salt moisturizing solution ___ gtt NASAL PRN prn
17. Mylanta 2 tsp oral tid prn prn
18. Milk of Magnesia 30 mL PO Q6H:PRN constipation
19. Atorvastatin 20 mg PO DAILY
20. Dexilant (dexlansoprazole) 60 mg oral bid
21. Lidocaine 5% Patch 2 PTCH TD QAM
22. lidocaine HCl-hydrocortison ac ___ % rectal bid
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
AFib, bradycardia
PMH:
Coronary Artery Disease
Depression
Gastroesophageal Reflux Disease
Hemorrhoids
Hyperlipidemia
Irritable Bowel Syndrome (Constipation)
Left Leg Weakness following Spine Surgery
Low Back Pain
Sciatica
Past Surgical History:
Hemorrhoidectomy ___
Laminectomy L4-L5 ___
Total Abdominal Hysterectomy ___
Cholecystectomy ___
Bladder Sling ___
Past Cardiac Procedures:
Stents (3) to RCA ___
Stent to RCA ___
POBA PDA and stent to LCX ___
Stent to RCA ___
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Left Chest PPM incision- c/d/i
Staples to occiput- to be discontinued ___
Edema 1+
Discharge Instructions:
SEE ATTACHED PERMANENT PACEMAKER DISCHARGE INSTRUCTION PAMPHLET
.
1. Please shower daily including washing incisions gently with
mild soap, no baths or swimming, and look at your incisions
2). Please NO lotions, cream, powder, or ointments to incisions
3). Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart
4). No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
5). No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
___
|
10395166-DS-20 | 10,395,166 | 20,689,488 | DS | 20 | 2180-02-17 00:00:00 | 2180-02-17 17:03:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro
Attending: ___
Chief Complaint:
Shortness of breath and chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization ___
History of Present Illness:
___ with H/O CAD s/p CABG x 3v in ___, S/P permanent pacemaker
for paroxysmal atrial fibrillation with sick sinus syndrome,
with recent admission for chest pain with recent
dipyridamole-MIBI showing no reversible defects (but chest
discomfort with vasodilator administration), who presents with
several day history of jaw and left arm pain (which is her
anginal equivalent), chest pain, and dyspnea.
She reports that the pain in her jaw has been constant and is
worsened over the past several days. The pain is worse with
exertion, with associated shortness of breath and diaphoresis.
Patient endorses chronic dyspnea, slightly worse from baseline
recently. She reported no cough, no nausea or vomiting, and no
other changes in symptoms in the interval since discharge.
Patient was admitted ___ for similar symptoms and
underwent dipyridamole-MIBI with no evidence of ischemia on
nuclear imaging and LVEF 65%, but dipyridamole induced chest
pressure radiating to throat and jaw. Her pacemaker was adjusted
at that point for increased rate responsiveness with exertion,
but there has not been any substantial improvement in her
respiratory symptoms. Overall, respiratory symptoms seem to have
come on gradually without any inciting event over the course of
multiple weeks.
In the ED initial vitals were: T 98.1 BP 142/81 HR 62 RR 16 SaO2
99% on RA. EKG showed atrial pacing at 63 bpm, normal axes and
intervals, and no ST elevations. CXR showed no acute
cardiopulmonary process with stable elevation of the right
hemidiaphragm. Labs/studies notable for Troponin-T <0.01, Na
127; Chem 7, CBC, coags otherwise normal. Patient was given ASA
325 mg, acetaminophen 1000 mg, and lorazepam 0.5 mg. Vitals on
transfer: T 97.8 BP 135/50 HR 61 RR 18 SaO2 98% on RA
On arrival to the cardiology ward, the patient reported some
ongoing shortness of breath and jaw pain with minimal chest
pressure.
Past Medical History:
-Coronary Artery Disease
-Stents (3) to RCA ___
-Stent to RCA ___
-POBA PDA and stent to LCX ___
-Stent to RCA ___
-CABG in ___ (LIMA-LAD, SVG-RCA, SVG-OM; Dr. ___
-Paroxysmal atrial fibrillation
-S/P pacemaker for sick sinus syndrome ___ after syncope with
10 second pauses after conversion to NSR from atrial
fibrillation
-Raynaud's
-subdural hematoma ___
-Depression
-Gastroesophageal Reflux Disease
-Hemorrhoids
-Hyperlipidemia
-Irritable Bowel Syndrome (Constipation)
-Left Leg Weakness following Spine Surgery
-Low Back Pain
-Sciatica
-Osteoarthritis
Past Surgical History:
-S/P Hemorrhoidectomy ___
-S/P Laminectomy L4-L5 ___
-S/P Total Abdominal Hysterectomy ___
-S/P Cholecystectomy ___
-S/P Bladder Sling ___
Social History:
___
Family History:
Mother - died of myocardial infarction, age ___
Father - died of stroke, age uncertain
Brother - died of complications from Diabetes mellitus, history
of CABG x3, age ___
Physical Exam:
On admission
GENERAL: elderly white woman in NAD. Oriented x3. Mood, affect
appropriate.
VS: T 97.8 BP 135/50 HR 61 RR 18 SaO2 98% on RA
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP flat at 90 degrees
CARDIAC: RR, normal S1, S2. No murmurs, rubs, gallops.
LUNGS: Resp were unlabored, no accessory muscle use, speaking
without difficulty. CTAB--no crackles, wheezes or rhonchi.
ABDOMEN: Soft, not distended. No HSM or tenderness.
NEURO: CN ___ intact, strength ___ and sensation intact
throughout
At discharge
GENERAL: elderly woman in NAD. Oriented x3. Mood, affect
appropriate.
VS: T 98.3 BP 111-147/47-107 HR 60-71 RR 18 SaO2 95% on RA
24 hours ins/outs: 1140/none reported
Overnight ins/outs: 0/none reported
Wt 68.2 kg
HEENT: NCAT. Sclera anicteric. MMM
NECK: Supple with JVP to lower third of neck.
CARDIAC: RR, normal S1, S2. No murmurs, rubs, gallops.
LUNGS: Resp were unlabored, no accessory muscle use, speaking
without difficulty. CTAB--no crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, not distended.
Ext: warm and well perfused; +1 distal and radial pulses
bilaterally, no edema. Right femoral arteriotomy site clean, dry
and intact; no femoral bruit.
Pertinent Results:
___ 12:00PM BLOOD WBC-5.9 RBC-4.76 Hgb-13.6 Hct-41.3 MCV-87
MCH-28.6 MCHC-32.9 RDW-13.5 RDWSD-43.2 Plt ___
___ 12:00PM BLOOD Glucose-95 UreaN-17 Creat-0.7 Na-127*
K-4.4 Cl-92* HCO3-24 AnGap-15
___ 12:00PM BLOOD cTropnT-<0.01
___ 06:05PM BLOOD cTropnT-<0.01
___ 07:55AM BLOOD cTropnT-<0.01
___ 06:00AM BLOOD CK(CPK)-39
___ 06:00AM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-99
___ 08:20AM BLOOD proBNP-168
___ 08:20AM BLOOD WBC-5.0 RBC-4.49 Hgb-13.0 Hct-39.0 MCV-87
MCH-29.0 MCHC-33.3 RDW-13.5 RDWSD-43.1 Plt ___
___ 08:20AM BLOOD ___ PTT-39.9* ___
___ 08:20AM BLOOD Glucose-107* UreaN-9 Creat-0.7 Na-134
K-4.5 Cl-99
HCO3-25 AnGap-15
___ 08:20AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.3
ECG ___ 11:04:03 AM
Atrial paced rhythm with intrinsic ventricular conduction. RSR'
pattern in lead V1 (normal variant). Compared to the previous
tracing of ___ the findings are similar.
CXR ___
A left-sided pacemaker and dual leads as well as sternotomy
wires are unchanged from prior examinations.
The heart is normal in size. Aorta is unfolded, similar to
prior. On lateral view, calcified or stented coronary artery is
noted, also unchanged.
Elevation and possible eventration of the right hemidiaphragm
is similar to the prior film.
No focal consolidation, pleural effusion, pulmonary edema or
pneumothorax is identified. In the right cardiophrenic region,
there is subsegmental atelectasis and/or scarring similar to ___ and ___. Linear atelectasis and/or
scarring at the left base is also unchanged. Minimal blunting of
one of the costo vertebral angles posteriorly is also unchanged.
IMPRESSION:
No acute pulmonary process identified. Stable elevation of the
right hemidiaphragm. Stable atelectasis/scarring at both bases.
Cardiac catheterization ___
Hemodynamics: State: Baseline
LV 196/10 HR 64
AO 194/71/116 HR 64
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery: The LMCA is normal.
* Left Anterior Descending: The LAD is moderately diseased mid,
supplied by ___. The ___ Diagonal is supplied by ___.
* Circumflex: The Circumflex is minimally diseased. The ___
Marginal is minimally diseased, supplied by SVG jump graft
* Right Coronary Artery: The RCA is moderately diffusely
diseased. Modest ostial dz. The Right PDA is minimally diseased.
CTA CHEST ___
The aorta and its major branch vessels are patent, with no
evidence of stenosis, occlusion, dissection, or aneurysmal
formation. There is no evidence of penetrating atherosclerotic
ulcer or aortic arch atheroma present.
There is a background of moderate calcific and noncalcific
atherosclerosis.
There is a dual lead pacemaker in situ, with leads located in
the right ventricle in the right atrium.
The pulmonary arteries are well opacified to the subsegmental
level, with no evidence of filling defect within the main,
right, left, lobar, segmental or subsegmental pulmonary
arteries. The main and right pulmonary arteries are normal in
caliber, and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar
lymphadenopathy. The thyroid gland appears unremarkable. There
is no evidence of pericardial effusion. There is no pleural
effusion.
Mild bibasal linear atelectasis. There is a small calcified
right apical granuloma. There is minimal bronchial wall
thickening within the right lower lobe.
Limited images of the upper abdomen demonstrate multiple
hypodense lesions within the liver, representing cysts or
biliary hamartomas.
No lytic or blastic osseous lesion suspicious for malignancy is
identified. There has been prior sternotomy.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mild bibasal linear atelectasis.
3. Multiple hepatic cysts versus biliary hamartomas.
Echocardiogram ___
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 aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. No aortic regurgitation is seen. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Symmetric LVH with normal global and regional
biventricular systolic function.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
Brief Hospital Course:
___ with H/O CAD s/p CABG x 3 in ___ (LIMA-LAD, SVG-OM,
SVG-RCA), S/P permanent pacemaker for paroxysmal atrial
fibrillation with sick sinus syndrome in ___, with recent
admission for chest pain with no objective evidence of ischemia
on dipyridamole-MIBI, who presented now with several day history
of jaw and left arm pain (which is her anginal equivalent),
chest pain, and dyspnea.
# Chest pain, CAD s/p CABG: Patient re-presenting with jaw and
left arm pain with chest pressure and shortness of breath, her
known angina equivalent. She had been admitted ___ with
similar presentation, which was thought to be musculoskeletal in
origin. She had a similar presentation during this admission.
Chest pain was not relieved with SL NTG. ECG was benign, and
troponin-T negative X 4. Since she had continued chest pain
despite a recent negative and reassuring pharmacological stress
test, cardiac catheterization was undertaken via the right
femoral artery which showed a normal LVEDP of 10 mm Hg. The LAD
had moderate disease with a patent LIMA. The RCA had moderate
ostial and disease disease. The CX was patent, as was the
SVG-OM. The SVG-RCA was not imaged. There was no evidence of
significant valvular or structural abnormalities by TTE.
Ultrasound technologist was able to reproduce Ms. ___
symptoms with pressure over sternum, directly over surgical
scar. There was no evidence of aortic dissection or pulmonary
embolus on chest CTA. Patient discharged on acetaminophen 1 g
TID for presumed musclosketal pain/costochondritis and diltiazem
30 mg TID for possible coronary microvascular disease. Given
prior CABG, her atorvastatin was increased from 20 mg BID to 40
mg BID. She was continued on home dose of ASA 81 mg daily for
cardiovascular prevention. Patient was not on a beta-blocker
given H/O exacerbation of Raynaud's with beta-blockers.
# Dyspnea - Chronic shortness of breath with acute worsening.
Limited functional capacity due to exertional dyspnea. No clear
cardiac etiology with vasodilator stress test negative for
imaging evidence of ischemia (and no reported bronchospasm).
LVEDP normal at left heart catheterization, and very low
NT-Pro-BNP twice. Pulmonary workup as an outpatient seems
warranted.
# Sick sinus syndrome/paroxysmal atrial fibrillation: s/p PPM.
A-paced with HR of 60. Pacemaker interrogated by EP at prior
admission and rate responsiveness was increased. Dyspnea did not
improve following adjustment of settings, suggesting non-optimal
pacemaker settings are unlikely to be contributing to her
respiratory complaints. CHADS2VASC score 4 suggested she may
benefit from anticoagulation, which she elected to discuss with
her outpatient providers.
# Hyponatremia: Patient intermittently hyponatremic in the past,
baseline Na of 129-135. On presentation had Na of 127, which
improved to 134 on discharge with fluid restriction.
# Chronic abdominal pain/IBS/GERD: Changed home dexilant 60 mg
daily to omeprazole 40 daily due to non-formulary. Continued
hydrocortisone suppository daily PRN.
# Chronic back pain: No pain. Held home cyclobenzaprine PRN.
Continued lidocaine patch BID PRN
# Anxiety: Continued home lorazepam 0.5 mg TID.
# Depression: Continued home Lexapro BID.
# Insomnia: Continued home Ambien 5 mg qHS.
TRANSITIONAL ISSUES:
- Patient is not on a beta blocker due to Raynaud's disease
- Would consider discussion of anticoagulation (given CHADS2VASC
of 4) for embolic prevention in patient with paroxysmal atrial
fibrillation as an outpatient
- Would strongly consider formal pulmonary work up including
PFTs and pulmonary referral as outpatient
- Patient was started on high dose atorvastatin 40 mg BID which
should be continued given her cardiovascular disease that
warranted CABG
- Patient was started on diltiazem 30 mg TID as anti-anginal for
possible microvascular disease. Please monitor blood pressures
and symptoms to ensure she continues to tolerate this
medications.
# CODE: DNR/DNI, confirmed
# CONTACT: ___ ___ (cell)
___ ___ (c), ___ (H)
___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO BID:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO BID
4. Escitalopram Oxalate 5 mg PO TID
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. Hydrocortisone Acetate Suppository ___AILY:PRN rectal
pain
7. Lidocaine 5% Patch 3 PTCH TD DAILY:PRN pain
8. LORazepam 0.5 mg PO TID
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Phenazopyridine 100 mg PO DAILY:PRN urinary pain
11. Vitamin D ___ UNIT PO DAILY
12. Zolpidem Tartrate 5 mg PO QHS
13. Cyclobenzaprine 5 mg PO TID:PRN back pain
14. Dexilant (dexlansoprazole) 60 mg oral DAILY
15. Lidocaine Jelly 2% 1 Appl TP Q6H:PRN hemorrhoids
16. Mylanta 2 teaspoons oral TID
17. salt irrigation solution ___ % nasal unknown
18. Senna with Docusate Sodium (sennosides-docusate sodium)
8.6-50 mg oral DAILY
19. TheraTears (carboxymethylcellulose sodium) 1 drop OPHTHALMIC
Frequency is Unknown
Discharge Medications:
1. Acetaminophen 1000 mg PO BID:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO BID
4. Escitalopram Oxalate 5 mg PO TID
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. Hydrocortisone Acetate Suppository ___AILY:PRN rectal
pain
7. Lidocaine 5% Patch 3 PTCH TD DAILY:PRN pain
8. Lidocaine Jelly 2% 1 Appl TP Q6H:PRN hemorrhoids
9. LORazepam 0.5 mg PO TID
10. Mylanta 2 teaspoons oral TID
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
12. Phenazopyridine 100 mg PO DAILY:PRN urinary pain
13. Vitamin D ___ UNIT PO DAILY
14. Zolpidem Tartrate 5 mg PO QHS
15. Cyclobenzaprine 5 mg PO TID:PRN back pain
16. Dexilant (dexlansoprazole) 60 mg oral DAILY
17. salt irrigation solution ___ % nasal unknown
18. Senna with Docusate Sodium (sennosides-docusate sodium)
8.6-50 mg oral DAILY
19. TheraTears (carboxymethylcellulose sodium) 1 drop OPHTHALMIC
Frequency is Unknown
20. Diltiazem 30 mg PO Q8H
RX *diltiazem HCl 30 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
- Shortness of breath
- Chest wall pain unlikely to be ischemic in origin
- Costochondritis
- Coronary artery disease
- Prior coronary artery bypass surgery
- Sick sinus syndrome
- Paroxysmal atrial fibrillation
- Prior implantation of a dual-chamber permanent pacemaker
- Hyponatremia
- Chronic back pain
- Gastroesophageal reflux disease
- Chronic abdominal pain
- Depression and anxiety
- Insomnia
- Raynaud's disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
Thank you for choosing to receive your care at ___. You were
admitted for shortness of breath and chest pressure. Given your
history of coronary artery disease and your recent hospital
admission for similar symptoms, we assessed the degree of heart
vessel blockage by coronary angiogram. The cornoary angiogram
did not reveal any blockages in the blood flow. You also
underwent a CT scan of your chest, which did not demonstrate any
clots or damage to the large vessels in your chest. We did an
ultrasound of your heart and the heart valves and pump function
was normal. The ultrasound did show that the left side of your
heart was enlarged but this was unchanged from your previous
ultrasound in ___. We think your pain is likely related to pain
in the muscles and bones in your chest wall affecting your jaw,
versus small vessel disease in your heart which would not cause
significant effects to your heart function.
Moving forward, you should make sure to take the medications as
listed below, and attend the follow up appointments listed
below. If you develop worsening shortness of breath, chest pain,
or other concerning symptom, please talk to your doctor right
away.
Again, it was our pleasure participating in your care here at
___.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
10395166-DS-22 | 10,395,166 | 29,333,432 | DS | 22 | 2183-02-26 00:00:00 | 2183-02-28 16:05:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
vertigo
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ woman with PMHx CAD s/p CABGx3 DEXx3, SSS/AF s/p
PPM,
HTN, HLD, chronic diplopia, chronic esophagitis, IBS, lumbar
laminectomies, hearing loss, and chronic vertigo who presented
due to a fall in the setting of worsening vertigo.
She notes falling off to the right, being unable to walk
straight
over the last few days. States that this sensation is new. Also
with several days of general fatigue. Yesterday crawled under a
chair to pick object, then became dizzy and fell over as she was
on her knees. Fell onto right side, no head strike. No other
symptoms than generalized weakness and pain with myalgias and
vertigo. She feels thirsty, not more than her baseline. Diet has
consisted of eggs, salt free yogurt, and PO intake slightly less
than normal.
Found to be hyponatremic, renal and neurology consulted. Started
on hypertonic saline 30cc/hr x 2 days.
In the ED,
Initial Vitals: T 96.3 HR 85 BP: 224/76 RR: 20 97% RA
Exam: periumbilical TTP, paraspinal muscle tenderness and
discomfort to palpation
Labs: Whole blood Na 115, serum Na 118 serum Osm 246, UNa 36,
Uosm 167
Imaging:
CT head: no acute abnormality
CTA head and neck:
Normal 3 vessel takeoff.
Subclavian, common carotid and internal carotid and vertebral
arteries are patent without evidence of stenosis, occlusion,
aneurysm or dissection.
Short segment of fusiform aneurysm in the basilar artery
measures
up to 3 mm. Proximal aspect of the basilar artery has multiple
areas of mild focal narrowing.
Consults: Renal, Neuro
Interventions: IV labetalol 10mg, started 3% Na
VS Prior to Transfer: T 98.4, HR 66, BP 165/75, RR 22, O2 sat
100% on RA
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
PMH/PSH:
ANEMIA
BACK PAIN
CERVICAL SPINE STENOSIS C5-6
COLONIC POLYPS
CORONARY ARTERY DISEASE
DEPRESSION
DUODENAL DIVERTICS
ESOPHAGITIS
H. PYLORI
MACULAR DEGENERATION
RT SHOULDER SUPRASPINATUS TEAR ___
URINARY INCONTINENCE
VERTIGO
GASTROESOPHAGEAL REFLUX
IRRITABLE BOWEL SYNDROME
SM BOWEL DIVERTICULI
*S/P CHOLECYSTECTOMY
HYPONATREMIA
INTERNAL HEMORRHOIDS
ATRIAL FIBRILLATION
HEMORRHOIDS
ANAL FISSURE
RAYNAUD'S PHENOMENON
SICK SINUS SYNDROME
CERVICALGIA
PELVIC FLOOR DYSSYNERGY
CAROTID STENOSIS
PSH:
TOTAL ABDOMINAL HYSTERECTOMY
Social History:
___
Family History:
Mother - died of myocardial infarction, age ___
Father - died of stroke, age uncertain
Brother - died of complications from Diabetes mellitus, history
of CABG x3, age ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 97.9, HR 69, BP 192/74, 21 97%
GEN: Pleasant, NAD
HEENT: Oropharynx clear without exudate
NECK: no JVD, thyroid non palpable
CV: Normal rate and regular rhythm, no m/r/g
RESP: CTAB
GI: Soft, nt,nd
SKIN: mild skin tenting over quadricepts, otherwise warm and
well perfused
NEURO: AOx3, ___ upper and lower extremity motor strength
DISCHARGE PHYSICAL EXAM:
========================
Vitals:
24 HR Data (last updated ___ @ 1106)
Temp: 98.3 (Tm 98.9), BP: 137/72 (128-169/59-73), HR: 75
(68-75), RR: 16 (___), O2 sat: 98% (97-100), O2 delivery: RA,
Wt: 131.61 lb/59.7 kg
GENERAL: lying comfortably in bed, no acute distress
HEENT: NT/AC, no conjunctival pallor, anicteric sclera, MMM
NECK: supple, non-tender
CV: RRR, S1 and S2 normal, no murmurs/rubs/gallops
RESP: CTAB, no wheezes/crackles
___: soft, non-tender, no distention, BS normoactive
EXTREMITIES: warm and well perfused, no lower extremity edema
NEURO: alert, moving all four extremities with purpose, CNs
grossly intact
PSYCH: calm, appropriate behavior
Pertinent Results:
ADMISSION LABS:
===============
___ 11:04PM BLOOD WBC-9.8 RBC-5.52* Hgb-15.2 Hct-42.9
MCV-78* MCH-27.5 MCHC-35.4 RDW-13.2 RDWSD-37.2 Plt ___
___ 11:04PM BLOOD Neuts-76.0* Lymphs-16.1* Monos-7.1
Eos-0.2* Baso-0.2 Im ___ AbsNeut-7.42* AbsLymp-1.57
AbsMono-0.69 AbsEos-0.02* AbsBaso-0.02
___ 06:34AM BLOOD ___ PTT-29.4 ___
___ 11:04PM BLOOD Glucose-123* UreaN-8 Creat-0.5 Na-118*
K-3.7 Cl-75* HCO3-24 AnGap-19*
___ 11:04PM BLOOD Glucose-123* UreaN-8 Creat-0.5 Na-118*
K-3.7 Cl-75* HCO3-24 AnGap-19*
___ 11:04PM BLOOD ALT-13 AST-20 AlkPhos-81 TotBili-0.9
___ 06:34AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.9
___ 11:04PM BLOOD %HbA1c-5.8 eAG-120
___ 11:04PM BLOOD Triglyc-51 HDL-51 CHOL/HD-2.1 LDLcalc-47
DISCHARGE LABS:
===============
___ 05:52AM BLOOD WBC-12.1* RBC-4.26 Hgb-11.7 Hct-35.8
MCV-84 MCH-27.5 MCHC-32.7 RDW-14.7 RDWSD-45.0 Plt ___
___ 05:52AM BLOOD Plt ___
___ 05:52AM BLOOD Glucose-116* UreaN-10 Creat-0.6 Na-136
K-4.3 Cl-100 HCO3-25 AnGap-11
___ 05:52AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.8
___ 03:30PM BLOOD TSH-1.7
MICROBIOLOGY:
=============
___ 12:22 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
RELEVANT IMAGING:
=================
___ CTA Head and CTA Neck
1. No acute intracranial abnormality.
2. 70% narrowing right, 60% narrowing left ICA origin, similar.
3. Significant narrowing posterior circulation multiple vessels,
similar.
4. Mild narrowing cavernous, paraclinoid ICA bilaterally,
similar.
5. Dental disease.
6. Degenerative changes cervical spine.
___ Line Placement
IMPRESSION:
In comparison with the study ___, there has been
placement of right
subclavian PICC line that extends to the lower SVC. Cardiac
monitor leads are stable. Cardiac silhouette is within normal
limits and there is no evidence of appreciable vascular
congestion, pleural effusion, or acute focal pneumonia.
___ CT Chest w/o Contrast
IMPRESSION:
No finding suggestive of malignancy in the chest.
Brief Hospital Course:
Ms. ___ is a ___ year old female with CAD, sick sinus
syndrome s/p PPM, HTN, chronic diplopia, chronic esophagitis,
IBS, lumbar laminectomies, hearing loss, and chronic vertigo who
presented with a fall in the setting of worsening vertigo
symptoms. She was found to have hyponatremia to 114 incidentally
in the ED. She was initially admitted to the MICU and treated
with hypertonic saline, salt tabs, and fluid restriction. Her Na
slowly corrected and she was transferred to floor, where her Na
remained stable for the remainder of her admission. At
discharge, nephrology recommended management with only fluid
restriction to not drink more than ___ glasses of any water
or beverage each day. Her salt tabs were also discontinued and
her sodium remained stable. She should have a repeat sodium
check in 1 week at her PCP ___ appointment.
TRANSITIONAL ISSUES:
==================
[ ] NEW/CHANGED MEDICATIONS - None
[ ] Please repeat sodium at PCP ___ with ___. ___ on
___
[ ] Discharge whole blood sodium was 137
[ ] She should continue fluid restriction, with intake of no
more than ___ glasses of any fluid per day.
[ ] If hyponatremia recurs while adhering to a fluid restricted
diet, her Lexapro use will need to be readdressed, as this is a
potential etiology of her hyponatremia
[ ] If she requires increased hypertensive therapy in the
future, would avoid thiazide diuretics
[ ] Consider MRI head WO contrast after discharge, per neurology
recommendations to evaluate for previous infarcts
[ ] Her missed ENT appointment was re-scheduled on discharge for
tilt-table testing to better assess her vertigo, but this
___ will need to be rescheduled on discharge
ACUTE ISSUES:
============
# Hyponatremia - Patient initially presented with fall and
worsening vertigo per below and incidentally was found to have
hyponatremia to 114 on admission, with urine osmolality 167 and
urine sodium 36. Renal was consulted and felt this hyponatremia
was likely multifactorial, with contribution from medications
(escitalopram), poor solute intake, and excessive free water
intake. She was initially admitted to the MICU and her Na level
improved with hypertonic saline, fluid restriction, and salt
tabs. Interestingly, once her sodium corrected to > 120, her
urine osmolality increased to 393 and urine sodium decreased to
<20, raising suspicion for a reset osmostat. Her TSH and AM
cortisol were normal and she had a CT Chest WO contrast which
was normal and did not show any pulmonary mass/nodule. She was
transferred to the floor, where her sodium remained stable and
she was managed with fluid restriction of 1.2L per day. She also
was previously receiving salt tablets 1 gram PO TID however this
was discontinued prior to discharge and her sodium remained
stable. her fluid restriction was liberalized to 1.5 L per day
and as an outpatient she should not have more than ___
glasses of any fluid per day. Her Na was 137 on day of
discharge. She will need a repeat sodium check in 1 week after
discharge at her PCP ___. If hyponatremia recurs while
adhering to a fluid restricted diet, her Lexapro use will need
to be readdressed, as this is a potential etiology of her
hyponatremia.
# Vertigo - This is a chronic problem for the patient, however
she had acute worsening of symptoms over the past ___ weeks
prior to admission, with associated "pulling" to the right side.
She had been evaluated by ENT with plan for tilt-table testing
as an outpatient. However, given recurrent falls, the patient
decided to present to the ED. CT head and CTA
head/neck were unremarkable for etiology of symptoms.
Interestingly, over the same time period sodium had decreased
from 137 -> 118, raising suspicion that this was responsible for
recrudescence of prior neuro deficits (right sided ptosis and
left dysmetria) and worsening of vertigo symptoms. Neurology was
consulted and recommended non-urgent MRI head to better assess
for previous infarcts, however this was deferred to the
outpatient setting. She is not having any current focal neuro
findings on exam. She did not have her vertigo symptoms while
admitted however this improved spontaneously prior to her
discharge.
# Leukocytosis - Patient's WBC had progressively increased,
reaching 17.0 on ___, in the absence of fevers, but then
downtrended. Patient did report mild dysuria although urine
studies were unremarkable. She also had one episode of diarrhea
on ___, however she had no further episodes to allow a sample
to be collected. The etiology was unclear, but she remained
clinically well and was not treated with antibiotics. She was
continued on home phenazopyridine for dysuria. WBC count
down-trended to 12.1 on discharge.
CHRONIC ISSUES:
==============
# HTN: She was continued on diltiazem ER 120 daily.
# GERD: She was continued on PPI
# Anxiety: She was continued on Ativan BID, and restarted on
Lexapro.
# SSS/Afib: with PPM, stable and chronic. DDDR, ___ device
check with stable parameters and battery life.
# CAD s/p CABG: She was continued on ASA and atorvastatin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Diltiazem Extended-Release 120 mg PO DAILY
5. Escitalopram Oxalate 5 mg PO BID
6. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN Back pain
7. LORazepam 0.5 mg PO BID anxiety
8. Vitamin D ___ UNIT PO DAILY
9. Zolpidem Tartrate 5 mg PO QHS
10. Cyclobenzaprine 5 mg PO TID:PRN Back pain
11. carboxymethylcellulose sodium ophthalmic (eye) BID
12. dexlansoprazole 60 mg oral DAILY
13. Fluticasone Propionate NASAL 1 SPRY NU BID
14. Hydrocortisone (Rectal) 2.5% Cream ___ID
15. lidocaine HCl-hydrocortison ac lidocaine 3%-hydrocortisone
2.5% 1 topical BID:PRN hemorrhoids
16. Phenazopyridine 95 mg PO DAILY:PRN Urinary Pain Relief
17. Senna with Docusate Sodium (sennosides-docusate sodium)
8.6-50 mg oral DAILY:PRN
18. Denosumab (Prolia) 60 mg SC ONCE
19. Simethicone 40 mg PO DAILY:PRN for gas
20. Anucort-HC (hydrocorTISone Acetate) 25 mg rectal DAILY:PRN
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Anucort-HC (hydrocorTISone Acetate) 25 mg rectal DAILY:PRN
3. Aspirin EC 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. carboxymethylcellulose sodium ophthalmic (eye) BID
6. Cyclobenzaprine 5 mg PO TID:PRN Back pain
7. Denosumab (Prolia) 60 mg SC ONCE
8. dexlansoprazole 60 mg oral DAILY
9. Diltiazem Extended-Release 120 mg PO DAILY
10. Escitalopram Oxalate 5 mg PO BID
11. Fluticasone Propionate NASAL 1 SPRY NU BID
12. Hydrocortisone (Rectal) 2.5% Cream ___ID
13. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN Back pain
14. lidocaine HCl-hydrocortison ac lidocaine 3%-hydrocortisone
2.5% 1 topical BID:PRN hemorrhoids
15. LORazepam 0.5 mg PO BID anxiety
16. Phenazopyridine 95 mg PO DAILY:PRN Urinary Pain Relief
17. Senna with Docusate Sodium (sennosides-docusate sodium)
8.6-50 mg oral DAILY:PRN
18. Simethicone 40 mg PO DAILY:PRN for gas
19. Vitamin D ___ UNIT PO DAILY
20. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- hyponatremia
SECONDARY DIAGNOSIS
- vertigo
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were found to have a very low sodium level, which caused
your fall and dizziness.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were initially treated in the Intensive Care Unit, where
you were given fluids to slowly increase the sodium level
-You began to improve, and were then treated with salt tablets,
as well as a limit on the amount of fluid you could drink each
day.
-By the time of your discharge, your sodium was back to a normal
level
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and ___
with your appointments as listed below.
-Do not drink more than ___ glasses of any water or beverage
each day.
-You will have your labs drawn to repeat your sodium level at
your PCP ___ in 1 week on ___, please keep this
appointment as it will be important to monitor your sodium level
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10395166-DS-23 | 10,395,166 | 20,136,370 | DS | 23 | 2183-06-01 00:00:00 | 2183-06-01 22:56:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Cipro
Attending: ___
Chief Complaint:
LEFT SIDED PAIN
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is an ___ year old right-handed woman with PMH of
CAD status post CABG in ___, ___ placement in ___ for atrial
fibrillation with conversion pauses leading to syncope, right
thalamic lacunar infarct identified on ___ in ___,
previous
neurologic evaluations for transient neurologic symptoms with
concern for transient ischemic attacks, bilateral internal
carotid stenosis, hypertension, hyperlipidemia, ___
phenomenon, lumbar spine disease, and anxiety/depression who Dr.
___ has sent to the ED for admission to general neurology
service for management of left-sided pain and MRI brain/cervical
spine with and without contrast to identify possible damage to
the right spinothalamic tract.
Mrs. ___ reports that she has been having pain on the
left
side of her body from the face to the bottom of the foot for at
least two months. Mrs. ___ does not think that she had
pain on the left-side six months ago. Mrs. ___ points to
the left hip and reports that this area is most severely
affected. Mrs. ___ reports that there is a radiation of
pain either from the left hip to the feet or from the feet into
the left hip. She is not certain, but tells me the whole left
leg is involved. The radiation of pain does not affect just the
posterior portion of the leg. Mrs. ___ reports less
severe pain affecting her left face, entire left arm, and entire
torso. Mrs. ___, interestingly, reports that the pain on
her face is bilateral on the forehead and only on the left side
on the lower portions of the face.
Mrs. ___ characterizes the pain as burning and throbbing
and it is excruciating. Mrs. ___ pain has progressed
and gotten more and more severe over the last two months. The
pain is present at all times. Mrs. ___ reports that the
pain is disabling. She cannot tolerate being touched on this
side. She has significant pain with showering and cannot sleep
on her left side. She cannot use her left arm. Sadly, Mrs.
___ feels that the pain is causing her to become
depressed.
Mrs. ___ was prescribed gabapentin by Dr. ___ in
___, but she never filled the prescription. Mrs. ___
received gabapentin 300 mg in the ED without benefit. Mrs.
___ takes acetaminophen which has not been of benefit.
She has taken up to 3000 mg daily. She sees a physical
therapist
for help with stretching and maintaining strength.
Pertinently, Mrs. ___ has had ___ phenomenon for
many years. She is uncertain who diagnosed her with this and
why
she has it. She does not believe she has hepatitis C. She
reports that this leads to significant pain in her hands and
feet
(feet>hands) and because of her pain described above the pain on
the left side is worse. Mrs. ___ reports that that her
hands and her feet become purple or black on a daily basis. She
has not appreciated an association with temperature changes
leading to these symptoms.
Pertinently, also, Mrs. ___ reports that ___ years ago
she had a lumbar spine surgery at L4-L5. She reports that she
was having shooting pain down her left leg and was also dragging
the left leg. She tells me she also has scoliosis of her upper
thoracic and lower cervical spine and lumbar spine stenosis.
Past Medical History:
CAD status post CABG in ___:
Prior to this had multiple stents placed. Patient managed with
aspirin and atorvastatin.
___ placement in ___ for atrial fibrillation with conversion
pauses leading to syncope:
___ interrogation over the years has not revealed recurrent
atrial
fibrillation
Right thalamic lacunar infarct identified on ___ in ___:
Patient presented to the hospital with multiple complaints
including blurred vision, unsteady gait, and slurred speech for
which code stroke was called. Dr. ___ the old right
thalamic infarct was from small vessel disease. Managed with
aspirin and atorvastatin
Bilateral internal carotid stenosis:
Last CTA ___ which read Atherosclerotic changes of the
carotid bifurcations are seen with 70% right and 60% left ICA
origin narrowing by NASCET criteria. Dr. ___
asymptomatic.
Hypertension and hyperlipidemia:
Per patient well controlled. LDL 47 ___.
___ phenomenon:
HCV and cryoglobulins negative in ___.
Lumbar spine disease:
Last Lumbar CT scan ___:
1. Multilevel lumbar spondylosis as described with dextroconvex
curvature of the lumbar spine with apex at L3 and multilevel
severe degenerative loss of disc height.
2. Scattered mild to mild to moderate neural foraminal narrowing
as described above. No high-grade spinal canal narrowing is
identified.
Does not look to be followed by spine or orthopedics here.
Social History:
___
Family History:
She does not know much about her family, but her mother died of
a
heart attack and her father died of a stroke. She thinks her
father was ___ years old when he had a stroke.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Comfortable and in no distress
Head: Temporal ___ were palpated and normal. No
irritation/exudate from eyes, nose, throat
Neck: Supple with no pain to flexion or extension
Cardio: Regular rate and rhythm, warm, no peripheral edema
Lungs: Unlabored breathing
Abdomen: Soft, non tender, non distended
Skin: Her feet a ruddy purple color.
MSK: Positive straight leg test on left
Mental status:
She is awake, alert, and cooperative with the exam. She has a
nice sense of humor. She is attentive, able to say months of
the
year backwards. Fund of knowledge is intact. She is oriented
to
place and date. Language is fluent. Memory for recent and
remote history is intact.
Cranial nerves:
Pupils are equal and reactive. Extraocular movements are full.
There is pain to touch of the forehead (left>right) and pain to
palpation of the left lower portions of the face. Facial
movements are intact and symmetric. Hearing is intact to finger
rub bilaterally. Palate elevates symmetrically. SCM and
trapezius are full strength bilaterally. Tongue is midline.
Motor:
Tone is normal. She has no slowness of movement. She has no
pronator drift or orbiting. She is full strength to
confrontational testing on the right side, but will not let me
perform testing on the left side because of pain.
Sensation:
Patient reports that it is painful when I touch her on any part
of the left side of the body including neck, arm, torso, and
legs, but not on the right. Patient lets me test pinprick on
the
thumbs and tells me that it is much sharper on the left compared
to the right. She tells me she will not have further testing of
pinprick or temperature because of pain. She can appreciate
large upward and downward excursions of her giant toes, but not
smaller ones.
Coordination:
She has mild intention tremor of both hands. Finger-nose-finger
without dysmetria. She refuses to participate in heal to shin
because of pain.
Reflexes:
She has a pectoral jerk and brisk reflexes, including cross
abductor and pre patellar reflex on the right side. She still
also has ankle reflex here. Plantar reflex on this side mute
versus flexor. She refuses to have reflexes tested on the left
side, citing pain.
===
DISCHARGE PHYSICAL EXAM:
Temp: 97.7 (Tm 97.8), BP: 148/77 (148-164/74-77), HR: 67
(60-67),
RR: 18, O2 sat: 95% (95-96), O2 delivery: Ra
General examination:
General: Comfortable and in no distress
Head: No
irritation/exudate from eyes, nose, throat. L eye with corneal
clouding ?cataract
Neck: Supple with no pain to flexion or extension
Cardio: Regular rate and rhythm, warm, no peripheral edema
Lungs: Unlabored breathing
Abdomen: Soft, non tender, non distended
Skin: L foot pale, other extremities WWP
MSK: Reports shooting pain down back of leg with passive raise
but no pain with active raise, on Right leg raisecomplains of
lumbosacral pain
Mental status:
She is awake, alert, and cooperative with the exam. She has a
nice sense of humor. She is attentive, able to say months of
the
year backwards. Fund of knowledge is intact. She is oriented
to
place and date. Language is fluent. Memory for recent and
remote history is intact.
Cranial nerves:
Pupils are equal and reactive. Extraocular movements are full.
Unlike yesterday, she does not have pain with touch on face, but
does endorse decreased sensation throughout V1, left less than
right. and decreased sensation in L V2/V3. Facial
movements are intact and symmetric. Hearing is intact to finger
rub bilaterally. Palate elevates symmetrically. SCM and
trapezius are full strength bilaterally. Tongue is midline.
Motor:
Tone is normal. She has no slowness of movement. She has no
pronator drift or orbiting. She is full strength to
confrontational testing bilaterally (able to cooperate this
morning)
Sensation:
Patient reports that it is painful when I touch her on any part
of the left leg but not other parts of her body this morning.
She
reports that the lateral aspect of her left leg has had
decreased
sensation since spinal surgery many years ago. sensation also
newly decreased to touch and temperature on L side of her arm,
torso, leg. Patient lets me test pinprick on the
thumbs and tells me that it is much sharper on the left compared
to the right. She can appreciate
large upward and downward excursions of her giant toes, but not
smaller ones.
Coordination:
She has mild intention tremor of both hands. Finger-nose-finger
and heel shin
without dysmetria.
Reflexes:
She has a pectoral jerk and brisk reflexes in bilateral upper
extremities. She has brisk lower R extremity including cross
abductor and pre patellar reflex. She still
also has ankle reflex here. Plantar reflex on this side mute. I
deferred left leg reflexes due to substantial pain with even
light touch.
Pertinent Results:
___ 10:11AM BLOOD WBC-8.6 RBC-4.91 Hgb-12.7 Hct-41.4 MCV-84
MCH-25.9* MCHC-30.7* RDW-15.3 RDWSD-46.4* Plt ___
___ 10:11AM BLOOD Neuts-75.5* Lymphs-16.0* Monos-7.1
Eos-0.5* Baso-0.6 Im ___ AbsNeut-6.52* AbsLymp-1.38
AbsMono-0.61 AbsEos-0.04 AbsBaso-0.05
___ 10:11AM BLOOD Glucose-114* UreaN-17 Creat-0.6 Na-138
K-5.7* Cl-102 HCO3-25 AnGap-11
___ 10:11AM BLOOD ALT-11 AST-27 AlkPhos-67 TotBili-0.2
___ 10:11AM BLOOD Lipase-24
___ 10:11AM BLOOD Albumin-3.8
___ 10:11AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-7*
Tricycl-NEG
MRI C-SPINE:
IMPRESSION:
1. Moderate to severe canal narrowing at C3-4 and C5-6, without
definite cord
signal abnormality. Overall, the extent of canal narrowing
appears similar to
___ given differences in imaging technique.
2. Severe right neural foraminal narrowing at C5-6, also similar
to ___.
MRI HEAD
IMPRESSION:
No evidence of acute intracranial process or hemorrhage.
Brief Hospital Course:
___ year old right-handed woman with PMH of CAD status post CABG
in ___, ___ placement in ___ for atrial fibrillation with
conversion pauses leading to syncope, right thalamic lacunar
infarct identified on ___ in ___, previous neurologic
evaluations for transient neurologic symptoms with concern for
transient ischemic attacks, bilateral internal carotid stenosis,
hypertension, hyperlipidemia, Raynaud's phenomenon, lumbar spine
disease, and anxiety/depression who was referred to the ED by
Dr. ___ management of left-sided pain and MRI.
Overall the patient's history suggested thalamic pain syndrome.
She had MRI Brain and cervical spine w/o contrast performed. It
was not felt that lumbar spine MRI was needed as her symptoms
did not clearly seem radicular. Straight leg test was not
positive. There was some pain with passive manipulation of leg,
but active ROM was fine. C spine MRI showed cervical spondylosis
not felt to be responsible for her symptoms. MRI brain w/o acute
findings and re-demonstrated her old R thalamic infarct. No
other findings on MRI to explain her symptoms. Given the MRI
findings and history it was felt she had thalamic pain syndrome.
Gabapentin was started but without much effect. On chart review,
GBP 600 mg BID in the past had made her too drowsy, as such she
was switched to duloxetine, started at 30 mg daily. She should
continue to uptitrate the duloxetine as an outpatient. There
were no interactions of duloxetine with her escitalopram. She
was discharged home.
TRANSITIONAL ISSUES:
#thalamic pain syndrome
-started duloxetine ___ 30 mg daily this admission, titrate as
needed
-consider stopping escitalopram once duloxetine at a higher dose
#cervical spondylosis
-continue to follow clinically
-no weakness or bowel/bladder symptoms this visit
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Cyclobenzaprine 5 mg PO TID:PRN back pain
4. Diltiazem Extended-Release 120 mg PO DAILY
5. Escitalopram Oxalate 5 mg PO BID
6. Lidocaine 5% Patch 1 PTCH TD QAM back pain
7. LORazepam 0.5 mg PO BID
8. Vitamin D ___ UNIT PO DAILY
9. dexlansoprazole 60 mg oral DAILY
10. Proctozone-HC (hydrocorTISone) 2.5 % topical DAILY:PRN
rectal pain
Discharge Medications:
1. DULoxetine ___ 30 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Cyclobenzaprine 5 mg PO TID:PRN back pain
5. dexlansoprazole 60 mg oral DAILY
6. Diltiazem Extended-Release 120 mg PO DAILY
7. Escitalopram Oxalate 5 mg PO BID
8. Lidocaine 5% Patch 1 PTCH TD QAM back pain
9. LORazepam 0.5 mg PO BID
10. Proctozone-HC (hydrocorTISone) 2.5 % topical DAILY:PRN
rectal pain
11. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
thalamic pain syndrome
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were hospitalized due to pain on the left side of your body.
This pain was felt to be due to nerves. We obtained a MRI of
your head and neck. This showed that ___ had some arthritis in
your neck. It showed that ___ had an old stroke as well. There
were no signs of new stroke or any masses or tumors. Overall we
feel that your pain is due to something called THALAMIC PAIN
SYNDROME. Sometimes, months to years after people have a stroke
in an area of the brain called the thalamus, they can develop
pain. We started gabapentin for your pain. However, we looked
back and saw that this made ___ drowsy in the past, so we
decided to stop this. We instead started duloxetine (Cymbalta).
This medication was originally discovered for depression, but
people later found that it can be very helpful in nerve pain, as
it changes the way the pain signals are processed. This will not
immediately resolve your pain, and will take time to build up in
your system before having its maximal effect. Please avoid
driving until ___ know how your body reacts to this medication.
This medication can be increased over time by your primary care
doctor. We think that when your duloxetine (Cymbalta) gets to a
higher dose, it may be a good idea to stop your escitalopram, as
duloxetine can be used for depression as well as pain.
New medications:
duloxetine (Cymbalta) 30 mg daily
Please be aware that duloxetine can sometimes cause headache,
nausea, drowsiness, fatigue, dry skin, and weakness.
If ___ have any thoughts of harming yourself, please stop taking
duloxetine and contact a doctor immediately.
Please follow up with your appointments as listed below, and
take your other medications as previously prescribed.
Sincerely,
Your ___ neurology team
Followup Instructions:
___
|
10395376-DS-7 | 10,395,376 | 24,270,186 | DS | 7 | 2171-04-24 00:00:00 | 2171-04-24 13:13:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
acute cholecystitis
Major Surgical or Invasive Procedure:
___: laparoscopic cholecystectomy
History of Present Illness:
___ w/ HIV (CD4 1241 ___, hiatal hernia, and esophagitis
(dx ___, nephrolithiasis, HLD who p/w epigastric and RUQ pain.
Last night he went out to eat scallops and shrimp and then at
midnight had acute onset throbbing epigastric pain and N/V. He
vomited about 12 times (orange, non-bloody) and said the pain
got
worse after vomiting. Denies radiation, CP/dysuria/
hematuria/hematemesis/F/C/D/melena/BRBPR. He says this does not
feel like his usual GERD symptoms or nephrolithiasis. Denies
ETOH
or recreational drug use or any changes in his medications.
Past Medical History:
PMH:
HIV (CD4 1241 ___, hiatal hernia, and esophagitis
(dx ___, nephrolithiasis, HLD
PSH:
-sinus surgery
Social History:
___
Family History:
Non contributory
Physical Exam:
At admission:
Vitals: 99.0 96 140/70 18 98% RA
GEN: A&O
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, diffusely tender to palpation, greatest
in RUQ, no rebound or guarding,
Ext: No ___ edema, ___ warm and well perfused
At discharge:
GEN: NAD
HEENT: EOMI, MMM, no scleral icterus
CV: RRR
PULM: nonlabored breathing
ABD: appropriate TTP near incisions port sites x4 c/d/I with
dermabond, non-distended
Ext: no edema
Neuro: A&Ox3
Psych: appropriate mood, appropriate affect
Pertinent Results:
Gallbladder US (___):
1. Cholelithiasis and sludge in a distended gallbladder with
wall edema. No sonographic ___ sign. Findings are
nonspecific. Recommend correlation with laboratories and
clinical exam. If there is continued high suspicion for acute
cholecystitis, a HIDA scan can be performed.
2. Mildly dilated common bile duct, measuring up to 9 mm.
Recommend LFT
correlation, and can obtain MRCP to further delineate the
biliary system.
3. Echogenic liver consistent with steatosis. Other forms of
liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot
be excluded on the basis of this examination.
MRCP (___):
1. Mild dilatation of the common bile duct, smoothly tapering
to the ampulla, without evidence for obstructing mass or
intraluminal filling defect.
2. Hepatic steatosis, with a fat fraction of 13.5%.
LFTs:
2.3->3.0->1.3->0.8
Brief Hospital Course:
Mr. ___ presented to the ___ ED on ___ with right upper
quadrant abdominal pain. Ultrasound and physical exam were
indicative of acute cholecystitis. He was taken to the Operating
Room where he underwent a laparoscopic cholecystectomy. For full
details of the procedure, please refer to the separately
dictated Operative Report. He was extubated and returned to the
PACU in stable condition. Following satisfactory recovery from
anesthesia, he was transferred to the surgical floor for further
monitoring.
Ultrasound showed a 9mm CBD and total bilirubin was elevated to
2.3 on arrival to ED and increased to 3.0 preoperatively. Given
these findings in the setting of known stones, patient had MRCP
post-operatively. MRCP was essentially normal and diet was
advanced after this finding. Bilirubin normalized
post-operatively and was 0.8 on discharge.
Patient was discharged home on ___ at which time he was
voiding spontaneously, ambulating independently, tolerating a
regular diet and pain was well controlled with oral medications.
He will follow up in clinic in 2 weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cialis (tadalafil) 10 mg oral Q72H:PRN
2. RiTONAvir 100 mg PO DAILY
3. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain
- Moderate
4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
5. Acyclovir 800 mg PO DAILY
6. Atazanavir 300 mg PO DAILY
7. LORazepam ___ mg PO QHS:PRN insomnia
8. Ranitidine 300 mg PO DAILY
9. Simvastatin 10 mg PO QPM
10. Acetaminophen 1000 mg PO BID:PRN Pain - Mild
11. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
Do not drink alcohol or drive while taking this medication.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
3. Acetaminophen 1000 mg PO BID:PRN Pain - Mild
4. Acyclovir 800 mg PO DAILY
5. Atazanavir 300 mg PO DAILY
6. Cetirizine 10 mg PO DAILY
7. Cialis (tadalafil) 10 mg oral Q72H:PRN
8. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
9. LORazepam ___ mg PO QHS:PRN insomnia
10. Ranitidine 300 mg PO DAILY
11. RiTONAvir 100 mg PO DAILY
12. Simvastatin 10 mg PO QPM
13. HELD- OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO
Q4H:PRN Pain - Moderate This medication was held. Do not
restart OxyCODONE--Acetaminophen (5mg-325mg) until you have
finished your oxycodone prescriptin.
Discharge Disposition:
Home
Discharge Diagnosis:
acute cholecystitis
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 ___ with acute cholecystitis. You were
taken to the Operating Room where you underwent laparoscopic
removal of your gallbladder. You had an MRCP after surgery to
check for residual gallstones. There was no evidence of
gallstones or obstruction. You have recovered well and are now
ready for discharge. Please follow the instructions below to
ensure a speedy recovery:
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 Your incisions are covered with Dermabond (skin glue). This
will wear off over time. Do not pick it off.
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.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Surgery Team
Followup Instructions:
___
|
10395651-DS-6 | 10,395,651 | 28,378,564 | DS | 6 | 2185-05-11 00:00:00 | 2185-05-11 21:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
doxazosin
Attending: ___.
Chief Complaint:
Black stool, difficulty swallowing
Major Surgical or Invasive Procedure:
EGD with Gastric biopsy
Supraclavicular lymph node biopsy
History of Present Illness:
This is a ___ year old ___ speaking male heavy smoker
with likely CAD (possible history of MI) presenting from home
with 3 weeks of vomiting, epigastric pain, black stools,
weakness, and sensation that he has a mass in his abdomen.
The interpreter is ___ speaking and unable to translate.
History is obtained from his daughter in law who is not a native
___ speaker.
It seems he has been having trouble swallowing solids, only
drinks, develops pain and nausea and vomits shortly. Vomit has
black material, no red blood. All stools have been black, no red
blood. He's been weak, fatigued. He has chest discomfort all the
time, though worse with food.
He has a sensation that something "is growing inside" his
abdomen, in the epigastric area. No personal history of cancer,
father had liver cancer. No fevers/chills, no cough, though some
shortenss of breath.
This has never happened to him before, though he was seen by GI
here for workup of dyspepsia with ___ ___ with single
polyp
removed.
In the ED:
vitals 97.8 146 108/67 18 98% RA
Hr improved to 60's
Lactate:2.9
138 99 30
--------------< 149
4.9 23 1.0
Trop-T: <0.01
ALT: 20 AP: 68 Tbili: 0.7 Alb: 3.8
AST: 42
Lip: 26
INR 1.0
11.0
8.8>----<232
32.8
EKG: normal sinus, RBBB, no ischemia
CXR: subtle opacity R lung base, possible pna
He was admitted to medicine for further workup.
ROS: Per hpi, otherwise rest of 10pt review negative
Past Medical History:
- Possible MI (episode of "feinting" and "heart blockage")
- Dyspepsia
- GERD
Social History:
___
Family History:
Father with liver cancer
Physical Exam:
ADMISSION PHSICAL EXAM
98.6 101/53 60 16 97 ra
GEN: Thin chronically ill appearing man in no distress
HEENT: Pink conjunctiva, sunken temples
HEART: RRR, no murmurs
LUNGS: CTA bilaterally, good air movement
ABD: ~3cm slightly mobile epigastric mass, hard, nontender. Soft
abd, not distended.
GU: No foely
EXT: Warm, thin, no edema
NEURO: Alert, moving all extreme spontaneously
PSYCH: Calm, cooperative
DISCHARGE PHYSICAL EXAM
VS: 98.3 ___
GEN: Well-appearing man in NAD
HEENT: Sclera anicteric, moist mucous membranes, oral thrush
Cards: RRR, nl S1/S2, no MRG
Pulm: Soft crackles in b/l bases, no wheezes
Abd: Soft, NTND, normoactive bowel sounds
Skin: No concerning lesions
Neuro: AAOx3, CN II-XII grossly intact
Pertinent Results:
ADMISSION LABS:
======================
___ 03:12PM BLOOD WBC-8.8 RBC-3.13* Hgb-11.0* Hct-32.8*
MCV-105* MCH-35.1* MCHC-33.5 RDW-13.7 RDWSD-51.7* Plt ___
___ 03:12PM BLOOD Neuts-71.0 ___ Monos-8.6 Eos-0.7*
Baso-0.2 Im ___ AbsNeut-6.27* AbsLymp-1.70 AbsMono-0.76
AbsEos-0.06 AbsBaso-0.02
___ 03:12PM BLOOD ___ PTT-27.8 ___
___ 03:12PM BLOOD Ret Aut-2.7* Abs Ret-0.09
___ 03:12PM BLOOD Glucose-112* UreaN-30* Creat-1.0 Na-138
K-5.6* Cl-99 HCO3-23 AnGap-22*
___ 03:12PM BLOOD ALT-20 AST-42* LD(___)-963* AlkPhos-68
TotBili-0.7
___ 03:12PM BLOOD Lipase-26
___ 03:12PM BLOOD cTropnT-<0.01
___ 03:12PM BLOOD Albumin-3.8 Iron-79
___ 03:12PM BLOOD calTIBC-286 Ferritn-130 TRF-220
___ 03:25PM BLOOD Lactate-2.9* K-4.9
___ 11:49PM BLOOD Lactate-1.6
RELEVANT LABS:
======================
___ 04:50PM BLOOD Hapto-135
___ 07:15AM BLOOD CEA-11.9* CA125-501*
DISCHARGE LABS
======================
___ 06:00AM BLOOD WBC-4.1 RBC-2.46* Hgb-8.7* Hct-25.5*
MCV-104* MCH-35.4* MCHC-34.1 RDW-13.9 RDWSD-53.0* Plt ___
___ 06:00AM BLOOD ___ PTT-32.1 ___
___ 06:00AM BLOOD Glucose-99 UreaN-23* Creat-0.6 Na-140
K-4.2 Cl-101 HCO3-30 AnGap-9
___ 06:00AM BLOOD ALT-38 AST-44* LD(___)-742* AlkPhos-138*
TotBili-0.6
___ 06:00AM BLOOD Albumin-3.2* Calcium-9.1 Phos-3.3 Mg-2.6
IMAGING
====================
Chest xray PA/lateral - ___
Subtle opacity at the right lung base, question pneumonia in the
correct clinical setting.
CT ABDOMEN/PELVIS ___. Diffuse, nodular mural thickening of the stomach which has
linitis
plastica morphology distally. Upper abdominal adenopathy..
Gastric
adenocarcinoma is likely. Differential consideration lymphoma.
Occasionally
metastatic breast, lung neoplasm can have similar appearance.
Inflammatory,
infectious process is unlikely.
2. Right lower lobe peripheral consolidation, moderate mucous
plugging, may
represent aspiration pneumonia with small area of cavitation,
mass cannot be
excluded, follow-up to resolution recommended.
3. Moderate lower lobe emphysema with fibrotic changes.
CT CHEST ___. No evidence of pulmonary embolism to the subsegmental level.
2. Masslike consolidation with central low attenuation at the
right lung base.
This again could represent a pulmonary mass or round pneumonia.
A repeat CT
chest after treatment in ___ weeks would be of additional
diagnostic value.
3. Extensive thoracic including supraclavicular adenopathy.
CHEST XRAY ___
No previous images. There is hyperexpansion of the lungs with
flattening
hemidiaphragms and coarseness of interstitial markings,
consistent with
chronic pulmonary disease. Retrocardiac opacification on the
lateral view
could represent aspiration/pneumonia as suggested in the
clinical history.
Prominence of the mediastinum is consistent with adenopathy seen
on the CT
study ___.
CHEST XRAY ___
Mild cardiomegaly and widening mediastinum are stable.
Mediastinal hilar
lymphadenopathy is better seen on prior CT. Right PICC tip is
at the
cavoatrial junction bibasilar opacities right greater than left
are unchanged.
There is no pneumothorax
PROCEDURES
====================
EGD - ___
Blood in the stomach
Gastric mass (biopsy)
Otherwise normal EGD to antrum
PATHOLOGY
=======================
Stomach, "gastric mass," mucosal biopsy: ___
- Minute focus of adenocarcinoma, diffuse-type in this limited
sample, and arising in a background of marked chronic active
gastritis with intestinal metaplasia. See note.
- Immunohistochemical stain for H. pylori is positive, with
satisfactory control.
Note: A minute, superificial aspect of tumor is identified only
on deeper levels (1A6 and 1A7) , extending into the overlying
mucosa with foci suspicious for lymphovascular invasion.
Immunostains demonstrate the tumor cells to be weakly
immunoreactive for cytokeratin 7, compatible with an upper
gastrointestinal origin (tumor is not present on CKAE1/AE3).
Special stain for mucicarmine is negative.
Supraclavicular lymph node, excisional biopsy: ___
- Metastatic poorly differentiated carcinoma; involving lymph
node and fibroadipose tissue.
Note: Immunohistochemical stains are performed. The tumor is
positive for cytokeratin
AE1/3&CAM5.2, and CK7. TTF-1 is focally positive. CK20, CDX-2,
and Napsin are negative.
Differential diagnosis includes upper-GI and pulmonary
primaries. Clinical correlation is
recommended.
A HER2 immuno-stain is negative (1+).
Brief Hospital Course:
Mr. ___ is a ___ male with past medical history
significant for syncope, gastritis, question of CAD who
presented with 3 weeks of progressive dysphasia along with slow
GI bleed found to have a large gastric mass, with biopsy
consistent with adenocarcinoma, diffuse type. Additional stains
could not be completed due to limited tissue.
Immunohistochemical stain for H. pylori was positive. He also
had supraclavicular lymphadenopathy, with biopsy consistent with
metastatic poorly differentiated carcinoma, involving lymph node
and fibroadipose tissue, Her2 negative. During admission, he
initiated treatment with FOLFOX C1D1= ___. He was also noted
to have an opacity in the R lung. He completed treatment with
levofloxacin for presumed pneumonia but needs repeat CT Chest in
4 weeks to assess resolution of the opacity.
#Metastatic Gastric adenocarcinoma, diffuse type: Patient
presented with progressive dysphasia over the last 3 weeks along
with CT scan showing linitis plastica appearance of the stomach.
Patient underwent EGD with biopsies consistent with gastric
adenocarcinoma, diffuse type. Biopsy of supraclavicular mass
showed metastatic poorly differentiated carcinoma, involving
lymph node and fibroadipose tissue, Her2 negative. Furthermore
he did have biopsies that also showed H. pylori. Given inability
to tolerate p.o. intake, he underwent placement of J-tube, but
had some difficulty tolerating tube feeds due to nausea/vomiting
early during admission. He did have one episode of small volume
hematemesis in the setting of walking with physical therapy. He
was switched to a more concentrated tube feed formulation, and
at discharge, he was tolerating tube feeds at goal rate 50ml/hr
without subsequent vomiting. Per GI and speech and swallow
evaluation, he can tolerate small sips (including Maalox which
significantly improves his chest discomfort from the gastic
mass). However, speech and swallow recommended video swallow
study to evaluation for aspiration risk, which he scheduled for
on ___. Until that time, he was instructed to limit PO intake
to small sips, mixed with applesauce. He initiated treatment
with FOLFOX ___. At discharge, his PICC was pulled, and he
has an appointment for port placement on ___ prior to next
chemotherapy on ___.
# R lung mass/consolidation:
Patient found to have right lower lung mass that was 4.8 x 3.1
cm on CTA. There was evidence of surrounding patchy opacity with
associated mucus plugging. These findings were concerning for
pulmonary mass v. round pneumonia. Based on these findings there
was concern for gastric adenocarcinoma metastasis v. primary
lung cancer v. pneumonia. He was treated with an 8 day course of
levofloxacin with concern for pneumonia. He continued to have a
productive cough, with occasional blood tinged sputum. Chest
xray on ___ showed unchanged bibasilar opacities, right > left.
Patient was stable on room air. Patient would benefit from
repeat CT chest in 4 weeks
# Positive H. pylori: Patient with positive H. pylori on
gastrointestinal biopsy. Will require treatment at some point;
however, treatment may be deferred in setting of likely
chemotherapy.
# Anemia
# Chronic GI bleed: Patient with hemoglobin on presentation of
11.0. Decreased to 9.2 in the setting of GI bleed. Iron studies
demonstrate iron is 79, TRF 220, TIBC 286, likely secondary to
combination of chronic blood loss along with anemia of chronic
disease. He was maintained on Pantoprazole 40 mg twice daily.
His CBC was stable between ___ during admission.
#Anxiety:
Patient endorsed feeling restless and anxious in the setting of
new diagnosis and chest discomfort secondary to his gastric
mass. He was started on Ativan prn, which greatly relieved these
symptoms.
#Severe malnutrition: Patient seen and evaluated by nutrition
and meets criteria for severe malnutrition with 7% weight loss
in 1 month along with nausea and vomiting. Likely related to
dysphasia from gastric mass status post placement of J-tube.
Patient received tube feeds at goal of 60mL/hr; however, he
could not tolerate this and was switched to Jevity 1.5 at
50cc/hr which he tolerated.
# ? History of CAD: Patient with unclear history of CAD. Reports
blockage in ___ but denies any stenting procedure. Has
complained of intermittent chest pressure and pain during his
hospitalization with unchanged EKGs which demonstrate RBBB.
Troponins are negative. Pain may be related to gastric mass and
improved with magic mouthwash. Held off on aspirin given concern
for bleeding mass, which can be restarted after discharge.
TRANSITIONAL ISSUES
===============================
[] Scheduled for follow up appointment with Dr. ___ on
___.
[] Patient was started on FOLFOX C1D1 on ___. Next infusion is
on ___.
[] Patient has appointment for port placement on ___.
[] Patient is scheduled for video swallow study on ___, per
speech and swallow given concern for aspiration risk. Until
then, he was recommended to minimize PO intake to small
sips/meds in applesauce.
[] J-tube placed during admission and patient initiated on tube
feeds with plan to continue as outpatient pending resolution of
gastric outlet obstruction. Jevity 1.5, Goal Rate: 50ml/hr, 75ml
free water q6h.
[] Patient was started on lorazepam 0.5mg every 6 hours prn for
anxiety. Reassess as outpatient and consider restarting
long-acting medication or SSRI depending on symptoms.
[] Patient was started on Maalox/Diphenhydramine/Lidocaine for
chest discomfort secondary to his gastric mass.
[] Patient was discharged on Morphine oral solution for pain.
[] Patient had right lung consolidation on CTA and completed
treatment for pneumonia. Please repeat CT chest in 4 weeks to
assess for resolution.
[] Gastric biopsies showed evidence of H. Pylori. Consider
referral to gastroenterology and treatment as an outpatient
pending
Name of health care proxy: ___
___: daughter
Phone number: ___
Code: Full Code
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
4. Simvastatin 20 mg PO QPM
5. Metoprolol Succinate XL 25 mg PO DAILY
6. TraZODone 50 mg PO QHS
7. Ranitidine 150 mg PO BID
Discharge Medications:
1. Bisacodyl ___AILY:PRN Constipation - Second Line
RX *bisacodyl 10 mg 1 suppository(s) rectally once a day Disp
#*50 Suppository Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 60 mg/15 mL 20 mL by mouth twice a day
Refills:*0
3. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 5 mL by mouth
every six (6) hours Refills:*0
4. Lansoprazole Oral Disintegrating Tab 30 mg Other DAILY
RX *lansoprazole [Prevacid SoluTab] 30 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
5. LORazepam 0.5 mg PO Q6H:PRN anxiety
RX *lorazepam [Ativan] 0.5 mg 1 tab by mouth every six (6) hours
Disp #*28 Tablet Refills:*0
6. Maalox/Diphenhydramine/Lidocaine 5 mL PO QID:PRN
pain/discomfort
RX *alum-mag hydroxide-simeth [Antacid] 200 mg-200 mg-20 mg/5 mL
5 ml by mouth every eight (8) hours Refills:*0
7. Morphine Sulfate (Oral Solution) 2 mg/mL ___ mg PO Q8H
RX *morphine 10 mg/5 mL 5 mL by mouth every four (4) hours Disp
#*200 Milliliter Refills:*0
8. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*60 Tablet Refills:*0
9. Senna 8.6 mg PO BID Constipation - First Line
RX *sennosides [senna] 8.8 mg/5 mL 5 ml by mouth twice a day
Refills:*0
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
11. Aspirin 81 mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Simvastatin 20 mg PO QPM
14. TraZODone 50 mg PO QHS
15.Rolling Walker
Rolling Walker
Diagnosis: Gastric Adenocarcinoma, C16.9
Prognosis: Good
Length of Need: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Metastatic gastric carcinoma
Secondary:
Pneumonia
H. Pilori
Severe malnutrition
Chronic GI bleed
Anemia
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you were having
trouble swallowing. We did a procedure to look into your stomach
and found a mass. We took a biopsy of the mass, and
unfortunately, we found that you have cancer in your stomach.
You also had an enlarged lymph node which we biopsied, and this
showed that your stomach cancer had spread to your lymph node.
While you were in the hospital, we started you on chemotherapy
called FOLFOX. You will continue this treatment as an
outpatient.
We also did a chest xray, which showed that there was something
in your lung. We think this was most likely a pneumonia, so we
treated you with antibiotics. There is a chance that this is
cancer as well. You will need a CAT scan of your lungs in 4
weeks to re-check this.
When you go home, you should take all of your medications as
prescribed. You will also need to see the speech and swallow
team as an outpatient on ___. They will evaluate whether it is
safe for you to have small amounts of fluids (juices, soups) by
mouth. Until you see them, we recommend avoiding drinking thin
liquids other than your medications. If you can, you should mix
these liquids with applesauce to make it easier for you to
swallow.
It was a privilege to participate in your care, and we wish you
all the best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10395651-DS-7 | 10,395,651 | 25,959,744 | DS | 7 | 2185-05-14 00:00:00 | 2185-05-14 23:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
doxazosin
Attending: ___
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Single lumen port placement
History of Present Illness:
Mr. ___ is a ___ male with recently diagnosed
metastatic gastric adenocarcinoma diffuse type on FOLFOX ___ discharged yesterday and re-presented today for vomiting and
hematemesis in the setting of rapid infusion of tube feeds due
to error using the pump.
He was discharged yesterday and was doing well at that time.
When he got home, the ___ arrived but wasn't sure how to operate
the tube feed machine. The family and the ___ tried to set it
up, and ended up giving a large volume of tube feeds over a
short period of time. In this setting, the patient began
vomiting and his daughter noted blood in the vomit. He was not
lightheaded or short of breath thereafter, but the family
brought him back to the ED out of concern. He also had a few
episodes of diarrhea after the large volume of tube feeds.
In the ED, initial vitals: 98.3 115 116/65 18 99% RA
- Exam notable for soft abdomen, no tenderness
- Labs were notable for: Hb 8.2, guaiac negative diarrhea
- Imaging: CXR as below
- Patient was given: NS, Zofran, morphine, famotidine,
Donnatal, magic mouth wash, pantoprazole
- Decision was made to admit to Omed for hematemesis in the
setting of gastric cancer
- Vitals prior to transfer were 98.2 86 108/70 19 96% RA
On arrival to the floor, he has no nausea and has not vomited.
He continues to have a productive cough and chest discomfort
consistent with the discomfort he had throughout last admission.
It is central/ epigastric, non-radiating, burning in quality. He
has had no more episodes of diarrhea.
He has had no fevers, chills, dyspnea, abdominal pain.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-In late ___, patient presenting from home with 3 weeks of
dysphagia to solids, vomiting, epigastric pain, black stool,
weakness, and sensation that he had a mass in his abdomen
-CT scan showing linitis plastica appearance of the stomach.
-Patient underwent EGD on ___ with biopsies consistent with
gastric adenocarcinoma, diffuse type. Furthermore he did have
biopsies that also showed H. pylori.
-Biopsy of supraclavicular mass showed metastatic poorly
differentiated carcinoma, involving lymph node and fibroadipose
tissue, Her2 negative.
-CT on ___ showed right lower lung mass that was 4.8 x 3.1 cm
concerning for pneumonia v. met. He was treated with
levofloxacin with plans to repeat Chest CT to assess for
resolution of the opacity.
-Given inability to tolerate p.o. intake he underwent placement
of J-tube, and started tube feeds.
-Initiated FOLFOX C1D1 ___
PAST MEDICAL HISTORY:
- Possible MI (episode of "feinting" and "heart blockage")
- Dyspepsia
- GERD
Social History:
___
Family History:
Father with liver cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.5 108 / 70 76 18 97 Ra
GEN: Ill-appearing man in NAD
HEENT: Sclera anicteric, dry mucous membranes, oral thrush
Cards: RRR, nl S1/S2, no MRG
Pulm: CTAB, no wheezes
Abd: Soft, NTND, normoactive bowel sounds
Neuro: AAOx3, CN II-XII grossly intact
DISCHARGE PHYSICAL EXAM:
VS: 97.8 120 / 68 87 18 96
GEN: Ill-appearing man in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Cards: RRR, nl S1/S2, no MRG
Pulm: Crackles at b/l bases, no wheezes/rales/rhonchi
Abd: Soft, NTND, normoactive bowel sounds
Neuro: AAOx3, CN II-XII grossly intact
Pertinent Results:
ADMISSION LABS
============================
___ 06:55AM BLOOD WBC-3.0* RBC-2.30* Hgb-8.1* Hct-24.1*
MCV-105* MCH-35.2* MCHC-33.6 RDW-13.9 RDWSD-53.1* Plt ___
___ 08:20AM BLOOD ___ PTT-28.7 ___
___ 01:05PM BLOOD Glucose-99 UreaN-27* Creat-0.7 Na-143
K-4.3 Cl-106 HCO3-24 AnGap-13
___ 01:05PM BLOOD ALT-29 AST-28 LD(LDH)-563* AlkPhos-115
TotBili-0.7
___ 01:05PM BLOOD Albumin-3.0* Calcium-8.6 Phos-2.8 Mg-2.5
___ 04:45AM BLOOD Hgb-9.7* calcHCT-29
DISCHARGE LABS
============================
___ 02:00PM BLOOD WBC-4.8 RBC-2.15* Hgb-7.5* Hct-22.3*
MCV-104* MCH-34.9* MCHC-33.6 RDW-13.7 RDWSD-51.8* Plt ___
___ 05:22AM BLOOD ___ PTT-29.8 ___
___ 05:22AM BLOOD Glucose-146* UreaN-22* Creat-0.6 Na-139
K-3.8 Cl-100 HCO3-28 AnGap-11
___ 05:22AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.5
IMAGING
============================
CXR ___
Right lower lobe mass and extensive mediastinal hilar
lymphadenopathy better
evaluated on prior CT are worrisome for malignancy..
Increasing opacities in the lower lobes likely represent
infection.
Apparently new right lower lobe nodule
PORT PLACEMENT ___
Successful placement of a single lumen chest power Port-a-cath
via the right
internal jugular venous approach. The tip of the catheter
terminates in the
right atrium. The catheter is ready for use.
MICROBIOLOGY
============================
___ 12:59 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).
Brief Hospital Course:
Mr. ___ is a ___ male with recently diagnosed
metastatic gastric adenocarcinoma difuse type on FOLFOX ___
discharged the day prior to admission and re-presented on ___
for vomiting and hematemesis in the setting of rapid infusion of
tube feeds due to error using the pump.
#Hematemesis: Patient presented with hematemesis in the setting
of rapid infusion of tube feeds via j-tube, due to error using
the pump. His daughters note that the ___ who came to their
house after discharge did not know how to use the pump. His
daughters then tried to administer the tube feeds, and hung the
tube feeds to gravity. This resulted in a rapid large volume
infusion, which is likely why he vomited. His gastric mass is
known to be bleeding/oozing, which is the likely source of
hematemesis. Hb was 8.1 in the ED, stable at 8.2-8.3 on the
floor, reassuring against ongoing bleeding. His nausea was
controlled with Compazine and Zofran in house. Patient's
hemoglobin prior to discharge was 7.5 and he received a
transfusion prior to discharge. He should have repeat CBC at his
appointment on ___. Consider surgery in ___ months for tumor to
improve obstruction and address risk of bleeding.
#Gastric adenocarcinoma, diffuse type, metastatic to
supraclavicular node: On FOLFOX ___. He underwent placement
of a single lumen port on ___. Patient will return for his
second cycle as an outpatient on ___. He was continued on small
volume magic mouth wash for chest discomfort, which GI okayed
last admission given concern for gastric outlet obstruction and
aspiration risk.
# Anemia
# Chronic GI bleed: Patient with hemoglobin on presentation of
8.1. Remained stable at 8.2-8.3 during admisison, reassuring
against ongoing bleeding. Iron studies last admission
demonstrated iron 79, TRF 220, TIBC 286, likely secondary to
combination of chronic blood loss along with anemia of chronic
disease. He was maintained on Pantoprazole 40 mg twice daily.
#Anxiety:
Patient endorsed feeling restless and anxious in the setting of
new diagnosis and chest discomfort secondary to his gastric
mass. He was continued on Ativan prn, which greatly relieved
these symptoms.
#Severe malnutrition: Patient seen and evaluated by nutrition
last admission and met criteria for severe malnutrition with 7%
weight loss in 1 month along with nausea and vomiting. Likely
related to dysphasia from gastric mass status post placement of
J-tube. Patient received tube feeds at goal of 60mL/hr; however,
he could not tolerate this and was switched to Jevity 1.5 at
50cc/hr which he tolerated.
# ? History of CAD: Patient with unclear history of CAD. Reports
blockage in ___ but denies any stenting procedure. Has
complained of intermittent chest pressure and pain during his
hospitalization with unchanged EKGs which demonstrate RBBB.
Troponins are negative. Pain may be related to gastric mass and
improved with magic mouthwash. Held off on aspirin given concern
for bleeding mass, which can be restarted after discharge.
TRANSITIONAL ISSUES
===============================
[] Scheduled for follow up appointment with Dr. ___ on
___.
[] Patient was started on FOLFOX C1D1 on ___. Next infusion is
on ___, now status post single lumen port placement on ___.
[] Patient's aspirin was held at discharge in the setting of
oozing gastric mass. Please consider re-starting this as an
outpatient if appropriate.
[] Patient is scheduled for video swallow study on ___, per
speech and swallow given concern for aspiration risk. Until
then, he was recommended to minimize PO intake to small
sips/meds in apples___.
[] J-tube placed during recent admission and patient initiated
on tube feeds with plan to continue as outpatient pending
resolution of gastric outlet obstruction. Jevity 1.5, Goal Rate:
50ml/hr, 75ml free water q6h.
[] Patient was recently started on lorazepam 0.5mg every 6 hours
prn for anxiety. Reassess as outpatient and consider restarting
long-acting medication or SSRI depending on symptoms.
[] Patient was recently started on
Maalox/Diphenhydramine/Lidocaine for chest discomfort secondary
to his gastric mass.
[] Patient was recently discharged on Morphine oral solution for
pain.
[] Patient had right lung consolidation on CTA and completed
treatment for pneumonia. Please repeat CT chest first week of
___ to assess for resolution.
[] Currently full code but would likely benefit from more in
depth code status discussion
[] Gastric biopsies showed evidence of H. Pylori. Consider
referral to gastroenterology and treatment as an outpatient
pending
Name of health care proxy: ___
___: daughter
Phone number: ___
Code: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
2. TraZODone 50 mg PO QHS
3. Docusate Sodium 100 mg PO BID
4. Morphine Sulfate (Oral Solution) 2 mg/mL ___ mg PO Q8H
5. Senna 8.6 mg PO BID Constipation - First Line
6. Aspirin 81 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Simvastatin 20 mg PO QPM
9. Lansoprazole Oral Disintegrating Tab 30 mg Other DAILY
10. Bisacodyl ___AILY:PRN Constipation - Second Line
11. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
12. LORazepam 0.5 mg PO Q6H:PRN anxiety
13. Maalox/Diphenhydramine/Lidocaine 5 mL PO QID:PRN
pain/discomfort
14. Ondansetron ODT 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
2. Aspirin 81 mg PO DAILY
3. Bisacodyl ___AILY:PRN Constipation - Second Line
4. Docusate Sodium 100 mg PO BID
5. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
6. Lansoprazole Oral Disintegrating Tab 30 mg Other DAILY
7. LORazepam 0.5 mg PO Q6H:PRN anxiety
8. Maalox/Diphenhydramine/Lidocaine 5 mL PO QID:PRN
pain/discomfort
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Morphine Sulfate (Oral Solution) 2 mg/mL ___ mg PO Q8H
11. Ondansetron ODT 4 mg PO Q8H:PRN nausea
12. Senna 8.6 mg PO BID Constipation - First Line
13. Simvastatin 20 mg PO QPM
14. TraZODone 50 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Metastatic gastric carcinoma, diffuse-type
Secondary:
Pneumonia
H. Pylori
Severe malnutrition
Chronic GI bleed
Anemia
Anxiety
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 you were vomiting and there
was blood in your vomit. This was probably because too much of
your tube feeds went into your intestine too quickly, due to
difficulty using the tube feed pump at home. There was blood in
the vomit because your stomach cancer oozes blood. This blood
can come up with the vomit. We checked your blood levels and
they were stable throughout your admission, which tells us that
you aren't having any ongoing significant bleeding that we
should be worried about right now.
You also had your port placed. This is how you will get
chemotherapy in the future.
When you go home, you should take all of your medications as
prescribed. You will also need to see the speech and swallow
team as an outpatient on ___. They will evaluate whether it is
safe for you to have small amounts of fluids (juices, soups) by
mouth. Until you see them, we recommend avoiding drinking thin
liquids other than your medications. If you can, you should mix
these liquids with applesauce to make it easier for you to
swallow.
It was a privilege to participate in your care, and we wish you
all the best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10395875-DS-16 | 10,395,875 | 29,101,374 | DS | 16 | 2156-08-29 00:00:00 | 2156-08-29 20:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetanus Antitoxin / Erythromycin Base
Attending: ___.
Chief Complaint:
LLQ pain
Major Surgical or Invasive Procedure:
NA
History of Present Illness:
Ms. ___ is a ___ female with history of
sigmoid diverticulitis with recent admission in ___ found to
have sigmoid diverticulitis with intramural abscess, chronic
adrenal insufficiency on prednisone, asthma, GERD, and OSA on
CPAP, who presents with recurrent LLQ abdominal pain.
Of note, patient had recent admission (___) after
presenting with abdominal pain, found on CT to have sigmoid
diverticulitis with 1.1 x 0.9 cm intramural abscess, treated
with
IV antibiotics, stress dose steroids, subsequently discharged on
a 10 day course of PO cipro/flagyl.
She has had ongoing baseline abdominal pain since her discharge,
recently saw PCP and GI on ___ given persistent abdominal
pain.
Decision was made to extend course of PO cipro/flagyl for
additional ___ hours prior to presentation, she
had
worsening LLQ pain, currently rated ___, associated with
nausea, denied emesis. Also denying fevers or chills. She called
her gastroenterologist who recommended going to ED for further
evaluation given concern of recurrent diverticulitis +/-
abscess.
In the ED,
Initial vitals: T 97.2 HR 101 BP 168/89 RR 18 O2sat 100% RA
Exam notable for: Abdomen: Soft, non-distended. +BS. Pain to
percussion and mild palpation of LLQ. Pain to palpation of RLQ
and states pain spreads across lower abdomen. No pain to
palpation in remainder of quadrants.
Labs notable for:
- WBC 9.2, H/H 13.6/40.9, PLT 284
- Lactate 2.1
- UA neg ___, negative nitrite
Imaging was notable for:
- CT A/P ___:
1. Previously demonstrated sigmoid diverticulitis with
intramural
abscess has essentially nearly resolved except for possible very
mild inflammation surrounding a sigmoid diverticulum suggestive
of minimal residual or early uncomplicated sigmoid
diverticulitis.
2. Unchanged mild L1 compression deformity. Unchanged
heterogeneity of the right sacral ala raising the possibility of
a prior insufficiency fracture.
Patient was given:
- 1000mg IV Acetaminophen
- NS 150mL/hr
- IV piperacillin-tazobactam 4.5g x1
Consults:
- Surgery: Recommending strict NPO, IV antibiotics, possible
surgery if worsening abdominal pain
Upon arrival to the floor, patient confirms the above
history. Currently endorsing ___ abdominal pain, denies any
nausea, vomiting. Denies any fevers, chills, cough, SOB. At
baseline has 3 loose stools per day, currently at baseline.
Denies dysuria or burning on urination.
Past Medical History:
Diverticulitis
Adrenal insufficiency
Asthma
Thoracic outlet syndrome
Bilateral carpal tunnel syndrome
MVP
Costochondritis
GERD
Obstructive sleep apnea on CPAP
Seasonal allergies
Osteoporosis
Social History:
___
Family History:
Father died of lung cancer. Mother still alive; ___
disease.
Physical Exam:
ADMISSION EXAM
==============
VITAL SIGNS: Temp 98.2 BP 125/78 HR 74 RR 18 O2 sat 97% RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NC/AT. Sclera anicteric and without injection. Moist
mucous membranes.
CARDIAC: Regular rhythm and rhythm. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
ABDOMEN: Soft, non-distended, normoactive bowel sounds. Mild TTP
in LLQ. No rebound or guarding, no evidence of peritoneal signs.
EXTREMITIES: 2+ peripheral pulses. Trace edema ___
bilaterally.
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. No focal neurological deficits.
AAOx3.
DISCHARGE EXAM:
===============
___ 0750 Temp: 98.1 PO BP: 135/71 HR: 72 RR: 18 O2 sat: 97%
GENERAL: Alert and interactive. In no acute distress.
CARDIAC: Regular rhythm and rhythm. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields.
ABDOMEN: Soft, non-distended, normoactive bowel sounds. Mild TTP
in LLQ without rebound or guarding.
EXTREMITIES: 2+ peripheral pulses. No edema in legs bilaterally.
SKIN: Warm. No rash.
NEURO: CN2-12 grossly intact. Moving all extremities with
purpose. Holding normal conversation.
Pertinent Results:
ADMISSION LABS
==============
___ 01:35PM BLOOD WBC-9.2 RBC-4.60 Hgb-13.6 Hct-40.9 MCV-89
MCH-29.6 MCHC-33.3 RDW-14.4 RDWSD-46.5* Plt ___
___ 01:35PM BLOOD Neuts-77.7* Lymphs-16.2* Monos-5.2
Eos-0.1* Baso-0.5 Im ___ AbsNeut-7.14* AbsLymp-1.49
AbsMono-0.48 AbsEos-0.01* AbsBaso-0.05
___ 01:35PM BLOOD Plt ___
___ 01:35PM BLOOD Glucose-97 UreaN-11 Creat-0.7 Na-140
K-4.4 Cl-99 HCO3-22 AnGap-19*
___ 01:57PM BLOOD Lactate-2.1*
DISCHARGE LABS
===============
___ 06:50AM BLOOD WBC-5.5 RBC-3.64* Hgb-10.8* Hct-32.9*
MCV-90 MCH-29.7 MCHC-32.8 RDW-14.8 RDWSD-49.2* Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD Glucose-89 UreaN-6 Creat-0.6 Na-143 K-3.5
Cl-104 HCO3-25 AnGap-14
___ 06:50AM BLOOD Calcium-9.1 Phos-4.4 Mg-1.8
MICROBIO
=========
Blood culture ___ pending
IMAGING
=======
CT A/P w/ contrast ___. Previously demonstrated sigmoid diverticulitis with
intramural abscess has essentially nearly resolved except for
possible very mild inflammation
surrounding a sigmoid diverticulum suggestive of minimal
residual or early
uncomplicated sigmoid diverticulitis.
2. Unchanged mild L1 compression deformity. Unchanged
heterogeneity of the right sacral ala raising the possibility of
a prior insufficiency fracture.
PENDING
========
Blood culture ___
Brief Hospital Course:
Ms. ___ is a ___ woman with history of sigmoid
diverticulitis, chronic adrenal insufficiency on prednisone,
asthma, GERD, and OSA on CPAP, who was admitted for
diverticulitis. She was admitted ___ and found to have
diverticulitis with 1.1 x 0.9cm mural intramural abscess. She
was treated with a 10 day course of cipro/flagyl with some
improvement, but then presented to her PCP ___ ___ with
recurrent abdominal pain and was started on what became a
prolonged, 20-day course of cipro/flagyl for presumed slow
healing of her intramural abscess. She did feel better, but
never returned to baseline of being free of pain. She presented
to the ED with worsening left lower quadrant pain and inability
to tolerate orals. She was found to have leukocytosis and CT
scan showed possible minimal residual vs. early uncomplicated
sigmoid diverticulitis. She was made NPO and given IV Zosyn,
which was switched to CTX/flagyl. The surgical team saw her in
house but felt no acute intervention while patient was still
actively infected. Her WBC count and abdominal exam improved and
she was tolerating a normal diet at time of discharge. She was
connected to an appointment with Dr. ___ in colorectal
surgery for consideration of possible surgical intervention to
prevent recurrence. She was ultimately discharged on PO
Augmentin for a total 14-day antibiotics course: ___.
# Adrenal insufficiency
Patient has a history of secondary adrenal insufficiency;
currently on prednisone 2.5mg daily. She was stable throughout
her admission so stress-dose steroids were not given.
CHRONIC ISSUES:
===============
# GERD
Continued home pantoprazole 40 mg PO Q12H.
# Asthma
Continued home albuterol PRN, dulera and montelukast.
# Allergies
Continued home fexofenadine.
#Obstructive Sleep Apnea:
She was on CPAP at night.
#Osteoporosis:
Continued home vit D in house. She receives zolendroic acid as
an outpatient.
TRANSITIONAL ISSUES
===================
[] Discharge antibiotic plan: PO Augmentin 875mg BID x 14 day
course of abx total (___)
[] Follow up with colorectal surgery for evaluation for surgical
intervention to prevent recurrent diverticulitis
[] Recommend ongoing treatment of osteoporosis. Patient has a
possible mild L1 compression fracture seen on imaging.
Imaging incidental finding:
Unchanged mild L1 compression deformity. Unchanged
heterogeneity of the
right sacral ala raising the possibility of a prior
insufficiency fracture.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation
BID
2. Fexofenadine 180 mg PO DAILY
3. Montelukast 10 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. PredniSONE 2.5 mg PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
7. Multivitamins 1 TAB PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Dulera (mometasone-formoterol) 100-5 mcg/actuation inhalation
1 puff at night
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Take until ___ (last day ___
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*19 Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
3. Dulera (mometasone-formoterol) 200-5 mcg/actuation
inhalation BID
4. Dulera (mometasone-formoterol) 100-5 mcg/actuation
inhalation 1 puff at night
5. Fexofenadine 180 mg PO DAILY
6. Montelukast 10 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. PredniSONE 2.5 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Sigmoid diverticulitis with intramural abscess
Secondary problems:
Adrenal insufficiency
Asthma
GERD
Allergies
OSA
Osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___!
WHY YOU WERE HERE?
You were having abdominal pain from diverticulitis with a pocket
of infection (abscess), which was diagnosed in ___.
This may have been a delayed healing from your prior episode or
a new, milder episode of diverticulitis.
WHAT WE DID FOR YOU?
We did an abdominal CT scan and found that you had improvement
of your abscess, but you had some mild diverticulitis in the
same area. We let your bowels rest and gave you antibiotics. The
surgery team saw you and recommended outpatient surgery
evaluation.
WHAT YOU SHOULD DO WHEN YOU LEAVE?
- Please follow-up with your PCP to see that your abdominal pain
is resolving (Dr. ___ on ___
- Please follow-up with colorectal surgery (Dr. ___ on
___ to assess your diverticulitis and need for surgery
- Please follow-up with your endocrinologist to assess your
cortisol levels and dose of prednisone.
- Please speak with your gastroenterologist, Dr. ___
scheduling your next appointment.
WHAT ARE REASONS I SHOULD RETURN TO THE HOSPITAL?
- If you have high fevers, chills, vomiting, new abdominal pain,
new frequent diarrhea, blood in your stool, or if you stop
passing stool and gas.
- If you have any symptoms that concern you.
We wish you the best!
Sincerely,
Your Care Team
Followup Instructions:
___
|
10396820-DS-7 | 10,396,820 | 29,909,621 | DS | 7 | 2141-03-20 00:00:00 | 2141-03-23 22:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Morphine / Chlor-Trimeton / Darvocet A500 / Lisinopril / Demerol
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ ex-lap/LOA, SBR with primary anastomosis
History of Present Illness:
This patient is a ___ year old female who complains of Abd
pain, Constipation. ___ yo woman presents with complaints of
constipation and abdominal pain over the last 5 days.
+nausea. No vomiting or diarrhea. Seen at ___ yesterday. No
CP, SOB. No dysuria, no back pain. No black or bloody
stools. No fever, cough, rash.
Past Medical History:
HTN, reflux, macular degeneration, nocturnal leg cramps,
osteopenia, squamous cell skin CA
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION:upon admission: ___
Temp: 98.2 HR: 73 BP: 122/63 Resp: 16 O(2)Sat: 100 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended, diffusely tender
Rectal: Heme Negative on resident exam
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema, + pulses
Skin: No rash, Warm and dry
Neuro: Speech fluent, GCS 15, full strength
Psych: Normal mood, Normal mentation
___: No petechiae
Physical examination upon discharge: ___:
Vital signs: 98, hr=72, bp=142/65,rr=16, oxygen sat=97%
CV: ns1, s2, -s3,-s4
LUNGS: clear, diminished in bases bil
ABDOMEN: soft, mildly distended, lower aspect of abdominal
wound erythematous, tender, mild distention
EXT: mild pedal edema bil, no calf tenderness bil
NEURO: alert and oriented x 3, speech clear, no tremors
Pertinent Results:
___ 05:40AM BLOOD WBC-9.9 RBC-3.17* Hgb-10.1* Hct-29.3*
MCV-92 MCH-31.9 MCHC-34.5 RDW-13.7 RDWSD-46.4* Plt ___
___ 06:20AM BLOOD WBC-8.1 RBC-3.41* Hgb-10.7*# Hct-32.3*
MCV-95 MCH-31.4 MCHC-33.1 RDW-13.7 RDWSD-47.5* Plt ___
___ 03:50PM BLOOD WBC-20.4*# RBC-5.15 Hgb-16.6* Hct-46.8
MCV-91# MCH-32.2* MCHC-35.5* RDW-13.6 Plt ___
___ 03:50PM BLOOD Neuts-87.1* Lymphs-4.6* Monos-7.8 Eos-0.5
Baso-0.1
___ 05:40AM BLOOD Plt ___
___ 07:33PM BLOOD ___ PTT-25.1 ___
___ 06:20AM BLOOD Glucose-106* UreaN-10 Creat-0.5 Na-132*
K-3.8 Cl-97 HCO3-27 AnGap-12
___ 06:07AM BLOOD Glucose-101* UreaN-15 Creat-0.5 Na-129*
K-3.7 Cl-96 HCO3-28 AnGap-9
___ 03:50PM BLOOD Glucose-184* UreaN-35* Creat-1.4* Na-127*
K-3.5 Cl-79* HCO3-32 AnGap-20
___ 03:50PM BLOOD ALT-25 AST-35 AlkPhos-65 TotBili-0.9
___ 03:50PM BLOOD Lipase-80*
___ 06:20AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.0
___ 03:40AM BLOOD Lactate-4.0*
___ 10:30PM BLOOD Hgb-14.1 calcHCT-42 O2 Sat-97
___ 10:30PM BLOOD freeCa-1.09*
___: cat scan of abdomen and pelvis:
Closed loop obstruction with hypoenhancing small bowel loops
concerning for ischemia. Ascites and mesenteric edema noted.
Surgical consult advised.
Brief Hospital Course:
Ms. ___ is an ___ female with a history of a
trans-vaginal hysterectomy and umbilical hernia repair in ___.
She presented to the hospital with diffuse abdominal pain.
Initial lab work showed an elevated white blood cell count and
an elevated lactate level. Cat scan imaging showed a closed
loop obstruction with hypo-enhancing small bowel loops
concerning for ischemia.
The patient was made NPO, given intravenous fluids and taken to
the operating room where she underwent an exploratory
laparotomy, small bowel resection with primary anastomosis. The
operative course was stable with minimal blood loss. The
patient was extubated after the procedure and monitored in the
recovery room. She had a ___ tube placed for bowel
decompression.
Her post-operative course was complicated by a decreased blood
pressure and urine output necessitating additional intravenous
fluids. On POD #4, she had return of bowel function and the
___ tube removed. She was started on clears and
advanced to a regular diet. Her vital signs remained stable and
she was afebrile. She was voiding without difficulty.
In preparation for discharge, the patient was evaluated by
physical therapy. Recommendations were made for discharge home
with ___ therapy assistance. The patient was
discharged home on POD # 6 in stable condition. An appointment
for follow-up was made in the acute care clinic.
Medications on Admission:
chlorthalidone 25', omeprazole 20', pravastatin 40', ranitidine
300', ASA 81', tylenol PRN, hydrocortisone cream
Discharge Medications:
1. Acetaminophen 650 mg PO TID
after ___ days take tylenol only as needed
2. Chlorthalidone 25 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Pravastatin 40 mg PO QPM
5. Docusate Sodium 100 mg PO BID
hold for diarrhea
6. Senna 8.6 mg PO BID:PRN constipation
7. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
may cause dizziness
RX *tramadol [Ultram] 50 mg 0.5 (One half) tablet(s) by mouth
every six (6) hours Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with abdominal pain. You were
found to have a bowel obstruction on cat scan. You were taken
to the operating room where you underwent a bowel exploration
and a resection of your small bowel. You are slowly recovering
from your surgery and you are preparing for discharge home with
the following instructions:
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red aroudn the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
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).
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing r clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluitds and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
IF you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, 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.
In some cases you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
10397160-DS-14 | 10,397,160 | 23,042,109 | DS | 14 | 2147-08-12 00:00:00 | 2147-08-14 13:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing
Attending: ___.
Chief Complaint:
Chest pain
Nausea/vomiting
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
Ms ___ is an ___ y/o with h/o CAD s/p PCI to LAD
and PTCA to OM, DM, HTN who presents with ___ days of mild chest
pain, n+v, LBBB, and troponin elevation.
Pt states that she fell last ___ and was found on the floor
by her daughter at least 6 hours later. She denies loss of
consciousness, hiting her head, or having any CP or SOB that
preceded the fall. Though she's uncertain of the timeline, she
believes she may have head some chest discomfort while she was
down. The next day, she began to experience intermittent nausea
and vomiting of non-bilious emesis. She last vomited 1 day prior
to arrival at ED, where she also endorsed difficulty with
keeping food down. She saw her PCP on ___, who advised
patient present to ED for further eval (w/ particular concern
for ___.
Patient describes orthopnea, paroxysmal nocturnal dyspnea, and
intermittent palpitations.
She denies ankle edema, syncope, or presyncope
On review of systems, she denies fever, but describes occasional
chills. She denies any prior history of stroke, TIA, DVT,
bleeding at time of surgery, myalgias, and cough.
In the ED, initial vitals were 98.4 80 200/120 16 100%. Labs
were notable for Hct 42.3, Cr 2.2. Troponins 2.63 -> 2.04 ->
1.49.
Past Medical History:
Diabetes Mellitus
Hypertension
Osteoarthritis
CAD/Stable angina
Left breast lumpectomy
HX of thyroidectomy in the past (for substernal thyroid)
?Nephrolithiasis
CRF baseline creatinine 1.2-1.9
TAH
Social History:
___
Family History:
Noncontributory
Physical Exam:
VS: wt: 78.5 ___ yest) T=97.8 BP=171-194/50s-80s HR=60s RR=18
O2 sat= 99 on RA
GENERAL: NAD. Frail appearing.
Neck: JVP ___
CV: RRR, normal S1/2, no m/r/g
Lungs: clear bilateral breath sounds, no crackles in lung bases
Abdomen: soft, nontender to palpation in epigastrium and RUQ;
tender to palpation of R flank
Ext: warm, no ___ edema
Skin: no rashes
Pertinent Results:
ADMISSION LABS
___ 05:18PM BLOOD CK-MB-52* MB Indx-8.3*
___ 05:18PM BLOOD ALT-26 AST-81* CK(CPK)-627* AlkPhos-60
TotBili-0.4
___ 05:18PM BLOOD Lipase-47
___ 05:18PM BLOOD ALT-26 AST-81* CK(CPK)-627* AlkPhos-60
TotBili-0.4
___ 05:18PM BLOOD Glucose-442* UreaN-42* Creat-2.2* Na-140
K-4.2 Cl-101 HCO3-26 AnGap-17
___ 05:18PM BLOOD ___ PTT-32.5 ___
___ 05:18PM BLOOD WBC-7.9# RBC-4.67 Hgb-12.8 Hct-42.3
MCV-91 MCH-27.3 MCHC-30.2* RDW-12.9 Plt ___
___ 07:46AM BLOOD Calcium-9.0 Phos-2.5* Mg-2.1
___ 05:18PM BLOOD cTropnT-2.63*
___ 08:45PM BLOOD CK-MB-7 cTropnT-1.50*
DISCHARGE LABS
___ 07:25AM BLOOD ALT-18 AST-24 LD(LDH)-258* TotBili-0.2
DirBili-0.1 IndBili-0.1
___ 07:46AM BLOOD Glucose-203* UreaN-41* Creat-1.6* Na-137
K-4.6 Cl-104 HCO3-26 AnGap-12
___ 07:46AM BLOOD WBC-5.0 RBC-3.55* Hgb-9.9* Hct-31.8*
MCV-89 MCH-27.8 MCHC-31.2 RDW-13.5 Plt ___
Radiology:
___ C CATH: Assessment & Recommendations
1.Single vessel coronary artery disease
2.Medical management with PCI of the OMB with symptoms and after
stabilization of her renal function
3.Medical therapy
___ ECHO: LVEF = ___ %
___ CT CSPINE: 1. Demineralized bones without evidence for a
displaced fracture.
2. Mild retrolisthesis of C5 on C6 is likely degenerative, but
there are no comparison exams to confirm chronicity. Mild
anterolisthesis of C2 on C3 is unchanged compared to a prior
head
CT.
3. Multilevel degenerative disease with probable moderate spinal
canal narrowing.
4. Status post partial left hemithyroidectomy with an enlarged
and nodular right thyroid lobe. The thyroid gland was last
assessed by sonography on ___.
___ CT ABDOMEN: No acute intraabdominal process. No fracture.
___ CT HEAD: 1. No evidence for acute intracranial injury or
calvarial fracture.
2. Stable hyperdense and partially calcified paratentorial
extra-axial lesion anterior to the right cerebellopontine angle,
consistent with a meningioma, with stable remodeling of the
adjacent pons. It appears to have increased calcification
posteriorly, but evaluation of its size in 3 ___ would be
best performed by MRI, if clinically warranted.
___ HIP/PELVIS: No fracture.
___ Echo
Conclusions
The left atrium is elongated. 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. There
is severe global left ventricular hypokinesis (LVEF = ___ %)
with regional inferior and mid anterior/mid septal akinesis.
Right ventricular chamber size is normal with depressed free
wall contractility. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is a
very small pericardial effusion. There are no echocardiographic
signs of tamponade.
Brief Hospital Course:
Ms ___ is an ___ y/o with h/o CAD (s/p PCI to LAD and PTCA
to obtuse marginal in ___, DM, and HTN who presented with ___
days of mild chest pain, n+v, LBBB, and troponin elevation after
a fall at home. Her medical problems were managed as listed:
CARDIAC
#NSTEMI- patient had an atypical ACS presentation, but with
elevated troponin c/w NSTEMI. She was started on a heparin drip
and received atorvastatin, as well as carvedilol and aspirin.
Echocardiogram on ___ was significant for severe global left
ventricular hypokinesis (LVEF = ___ %) with regional inferior
and mid anterior/mid septal akinesis. Pt's scheduled cardiac
cath was postponed when she had ___ with Cr bump that peaked
at 3.2. Upon improvement ___ by ___, she had a cardiac
catheterization that revealed single vessel coronary artery
disease, which did not explain the reduced systolic function.
Patient was treated with medical management and is being
discharged on 75 mg of Plavix.
#Systolic congestive heart failure - Patient appeared euvolemic
throughout hospitalization and thus did not receive diuresis.
Her discharge weight was 78.5 kg.
#Coronary artery disease- pt's home simvastatin was switched to
atorvastatin. She also received 81 mg of daily aspirin. After
her cardiac cath, pt was also treated with 75 mg of plavix,
which she will continue to take at home.
#Hypertension - patient was treated with 25 mg carvedilol BID in
addition to 30 of nifedipine. Given her ___ and question of
hypoperfusion leading to renal injury, her BP meds were reduced
to allow for SBP of ~140. By time of discharge, her medications
include: losartan 50 mg (home dose was 100mg), carvedilol 6.25
BID (home dose was 25mg BID, but her HR remained mostly in the
___, nifedipine 30mg (home dose). Her home 25 mg HCTZ was held.
She was started on 30 mg isosorbide mononitrate. She will
follow-up for additional blood pressure control as an
outpatient.
RENAL
___ - baseline Cr of ~2, with Cr elevated to 2.2 on admission.
Likely occurred within the context of pt's persistent n/v prior
to admission, with poor oral intake v. ischemia. Pt's Cr
increased to 3.2 where it remained stablem. Her urine was w/o
any sediments and Fena was <1. Given pre-renal picture, she
received a total of 1.5 L over 2 days (including post-cath)
fluids, with resolution of ___. It was felt that hypoperfusion
also contributed, so her blood pressure regimen was changed,
with temporary discontinuation of coreg (please refer to
'Hypertension' section of d/c summary for additional detail).
GI
#N/V and R abdominal/flank pain- The differential included
intraabdominal/ infectious process v. atypical presentation of
NSTEMI. With normal imaging, no leukocytosis, and lack of
fevers, it was felt that the latter was most likely. Pt received
prn zofran and simethicone. When she complained of repeat, night
time abdominal pain (which she stated occurred after eating),
she was started on a PPI. Before discharge, her n/v resolved,
but she complained of ___ flank pain for which a repeat UA
ruled out UTI. Since palpation reproduced her pain, the likely
cause seemed musculoskeletal-- her LFTs were wnl. Her pain
improved with lidocaine patch, and she was discharged home with
this, in addition to her home toradol.
HEMATOLOGIC
#Normocytic anemia - Patient's hemoglobin dropped from 12.4 to
11.5 to 10.3. Her guiac was negative, and her heparin was held.
She was typed/screened and consented, but ultimately did not
require transfusion. Her hemolysis labs (haptoglobin, T/d bili,
LDH) were all within normal limits. Her H/H stabilized at ~10 by
time of discharge.
ENDOCRINE
#DM - this chronic medical problem was adequately controlled
with SSI.
MUSCULOSKELETAL
#R hip pain - she complained of severe R hip two days prior to
discharge. Even with lidocaine patch during the day, she needed
additional oxycodone for breakthrough. By day of discharge, she
stated her pain improved significantly. She will continue to be
seen by ___ at home and was discharged on lidocaine patch,
tylenol, and toradol.
#H/o falls - Given her repeat hx of numerous falls, patient was
evaluated by physical therapy during this hospitalization. ___
helped patient with mobilit during hospitalization, and will
continue to follow her home to ensure that she is able to
function well in her typical environment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. omeprazole 20 mg oral once daily
2. GlipiZIDE XL 10 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. NIFEdipine CR 30 mg PO DAILY
6. Carvedilol 25 mg PO BID
7. Losartan Potassium 100 mg PO DAILY
8. Aspirin (Buffered) 325 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL PRN PRN
10. Doxazosin 2 mg PO HS
11. TraMADOL (Ultram) 50 mg PO Q6H:PRN PRN
12. Acetaminophen 500 mg PO Q6H:PRN PRN
13. Cyanocobalamin Dose is Unknown PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
16. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
17. Sertraline 100 mg PO DAILY
18. calcium gluconate 45 mg (500 mg) oral BID
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN PRN
2. Atorvastatin 80 mg PO DAILY
3. Carvedilol 6.25 mg PO BID
4. Losartan Potassium 50 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. NIFEdipine CR 30 mg PO DAILY
7. Nitroglycerin SL 0.4 mg SL PRN PRN
8. omeprazole 20 mg oral once daily
9. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 (One) tablet(s) by
mouth once a day Disp #*30 Tablet Refills:*1
10. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate [Imdur] 30 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
12. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine 5 % (700 mg/patch) Please keep this patch on for
12 hours, as needed for pain. every twelve (12) hours Disp #*10
Patch Refills:*0
13. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
14. GlipiZIDE XL 10 mg PO DAILY
15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
16. Sertraline 100 mg PO DAILY
17. TraMADOL (Ultram) 50 mg PO Q6H:PRN PRN
18. Simethicone 40-80 mg PO QID:PRN bloating, gi upset
RX *simethicone 180 mg 1 tab by mouth prn Disp #*30 Capsule
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
NSTEMI
Systolic Heart Failure with EF 25%
Acute on chronic kidney injury
Type 2 DM
HTN
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ has been a pleasure to participate in your care during your
stay at ___. You presented to
your primary care doctor's office, after having a fall over the
weekend. After presenting to the emergency department, your
blood work revealed you had a heart attack.
While at ___, we followed up on this by performing an imaging
study of your heart that showed that your heart's pumping
function was severely reduced. To see if there were any
blockages that could cause this, you underwent a procedure
called a cardiac catheterization that showed no significant
blockages of the blood supply to your heart. Your doctors think
that the best way to treat your illness is by medical
management-- you will now take 75 mg of Plavix everyday, as well
as 81 mg of aspirin. Your atorvastatin dose has increased to 80
mg. However, if you continue to have symptoms, you should
follow-up with your cardiologist to talk about other
interventions.
We are also in the process of adjusting your blood pressure
medications. We have scheduled close follow up so that these
medications can be adjusted.
Since you had fallen, you had other imaging studies, including a
CT scan of your spine, abdomen, and hip that showed no
fractures. You have been complaining of some burning pain with
eating, so you are being discharged home on a medication to help
with this symptom of reflux. To control your pain, you may use
the toradol you have at home as well as tylenol and the
lidocaine patch.
Follow up with your primary care doctor to determine how to best
continue your care once you are out of the hospital.
Wishing you all the best,
Your treatment team at ___
Followup Instructions:
___
|
10397264-DS-6 | 10,397,264 | 24,242,797 | DS | 6 | 2188-03-14 00:00:00 | 2188-03-14 18:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness, falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
CC: ___
HISTORY OF PRESENT ILLNESS:
___ ___ speaking with a history of diabetes and dementia
(most recent ___ ___ who presents after being found down in
her apartment.
She reports that she woke up and was walking to the bathroom
and
was incontinent on the way to the bathroom. She ended up on the
floor, but is not entirely sure how she ended up there. Her
visiting medical assistant came to the door in the morning and
she was not answering. 15 minutes later, they got into her
apartment and found her on the floor--she had been there for an
unknown amount of time. She denies headstrike, though she is
unsure of how she got to the floor. Per EMS she was found
unclothed on the bathroom floor. She was reportedly unsteady on
her feet when she was assisted to standing.
She endorses several weeks of increased urination and weakness
since starting Diamox for her glaucoma. She denies dysuria,
change in urine color, fall, or headstrike. She denies any
chest
pain, nausea, vomiting, diarrhea, or black or bloddy stools.
Her
blood sugar was 130 in the ambulance. She denied any injuries
or
falls.
In the ED, she was afebrile (96.5) and hemodynamically
stable,though slightly bradycardic (56). She was severely
orthostatic (BP: 154/80 supine -118/74 sitting). Her labs were
notable for a mildly elevated white count (10.4, 70% PMNs). CXR
showed bibasilar opacities concerning for infection vs.
aspiration. She received 1L NS, 2g Cefepime, and 1 mg
Vancomycin
and was transferred to medicine for further management.
Of note she had a recent hospitalization after multiple falls,
thought to be secondary to orthostasis, after starting Diamox.
A
full cardiac and neurologic work-up was done and was negative.
Her orthosatsis persisted despite aggressive hydration and she
was started on midodrine 2.5 mg and pyridostigmine.
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
Macular degeneration
Headache
Osteoarthritis
Esophageal reflux
Depressive disorder
Anxiety states
Colonic polyp
Irritable bowel syndrome
Osteoporosis
Hypercholesterolemia
DM (diabetes mellitus), type 2
Lichen sclerosus et atrophicus
Spinal stenosis, lumbar
MYALGIA, myofascial pain syndrome RT sacrospinalis
Bronchiolitis
Memory loss, short term
Disequilibrium
Pseudoexfoliation glaucoma, severe stage
Primary open angle glaucoma of right eye, severe stage
Myopic degeneration
Pseudophakia of both eyes
PXF (pseudoexfoliation of lens capsule)
Social History:
___
Family History:
Her mother had breast cancer and her father died in ___. Her
grandmother was blind and died young, but she is not sure why
she died.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: T:97.7 BP: 153/83 HR:62 RR:18 O2sat: 96 ra
GENERAL: NAD
HEENT: Eyes injected, anicteric sclera, pink conjunctiva, MMM,
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
PULSES: 2+ DP pulses bilaterally
NEURO: R pupil ~4mm and did not constrict, L pupil constricts
3->2. Otherwise CN II-XII intact. Strength ___ in upper
extremities bilaterally. Strength in lower extremities was ___,
however may have been reduced due to lack of patient effort.
Sensation grossly intact bilaterally. FNF intact bilaterally.
Gait differed.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=========================
PE Vitals: Tc 97.5 Tm 98.2 HR 57 BP 153/92 RR 18 SaO2 95% on
RA
___
10:36 90 / 58 Standing 73
10:36 87 / 56 Standing 73
10:36 121 / 69 Lying 69
General: No acute distress
HEENT: sclera anicteric, moist mucous membranes, injected
conjuctiva
Lungs: CTAB, no wheezes, rales or rhonchi
CV: Regular rate and rhythm, no murmurs/rubs/gallops
Abdomen: Soft, non-distended, no tenderness to palpation over
suprapubic region
Ext: Warm and dry, no edema bilaterally
Psych: Normal mood and affect
Neuro: A&Ox3, grossly moving all extremities
Pertinent Results:
ADMISSION LABS
==============
___ 10:20AM BLOOD WBC-10.4* RBC-4.94 Hgb-13.8 Hct-42.3
MCV-86 MCH-27.9 MCHC-32.6 RDW-14.2 RDWSD-43.9 Plt ___
___ 10:20AM BLOOD Neuts-70 Bands-0 Lymphs-18* Monos-11
Eos-1 Baso-0 ___ Myelos-0 AbsNeut-7.28* AbsLymp-1.87
AbsMono-1.14* AbsEos-0.10 AbsBaso-0.00*
___ 10:20AM BLOOD Glucose-151* UreaN-13 Creat-0.7 Na-136
K-4.5 Cl-104 HCO3-21* AnGap-16
___ 10:20AM BLOOD Calcium-10.3 Phos-2.4* Mg-2.1
PERTINENT LABS
==============
___ 11:26AM BLOOD Lactate-1.3
___ 12:18PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
DISCHARGE LABS
==============
___ 07:00AM BLOOD WBC-5.0 RBC-4.38 Hgb-12.5 Hct-37.8 MCV-86
MCH-28.5 MCHC-33.1 RDW-14.6 RDWSD-45.5 Plt ___
___ 07:00AM BLOOD Glucose-163* UreaN-15 Creat-0.6 Na-140
K-4.4 Cl-98 HCO3-24 AnGap-22*
___ 07:00AM BLOOD Calcium-9.9 Phos-2.7 Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ year old female with history of orthostatic
hypotension and glaucoma who presented after she had been found
down at home, with recent history of multiple falls thought to
be secondary to orthostatic hypotension.
Acute Issues
============
#Orthostatic hypotension, falls
Ms. ___ has had persistent orthostatic hypotension, requiring
a few hospitalizations for falls, thought to be exacerbated by
acetazolamide. She was previously started on midodrine and
pyridostigmine. Neurologic and cardiac workup performed at
___ were negative, including an ECHO which was without
valvular abnormalities or diastolic dysfunction. Her orthostatic
hypotension is felt to be due to autonomic instability given her
age and was likely exacerbated by acetazolamide. After
discussion with her oupatient ophthalmologists, acetazolamide
was held. Her midrodrine was up-titrated to 5 mg QAM, 2.5 mg BID
(from 2.5 mg TID), pyridostigmine was continued and she was
given IV fluids as needed. Orthostatics were checked daily and
continued to be positive, with improvement noted on the day of
discharge. Subjectively, her dizziness improved and at the time
of discharge, she was able to sit up comfortably in the chair
and walk with minimal dizziness. Conservative measures were also
encouraged throughout hospitalization and upon discharge,
including maintaining the head of the bed at 30 degrees, getting
out of bed to the chair as much as possible, wearing compression
stockings and staying well hydrated. We will continue to hold
acetazolamide on discharge until she is seen by outpatient
ophthalmology. She was continued on midodrine and pyridostigmine
on discharge.
#Urinary frequency/incontinence
Ms. ___ notes ongoing urinary frequency and incontinence
which she has been experiencing for quite some time, requiring
her to wear diapers continuously. The origin is likely
multifactorial given her age, however was likely exacerbated by
acetazolamide. Urinalysis and urine culture were negative.
#Falls
Her recent falls are thought to be secondary to orthostatic
hypotension, exacerbated by acetazolamide. Physical therapy has
seen the patient and has recommended 24 hour home services. We
have been working with her daughter, ___ (___), who
is aware of this need and is actively coordinating 24 hour care
for her mother.
#Glaucoma
Discussed with her outpatient ophthalmologist who recommended
continuing outpatient glaucoma regimen during this admission,
with the exception of acetazolamide. She will likely need
surgery as an outpatient and they requested close post-discharge
follow up. Ophthalmology noted that we could consider starting
methazolamide, but this was not started and can be revisited as
an outpatient.
CHRONIC ISSUES
==============
#Lung opacity
Chronic changes consistent with CT scan from ___, no evidence
of pneumonia on this admission. Received vancomycin/cefepime x 1
in the emergency department, but these were not continued as
there was a low index for suspicion for infection. Patient
remain asymptomatic.
#Esophageal Reflux
Continued on omeprazole 20 mg PO daily
#Depressive disorder and anxiety states
Continued sertraline 100 mg PO daily
#Hypercholesterolemia
Continued atorvastatin 20 mg PO and aspirin 81 mg PO daily
#Diabetes mellitus
Diabetic diet
#Irritable bowel syndrome
Continued alpha-d-galactosidase 300 unit oral with meals as
needed
#Nutrition supplementation
Continued on cyanocobalamin 1000 mcg PO daily
TRANSLATIONAL ISSUES
=======================
[] consider hospice care enrollment
[] patient will need 24 hour care
[] titrate midodrine for orthostatic hypotension
[] patient will need continued teaching for management of
lifestyle changes for orthostatic hypotension
[] follow up with ___ need evaluation for glaucoma
treatment medication vs. surgical intervention
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 100 mg PO DAILY
2. AcetaZOLamide 250 mg PO BID
3. Omeprazole 20 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Midodrine 2.5 mg PO TID W/MEALS
6. Pyridostigmine Bromide 30 mg PO BID
7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
8. Aspirin 81 mg PO DAILY
9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. Atorvastatin 20 mg PO QPM
12. Albuterol Inhaler 2 PUFF IH QID:PRN SOB, wheeze
13. brimonidine 0.1 % ophthalmic TID
14. alpha-d-galactosidase 300 unit oral with meals PRN
Discharge Medications:
1. Senna 8.6 mg PO DAILY constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth daily Disp #*30
Tablet Refills:*0
2. Midodrine 5 mg PO QAM
3. Midodrine 2.5 mg PO BID
to be taken at 1400, ___
RX *midodrine 2.5 mg 1 tablet(s) by mouth three times a day Disp
#*60 Tablet Refills:*0
4. Albuterol Inhaler 2 PUFF IH QID:PRN SOB, wheeze
5. alpha-d-galactosidase 300 unit oral with meals PRN
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 20 mg PO QPM
8. brimonidine 0.1 % ophthalmic TID
9. Cyanocobalamin 1000 mcg PO DAILY
10. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. Omeprazole 20 mg PO DAILY
13. Pyridostigmine Bromide 30 mg PO BID
14. Sertraline 100 mg PO DAILY
15. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
16.Equipment
ICD-10-I95.1- Orthostatic hypotension - Please provide patient
with compression stockings.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=================
Orthostatic hypotension
Urinary incontinence
Secondary diagnosis
=====================
Glaucoma
Chronic lung abnormality
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with 24 hour surveillance to avoid
falls. Patient should use a walker.
Discharge Instructions:
Dear Ms. ___,
It has been a pleasure taking care of you here at ___
___.
Why was I here?
- You were here because you were found down at home and you have
had multiple falls recently.
- We think you were falling because your blood pressure was
getting low when you stand up.
What was done while I was here?
- We think that your blood pressure was getting low when you
stand up because of your eye medications, acetazolamide.
- You also were having trouble keeping your urine in, which may
also be due to acetazolamide.
- We stopped acetazolamide to see if it would help with your
dizziness and with keeping your urine in.
- While you were here, your dizziness improved and you were not
having as much trouble with your urine.
What should I do when I get home?
- Your blood pressure is still getting low when you stand up. Be
careful to stand up slowly. Also, if you are laying down, sit on
the edge of the bed for a few minutes before you stand.
- Keep the bed up at 30 degrees when you are lying down.
- Sit in a chair as often as possible and avoid lying down
during the day.
- Wear compression stockings as often as possible to help keep
up your blood pressure when you stand.
- Please try to stay well hydrated and drink lots of fluids.
- It is recommended that you have 24 hour home services.
It has been a pleasure to take care of you!
- Your ___ team
Followup Instructions:
___
|
10397381-DS-8 | 10,397,381 | 24,947,977 | DS | 8 | 2134-06-29 00:00:00 | 2134-06-29 17:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Post-operative ileus
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p open repair of a 4cm umbilical hernia defect on ___ who
now presents with nausea and vomiting. Her procedure went
without complications and the defect was closed using an 8-cm
ventralex mesh underlay. She reports that since she went home on
___, she felt nauseated after having some chicken soup. Since
then, she has had nausea and vomiting every day. She has had 6
episodes of vomiting and has not been able to tolerate food. She
has not been taking any pain meds since ___ because she is
afraid of the nausea it might cause. She has not passed flatus
or had a bowel movement since.
Past Medical History:
PMH:
asthma
PSH:
___ open umbilical hernia repair
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 96.2 HR 105 BP 131/84 RR 20 O2 98% RA
GEN: AAOx3, uncomfortable in bed
HEART: RRR
LUNGS: CTA b/l
ABD: Abdomen soft, non distended, tender to palpation in the RLQ
and LLQ. Incision c/d/I, steri-strips in place.
Extremities: no cyanosis or edema
DISCHARGE PHYSICAL EXAM:
VS: Temp 98.7 HR 84 BP 114/63 RR 20 O2 99% RA
GEN: AAOx3, appears comfortable
HEART: RRR
LUNGS: CTA b/l
ABD: Abdomen soft, non distended, appropriately incisionally
tender
INCISION: c/d/i, sterri-strips in place.
EXT: no cyanosis or edema
Pertinent Results:
___ 03:20PM URINE HOURS-RANDOM
___ 03:20PM URINE UCG-NEGATIVE
___ 03:20PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 03:20PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-2
___ 03:20PM URINE HYALINE-1*
___ 03:20PM URINE AMORPH-RARE
___ 03:20PM URINE MUCOUS-MANY
___ 01:38PM LACTATE-2.0
___ 01:27PM GLUCOSE-126* UREA N-12 CREAT-0.7 SODIUM-139
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-21* ANION GAP-25*
___ 01:27PM estGFR-Using this
___ 01:27PM ALT(SGPT)-14 AST(SGOT)-19 ALK PHOS-52 TOT
BILI-0.6
___ 01:27PM ALBUMIN-5.0 CALCIUM-10.5* PHOSPHATE-3.1
MAGNESIUM-2.2
___ 01:27PM WBC-14.5* RBC-5.67* HGB-14.6 HCT-44.8 MCV-79*
MCH-25.7* MCHC-32.6 RDW-13.8 RDWSD-39.2
___ 01:27PM NEUTS-75.5* LYMPHS-16.7* MONOS-7.0 EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-10.97* AbsLymp-2.43 AbsMono-1.01*
AbsEos-0.00* AbsBaso-0.04
___ 01:27PM PLT COUNT-315
___ 01:27PM ___ PTT-27.2 ___
Brief Hospital Course:
Patient was admitted to the hospital on ___ with nausea,
vomiting post-operatively, concerning for ileus. She did well
with bowel rest and IV fluids. Abdominal CT was obtained and
showed dilated loops of bowel without any clear transition
point. Serial KUB exams showed passage of oral contrast from the
small bowel into the colon, suggesting adequate return of bowel
function.
Patient was discharged home on ___. At the time of
discharge, patient was having bowel function and was able to
tolerate a regular diet. Her pain was well controlled with oral
medications. She will follow up with Dr. ___ in clinic in 1
week.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Polyethylene Glycol 17 g PO DAILY
Drink plenty of fluids while taking this medication. Stop if ___
develop diarrhea.
RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 17 gms by
mouth twice a day Refills:*0
3. Ondansetron 8 mg PO Q8H:PRN nausea
Take 1 pill up to every 8 hours as needed for nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth three times a day Disp
#*30 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
Take twice a day with plenty of fluids. Stop if loose stools or
diarrhea develop
RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 tab by mouth
twice a day Disp #*60 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain
Discharge Disposition:
Home
Discharge Diagnosis:
Post-operative ileus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ were admitted to the hospital for nausea and vomiting, and
dehydration following recent umbilical hernia repair. Your
symptoms were likely related to a condition called
post-operative ileus, a frequent complication after abdominal
surgery. ___ are now ready to be discharged home to complete
your recovery.
Please follow these instructions to ensure good recovery.
DIET: ___ may resume regular diet as before. Drink plenty of
fluids.
MEDICATIONS: ___ may resume all your home medications
ACTIVITY: ___ may resume regular activity, but avoid heavy
lifting for ___ weeks after surgery. ___ may shower, walk,
drive, and exercise as long as ___ are not doing any heavy
lifting.
PAIN CONTROL: ___ may continue taking narcotic pain medication
called oxycodone as before. In addition, we recommend taking
Tylenol up to 1 gm every 6 hours, but do not exceed 4 gms in 24
hour period. ___ may place ice on your incision for comfort.
INCISION CARE: ___ may shower, but do not rub your incision or
place any creams or lotions on it. ___ may cover it up with
clean dry dressing to protect your clothing or leave it open to
air.
FOLLOW-UP: please make sure ___ make an appointment with Dr.
___ to follow-up in 1 week after your discharge from the
hospital.
Thank ___ for letting us participate in your care.
Good luck!
Followup Instructions:
___
|
10397575-DS-5 | 10,397,575 | 29,792,874 | DS | 5 | 2159-12-17 00:00:00 | 2159-12-17 18:51:00 |
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, right sided numbness and speech difficulty
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Reason for consult: code stroke
Neurology at bedside for evaluation after code stroke activation
within: 3 minutes
Time the patient was last known well: 21:00
___ Stroke Scale Score:
t-PA given: No
Reason t-PA was not given or considered: has had similar
symptoms
in the past associated with headache as well which resolved
after
___ hours, normal imaging today and in the past, low suspicion
for ischemic process
___ Stroke Scale score was : 3
1a. Level of Consciousness: 0
1b. LOC Question: 1
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 2
10. Dysarthria: 0
11. Extinction and Neglect: 0
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
HPI: (obtained from OMR, husband, mother)
Ms. ___ is a ___ year old morbidly obese woman who presents
for evaluation of an episode headache, SOB, tongue numbness, R
hand/L foot numbness and word production difficulty. Today was
the first day that Ms. ___ woke up headache free since ___
(see below for details of prior symptoms). Then, in the
afternoon, she again reported a left sided headache like the
ones
she has been having. At around 7:30pm, she suddenly stopped
what
she was doing and held on to the kitchen table. She reported to
her husband that she had headache, SOB, tongue numbness, R
hand/L
foot numbness. She sat down and her husband gave her some food.
After 20 minutes, she felt back to normal so they went out for
dinner. When they returned home at 9:15pm, she began to feel
very cold as she often does with her episodes, restless, and
then
very scared. Suddenly, she was having difficulty with speech
production, saying short phrases like "can you" and "blanket."
So, her husband took her to the ED. Of note, he and mom say
that
these are the exact symptoms that she had with word finding
difficulty on ___. At that time, they lasted 12 hours and
resolved. Ms. ___ has not had recent fevers/chills, abd pain,
dysuria, cough per husband. The headache she had earlier was
just like those prior, not sure about details. She was
scheduled
for an open MRI today but could not tolerate it as it was not
open, but only a larger tube. Currenly, Ms. ___ nods her head to
headache, trouble talking, seems to be denying other symptoms.
Per note of Dr. ___ on ___: "Notably, Ms. ___
was recently admitted to ___ for similar symptoms
and
was found to have CSF consistent with a viral meningitis. To
briefly review on ___ she began to experience a
headache that she describes as going up the back of her neck to
her jaw. She was seen in the ED and was started on blood
pressure
medication and a cough suppressant upon discharge. The next day,
she was having worsening of the headache with each lasting only
a
few minutes. She described the headache as throbbing in
character
and that she could hear her heartbeat in her ears. She then
began
to develop difficulty speaking, wouldnot be able to complete
sentences, some word finding difficulty
and this progressed to tingling of her hands and worsening pain.
In ___ ED she was evaluated by head CT and labs with
concern
for stroke and due to persistent symptoms she was admitted. She
states that the symptoms that persisted from the day of
admission
and improved over the next few days were primarily her word
finding difficulty and the headache had improved. She had a
workup including CTx2, MRI (limited due to inability to
tolerate), CSF and some infectious studies which all hinted at a
likely viral meningitis. She was discharged home on ___ with
plan for outpatient MRI and neurolgy follow up as well as to
continue the HCTZ that had been started. Since then she has been
"laying low" at home and has continued to have some mild
headaches but no other significant symptoms until today
___
On ___, patient presented "for evaluation of an episode of
headache, word finding difficulty, blurred vision, right hand,
right foot and left hand tingling. Ms. ___ says she was at
home with her mom and had been on the phone talking to someone
who asked her to look
something up on the computer when she began to experience a
headache, up the back of her neck to her jaw and left temple
that
was throbbing in character. This started when looking at the
computer screen and then she noticed that she was having trouble
visualizing the screen but thinks the blurriness was from both
eyes. She went to lay down and felt cold as this was occurring
and when laying down she began to feel tingling in her right
hand
(fingers), then her right toes. Due to this she stood up and her
hand began to feel better but she then felt tingling in her left
hand. The entire event lasted about ~20 minutes and she now has
a
lingering posterior and left temple headache that she describes
as ___ in severity."
In the ED today, patient required several doses of ativan to
tolerate even CTA head/neck.
Past Medical History:
Obesity
Hypertension
Thalassemia trait
likely viral meningitis diagnosed at ___ ___
Social History:
___
Family History:
No family history of strokes, seizures, migraines or other
neurologic problems. No significant family history of any other
systemic illnesses per pt and her mother.
Physical Exam:
Vitals: T 98.6 HR 98 BP 129/79 RR 20 100% RA
General: Awake, cooperative, anxious appearing, obese
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated.
Pulmonary: CTABL but exam limited by habitus
Cardiac: RRR, no murmurs
Abdomen: soft, obese, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake,alert, oriented to name. When asked the
month, repeats her name, then says "hold on a second." Later in
exam, says ___, then says other months, says ___ and other
years. Answers ___ to further questions. Cannot name shoe.
Unable to point to her shoe when asked. Follows the command
"take off your shoes" accurately. Cannot name, cannot repeat.
Follows commands quite consistently.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
Difficulty with FNF, can do finger finger and can track, no
overshoot.
-Gait: not tested
****************
DISCHARGE EXAMINATION:
AF VSS (BP in 130s)
MS: alert, awake, oriented x3. Speech fluent with intact
repetition. Able to name ___ without difficulty.
CN: unremarkable
Motor: trace R deltoid weakness and subtle right pronator drift
on attending exam, otherwise full.
Sensory: intact to LT throughout
Reflexes: normal and symmetric throughout
Coordination: no dysmetria on FNF
Pertinent Results:
ADMISSION LABS:
___ 10:53PM BLOOD WBC-11.5* RBC-5.63* Hgb-9.9* Hct-31.8*
MCV-57* MCH-17.6* MCHC-31.1 RDW-16.7* Plt ___
___ 10:53PM BLOOD Plt ___
___ 10:53PM BLOOD ___ PTT-30.4 ___
___ 10:53PM BLOOD ESR-27*
___ 10:53PM BLOOD UreaN-11
___ 11:01PM BLOOD Creat-0.5
___ 10:53PM BLOOD CRP-4.9
IRON STUDIES:
___ 10:53PM BLOOD Iron-24*
___ 10:53PM BLOOD calTIBC-485* Ferritn-14 TRF-373*
URINALYSIS:
___ 01:00AM URINE Color-Straw Appear-Clear Sp ___
SERUM/URINE TOX:
___ 10:53PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:00AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
*******************
IMAGING:
CTA HEAD/NECK ___:
1. Mildly degraded image quality secondary to suboptimal bolus
timing and
patient's body habitus.
2. Major intracranial vessels patent, without intracranial
aneurysm,
arteriovenous malformation or distal occlusion.
3. Major cervical vessels patent, without significant
atherosclerotic disease by NASCET criteria.
CXR ___: Low lung volumes, exaggerating mild cardiomegaly.
EEG ___ (prelim): no seizure activity
Brief Hospital Course:
Ms. ___ is a ___ yo woman with obesity and recently
diagnosed HTN and likely viral meningitis who presented for
evaluation of episodic headache, tongue numbness, R hand/foot
numbness and difficulty with speech. Her symptoms improved
spontaneously with essentially normal exam except for a possible
subtle weakness of right deltoid and right pronator drift. Given
the episonic nature of her symptoms, she was evaluated for
seizures with an overnight video EEG which did not show evidence
of seizures. Her diagnosis is unclear at the time of discharge.
It was thought to be possibly related to ongoing stressors so
social work was consulted and patient will try to obtain
outpatient care as well.
She was hypokalemic on admission, thought to be due to recently
started HCTZ. HCTZ was held and patient's SBP was in 130s so it
was not restarted. She was advised on lifestyle changes to try
to lower her blood pressure.
She was found to have very microcytic cells, likely due to her
thalassemia trait. Iron studies were sent and she was found to
have low iron at 24. She will discuss this with her primary care
physician to see whether she needs iron supplementation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Ibuprofen 600 mg PO Q8H:PRN Pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: episodic headaches, numbness
Secondary Diagnosis: thalassemia trait
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital because of the
episodes of headache, right sided numbness and difficulty with
speech/confusion.
CT and CTA did not show acute abnormalities or bleeding in your
brain. MRI was not attempted because your symptoms improved
spontaneously.
EEG (brain waves) showed no seizures.
You were also found to have anemia (likely from your
thalassemia) but your iron level was also low. Please discuss
with your primary care physician to see if you need to be
started on iron supplementation.
Followup Instructions:
___
|
10397864-DS-13 | 10,397,864 | 24,931,117 | DS | 13 | 2153-12-21 00:00:00 | 2153-12-23 12:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___
Chief Complaint:
Chest Tightness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo M with PMHx significant for hypertension
and hyperlipidemia who presents with chest pain and numbness of
left arm. He reports the pain has been ongoing since ___
after a tennis match. The pain is left-sided and radiates to the
neck (has burning in throat) and left shoulder. He feels
pressure in his chest and occasionally feels like someone is
"poking him with a knife." He also complains of dizziness,
numbness of left arm, left cheek, and left foot which he has had
for several years but has recently become more progressive. He
endorses nausea and intermittent shortness of breath. His
shortness of breath has worsened and is not associated with
increases in activity. Advair failed to provide relief. He was
recently seen by Dr. ___ on ___ for a similar
complaint. He denies any abdominal pain, vomiting, diarrhea,
fevers, and chills.
Of note, he has been seen for intermittent palpitations for the
past several years and it has been extensively evaluated
(including having multiple Holter monitors, an echocardiogram,
and an exercise stress test) which showed no ischemic changes.
His last echocardiogram on ___ showed an LVEF >55% with
preserved global systolic function and LV hypertrophy.
In the ED, initial vitals were: T 97.9 HR 67 BP 148/89 RR 20
SaO2 99%. His CBC, Chem10, D-dimer, and UA were unremarkable. He
was given aspirin 325 mg. His CK-MB was 1 and his Troponin-T <
0.01. ECG was in normal sinus rhythm. He was given IV morphine
for pain.
Upon arrival to the floor: He was resting comfortably in bed. He
continued to have left sided numbness and feels flushed. He
rated his chest pain ___.
REVIEW OF SYSTEMS:
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, or syncope.
Past Medical History:
1. CAD RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: None.
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS: None.
-PACING/ICD: None.
3. OTHER PAST MEDICAL HISTORY:
- Hypertension (since age ___, untreated for about ___ yrs)
- Hyperlipidemia
- ? Adult onset Asthma
- Palpitations
- Appendectomy
- Lumbar Disc herniation
Social History:
___
Family History:
Mother: Living age ___.
Father: ___ age ___ ___ Infarcts), First MI age
___, diabetes mellitus, PVD
Sister: Living age ___, diabetes mellitus
Physical Exam:
On Admission:
General: middle-aged man alert and oriented, in no acute
distress
VS: T= 98.3 BP= 140/72 HR= 68 RR= 20 O2 sat= 97% on RA
HEENT: sclera anicteric, oropharynx clear
Neck: supple, JVP 5 cm
CV: Regular, rate, and rhythm; no murmurs, rubs or gallops
Lungs: clear to auscultation bilaterally--no wheezes or crackles
Abdomen: soft, non-tender, non-distended, BS present
GU: no Foley
Ext: 2+ DP pulses, no clubbing, cyanosis, or edema
Neuro: CN II-XII intact and symmetric, sensation to light touch
intact throughout. Strength ___ in all extremities.
Skin: warm, dry, no rashes
Discharge Physical Exam:
General: alert and oriented, no acute distress
VS: T= 98.2 BP= 130/74 (128/72-140/72) HR= 55(55-68) RR= 20 O2
sat= 96% on RA
Exam unchanged from admission
Pertinent Results:
Admission Labs:
___ 03:00PM WBC-8.2 RBC-4.93 HGB-15.4 HCT-43.6 MCV-88
MCH-31.2 MCHC-35.3* RDW-13.3
___ 03:00PM NEUTS-65.1 ___ MONOS-5.0 EOS-1.6
BASOS-0.7
___ 03:00PM PLT COUNT-250
___ 03:00PM ___ PTT-30.5 ___
___ 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 03:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:00PM GLUCOSE-104* UREA N-12 CREAT-0.9 SODIUM-141
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-26 ANION GAP-15
___ 03:00PM CALCIUM-10.2 PHOSPHATE-2.6* MAGNESIUM-2.3
___ 03:00PM CK(CPK)-62 CK-MB-1 cTropnT-<0.01
___ 04:07PM D-DIMER-<150
___ 09:15PM CK-MB-1 cTropnT-<0.01
Discharge Labs:
___ 07:44AM BLOOD WBC-7.1 RBC-4.97 Hgb-15.6 Hct-44.3 MCV-89
MCH-31.5 MCHC-35.3* RDW-13.3 Plt ___
___ 07:44AM BLOOD Glucose-116* UreaN-14 Creat-1.0 Na-141
K-4.1 Cl-104 HCO3-24 AnGap-17
___ 07:44AM BLOOD Calcium-9.7 Phos-3.8 Mg-2.2
___ 07:44AM BLOOD TSH-0.65
___ 07:44AM BLOOD CK-MB-1 cTropnT-<0.01
Microbiology:
Urine Culture (___): No growth.
Pathology: None.
Imaging/Studies:
# ECG (___): Sinus rhythm. Consider left atrial abnormality.
Early R wave progression. Minor precordial T wave abnormalities.
No previous tracing available for comparison. Clinical
correlation is suggested.
# CXR (___):
Heart size is top normal. Lungs are slightly lower, but clear
of any focal abnormality. No pleural abnormality or evidence of
central adenopathy. Aortic contours are normal.
# Exercise Stress Test (___):
This ___ yo man with h/o HTN, HLD, and asthma was referred to the
lab from the floor following negative serial cardiac enzymes for
evaluation of chest discomfort. The patient exercised for 12.5
minutes of ___ protocol and was stopped for fatigue. The
estimated peak MET capacity was 13.3, which represents an
excellent exercise tolerance for his age. The patient presented
with a ___ left chest/shoulder discomfort that did not change
throughout the study. At peak exercise, there were 1mm upsloping
ST segment changes laterally that resolved by minute 3 of
recovery. Rhythm was sinus with rare isolated APBs and one VPB
in recovery. The heart rate and blood pressure responses were
appropriate during exercise and recovery.
IMPRESSION: Non-anginal type symptoms with non-specific EKG
changes at a high cardiac demand and excellent functional
capacity. Normal hemodynamic response to exercise. Duke Score of
12.5 represents a low CV Mortality risk.
Brief Hospital Course:
Mr. ___ is a ___ yo M with PMHx significant for hypertension
and hyperlipidemia who presents with chest pain and numbness of
left arm.
Active Diagnosis.
# Chest tightness/Palpitations: He has had persistent atypical
chest pain since playing tennis on ___. His cardiac
biomarkers were negative. His ECG was without acute ischemic
abnormalities, and he remained in NSR on telemetry and ECG. He
was given 325 mg of aspirin in the ED and IV morphine for pain.
He achieved ___ METs on exercise tolerance test with a normal
hemodynamic response to exercise; his symptoms were felt to be
not anginal with non-specific EKG changes at a high cardiac
demand and excellent functional capacity. His stress test
performance put him at low risk for cardiovascular mortality. He
was given a GI cocktail and was discharged with a prescription
for pantoprazole. He will follow up with his PCP's office on
___.
# Lightheadness and Facial Numbness: This is an ongoing problem
that appears mildly worse than his baseline. His neurological
exam was unremarkable. He had an MRI of his brain for similar
symptoms in ___ which was unremarkable. According to a
neurology clinic note from ___, the goals of treating these
symptoms are to adequately control blood pressure, cholesterol,
blood sugar, and continue taking aspirin.
# Dyspnea/Question of adult onset asthma: His dyspnea was
unchanged with physical activity and was intermittent. The
patient does not believe his dyspnea is caused by asthma because
it does not reliably occur with increased exertion. His O2 sats
were within normal limits. Advair and albuterol were continued
as needed.
Chronic Diagnoses:
# Hypertension: He has been hypertensive since age ___. His BP at
home ranges from 140s-160s. His home dose atenolol was continued
and his olmesartan was held because it was a non-formulary
medication. His systolic BP ranged from 130s-140s during this
admission. He will resume olmesartan upon discharge.
# Hyperlipidemia: Continued pravastatin.
#CODE: Full (Confirmed)
#CONTACT: Son ___: cell ___
Transitional Issues:
# He complained of left sided facial flushing during this
admission admission. His TSH was 0.65. Consider outpatient
workup for pheochromocytoma and carcinoid syndrome.
# Will follow up in his PCP's office on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
2. Atenolol 50 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
4. olmesartan 20 mg Oral daily
5. Pravastatin 40 mg PO DAILY
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO BID
4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
5. Pravastatin 40 mg PO DAILY
6. olmesartan 20 mg Oral daily
7. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth Daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Chest Pain without objective evidence of ischemia
Hypertension
Hyperlipidemia
Shortness of breath
Lightheadedness
Facial numbness
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 hospital after having chest tightness and
numbness to your left cheek, left hand, and left shoulder for
the past several days. In the hospital, your ECGs and cardiac
enzymes remained normal. You had an echocardiogram that looked
at how your heart was beating under stress. The echocardiogram
was normal and it appeared that your chest tightness was not
related to your heart function.
Please follow up with Dr. ___ office on ___.
We wish you the best in the recovery process.
========
Editor's note: The above information provided to the patient was
incorrect, as the patient did not undergo echocardiographic
imaging during this admission. He did undergo an exercise stress
test that was normal.
Followup Instructions:
___
|
10398029-DS-19 | 10,398,029 | 29,053,367 | DS | 19 | 2193-04-22 00:00:00 | 2193-04-30 18:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ man with H/O aortic stenosis (bicuspid
valve), thoracic aortic aneurysm S/P aortic arch repair with
CABG (SVG-RCA for 80% proximal RCA lesion ___,
hypertension, and BPH, who is presenting with chest pain. He
reports that for the past ___ weeks, he has been experiencing
worsening exertional chest tightness. He reports that his
symptoms come on when he walks about 400 feet or when he is
doing yard work. He reports that about two weeks ago, he had a
particularly bad episode of chest tightness while doing yard
work that was associated with diaphoresis. He went to the porch
to sit down and passed out for an unknown amount of time. After
this episode, he went to see a local cardiologist who sent him
for an echocardiogram. He was informed by telephone that he had
aortic stenosis but that he should follow up in 3 months.
He sought a second opinion the day of admission at ___
___ outpatient cardiology clinic. The cardiologist
there, Dr. ___, was concerned about the severity of
the aortic stenosis described on the outside echocardiogram
report and wanted the patient to be admitted. Due to insurance
coverage issues, he was not able to be admitted to ___ so was
sent directly to ___ ED. In the ED, initial vitals were: T
97.9 57 BP 161/65 RR 16 SaO2 100% on RA. Labs notable for
Troponin-T negative with normal CBC, INR, and Chem 7. CXR showed
no acute cardiopulmonary abnormality with normal heart size. EKG
showed sinus rhythm at 57 bpm, normal axis, borderline first
degree heart block, no ST segment changes. Cardiac surgery was
consulted and recommended cardiology work up. Vitals prior to
transfer HR 51 BP 143/47 RR 16 SaO2 99%.
After arrival to the cardiology ward, the patient reported mild
___ chest tightness. On further questioning, the patient
reported a different type of chest pressure and difficulty
catching his breath prior to his CABG. He reported that his
current symptoms only occur with exertion and never at rest, but
have been increasing in frequency over the last 6 weeks
accompanied by weight gain. He has only had 1 syncopal episode
as above and one episode of feeling faint while clearing the
chute from his riding lawnmower. He works as an ___
___. Walking >25 feet or up stairs results in
lightheadedness, chest pain, and dyspnea.
Echocardiogram report from ___ ___ showed
bicuspid aortic valve with peak gradient 61 and mean gradient 36
mm Hg, ___ ~0.8, LVEF 55-60%, wall thickness 11 mm, PASP 25+RA,
with a 4.3 cm ascending aorta.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, cough, palpitations,nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits.
Past Medical History:
# Aortic stenosis (bicuspid valve)
# Thoracic aortic aneurysm s/p graft (___)
# Coronary artery disease s/p CABG x1 (___)
# Hypertension
# Benign prostatic hypertrophy
Social History:
___
Family History:
No family history of premature CAD, arrhythmias.
Physical Exam:
On admission
General: Youthful elderly white man, alert, oriented, in no
acute distress
Vital Signs: T 98.2 BP 185/61 HR 61 RR 16 SaO2 100% on RA
HEENT: Sclera anicteric, mucous membranes moist, oropharynx
clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
heard best and right and left USB, radiating to carotids
Lungs: Clear to auscultation bilaterally--no wheezes, rales,
rhonchi
Abdomen: Protuberant, Soft, non-tender, non-distended, bowel
sounds present
GU: No Foley
Ext: Warm, well perfused, 2+ pulses, trace bilateral pitting
edema
Neuro: grossly intact
At discharge
General: In bed, in NAD, mental status intact
Vital Signs: T 98.2 BP 125-185/45-61 HR 53-61 RR 16 SaO2 99% on
RA
HEENT: Mucous membranes moist, JVD not appreciable, no carotid
bruits
CV: Regular rate and rhythm, normal S1 + S2, ___ harsh systolic
murmur heard best at the left sternal border
Lungs: Clear to auscultation bilaterally--no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present
Ext: Warm, well perfused, 2+ radial and distal pulses
bilaterally. Trace bilateral edema.
Pertinent Results:
___ 07:50PM WBC-5.5 RBC-4.17* HGB-13.7 HCT-38.6* MCV-93
MCH-32.9* MCHC-35.5 RDW-13.2 RDWSD-44.7
___ 07:50PM NEUTS-47.8 ___ MONOS-11.4 EOS-2.7
BASOS-0.5 IM ___ AbsNeut-2.65 AbsLymp-2.06 AbsMono-0.63
AbsEos-0.15 AbsBaso-0.03
___ 07:50PM PLT COUNT-161
___ 07:50PM ___ PTT-28.1 ___
___ 07:50PM GLUCOSE-89 UREA N-17 CREAT-1.0 SODIUM-140
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-27 ANION GAP-12
___ 07:50PM cTropnT-<0.01
___ 07:05AM cTropnT-<0.01
___ 07:05AM WBC-5.5 RBC-4.33* Hgb-13.8 Hct-39.7* MCV-92
MCH-31.9 MCHC-34.8 RDW-13.2 RDWSD-43.8 Plt ___
___ 07:05AM Glucose-103* UreaN-16 Creat-1.1 Na-140 K-4.2
Cl-106 HCO3-25 AnGap-13
___ 07:05AM Calcium-9.0 Phos-3.2 Mg-2.2
ECG ___ 5:44:52 ___
Sinus bradycardia. Right axis deviation. Possible inferior wall
myocardial infarction of indeterminate age, versus left
posterior fascicular block. Poor R wave progression in leads
V1-V4. Cannot exclude anterior wall myocardial infarction of
indeterminate age. Compared to the previous tracing of ___
there is no diagnostic change.
PA/lateral CXR ___ 8:25pm
Patient is status post median sternotomy and CABG. Cardiac
silhouette size is within normal limits. The aorta remains
tortuous. The mediastinal and hilar contours are unremarkable.
The pulmonary vasculature is normal. Lungs are clear. No pleural
effusion or pneumothorax is visualized. There are mild
degenerative changes noted in the thoracic spine. Surgical
anchors project over the right proximal humerus.
IMPRESSION: No acute cardiopulmonary abnormality. Normal heart
size.
Echocardiogram ___ 2:03pm
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: 4.6 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.7 cm
Left Ventricle - Fractional Shortening: 0.41 >= 0.29
Left Ventricle - Ejection Fraction: 60% >= 55%
Left Ventricle - Stroke Volume: 98 ml/beat
Left Ventricle - Cardiac Output: 5.11 L/min
Left Ventricle - Cardiac Index: 2.33 >= 2.0 L/min/M2
Aorta - Sinus Level: *4.5 cm <= 3.6 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *3.0 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *35 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 20 mm Hg
Aortic Valve - Valve Area: *1.1 cm2 >= 3.0 cm2
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg).
Doppler parameters are most consistent with Grade II (moderate)
left ventricular diastolic dysfunction. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The right ventricular cavity is mildly
dilated with normal free wall contractility. The aortic root is
moderately dilated at the sinus level. The ascending aorta is
mildly dilated. The aortic valve is bicuspid. The aortic valve
leaflets are moderately thickened. There is moderate aortic
valve stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic
regurgitation is seen. The aortic regurgitation jet is
eccentric. The mitral valve leaflets are structurally normal.
There is no mitral valve prolapse. Trivial mitral regurgitation
is seen. The pulmonary artery systolic pressure could not be
determined. There is an anterior space which most likely
represents a prominent fat pad.
Brief Hospital Course:
This is a ___ man with S/P ascending aortic arch repair
with CABG (SVG-RCA) for thoracic aortic aneurysm in ___ with
known aortic stenosis from a congenital bicuspid valve who
presented with exertional chest pain, dyspnea and
lightheadedness with 1 syncopal and at least 1 near syncopal
episode.
# Chest pain: Patient with exertional chest tightness that has
been progressive over the past several weeks, associated with
one episode of syncope, likely related to progressive aortic
stenosis. We cannot exclude an ischemic component to his
symptoms given known CAD with ___ year-old SVG-RCA. Troponin-T x
2 negative and EKG without any acute changes. Echo on ___
showed bicuspid aortic valve with severe stenosis and mild
regurgitation, as well as mild-moderate dilation of the aortic
root and mild dilation of the ascending aorta. LVEF was 60%
without wall motion abnormalities. There were no repeat episodes
of the chest pain in the hospital. Since the patient's symptoms
were only exertional and because we were unable to accommodate
him into the very busy cardiac catheterization laboratory
schedule on a ___, the patient was discharged home with
instructions to limit his physical activities and return as an
outpatient on ___ for cardiac catheterization and
coronary angiography. He was continued on aspirin 81 mg daily,
metoprolol succinate 25 mg daily, and rosuvastatin 20 mg daily.
# Hypertension: Continued metoprolol succinate 25 mg daily
# BPH: Continued Finasteride 5 mg PO DAILY and Tamsulosin 0.4 mg
PO QHS
# GERD: continued Ranitidine 150 mg PO DAILY
TRANSITIONAL ISSUES:
[ ] cardiac catheterization on ___
[ ] avoid nitrates in the setting of chest pain due to aortic
stenosis
[ ] avoid strenuous activity upon discharge
[ ] may refer to cardiac surgery pending results of cardiac
catheterization
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Ranitidine 150 mg PO DAILY
3. krill oil 500 mg oral DAILY
4. Rosuvastatin Calcium 20 mg PO QPM
5. Aspirin 81 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Finasteride 5 mg PO DAILY
8. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Ranitidine 150 mg PO DAILY
5. Rosuvastatin Calcium 20 mg PO QPM
6. Tamsulosin 0.4 mg PO QHS
7. Metoprolol Succinate XL 25 mg PO DAILY
8. krill oil 500 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
-Severe bicuspid aortic stenosis
-Syncope
-Coronary artery disease with prior venous bypass graft surgery
-Hypertension
-Benign prostatic hyperterophy
-Gastroesophageal reflux disease
Discharge Condition:
Mental status: clear and coherent
Level of consciousness: alert and interactive
Activity status: ambulatory
Discharge Instructions:
Dear Mr ___,
You were admitted to ___
(___) from the Emergency Dept on ___ for you aortic
stenosis.
What happened during you hospital stay?
=======================================
- You had an ultrasound of your heart (called an echocardiogram)
to look at the narrowing of your heart valve (aortic stenosis).
This did not show any need for emergent procedures.
What should you do following discharge?
=======================================
- You have been scheduled for a cardiac catheterization on
___. Please do not drink or eat anything after
midnight that day. You should come to ___ 4
for this procedure.
- Continue to take all of your medications as prescribed
- At discharge, you weighed 236lbs. Please weigh yourself every
day in the morning after you go to the bathroom and before you
get dressed. If your weight goes up by more than 3 lbs in 1 day
or more than 5 lbs in 3 days, please call your heart doctor or
your primary care doctor and alert them to this change.
- You will need to have outpatient evaluation of your aortic
valve and need for surgery.
- Please do not perform any vigorous activity over the weekend.
If you develop any chest pain or pass out, please call ___ right
away.
Sincerely,
Your ___ Cardiac Care Team
Followup Instructions:
___
|
10398029-DS-21 | 10,398,029 | 20,306,012 | DS | 21 | 2195-05-30 00:00:00 | 2195-05-30 13:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
Shortness of breath and chest pain
Major Surgical or Invasive Procedure:
___
1. Redo sternotomy.
2. Coronary artery bypass grafting x2 with left internal
mammary artery to left anterior descending artery and reverse
saphenous vein graft to the posterior descending artery.
3. Aortic valve replacement with a 29 ___ Ease
pericardial tissue valve, model ___, TFX, serial number is
___.
4. Reconstruction of pericardium with CorMatrix
History of Present Illness:
___ year old male with past medical
history of hypertension, hyperlipidemia, and s/p ascending
aortic
aneurysm repair and single vessel bypass (SVG-PDA) in ___ at
___ who presented to OSH with shortness of breath. He was seen
by Dr. ___ in ___ after CTA chest revealed saccular
outpouching of contrast, 1.1 x 1.8 cm, at the site of his aortic
root repair, not seen on prior imaging studies and concerning
for
pseudoaneurysm, no surgery indicated at that time and plan was
to
follow up with echo. CTA at ___ showed mural thrombus.
Patient transferred to ___ on Heparin gtt for further
evaluation. Cardiac surgery consulted.
Past Medical History:
Ascending Aortic Aneurysm repair with 26 mm gelweave graft/ CABG
x1(SVG-PDA) in ___ at ___ w/ Dr. ___ c/b MRSA sternal
wound infection (6 weeks of vancomycin)
Coronary Artery Disease
Bicuspid aortic valve
Aortic stenosis
GERD
BPH
Hypertension
Hyperlipidemia
Umbilical hernia
Urosepsis
Left spontaneous PTX requiring CT placement
Bilateral Shoulder surgery x 5 -most recent ___
Umbilical Hernia repair
C5-C6 fusion
Social History:
___
Family History:
Denies significant family history
Physical Exam:
ADMISSION PHYSICAL EXAM
============================
VS: T 98.7 HR 60 BP 150/58 RR 18 O2 Sat 98% RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CHEST: Sternal incision, well healed
CV: ___ midsystolic murmur auscultated in upper sternal area
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, mildly distended, nontender, +umbilical hernia
EXTREMITIES: no cyanosis, clubbing. Trace edema
MSK: Bilateral shoulder incisions, well healed
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: Multiple tattoos covering chest and arms. Warm and well
perfused, no excoriations or lesions, no rashes
.
DISCHARGE PHYSICAL EXAM:
98.6 125 / 67 70 18 97 Ra
General: NAD [x]
Neurological: A/O x3 [x] non-focal [x]
HEENT: PEERL [x]
Cardiovascular: RRR [x] Irregular [] Murmur [] Rub [x]
Respiratory: CTA [x] No resp distress []
GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]
Extremities:
Right Upper extremity Warm [] Edema
Left Upper extremity Warm [] Edema
Right Lower extremity Warm [x] Edema 1+
Left Lower extremity Warm [x] Edema 1+
Pulses:
DP Right: Left:
___ Right: Left:
Radial Right: Left:
Skin/Wounds: Dry [x] intact [x]
Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [] Prevena []
Lower extremity: Right [] Left [x] CDI [x]
Pertinent Results:
ADMISSION LABS
========================
___ 05:30PM BLOOD WBC-7.1 RBC-4.15* Hgb-13.1* Hct-37.6*
MCV-91 MCH-31.6 MCHC-34.8 RDW-14.7 RDWSD-48.3* Plt ___
___ 05:30PM BLOOD Neuts-88.6* Lymphs-9.5* Monos-1.3*
Eos-0.1* Baso-0.1 Im ___ AbsNeut-6.24* AbsLymp-0.67*
AbsMono-0.09* AbsEos-0.01* AbsBaso-0.01
___ 05:30PM BLOOD ___ PTT-50.1* ___
___ 05:30PM BLOOD Glucose-151* Creat-1.1 Na-140 K-5.4
Cl-104 HCO3-17* AnGap-19*
___ 05:30PM BLOOD ALT-23 AST-42* AlkPhos-62 TotBili-0.6
___ 05:30PM BLOOD cTropnT-<0.01
___ 10:24PM BLOOD cTropnT-<0.01
___ 05:30PM BLOOD Lipase-20
___ 05:30PM BLOOD Albumin-4.1
___ 07:12PM BLOOD %HbA1c-5.5 eAG-111
IMAGING
==========================
___ TTE
The left atrial volume index is moderately increased. The right
atrium is mildly enlarged. There is no evidence for an atrial
septal defect by 2D/color Doppler. The estimated right atrial
pressure is ___ mmHg. There is moderate symmetric left
ventricular hypertrophy with a normal cavity size. There is
normal regional and global left ventricular systolic function.
Overall left ventricular systolic function is low normal.
Quantitative 3D volumetric left ventricular ejection fraction is
50 %. There is no resting left ventricular outflow tract
gradient. Tissue Doppler suggests an increased left ventricular
filling pressure (PCWP greater than 18mmHg). Mildly dilated
right ventricular cavity with normal free wall motion. The
aortic sinus is mildly dilated with mildly dilated ascending
aorta. The aortic arch is mildly dilated. The aortic valve is
bicuspid with moderately thickened leaflets with fusion of the
right/left raphe. There is severe aortic valve stenosis (valve
area less than 1.0 cm2). There is an eccentric, anterior mitral
leaflet directed jet of moderate [2+] aortic regurgitation. The
mitral valve leaflets appear structurally normal with no mitral
valve prolapse. There is mild to moderate [___] mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is mild [1+] tricuspid regurgitation. There is
moderate to severe pulmonary artery systolic hypertension. There
is a trivial pericardial effusion. IMPRESSION: Moderate
symmetric left ventricular hypertrophy with normal cavity size
and lownormal global systolic function. Increased PCWP. Bicuspid
aortic valve with fusion of the right and left commissures
___ 1A). Severe aortic valve stenosis. Moderate aortic
regurgitation. Mild to moderate mitral regurgitation. Mild
tricuspid regurgitation. Moderate to severe pulmonarya rtery
systolic hypertension. Mild thoracic aortic enlargement.
Compared with the prior TTE ___ , the aortic valve area
is now smaller, the degree of aortic regurgitation has
increased, and left ventricular systolic function is slightly
worse.
___ CAROTID US
No atherosclerotic plaque or hemodynamically significant
stenosis of the
bilateral carotid arteries.
___ CXR
Small bilateral pleural effusions and mild atelectasis in the
lung bases.
.
preliminary TEE report ___
PREBYPASS
1. Overall normal LVEF
2. Severe Aortic stenosis with bicuspid severely calcified Ao
valve (valve area 0.8 cm2)
3. Moderate AI with eccentric jet towards AMVL
No spontaneous echo contrast or thrombus is seen in the body of
the right atrium or the right atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). There is mild symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is normal (LVEF>55%). No masses or thrombi are seen in
the left ventricle. Right ventricular chamber size and free wall
motion are normal. with normal free wall contractility. The
aortic root is mildly dilated at the sinus level. There are
simple atheroma in the descending thoracic aorta. The aortic
valve is bicuspid. The aortic valve leaflets are severely
thickened/deformed. No masses or vegetations are seen on the
aortic valve, but cannot be fully excluded due to suboptimal
image quality. The mean LVOT gradient is 0.9 mmHg. There is
severe aortic valve stenosis (valve area <1.0cm2). The aortic
regurgitation jet is eccentric, directed toward the anterior
mitral leaflet. The mitral valve appears structurally normal
with trivial mitral regurgitation. No mass or vegetation is seen
on the mitral valve. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion.
POSTBYPASS
RHYTHM: A paced.
INFUSIONS: Epi and neo
Well seated bioprosthesis noted in the aortic position.
Biventricular LV fuction remains unchanged.
Interpretation assigned to ___, MD, Interpreting
physician
.
___ 04:14AM BLOOD WBC-6.1 RBC-2.54* Hgb-7.9* Hct-23.3*
MCV-92 MCH-31.1 MCHC-33.9 RDW-15.0 RDWSD-50.4* Plt ___
___ 04:14AM BLOOD ___
___ 04:18AM BLOOD ___ PTT-26.6 ___
___ 09:31AM BLOOD ___ PTT-28.2 ___
___ 02:10AM BLOOD ___ PTT-27.3 ___
___ 09:25PM BLOOD ___ PTT-34.7 ___
___ 04:14AM BLOOD Glucose-113* UreaN-24* Creat-1.0 Na-137
K-4.1 Cl-101 HCO3-26 AnGap-10
___ 04:01AM BLOOD Glucose-98 UreaN-30* Creat-0.9 Na-137
K-3.8 Cl-98 HCO3-24 AnGap-15
___ 02:10AM BLOOD ALT-22 AST-107* LD(LDH)-509* AlkPhos-36*
Amylase-50 TotBili-0.3
___ 04:14AM BLOOD Mg-2.3
Brief Hospital Course:
This is a ___ male who had previously underwent an
ascending aortic hemiarch replacement back in ___ for an
aneurysm. He also had a saphenous vein graft to
the posterior descending artery. He presented with shortness of
breath and a CT scan was performed and this demonstrated
possible aortic intramural thrombus of the ascending aorta.
Further workup revealed aortic stenosis. The usual preoperative
work up included Dental clearance, carotid US, and Chest CT.
ON ___ he was taken to the operating room and underwent the
following: 1.Redo sternotomy.2.Coronary artery bypass grafting
x2 with left internal mammary artery to left anterior descending
artery and reverse saphenous vein graft to the posterior
descending artery.3. Aortic valve replacement with a 29 mm
___ Ease
pericardial tissue valve, model ___, TFX, serial number is
___. 4. Reconstruction of pericardium with CorMatrix.
Please see operative report for further surgical details.
He tolerated the procedure well and was transferred to the CVICU
for recovery and invasive monitoring. He required inotropy and
pressor support to augment his hemodynamics postop. FFP, PRBCs
and Protamine were administered for elevated chest tube
drainage. He awoke neurologically intact and weaned to extubate.
He was started on ___, Lasix. He continued to
progress and was transferred to the step down unit for further
recovery. Chest tubes remained in due to elevated drainage.
Pacing wires were discontinued per protocol without incident.
Physical Therapy was consulted for evaluation of strength and
mobility. POD# 4 Chest tubes were discontinued per protocol
without incident. His rhythm went into Atrial fibrillation and
Amiodarone was administered. Anticoagulation was initiated and
will be managed by ___ Medical in ___ as discussed
with ___.
By the time of POD 5 he was ambulating independently, wounds
healing, and pain controlled. He was cleared for discharge to
home with ___ services. All follow up appointments were advised.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Rosuvastatin Calcium 40 mg PO QPM
4. NIFEdipine (Extended Release) 30 mg PO DAILY
5. Ranitidine 150 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. krill oil 1,000-170-50-80 mg oral DAILY
9. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
- Ascending aortic aneurysm pseudoaneurysm
- Severe aortic stenosis
- Moderate aortic regurgitation
SECONDARY DIAGNOSES
- Coronary artery disease
- Hyperlipidemia
- Hypertension
- GERD
- BPH
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 1+
Discharge Instructions:
Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10398173-DS-4 | 10,398,173 | 29,062,872 | DS | 4 | 2168-06-09 00:00:00 | 2168-06-11 09:52:00 |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___ Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
L IT femur fracture
Major Surgical or Invasive Procedure:
Left open reduction internal fixation
History of Present Illness:
Ms. ___ is a ___ y/o F with PMHx of DM II and HTN, who was
initially
aditted on ___ to the orthopedics service with L femur fx from
mechanical fall. She underwent left hip ORIF on ___. On POD #2
(___), medical team was consulted for hypoxia. Patient had
___ O2 requirement since surgery, but acutely worsened over
the course of ___, where she was hypoxic to the ___ on RA, and
low ___ on 10L ventimask. She was found to have PE on CTA and
was started on heparin gtt. She was also started on vancomycin
and cefepime empirically for HCAP before being transferred to
the MICU. While in the MICU she was initially on NRB, but has
been weaned to 3 O2.
Currently, patient is sleeping comfortably, but awakens easily.
With her daughter translating, she notes persistent SOB and
cough. She denies any pain at this time, but has had persistent
soreness from her surgical site. She reports having a fever 2
days ago.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied chest pain or tightness, palpitations. Denied nausea,
vomiting, diarrhea, constipation or abdominal pain. ___ recent
change in bowel or bladder habits. ___ dysuria.
Past Medical History:
DM II
HTN
Social History:
___
Family History:
NC
Physical Exam:
Admission physical exam:
Afebrile
NAD, Alert x oriented x 3.
NCAT
Breathing comfortably on RA
Pulse regular
BUE: Nontender, ___ deformity or echhymoses. ___ pain w/ ROM.
Fires Bi, Tri, grasp. 2+DP
LLE: Internally rotated. Pain hip w/ log roll. ___ TTP
thigh/knee/leg. Fires ___. SILT DP SP S S T. 2+DP.
RLE: ___ deformity or ecchymoses. ___ pain w/ ROM. ___ TTP
thigh/knee/leg. Fires ___. SILT DP SP S S T. 2+DP.
Discharge physical exam:
Vitals: Tc 98.3, BP 134/61, HR 71, RR 18, O2 98% RA
General: Sleeping but easily arousable, ___ acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Breathing comfortably without accessory muscle use.
Diffuse wheezing through the lung fields bilaterally,
anteriorly.
CV: Regular rate and rhythm, normal S1 + S2, ___ SEM heard best
over LSB.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
___ rebound tenderness or guarding.
Ext: Warm, well perfused, 2+ pulses, ___ clubbing, cyanosis or
edema. Left hip incision with ___ erythema, drainage.
Neuro: CNII-XII intact, responds appropriately. Moving all
extremities.
Pertinent Results:
Admission Labs:
___ 09:15PM BLOOD WBC-15.5* RBC-4.53 Hgb-12.1 Hct-36.2
MCV-80* MCH-26.8* MCHC-33.5 RDW-13.2 Plt ___
___ 09:15PM BLOOD Neuts-84.7* Lymphs-10.5* Monos-3.2
Eos-1.4 Baso-0.3
___ 09:15PM BLOOD ___ PTT-30.1 ___
___ 10:30PM BLOOD Glucose-261* UreaN-12 Creat-0.7 Na-137
K-4.6 Cl-100 HCO3-26 AnGap-16
___ 12:01PM BLOOD Calcium-8.6 Phos-3.1 Mg-1.5*
___ 05:56AM BLOOD %HbA1c-7.6* eAG-171*
IMAGING:
Knee Xray
FINDINGS: Two views of the left knee were obtained. Severe
osteoarthritic changes are seen, including lateral greater than
medial joint space narrowing and adjacent tibial plateau
irregularity. ___ suprapatellar joint effusion is seen.
Condylar spurring is noted.
Hip Xray:
FINDINGS: AP view of the pelvis and AP and lateral views of the
left hip were obtained. There is a comminuted left
intertrochanteric fracture with varus angulation of the left
femoral head. ___ dislocation is seen. The pubic symphysis and
sacroiliac joints are intact. Degenerative changes are seen
along the lower lumbar spine. Soft tissue calcifications are
seen overlying bilateral buttock at the level of superior iliac
wing may represent calcified granulomas.
IMPRESSION: Comminuted left intertrochanteric fracture with
varus angulation of the left femoral head.
Hip Xray post ORIF:
FINDINGS: Two spot films from the OR were obtained. There is a
total of
136.0 seconds of fluoroscopy time. There is interval placement
of an
intramedullary rod and hip screw. At the end of the procedure
the alignment was good.
CTA ___:
FINDINGS: The pulmonary vasculature is well opacified and with
an eccentric nonocclusive filling defect noted in the
subsegmental branches of the right upper lobe (3:14). ___ other
lobes appear affected. Heart size is normal without evidence of
right heart strain. Atherosclerotic calcifications are evident
within the thoracic aorta without aneurysmal dilatation or
dissection.
CT CHEST: There is ___ supraclavicular or axillary
lymphadenopathy identified. Multiple lymph nodes are noted
within the prevascular, right upper paratracheal and subcarinal
space, none of which meet CT criteria for pathological
enlargement. ___ hilar lymphadenopathy identified. Secretions
are evident within the segmental and subsegmental branches of
the bilateral lower lobe airways with associated partial left
lower lobe collapse. Of note, area of left lower lobe collapse
is hypodense to surrounding collapsed lung concerning for
developing pneumonia (3:38). ___ pleural effusion or
pneumothorax identified.
Limited assessment of the abdomen demonstrates a
normal-appearing liver,
pancreas, spleen, and bilateral adrenal glands.
___ suspicious lytic or blastic lesions identified.
IMPRESSION:
1. Subsegmental pulmonary embolism of the right upper lobe. ___
right heart strain.
2. Secretions within the segmental and subsegmental branches of
the bilateral lower lobes and associated partial left lower lobe
collapse with areas of relative hypodensity. Findings consistent
with aspiration complicated by developing pneumonia. ___
pleural effusion identified.
Echo ___:
Findings
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. ___ ASD or PFO
by 2D, color Doppler or saline contrast with maneuvers.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). ___ resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). ___ AS. ___ AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. ___
MVP. Mild mitral annular calcification. Calcified tips of
papillary muscles.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
___ PS. Physiologic PR.
PERICARDIUM: ___ pericardial effusion.
GENERAL COMMENTS: Contrast study was performed with 1 iv
injection of 8 ccs of agitated normal saline at rest. Suboptimal
image quality as the patient was difficult to position.
Conclusions
The left atrium is elongated. ___ atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and ___ aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is ___ mitral valve prolapse.
There is mild pulmonary artery systolic hypertension. There is
___ pericardial effusion.
IMPRESSION: ___ PFO or ASD. Normal global and regional
biventricular systolic function. Mild pulmonary hypertension.
Microbiology:
___ 6:00 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ 3:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: ___ GROWTH.
___ 1:36 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: ___ GROWTH.
___ 5:09 pm BLOOD CULTURE Source: Venipuncture #1 and
2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: ___ GROWTH.
HIP UNILAT MIN 2 VIEWS
IMPRESSION
1. Status post open reduction internal fixation of a comminuted
left
intertrochanteric femur fracture which secured in good anatomic
alignment.
2. Surgical hardware intact with ___ evidence for hardware
failure.
Discharge labs:
___ 07:25AM BLOOD WBC-14.9* RBC-3.50* Hgb-9.1* Hct-28.2*
MCV-81* MCH-26.0* MCHC-32.2 RDW-16.0* Plt ___
___ 07:50AM BLOOD ___ PTT-47.0* ___
___ 07:40AM BLOOD Glucose-96 UreaN-11 Creat-0.6 Na-140
K-3.9 Cl-110* HCO3-20* AnGap-14
Brief Hospital Course:
Hospital course by service:
Orthopaedic course: Patient had mechanical fall and noted to
have internally rotated left leg. Films showed comminuted
intertrochanteric fracture. Admitted to Ortho and underwent
ORIF on ___. Tolerated procedure well. On POD #2, became
suddenly hypoxic - CTA showed subsegmental Pulmonary embolism
and left pneumonia. Patient was started on heparin gtt,
levoflox, flagyl initially for aspiration pneumonia and
transferred to MICU.
Medical ICU course- Patient sent to ICU due to increased oxygen
requirement. Patient placed on NRB initially and was able to
maintain oxygen sat in the high 90's. Given recent intubation
and hospital stay of 48 hours, antibiotics were broadened to
vancomycin/cefepime. She was continued on heparin gtt and
initiated on coumadin. Echo showed ___ right heart strain.
oxygen was able to be weaned to nasal cannula and patient was
transferred to the medicine floor. Hypoxemia was felt to be
more likely from pneumonia than pulmonary embolism given
subsegmental nature of them.
Medicine floor course - Vancomycin/Cefepime were continued to
complete 8 day course of antibiotics (completed ___. The
patient was successfully weaned from oxygen during her course on
the medicine floor. Heparin drip was discontinued on the floor,
once coumadin was therapeutic (goal 2.0-3.0). The decision was
made with her family to continue the patient on coumadin as
opposed to transitioning to Lovenox secondary to family's
comfort with administration of Lovenox injections. She will need
to complete at least a 3 month course of coumadin for treatment
of her pulmonary emoblism. As the patient as greater support in
___, the decision was made by the patient's family to
transition her care to ___. Dr. ___
(___) of ___ was personally contacted by the
inpatient team to notify the patient of her need for coumadin
for treatment of pulmonary embolism and to make him aware that
the patient will need her next INR check on ___. The patient was seen by ___ regularly and was able to bear
weight as tolerated on her left lower extremity by day of
discharge. Orthopaedics followed the patient through her
hospitalization. Her surgical incision site was non-erythematous
withour drainage throug her hospitalization. Staples were
removed by orthopaedics on day of discharge and repeat left hip
films were obtained prior to the patient's discharge.
Orthopaedics evaluated the patient on day of discharge and
evaluated films of the left hip; radiology noted that the
fracture and hardware were unremarkable. In regards to her
diabetes mellitus, the endocrine consult service initially
followed the patient and agreed with discharging the patient on
oral medications. Patient's hypertension was controlled with
atenolol and amlodipine through her floor course.
Transitional Issues:
- Orthopaedic follow-up to be arranged by the patient's family.
- INR to be monitored by Dr. ___ (___) of
___. Goal INR 2.0-3.0 for the next 3 months. Her next
scheduled INR check is ___ by Dr. ___.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. glimepiride *NF* 4 mg Oral daily
3. Amlodipine 5 mg PO DAILY
4. Atenolol 50 mg PO DAILY
Discharge Medications:
1. glimepiride *NF* 4 mg Oral daily
RX *glimepiride 4 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
2. MetFORMIN (Glucophage) 1000 mg PO BID
RX *metformin 1,000 mg 1 tablet(s) by mouth Twice daily Disp
#*28 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H
4. Warfarin 1 mg PO DAILY16
RX *warfarin 1 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
5. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
6. Atenolol 50 mg PO DAILY
RX *atenolol 50 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain
RX *oxycodone 5 mg Half to 1 tablet(s) by mouth every 6 hours
Disp #*56 Tablet Refills:*0
8. Senna 1 TAB PO BID:PRN Constipation
9. Docusate Sodium (Liquid) 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Left intertrochanteric femur fracture, HCAP, pulmonary
embolism, diabetes mellitus
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:
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted to
the Orthopedic service because of a broken femur (hip bone) you
had after a fall. They repaired this in the oeprating room.
While you were recovering, you unfortunately developed a
pneumonia and blood clots in your lungs. We treated this with
antibiotics and blood thinners, respectively. Your breathing
status improved. You will be going to rehab to continue to gain
strength and improve your ability to walk.
Take all medications as instructed. Please note the following
medication changes: You are being discharged home on a new
medication called coumadin to treat the clot in your lung
(pulmonary emoblism). You are also being discharged home on new
pain medications- oxycodone and acetaminophen (tylenol)- to be
taken as needed. If you find yourself taking oxycodone recently
then take senna, colace to prevent constipation.
Keep all hospital follow-up appointments. You will need to have
your blood check to ensure coumadin (blood thinning medication)
is at the appropriate level on ___ By Dr.
___ in ___ at ___, telephone
number ___. It is EXTREMELY important that you keep
this appointment. They are provided in a list for you in your
discharge paperwork.
Followup Instructions:
___
|
10398209-DS-19 | 10,398,209 | 26,551,658 | DS | 19 | 2132-12-19 00:00:00 | 2132-12-19 16:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Zestril
Attending: ___.
Chief Complaint:
tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of hypertension, hyperlipidemia, recent
admission for right parietotemporal stroke after left heart cath
& PCI presents from rehabilitation with tachycardia. Per report,
the patient was noted to be tachycardic to the 130s to 150s for
the past several days. This was thought to be due to dehydration
as his BUN and creatinine were elevated, but did not improve
significantly with IV fluids. EKG showed read at rehab as sinus
tachycardia. Troponin was negative at rehab. However, d-dimer
was elevated so he was sent to the emergency department for PE
workup. Patient denies any chest pain, shortness of breath,
fevers, chills, abdominal pain nausea, vomiting. No lower
extremity pain or swelling. No history of the venous
thromboembolic disease. Pt denies ever having an arythmia in the
past including a.fib. He has been having a productive cough for
the past week. Denies sob, fevers, chills.
Pt was recently admitted to the hospital for an elective
cardiac cath, where a drug eluting stent was placed to the left
circumflex artery. After waking up from this procedure, he was
found to have a dense left hemiparesis. Code stroke was called
and he was taken for STAT NCHCT and CTA which showed some
contrast extravasation in the right MCA distribution and a
cutoff in the inferior division of the right MCA. He was taken
urgently to angio and the vessel was recannalized with 5mg of IA
tPA. Around this same time he was noted to have an irregular
atrial rhythm. He was initially started on ASA 81mg and plavix
75mg per cardiology recommendations given placement of DES. He
underwent TTE which was poor quality but showed an EF 55% and a
mildly dilated left atrium. On MRI scan on ___, he was noted
to have hemorrhagic conversion of his stroke. At this point,
after discussion with cardiology, ASA and plavix were held on
___. Repeat head CTs were preformed and remained stable, so
ASA was restarted on ___, and he was transferred out of the
ICU. Then plavix was restarted on ___. Exam remained stable,
although he had some waxing and waning mental status with
intermittent confusion and sleepiness. He is an ___
cardiology pt.
Disposition/Pending: admit for new afib, UTI. Discussed with
___ cardiology.
In the ED initial vitals were: 98.4 156 121/87 18 95%
Past Medical History:
CAD
PCI s/p DES to the L Circ this AM
HTN
HLD
DM type 2
Obesity
Positive PPD
OA
BPH
SDH after a fall and evacuation ___
Cholecystectomy
Remote hematuria
OSA
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T:98.1 BP:131/79 HR:95 RR:16 02 sat:96%RA
GENERAL: NAD, sleeping
HEENT: left sided ptosis, w/ left sided facial droop,L eye
conjuctival injection, poor dentition
CARDIAC: irregular rate, S1/S2, no murmurs, gallops, or rubs
LUNG: rhonci present throughout chest on anterior exam, coughing
frequently
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no ___ edema
PULSES: 2+ DP pulses bilaterally
NEURO: left sided facial droop, LUE strength ___, RUE ___, RLE
___, LLE ___, sensation intact in both ___
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS: 98.5 141/65 85 20 96RA
I/O: 1060/1450
GENERAL: NAD, coughing
HEENT: left sided ptosis, w/ left sided facial droop,L eye
conjuctival injection, poor dentition
NECK: No JVP
CARDIAC: regular rate, S1/S2, no murmurs, gallops, or rubs
LUNG: rhonchi present throughout lung fields
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: no ___ edema
NEURO: left sided facial droop, LUE strength ___, RUE ___, RLE
___, LLE ___, sensation intact in both ___
Pertinent Results:
ADMISSION LABS
___ 06:51PM BLOOD WBC-9.5 RBC-4.48* Hgb-13.6* Hct-40.9
MCV-91 MCH-30.3 MCHC-33.2 RDW-13.4 Plt ___
___ 06:51PM BLOOD Neuts-57.4 ___ Monos-6.0 Eos-4.6*
Baso-0.6
___ 06:51PM BLOOD ___ PTT-21.4* ___
___ 06:51PM BLOOD Glucose-191* UreaN-38* Creat-1.3* Na-137
K-5.3* Cl-103 HCO3-25 AnGap-14
___ 06:51PM BLOOD Calcium-8.8 Phos-3.2 Mg-2.4
___ 06:51PM BLOOD TSH-7.5*
___ 06:51PM BLOOD Free T4-1.3
___ 07:10PM BLOOD Lactate-2.9*
___ 11:59PM BLOOD Lactate-1.8
DISCHARGE LABS:
___ 07:40AM BLOOD WBC-5.0 RBC-3.34* Hgb-10.2* Hct-31.6*
MCV-95 MCH-30.5 MCHC-32.2 RDW-13.5 Plt ___
___ 07:40AM BLOOD Glucose-103* UreaN-16 Creat-0.9 Na-139
K-4.0 Cl-111* HCO3-20* AnGap-12
___ 07:40AM BLOOD Albumin-2.9* Calcium-7.7* Phos-2.4*
Mg-1.7
___ 06:45AM BLOOD ALT-39 AST-33 AlkPhos-62 TotBili-0.3
___ 06:45PM URINE Color-Yellow Appear-Hazy Sp ___
___ 06:45PM URINE RBC-23* WBC-32* Bacteri-FEW Yeast-NONE
Epi-0
___ 06:45PM URINE CastHy-11*'
MICROBIOLOGY:
___ 10:33 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
ECGStudy Date of ___ 6:33:28 ___
Atrial fibrillation with a rapid ventricular response. There are
non-diagnostic Q waves in the inferior leads. Non-specific ST-T
wave changes. Compared to the previous tracing of ___ the
rhythm has changed
ECGStudy Date of ___ 10:10:50 ___
Artifact is present. Probable atrial flutter with 2:1 A-V block.
There are non-diagnostic Q waves in the inferior leads.
Non-specific ST-T wave changes. Compared to the previous tracing
of the same date, atrial flutter has replaced atrial
fibrillation.
CXR ___
FINDINGS: AP upright portable view of the chest was provided.
The lungs are clear bilaterally. The heart is top normal in
size. No focal consolidation, effusion or pneumothorax. No
signs of pulmonary edema. Bony structures areintact. No free
air below the right hemidiaphragm.
IMPRESSION: No acute findings. Please refer to subsequent CTA
of the chestfor further details.
CTA CHEST ___
IMPRESSION:
1. No evidence of a pulmonary embolus.
2. Bronchiectasis with mucous plugging at the lung bases
bilaterally may besecondary infection or aspiration, likely
sequelae of small airways disease.
3. Prominent right hilar lymph nodes are likely reactive.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION:
Mr. ___ is a ___ h/o DM II, with CAD and larrge R MCA
stroke with hemorrhagic conversion following an elective left
heart cath with placement of DES to LCx who presented from ___
with tachycardia and found to have afib with RVR in ED.
ACTIVE ISSUES:
# Atrial fibrillation/tachycardia: The patient was found to be
in atrial fibrillation, atrial flutter and atrial tachycardia
intermittently on arrival. CTA was negative for PE as
instigating factor but did show bronchiectasis and concern for
infection (see below) which may have been a trigger. He received
dilt and his metoprolol was increased and he converted to sinus
after arrival to the floor. He was started then on amiodarone
400mg TID for loading and stayed in sinus with rates in the ___
throughout the remainder of his admission. TSH was 7.5 with nml
T4 and normal LFTs. Given his CHADS2 of 5, Stroke Neurology was
consulted for anticoagulation guidance. While he has been
continued on asa and plavix after DES was placed, the stroke
team recommended that if the patient were to be placed on
warfarin, he should have heparin gtt (goal PTT 50-70, with q6h
checks) with repeat CT head once therapeutic to r/o new
bleeding. He will be discharged on asa and plavix with further
discussion of anticoagulation to continue as an outpatient.
# Cough/pneumonia: The patient had a productive cough on
admission that he reported was ongoing for about one week prior
to admission. No fevers or leukocytosis. Sputum culture
contaminated with epis. Given lung exam and CT findings
concerning for an infection, he was started initially on
azithromycin and ceftriaxone but switched to vancomycin and
cefepime for HCAP. He will continue on IV antibiotics until ___.
# UTI, foley: The patient had been treated for UTI with bactrim
x 10 days (last day ___. He was admitted from ___ with foley
in place that was supposed to have been removed on ___. He
should have the foley removed with voiding trial on discharge.
If he cannot void, he may need urology follow-up.
CHRONIC ISSUES:
# CAD s/p DES to LCx: As per above, continued asa and plavix.
# H/o CVA: Residual left-sided weakness.
#Conjunctival hemorrhage: Stable. Developed during prior
admission on ___, with conjunctival bleeding and bleb formation
of the L eye. Continued on artificial tears per prior
ophthalmological recommendation.
#Diabetes Mellitus type 2: On lantus and sliding scale. This
should be adjusted as needed.
TRANSITIONAL ISSUES:
- Amiodarone taper: He was on amiodarone 400mg TID (___) and
will be discharged on amio 400mg BID x 1 week (___) then
decreased to 400mg daily. TSH was 7.5 although T4 was normal.
LFTs wnl.
- Anticoagulation: He will be discharged on his home asa and
plavix. If he were to be placed on warfarin, he should have
heparin gtt (goal PTT 50-70, with q6h checks) with repeat CT
head once therapeutic to r/o new bleeding.
- Foley should be removed and patient should have voiding trial.
If unable to void, he may benefit from urological eval
- Please keep on telemetry until antibiotic course is complete.
- Please avoid qtc prolonging medications (QTc 473 on ___
- Last day for vancomycin/cefepime: ___
- Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Rosuvastatin Calcium 10 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Metoprolol Tartrate 25 mg PO BID
7. Senna 8.6 mg PO BID
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH PRN SOB
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
11. Glucose Gel 15 g PO PRN hypoglycemia protocol
12. Artificial Tears 1 DROP LEFT EYE 6 TIMES PER DAY
13. Bisacodyl ___AILY
14. Polyethylene Glycol 17 g PO DAILY constipation
15. Acetaminophen 325-650 mg PO Q6H:PRN pain
16. Guaifenesin ___ mL PO Q6H:PRN cough
17. insulin glargine 24 u subcutaneous qhs
18. melatonin 5 mg oral qhs
19. Mirtazapine 15 mg PO HS
20. TraZODone 25 mg PO HS:PRN insomnia
21. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Bisacodyl ___AILY
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH PRN SOB
7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
8. Glucose Gel 15 g PO PRN hypoglycemia protocol
9. Guaifenesin ___ mL PO Q6H:PRN cough
10. Metoprolol Tartrate 25 mg PO Q8H
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth every eight
(8) hours Disp #*80 Tablet Refills:*0
11. Mirtazapine 15 mg PO HS
12. Multivitamins 1 TAB PO DAILY
13. Nitroglycerin SL 0.4 mg SL PRN chest pain
14. Polyethylene Glycol 17 g PO DAILY constipation
15. Rosuvastatin Calcium 10 mg PO DAILY
16. Senna 8.6 mg PO BID
17. TraZODone 25 mg PO HS:PRN insomnia
18. CefePIME 2 g IV Q12H
19. Vancomycin 1000 mg IV Q 12H
20. insulin glargine 24 u subcutaneous qhs
21. melatonin 5 mg oral qhs
22. MetFORMIN (Glucophage) 1000 mg PO BID
23. Artificial Tears 1 DROP LEFT EYE 6 TIMES PER DAY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
- atrial tachycardia
- pneumonia, hospital acquired
Secondary diagnoses:
- coronary artery disease
- cerebral vascular accident
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure participating in your care here at ___.
You were admitted on ___ after having a fast heart rate at
your rehab. You were found to have an irregular heart rhythm and
were started on a new medication called amiodarone. You also had
a bad cough and were started on IV antibiotics for a pneumonia.
If you have fevers, chills, chest pain, palpitations, shortness
of breath, burning with urination, or any other concerning
symptom, please let your doctors ___.
Again, it was our pleasure participating in your care.
We wish you the best!
Followup Instructions:
___
|
10398333-DS-17 | 10,398,333 | 25,788,746 | DS | 17 | 2166-10-09 00:00:00 | 2166-10-15 16:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of COPD (Ambulatory O2, ___ on ambulation order
but not started; ___ PFTs: FEV1: 55% predicted, FEV1/FVC: 85%)
and ___ pack per day smoking history (for decades), presents
with a 3 day history of increasing productive cough, dyspnea and
chest tightness. She reports that at home over the last several
days her home O2 sat has been in the law to mid ___ at rest. She
denies CP, fever, chills.
The patient was seen in ___ on ___ and had a resting pulse
ox of 91, it went down to 85 whenpatient had a 3 minute walk in
the office. The patient was symptomatic, she was complaining of
shortness of breath,increased fatigue. At this time she was
ordered for ambulatory O2 but has not started on it.
In the ED, initial vs were 96 59 132/73 20 97% Other. Labs were
notable for WBC count of 10.8. ABG showed: pH 7.36/pCO2 54/pO2
112/HCO3 32. Lactate was 2.4. CXR showed no acute
cardiopulmonary process. She was given albuterol/ipratropium
nebulizers, Solumedrol 125mg, lorazepam 2mg for anxiety. She was
admitted for the management of a COPD exacerbation.
Vitals prior to transfer were: HR:94 RR:27 O2 sat 91%. Given
tachycardia, she was placed on telemetry at the time of transfer
to floor.
Past Medical History:
-asthma/COPD
-new type 2 diabetes
-allergic rhinitis
-severe chronic insomnia/anxiety/depression
-GERD
-hypertension
-hyperlipidemia
-obesity,
-gait disorder
Social History:
___
Family History:
CAD, Stomach cancer, Sisters died of lung cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 98.2, 134/86, 102, 18, 99%4L NC
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
DISCHARGE PHYSICAL EXAM:
VS 97.9, 128/68, 74, 20, 95%2L NC
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no w/r/rh, improved over admission exam
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
___ 11:00AM BLOOD WBC-10.8# RBC-4.49 Hgb-13.9 Hct-41.8
MCV-93 MCH-30.9 MCHC-33.2 RDW-14.3 Plt ___
___ 07:15AM BLOOD WBC-7.2 RBC-4.08* Hgb-12.3 Hct-38.2
MCV-94 MCH-30.1 MCHC-32.2 RDW-14.0 Plt ___
___ 11:00AM BLOOD Glucose-168* UreaN-14 Creat-0.9 Na-137
K-4.8 Cl-98 HCO3-25 AnGap-19
___ 07:15AM BLOOD Glucose-85 UreaN-37* Creat-1.0 Na-140
K-4.4 Cl-100 HCO3-30 AnGap-14
___ 12:11PM BLOOD pO2-117* pCO2-54* pH-7.36 calTCO2-32*
Base XS-3
CXR: No acute cardiopulmonary process.
CARDIAC ECHO: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function.
Brief Hospital Course:
___ with PMH of COPD (Ambulatory O2, ___ on ambulation
ordered but not started ___ PFTs: FEV1: 55% predicted,
FEV1/FVC: 85%) and ___ pack per day smoking history (for
decades), presents with a 3 day history of increasing productive
cough, dyspnea and chest tightness.
ACUTE:
#COPD Exacerbation: 3 day history of productive cough, dyspnea
and chest tightness in a patient with know COPD (no O2 at home;
___ PFTs: FEV1: 55% predicted, FEV1/FVC: 85%). She had a
productive cough that started ___ days prior to admission.
Denied fever or chills. CXR no PNA. Possible bronchitis, no s/s
of CHF exacerbation. No clinical exam or EKG findings consistent
with PE. She was started on Prednisone, Azithromycin, albuterol
and ipratropium. She continued to improve. She continued to
desat to the low ___ on RA on ambulation but was able to
ambulate on 2L NC and maintain sats in the low ___. She was
discharged on home O2.
CHRONIC:
#DM2, controlled: On metformin as an outpatient. This was held
while in the hospital and was maintained on HISS.
#GERD: Continued Protonix
#HTN: Continued hydrochlorothiazide, losartan
#HLD: Continued pravastatin
TRANSITIONAL:
The patient was discharged on home O2, She will need follow up
for titration.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Atenolol 25 mg PO DAILY
3. Citalopram 20 mg PO QHS
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Hydrochlorothiazide 25 mg PO DAILY
6. Losartan Potassium 50 mg PO DAILY
7. MetFORMIN XR (Glucophage XR) 500 mg PO QPM
Do Not Crush
8. Pantoprazole 40 mg PO Q24H
9. Pravastatin 20 mg PO DAILY
10. Tiotropium Bromide 1 CAP IH DAILY
11. Aspirin EC 81 mg PO DAILY
12. Calcium Carbonate 750 mg PO BID:PRN heartburn
13. Vitamin D 1000 UNIT PO DAILY
14. Lidocaine 5% Patch ___ PTCH TD DAILY
12 hours on, 12 hours off
15. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO TID:PRN pain
16. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Calcium Carbonate 750 mg PO BID:PRN heartburn
4. Citalopram 20 mg PO QHS
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Hydrochlorothiazide 25 mg PO DAILY
7. Lidocaine 5% Patch ___ PTCH TD DAILY
12 hours on, 12 hours off
8. Losartan Potassium 50 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Pravastatin 20 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Azithromycin 250 mg PO Q24H Duration: 1 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth Daily Disp #*1
Tablet Refills:*0
13. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL ___ mL by mouth Every
6 hours Disp #*200 Milliliter Refills:*0
14. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour Apply 1 patch Daily Disp #*15
Transdermal Patch Refills:*0
15. PredniSONE 60 mg PO DAILY Duration: 1 Days
RX *prednisone 20 mg 3 tablet(s) by mouth Daily Disp #*3 Tablet
Refills:*0
16. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
17. MetFORMIN XR (Glucophage XR) 500 mg PO QPM
Do Not Crush
18. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO TID:PRN pain
19. Tiotropium Bromide 1 CAP IH DAILY
20. Home Oxygen
Please use ___ continous via NC
Pulse dose for portability
Diagnosis: COPD with desat to 85% on RA at rest
21. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
RX *albuterol sulfate 0.63 mg/3 mL 1 Solution inhaled Every 6
hours Disp #*30 Unit Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
COPD exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms ___,
It was a pleasure taking care of you while you were in the
hospital. You were hospitalized with 3 days of increasing
shortness of breath and cough. You were diagnosed with a COPD
exacerbation and treated with antibiotics, steroids, and
nebulizers. You improved and are now felt to be safe for
discharge home.
Due to your oxygenation saturation when walking you are being
sent home on ambulatory oxygen. You can not smoke in your
house/apartment with the oxygen. You at risk of death if you
smoke because of explosion and/or fire. You are being prescribed
nicotine patches so that you do not smoke.
Please keep the below appointments with your primary care doctor
and pulmonologist.
We made the following medication changes:
START Azithromycin DAILY for 1 day
START Prednisone DAILY for 1 day
START Guaifenesin-CODEINE Cough medicine every 6 hours as needed
for cough.
START Home Oxygen. You CAN NOT SMOKE while you have home oxygen.
Please see above.
Followup Instructions:
___
|
10398333-DS-20 | 10,398,333 | 24,769,108 | DS | 20 | 2170-08-14 00:00:00 | 2170-08-15 10:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / oxycodone
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Cardiac catheterization (___)
History of Present Illness:
___ with COPD, DMII, GERD, HTN, meningioma, nephrolithiasis who
re-presents with dyspnea after leaving AMA from recent admission
for fatigue, diarrhea, nausea and vomiting.
With regard to her COPD, last known spirometry in ___ was
notable for: FVC 1.64 liters, 64% predicted; FEV1 0.99 liters,
54% predicted; and FEV1/FVC ratio is reduced and overall there
has been a slight worsening in her obstructive ventilatory
defect with an FEV1 that has decreased from 61% down to 54%.
With regard to her recent admission ___, she was initially
referred from clinic due to 1.5-2 weeks of nausea, emesis, dry
heaving, and diarrhea. Patient noted that she had anywhere from
___ episodes of loose stools daily, with no blood. Never had a
colonoscopy in the past. Creatinine was elevated to 1.9 on
admission, up from 1.0 at baseline, with FENa suggestive of
pre-renal etiology. Creatinine improved with IVF, and was down
to 1.2 on discharge. Losartan and hydrochlorothiazide were
initially held, and restarted on discharge. There was no
evidence of colitis or enteritis radiographically on admission
abdominal CT, and diarrhea improved with supportive care.
On day of discharge, she had elevated systolic blood pressure to
200's. Medical team recommended staying in the hospital for
further monitoring, but she left against medical advice.
On ___ at around 3pm, patient was sitting and playing video
games and became SOB. No obvious triggers. Patient was not too
concerned at that time. She went to bed early and woke up at 7pm
on the ground, still with her home O2 on, but extremely SOB and
anxious. Called brother who lives in same home to assist her.
Through the night, patient had "cat naps." The morning of ___,
patient was extremely SOB worse than the prior day and decided
it was time to go back to the hospital
-Denies: fever, shaking chills, purulent sputum production.
Denies chest pain, abdominal pain, diarrhea, urinary symptoms,
new muscle weakness or new sensation changes.
-Confirms: headache, possibly increased cough, white sputum
production with an amount at her baseline.
She was transferred to the ED for further evaluation. Initially
she was placed on BiPAP. This was weaned at 0800 which she
tolerated well.
Past Medical History:
-asthma/COPD
-new type 2 diabetes
-allergic rhinitis
-severe chronic insomnia/anxiety/depression
-GERD
-hypertension
-hyperlipidemia
-obesity,
-gait disorder
-meningioma
Social History:
___
Family History:
CAD, Stomach cancer, Sisters died of lung cancer
Physical Exam:
ADMISSION EXAM:
===============
Vitals- 97.9 124 / 80 71 18 96 3L
GENERAL: AOx3, in no acute distress
HEENT: NCAT. PERRL. EOMI.
NECK: supple
CARDIAC: RRR. Distant heart sounds.
LUNGS: Pursed lip breathing. Diffuse wheezing on expiration in
all lung fields.
ABDOMEN: Obese, soft, somewhat tender to deep palpation
(diffusely), nondistended. No rebound, guarding rigidity.
EXTREMITIES: warm extremities, pitting edema bilaterally at
least 1cm at midshin bilaterally. Tender to touch and could not
assess completely.
NEUROLOGIC: grip/bicep/tricep/knee flexion and extension ___
strength bilaterally.
DISCHARGE EXAM:
===============
Vitals: 98.5 ___ 60-70's 21 94% 2LNC
I/O: ___
Weight: ___ kg, 112.9kg ___, 114.2kg on ___, 113.2
kg on ___, 112.8kg ___, 113kg ___
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM
Neck: supple, difficult to assess JVP.
Lungs: CTA b/l w/ mild R basilar crackles. No wheezing, rhonchi.
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, 1+ edema bilaterally
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION/PERTINENT LABS:
===============
___ 01:50PM BLOOD WBC-6.6 RBC-3.30* Hgb-9.6* Hct-31.2*
MCV-95 MCH-29.1 MCHC-30.8* RDW-13.4 RDWSD-46.3 Plt ___
___ 01:50PM BLOOD Neuts-93.2* Lymphs-4.5* Monos-1.2*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-6.16* AbsLymp-0.30*
AbsMono-0.08* AbsEos-0.00* AbsBaso-0.01
___ 01:50PM BLOOD Glucose-311* UreaN-23* Creat-1.2* Na-138
K-4.0 Cl-99 HCO3-27 AnGap-16
___ 01:50PM BLOOD CK-MB-12* cTropnT-0.22*
___ 07:21AM BLOOD proBNP-7271*
___ 07:21AM BLOOD Calcium-8.9 Phos-4.9* Mg-1.3*
___ 07:09AM BLOOD ___ Rates-/26 pO2-60* pCO2-70*
pH-7.24* calTCO2-31* Base XS-0 Comment-BI PAP
___ 07:13AM BLOOD Lactate-1.3
___ 07:09AM BLOOD O2 Sat-89
___ 07:19AM BLOOD Glucose-478* UreaN-51* Creat-1.7* Na-135
K-3.9 Cl-93* HCO3-29 AnGap-17
___ 10:34AM BLOOD Glucose-126* UreaN-51* Creat-1.8* Na-139
K-3.8 Cl-96 HCO3-29 AnGap-18
___ 07:45PM BLOOD Glucose-354* UreaN-48* Creat-1.4* Na-134
K-3.9 Cl-93* HCO3-30 AnGap-15
___ 07:06AM BLOOD Glucose-119* UreaN-41* Creat-1.1 Na-144
K-3.9 Cl-100 HCO3-31 AnGap-17
___ 08:24AM BLOOD Glucose-180* UreaN-27* Creat-1.0 Na-140
K-4.1 Cl-99 HCO3-29 AnGap-16
___ 07:40AM BLOOD Free T4-1.1
___ 07:40AM BLOOD TSH-2.9
___ 01:50PM BLOOD CK-MB-12* cTropnT-0.22*
___ 06:05AM BLOOD CK-MB-8 cTropnT-0.13*
___ 06:34AM BLOOD CK-MB-6 cTropnT-0.08*
___ 02:50PM BLOOD CK-MB-3 cTropnT-0.08*
___ 08:05AM BLOOD CK-MB-2 cTropnT-0.06*
___ 07:40AM BLOOD proBNP-779*
MICROBIOLOGY:
=============
All blood cx: negative
Sputum culture (___): Negative
MRSA screen (___): Negative
STUDIES:
========
___ CXR IMPRESSIONS:
Right middle lobe opacity, may represent pneumonia in the right
clinical
setting.
___ ___
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ Echo
IMPRESSION: Moderately depressed regional left ventricular
systolic function consistent with multivessel coronary artery
disease. Increased left ventricular filling pressure. No
clinically significant valvular regurgitation or stenosis.
Normal pulmonary artery systolic pressure. Compared with the
prior study (images reviewed) of ___, the regional wall
motion abnormalities and decline in left ventricular systolic
function are new.
Cath ___ Impressions:
No significant CAD.
Mild elevation of LVEDP to 21
DISCHARGE LABS:
===============
___ 06:50AM BLOOD WBC-5.8 RBC-3.07* Hgb-8.9* Hct-30.2*
MCV-98 MCH-29.0 MCHC-29.5* RDW-14.4 RDWSD-51.8* Plt ___
___ 06:50AM BLOOD Glucose-226* UreaN-25* Creat-1.1 Na-139
K-4.4 Cl-95* HCO3-28 AnGap-20
___ 06:50AM BLOOD Calcium-9.7 Phos-3.9 Mg-2.2
Brief Hospital Course:
Ms. ___ is a ___ year old female with past medical history
notable for COPD, diabetes, GERD, dyslipidemia, hypertension,
meningioma, nephrolithiasis, with recent admission for acute
kidney injury presented with acute shortness of breath. She was
initially treated for a COPD exacerbation with 5-day course of
steroids and levofloxacin transitioned to doxycycline due to
QTc. At the same time, she appeared to be fluid overloaded with
a BNP 7700 and was diuresed. However, on ___ she was in
respiratory distress requiring BIPAP and was transferred to the
ICU and was intubated. An echo revealed 35% ejection fraction
(last echo in ___ with normal EF). She was aggressively
diuresed in the ICU. Within 24hrs, patient was extubated and was
transitioned back to nasal cannula and transferred back to the
medical floor. On admission, troponins were elevated to 0.22 and
downtrending. She had new EKG changes with TWI in the
anterolateral leads. She was started on heparin gtt >48 hours
for NSTEMI. She received a cardiac cath on ___, when she was
able to tolerate laying flat, which revealed normal coronary
arteries. She was diuresed and her respiratory status improved.
Patient also presented with ___ that improved back to baseline
with diuresis. Discharge weight 111.4 kg.
Of note, the patient requested discharge on ___ given her
prolonged hospital stay. We discussed with her that she
continued to have signs of volume overload and that she could
benefit from additional diuresis in the hospital, but she wished
to return home. She understands that moving forward she will
require very close follow-up with her PCP and future
cardiologist regarding her fluid balance, oxygen requirement,
and diuretic dosing.
#NSTEMI: Admission troponins were elevated to 0.22 and
downtrending. She had new EKG changes with TWI in the
anterolateral leads. She was evaluated by cardiology and was
started on heparin drip for 48 hours for NSTEMI. She received a
cardiac cath on ___, when she was able to tolerate lying flat,
which revealed normal coronary arteries. She was started on
atorvastatin 80mg transitioned to 20mg after results of cardiac
cath, metoprolol, and continued on aspirin.
#Acute systolic heart failure: Patient with elevated BNP to 7000
on admission with ___ edema, and patient had received fluids on
recent admission for ___. She was started on diuretics. However
on ___, she was in respiratory distress requiring BIPAP and
was transferred to the ICU. She was intubated on ___,
extubated ___, weaned to Bipap then home O2. She had an echo
revealing depressed EF of 35% (last echo with normal EF in
___. She was diagnosed with new heart failure with reduced
ejection fraction. Cardiac cath revealing normal coronary
arteries. Her non-ischemic cardiomyopathy is of unclear
etiology, but may reflect stress in the setting of COPD
exacerbation. Patient was diuresed with IV lasix and
transitioned to PO lasix with improvement of her volume and
respiratory status. Patient was started on metoprolol. Losartan
was held initially due to ___, but restarted after ___ resolved
and titrated up to home dose of 100mg. Discharge weight 111.4 kg
and discharged on lasix 80mg PO.
#Acute hypercarbic respiratory failure: COPD likely main
contributor (on 3L at home), however, CXR with unilateral
infiltrates concerning for aspiration +/- cough. Volume overload
due to CHF may also be contributing given elevated proBNP, ___
edema, and pt recently received fluids on recent admission for
___. Of note, she received MethylPREDNISolone Sodium Succ 185 mg
total on ___, continued on prednisone 60mg daily afterwards to
complete a 5 day course. She was initially treated empirically
with levofloxacin, then vancomycin/cefepime/doxycycline on
transferred to the ICU, and then transitioned to doxycycline to
complete a 5 day course. Patient's wheezing improved and she was
continued on albuterol, duonebs, and fluticasone/salmeterol as
symbicort was not on formulary.
#Acute renal failure: Cr normal in ___. Her creatinine peaked
at 1.9, and improved with diuresis suggesting cardiorenal
etiology. Losartan was held initially due to ___ and restarted
after it resolved.
#Diabetes Mellitus: Metformin was held. She was placed on
insulin sliding scale. Her blood glucose was initially elevated
in the setting of steroids, but improved after steroid course
finished. However, patient still had elevated blood sugars in
200's.
#Normocytic anemia: Stable. Kappa/lambda levels increased, but
ratio wnl. UPEP negative. In discussion with hematology fellow,
suggest repeating light chains as outpatient; has previously
scheduled hematology follow-up.
#Thrombocytopenia: Platelet count of 120 at discharge following
gradual decline over the course of admission, likely reflecting
marrow suppression from physiologic stress. No clear culprit
medication. She was advised that she could benefit from
continued observation to ensure normalization of platelet count,
but wished to return home and understands that she will require
close monitoring as an outpatient.
#HTN: Home hctz/losartan held due to ___. She was restarted on
losartan after ___ resolved and blood pressures were controlled
with SBP <130's.
#Depression/anxiety: Continued home citalopram 40mg
#GERD: Continued home pantoprazole
#Tobacco Use: Was given nicotine patch and lozenges prn.
TRANSITIONAL
[] Discharge weight 111.4kg.
[] Titrate diuretic as indicated as outpatient, discharged on
80mg PO Lasix daily; close cardiology follow-up pending.
[] Patient should have repeat laboratory evaluation on ___
___ with CBC for thrombocytopenia and chemistry panel given
discharge on diuretics.
[] Continue to monitor diabetes and A1c. FSG in 200's while
inpatient.
[] Please readdress the importance of colonoscopy.
[] Repeat free light chains as outpatient; previously scheduled
hematology follow-up is in ___.
[] Sleep studies for evaluation of sleep apnea advised.
[] Consider addition of spironolactone, given LVEF of 35% if
repeat TTE shows persistently reduced LVEF.
New Medications:
Lasix 80mg
Atorvastatin 20mg
Metoprolol succinate 25mg
Medications stopped:
Pravastatin 20mg
hydrochlorothiazide 25mg
# Code Status: full code
# Emergency Contact: HCP: ___
___: Daughter
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Citalopram 40 mg PO QHS
5. Pantoprazole 40 mg PO Q24H
6. Pravastatin 20 mg PO QPM
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath,
wheezing
8. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
9. Hydrochlorothiazide 25 mg PO DAILY
10. Losartan Potassium 100 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
2. Furosemide 80 mg PO DAILY
RX *furosemide 80 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
3. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath,
wheezing
6. Aspirin 81 mg PO DAILY
7. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
8. Citalopram 40 mg PO QHS
9. Losartan Potassium 100 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO DAILY
11. Pantoprazole 40 mg PO Q24H
12.Outpatient Lab Work
Acute heart failure with reduced ejection fraction ICD-10:
I50.21. Please draw CBC and chem10 on ___, and fax results to
ATTN: ___ Dr. ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Non-ischemic cardiomyopathy
Acute systolic heart failure
COPD exacerbation
Acute Kidney Injury
SECONDARY:
Hypertension
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You were concerned about your shortness of breath
What did you receive in the hospital?
- We treated you for a COPD exacerbation with steroids and
antibiotics.
- You were found to have newly diagnosed heart failure, and had
fluid in your lungs (causing you to be short of breath) and in
your legs, so we gave you medication to help you urinate out the
excess fluids
- For your heart failure, you underwent a cardiac
catheterization, which showed that your coronary arteries (the
arteries that supply blood to your heart) are all normal.
What should you do when you leave the hospital?
- You should continue taking all your medications including the
water pill and follow up with your primary care doctor and
cardiologist
- ___ your weight goes up by more than 3 pounds, please call
your primary care doctor.
We wish you the ___!
Your ___ Care Team
Followup Instructions:
___
|
10398540-DS-17 | 10,398,540 | 23,601,060 | DS | 17 | 2148-07-10 00:00:00 | 2148-07-11 21:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / codeine / simvastatin / amlodipine / metocopramide
/ alendronate sodium / ezetimibe / rosuvastain / shellfish
derived / heparin
Attending: ___.
Chief Complaint:
Bilateral PEs
Bilateral DVTs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient was discharged to rehab after uncomplicated TKR. Was
discharged on lovenox 40mg daily. While at rehab, about four
days
prior to presentation, patient noted increasing dyspnea,
especially with exertion. Associated with chest tightness,
lightheadedness, and mild cough. Denies lower extremity swelling
or pain, hemoptysis, pleuritic chest pain. Denies any syncope or
loss of consciousness. She was brought to ___ for
evaluation. She was found to be hypoxic to mid-80s on room air.
She was hemodynamically stable without tachycardia. CTA revealed
bilateral PE with CT evidence of right heart strain. Patient was
started on argatroban infusion, given thrombocytopenia and
concern for HIT, and transferred to ___.
In the ED, patient was evaluated by ___, who recommended
continuing argatroban, with no role for advanced therapies.
Patient was evaluated by hematology who recommended continuing
argatroban for presumed HITT.
Past Medical History:
HTN
Asthma
OA
Hip fracture
HLD
Melanoma of face s/p resection
Social History:
___
Family History:
No family history of bleeding or clotting disorders, autoimmune
disorders.
Physical Exam:
Admission PE:
VITALS: ___ 0007 Temp: 98.5 PO BP: 163/82 R Lying HR: 93
RR:
18 O2 sat: 98% O2 delivery: 2 L
GENERAL: Lying in bed comfortably in no acute distress.
HEENT: Sclera anicteric and without injection. MMM. Well healed
surgical scar on left side of face
NECK: JVP ~8cm
CARDIAC: Normal rate and rhythm. Audible S1 and S2. No murmurs,
rubs or gallops. No palpable RV heave.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowel sounds. Soft, non distended, non-tender to
deep palpation in all four quadrants.
EXTREMITIES: Warm, well perfused. Calf size symmetric without
swelling, nontender. No clubbing, cyanosis, or edema. Pulses
DP/Radial 2+ bilaterally. Surgical scar on left knee with
staples, no surrounding erythema or induration, no exudate,
mildly tender to palpation, warm to touch lateral to surgical
incision.
NEUROLOGIC: AAOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
Discharge PE:
===================
24 HR Data (last updated ___ @ 1149)
Temp: 97.9 (Tm 98.9), BP: 154/75 (144-165/74-82), HR: 92
(74-92), RR: 17 (___), O2 sat: 97% (95-97), O2 delivery: Ra
GENERAL: Sitting in bed comfortably in NAD on RA
HEENT: Sclera anicteric and without injection. MMM. Well healed
surgical scar on left side of face
NECK: JVD not appreciated at 60 degrees
CARDIAC: RRR, S1/S2 audible. No murmurs, rubs or gallops.
LUNGS: CTAB. Minimal wheezes, no rhonchi or rales. Dry
coughing with deep inhalation.
ABDOMEN: Non-tender, non-distended, no rebound or guarding
EXTREMITIES: Surgical scar on left knee with staples, no
surrounding erythema or induration, no exudate, mildly tender to
palpation. TTP of the b/l calves. RLE slightly larger
than LLE.
NEUROLOGIC: Moving all 4 limbs spontaneously, ambulated with
assistance. Normal sensation.
Pertinent Results:
ADMISSION LABS:
___ 08:35PM BLOOD WBC-12.9* RBC-3.48* Hgb-10.5* Hct-32.2*
MCV-93 MCH-30.2 MCHC-32.6 RDW-13.5 RDWSD-45.1 Plt Ct-25*
___ 08:35PM BLOOD Neuts-60.3 ___ Monos-8.5 Eos-0.9*
Baso-0.5 NRBC-0.3* Im ___ AbsNeut-7.78* AbsLymp-3.74*
AbsMono-1.10* AbsEos-0.12 AbsBaso-0.07
___ 08:35PM BLOOD ___ PTT-75.4* ___
___ 08:35PM BLOOD Glucose-107* UreaN-20 Creat-0.9 Na-138
K-3.9 Cl-101 HCO3-23 AnGap-14
___ 08:35PM BLOOD ALT-66* AST-39 AlkPhos-72 TotBili-0.5
___ 08:35PM BLOOD proBNP-5003*
___ 08:35PM BLOOD cTropnT-0.03*
___ 08:35PM BLOOD Albumin-4.1 Calcium-9.8 Phos-2.9 Mg-2.2
___ 09:05PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:05PM URINE Blood-TR* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 09:05PM URINE RBC-3* WBC-0 Bacteri-NONE Yeast-NONE
Epi-2
DISCHARGE LABS:
___ 10:32AM BLOOD WBC-7.2 RBC-3.21* Hgb-9.8* Hct-30.4*
MCV-95 MCH-30.5 MCHC-32.2 RDW-12.8 RDWSD-43.9 Plt Ct-76*
___ 03:57AM BLOOD ___ PTT-76.9* ___
MICROBIOLOGY:
=============
___ 9:05 pm URINE
**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.
ESCHERICHIA COLI. 10,000-100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING/STUDIES:
================
Bilateral ___ Doppler US ___:
IMPRESSION:
1. Small nonocclusive thrombus within the left common femoral
vein.
2. Partially occlusive thrombus within the left popliteal vein.
3. Occlusive thrombus within the left posterior tibial veins and
left peroneal
veins.
4. No evidence of deep venous thrombosis in the rightlower
extremity veins.
TTE ___:
IMPRESSION: Right ventricular cavity dilation with free wall
hypokinesis and mild to moderate
pulmonary artery hypertension c/w acute or acute on chronic
pulmonary process (e.g. pulmonary
embolism, bronchospasm, etc.). Mild symmetric left ventricular
hypertrophy with normal cavity
size and regional/global systolic function.
Bilateral ___ Doppler US ___:
IMPRESSION:
1. New, near complete occlusive thrombus within the right
posterior tibial
vein.
2. Persistent occlusive thrombus within the left peroneal vein.
Bilateral ___ Doppler US ___:
IMPRESSION:
1. Nonocclusive thrombus in the right popliteal vein.
Previously demonstrated
right posterior tibial vein thrombus is no longer seen.
2. No evidence of deep venous thrombosis in the leftlower
extremity veins.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
====================
Ms ___ is a ___ F s/p recent TKR (___) discharged on LMWH
who was admitted for bilateral submassive PE and severe
thrombocytopenia found to have HITT. She was continued on
argatroban and transitioned to rivaroxaban when platelets were
uptrending and up to 66 (rise ~20 in 1 day). She continues to
have dyspnea on exertion likely related to her PE as well as
aching bilateral leg pain related to known ___ DVTs and
deconditioning. All heparin products were avoided.
TRANSITIONAL ISSUES:
====================
[ ] Follow-up with PCP, ___ (Dr. ___, Hematology, and
Vascular Medicine
[ ] Staples removal from left knee incision ___ with
application of steri-strips
[ ] TTE in 3 months to reevaluate RV function
[ ] Discharge hemoglobin 9.8, platelets 76
[ ] Should continue loading dose of Rivaroxaban (15mg BID) for
total of 21 days (through ___ then continue with Rivaroxaban
20mg Daily thereafter as maintenance dose
[ ] Please check CBC one week after discharge to ensure
continued uptrend in platelet count
ACUTE/ACTIVE ISSUES:
====================
#HITT
#Severe thrombocytopenia
Patient was discharged recently on LMWH and found to have severe
thrombocytopenia and thrombosis on admission. 4T score of ___,
high probability (1 for nadir <20, 1 for timing given missing
counts, 2 for thrombosis, 2 for no other causes) with positive
HIT Ab immunoassay. She had no signs of clinically significant
bleeding. All heparin products were held. Plt count nadir at 10,
rose over course of hospitalization and were 76 at discharge.
Management of thrombosis and anticoagulation as below.
#Bilateral acute pulmonary embolism, intermediate
risk/submassive,
#Hypoxemia
Admitted on argatroban drip in the setting of concern for HITT
as above. Right heart strain was evident on EKG, CT, and TTE.
MASCOT (Advanced PE Therapy) team recommended no thrombolytic
therapy given her hemodynamic stability and severe
thrombocytopenia. She continued to have significant dyspnea with
minimal exertion and chest tightness for much of hospitalization
which slowly improved. Subsequent EKGs showed no ischemia.
Weaned to room air at rest by time of discharge. She was
transitioned to rivaroxaban for outpatient anticoagulation.
#Bilateral ___ DVTs - Provoked
#Bilateral leg pain
Initial ___ duplex ultrasound showed thrombosis of the left
peroneal and posterior tibial veins. On HD #2 she began to have
___ aching pain intermittently without signs or symptoms of limb
ischemia. Repeat ___ ultrasounds ___ showed new thrombosis of
the right posterior tibial vein. There was some concern for
treatment failure, which would require IVIG, although it was
thought that these clots may have developed shortly after
starting argatroban while she was still hypercoagulable from her
HITT. Repeat ultrasounds ___ showed migration of the right
posterior tibial clot and no clots in the LLE (no new
thrombosis). Pain was managed with Tylenol and lidocaine
patches. Anticoagulation as above
#HTN
Continued home HCTZ 25 mg daily, lisinopril 40 mg daily. Held
home long-acting verapamil SR 480mg daily given concern for
stability, restarted at half dose on discharge.
CHRONIC/STABLE ISSUES:
======================
#Asthma
Continued home fluticasone IH BID and albuterol q6h:PRN
#Left TKR
Surgical wound clean dry intact with staples in place, with no
bleeding. Was visited by Dr. ___, colleague of Dr.
___ admitted.
[x]>30 minutes spent on discharge planning and care coordination
on day of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fish Oil (Omega 3) 1000 mg PO DAILY
2. biotin 1 mg oral DAILY
3. Vitamin B Complex 1 CAP PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Denosumab (Prolia) 60 mg SC Q6MONTHS
8. Verapamil SR 480 mg PO DAILY
9. Fluticasone Propionate NASAL 2 SPRY NU BID
10. Fluticasone Propionate 110mcg 1 PUFF IH BID
11. Vitamin D 1000 UNIT PO DAILY
12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
BID:PRN dyspnea
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QAM PRN for leg pain
2. Lidocaine 5% Patch 1 PTCH TD QAM PRN for leg pain--other leg
3. Rivaroxaban 15 mg PO BID Duration: 21 Days
4. biotin 1 mg oral DAILY
5. Denosumab (Prolia) 60 mg SC Q6MONTHS
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Fluticasone Propionate 110mcg 1 PUFF IH BID
8. Fluticasone Propionate NASAL 2 SPRY NU BID
9. Hydrochlorothiazide 25 mg PO DAILY
10. Lisinopril 40 mg PO DAILY
11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
BID:PRN dyspnea
12. Verapamil SR 480 mg PO DAILY
13. Vitamin B Complex 1 CAP PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until you are told to do so by your
physician
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypoxemia
Heparin-induced thrombocytopenia with thrombosis
Severe thrombocytopenia
Bilateral submassive pulmonary emboli with RV strain/elevated
troponin/BNP
Left peroneal/posterior tibial vein occlusive thrombosis
Left Total Knee Replacement
Hypertension
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
-You were transferred to ___ for management of heparin induced
thrombocytopenia, which caused your low platelets, pulmonary
embolism (blood clots in your lungs) and deep vein thromboses
(clots in your leg pain).
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
We gave you a blood thinner, argatroban, through the IV. We
switched you to a blood thinner pill to take at home.
We took an ultrasound of your heart which showed it was working
harder because of the clots in your lungs. You will need a
repeat ultrasound of your heart in 3 months.
Your leg pain was thought to be due to clots. Your body should
dissolve these over time.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10398549-DS-9 | 10,398,549 | 29,979,201 | DS | 9 | 2153-06-29 00:00:00 | 2153-06-30 13:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain - STEMI
Major Surgical or Invasive Procedure:
CARDIAC CATHETERIZATION ___
History of Present Illness:
___ y/o F with PMH of HTN, CHF, paroxysmal A-Fib on Eliquis, and
HFrEF who presents to ED via EMS w/ chest pain and associated
palpitations. Per EMS, the patient felt baseline when she
arrived
at work earlier today. Then around 3p today, she began
experiencing chest pain w/ palpitations. Her co-workers report
that the patient had a syncopal episode which prompted her to
return home. When the patient arrived at home around 5p, had the
acute onset of crushing chest pain. For EMS was noted to be in
afib with RVR, given IV metoprolol, ASA, SL nitro initially with
no improvement.
In the ED, patient endorsed the above history and stated chest
pain was persistent
- Initial vitals were: T: 98.1, HR: 123, BP: 147/114, RR: 28,
O2Sat: 92%
- Exam notable for: Irregular, tachycardic heart sounds
- Labs notable for: Trop-T: 0.22
- Studies notable for: ECG with AFib with RVR and St segment
elevation in V3-V4
- Patient was given: Ticagrelor loading dose, heparin gtt and
nitro gtt
Patient was ___ transferred to the cath lab given STEMI
diagnosis. She was found to have distal thrombotic occlusion of
LAD, embolic appearing and underwent successful aspiration
thrombectomy with restoration of flow. No stent was placed.
On arrival to the CCU, patient endorses the above history.
States
she is now chest pain free and denies any other symptoms
including shortness of breath, plapitations, dizziness, or
lightheadedness. Of nothe there is no clarity regarding
outpatient medication regimen and patient states she was taking
the apixaban just once daily.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative.
Past Medical History:
HFrEF (EF ___ on ___
Atrial Fibrillation
Hypertension
Colon Polyps
H.Pylori
Social History:
___
Family History:
No family history of heart disease, diabetes, or abnormal heart
rhythms.
Physical Exam:
ADMISSION EXAM:
===============
VS: T: 97.7, HR ___, BP 110s/70-80s, O2Sat 96%,
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.
NECK: Supple. JVP low neck at 45 degrees.
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Occasional wheezes. No
crackles
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM:
===============
VS: T 98.66, BP 117/80, Hr 70-110, RR 18, O2 99
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.
NECK: Supple. JVP at clavicle
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Mild crackles in
posterior lobes ___
ABDOMEN: Soft, non-distended. Tender to deep palpation in ___
lower quadrants. No palpable hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS:
===============
___ 08:10PM BLOOD WBC-11.5* RBC-4.13 Hgb-13.1 Hct-41.1
MCV-100* MCH-31.7 MCHC-31.9* RDW-13.1 RDWSD-47.9* Plt ___
___ 08:10PM BLOOD Neuts-74.0* ___ Monos-3.1*
Eos-0.3* Baso-0.4 Im ___ AbsNeut-8.49* AbsLymp-2.51
AbsMono-0.35 AbsEos-0.03* AbsBaso-0.05
___ 08:10PM BLOOD ___ PTT-28.1 ___
___ 08:10PM BLOOD Glucose-150* UreaN-13 Creat-0.7 Na-135
K-5.0 Cl-102 HCO3-18* AnGap-15
___ 06:48AM BLOOD ALT-29 AST-153* AlkPhos-84 TotBili-1.2
___ 08:10PM BLOOD cTropnT-0.22*
___ 08:10PM BLOOD Calcium-9.4 Phos-3.3 Mg-1.9
DISCHARGE LABS
================
___ 07:18AM BLOOD WBC-9.5 RBC-3.79* Hgb-12.1 Hct-36.7
MCV-97 MCH-31.9 MCHC-33.0 RDW-12.7 RDWSD-45.1 Plt ___
___ 07:18AM BLOOD Plt ___
___ 07:18AM BLOOD ___ PTT-28.2 ___
___ 07:18AM BLOOD Glucose-86 UreaN-22* Creat-1.3* Na-135
K-4.8 Cl-98 HCO3-24 AnGap-13
___ 07:18AM BLOOD ALT-27 AST-38 AlkPhos-78 TotBili-0.8
___ 07:18AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.0
PERTINENT IMAGING
=================
The left atrium is dilated. The estimated right atrial pressure
is >15mmHg. There is normal left
ventricular wall thickness with a normal cavity size. There is
moderate-severe global left ventricular
hypokinesis. No thrombus or mass is seen in the left ventricle.
There is beat-to-beat variability in the left
ventricular contractility due to the irregular rhythm.
Quantitative biplane left ventricular ejection
fraction is 27 % (normal 54-73%). There is no resting left
ventricular outflow tract gradient. No
ventricular septal defect is seen. Normal right ventricular
cavity size with moderate global free wall
hypokinesis. Tricuspid annular plane systolic excursion (TAPSE)
is depressed. The aortic sinus diameter
is normal for gender with a mildly dilated ascending aorta. The
aortic arch diameter is normal with a
normal descending aorta diameter. The aortic valve leaflets (3)
are mildly thickened. There is no aortic
valve stenosis. There is no aortic regurgitation. The mitral
valve leaflets appear structurally normal with
no mitral valve prolapse. There is mild to moderate [___]
mitral regurgitation. The pulmonic valve
leaflets are normal. There is significant pulmonic
regurgitation. The tricuspid valve leaflets appear
structurally normal. There is mild [1+] tricuspid regurgitation.
There is moderate pulmonary artery
systolic hypertension. The end-diastolic PR velocity
Brief Hospital Course:
PATIENT SUMMARY STATEMENT FOR ADMISSION
=========================================
___ y/o F with PMH of HTN, CHF, paroxysmal A-Fib on Eliquis, and
HFrEF who presents with chest pain and ECG changes concerning
for STEMI. Underwent coronary angiography with right radial
access with findings of distal thrombotic occlusion of the LAD
and underwent successful thombus aspiration with no need of
stent placement. Thrombus thought to be from atrial
fibrillation. After intervention chest pain resolved.
TRANSITIONAL ISSUES
===================
Discharge weight: 148.59 lb
Discharge Cr: 1.3
Discharge Hgb: 12.1
New medications:
- atorvastatin 80
- clopidogrel 75
- isosorbide dinitrate 10mg TID
- hydralazine 10mg TID
Changed medications: Lasix 40 PO
Metoprolol XL 100mg daily
Stopped medications: amiodarone
[ ] Once creatinine returns to baseline, consider transition
from isosorbide/hydralazine to lisinopril. She was unable to
tolerate lisinopril while inpatient given increasing creatinine
in the setting of recent contrast load with cardiac cath, but
she is at high risk of non-compliance with
isosorbide/hydralazine
[ ] consider decreasing dose of Lasix once creatinine has
stabilized
[ ] Close follow-up to ensure medication compliance and try to
have medication instructions written in ___
[ ] Lasix was increased at discharge given ___ and was
maintaining euvolemia. Continue to follow up weights after
discharge
[] continue clopidogrel for at least ___ year
[ ] needs to follow up with ___ regarding insurance given
her current coverage does not cover her medications
[ ] Would consider blister packing medications when regimen is
stabilized.
#CODE: Full Code
#CONTACT/HCP: ___ - ___
___) - ___
ACUTE ISSUES:
=============
# Embolic STEMI
# Thrombotic/Embolic occlusion of the LAD
# S/p Thrombus aspiration
Patient with clinical symptoms consistent with ACS and ECG
finding concerning for ST elevation myocardial infarction.
Despite recent catheterization in ___ that revealed no
coronary artery disease, she was found to have thrombotic
occlusion of the distal LAD likely from a cardioembolic source
given history of atrial fibrillation and apparent lack of
compliance with the apixaban. Patient reported that she was only
taking 5mg daily of apixaban instead of 5mg twice daily as
prescribed.
After thrombus aspiration patient had resolution of the chest
pain. She received ticagrelor loading dose and aspirin and was
initially started on a heparin drip, which was stopped. She was
reloaded with clopidogrel 300mg once after PCI, and was started
on 75mg the day after PCI. Her aspirin was held after PCI. She
had a transthoracic echocardiogram after PCI which showed an EF
27% with normal left ventricular cavity size with moderate to
severe global hypokinesis and mild right ventricular
hypokinesis. EF reported from prior echo was ___ in ___. She
was also found to have moderate pulmonary hypertension and mild
to moderate mitral regurgitation. She was discharged on 5mg
apixaban BID, 75mg clopidogrel daily (which she will take for
one year), lisinopril 10mg daily, metoprolol succinate XL 50mg
daily, and atorvastatin 80mg daily. She was counseled
extensively with the help of a translator the importance of
taking all of her medications for preventing a repeat MI or
stroke.
# Paroxysmal atrial fibrillation
# Suspected embolic complication
Patient with history of paroxysmal atrial fibrillation
complicated by RVR, likely tachycardia induced cardiomyopathy
(last EF ___. Patient presented with embolic complication
likely secondary to underdosed apixaban. According to last
discharge paperwork patient was on rhythm control with
amiodarone and rate control with metoprolol. However, it is
unclear whether she was taking either of these medications.
Furthermore, apixaban was likely underdosed given that patient
was taking just once daily. Upon admission to CCU patient, was
in atrial fibrillation with appropriate rate control. She will
be discharged on 100mg metoprolol succinate XL daily and
apixaban 5mg bid.
# Heart failure with reduced ejection fraction
# Tachycardia induced cardiomyopathy
Patient with last admission on ___ for heart failure
exacerbation found to be in AFIb with RVR. Given absence of
coronary artery disease and new diagnosis of AFib with RVR
etiology of reduced ejection fraction (quantified at ___ was
thought to be tachycardia induced. During this CCU admission,
the patient appeared euvolemic on exam and denied having any
symptoms suggestive of fluid overload. We held her Lasix based
on her volume status. She will be discharged with metoprolol
100mg XL daily and afterload reduction with isosorbide 10mg TID
and hydralazine 10mg TID. She was discharged with Lasix 40mg PO
CHRONIC ISSUES:
================
# Hypertension- regimen as above
# Hyperlipidemia
- She will be discharged on high intensity statin, as above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Apixaban 5 mg PO BID
4. Simethicone 120 mg PO QID:PRN distention
5. Amiodarone 200 mg PO BID
6. DiphenhydrAMINE 25 mg PO QHS
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Clopidogrel 75 mg PO DAILY
3. Furosemide 40 mg PO ONCE Duration: 1 Dose
4. HydrALAZINE 10 mg PO Q8H
5. Isosorbide Dinitrate 10 mg PO TID
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Apixaban 5 mg PO BID
8. Simethicone 120 mg PO QID:PRN distention
9. Lisinopril 40mg PO daily
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
ST-Elevation Myocardial Infarction
Heart Failure with Reduced Ejection Fraction
Paroxysmal atrial fibrillation
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHAT DID WE DO FOR YOU?
- You came in with chest pain because you had a heart attack.
This heart attack was caused by blockages in the arteries (blood
vessels) that supply your heart. This was likely caused by
missing doses of your anticoagulation medicine, Apixaban. You
should continue to take this twice a day.
- You had a procedure called a coronary angiogram and had clot
removed from your artery. This procedure was successful in
relieving the blockage, so your chest pain went away.
- We think that you developed this blockage because you have not
been taking your apixaban as prescribed twice daily. You have
taken this medication for an abnormal heart rhythm called atrial
fibrillation. This rhythm puts you at risk for forming clots in
your heart, lungs, brain, and other organs in your body. It is
very important that your continue to take your apixaban as
prescribed every day, 5mg twice daily.
WHAT SHOULD YOU DO AFTER YOU ARE DISCHARGED?
- In addition to taking your apixaban as prescribed before, 5mg
twice daily, you will be prescribed another blood thinner
medication called clopidogrel (Plavix) 75mg once daily. This
will also help you from developing blood clots.
- You will also be prescribed a cholesterol medication called
atorvastatin, of which you will take 80mg once daily.
- You should continue taking isosorbide 10mg and hydralazine
10mg three times daily and metoprolol XL 100mg once daily for
your heart and blood pressure.
WHEN SHOULD YOU CALL YOUR PRIMARY CARE PROVIDER?
- If your weight goes up more than 3 lbs. You should weigh
yourself every morning.
- If you develop increased swelling in your legs or belly.
- If you develop nausea and vomiting.
- If you have difficulty taking your medications or obtaining
your prescribed medications.
WHEN SHOULD YOU GO TO THE EMERGENCY ROOM?
- If you develop chest pain.
- If you develop difficulty breathing.
- If you develop dizziness or lightheadedness.
- If you pass out.
We wish you the best.
Sincerely,
___
Followup Instructions:
___
|
10398829-DS-6 | 10,398,829 | 27,781,983 | DS | 6 | 2129-03-29 00:00:00 | 2129-03-30 17:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Oxycodone
Attending: ___.
Chief Complaint:
Food impaction
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
Endotracheal Intubation
History of Present Illness:
___ yo F with history of dysphagia and esophageal stricture s/p
dilation as recently as ___ admitted for food bolus impaction.
Over the past month patient has had transient obstructions that
cleared on their own and have not required endoscopic
management. Last night she was eating dinner and tolerated soup,
bread, and salad without issue. However, was eating chicken with
stuffing which got stuck. She felt the food get stuck and
wretched but was unsuccessful in dislodging it. Since then has
needed to spit up her saliva and cannot drink liquids. No chest
pain, fevers, or chills. No sob. Moved bowels twice today.
Went to ___ where endoscopy was unsuccessful in
removing the food bolus. She received Versed 8mg and 100mg
fentanyl during procedure.
In the ED, initial vitals: 98.2 83 174/58 16 96% ra. Labs were
all normal. She was evaluated by GI in the ED. They plan to
admit to the MICU for urgent EGD w/ intubation to protect airway
and allow for optimal sedation.
On transfer, vitals were: 67 148/72 20 100% RA
On arrival to the MICU, patient is in no distress and is
actually quite comfortable. She denies any chest or abdominal
pain.
Review of systems:
(+) Per HPI. 10-point ROS conducted and otherwise negative
Past Medical History:
esophageal stricture s/p dilation in ___
HTN
Hyperlipidemia
history of melanoma s/p resection
history of basal cell carcinoma s/p resection,
s/p CCY
history of uterine cancer s/p hysterectomy
s/p hernia repair,
Social History:
___
Family History:
Mother: Liver / pancreatic cancer
Sister: Lung cancer
No history of esophageal cancer.
Physical Exam:
Admission exam:
===============
Vitals- 98.2 83 174/58 16 96% ra
General- NAD. well-appearing. very pleasant
HEENT- No saliva pooling. OP clear. EOMI. PERRL.
Neck- supple. no cervical lymph node enlargement. No
thyromegaly.
CV- RRR. no m/r/g
Lungs- CTAB
Abdomen- soft, NT/ND, +BS
Ext- wwp. no cce
Neuro- no focal deficits. alert and oriented x3. moving all 4
extremities.
Discharge exam:
===============
Vitals- 98.2 150/54 59 16 97%RA
General- NAD. well-appearing. very pleasant
CV- RRR. no m/r/g
Lungs- CTAB
Abdomen- soft, NT/ND, +BS
Ext- wwp. no cce
Pertinent Results:
Admission labs:
___ 04:30PM BLOOD WBC-5.3 RBC-4.29 Hgb-11.9* Hct-37.8
MCV-88 MCH-27.7 MCHC-31.4 RDW-14.9 Plt ___
___ 04:30PM BLOOD Neuts-66.6 ___ Monos-6.3 Eos-3.3
Baso-0.6
___ 04:30PM BLOOD ___ PTT-30.9 ___
___ 04:30PM BLOOD Glucose-94 UreaN-17 Creat-0.4 Na-140
K-3.9 Cl-106 HCO3-22 AnGap-16
Discharge labs:
___ 05:50AM BLOOD WBC-8.0# RBC-4.20 Hgb-11.5* Hct-36.9
MCV-88 MCH-27.4 MCHC-31.2 RDW-14.8 Plt ___
___ 05:50AM BLOOD Glucose-84 UreaN-16 Creat-0.5 Na-142
K-3.5 Cl-107 HCO3-25 AnGap-14
Imaging:
-CXR (___):
ET tube in standard placement. Right lung clear. Heart size
normal.
Opacification at the base of the left lung could be atelectasis
or aspiration, and should be followed.
-EGD (___):
Impression: Stenosis of the distal 2cm of the esophagus to the
GE junction
Erythema and friability in the GE junction and distal 2cm of the
esophagus\
No food bolus was encountered in the esophagus suggesting
spontaneous passage
Medium hiatal hernia
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
___ yo F with history of dysphagia and esophageal stricture s/p
dilation as recently as ___ admitted for food bolus impaction.
#Food bolus impaction: Unsuccessful EGD at OSH. Patient
intubated for EGD in MICU. EGD showed spontaneous passage of
food bolus with some ulceration 2cm proximal to GE junction.
Esophageal stricture present, which will need dilation in the
future, but will hold off for now given friable mucosa at the
site. She tolerated a soft diet without issue. She will continue
soft diet until esophageal dilation as an outpatient by Dr.
___.
#HTN: Continued on home amlodipine and clonidine
#HLD: Continued on home atorvastatin
#DM2: Metformin intially held and she was covered with ISS.
Restarted ___.
Transitional issues:
#Follow-up with Dr. ___, ___, for esophageal
dilation.
#Code status: Full.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CloniDINE 0.1 mg PO BID
2. Atorvastatin 10 mg PO DAILY
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Amlodipine 2.5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Amlodipine 2.5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. CloniDINE 0.1 mg PO BID
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*60 Tablet Refills:*0
8. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth twice a day Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Food impaction
Esophageal 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 in the hospital. You were
admitted for a food impaction of your esophagus. Upper endoscopy
was performed and found that the food has spontaneously cleared.
You should stay on a liquid diet until your esophageal stricture
is dilated by Dr. ___ as below.
Followup Instructions:
___
|
10398856-DS-20 | 10,398,856 | 22,821,422 | DS | 20 | 2160-02-22 00:00:00 | 2160-02-23 14:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine
Attending: ___.
Chief Complaint:
Left leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of blindness secondary to retinitis pigmentosa,
hypothyroidism and depression presenting with left leg pain.
Patient reports L ankle swelling x ___ days which acutely
worsened today after he tripped over a box and heard a pop.
In the ED, initial vs were: 98.0 81 129/87 14 96% RA. Exam was
significant for a positive ___ test, U/S reportedly
showed disruption of tendon with inflammation. Labs were not
obtained. Orthopedics evaluated the patient and determined that
he had a nonoperative achilles rupture, they placed the LLE in a
hard cast. Patient was given oxycodone, diazepam and ibuprofen
and transferred to medicine for further management. Vitals on
Transfer: 60 120/45 16 100%.
On the floor, vs were: 97.9, 141/93, 58, 18,99% RA. Patient c/o
L ankle and calf pain. Otherwise no complaints. Reports he has
depression that is at his baseline, but this injury makes it
worse. He denies any SI or HI.
Past Medical History:
- Recurrent left parotitis
- Legally blind secondary to Retinitis Pigmentosa
- Depression
- Hypothyroidism
Social History:
___
Family History:
-Denies family history of stroke
-Mother: ___ disease
-Father: Lung adenocarcinoma
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.9, 141/93, 58, 18,99% RA
General: alert, NAD, lying in bed
HEENT: MMM
Neck: no LAD, JVP not elevated
Lungs: trace crackles otherwise clear to auscultation, no
wheezing
CV: RRR, no MRG, normal S1S2
Abdomen: soft NT ND
Ext: WWP, L foot and ankle in cast, normal sensation in toes
Skin: no rashes
Neuro: able to wiggle toes on left, otherwise grossly intact
aside from baseline blindness
DISCHARGE PHYSICAL EXAM:
VS: 97.5 58 109/71 96RA
GEN: Lying in bed, in no acute distress.
CARD: RRR, S1 and S2 heard. No murmur appreciated.
LUNGS: CTA b/l
EXT: LLE in hard cast. Toes warm, able to move.
Pertinent Results:
LABS ON ADMISSION:
___ 07:05AM BLOOD WBC-5.8 RBC-4.73 Hgb-13.7* Hct-40.3
MCV-85 MCH-29.0 MCHC-34.0 RDW-13.5 Plt ___
___ 07:05AM BLOOD Glucose-102* UreaN-15 Creat-1.0 Na-138
K-3.6 Cl-100 HCO3-27 AnGap-15
LABS ON DISCHARGE:
None
PERTINENT IMAGING:
ANKLE (AP, MORTISE & ___:
"FINDINGS: No acute fracture or dislocation is present. The
ankle mortise is symmetric and the talar dome is smooth. Well
corticated ossific densities distal to the medial malleolus
likely reflect the sequela of prior injury. No significant
stranding is seen within ___ fat pad. No radiopaque foreign
bodies or soft tissue calcifications are present.
IMPRESSION:
No acute fracture or dislocation."
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
___ with history of blindness secondary to retinitis pigmentosa,
hypothyroidism and depression presenting with left leg pain
after fall, found to have Achilles tendon rupture.
ACTIVE ISSUES:
#Achilles Rupture: Pt has h/o blindness and is s/p fall at home
with increased L ankle pain and swelling. Imaging and exam
concerning for Achilles rupture. Ortho evaluated pt in ED and
determined that the injury is nonoperative; they placed the left
lower extremity in a hard cast. He was admitted for evaluation
by physical therapy and for pain management. It was determined
that the best placement would be a short stay in a
rehabilitation center. Of note, the patient was recently
treated for community acquired pneumonia with levofloxacin which
increases the risk of rupture by 2.4 times for recent exposure.
Patient also on oral steroids which has been shown in elderly
patients to increase risk of achilles tendon rupture when used
with a fluroquinolone. Fluroquinolones should be avoided in this
patient in the future.
CHRONIC ISSUES:
#Depression: Patient with significant depression. His home
medications were continued: LaMOTrigine 125 mg PO/NG QHS;
Dextroamphetamine 30 mg PO QPM; OLANZapine 5 mg PO HS;
Dextroamphetamine 50 mg PO QAM; Sertraline 300 mg PO/NG DAILY
#Hypothyroid: home medications were continued: Levothyroxine
Sodium 200 mcg PO/NG qMWTuThFSat; Levothyroxine Sodium 400 mcg
PO/NG qSUN.
#Blindness: Patient has a history of retinitis pigmentosa and
takes Vitamin A 15,000 UNIT PO DAILY. He was given 10,000 units
while hospitalized since the formulary here does not stock
15,000u doses.
TRANSITIONAL ISSUES:
-Patient will need a follow-up appointment with Dr. ___
in the orthopedic surgery clinic 1 week post-discharge for
evaluation. He is to call ___ to schedule appointment
upon discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H dyspnea
2. Dextroamphetamine 30 mg PO QPM
3. Dextroamphetamine 50 mg PO QAM
4. ZYRtec *NF* 10 mg Oral QHS
5. Propecia *NF* (finasteride) 1 mg Oral daily
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. FoLIC Acid 1 mg PO DAILY
8. LaMOTrigine 125 mg PO QHS
9. Levothyroxine Sodium 200 mcg PO QMOTUWEDTHURFRISAT
10. Levothyroxine Sodium 400 mcg PO QSUN
11. Lorazepam 1.5 mg PO QAM
12. Lorazepam 2.5 mg PO HS
13. OLANZapine 5 mg PO HS
14. Omeprazole 20 mg PO DAILY
15. Prazosin 4 mg PO HS
16. Sertraline 300 mg PO DAILY
17. Simvastatin 40 mg PO DAILY
18. Sildenafil 20 mg PO PRN sexual activity
19. PredniSONE 10 mg PO DAILY
Daily ___
5 mg ___
Tapered dose - DOWN
20. Aspirin 81 mg PO DAILY
21. Vitamin D ___ UNIT PO DAILY
22. Vitamin A 15,000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Dextroamphetamine 30 mg PO QPM
3. Dextroamphetamine 50 mg PO QAM
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. FoLIC Acid 1 mg PO DAILY
6. LaMOTrigine 125 mg PO QHS
7. Levothyroxine Sodium 200 mcg PO QMOTUWEDTHURFRISAT
8. Levothyroxine Sodium 400 mcg PO QSUN
9. Lorazepam 1.5 mg PO QAM
10. Lorazepam 2.5 mg PO HS
11. OLANZapine 5 mg PO HS
12. Omeprazole 20 mg PO DAILY
13. Prazosin 4 mg PO HS
14. PredniSONE 10 mg PO DAILY Duration: 2 Days
prednisone 10mg on ___ and ___, then 5mg on ___ and ___,
then stop
Tapered dose - DOWN
15. Sertraline 300 mg PO DAILY
16. Simvastatin 40 mg PO DAILY
17. Vitamin A 15,000 UNIT PO DAILY
18. Vitamin D ___ UNIT PO DAILY
19. Acetaminophen 650 mg PO Q6H
20. Docusate Sodium 100 mg PO BID
21. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*180 Tablet Refills:*0
22. Polyethylene Glycol 17 g PO DAILY:PRN constipation
23. Senna 1 TAB PO BID:PRN constipation
24. Albuterol Inhaler ___ PUFF IH Q4H dyspnea
25. Propecia *NF* (finasteride) 1 mg Oral daily
26. Sildenafil 20 mg PO PRN sexual activity
27. ZYRtec *NF* 10 mg Oral QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left Achilles tendon rupture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at ___
___. You were admitted on ___ and found to have
a left achilles tendon rupture. This was set in a cast by the
Orthopedic Surgery team. You will need to follow-up with them
(see appointment info below) for further management of your
injury.
CAST CARE:
- Please keep cast on and dry until your follow-up appointment.
ACTIVITY AND WEIGHT BEARING:
- Nonweightbearing left lower extremity
Again, it was a pleasure to meet and care for you.
Followup Instructions:
___
|
10398856-DS-21 | 10,398,856 | 29,250,107 | DS | 21 | 2160-03-18 00:00:00 | 2160-03-18 11:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Compazine / Levaquin
Attending: ___.
Chief Complaint:
left ankle pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: ___ with Left ankle pain SP achilies tendon repair on
___. Been at rehab with posterior splint in place, non weight
bearing. Increased pain for the past few days with pain getting
worse. Pt denies any fevers, or chills
Past Medical History:
- Recurrent left parotitis
- Legally blind secondary to Retinitis Pigmentosa
- Depression
- Hypothyroidism
Social History:
___
Family History:
-Denies family history of stroke
-Mother: ___ disease
-Father: Lung adenocarcinoma
Physical Exam:
On admission:
In general, the patient is a pleasant man in NAD
Left lower extremity:
Incision CDI
Soft, tender leg with erythemia over medial malleolus with
tenderness on palpation over erythemia.
Full, painless AROM/PROM of hip and knee
deferred motor of ___ due to recent surgery
___
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
On Discharge:
In general, the patient is a pleasant man in NAD
Left lower extremity:
Incision CDI
Soft, tender leg, however no longer any erythema.
Full, painless AROM/PROM of hip and knee
deferred motor of ___ due to recent surgery
___
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
posterior slab splint in place, dressing changed ___.
Pertinent Results:
IMAGING:
US-Demonstrated DVTS in LLE.
Brief Hospital Course:
On ___ the patient was admitted to the ortho trauma service for
left ankle pain. The pt was noted to have some erythema, but the
pain was ultimately attributed to the presence of a DVT found on
ultrasound rather than a cellulitis.
The patient was begun on 5mg coumadin per medicine recs, and
daily INR was checked with last value 1.6 on ___. He is to be
kept on lovenox 30mg BID until therapeutic on coumadin.
On ___ the pt was noted to have pain not adequately controlled.
Pain management saw pt and recommended switching to PO dilaudid
___, with ibuprofen and tylenol.
On ___, the patient was much more comfortable. He required only
2 mg of the ___ dilaudid. His dressing was changed, and the
incision was noted to be healing very well without drainage or
exudate. There is no erythema or evidence of cellulitis. With
adequate pain control, the pt was ready for transfer back to
rehab, with the plan to continue lovenox bridging to therapeutic
coumadin with goal INR ___.
Discharge Medications:
1. Dextroamphetamine 30 mg PO QHS anxiety
2. Dextroamphetamine 50 mg PO QAM anxiety
3. Docusate Sodium 100 mg PO BID constipation
4. Enoxaparin Sodium 90 mg SC Q12H Start: ___, First Dose:
Next Routine Administration Time
until INR therapeutic goal ___. Fluticasone Propionate NASAL 2 SPRY NU BID
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. LaMOTrigine 100 mg PO DAILY
8. LaMOTrigine 25 mg PO DAILY
9. Levothyroxine Sodium 200 mcg PO DAILY
10. Lorazepam 1.5 mg PO QAM
11. Lorazepam 2.5 mg PO QHS
12. OLANZapine 5 mg PO HS
13. Omeprazole 20 mg PO DAILY
14. Ondansetron 4 mg IV Q8H:PRN nausea
15. Prazosin 4 mg PO HS
16. Senna 2 TAB PO QHS constipation
17. Sertraline 300 mg PO DAILY
18. Simvastatin 40 mg PO DAILY
19. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
20. Warfarin 5 mg PO DAILY16
21. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 4 hours Disp
#*120 Tablet Refills:*0
22. Ibuprofen 400-600 mg PO Q6H:PRN pain
23. Acetaminophen 1000 mg PO TID:PRN pain
do not exceed 4g/day
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
deep venous thrombosis left lower extremity after left achilles
tendon repair
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:
Expected length of rehab stay is less than 30 days.
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.
-Please continue current pain regimen (ibuprofen 400-600,
tylenol ___ TID, and PO dilaudid ___, as needed for pain
control)
ANTICOAGULATION:
Lovenox bridge to coumadin with goal INR ___:
Treatment dose enoxparin 90 mg (1mg/kg) SC BID, warfarin 5mg
daily.
Continue treatment dose enoxaparin until INR is between ___ on
warfarin for 24 hours.
Encourage ambulation.
Monitor respiratory status.
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
**However, if ace bandage bothers patient or pt has any
discomfort, bandaging can be changed as needed.
ACTIVITY AND WEIGHT BEARING:
Physical Therapy:
non weight-bearing LLE
Treatments Frequency:
please follow wound care instruction from prior discharge per
surgeon Dr. ___ (appointment is scheduled for
___, pt aware) - continue posterior slab splint
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 postop follow up appointment.
- No dressing is needed if wound continues to be non-draining.
Followup Instructions:
___
|
10399235-DS-6 | 10,399,235 | 24,628,930 | DS | 6 | 2188-11-30 00:00:00 | 2188-11-30 22:26:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / codeine / lisinopril
Attending: ___.
Chief Complaint:
right shoulder pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with h/o HTN, DMII and h/o
hemorrhagic stroke in ___ (with residual aphasia and R
sided weakness), who presented to the ED on ___ with acute
on chronic R sided shoulder pain found to have pulmonary
embolism.
In the ED, pt reported R sided shoulder pain that worsened on
day
of evaluation after exercise.
In the ED, initial VS were: 97.4 78 159/134 18 99% RA, notabley
R sided arm pressures were significantly less than L sided (SBP
___ vs. 140s-160s)
Labs showed: normal CBC, normal chem 7, urine bland, Trop < .01
x2
Imaging showed:
--DX SHOULDER AND HUMERUS: No fracture, dislocation, lytic or
sclerotic lesion.
--CXR: No acute cardiopulmonary process
--CTA: Extensive pulmonary emboli from the distal right main
pulmonary artery through the segmental branches inferiorly and
into the subsegmental branches superiorly w/o evidence of right
heart strain
--NON CON CT HEAD: No acute intracranial abnormality
Neurology was consulted given history of hemorrhagic stroke and
need for anticoagulation. They agreed with treatment with
anticoagulation (goal PTT 50-70) with close monitoring of
neurologic status and CT head if any change.
Patient received: 1000 mg PO acetaminophen, 2 grams IV morphine,
IV heparin (started at 1450 cc/hr)
Transfer VS were: 97.5 58 138/87 15 100% RA
On arrival to the floor, patient reports R shoulder pain that
worsened this AM. Has been going on for several weeks. Acutely
worsened this AM. No trauma or event that occurred this AM to
worsen pain. Pain is located at R shoulder and then radiates
down
the hand. Says that arm "feels funny," and endorses n/t of the
arm. Denies neck pain. Endorses back pain.
Denies fevers, chills, CP, SOB, palpitations, hemoptysis, no ___
swelling or leg pain. Had recent trip to ___- flew to ___ (6
hours) on ___ and flew home (7 hours) on ___. Worse
compression stockings to prevent swelling. No lightheadedness or
passing out. No history of clot.
No abdominal pain, nausea, vomiting, diarrhea, constipation,
blood in stools, black stools
Past Medical History:
-hemorrhagic stroke (___)
-HTN
-DMII
-hysterectomy
Social History:
___
Family History:
Mother deceased at young age from unknown cause;
Father also deceased but at older age, cause unknown. She has 2
brother with diabetes and a sister with ___ disease.
No known family h/o clot or bleeding disorder.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.7 143 / 77 61 18 96 RA
GENERAL: No acute distress
HEENT: PERRL, EOMI
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTABL, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: NABS, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema, no pain
w/palpation
of the legs
Passive and active range of the R arm is intact w/o pain, No
pain
with palpation of the R shoulder joint, strength ___, neer
negative
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, CN ___ intact, ___ strength in the ___ and ___
DISCHARGE PHYSICAL EXAM
Vitals: 97.8 108/67 55 18 99% RA
General: Pleasant, alert, and interactive. No acute distress.
HEENT: MMM. No lesions of oral mucosa.
Lungs: Symmetrical chest expansion. Lungs CTAB, no wheezes,
rhonchi, or rales.
CV: RRR. No murmurs, rubs, or gallops.
Abdomen: Soft, NT, ND.
Ext: Able to appreciate faint R radial pulse via palpation. R
radial and ulnar pulses identified via Dopplers. 2+ L radial
pulse. L hand slightly cooler than R hand; no mottling of either
___ DP pulses intact and symmetrical. ___, no ___ edema.
Neuro: Mixed receptive/expressive aphasia. ___ strength in
bilateral ___ and ___. Sensation in bilateral ___ and ___ grossly
intact. CN III-XII intact.
Pertinent Results:
ADMISSION LABS:
==============
___ 10:40AM WBC-6.1 RBC-4.80 HGB-12.9 HCT-40.6 MCV-85
MCH-26.9 MCHC-31.8* RDW-14.0 RDWSD-43.3
___ 10:40AM NEUTS-72.7* ___ MONOS-4.9* EOS-0.3*
BASOS-0.3 IM ___ AbsNeut-4.43 AbsLymp-1.32 AbsMono-0.30
AbsEos-0.02* AbsBaso-0.02
___ 10:40AM CALCIUM-9.6 PHOSPHATE-3.8 MAGNESIUM-2.0
___ 10:40AM proBNP-204
___ 10:40AM cTropnT-<0.01
___ 10:40AM GLUCOSE-111* UREA N-12 CREAT-0.8 SODIUM-143
POTASSIUM-5.6* CHLORIDE-101 TOTAL CO2-27 ANION GAP-15
___ 12:06PM K+-4.6
___ 02:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 02:20PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:00PM cTropnT-<0.01
IMAGING:
=======
SHOULDER AND HUMERUS XR (___)
There is no evidence of fracture, dislocation, lytic or
sclerotic lesions
demonstrated. Image portion of the lungs is unremarkable.
No abnormality within the humerus noted as well.
CTA CHEST (___)
1. Extensive pulmonary emboli extending from the distal right
main pulmonary
artery through the segmental branches inferiorly and into the
subsegmental
branches superiorly. No evidence for right heart strain.
2. Additional pulmonary embolus in segmental branch of the left
upper lobe
pulmonary artery.
3. No acute aortic pathology.
CT HEAD W/O CONTRAST (___)
1. No acute intracranial abnormality including no hemorrhage.
2. Encephalomalacia within the left temporal and parietal lobes
compatible
with remote infarction.
ARTERIAL DUPLEX U/S BILATERAL ___ (___)
1. Near occlusive thrombus within the right axillary artery.
There are two
right brachial arteries, 1 of which demonstrates occlusive
thrombus.
Diminished waveforms are seen distally within the right radial
and ulnar arteries.
2. Patent left upper extremity arterial vasculature with
triphasic waveforms
throughout.
CTA ___ (___)
1. Interval improvement in the extent of pulmonary emboli
compared to the
prior exam from ___.
2. Evaluation of the right axillary vessels are limited
secondary to if the
lateral contrast bolus injection however there does appear to be
a possible
occlusion of the distal right axillary artery, better evaluated
on the prior
ultrasound. If there is further clinical concern, a repeat CTA
with injection
of contrast on the contralateral side of the vessels of concern
would be
recommended.
3. No concerning pulmonary nodules identified.
TTE W/ BUBBLE STUDY (___)
There is early appearance of agitated saline/microbubbles in the
left atrium/ventricle at rest most consistent with an atrial
septal defect or stretched patent foramen ovale (though a very
proximal intrapulmonary shunt cannot be fully excluded).
ARTERIAL DUPLEX U/S BILATERAL ___ (___)
1. Patent right axillary artery, with interval resolution of the
near
occlusive thrombus seen on prior exam.
2. Occlusive thrombus within 1 of the 2 brachial arteries on
prior exam has
improved, and is now nonocclusive.
3. Improved arterial waveforms are seen within the right radial
and ulnar arteries.
DISCHARGE LABS:
==============
___ 06:40AM BLOOD WBC-3.4* RBC-4.61 Hgb-12.5 Hct-39.3
MCV-85 MCH-27.1 MCHC-31.8* RDW-15.0 RDWSD-46.8* Plt ___
___ 06:40AM BLOOD Neuts-38.1 ___ Monos-10.0 Eos-3.5
Baso-0.6 Im ___ AbsNeut-1.29* AbsLymp-1.61 AbsMono-0.34
AbsEos-0.12 AbsBaso-0.02
___ 06:40AM BLOOD ___ PTT-32.0 ___
___ 06:40AM BLOOD Glucose-109* UreaN-22* Creat-1.0 Na-145
K-4.3 Cl-104 HCO3-29 AnGap-12
___ 06:40AM BLOOD Calcium-9.8 Phos-4.1 Mg-1.9
Brief Hospital Course:
Ms. ___ is a ___ h/o HTN, DMII, ASD secundum, and h/o
hemorrhagic stroke ___ (with residual aphasia and R sided
weakness) p/w R sided arm pain found to have sub-massive PE and
brachial and axillary arterial occlusions.
ACUTE ISSUES
#Brachial and axillary artery thromboembolism. Pt presented to
___ ED on ___ with 10 days of worsening phlebitic right
arm pain since returning from ___, associated with occasional
numbness and tingling of her R hand but no R hand pain or color
change. She was found to have R arm BPs substantially lower than
L, concerning for aortic dissection vs. subclavian steal vs.
thromboembolic disease. CTA was negative for aortic pathology,
but did show sub-massive PE. She was started on a heparin drip,
described in further detail below. Physical exam showed weakly
Dopplerable pulses in her R radial artery and R brachial artery
and palpable R axillary artery. Pulses in the LUE and ___ lower
extremities were 2+. The patient received ___ Doppler ultrasound
studies of her upper and lower extremities, which showed
occlusive thrombus in one of her two R brachial arteries and
near-occlusive thrombus in her R axillary artery. Vascular
surgery was consulted, and recommended non-surgical management.
The patient's right arm pain and pulse exam improved throughout
her hospital course. Repeat RUE Doppler ultrasound showed
non-occlusive thrombus in her R brachial artery and resolution
of thrombus in her R axillary artery. Acetaminophen and
lidocaine patch were given as needed for pain. On the day of
discharge, the patient had palpable pulses in her RUE, and
denied R arm pain.
#Sub-massive pulmonary embolism. The patient was found to have
sub-massive PE on CTA in the ED. She was started on a heparin
drip at 1450. Neurology was consulted given h/o hemorrhagic
stroke and recommended goal PTT of 50-70. Heparin drip was
titrated to 600 with achievement of goal PTT. The patient denied
chest pain, shortness of breath, or new leg swelling. Troponon,
EKG, proBNP, and TTE were negative for right heart strain.
Repeat CTA on ___ showed interval decrease in size of her
pulmonary emboli. The patient's vital signs were closely watched
for signs of hemodynamic instability, of which there were none.
The patient was transitioned from heparin to oral apixiban on
___ for a 7-day course of apixiban 10mg BID followed by
apixiban 5mg indefinitely. Patient was recommended to follow-up
with a hematologist for long-term management of her
anti-coagulation.
#Atrial septal defect, secundum. Pt has a history of ASD
secundum per OSH records, though patient and patient's families
could not recall the circumstances of this diagnosis. Patient
denied taking any blood thinners or anti-coagulants at home. TTE
with bubble study showed early appearance of agitated
saline/microbubbles in the left atrium/ventricle at rest most
consistent with an atrial septal defect or stretched patent
foramen ovale (though a very proximal intrapulmonary shunt
cannot be fully excluded). Paradoxical embolism from the
patient's DVT/PE was felt to be the cause of her RUE arterial
thromboembolic disease. The patient was recommended to follow-up
with cardiology after discharge for long-term management of her
ASD.
CHRONIC ISSUES
========================
#Hypertension. The patient was continued on home
anti-hypertensive regimen (clonidine patch, chlorthalidone,
losartan, metoprolol, amlodipine)
#h/o hemorrhagic stroke. The patient has a h/o hemorrhagic
stroke in ___ with residual neurologic defects (homonymous
hemianopia, aphasia, R-sided weakness). Neurology followed the
patient. The patient was closely monitored for new focal
neurological defects, of which there were none. Patient's home
simvastatin was continued.
#Diabetes. Home metformin was held for increased risk of lactic
acidosis. Pt's blood sugars were well-controlled with insulin
sliding scale.
#Insomnia. Home mirtazapine was continued.
#Other. Home multivitamins were continued. Home miralax was
given as needed for constipation.
TRANSITIONAL ISSUES
========================
[ ] PFO/ASD: F/u anticoagulation plan - 7 days of Apixaban 10mg
BID (day 1 = ___ dose on ___, then 5mg BID (starting on ___
dose of ___ indefinitely, given this defect.
[ ] PFO/ASD: At cardiology appointment, please consider if
closure of the defect be considered.
[ ] Please ensure follow-up with vascular surgery,
hematology/oncology, and cardiology. Please help make heme/onc
appointment.
[ ] Continue to monitor for focal neurologic deficits, given the
patient's higher risk of repeat stroke while on apixaban I/s/o
her prior hemorrhagic stroke.
[ ] Given the patient's need for 5 BP meds at home, please
consider secondary hypertension workup.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON
3. Ferrous Sulfate 325 mg PO DAILY
4. Magnesium Oxide 400 mg PO DAILY
5. Metoprolol Tartrate 100 mg PO BID
6. Mirtazapine 15 mg PO QHS
7. Losartan Potassium 50 mg PO BID
8. Chlorthalidone 50 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Potassium Chloride 10 mEq PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Simvastatin 20 mg PO QPM
13. Polyethylene Glycol 17 g PO QHS
Discharge Medications:
1. Apixaban 10 mg PO BID Duration: 12 Doses
Your last dose of this 10mg pill should be the AM of ___.
Switch to 5mg pill for ___ ___ dose.
RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice a day
Disp #*24 Tablet Refills:*0
2. Apixaban 5 mg PO BID
Please take first dose the evening of ___. Then continue until
you are told to stop.
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
3. amLODIPine 10 mg PO DAILY
4. Chlorthalidone 50 mg PO DAILY
5. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON
6. Ferrous Sulfate 325 mg PO DAILY
7. Losartan Potassium 50 mg PO BID
8. Magnesium Oxide 400 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Metoprolol Tartrate 100 mg PO BID
11. Mirtazapine 15 mg PO QHS
12. Multivitamins 1 TAB PO DAILY
13. Polyethylene Glycol 17 g PO QHS
14. Potassium Chloride 10 mEq PO DAILY
Hold for K >
15. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses
#Sub-massive pulmonary embolism
#Axillary and brachial arterial thromboembolism
#Atrial septal defect secundum
Secondary diagnosis
#h/o hemorrhagic stroke
#h/o bladder cancer
#Hypertension
#Diabetes
#Insomnia
#Constipation
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 ___ on
___ for blood clots in your lungs (pulmonary embolism) and in
the arteries of your arms.
Here's what happened while you were here:
- You were given a blood thinner (heparin) via an IV to prevent
further growth of your blood clots
- You were seen by our Vascular Surgery team, who determined
that you did not require surgery to manage your blood clots
- You received CT scans and ultrasound studies of your right
arm, which showed decreased size of the blood clots in your
right arm
- You received CT scans of your chest, which showed decreasing
size of the blood clots in your lungs
- You received an echocardiogram of your heart, which showed an
abnormal opening between the right and left sides of your heart.
You were CONTINUED on the following home medications while you
were an inpatient. You should continue taking these medications
when you return home: chlorthalidone, clonidine patch, losartan,
mirtazapine, multivitamins, metoprolol tartrate, simvastatin,
amlodipine
You were STARTED on the following medication as an inpatient:
Apixaban (a blood thinner to keep you from developing new blood
clots). You should continue taking this medication when you
return home. You should take Apixaban 10mg twice per day for a
7-day course (___). Starting on the evening of
___, please take apixiban 5mg twice per day until a doctor
tells you otherwise.
When you leave the hospital, you should also go to all of your
doctors ___, including ___ with your primary
care doctor, the vascular surgeons, and a cardiologist. At your
primary care doctor's appointment, they will help you to set up
an appointment with a hematology/oncology doctor.
You should call your doctor and return to the hospital if you
notice new worsening right arm pain; if your right arm becomes
cold or pale; or if you develop new chest pain, shortness of
breath, weakness, or bleeding.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10400109-DS-3 | 10,400,109 | 25,995,705 | DS | 3 | 2139-11-04 00:00:00 | 2139-11-04 08:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right forehead laceration.
Major Surgical or Invasive Procedure:
___ - Irrigation and debridement of right forehead wound
with microsurgical repair of injured nerve
History of Present Illness:
___ assaulted around ___ with a glass bottle. Denies LOC,
no visual changes, no numbness/weakness/paresthesias, no
difficulty ambulating, denies malocclusion. Laceration was
irrigated and closed by the ED using lidocaine with epinephrine
around 6a. Tetanus given in ED.
Past Medical History:
PMH - None
PSH - Repair of "sports" hernia
Social History:
___
Family History:
Non-contributory.
Physical Exam:
EXAM ON ADMISSION:
97.7 84 131/87 18 98%
There is a 7cm right forehead laceration from the lateral brow
nearly straight back to the hairline with a small underlying
hematoma. Full sensation has returned to the laceration.
CN II, III, IV, V, VI, XII intact. He has zero brow elevation
on
the right. Facial nerve otherwise intact. Orbicularis oculi is
full strenght and equal b/l.
No conjunctival hemorrhage, EOMI, pupils equal, round, reactive.
No nasal septal hematoma, no intraoral injury, no malocclusion.
EXAM ON DISCHARGE:
VS - 97.9 65 120/61 16 98%RA
GEN - NAD, comfortable in bed
CNS - CN II, III, IV, V, VI, XII intact. No brow elevation on
the right. Facial nerve otherwise intact. Orbicularis oculi is
full strenght and equal bilaterally. EOMI, PERRL, no
conjunctival hemorrhage.
INCISION - Clean, dry, and intact with no erythema, hematoma, or
drainage. Steri strips in place.
Pertinent Results:
CT HEAD (___) - Right frontotemporal subgaleal hematoma.
No definite intracranial hemorrhage. Two punctate foci are noted
in the left frontal lobe and are likely artifactual.
Brief Hospital Course:
The patient presented to the ___ emergency department with a
right eyebrow laceration and after initial evaluation and repair
of forehead laceration by the ED, the plastic surgery team was
consulted regarding a possible right facial nerve injury. The
plastic surgery team decided that surgical exploration and
repair of the nerve was indicated and so the patient was taken
to the operating room on ___ for irrigation and debridement
of right forehead wound with repair of nerve injury, which the
patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the plastic surgery floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD1. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that
were within normal limits, pain was well controlled with oral
medications, incisions were clean/dry/intact, the patient was
ambulating safely, was voiding and moving bowels spontaneously.
The patient will follow up with Dr. ___ in ___ days for a
wound check and suture removal. A thorough discussion was had
with the patient regarding the expected post-discharge course,
and all questions were answered.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever, headache, mild pain
2. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN moderate to
severe pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Q4 hours Disp #*40
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right forehead laceration
Right facial nerve injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
- You may shower 48 hours after surgery, but please do not
vigorously scrub the wound, and pat it dry gently at the
completion of your shower.
- Please take all medication as prescribed and do not drink
alcohol, drive, or operate machinery while taking your narcotic
pain relievers (oxycodone).
- Please keep the steri-strips (small white bandaids on your
incision) until they fall off in ___ days. If the fall off
sooner, you may replace them as needed.
- Please attend all follow up appointments as scheduled and
please call the office or return to the emergency department if
you experience any of the symptoms listed below.
Followup Instructions:
___
|
10401051-DS-16 | 10,401,051 | 20,658,510 | DS | 16 | 2142-08-13 00:00:00 | 2142-08-13 15:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left shoulder and back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o otherwise healthy female presents via EMS complaining of
L shoulder and back pain. Patient was riding her horse when she
was thrown from her saddle and landed on her L side/shoulder.
She was wearing a helmet and endorses headstrike but denies LOC.
She experienced immediate onset of L sided shoulder and back
pain and was brought via EMS to ___ ED.
She denies any numbness/tingling in her left shoulder or arm.
Past Medical History:
Asthma
Social History:
___
Family History:
Non-contributory
Physical Exam:
T98.2 HR62 BP86/55 RR18 Pox99RA
GEN: NAD, AAOx3, breathing comfortably
HEENT: NCAT, EMOI, PERRLA, nares patent, moist mucous membranes
HEART: RRR S1S2
PULM: CTAB, no m/r/g
AB: soft, NT, ND, normal bowel sounds
EXT: left arm in sling, periperial pulses intact bilaterally
NEURO: oriented to person, place, and time
Pertinent Results:
GLENO-HUMERAL SHOULDER (W/ Y VIEW) LEFT ___
Comminuted, mildly displaced fractures involving the left
scapula and mid left clavicle. No dislocation. Fractures of
the left ___ and 4th ribs. Small left apical pneumothorax is
likely.
CHEST (PA & LAT) ___
Small left apical pneumothorax
Brief Hospital Course:
The patient was admitted to the Acute Care Surgery Service on
___ after she fell off her horse. The patient was
transferred to the hospital floor for further care. The hospital
course was uneventful and the patient was discharged to home.
Hospital Course by Systems:
Neuro: Pain was well controlled, initially with IV regimen which
was transitioned to oral regimen. Reported headaches and light
sensitivity. Refused CT Head due to radiation. Advised to have
CT head for any changes in mental status.
Cardiovascular: Remained hemodynamically stable.
Pulmonary: CT chest on HD1 showed small apical pneumothorax on
left. PA/lateral CXR on HD2 showed slightly improved apical
pneumothorax on left.
GI: Diet was advanced as tolerated. Bowel regimen was given prn.
GU: Patient was able to void independently.
Heme: Received heparin subcutaneously and pneumatic compression
boots for DVT prophylaxis.
MSK: Evaluated by orthopedics, advised to keep left arm in sling
until follow up.
The patient was discharged to home in stable condition,
ambulating, and voiding independently, and with adequate pain
control. The patient was given instructions to follow-up in the
ACS and Orthopedics clinics in ___ weeks. The paitent was also
given detailed discharge instructions outlining activity, diet,
follow-up and the appropriate medication scripts.
Medications on Admission:
Advair
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H pain
2. Docusate Sodium 100 mg PO BID
3. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every 8
hours Disp #*35 Tablet Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp
#*75 Tablet Refills:*0
5. Lorazepam 0.5 mg PO HS:PRN anxiety
RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth every ___ hours
as needed Disp #*50 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left clavicle fracture
Left scapula fracture
Left rib ___ fracture
Left small pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the Acute Care Surgery service on ___
after falling off your horse. You are now ready to complete
your recovery at home. Please follow the instructions below:
-You are being given a prescription for narotic pain medication.
Please do not drink alcohol or drive while taking this
medication. If you have constipation, you may take over-the
counter colace.
-Please call to schedule follow up appointments in the Acute
Care Surgery clinic and the Orthopedic Surgery clinic. Please
schedule a chest x-ray on the morning of your appointment in the
Acute Care Surgery clinic.
-You may ambulate as tolerated. Please avoid strenuous activity
and heavy lifting until you follow up in the Acute Care Surgery
clinic.
-Please resume all home medications as prescribed, and follow up
with your primary care physician ___ ___ weeks.
-Please go to the nearest emergency room, and have a CT head, if
you experience dizziness, confusion, or change in mental status.
-Please call the Acute Care Surgery clinic, or go to the nearest
emergency room, if you experience severe pain with pain
medications, fevers >101, chest pain, shortness of breath, or
for anything else that concerns you.
Followup Instructions:
___
|
10401131-DS-9 | 10,401,131 | 29,570,609 | DS | 9 | 2190-06-09 00:00:00 | 2190-06-15 23:24:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Chief Complaint: confusion
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
___ y/o male with sleep apnea, HTN, anxiety/depression, ADD,
chronic LBP presents with acute AMS (confusion).
.
Patient unable to describe chief complaint in ED. Wife states he
was rigoring for ___ hours last night. He never checked his
temperature. He proceeded to walk to the restroom, and called
out to his wife that he was walking to the bathroom, but
instead, he walked into the closet and urinated there. He was
heard to become unstable and become off balance. He returned to
bed disoriented. He again urinated in the bed and his wife
brought him in. She denies any recent head trauma or falls. Of
note, at baseline, he is quite healthy with normal mental
status. No reported trauma or fall.
.
Per discussion with patient and wife at bedside, he has had
severe arthritic pain x 2 weeks. He was in his USOH until
yesterday ___, when he felt very sore with diffuse muscle aches.
He also reported nausea without vomiting along with chills. His
wife noted increased breathing rate. She also reports confusion
over ___ days. He reports cough, without sputum production.
.
ROS notable for some night sweats, no fever, some ataxia but
increased loss of balance PTA. No recent hospitalizations. No
recent travel or sick contacts. Of note, he received pneumonia
vaccine and influenza vaccine 2 weeks ago.
.
In the ED, initial VS were: 100.4 106 131/53 16 90% RA. Exam
with non-focal neuro exam.
Labs notable for WBC 5.3, INR 1.2, Stox negative, Cr 1.0,
lactate 1.6, U/A wnl. Bcx and Ucx pending.
CXR showing multifocal pneumonia
Head CT without acute process
EKG showing new RBBB and ST changes, but CE's negative.
.
Pt was given vancomyzin, zosyn, and 3L IVF. He subsequently
required Bipap for increasing and persistent tachypnea. Most
recent ABG ___ on Bipap. Per ED, intubation was
discussed but unable to rationalize it currently. He "appeared
to improve" with mental status which was improved to AOx2.
.
Vitals on transfer - HR 84, BP 125/68, RR 28, 96% on 4L NC (off
bipap for 15 mins)
Access - 16G, 18G
.
On arrival to the MICU, patient is sleepy, arousable, alert to
name, BI, year, president
.
Review of systems:
(+) Per HPI. Also positive for mild HA, sinus congestion,
myalgia. Remainder of ROS negative.
Past Medical History:
- Hypertension
- anxiety/depression
- ADD
- insomnia
- cervical spinal stenosis
- footdrop secondary to lumbar disc surgery
- chronic low back pain
- hx of right knee infection, on suppression Abx
- sleep apnea (does not wear mask)
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission PEx:
Vitals: 98.8, 111/36, 76, 24, 97% on 4L NC
General: mild tachypnea, but appears comfortable. Awakes to
voice.
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: subtle rhonchi and crackles at bases, no wheezes
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, psoriatic rash below right knee
Neuro: oriented to name, BI, year, president. CNII-XII intact,
___ strength upper/lower extremities, grossly normal sensation,
2+ reflexes bilaterally, gait deferred, finger-to-nose intact
.
.
.
Discharge PEx:
Vitals: 98.3/97.6 137/62 74 18 96%RA
General: comfortable. A&Ox3, laughing/talking with family
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no crackles, wheezing
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, psoriatic rash below right knee
Neuro: grossly intact
Pertinent Results:
Admission labs:
___ 06:20AM BLOOD WBC-5.3 RBC-4.79 Hgb-14.2 Hct-40.8
MCV-85# MCH-29.8 MCHC-34.9 RDW-13.2 Plt ___
___ 06:20AM BLOOD Neuts-81.8* Lymphs-12.3* Monos-5.2
Eos-0.5 Baso-0.3
___ 06:20AM BLOOD ___ PTT-27.5 ___
___ 06:20AM BLOOD Glucose-130* UreaN-18 Creat-1.0 Na-136
K-3.7 Cl-99 HCO3-25 AnGap-16
___ 06:20AM BLOOD ALT-24 AST-34 LD(LDH)-186 CK(CPK)-95
AlkPhos-118 TotBili-0.7
___ 06:20AM BLOOD Albumin-4.1 Calcium-9.2 Phos-2.2*# Mg-1.7
___ 09:32AM BLOOD Type-ART pO2-82* pCO2-33* pH-7.45
calTCO2-24 Base XS-0
EKG: Sinus tachycardia. Left bundle-branch block. Left
ventricular hypertrophy. Intra-atrial conduction defect. Since
the previous tracing of ___ left bundle-branch block has
appeared as well as prominent voltage.
___
___
.
ECHO:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size is 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. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trace mitral regurgitation is seen. There is no
pericardial effusion.
No vegetation seen (cannot definitively exclude).
Chest PA/Lateral:
There is confluent consolidation in the right and left lower
lungs which on the lateral view correspond to opacities
overlying the heart and the lower lumbar spine, findings which
raise the concern for multifocal pneumonia in the right middle
and bilateral lower lobes. No pleural effusions are evident.
There is no pneumothorax. Mild pulmonary edema is new from prior
examination. Cardiomediastinal and hilar contours are within
normal limits.
IMPRESSION:
1. Multifocal basilar opacities concerning for multifocal
pneumonia
2. New mild pulmonary edema though no pleural effusions
CT Head:
FINDINGS: There is no hemorrhage, edema, mass effect, or
territorial
infarction. Ventricles and sulci are mildly prominent consistent
with age
related involutional changes. There is mild mucosal thickening
of the right sphenoid sinus as well as polyp or mucus retention
cyst in the left frontal sinus. The remainder of the visualized
paranasal sinuses, mastoid air cells and middle ear cavities are
clear. Osseous structures are unremarkable.
IMPRESSION: No acute intracranial process.
Brief Hospital Course:
___ y/o male with HTN, sleep apnea, anxiety/depression, ADD,
chronic LBP presents with acute mental status changes and
confusion, found to have multifocal pneumonia, with dramatic
improvement after administration of antibiotics.
.
# Severe multifocal community acquired pneumonia: CURB 65 score
is 3, implying severe community acquired pneumonia with 14%
30-day mortality. No recent hospitalizations, no recent rehab
stay, and no risk factors to suggest MDR organism. Of note, did
recently receive pneumonia vaccine and flu vaccine. Patient was
admitted to ICU for respiratory monitoring. He received
vancomycin, ceftriaxone, and levofloxacin for severe ICU
admission requiring community acquired pneumonia. Patient's
mental status and respiratory status rapidly improved with
antibiotics and he was called out of the MICU. Patient continued
to improve on the floor, and did not have any need for O2.
Patient was transitioned to PO antibiotic regimen of
doxycycline/levoquin for a total of 7 days.
# Altered mental status: Most likely ___ infection although
other possibilities were considered such as seizure (possible
given report of ? shaking/rigors/incontinence), or intracranial
insult such as ICH (less likely given normal head CT and no
reported trauma). Serum tox was negative in ED. Patient's
enecphalopathy improved quickly as his pneumonia was treated and
his family felt he returned to baseline upon arrival to the
floor.
.
# RBBB with non-specific TWI: negative cardiac enzymes and no
reported chest pain. Patient underwent ECHO showing no valvular
disease, normal systolic function.
.
# HTN: Hypertensives held in the MICU; restarted on the floor,
stable.
.
# Depression/anxiety/ADD: Continued adderall, risperdal, effexor
.
.
.
Transitional Issues:
--Patient to take doxycycline/levoquin for 4 more days upon
discharge for a total of 7 days of antibiotics. Patient to
follow up with PCP ___ 1 week of discharge, as detailed
below.
Medications on Admission:
- effexor 37.5 mg bid
- D amphetamine salt combo 10 mg tid
- nabumetone 500 mg bid
- risperdal 0.5 mg tid
- tylenol with codeine tid
- cefadrotil 1 gram daily
Discharge Medications:
1. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
2. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days: to end on ___.
Disp:*4 Tablet(s)* Refills:*0*
3. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 4 days.
Disp:*8 Capsule(s)* Refills:*0*
4. acetaminophen-codeine 300-30 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day) as needed for pain.
5. venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. amphetamine-dextroamphetamine 5 mg Tablet Sig: Two (2) Tablet
PO TID (3 times a day).
7. nabumetone 500 mg Tablet Sig: One (1) Tablet PO twice a day.
8. cefadrotil Sig: One (1) gram once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
pneumonia
.
seconary:
- Hypertension
- sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital for
confusion and was found to have a pneumonia. We treated you with
antibiotics and you have improved tremendously over the past
couple of days. We will send you home on a course of oral
antibiotics with the last doses to be taken on ___.
.
The following changes have been made to your medications:
--Please START Levofloxacin 750mg by mouth daily
--Please START Doxycycline 100mg by mouth twice daily
.
Please follow up with your PCP upon your discharge. Details of
your appointment with Dr. ___ listed below:
Followup Instructions:
___
|
10401251-DS-5 | 10,401,251 | 23,673,616 | DS | 5 | 2161-02-28 00:00:00 | 2161-02-28 16:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro
Attending: ___.
Chief Complaint:
HMED Admission Note
___
cc: JP drainage
Major Surgical or Invasive Procedure:
gastrostomy tube removal
History of Present Illness:
___ year old F s/p recent roux en y gastric bypass complicated by
bile leak requiring ERCP and stenting on ___. Pt had repeat
ERCP on ___ with removal of the plastic stent in the CBD and
has completed 5 day course of augmentin post procedure. Pt with
JP drain still in place. Foley catheter left in place at
gastrostomy site to keep tract patent in case of repeat ERCP.
Pt presents today with suprapubic abdominal pain of two days.
Reports dysuria yesterday. No fevers or chills no flank pain. Pt
reports increased JP drainage since stent pull on ___.
Typically ___ cc/s increased from < 10 cc's prior to the
procedure. Appearance of fluid was serous and serosanguinous. In
the past day she had a total of 120 cc of drainage, so given her
pain and increased drainage her ___ recommended she come to the
ED for evaluation.
In the ED, pt afebrile. No leukocytosis. LFT's unremarkable. CT
abdomen shows no fluid collection or abscess. Pt admitted for
observation.
ROS: currently menstruating, otherwise negative except as above
Past Medical History:
Roux en Y Gastric bypass ___
Hypothyroidism
GERD
Social History:
___
Family History:
No family history of hepatobilliary disease.
Physical Exam:
Vitals: 97.3 94/62 71 16 100%RA
Gen: NAD, lying in bed
HEENT: hirsut, no jaundice
CV: rrr, no r/m/g
Pulm: clear b/l
Abd: soft, suprapubic tenderness, no CVA tenderness
Ext: no edema
Neuro: alert and oriented x 3
Pertinent Results:
___ 08:20PM WBC-7.8 RBC-5.02 HGB-14.4 HCT-42.6 MCV-85
MCH-28.8 MCHC-33.9 RDW-12.9
___ 08:20PM PLT COUNT-226
___ 08:20PM GLUCOSE-90 UREA N-7 CREAT-0.5 SODIUM-136
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-24 ANION GAP-15
___ 08:20PM ALT(SGPT)-29 AST(SGOT)-29 ALK PHOS-139* TOT
BILI-0.6
___ 08:20PM LIPASE-27
___ 08:20PM ALBUMIN-4.3
___ 08:28PM LACTATE-1.7
___ 02:00AM URINE RBC->182* WBC-13* BACTERIA-NONE
YEAST-NONE EPI-1
___ 02:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM
___ 07:00AM BLOOD WBC-7.4 RBC-4.42 Hgb-12.9 Hct-37.4 MCV-85
MCH-29.1 MCHC-34.4 RDW-12.7 Plt ___
___ 07:00AM BLOOD Glucose-82 UreaN-6 Creat-0.5 Na-139 K-4.7
Cl-103 HCO3-30 AnGap-11
___ 08:20PM BLOOD Lipase-27
___ 08:20PM BLOOD Albumin-4.3
___ 08:20PM BLOOD ALT-29 AST-29 AlkPhos-139* TotBili-0.6
___ 08:20PM BLOOD HCG-LESS THAN
.
CT abdomen:
IMPRESSION:
1. Post Roux-en-Y gastric bypass with a percutaneous catheter
terminating
within the excluded portion of the stomach, presumably through
the reported gastrostomy fistula.
2. No bowel obstruction.
3. No bile duct dilation. Post cholecystectomy.
4. No organized fluid collections. Small amount of free fluid
within the
pelvis.
.
GTUBE CHECK:
Preliminary ReportAppropriate placement of G-tube without
evidence of a leak
.
___ cx:
___ 2:00 am URINE Site: NOT SPECIFIED
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
Assessment/Plan: ___ y.o female s/p gastric bypass, CCY, c/b bile
leak, recent ERCP, hypothyroidism who presented with suprapubic
abdominal pain
.
#Suprapubic abdominal pain initally concerning for #UTI- pt with
JP drain, recent bile leak and gastrostomy tube placement.
Afebrile, LFTs WNL, CT without acute process. Gtube study
without leak. Pt reported dysuria x1 prior to admission. UCX
with mixed genital flora. She did not have any further symptoms
of UTI so her empiric abx (bactrim) were discontinued. She was
passing flatus and tolerating good PO without any n/v. She did
have intermittent reports of constipation prior to admission but
imaging did not show stool burden and abdomen was soft. Her pain
improved/resolved during admission.
.
#s/p recent CCY with bile leak-s/p JP drain and gastrostomy with
foley catheter and recent ERCP with stenting. No fever, LFTs
normal, CT without acute process. G tube study showed no leak. G
tube removed by ERCP Team the morning of discharge. Plan to
cover with gauze and f/u with outpt surgeon for ongoing care. If
leakage persists pt to call her primary surgeon to discuss
closure. JP still in place at time of discharge. ___ will be
following up with her primary surgeon for ongoing care.
.
#hypothyroidism-continued synthroid
.
DVT PPx: hep SC TID
.
Transitional care
1.Pt to f/u with her primary surgeon for ongoing care, to
discuss JP drain removal and to monitor gastrostomy site. See
appointment below.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 125 mcg PO DAILY
2. Scopolamine Patch 1 PTCH TD Q72H
3. Ondansetron 4 mg PO Q8H:PRN nausea
4. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Cyanocobalamin 200 mcg IM/SC DAILY
PLEASE CONFIRM YOUR HOME DOSE. THIS WAS NOT CHANGED. TAKE THE
SAME DOSE AS PREVIOUSLY PRESCRIBED
3. Ferrous Sulfate 325 mg PO DAILY
PLEASE TAKE THE DOSE YOUR WERE TAKING AT HOME. MEDICATION NOT
CHANGED
4. Levothyroxine Sodium 125 mcg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
abdominal pain
s/p CCY with JP drain and gastrostomy tube placement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for work up of abdominal pain. You had a CT
scan, urine culture and a study of your G-tube that did not
reveal any concerning findings. Your stomach tube was removed by
the gastroenterology doctors on the ___ of discharge. You should
keep this wound covered with gauze. If the wound continues to
leak in ___ week's time. Please be certain to follow up with
your surgeon Dr. ___ to discuss the need for more permanant
closure. In addition, you will need to be sure to follow up with
Dr. ___ as per below to discuss when you can have your JP
drain removed.
Followup Instructions:
___
|
10401337-DS-10 | 10,401,337 | 29,905,963 | DS | 10 | 2179-05-30 00:00:00 | 2179-05-30 12:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
low urine output
Major Surgical or Invasive Procedure:
Nephrostomy replacement left (___)
Nephrostomy replacement right (___)
History of Present Illness:
HMED ATTG ADMISSION NOTE
.
DATE ___
TIME 0200
.
HEME/ONC ___
UROLOGY ___
PCP ___ ___
.
___ yo M with widespread metastatic prostate cancer on
lupron/casodex, obstructive uropathy s/p bilateral nephrostomy
tubes, recent CVA, HTN and CAD who presents from ___
___ with low urine output.
.
Patient with recent prolonged hospitalization ___ - ___
after presenting with no known prior history and AMS,
hyperkalemia, fulminant renal failure and hypertensive
emergency. Patient found to have widely metastatic prostate
cancer with course complicated by NSTEMI, CVA with left-sided
hemiparesis and delirium. His renal failure was due to
obstructive uropathy from metastatic disease and required HD
with eventual placement of bilateral nephrostomy tubes. Of
note, his right tube averaged 150-200cc per day, which was felt
to reflect decreased renal function on that side. Regarding his
prostate cancer, he underwent XRT (for significant hematuria)
and was started on casodex. Patient discharged to ECF. Since
discharge, he was started on Lupron by Dr. ___. Plan per
urology is to perform a nephrogram in ___ months and if no
obstruction, cap tubes and attempt spontaneous voiding. Per
phone note, ___, patient treated with ciprofloxacin for
possible UTI (low grade fever and back pain).
.
Per ECF report, this afternoon patient with no urine output from
right nephrostomy tube and small amount of bloody output from
left nephrostomy tube. Patient denies any back or abdominal
pain. No fevers, nausea or vomiting. No cp or sob. Reports
poor po intake
.
ED: 100.1 104 150/90 18 97%; very positive UA; given CTX 1gm;
renal ultrasound shows unchanged/improved mild hydro, unable to
assess position of nephrostomy tubes; d/w urology - likely dry
plus UTI, attempt hydration might perform nephrogram in am;
given 1L of NS
.
During transport by EMT to ___, patient's left
nephrostomy tube became dislodged, found on the bed next to the
patient.
.
ROS as per HPI, 10 pt ROS otherwise negative
Past Medical History:
Metastatic prostate cancer s/p XRT on lupron/casodex
Obstructive uropathy s/p bilateral nephrostomy tubes
Recent CVA with left arm hemiparesis
HTN
CAD
Social History:
___
Family History:
No fhx of prostate cancer.
Physical Exam:
VS 99.7 156/95 76P 16 98%RA
Appearance: alert, NAD
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmd, no JVD, neck supple
Cv: +s1, s2 -m/r/g, no peripheral edema, 2+ dp/pt bilaterally
Pulm: clear bilaterally
Abd: soft, nt, nd, +bs
Back: no CVA ttp, left nephrostomy tube removed, no drainage
from old site or tenderness, right nephrostomy tube c/d/i
Msk: left arm hemiparesis
Neuro: cn ___ grossly intact, no focal deficits
Skin: no rashes
Psych: appropriate, pleasant
Heme: no cervical ___
___ Results:
___ 08:35PM URINE MUCOUS-MANY
___ 08:35PM URINE HYALINE-53*
___ 08:35PM URINE RBC->182* WBC->182* BACTERIA-MANY
YEAST-NONE EPI-0 RENAL EPI-38
___ 08:35PM URINE BLOOD-LG NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG
___ 08:35PM URINE COLOR-YELLOW APPEAR-Cloudy SP ___
___ 08:35PM URINE GR HOLD-HOLD
___ 08:35PM URINE HOURS-RANDOM
___ 09:20PM PLT COUNT-241
___ 09:20PM NEUTS-73.2* ___ MONOS-5.4 EOS-0.6
BASOS-0.2
___ 09:20PM WBC-7.8 RBC-3.74* HGB-9.8* HCT-29.1* MCV-78*
MCH-26.3* MCHC-33.8 RDW-16.1*
___ 09:20PM estGFR-Using this
___ 09:20PM estGFR-Using this
.
___ Renal ultrasound:
1. Stable mild hydronephrosis of the right kidney.
2. Slight improvement of mild hydronephrosis in the left
kidney.
3. Partially collapsed bladder with internal debris.
4. Stable right renal cyst.
.
CT ABD and Pelvis with IV Contrast
INDICATION: ___ male with history of metastatic
prostate cancer with UTI, now nonfunctioning right nephrostomy
tube, evaluate for hydronephrosis and for metastatic
progression.
COMPARISONS: CT abdomen and pelvis without contrast ___.
TECHNIQUE: MDCT axial images were obtained from the dome of the
liver to the pubic symphysis after the uneventful administration
of IV contrast. Coronal and sagittal reformations were provided
and reviewed.
DLP: 1035.17 mGy-cm.
ABDOMEN: The visualized lung bases are clear. There is no
pleural effusion or pneumothorax. The imaged portion of the
heart is top normal in size, but there is no pericardial
effusion.
There are multiple hypodensities seen throughout the liver,
compatible with metastatic disease. For example, there is a 3.3
x 2.5 cm hypodensity in segment V (2H:27). Another example of
the multiple hypodensities is seen in segment VI and measures
2.3 x 2.1 cm (2H:13). Comparison to prior is difficult given
the lack of IV contrast.
The spleen, pancreas and adrenal glands are unremarkable. A
left nephrostomy tube is seen within a normal left kidney which
does not demonstrate hydronephrosis. The right kidney
demonstrates a delay in enhancement and moderate hydronephrosis
and hydroureter. A prior nephrostomy tract is seen in the
posterior right paraspinal muscles. The stomach, large and
small bowel are normal.
There is diffuse retroperitoneal lymphadenopathy. For example,
there is a right paraaortic node which measures 2 x 1.3 cm
(2H:36). Nodes near the aortic bifurcation measure up to 0.9
cm. There is no free air or free fluid. The abdominal aorta and
its major branches are unremarkable.
PELVIS: The bladder is collapsed. A large heterogeneous mass
is seen in the pelvis measuring 7 x 5.9 cm, which has increased
in size from prior. The mass is compatible with known prostatic
adenocarcinoma and appears to be invading the seminal vesicles
and anterior wall of the rectum. A left pelvic wall lymph node
measures 1.9 x 1.3 cm (2:74) and a right iliac node now measures
1.7 x 1.3 cm (2:50) and has increased in size since prior exam.
There is no free pelvic fluid.
BONES: There are innumerable osseous metastases, increased
since prior. An expansile sclerotic lesion is seen in the right
iliac wing and measures 4.2 x 2.1 cm. No pathological fractures
identified.
IMPRESSION:
1. Right side hydroureteronephrosis and delayed nephrogram.
2. Progression of metastatic prostate cancer, marked by an
increase in size of retroperitoneal lymphadenopathy and number
of osseous metastases. No comparison for extensive liver
metastases. The primary mass invades the seminal vesicles and
likely the anterior wall of the rectum.
3. Left nephrostomy tube in appropriate position.
Brief Hospital Course:
___ yo M with widespread metastatic prostate cancer on
lupron/casodex, obstructive uropathy s/p bilateral nephrostomy
tubes, recent CVA, HTN and CAD admitted with decreased urine
output and UTI with course complicated by accidental removal of
left nephrostomy tube during transport.
.
# Oliguria and bilateral hydronephrosis: Likely due to
dehydration in setting of infection vs dislodged nephrostomy
tubes. L nephrostomy tube was replaced on ___, R replaced on
___. The patient tolerated the procedure without difficulty and
had good output (L>R - has reportedly baseline reduced output
from R kidney) from both tubes.
# Citrobacter UTI: very positive urinalysis with low grade
fever. Pt was treated with IV Ceftriaxone with good response.
He was afebrile and had no leukocytosis during the hospital
stay. Repeat u/a showed 21 WBC/hpf with a negative urine
culture. Given the complicated nature of the UTI (in setting of
bilateral nephrostomy tubes), a total of 10 days of abx will
given. After completing 5 days of abx (started ___, he will be
given an additional 5 days of PO ceftin.
.
#Prostate cancer: Appears to have advanced since prior CT. The
CT showed "progression of metastatic prostate cancer, marked by
an increase in size of retroperitoneal lymphadenopathy and
number of osseous metastases. No comparison for extensive liver
metastases. The primary mass invades the seminal vesicles and
likely the anterior wall of the rectum." A repeat PSA here
showed level of 141.9 (actually decreased compared to past). He
was evaluated by Dr. ___ in the hospital and has
a follow up visit in 2 weeks.
.
#HTN: benign
--moderately controlled labetalol
--holding asa in anticipation of nephrostomy tube placement.
The aspirin can be resumed in 1 week's time.
.
#Depression:
--cont lexapro
.
Emergency contact: ___ (wife) ___ (c),
___ (h)
Letter sent to PCP ___
___ on Admission:
ascorbic acid ___ daily
asa 81
atorvastatin 20mg qhs
bicalutamide 50mg daily
calcium acetate 667mg 2 caps tid
cyanocobalamin 50mcg daily
colace 100mg bid
folic acid 1mg daily
labetalol 400mg bid
lexapro 10mg daily
oxycodone 2.5mg tid
miralax prn
senna 1 tab bid
sorbitol 15cc solution bid
tylenol prn
vit d3 1000 iu daily
Discharge Medications:
1. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).
10. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. sorbitol 70 % Solution Sig: One (1) 15 cc Miscellaneous BID
(2 times a day).
13. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
14. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. Ceftin 250 mg Tablet Sig: One (1) Tablet PO twice a day for
5 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
- Bacterial UTI
- Hydronephrosis
- Metastatic Prostate CA
.
Secondary Diagnoses
- Hx of CVA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with a urinary tract infection
and were treated with antibiotics. In addition you had both of
your nephrostomy tubes replaced.
.
Please continued to take all of your medications as prescribed.
Please take the antibiotics (ceftin) for an additional 5 days.
.
Please resume the aspirin in 1 week's time (___).
.
Please keep all of your appointments.
Followup Instructions:
___
|
10401337-DS-11 | 10,401,337 | 28,174,159 | DS | 11 | 2179-06-07 00:00:00 | 2179-06-07 15:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
decreased nephrostomy tube output
Major Surgical or Invasive Procedure:
Left nephrostomy tube replacement by ___ ___
Transfusion 1 unit pRBC for anemia
History of Present Illness:
___ with widespread metastatic prostate cancer on
lupron/casodex, obstructive uropathy s/p bilateral nephrostomy
tubes, recent CVA, HTN and CAD who presents from ___
___ with c/o diminished nephrostomy output. No other c/o.
Came because last time this occurred the patient was diagnosed
with UTI. States he currently has no drainage from either tube.
Last drained yesterday. At that time noted a little blood in
nephro output but otherwise no hematuria including from urine
via urethra. No flank pain, back pain, abd pain, fevers, chills,
sweats, dysuria. Of note, he was recently hosp on ___ for
UTI. U/A pos and Cx grew citrobacter as well as contaminant
flora - report read to intepret with caution. Pt with fever to
100.1 max on admission, no leukocytosis, no further fevers. was
treated with CTX and discharged on cefitin (completed 10d course
on ___. Nephro tubes last changed on ___ (left) and ___
(right).
In the ED, VS 98.9 70 147/102 20 100%. Rectal negative. urine
draining from nephro tubes. Labs significant for Hct 17.1 ___
___, WBC 3.9, cr 1.3 (baseline 1.3), LFTs WNL except AP and
LDH which are similar to priors in ___. Hapto WNL. INR 1.4
at baseline. U/A pos for RBC >182, WBC 122, few bacteria, orange
and hazy. Given 1 unit PRBC. Started on CTX. CT A/P showed
dislodged left nephro tube. renal u/s unremarkable. CXR showed
Small bilateral pleural effusions. VS on transfer 99po 78 22 98%
RA 163/99
On the floor VS 98.9, 171/108, 83, 18, 98% RA. Pt resting and
has no c/o.
Past Medical History:
Metastatic prostate cancer s/p XRT on lupron/casodex
Obstructive uropathy s/p bilateral nephrostomy tubes
Recent CVA with left arm hemiparesis
HTN
CAD
Social History:
___
Family History:
No fhx of prostate cancer.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VITALS: 98.6F, 160/88, HR 77, RR 20, 99%RA
GENERAL: male in NAD, affect sad, sitting on edge of bed
HEENT: MMM,PERRL, EOMI
NECK: neck supple no ___ or JVD appreciated
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, non distended
BACK: no erythema or drainage at nephro tube site. Both draining
light yellow urine
EXTREMITIES: No c/c/e, ___ strength in LLE, ___ strength in LUE,
___ upper and lower strength on right
NEUROLOGIC: A+OX3, CN II-XII grossly intact
DISCHARGE PHYSICAL EXAMINATION:
VITALS: ___, BP 158/92, HR 73, RR 16, 95%RA
GENERAL: male in NAD, upright in bed
HEENT: MMM,PERRL, EOMI
NECK: neck supple no ___ or JVD appreciated
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, non distended
BACK: no erythema or drainage at nephro tube site. Both draining
light yellow urine, left more than right
EXTREMITIES: No c/c/e, ___ strength in LLE, ___ strength in LUE,
___ upper and lower strength on right
NEUROLOGIC: A+OX3, CN II-XII grossly intact
Pertinent Results:
ADMISSION LABS:
___:30PM BLOOD WBC-3.9* RBC-2.16*# Hgb-5.7*# Hct-17.1*#
MCV-80* MCH-26.6* MCHC-33.5 RDW-16.9* Plt ___
___ 03:21AM BLOOD Hct-29.2*#
___ 04:10PM BLOOD Glucose-86 UreaN-10 Creat-1.3* Na-140
K-3.8 Cl-105 HCO3-28 AnGap-11
___ 04:10PM BLOOD ALT-24 AST-30 LD(LDH)-279* AlkPhos-382*
TotBili-0.2
___ 04:10PM BLOOD Albumin-3.6 Calcium-9.1 Phos-3.2 Mg-1.6
___ 04:10PM BLOOD Hapto-238*
___ 04:14PM BLOOD Lactate-0.8
DISCHARGE LABS:
___ 07:26AM BLOOD WBC-6.1 RBC-3.84* Hgb-9.9* Hct-29.4*
MCV-77* MCH-25.9* MCHC-33.8 RDW-16.3* Plt ___
___ 07:26AM BLOOD Glucose-97 UreaN-9 Creat-1.2 Na-138 K-3.3
Cl-104 HCO3-24 AnGap-13
___ 07:26AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.9
PERTINENT IMAGING:
IMPRESSION:
1. Left nephrostomy catheter is malpositioned, currently within
the lower pole renal cortex. New mild to moderate left
hydronephroureter.
2. New right nephrostomy catheter in satisfactory position with
resolution of the previously noted hydronephroureter.
3. Heterogeneous pelvic mass compatible with known prostate
adenocarcinoma, similar to prior, with invasion into the bladder
and possibly the rectum. Retroperitoneal lymphadenopathy and
diffuse osseous metastases, similar to prior.
4. Small bilateral pleural effusions.
PERTINENT MICRO:
URINE CULTURE ___ NO GROWTH - FINAL
BLOOD CULTURE ___ NO GROWTH TO DATE (___) - PRELIM
Brief Hospital Course:
___ gentleman with widespread metastatic prostate cancer on
lupron/casodex, obstructive uropathy s/p bilateral nephrostomy
tubes, recent CVA, HTN and CAD who presented with diminished
nephrostomy output who was found to have a dislodged left
nephrostomy tube.
# Dislodged L nephostomy tube: Patient presented from ___
___ with decreased output from left nephrostomy tube
and a small amount of hematuria from that side. At baseline,
right tube output is usually lower than left. Urine culture were
not consistent with UTI, and CT abdomen was acquired in the ED
show left tube dislodgement. ___ replaced the left tube on
___ and output was much improved the following day. Patient
was hemodynamically stable throughout admission.
-Continue to monitor UOP from nephrostomy tubes. Patient reports
that right tube output is chronically lower than left.
# Anemia: Patient had Hct in ED of 17.1, was transfused 1 unit
pRBCs. Repeat Hct following transfusion was 29.2, so original
value likely spurius, possibly drawn downstream of IVF. Patient
was hemodynamically stable and on discharge Hct was 29.4.
-CBC should be followed weekly by outpatient care givers
# Documented history of the following conditions, for which
patient was clinically stable on home regimen:
#depression (escitalopram)
#HTN (labetalol)
#CAD (atorvastatin)
#Metastatic prostate cancer (oxycodone, APAP)
Transitional issues for this patient:
- Continued rehabilitation at ___.
- Pending studies: Blood cultures drawn ___ no growth at
time of discharge.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Ascorbic Acid ___ mg PO DAILY
2. Atorvastatin 20 mg PO HS
3. Calcium Acetate 1334 mg PO TID W/MEALS
4. Cyanocobalamin 50 mcg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Labetalol 400 mg PO BID
7. Escitalopram Oxalate 10 mg PO DAILY
8. OxycoDONE (Immediate Release) 2.5 mg PO TID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Acetaminophen 325 mg PO Q6H:PRN pain
11. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Cyanocobalamin 50 mcg PO DAILY
3. OxycoDONE (Immediate Release) 2.5 mg PO TID
4. Vitamin D 400 UNIT PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Labetalol 400 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Escitalopram Oxalate 10 mg PO DAILY
9. Calcium Acetate 1334 mg PO TID W/MEALS
10. Ascorbic Acid ___ mg PO DAILY
11. Atorvastatin 20 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left nephrostomy tube dislogement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care during your
hospitalization at ___. You were admitted for decreased urine
from your nephrostomy tubes and a CAT scan of the abdomen showed
that the left tube was not in the correct position. The
interventional radiologists replaced the tube and your urine
output improved. You are going to be discharged back to rehab.
It is important that you follow up with your oncologist at the
appointment listed below.
No changes were made to your home medications.
Followup Instructions:
___
|
10401337-DS-12 | 10,401,337 | 29,230,506 | DS | 12 | 2179-06-12 00:00:00 | 2179-06-12 18:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
no right nephrostomy tube drainage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with widespread metastatic prostate cancer on
lupron/casodex, obstructive uropathy s/p bilateral nephrostomy
tubes, recent CVA, HTN and CAD who presents with lack of right
nephrostomy tube output. He was recently admitted from ___
and had his L nephrostomy tube replaced due to poor output. UA
during that admission with copious WBCs, but negative culture.
Denies fever, chills, abdominal pain, flank pain.
No SOB, CP, nausea or vomitting.
.
In the ED, initial VS were:97.8 72 140/95 16 100% RA. Labs
notable for Cr 1.6 (baseline 1.2-1.3), HCT 29 (baseline ___,
MCV 78. CT showed appropriate placement of bilateral nephrostomy
tubes without hydronephrosis. VS prior to transfer were: 98.6po,
69, 18, 166/96 96% RA.
Past Medical History:
Metastatic prostate cancer s/p XRT on lupron/casodex
Obstructive uropathy s/p bilateral nephrostomy tubes
Recent CVA with left arm hemiparesis
HTN
CAD
Social History:
___
Family History:
No fhx of prostate cancer.
Physical Exam:
Admission PHYSICAL EXAMINATION:
VITALS: 98.2 160/98 69 20 100%RA
GENERAL: NAD, pleasant
HEENT: PERRL, EOMI, MMM
LUNGS: CTAB, no W/R/R
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3, normal mentation
Discharge physical exam:
VITALS: 98.2 140/98 66 18 98%RA
GENERAL: NAD, pleasant, lethargic, arousable to voice
HEENT: PERRL, EOMI, MMM
LUNGS: CTAB, no W/R/R but poor effort on exam
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
BACK: nephrostomy tubes in place, nontender without exudate,
left tube draining yellow urine with some red sediment, right
tube draining scnat fluid
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3, normal mentation
Pertinent Results:
___ 06:28AM BLOOD WBC-4.7 RBC-3.79* Hgb-10.0* Hct-29.6*
MCV-78* MCH-26.3* MCHC-33.7 RDW-16.6* Plt ___
___ 10:40PM BLOOD WBC-4.8 RBC-3.73* Hgb-10.0* Hct-29.1*
MCV-78* MCH-26.7* MCHC-34.3 RDW-16.6* Plt ___
___ 06:28AM BLOOD Plt ___
___ 10:40PM BLOOD Plt ___
___ 06:35AM BLOOD UreaN-10 Creat-1.2 Na-138 K-3.8 Cl-103
HCO3-24 AnGap-15
___ 10:40PM BLOOD Glucose-100 UreaN-14 Creat-1.6* Na-140
K-4.4 Cl-105 HCO3-25 AnGap-14
CT abdomen pelvis IMPRESSION:
1. Appropriate positioning of bilateral nephrostomy tubes
within the renal
pelvises. No hydroureter.
2. Unchanged heterogeneous pelvic mass compatible with known
prostatic
adenocarcinoma with invasion into the bladder and possibly the
rectum.
Unchanged retroperitoneal and osseous metastases.
3. Small left pleural effusion.
Brief Hospital Course:
___ year old man with widespread metastatic prostate cancer on
lupron/casodex, obstructive uropathy s/p bilateral nephrostomy
tubes, presents with lack of urine output from right nephrostomy
tube.
# Blocked right nephrostomy tube: Appears to be in appropriate
position per CT. No associated hydronephrosis. ___ flushed tube
and found no blockage or obstruction. There was no need to
replace or reposition tube.
Notably, right tube chronically drains less than left and may
have worsened recently. Kidney function is stable and back to
baseline, indicating likely appropriate compensation of the left
kidney. Right side will drain 20cc in comparison to >500cc on
the left; this is not obstruction but likely new baseline.
# ___: Borderline ___ as increase by 0.3, and repeat back to
normal. No obstruction, tube is patent.
#HTN: Continued labetolol, required two doses of hydralazine to
bring BP down from systolic170-180s. ___ consider increasing or
adding medication as outpatient.
# Metastatic prostate cancer:
- Continue lupron/casodex as outpatient
# Depression: continue escitalopram
# HLD: continue atorvastatin
# Anemia: at recent baseline, suspect secondary to CKD
- trend HCT
# Health Maintenance:
- continue B12, folic acid, calcium, vit C
Transitional issues:
-CODE STATUS: Full confirmed
-EMERGENCY CONTACT: ___ (HCP) ___
-follow up with PCP
-___ up with Heme/Onc
-follow up with Urology
-increase BP meds as outpatient as needed
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Cyanocobalamin 50 mcg PO DAILY
3. OxycoDONE (Immediate Release) 2.5 mg PO Q8H:PRN pain
4. Vitamin D 400 UNIT PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Labetalol 400 mg PO BID
hold for HR <60 or SBP <90
7. FoLIC Acid 1 mg PO DAILY
8. Escitalopram Oxalate 10 mg PO DAILY
9. Calcium Acetate 1334 mg PO TID W/MEALS
10. Ascorbic Acid ___ mg PO DAILY
11. Atorvastatin 20 mg PO HS
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Ascorbic Acid ___ mg PO DAILY
3. Atorvastatin 20 mg PO HS
4. Calcium Acetate 1334 mg PO TID W/MEALS
5. Cyanocobalamin 50 mcg PO DAILY
6. Escitalopram Oxalate 10 mg PO DAILY
7. OxycoDONE (Immediate Release) 2.5 mg PO Q8H:PRN pain
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. FoLIC Acid 1 mg PO DAILY
10. Labetalol 400 mg PO BID
hold for HR <60 or SBP <90
11. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Obstructed right nephrostomy tube
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because there was concern that
your right nephrostomy tube was not functioning correctly. You
had a CT which showed that the tube was in the right place, and
you were seen by interventional radiology who made sure that it
was flushing properly. It appears that your right nephrostomy
tube always put out less urine than the left. It is possible
that this is getting worse now due to worsening kidney function,
but the tube is working. However your overall kidney function is
back to normal.
Please continue taking your medications as before your
admission.
Followup Instructions:
___
|
10401337-DS-13 | 10,401,337 | 25,925,458 | DS | 13 | 2179-08-29 00:00:00 | 2179-08-31 23:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fatigue; hematuria
Major Surgical or Invasive Procedure:
R NEPHROSTOMY TUBE REPLACED
History of Present Illness:
___ yo M with h/o metastatic prostate cancer s/p XRT, on
lupron/casodex, with obstructive uropathy s/p bilateral
nephrostomy tubes, HTN, CAD, and recent CVA with left arm
hemiparesis, with two week history of fatigue, weakness, and
intermittent bleeding from his nephrostomy tubes. Pt missed
previously arranged urology follow up.
Pt was seen in HCA today and felt to have possible UTI; he was
referred to the ED for urology evaluation. The urology team
felt that he would need eventual removal/internalization of
urostomy, but that this should be deferred until after his UTI
is treated. He received ceftriaxone in the ED for presumed UTI.
The OMED (oncology) service was capped, so he was admitted to
the medical service for further care.
He feels better now, at "65%; I was at 50% yesterday." He
reports some mild transient back pain when standing, but
otherwise feels ok.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: + fatigue/malaise
HEENT: [X] All Normal
RESPIRATORY: + cough (no recent change)
CARDIAC: [X] All Normal
GI: [X] All Normal
GU: As per HPI
SKIN: [X] All Normal
MS: [X] All Normal
NEURO: [X] All Normal
ENDOCRINE: [X] All Normal
HEME/LYMPH: [X] All Normal
PSYCH: [X] All Normal
[+]all other systems negative except as noted above
Past Medical History:
-Metastatic prostate cancer s/p XRT on lupron/casodex
-Obstructive uropathy s/p bilateral nephrostomy tubes
-Recent CVA with left arm hemiparesis
-HTN
-CAD s/p NSTEMI
Social History:
___
Family History:
No history of prostate cancer.
Physical Exam:
Admission PE
VS: T = afeb P = 78 BP = 130/70 RR = 12 O2Sat = 96 % on RA
GENERAL:
Mentation: Alert, speaks in full sentences.
Eyes:NC/AT, PERRL, EOMI
Ears/Nose/Mouth/Throat: MMM
Respiratory: CTA bilat
Cardiovascular: RRR, nl. S1S2
Gastrointestinal: soft, NT/ND, normoactive bowel sounds
Genitourinary: R nephrostomy with min output; L nephrostomy with
min bloody output
Skin: no rashes or lesions noted
Extremities: No edema
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-motor: normal bulk, strength and tone throughout.
Psychiatric: WNL
.
Discharge PE
VSS
GU: NT with normal output, slight ___ color to it, no pain
localized to NT sites, no expanding hematoma
PE otherwise wnl
.
Pertinent Results:
___ 01:55PM WBC-5.3 RBC-3.93* HGB-10.2* HCT-30.4* MCV-78*
MCH-26.0* MCHC-33.5 RDW-17.8*
___ 01:55PM NEUTS-65.0 ___ MONOS-4.9 EOS-2.6
BASOS-0.9
___ 01:55PM PLT COUNT-234
___ 05:00PM GLUCOSE-111* UREA N-20 CREAT-1.7* SODIUM-139
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-24 ANION GAP-17
___ 05:00PM CALCIUM-9.0 PHOSPHATE-3.2 MAGNESIUM-1.8
___ 05:00PM URINE COLOR-Orange APPEAR-Cloudy SP ___
___ 05:00PM URINE BLOOD-LG NITRITE-POS PROTEIN->300
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-7.5 LEUK-LG
___ 05:00PM URINE RBC->182* WBC->182* BACTERIA-MANY
YEAST-NONE EPI-2
.
___ Lumbar spine XR
IMPRESSION:
1. Intact nephroureteral stents.
2. Osseous metastasis.
3. No acute compression fracture.
.
___ ___ procedure
ReportCONCLUSION: Uncomplicated replacement of right-sided
nephrostomy drain
Preliminary Reportthrough existing tract. While the initial
order requested internalization, in
Preliminary Reportdiscussion with urology as above, this was
deferred to a later time.
.
___ CXR
IMPRESSION: No acute cardiopulmonary process.
.
EKG ___
Normal sinus rhythm. Left axis deviation. Possible inferior
myocardial
infarction of indeterminate age. Q-T interval prolonged for
rate.
Non-specific ST-T wave abnormalities. Slightly delayed
precordial R wave
transition of uncertain significance. Compared to the previous
tracing
of ___ inferior QRS morphology is now more suggestive of
prior inferior
myocardial infarction. Clinical correlation is suggested.
Otherwise, no
diagnostic change.
.
___ 3:20 pm URINE Site: NEPHROSTOMY RIGHT
NEPHROSTOMY.
**FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed fecal flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.
>100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| STENOTROPHOMONAS
(XANTHOMONAS) MALTOPH
| |
AMPICILLIN------------ 16 I
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- ___ I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
.
BC negative from ___
.
Brief Hospital Course:
.
___ yo M with h/o HTN, CAD, and metastatic prostate CA with
ureteral obstruction requiring bilateral nephrostomy placement,
admitted with two week history of fatigue, in the setting of
suspected UTI
.
# e. coli and stenotrophomonas UTI with bilateral nephrostomy
He was empirically started on ceftriaxone in house. The first
hospital night his R nephrostomy tube dislodged when he moved in
bed and this nephrostomy tube was replaced on ___ by ___
following discussion with urology and ___. At this time urology
did not advise that the drains be internalized. His course was
complicated by some blood tinted urine output from the right
sided drain. ___ indicated some level of this is expected and
this improved over time. The patient was transitioned to
Bactrim once the sensitivities returned. The patient was
discharged on 7 additional days of Bactrim. Blood cultures were
negative from the day of admission, his WBC was wnl and he was
AF on the day of discharge.
.
# Low back pain with known bone mets
He had no focal tenderness along his spine, normal rectal tone,
no saddle anesthesia, no new complaints or evidence ___ motor
weakness or numbness. At times he stated pain was because
nephrostomy tubes were in place, but otherwise vague about
location about pain. The day of discharge the patient had no
pain. He was encouraged to use narcotics if necessary for his
pain but he was reluctant. He was sent home with Tylenol and
oxycodone for pain. He was also warned of the side effect of
constipation and advised to use OTC colace for this prn.
.
#Acute on chronic renal failure:
The patient has a history of obstructive uropathy with admission
creat 1.7 (baseline 1.2-1.3), with improving trend to 1.5. The
patient was given a prescription to have this followed as an
outpatient prior to his follow up with Dr. ___ encourage
to stay hydrated.
.
# Metastatic prostate CA
Spoke with his oncologist re: rising PSA and he ___ see him on
___ to discuss new prostate cancer therapy for castrate
resistant disease and management of bony metastasis, though he
did not currently requiring opiates. He has diffuse disease not
concentrated at one spot now that would benefit from radiation
therapy at this time. Dr. ___ also arrange for loopogram
and evaluation of urinary drainage for assessment of possible
internalization of drain.
.
# Microcytic Anemia (chronic disease)
Patient initially presented with Hgb at 10.2. Recent baseline
appears to be between ___. Patients Hgb stabilized prior to
discharge and the source of the blood loss was likely due to
this procedure. The patient had been on iron supplements before
per Dr. ___ was instructed to continue this.
.
# Coagulopathy
Received 3 doses of vitamin K with minimal improvement. Likely
due to malnutrition although last albumin was wnl.
.
# Transitional Issues:
-Patients Mass Health insurance application was pending and the
discharge plan was reviewed at length with the family.
Unfortunately his options are limited for support until the
patients application is completed. ___ care is unfortunately
not available. The patient and family understood and indicated
they wanted to take the patient home and attempt to care for him
themselves along with ___ private pay RN. The plan is to follow
up with Dr. ___ on ___
.
Medications on Admission:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Ascorbic Acid ___ mg PO DAILY
3. Atorvastatin 20 mg PO HS
4. Calcium Acetate 1334 mg PO TID W/MEALS
5. Cyanocobalamin 50 mcg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Labetalol 400 mg PO BID
hold for HR <60 or SBP <90
8. Vitamin D 400 UNIT PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO HS
5. Calcium Acetate 1334 mg PO TID W/MEALS
6. Cyanocobalamin 50 mcg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Labetalol 400 mg PO BID
hold for HR <60 or SBP <90
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Vitamin D 400 UNIT PO DAILY
11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
12. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0
13. Outpatient Lab Work
599.0 UTI-Please draw a CBC and BMP in 1 week prior to
appointment with Dr. ___ (___) if requested by Dr. ___
___ fax to his office, call ___
14. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*20 Tablet Refills:*0
15. Prochlorperazine 5 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 5 mg 1 tablet(s) by mouth every six
(6) hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Facility:
___
Discharge Diagnosis:
BACTERIAL UTI
METASTATIC PROSTATE CANCER
BACK PAIN FROM BONE METASTASIS
RENAL OBSTRUCTION WITH NEPHROSTOMY TUBE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
YOU WERE HOSPITALIZED FOR A BACTERIAL URINARY TRACT INFECTION
(UTI) YOU ___ NEED AN ADDITIONAL WEEK OF ANTIBIOTICS. YOUR
RIGHT NEPHROSTOMY TUBE WAS REPLACED AND FOLLOWING THIS THERE WAS
SOME BLEEDING IN YOUR URINE. YOUR PSA IS RISING AND ___. ___
___ MEET WITH YOU LATER THIS MONTH TO DISCUSS FUTURE
THERAPY FOR YOUR PROSTATE CANCER.
IT IS OK TO TAKE PAIN MEDICATION FOR YOUR BACK PAIN AS THERE IS
SPREAD OF CANCER TO YOUR BONE. TAKING SMALL AMOUNT OF PAIN
MEDICINE WHEN YOU HAVE PAIN ___ NOT LEAD TO ADDICTION.
.
Please discuss with Dr. ___ up with Interventional
Radiology and considering internalizing your kidney drains.
.
Medication changes:
1) oxycodone 5 mg Q4H prn pain
2) bactrim DS 1 tab BID, stop after your last dose on ___
-you should not take lexapro until further disucssion with Dr.
___ your PCP
3) zofran ___ m PO Q4H prn nausea
4) compazine 5 mg PO Q6H prn nausea
Followup Instructions:
___
|
10401617-DS-18 | 10,401,617 | 24,415,026 | DS | 18 | 2130-07-02 00:00:00 | 2130-07-02 17:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Pericardiocentesis, pericardial drain placement ___
History of Present Illness:
___ year old gentleman with a past medical history significant
for diabetes, hypertension, dyslipidemia, obesity, and sleep
apnea recently admitted to ___ from ___ for
evaluation of chest pain, responsive to NTG. Per dc summary, non
specific T wave changes, trops trended x 3 negative, nuclear
stress with normal perfusion, no TTE performed.
In the ED initial vitals were: 151 115/89 18 100% RA
EKG: normal axis, 1:2 aflutter c HR 150, nl intervals
Labs/studies notable for: nl CBC, nl coags, trop neg x 1
Patient was given: 1500 cc NS
Patient evaluated by cardiology in the ED, and bedside echo
showed a large pericardial effusion with tamponade physiology.
Transferred to cath lab for intervention. There he underwent
drainage of 850cc of sanguinous fluid from the pericardium and
placement of drain with significant improvement of his symptoms.
Post procedure bedside echo showed no significant remaining
effusion.
On arrival to the CCU: He confirmed the above history. He was
at ___ last week where workup for ischemia was negative
but no echo performed. He continued to have weakness and dyspnea
on exertion which led him to call his PCP who sent him to the ED
for further evaluation. Currently much improved following
draining of his effusion. No complaints of pain, weakness or
SOB. at this time. He denies any recent viral illness or
prodrome, but does report having some chills/feverish symptoms
intermittently.
REVIEW OF SYSTEMS:
Positive per HPI.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Type 2 Diabetes
- Dyslipidemia
2. CARDIAC HISTORY
- Coronaries - Normal Nuclear Stress
- Pump - 55% on nuclear stress
- Rhythm - sinus
3. OTHER PAST MEDICAL HISTORY
- OSA
- Morbid Obesity
- Asthma
- HTN
- Abdominal hernia
Social History:
___
Family History:
Mother: ___, stroke, myocardial infarction in ___
Father: ___ in ___, CABG. Died of repeat MI
in ___
Physical Exam:
ADMISSION EXAM
==============
GENERAL: Well developed, obese man in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP below clavicle at 30 degrees.
CARDIAC: Regular, Tachycardic. Normal S1, S2. No murmurs, rubs,
or gallops appreciated.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, obese. No hepatomegaly or
splenomegaly appreciated though exam limited by habitus.
EXTREMITIES: Upper extremities warm, well perfused. No clubbing,
cyanosis, or peripheral edema. Lower extremities slightly cool
but pulses palpable bilaterally
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM
==============
Pertinent Results:
ADMISSION LABS
==============
___ 01:19PM BLOOD WBC-9.6 RBC-4.36* Hgb-12.6* Hct-38.2*
MCV-88 MCH-28.9 MCHC-33.0 RDW-12.8 RDWSD-40.5 Plt ___
___ 06:30PM BLOOD WBC-9.0 RBC-4.00* Hgb-11.8* Hct-34.7*
MCV-87 MCH-29.5 MCHC-34.0 RDW-12.7 RDWSD-40.0 Plt ___
___ 01:19PM BLOOD Neuts-62.5 ___ Monos-11.4 Eos-2.7
Baso-0.8 Im ___ AbsNeut-6.02 AbsLymp-2.08 AbsMono-1.10*
AbsEos-0.26 AbsBaso-0.08
___ 01:19PM BLOOD ___ PTT-29.9 ___
___ 01:19PM BLOOD Plt ___
___ 06:30PM BLOOD Plt ___
___ 01:19PM BLOOD Glucose-153* UreaN-34* Creat-1.1 Na-136
K-5.9* Cl-101 HCO3-20* AnGap-21*
___ 06:30PM BLOOD Glucose-111* UreaN-31* Creat-1.0 Na-140
K-4.7 Cl-105 HCO3-24 AnGap-16
___ 01:19PM BLOOD cTropnT-0.01
___ 06:30PM BLOOD Calcium-8.5 Phos-3.7 Mg-1.8
PERTIENT LABS
=============
___ 01:19PM BLOOD cTropnT-0.01
___ 03:09AM BLOOD ___ CRP-136.4*
MICRO
=====
IMAGING/STUDIES
===============
___ PERICARDIOCENTESIS
Interventional Details
Pericardiocentesis was performed from the subxyphoid approach.
Initial pericardial pressure was 30 mmHg. 820 cc Bloody fluid
was removed and sent for studies. Final pericardial pressure was
15 mm Hg.
Cardiac echo showed only a small amount of residual pericardcial
fluid.
Intra-procedural Complications: None
Impressions:
Successful pericardiocentesis
Recommendations
Drain left in overnight in CCU with removal tomorrow if repeat
echo shows no reaccumulation of fluid. Workup of cause for
pericardial fluid
___ TTE
The estimated right atrial pressure is ___ mmHg. There is
abnormal septal motion/position. There is a small to moderate
sized pericardial effusion. The effusion appears circumferential
however there is predominance of the pericardial effusion over
the inferolateral wall. There is no chamber collapse in
diastole. The respirophasic variation of the IVC suggests normal
RA pressure. There is variation of mitral inflow and in
particular RV outflow. The variation is partly respirophasic but
also follows preceeding RR interval length in particular for
mitral inflow but RV outflow variation are purely respirophasic
in absence of large swings of the heart causing insonation angle
to vary only slightly. LV function assessment is very difficult
to unreliable without IV contrast due to tachycardia and
variation in LVEF due to variation in RR interval and also
EXTREMELY compromised image quality. The only area with
acceptable echocardiographic windows is the subcostal view which
suggest septal dyskinesis due to IVCD and probably mild
reduction of intrinsic myocardial contractility of the
inferoseptal and anterolateral myocardial segments. Regional
wall motion abnormalities cannot be excluded in other walls
since those have not been visualized.
IMPRESSION:
1) Small to moderate pericardial effusion largely
circumferential however more prominent over inferolateral wall.
Low pressure tamponade physiology in setting of what appears on
echocardiogram atrial flutter with variable block cannot be
excluded.
2) Possible mild reduction in global LV systolic function.
DISCHARGE LABS
==============
Brief Hospital Course:
___ is a ___ year old man with history of HTN, HLD,
morbid obdesity, and recent episodes of non-ischemic chest pain
who presented with cardiac tamponade s/p
pericardiocentesis/pericardial drain placement and
anticoagulated due to aflutter without reaccumulation.
# CORONARIES: SPECT Stress Negative ___
# PUMP: Last EF 55% at stress, 50% TTE ___
# RHYTHM: Atrial Flutter, rates 60-80's
# CARDIAC TAMPONADE:
# PERICARDITIS
Recent chest pain ___ have been related. Presented with
tamponade physiology. Drained 850cc sanguinous fluid initially,
total 1100cc before removal of drain. Started on indomethacin
and colchicine. No further drain output next ___ hours and repeat
echo showed smaller effusion on ___. Drain pulled ___ AM without
complication and patient transferred to the floor. Indomethacin
was discontinued ___ due to concurrent anticoagulation, he was
continued on colchicine and aspirin. Concern for possible
constrictive physiology given concurrent signs of CHF and dense
effusion on ___, however rate limiting repeat focused ___ TTE
interpretation with regard to ventricular interdependence,
respirophasic variation. PPD read ___ was negative at 48hours.
#ATRIAL FLUTTER
Present on admission, likely due to pericarditis/effusion.
Persistent with HR elevated to 150's. Metoprolol was uptitrated
then defractionated to 200mgXL with good effect. Patient with
CHADS@ of 2, started on Heparin ___ while drain in place without
further bleeding as assessed on follow up echocardiogram ___,
___. Warfarin was selected for anticoagulation due to obesity,
started ___.
TRANSITIONAL ISSUES
===================
[] anticoagulation -- at least 1 month therapeutic then question
cardioversion if necessary
[] Next INR ___
[] repeat inflammatory markers as outpatient after improvement
[] consider nutritionist referral, patient very motivated for
weight loss
=============
# CODE: FULL
# CONTACT/HCP: ___, wife, ___,
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q24H
2. Lisinopril 30 mg PO DAILY
3. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
5. Atorvastatin 80 mg PO QPM
6. dulaglutide 1.5 mg/0.5 mL subcutaneous 1X/WEEK
7. Aspirin 81 mg PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. cinnamon bark Dose is Unknown oral DAILY
11. psyllium husk Dose is Unknown oral DAILY
12. Gabapentin 300 mg PO BID
Discharge Medications:
1. Colchicine 0.6 mg PO BID
RX *colchicine 0.6 mg 1 capsule(s) by mouth twice a day Disp
#*30 Capsule Refills:*0
2. Metoprolol Succinate XL 150 mg PO BID
RX *metoprolol succinate [Toprol XL] 50 mg 3 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
3. Warfarin 7.5 mg PO DAILY16
RX *warfarin [Coumadin] 7.5 mg 1 tablet(s) by mouth daily Disp
#*10 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. cinnamon bark Dose is Unknown oral DAILY
7. dulaglutide 1.5 mg/0.5 mL subcutaneous 1X/WEEK
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. Gabapentin 300 mg PO BID
10. Lisinopril 30 mg PO DAILY
11. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
12. Pantoprazole 40 mg PO Q24H
13. psyllium husk Dose is Unknown oral DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. HELD- Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain This
medication was held. Do not restart Nitroglycerin SL until ___
follow up with your cardiologist.
Discharge Disposition:
Home
Discharge Diagnosis:
Pericardial effusion
Pericarditis
Aflutter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of ___ at the ___
___!
Why was I admitted to the hospital?
-___ were admitted because ___ had shortness of breath and chest
pain. ___ were found to have fluid around your heart due to
inflammation called "pericarditis." This can happen for a
number of reasons; ___ probably had a viral infection although
some test are still pending.
- ___ were found to be in an abnormal heart rhythm called
"atrial flutter" which can happen when ___ have fluid around
your heart
What happened while I was in the hospital?
-___ had the fluid around your heart drained called a
"pericardiocentesis." This fluid is being analyzed at our lab.
-___ were started on medication to treat the inflammation to the
sac around your heart.
-___ were started on medication to keep your heart from going
too fast in the abnormal rhythm
-___ were started on blood thinners (coumadin) reduce the risk
of stroke when ___ are in this abnormal heart rhythm
What should I do after leaving the hospital?
- take your medications as prescribed
- follow up with your doctors as directed
- ___ need frequent labwork to monitor your blood levels
("INR") while on coumadin
Thank ___ for allowing us to be involved in your care, we wish
___ all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10401698-DS-9 | 10,401,698 | 22,486,645 | DS | 9 | 2194-12-10 00:00:00 | 2194-12-11 21:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Pollen/Hayfever / Midazolam / Neurontin / bees
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female h/o mixed collagen vascular disorder, UC,
depression, anxiety, PTSD, who is POD #7 from right TKR ___
who presents with altered mental status.
.
She is being admitted from rehab due to increasing confusion and
refusing meds. She currently denies a psych history but history
unclear. She is "eccentric and reclusive" per her POA who is
with her. She was admitted ___ to ___ for elective right
TKR with uncomplicated course and was discharged to rehab. She
has been increasingly more "agitated" and "tangential" per
psychiatrist at rehab, who put a ___ on her for refusing
Rx and inability to make safe decisions. She was sent in for
psychiatric evaluation.
.
In the ED, initial vitals were T 99 98 18 126/73 97% RA. Labs
were significant for Hct 22.5, ESR 60, tox positive for opiates
and amphetamines, ___ 102. Seen by ortho who recommended
toxic/metabolic workup and did not feel indicated to tap knee.
CT head showed no acute process. Given 1L NS, got 2.5mg haldol
IM. Admitted for post-operative delerium vs psych
decompensation. Most recent vitals 98.6 89 18 125/84 99% RA. POA
was in ED, agreed that pt is not herself, speech, thought
process and content are off.
.
Currently, her pt care advocate is present and provides
additional Hx; pt is at baseline "eccentric" but very
intelligent. Since ___, pt has been becoming more and more
agitated, worsening on ___ and ___. It is harder for her to
communicate, and she keeps saying she is tired.
Per ___ notes, they had to take 2 box cutters away from pt
PTA; pt was refusing rehab exercises.
Pt currently endorses some pain at R knee where she had the
surgery. Denies HA, SOB, CP, abdom pain, diarrhea, dysuria,
vomiting/nausea. Says that she has to keep moving to avoid blood
clots. No constipation.
Past Medical History:
Mixed collagen vascular disorder
Sjogren's syndrome
Ulcerative colitis
Rheumatic fever
Cervical spinal stenosis
Migraines
Depression
Anxiety
Posttraumatic stress disorder
Raynaud's disease
Social History:
___
Family History:
negative with the exception of psoriasis.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 98.3F, BP 141/61, HR 82, R 17, O2-sat 95% RA
GENERAL - thin-appearing woman lying in bed, keeps eyes closed
throughout H+P, disheveled hair, fidgeting and squirming all 4
limbs throughout H+P.
HEENT - NC/AT, PER, not immediately reactive to light, EOMI,
sclerae anicteric, dry mucous membranes, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, nl S1-S2, ___ RUS and LUS border
systolic murmur
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, some guarding on
exam but nontender throughout.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions; fentanyl patch in LLQ on abdomen. R
knee has surgical scar with staples, some surrounding erythema
with no drainage
NEURO - awake and conversant, observed to be talking to herself
when ___ else is in the room, A&Ox3, making frequent hand,
foot, and mouth motions, CNs II-XII grossly intact, muscle
strength ___ throughout, sensation grossly intact throughout, no
asterixis, unsteady gait. Hyperreflexic throughout, low to
normal tone, no rigidity. Few beats of clonus on feet, but not
marked.
.
DISCHARGE PHYSICAL EXAM:
VS - Temp 97.3F, BP 118/75, HR 83, R 18, O2-sat 100% RA
GENERAL - thin-appearing woman lying in bed. pleasant this AM,
much less fidgety and squirmy compared to admission.
HEENT - NC/AT, EOMI, sclerae anicteric, dry mucous membranes, OP
clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, nl S1-S2, ___ RUS and LUS border
systolic murmur
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, some guarding on
exam but nontender throughout.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions; fentanyl patch in LLQ on abdomen. R
knee has surgical scar with staples, some surrounding erythema
with no drainage (less on ___ than ___
NEURO - awake and conversant, pleasant and cooperative with H+P,
A&Ox3, CNs II-XII grossly intact, muscle strength ___
throughout, sensation grossly intact throughout, no asterixis,
slightly unsteady gait on ___.
Pertinent Results:
ADMISSION LABS:
___ 01:30PM BLOOD WBC-6.7 RBC-2.42* Hgb-7.4* Hct-22.5*
MCV-93 MCH-30.7 MCHC-33.0 RDW-13.9 Plt ___
___ 01:30PM BLOOD Neuts-83.5* Lymphs-8.9* Monos-4.3 Eos-3.1
Baso-0.2
___ 01:30PM BLOOD ___ PTT-33.0 ___
___ 01:30PM BLOOD ESR-60*
___ 01:30PM BLOOD ALT-32 AST-27 CK(CPK)-79 AlkPhos-128*
TotBili-0.4
___ 01:30PM BLOOD Albumin-3.3* Calcium-8.7 Phos-4.7* Mg-2.0
___ 01:30PM BLOOD TSH-1.3
___ 01:30PM BLOOD CRP-85.6*
___ 01:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-POS
___ 01:35PM BLOOD Glucose-101 Lactate-1.4 Na-138 K-4.3
Cl-100 calHCO3-30
.
DISCHARGE LABS:
___ 07:05AM BLOOD WBC-3.9* RBC-2.65* Hgb-8.1* Hct-24.7*
MCV-93 MCH-30.8 MCHC-33.0 RDW-14.4 Plt ___
___ 06:20AM BLOOD Glucose-84 UreaN-8 Creat-0.6 Na-141 K-4.5
Cl-104 HCO3-29 AnGap-13
___ 06:20AM BLOOD Calcium-8.5 Phos-4.4 Mg-2.1
.
MICROBIOLOGY:
___ 1:40 pm BLOOD CULTURE SET#2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 1:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 1:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
.
IMAGING:
.
CXR:
IMPRESSION: No visualized acute cardiopulmonary process.
.
CT head:
IMPRESSION: No acute intracranial process.
.
R Knee XR:
FINDINGS: AP and cross-table lateral views of the right knee are
compared to
previous exam from ___. Postoperative changes of
total knee
arthroplasty are again seen. There is no periprosthetic lucency.
Small
suprapatellar joint effusion is again seen. Overlying soft
tissue swelling
has decreased. Skin staples remain in place.
IMPRESSION: No acute fracture. Small suprapatellar effusion.
Brief Hospital Course:
Ms. ___ is a ___ year old female h/o mixed collagen vascular
disorder, UC, depression, anxiety, PTSD, who is POD #7 from
right TKR ___ who presents with altered mental status.
.
# Encephalopathy, acute, related to medications (likely
including dextroamphetamine and opiates in part): Pt was
reported to be increasingly more "agitated" and "tangential" per
psychiatrist at rehab, who put a ___ on her for refusing
Rx and inability to make safe decisions. Seen by psych in ED,
who recommend medical w/u before psych eval. Her neuro exam is
nonfocal, although her mannerisms and baseline
fidgeting/frequent motor movements suggest some level of
agitation or nervousness.
In summary, she likely had delirium, likely caused by a
toxic-metabolic encephalopathy. Infection and metabolic causes
were ruled out; she had recently been d/c'd after her TKR on a
75mcg fentanyl patch and ___ of dilaudid q4hr, and also was
receiving dextroamphetamine standing (she had not taken this for
several months) and ritalin. TSH was wnl. We decreased doses of
narcotics (to 50mcg fentanyl patch, 4mg hydromorphone as
needed)), cont APAP and ibuprofen. Per psych recs, we held her
dextroamphetamine, restarted her methylphenidate, held diazepam;
decreased amitriptyline dose, cont duloxetine 60mg BID. She did
not require haldol on the floor. As of ___ and ___, the pt
was much more calm and cooperative and had no complaints, and
per the ortho team who saw her previously she was back to her
mental status baseline.
.
#Acute on chronic anemia: Admission Hct 22.5, same as Hct upon
d/c after TKR, but her baseline is in low-mid 30___s. Likely ___
typical blood loss after TKR. Fe studies at OSH had Fe 24, TIBC
174, Transferrin 13.8, c/w anemia of chronic dz; we continued Fe
repletion.
.
#s/p recent Total knee replacement by Dr. ___: eval'd by ortho
in ED, who recommended no indication for knee arthrocentesis at
this time, and to keep the knee elevated.
.
#Inflammatory states: Mixed collagen vascular disorder/Sjogren's
syndrome/Ulcerative colitis. Do not appear to be active.
.
#Psych: pt has h/o Depression, Anxiety, Posttraumatic stress
disorder.
-cont psych Rx as above
.
TRANSITIONS OF CARE:
The following changes were made to her medications:
NEW:
-Ibuprofen for pain
.
CHANGED:
-decreased Amitriptyline to 50mg
-decreased fentanyl patch to 50mcg/hour
-decreased dilaudid to 4mg every 6 hours
.
STOPPED:
-dextroamphetamine
-diazepam
Medications on Admission:
MEDICATIONS PER D/C SUMMARY IN ___:
1. acetaminophen 500 mg Capsule Sig: ___ Capsules PO Q6H (every
6 hours).
2. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous once a day for 3 weeks.
Disp:*21 syringe* Refills:*0*
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO twice a day for
3 weeks: to begin once lovenox has stopped. .
Disp:*42 Tablet(s)* Refills:*0*
4. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q4H (every 4 hours).
7. fluticasone 100 mcg/Actuation Disk with Device Sig: One (1)
Puff Inhalation BID (2 times a day).
8. amitriptyline 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. dextroamphetamine 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
11. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal BID (2 times a day).
12. methylphenidate 20 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
13. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours).
14. diazepam 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
15. fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours) for 2 weeks: To be continued
for 2 weeks. .
Disp:*2 Patch 72 hr(s)* Refills:*0*
16. cevimeline 30 mg Capsule Sig: One (1) Capsule PO QID (4
times a day). (parasympathomimetic and muscarinic agonist for
dry mouth in Sjogren's)
17. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*200 Tablet(s)* Refills:*0*
18. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
.
Med list per ___ Pharmacy where pt obtains Rx:
Fentanyl 75mcg/hr patches ___
Methylphenidate 20mg qid ___ monthly
Hydromorphone 4mg 1 tab q4h prn pain ___
Cevimiline 30mg tid ___
Amitriptyline 100-150mg qhs ___ monthly
Valcyclovir 1000mg bid ___
Cymbalta 60mg bid ___
Sumatriptan 6mg kit as directed ___
Folbic multivit daily ___
*Dextroamphetamine 5mg po qid, hasn't filled for 2 months b/c
backordered
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
2. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
once a day for 15 days.
Disp:*15 * Refills:*0*
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
to begin once lovenox has stopped.
4. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q4H (every 4 hours) as needed for
SOB/wheezing.
5. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
6. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
7. methylphenidate 10 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
8. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO every
twelve (12) hours.
9. cevimeline 30 mg Capsule Sig: One (1) Capsule PO four times a
day.
10. hydromorphone 2 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*56 Tablet(s)* Refills:*0*
13. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Transdermal
every ___ (72) hours.
Disp:*6 * Refills:*0*
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once
a day.
Disp:*30 Capsule(s)* Refills:*2*
15. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Altered Mental status/Toxic metabolic encephalopathy
Secondary diagnoses:
Total knee replacement (right)
Mixed collagen vascular disorder
Sjogren's syndrome
Migraines
Depression
Anxiety
Posttraumatic stress disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege to provide care for you here at the ___
___. You were admitted because you were
found to have altered mental status at your rehab facility. We
reviewed your medications, and in consultation with the
psychiatry team, we made several adjustments to your medicines.
Your condition has improved and you can be discharged home with
physical therapy.
The following changes were made to your medications:
NEW:
-Ibuprofen for pain
CHANGED:
-decreased Amitriptyline to 50mg
-decreased fentanyl patch to 50mcg/hour
-decreased dilaudid to 4mg every 6 hours
STOPPED:
-dextroamphetamine
-diazepam
Please keep your follow-up appointments as scheduled below.
Followup Instructions:
___
|
10402073-DS-11 | 10,402,073 | 20,966,440 | DS | 11 | 2137-09-02 00:00:00 | 2137-09-02 12:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
Speech disturbance; right face, arm, and leg weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an ___ year old right handed woman with past medical
history of atrial fibrillation not on anticoagulation whom
presents as transfer from ___ with suspected left MCA
syndrome and consideration of possible thrombectomy.
Patient's history was obtained after speaking to her neighbor
whom is her health care proxy on the phone.
Patient's neighbor reports that she had a conversation with
patient on the phone at about 5:00 ___ and patient was in normal
state of health and without dysarthria.
Patient at about 9:30 ___ arrived at neighbor's door and was
signaling for help. Patient could not speak and had a right
facial droop. Patient could walk on her own and did not look
unsteady.
EMS was immediately called and neighbor noticed that the patient
could not reliably follow any directions on both sides of body.
Patient was taken to ___. Patient's initial images were
of poor quality and it could not be determined if there was
proximal major vessel cutoff. Patient was transferred to ___
for escalation of care by ground transportation.
Per neighbor, patient is very independent at baseline and
requires no assistance with activities of daily living.
Patient's
neighbor had patient's home medications and they are:
Aspirin 81 mg daily
Metoprolol 25 mg BID
Torsemide 20 mg daily
Dorzolamide eye drops, 1 drop in right eye twice daily
Latanoprost eye drop, 1 drop in right eye twice daily
Patient's neighbor knew that patient had atrial fibrillation,
but
did not know why she was not on anticoagulation.
Past Medical History:
Atrial fibrillation not on anticoagulation, reason unknown
Chronic swelling of her legs
Right eye problems, neighbor did not know issue
Social History:
Patient lives alone in a home. Patient's husband lives in a
nursing home and has severe alzheimer's disease. Patient has no
children and no other family.
Modified Rankin Scale:
[x] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
Neighbor does not know, not pertinent to this admission.
Physical Exam:
ADMISSION EXAMINATION
=====================
Vitals:
Temperature: 97.8
Blood pressure: 149/98
Heart rate: 67
Oxygen saturation: 95%
General physical examination:
General: Comfortable and in no distress
Head: No irritation/exudate from eyes, nose, throat
Neck: Supple with no pain to flexion or extension
Cardio: Regular rate and rhythm, warm, no peripheral edema
Lungs: Unlabored breathing
Abdomen: Soft, non tender, non distended
Skin: No rashes or lesions
Neurologic:
Mental status:
Patient alert, crying, appears very frustrated and confused.
Patient is trying to communicate, but examiner cannot understand
what she is trying to say (broken words).
Cranial nerves:
Patient with post surgical fixed right ovoid pupil, left pupil
briskly reactive to light. EOMI grossly normal, but cannot
formally test. Facial sensation intact. Right lower quadrant
facial droop. Hearing intact. Patient will not open mouth.
Shoulders sit symmetrically.
Motor examination:
Patient will not comply for formal examination. Patient's left
side of the body is strongly antigravity. Patient's right arm
when lifted at the shoulder quickly falls back the bed. Patient
with antigravity ability to flex at elbow. Patient with right
wrist drop and her fingers are held in flexion. Of note, the
movement of the right upper extremity is greatly improved from
initial presentation when it appeared densely plegic. Patient's
right lower extremity is strongly antigravity.
Sensation:
Patient signals that she appreciates sensation of crude touch in
upper and lower extremities. Patient without tactile neglect.
Coordination:
Could not assess
Reflexes:
Patient would not relax for examination. No pectoral or cross
abductor reflexes. Ankle reflexes symmetric. Strong withdrawal
to plantar reflexes.
Gait:
Deferred.
DISCHARGE EXAMINATION
=====================
Vitals: Temp: 98.2 (Tm 98.5), BP: 103/59 (93-120/42-72), HR: 73
(72-88), RR: 18 (___), O2 sat: 96% (92-100), O2 delivery: RA
General: awake, cooperative, NAD
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: breathing comfortably, no tachypnea or increased WOB
Cardiac: skin warm, well-perfused
Abdomen: soft, ND
Extremities: symmetric, no edema
Neurologic:
-Mental Status: Alert, cooperative. Non-fluent aphasia with
impaired comprehension, though able to follow some midline and
appendicular commands, and somewhat improved compared to prior.
-Cranial Nerves: No BTT in right field OD, though with limited
visual acuity per patient. Face largely symmetric with
activation. Hearing intact to conversation.
-Motor: No pronator drift, able to maintain BUE and BLE against
gravity.
-Sensory: Deferred.
-DTRs: ___.
-Coordination: Deferred.
Pertinent Results:
___ 06:25AM BLOOD WBC-6.1 RBC-3.82* Hgb-11.4 Hct-35.7
MCV-94 MCH-29.8 MCHC-31.9* RDW-16.0* RDWSD-54.9* Plt ___
___ 09:45AM BLOOD ___ PTT-30.0 ___
___ 06:25AM BLOOD Glucose-81 UreaN-11 Creat-0.9 Na-146
K-4.2 Cl-111* HCO3-20* AnGap-15
___ 09:45AM BLOOD ALT-25 AST-32 LD(LDH)-215 CK(CPK)-64
AlkPhos-45 TotBili-1.2
___ 04:10AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.4
___ 09:45AM BLOOD GGT-28
___ 09:45AM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:45AM BLOOD %HbA1c-5.4 eAG-108
___ 09:45AM BLOOD Triglyc-97 HDL-49 CHOL/HD-3.1 LDLcalc-85
___ 09:45AM BLOOD TSH-3.6
___ 09:45AM BLOOD CRP-2.4
___ 02:18AM URINE Color-Straw Appear-Clear Sp ___
___ 02:18AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 02:18AM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
___ 2:18 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 1:28 AM CTA HEAD AND CTA NECK; CT BRAIN PERFUSION
1. Study is degraded by motion and dental amalgam streak
artifact, especially limiting evaluation of the posterior fossa.
2. Within limits of study, no definite acute intracranial
hemorrhage. Please note MRI of the brain is more sensitive for
the detection of acute infarct.
3. CT perfusion demonstrates increased mean transit time with
areas of mildly decreased cerebral blood flow within the left
parietal temporal lobe. If
clinically indicated, consider brain MRI for further evaluation.
4. Decreased distal arborization of the left M3/M4 branches,
which may
correlate with the area of decreased cerebral perfusion.
5. Punctate left expected P1 origin probable infundibulum versus
approximately 1 mm aneurysm.
6. Otherwise grossly patent intracranial and cervical carotid
and vertebral arteries.
7. 1.5 cm partially calcified inferior left thyroid nodule.
Please see
recommendation below.
8. Nonspecific cervical lymphadenopathy as described, image may
be reactive, however neoplastic or inflammatory etiologies are
not excluded on the basis of this examination. Recommend
correlation with oncologic history.
9. Limited imaging lungs demonstrate moderate to severe
centrilobular
emphysematous changes with air trapping. If clinically
indicated, consider dedicated chest imaging for further
evaluation.
___ 6:36 ___ CHEST (PORTABLE AP)
There is no opacity projecting along the periphery of the right
mid lung which may reflect atelectasis and/or consolidation.
Patchy retrocardiac opacities likely also reflect atelectasis.
There is no pneumothorax or large pleural effusion. The size of
the cardiac silhouette is mildly enlarged and there is a
tortuous
thoracic aorta. No radiodense foreign object is seen within the
visualized thorax.
___ 6:36 ___ PORTABLE ABDOMEN
No radiopaque foreign object is identified within the abdomen or
pelvis.
Portable TTE ___ at 11:04:10 AM
Mild symmetric left ventricular hypertrophy with preserved
global
and regional biventricular systolic function. Suggestion of
elevated LV filling pressure and significant diastolic
dysfunction. Mild aortic regurgitation. Moderate to severe
mitral
regurgitation. Moderate pulmonary hypertension. Possible ASD
with
left to right flow, a focused study with saline contrast may be
considered for further evaluation if clinically indicated.
___ 9:41 AM VIDEO OROPHARYNGEAL SWALLOW
1. Trace penetration of nectar thick liquids.
2. Trace silent aspiration with thin liquids.
___ 8:50 AM MR HEAD W/O CONTRAST
1. Multiple foci of acute to subacute left MCA territory
infarct,
likely thromboembolic given distribution pattern.
2. Sequelae of probable chronic small vessel ischemic disease.
Brief Hospital Course:
Ms. ___ is an ___ woman with history notable for
atrial fibrillation (not on anticoagulation), HFpEF, and
___ transferred from ___ after presenting with
aphasia and right face, arm, and leg weakness, found to have
multifocal L MCA ischemic infarcts. Thrombolytics not
administered due to presentation outside the tPA window, and CT
imaging of the head and neck otherwise negative for large vessel
occlusion amenable to thrombectomy. Mechanism of infarction
accordingly most likely atrial fibrillation not on
anticoagulation, which, per discussion with Ms. ___ PCP,
was due to patient preference. Accordingly, anticoagulation
initiated with apixaban to reduce risk of future strokes, along
with low-intensity atorvastatin therapy given likely
cardioembolic mechanism and low atherosclerotic burden on
imaging.
Hospital course complicated by non-fluent aphasia and
dysarthria, for which SLP evaluation recommended modified diet.
TRANSITIONAL ISSUES
1. Continued SLP evaluation and advancement of diet as
indicated.
2. Thyroid ultrasound to evaluate incidentally-noted left
thyroid nodule.
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 = 85) - () No
5. Intensive statin therapy administered? () Yes - (x) No [Low
atherosclerotic burden and cardioembolic mechanism of stroke]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? () Yes - (x) No [Low
atherosclerotic burden and cardioembolic mechanism of stroke]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A
35 minutes were spent on discharge.
Medications on Admission:
1. Aspirin EC 81 mg PO DAILY
2. Metoprolol Tartrate 25 mg PO BID
3. Torsemide 20 mg PO DAILY
4. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE BID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE BID
Discharge Medications:
1. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 (One) tablet(s) by mouth twice a
day Disp #*30 Tablet Refills:*0
2. Atorvastatin 10 mg PO QPM
RX *atorvastatin 10 mg 1 (One) tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
3. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE BID
4. Latanoprost 0.005% Ophth. ___. 1 DROP RIGHT EYE BID
5. Metoprolol Tartrate 25 mg PO BID
6. Torsemide 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Left middle cerebral artery ischemic infarct
2. Atrial fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for
evaluation of speech disturbance and weakness on your right
side. CT and MRI scans of your head and neck showed that your
symptoms were due to a stroke. It is likely that your stroke was
due to a blood clot arising from your atrial fibrillation, so we
started you on a blood thinner (apixaban/Eliquis) to reduce your
risk of future strokes.
Please follow up with your primary care provider within one week
of discharge from your acute rehabilitation facility. Please
also follow up with a neurologist within the next ___ months;
your primary care provider can help refer you to a neurologist.
It was a pleasure taking care of you at ___.
Sincerely,
Neurology at ___
Followup Instructions:
___
|
10402372-DS-9 | 10,402,372 | 27,447,687 | DS | 9 | 2144-10-05 00:00:00 | 2144-10-17 23:03:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
worsening cough
Major Surgical or Invasive Procedure:
EGD with fine needle aspiration of gastric mass and esophageal
biopsies
Skin punch biopsies (chest and shoulder)
Laparoscopic gastric wedge resection with biopsy of gastric mass
History of Present Illness:
___ man with a constillation of symptoms including
cough, sore throat, fevers, uvitis, diffuse rash and 35 pound
weight loss and test results significant for monoclonal
gammopathy, biopsies with lichen planus, Gottron's papules,
gastric mass, and recent re-diagnosis of pneumonia on
levofloxacin and fluconazole, presenting ___ with worsening
symptoms. Patient was ___ his usual state of health until ___ when he began to take propranolol for an eye twitch. He
continued it for 2 weeks until food and water began to taste
like paste. This was intermittant for the next year until the
___ when he began to develop a stuffy nose and cough.
He was diagnosed with pneumonia and treated with azithromycin
and completed his course without resolution of his symptoms. He
then began to develop a fevers up to 102.6 following a flu shot
and a pneumovax. Patient then had a continued work up detailed
below, again without unifying diagnosis or resolution of his
symptoms. Patient was hospitalized at ___ from ___
and diagnosed with Pneumonia, Lichen Planus, Dermatomyositis and
a Gastric Mass and treated with azithromycin x5 days. Patient
presented ___ to the ED and was again diagnosed with pneumonia
and started on levofloxacin, with fluconazole added on a day
later. The past few days, patient has been having increasing
yellow discharge and swelling around his eyes and having to pry
his eyes open each morning.
.
___ the ED, initial VS: 99.6, 101, 116/78, initially 91% on room,
94% 4L NC. Patient was given 1L normal saline and Tylenol 1g.
.
On the floor, patient contiues to cough, productive of tan
colored phlegm. He is able to speak ___ full sentences, but has
to pause to cough throughout the interview.
.
REVIEW OF SYSTEMS:
(+) Per HPI including fevers, chills, night sweats, loss of
appetite, weakness and fatigue, rhinorrhea, nasal congestion,
cough, sputum production, dyspnea on exertion.
(-) Head ache, neck stiffness, chest pain, palpitations,
hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal dyspnea,
nausea, vomiting, diarrhea, constipation, hematochezia, melena,
dysuria, urinary frequency, urniary urgency, focal numbness,
focal weakness, myalgias, arthralgia, bone pain, heat or cold
intolerance.
Past Medical History:
-Numerous episodes of bronchitis and an episode of walking
pneumonia as a child
-Hernia operation at the age of ___
-Shingles approxmiately ___
-No history of blood transfusions
-RPR and Hepatititis A, B, C serologies negative from ___
Social History:
___
Family History:
Mother died of MI ___ her ___. Father had emphysema and angina
and died at ___. Had one older brother who died of MVA ___
college.
Physical Exam:
Vitals: T: 98.5 BP:101/74 P:92 O2: 96% 4L, -> 93% RA
General: Alert, oriented, no acute distress, frail and ill
appearing
HEENT: Scalp is free of lesions or dandruff. Tympanic membranes
appear red, but without visible fluid level. Fundoscopic exam
is unremarkable. Sclera is injected with crusted amber discharge
surrounding the eye lashes. Nares are beefy red. Throat and
sides of cheeks are covered ___ a white plaque.
Neck: supple, JVP not elevated, ___ approximately 1cm lymphnodes
___ cervical chain, rubbery and non-tender.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops.
Abdomen: soft, non-tender, non-distended. + bowel sounds. no
rebound or guarding.
Ext: warm, well-perfused. no cyanosis, clubbing, or edema. 2+
DP and ___ pulses.
Neuro: AAOx3, CN II-XII intact bilaterally. Strength ___
throughout upper and lower extremities. Normal
finger-nose-finger testing. 2+ patellar, biceps, triceps,
brachioradialis reflexes and downgoing Babinski. Sensation
intact to light touch. Gait not assessed.
Skin: Diffuse red, slightly raised macularpapular rash covering
arms and legs, trunk and neck. Skin on toes is peeling and
appears dry.
Genital exam: Foreskin is chapped and injected, adherent to the
glans inferiorly, with no open ulcers. Testicles are
erythematous but normal size and without masses.
Pertinent Results:
ADMISSION LABS:
___ 01:30PM BLOOD WBC-4.5 RBC-4.21* Hgb-12.4* Hct-36.4*
MCV-87 MCH-29.4 MCHC-34.0 RDW-12.9 Plt ___
___ 01:30PM BLOOD Neuts-78.1* Lymphs-12.4* Monos-8.7
Eos-0.6 Baso-0.3
___ 07:40AM BLOOD ___ PTT-32.0 ___
___ 01:30PM BLOOD Glucose-105* UreaN-18 Creat-0.7 Na-130*
K-3.6 Cl-95* HCO3-25 AnGap-14
___ 07:40AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.0
___ 07:40AM BLOOD CK(CPK)-47
___ 07:20AM BLOOD ALT-36 AST-31 LD(LDH)-213 CK(CPK)-55
AlkPhos-68 TotBili-0.4
___ 08:25AM BLOOD Albumin-3.0*
___ 06:55AM BLOOD TotProt-6.0* Calcium-8.7 Phos-4.3 Mg-2.2
.
DISCHARGE LABS:
___ 01:45PM BLOOD WBC-5.4 RBC-4.61 Hgb-13.6* Hct-39.8*
MCV-86 MCH-29.5 MCHC-34.1 RDW-13.1 Plt ___
___ 01:45PM BLOOD Glucose-126* UreaN-14 Creat-0.5 Na-133
K-3.7 Cl-97 HCO3-29 AnGap-11
___ 01:45PM BLOOD Calcium-8.8 Phos-3.6 Mg-2.1
.
MISCELLANEOUS LABS:
___ 07:40AM BLOOD ESR-55*
___ 07:40AM BLOOD Osmolal-265*
___ 07:40AM BLOOD ANCA-NEGATIVE B
___ 07:40AM BLOOD dsDNA-NEGATIVE
___ 07:40AM BLOOD CRP-119.2*
___ 06:55AM BLOOD PEP-ABNORMAL B IgG-1173 IgA-99 IgM-15*
___ 07:40AM BLOOD C3-138 C4-47*
___ 07:40AM BLOOD HIV Ab-NEGATIVE
___ 01:45PM BLOOD QUANTIFERON-TB GOLD-Indeterminant
___ 06:55AM BLOOD QUANTIFERON-TB GOLD-Indeterminant
___ 08:00AM BLOOD PREALBUMIN-8
___ 07:10AM BLOOD MI-2 AUTOANTIBODIES-Not detected
___ 07:10AM BLOOD SRP AUTOANTIBODIES-Not detected
___ 07:10AM BLOOD SM ANTIBODY-<1.0
___ 07:10AM BLOOD RO & LA- <1.0
___ 07:10AM BLOOD RNP ANTIBODY-<1.0
___ 07:10AM BLOOD ANTI-JO1 ANTIBODY-<1.0
.
MICROBIOLOGY
___ 1:30 pm BLOOD CULTURE #1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 11:48 pm THROAT FOR STREP ORAL.
**FINAL REPORT ___
GRAM STAIN- R/O THRUSH (Final ___:
NEGATIVE FOR YEAST.
NO ___ ORGANISMS SEEN.
VIRAL CULTURE (Final ___:
SPECIMEN NOT PROCESSED DUE TO: INAPPROPRIATE
SPECIMEN(CHARCOAL SWAB)
RECEIVED FOR TEST REQUESTED.
Reported to and read back by ___ @ ___ ON
___ - FA5.
TEST CANCELLED, PATIENT CREDITED.
___ 12:50 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
___ 7:40 am SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
___ 7:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:00 pm BLOOD CULTURE #2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:54 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final ___:
RARE GROWTH Commensal Respiratory Flora.
YEAST. RARE GROWTH.
___ 7:40 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___ 6:35 am SEROLOGY/BLOOD CHEM# ___ ___.
**FINAL REPORT ___
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
___ 8:38 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___:
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
IMAGING:
CXR ___:
FINDINGS: No focal consolidation, pleural effusion, or
pneumothorax is seen. Heart and mediastinal contours are within
normal limits. Lungs are again noted to be hyperinflated.
IMPRESSION: Stable chest radiographs without acute change.
.
CXR ___:
Cardiomediastinal contours are normal. The lungs are
hyperinflated suggesting the presence of COPD. The
hemidiaphragms are flattened. There is a small left pleural
effusion. There is evidence of bronchial wall thickening ___ the
lower lobes bilaterally, more so ___ the left consistent with
bronchitis. Of note, ___ ___ CT, there was evidence of an
infection process ___ the lower lobes bilaterally; this has not
worsened, probably improved. The comparison is difficult due to
the difference ___ technique.
.
CHEST CT ___:
FINDINGS: The airways are patent to the segmental level. There
are multiple areas of bronchial impaction ___ multiple distal
bronchi ___ the lower lobes bilaterally. There is mild
bronchiectasis ___ the lower lobes, right middle lobe, and less
so ___ the upper lobes bilaterally. There is diffuse bronchial
wall thickening, unchanged from prior study. There is mild upper
lobe predominant centrilobular emphysema. There are no lung
masses. There are few calcified granulomas. Right lower lobe
lung nodules measuring less than 3 mm are stable (102: 59 and
55). There are residual small areas of peribronchial
ground-glass opacity ___ the left upper lobe and lower lobes
bilaterally. There are no new lung abnormalities. There is no
pneumothorax or pleural effusion. Trace pericardial effusion is
physiologic. Bilateral axillary lymph nodes are small. There are
no enlarged mediastinal or hilar lymph nodes. Cardiac size is
normal. The aorta is normal ___ caliber.
This examination is not tailored for subdiaphragmatic
evaluation. Left renal hypodense lesion is again noted. Stable
densely calcified mass ___ the gastric fundus.
There are no bone findings of malignancy.
IMPRESSION: Improved bronchiolitis. No evidence of lung masses
or lobar
pneumonia.
Stable tiny lung nodules including a perifissural lung nodule on
the right
(301, 150) from ___. Followup ___ one year is
recommended if there
are risk factors for lung cancer.
Left renal lesion is stable, likely cyst. Ultrasound is
recommended for
further characterization.
Stable densely calcified mass ___ the gastric fundus.
Bilateral hilar lymphadenopathy has improved.
.
EGD ___:
Impression: EGD: Severe esophagitis ___ the mid-upper esophagus -
biopsied. Findings not consistent with reflux esophagitis.
Consider bullous diseases of the esophagus.
EUS: Unchanged appearance/size of the 1.4 cm gastric submucosal
mass - FNA was performed.
Two simple 5 mm cysts ___ the pancreas.
.
VIDEO SWALLOW ___
SWALLOWING VIDEOFLUOROSCOPY: Oropharyngeal swallowing
videofluoroscopy was
performed ___ conjunction with the speech and swallow division.
Multiple
consistencies of barium were administered. Barium passed freely
through the oropharynx without evidence of obstruction.
Penetration and reflux into the nasopharynx was seen with thin
liquids.
IMPRESSION: Penetration and reflux into the nasopharynx with
thin liquids.
.
CXR ___:
IMPRESSION: PA and lateral chest compared to ___:
Slight hyperinflation, chest CTA prior to surgery did not show
emphysema. It did show mild to moderately severe bronchiectasis,
particularly ___ the left lower lobe. Postoperatively, left lower
lobe consolidation is probably due to atelectasis, stable since
___. There is new peribronchial opacification on the
right, conceivably aspiration. Exacerbation of bronchiectasis is
another possibility. There is no pulmonary edema, and the upper
lungs are clear. Tiny left pleural effusion is of no clinical
significance. Heart size is normal.
.
PFTs ___:
Mechanics: The FVC is mildly reduced. The FEV1 and FEV1/FVC
ratio are
severely reduced.
Flow-Volume Loop: Moderate expiratory coving with a mildly
reduced volume
excursion.
Lung Volumes: The TLC, FRC, RV and RV/TLC ratio are normal.
DLCO: The Diffusing Capacity corrected for hemoglobin is
moderately reduced.
Impression:
Severe obstructive ventilatory defect with a moderate gas
exchange
defect. There are no prior studies available for comparison.
.
PATHOLOGY:
SKIN BIOPSY ___
DIAGNOSIS:
Skin, central chest, biopsy:
Lichenoid interface dermatitis with dyskeratosis, see note.
Note: The epidermis shows hyperkeratosis, mild/focal
parakeratosis, acanthosis, and marked dyskeratosis. Areas
suggestive of follicular plugging are noted. The dermoepidermal
junction is affected by diffuse interface dermatitis with
vacuolar changes, and multiple colloid bodies are present. The
lichenoid inflammation is relatively conspicuous and is
predominantly composed of lymphocytes. No eosinophils were seen.
Vasculitis is not present, and "vascular drop out" is not
appreciated. The PAS stain is negative for fungi, and also
failed to highlight overt thickening of the basement membrane.
Alcian blue stain did not highlight dermal mucin deposition. The
findings ___ this biopsy are not diagnostic for classical
dermatomyositis. Epidermal hyperplasia, lichenoid inflammatory
reaction, marked dyskeratosis, and absence of superficial dermal
vascular injury are among a few features seen ___ the current
specimen corroborating the above. Given the clinical
presentation, results of the previous biopsy, and ___ light of
the current findings, the histopathological differential
diagnosis includes an overlap syndrome, with a component of
lichen planus, likely combined with connective tissue disease.
Follow-up with serology and direct immunofluorescence studies
(DIF) is suggested to further elucidate this possibility.
Multiple levels have been examined. The results were discussed
with Dr. ___ on ___.
.
SKIN BIOPSY ___:
1. Skin, erythematous lesion, anatomic site not further
specified, biopsy (light microscopy):Lichenoid interface
dermatitis and upper to mid-dermal perivascular lymphocytic
infiltrate and associated focal slight increase ___ dermal mucins
(see note).
2. Skin, erythematous lesion, anatomic site not further
specified, biopsy (direct immunofluorescence):IgG, IgM, IgA, C3
deposition within intraepidermal and dermal colloid bodies. No
basement membrane zone or vascular deposits are seen.
Fibrinogen noted along areas of the epidermal and dermal
interface and within colloid bodies.
Note: Lichenoid inflammation with associated with irregular
epidermal hyperplasia and abundant apoptotic
keratinocytes/colloid bodies is well developed ___ this biopsy
(similar to prior biopsy ___ with the additional
features of dermal perivascular lymphocytic infiltrate, slight
increase ___ dermal mucins (highlighted by Alcian blue stain),
and patchy thickening of the basement membrane zone (highlighted
by PAS stain). These changes most suggest an overlap syndrome of
lichen planus and a connective tissue disorder. Clinical
correlation is needed for further characterization.
.
ESOPHAGEAL BIOPSY ___
DIAGNOSIS:
Esophageal mucosal biopsies:
A) Upper:
- Active (neutrophilic) esophagitis with ulceration.
- Immunostains for Herpes Simplex Virus (I & II) and
Cytomegalovirus are negative with adequate controls.
- A GMS stain is negative for fungal organisms with
adequate controls.
B) Mid:
- Active (neutrophilic) esophagitis with ulceration.
- Immunostains for Herpes Simplex Virus (I & II) and
Cytomegalovirus are negative with adequate controls.
- A GMS stain is negative for fungal organisms with
adequate controls.
.
FNA, Gastric submucosal mass ___:
NON-DIAGNOSTIC.
Mucus, degenerated gastric epithelial cells, and one fragment
of spindle cells, too scant to categorize.
.
GASTRIC MASS ___:
Stomach, wedge resection:
Gastrointestinal stromal tumor, 4.2 cm; peripheral specimen
margins negative for tumor; see note.
Note: Immunohistochemistry is strongly positive for KIT and
CD34. Negative stains include S100, desmin, and actin; controls
are adequate. The mitotic rate is ___ high power field. ___
combination with tumor site and size, this lesion has a very low
risk (1.9%) of progressive disease.
Brief Hospital Course:
___ man with a constellation of symptoms including
cough, sore throat, fevers, conjunctivitis, diffuse rash and 35
pound weight loss and test results significant for monoclonal
gammopathy, biopsies with lichen planus, Gottron's papules,
gastric mass, and recent re-diagnosis of pneumonia on
levofloxacin and fluconazole, presented ___ with worsening
symptoms and new conjunctivitis and persistent fevers. He had a
thorough work-up to determine the etiology of his symptoms,
including complete rheumatologic work-up and resection of
gastric mass. Rheumatology, dermatology, ophthalmology, surgery,
nutrition and physical therapy were all involved ___ his care.
.
ACTIVE ISSUES:
# Skin rash:
The heliotrope rash on the face, the erythematous plaques over
the dorsum of hands and diffuse erythematous papular rash over
chest and lower extremities were thought to be a clinical
manifestation consistent with dermatomyositis sine myositis,
although skin punch biopsies of the rash from chest and shoulder
were read as an overlap syndrome with lichen planus/MCTD.
Multiple rheumatologic tests specific and non-specific for
dermatomyositis and other rheumatologic diseases were all
negative. The rash was treated with topical clobetasol and
showed moderate improvement throughout the two weeks of
hospitalization. Facial and genital rash was treated initially
with clobetasol as well, with transition to desonide prior to
discharge. Given that patient improved symptomatically with
topical steroids, and no clear etiology of his possible
dermatomyositis was determined, the patient was not started on
systemic steroids during this admission. However, he may require
initiation of steroids ___ the future and the patient was set up
with close follow-up.
.
# Oropharyngeal inflammation:
The patient had persisting oropharyngeal erythema with
yellow-white plaques over the soft palate and pharynx associated
with dryness, odynophagia and dysgeusia. EGD showed esophagitis.
Based on the clinical appearance of his mouth and prior biopsies
consistent with lichen planus, he was treated with dexamethasone
swish and spit and magic mouthwash with improvement of
odynophagia. Although throat culture did not grow yeast, oral
swish and spit antifungal was administered for prophylaxis. At
time of discharge, pt was better able to tolerate PO intake.
.
# Eye dryness and inflammation:
His eye inflammation was evaluated by ophthalmology, and was
concerning for blepharitis. He was treated with
tobramycin-dexamethasone ophth ointment for 7 days. He was also
noted to have a clear film covering his cornea, concerning for
possible lichen planus involvement. Ophthalmology recommended
treatment with oral doxycycline as well, however the patient
declined oral antibiotics.
.
# Poor oral intake/malnutrition:
Pt was admitted with greater than 35 pound weight loss at time
of admission. Per patient, this was secondary to odynophagia and
dysgeusia from lichen planus oral inflammation and esophagitis.
Video oropharyngeal swallow test showed mild nasal
regurgitation. He also noted early satiety. He was evaluated by
nutrition on multiple occasions and calorie counts were
monitored. Pt was able to take ___ adequate calories with Ensure
at every meal, ensure pudding, and benoprotein. His weight had
stabilized at time of discharge, though he had not re-gained any
significant weight. Supplemental feedings via PEG vs TPN were
discussed with the patient, however he preferred to be
discharged home for a trial of PO intake. He met with the
nutrition team again on the day prior to discharge and felt
comfortable understanding ways to increase his calorie intake at
home.
.
# Gastric mass:
This was seen on previous CT scan with previously inconclusive
FNA. This was evaluated again with EGD on this hospitalization
but again with inconclusive FNA read. As a result, the patient
underwent laparoscopic gastric wedge resection on ___ without
complications and with good post-operative recovery. The final
pathology of the mass was read as gastrointestinal intestinal
tumor with negative margins for tumor.
.
# Fever:
The patient was persistently febrile for the first week of his
hospitalization, and then resolved spontaneously. Fevers were
initially thought to be associated with his skin rash and
inflammatory state, or due to a recurrence of pneumonia,
possible underlying malignancy or occult infection. A repeat
chest CT on ___ showed improvement from previous ___ early
___. Urinary histoplasma antigen was negative, blood fungal
and AFB cultures did not grow fungi or mycobacteria and repeat
quantiferon gold for TB was pending on discharge. The patient
also never developed leukocytosis, thus was not started on
antibiotics.
.
# Cough:
Pt was admitted with a dry, nonproductive cough that had been
persistent for several weeks. A repeat chest CT on ___ showed
improvement from previous ___ early ___. Given improvement
___ his CT scan, along with normal WBC, he was not treated for an
infectious process.
.
# Hypoxia:
The patient was admitted with oxygen saturation ___ the mid-90s.
During the course of his hospitalization, he had worsening of
his dyspnea on exertion and was noted to desaturate on
ambulation, especially ___ the post-operative time period. He had
pulmonary function tests performed which were more suggestive of
obstructive picture rather than interstitial pulmonary fibrosis.
Given improvement ___ his chest CT, he was not started on
antibiotics. He was treated symptomatically with albuterol and
was weaned off oxygen by the time of discharge with ambulatory
saturations remaining 92-94%.
.
# Hyponatremia:
Pt was euvolemic on admission and urine electrolytes were
suggestive of SIADH, ___ setting of possible lung disease,
chronic malnutrition, or potential underlying malignancy. His
sodium improved on fluid restriction and oral salt tablet
supplementation. Hypothyroidism or adrenal insufficiency were
ruled out with normal TFT and electrolytes.
.
# Diarrhea:
During hospitalization, the patient developed 1 day of diarrhea,
thought to be attributed to an increased number of nutrition
supplements and possible mild lactose intolerance. The patient
had no abdominal pain or fevers. C. difficile stool test was
negative. Supplementation was changed from Magic Cup to Ensure
pudding with resolution of his diarrhea.
.
CHRONIC ISSUES:
# Monoclonal gammopathy of undetermined significance:
Pt was admitted with known diagnosis of MGUS. He had a skeletal
survey performed ___ skeletal survey which was negative.
Repeat SPEP was abnormal, repeat UPEP was negative. The
possibility that a smoldering multiple myeloma may be leading to
paraneoplastic dermatomyositis was entertained so skin biopsy
was obtained, however there was no evidence of monoclonal light
chain protein deposition on skin biopsy.
.
# Anemia:
Pt had a normocytic anemia with hematocrit which had been stable
___ the 36-38 range since ___. His hematocrit continued to
remain stable.
.
TRANSITIONAL ISSUES:
Pt is full code.
.
Borderline pulmonary artery hypertension, thyroid nodule and
left renal cyst found incidentally on previous chest and
abdominal CT were inactive issues on this hospitalization and
they can be followed up ___ the outpatient setting.
.
Pt had several follow-up appointments scheduled for him as an
outpatient, including rheumatology, ophthalmology, hem/onc,
surgery, and dermatology.
.
Given that patient's symptomatic improvement during his
hospitalization, stabilization of weight, and still unclear
etiology of his symptoms, initiation of steroids was deferred
during the inpatient setting. However, pt may benefit from
systemic steroids and he requires close follow up as an
outpatient for possible initiation of steroids.
Medications on Admission:
Levofloxacin 750mg daily
fluconazole 200 mg PO qd. ___ until ___
Robutussin DM
fluticasone 50 mcg Spray, Suspension 2 sprays(s) ___ each nostril
qd lidocaine HCl 40 mg/mL Solution Gargle and swallow PRN Prior
to eating 200 mL
___ [FIRST-Mouthwash BLM]
betamethasone dipropionate 0.05 % Ointment Apply to effected
areas at bedtime as needed
Discharge Medications:
1. polyvinyl alcohol 1.4 % Drops Sig: ___ Drops Ophthalmic QID
(4 times a day).
Disp:*1 bottle* Refills:*2*
2. desonide 0.05 % Cream Sig: One (1) Appl Topical BID (2 times
a day): can apply to face and genitals.
Disp:*1 tube* Refills:*0*
3. clobetasol 0.05 % Cream Sig: One (1) Appl Topical BID (2
times a day): apply to body, avoid face and genitals.
Disp:*1 tube* Refills:*0*
4. dexamethasone 0.5 mg/5 mL Elixir Sig: Five (5) ML PO Q4H
(every 4 hours) for 14 days.
Disp:*qs * Refills:*0*
5. codeine-guaifenesin ___ mg/5 mL Syrup Sig: ___ MLs PO Q6H
(every 6 hours) as needed for cough.
Disp:*1 bottle* Refills:*0*
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
___ puffs Inhalation every ___ hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*0*
7. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day).
Disp:*450 ML(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
possible dermatomyositis
Lichen planus
gastric mass - pathology pending
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 for a consillation of symptoms
including cough, fevers, eye dryness and irritation, oral pain
and inflammation, worsening rash over your face, body, arms,
legs and back of your hands, as well as penile lesions. As part
of your work-up, you had several chest xray and a chest CT that
did not show any signs of pneumonia. There was no evidence of
any infection ___ your blood either. You were evaluated by the
rheumatology specialists and all the tests for various
rheumatologic diseases came back negative.
You were also seen by dermatology, who took two skin biopsies
from your rash. They recommended that we treat the skin rash,
oral inflammation and penile lesions with topical steroid cream.
Your oral pain and dryness was managed with topical anesthetic
and antifungal.
Ophthalmology saw you as well for your eye irritation and
treated you with artificial tears, antibiotic oitment and
topical steroids.
Given your difficulty and pain with swallowing you were
evaluated with a video oropharyngeal swallow test, which showed
mild reflux of food content ___ your nasopharynx. You also had an
EGD that showed inflammation of your upper esophagus. Because we
were unable to get an adequate biopsy of the gastric mass, you
went to surgery for complete resection. Pathology results are
still pending.
Finally, you were evaluated by nutrition specialists for the
weight loss, whose recommendations we followed for the past two
weeks of your stay ___ the hospital.
Followup Instructions:
___
|
10402406-DS-13 | 10,402,406 | 23,726,139 | DS | 13 | 2120-07-21 00:00:00 | 2120-07-22 07:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
PERC NEPHROSTOMY TUBE ___
History of Present Illness:
Mrs. ___ is a ___ y/o woman with a PMH of stroke with
residual right sided deficits, PE (on apixaban), recurrent
nephrolithiasis with bilateral stents, depression, anxiety,
dementia, and chronic pain, who presents as a transfer from ___
___ with severe sepsis secondary to pyelonephritis.
She was taken from her nursing home (where she lives because of
her stroke) to ___ after she had fevers to
___. Ct scan at the OSH was concerning for appendicitis. She
was initiated on vancomycin and Zosyn. Her blood pressures
dropped into SBPs of ___, for which she received 2L IVF and was
initiated on peripheral norepinephrine. She was transferred to
___.
In ED initial VS: T 98.3F BP 127/78 mmHg P ___ RR 16 O2 95% RA
Labs notable for: lactate 1.7, Cr 1.2, WBC 15.5, 6% bands, INR
1.6, UA with large leuks and blood, > 182 RBCs, 172 WBCs, few
bacteria, 100 protein.
Patient was given: 1L fluids and Zosyn.
Imaging notable for: OSH CT abdomen/pelvis that showed dilated
appendix with stranding densities about the appendix and RLQ;
unable to exclude appendicitis. Multiple renal calculi
bilaterally with mild hydronephrosis and indwelling L ureteral
stent. L inguinal hernia containing colonic bowel loops without
dilatation. R basilar density with air bronchograms suggesting
infiltrate.
Consults: General surgery, who felt suspicion for appendicitis
was low. Urology, who agreed with ICU admission, Foley catheter
placement for maximal GU decompression, broad spectrum abx to be
driven by prior culture results, seral Cr, and consideration of
decompression of L kidney via PCN tube.
On arrival to the MICU, she reported that she has been
experiencing five days of back pain, abdominal pain, and fevers
at her nursing home. She lives at the nursing home because she
is unable to walk as an effect of her stroke. She endorses
nausea, vomiting, dysuria, and hematuria. She denies chest pain,
shortness of breath, diarrhea, constipation, hematochezia, or
melena.
REVIEW OF SYSTEMS:
- as above, otherwise negative
Past Medical History:
- HTN
- depression
- history of stroke w/ R-sided hemiplegia
- bilateral PE (on apixaban)
- recurrent nephrolithiasis s/p bilateral stent placement
- history of gastric bypass surgery
- dementia
- history of delusional disorder
- Pseudomonas UTI
Social History:
___
Family History:
- non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 99.6F BP ___ mmHg P 81 RR 25 O2 97% RA
General: Uncomfortable appearing, NAD.
HEENT: Dry mucous membranes; anicteric sclerae. EOMs intact.
Neck: Supple, JVP flat.
CV: RRR, soft II/VI murmur best heard over LLSB. No rubs or
gallops.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Diffusely tender, most pronounced over LUQ, with voluntary
guarding. NABS.
Back: + b/l CVA tenderness.
Ext: Warm and well-perfused. No edema. 2+ pulses bilaterally.
Neuro: Alert and oriented. R-sided hemiplegia, chronic
DISCHARGE EXAM:
Vitals: 98.9 113/73 77 18 95% on RA
General: comfortable appearing, NAD, lying in bed.
HEENT: moist mucous membranes; anicteric sclerae. EOMs intact.
Neck: Supple, JVP flat.
CV: RRR, no appreciable murmurs, rubs or gallops.
Pulm: unable to examine posteriorly, anteriorly lung fields
CTAB, no accessory muscle use.
Abd: nontender, nondistended
Back: L nephrostomy tube in place with clear urine draining,
dressing clean dry and intact, mild CVA tenderness
Ext: L PICC line, Warm and well-perfused. No edema. 1+ pulses
bilaterally.
Neuro: Alert, follows commands, answers questions but with mild
cognitive impairment. R-sided hemiplegia, chronic
Pertinent Results:
ADMISSION LABS
___ 01:15AM BLOOD WBC-15.5* RBC-4.15 Hgb-10.8* Hct-34.8
MCV-84 MCH-26.0 MCHC-31.0* RDW-17.2* RDWSD-52.8* Plt ___
___ 01:15AM BLOOD Neuts-87* Bands-6* Lymphs-5* Monos-1*
Eos-1 Baso-0 ___ Myelos-0 AbsNeut-14.42*
AbsLymp-0.78* AbsMono-0.16* AbsEos-0.16 AbsBaso-0.00*
___ 01:15AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-1+ Polychr-NORMAL
___ 01:15AM BLOOD ___ PTT-36.0 ___
___ 01:15AM BLOOD Glucose-102* UreaN-23* Creat-1.2* Na-134
K-4.0 Cl-101 HCO3-18* AnGap-19
___ 01:15AM BLOOD ALT-14 AST-20 AlkPhos-94 TotBili-0.3
___ 01:15AM BLOOD Albumin-2.7* Calcium-7.7* Phos-2.8 Mg-2.1
___ 09:04PM BLOOD Tobra-4.0*
___ 01:13AM BLOOD Lactate-1.7
___ 12:50AM URINE Color-Red Appear-Hazy Sp ___
___ 12:50AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG
___ 12:50AM URINE RBC->182* WBC-172* Bacteri-FEW Yeast-NONE
Epi-1
DISCHARGE LABS
___ 06:34AM BLOOD WBC-9.2 RBC-3.80* Hgb-9.5* Hct-31.9*
MCV-84 MCH-25.0* MCHC-29.8* RDW-17.3* RDWSD-52.6* Plt ___
___ 07:41AM BLOOD Neuts-88* Bands-3 Lymphs-5* Monos-2*
Eos-2 Baso-0 ___ Myelos-0 AbsNeut-12.74*
AbsLymp-0.70* AbsMono-0.28 AbsEos-0.28 AbsBaso-0.00*
___ 06:34AM BLOOD Plt ___
___ 06:34AM BLOOD ___
___ 06:34AM BLOOD Glucose-81 UreaN-9 Creat-0.6 Na-143
K-3.0* Cl-104 HCO3-28 AnGap-14
___ 07:41AM BLOOD ALT-11 AST-13 LD(LDH)-177 AlkPhos-81
TotBili-0.3
___ 06:34AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.8
___ 07:45AM BLOOD Vanco-7.5*
IMAGING
Radiology Report RENAL ___. PORT Study Date of ___ 9:39
AM
FINDINGS:
The right kidney measures 12.7 cm. The left kidney measures 10.6
cm. Multiple
small nonobstructing stones are seen in the in the interpolar
and lower polar
region of the right kidney, measuring up to 1.5 cm. No
right-sided ureteric
stent is visualized and there is no right-sided hydronephrosis.
The left
kidney is a decompressed by an ureteric stent and demonstrates
minimal
residual hydronephrosis. Linear echogenicity with posterior
shadowing, likely
representing soft stones, is seen in the lower pole of the left
kidney, while
a more well formed 1.8 cm stone is seen within the left renal
pelvis. Normal
cortical echogenicity and corticomedullary differentiation are
noted
bilaterally.
The bladder is minimally distended and contains a Foley
catheter.
IMPRESSION:
1. An ureteric stent is seen in the left kidney, with minimal
residual
left-sided hydronephrosis. Soft stones are seen in the lower
pole of the left
kidney while a more well formed 1.8 cm stone is noted in the
renal pelvis.
2. Nonobstructing stones are seen in the right kidney, measuring
up to 1.5 cm.
Radiology Report CHEST (PORTABLE AP) Study Date of ___
9:41 AM
IMPRESSION:
1. Persistent bilateral lower lobe parenchymal opacities
despite interval
decreased bibasilar atelectasis with improved lung volumes is
concerning for
infection and/or aspiration in the appropriate clinical
situation.
2. Persistent small right pleural effusion.
Brief Hospital Course:
Mrs. ___ is a ___ y/o woman with a PMH of stroke with
residual right sided deficits, PE (on apixaban), recurrent
nephrolithiasis with bilateral stents, depression, anxiety,
dementia, and chronic pain, who presented as a transfer from
___ with severe sepsis secondary to pyelonephritis.
Patient was first transferred to MICU due to pressor
requirement, however, was immediately weaned off after first day
and then transferred to floow. Pyelonephritis most likely ___
post-renal obstruction evidence by L sided hydronephrosis I/s/o
recurrent stones with bilateral ureteral stents that, per
urology, have become encrusted. We relieved the obstruction with
___ placed L PCN and treated her infection with broad-spectrum
abx, vanc/zosyn (day ___, which after sensitivities returned
were narrowed to zosyn to complete a ___nding on
___. L PICC line was placed to facilitate outpatient
administration of abx. Per ID, she will need suppressive abx
since kidney stones and encrusted stents may serve as a nidus
for infection. At OSH, UCx was positive for E.Coli, enterococcus
and GNRs and Blood Cx was positive for enterococcus and GNRs.
Due to enterococcus bacteremia, evaluated for endocarditis. Echo
was neg.
Also, on presentation due to post-renal obstruction, she had an
___, doubling her baseline SCr. (0.5-0.6). After decompression
and fluids, ___ resolved and she returned back to baseline. For
her PE, her apixaban was held in setting of ___ PCN placement and
was restarted on ___.
# SEPTIC SHOCK ___ PYELONEPHRITIS/ACUTE KIDNEY INJURY- Presented
with fever, back pain, positive UA, dysuria, hematuria, and
positive CVA tenderness, in the setting of recurrent stones with
bilateral ureteral stent placement. In discussing with urology,
her stones have been in place for some time and have become
encrusted. Her urologist attempted to remove her stents but was
unable to because of the encrustation. Given her L-sided
hydronephrosis and doubling of her Cr, this is concerning for
possible obstructive pyelonephritis. She was treated broadly
with vanc/cefepime and tobramycin. Given IVF. Urology was
consulted and recommended ___ consultation. ___ placed L sided
perc nephrostomy tube on ___. Patient tolerated procedure well.
Blood cultures at OSH were growing GNR, urine culture growing
GNR and enterococcus. Patient was transferred to the medical
floor where the patient gradually recovered on IV antibiosis,
which was guided by the infectious disease. She underwent L PICC
placement on ___. Urology recommended abx suppressive
regimen per ID, PCN tube to gravity until definitive stone
procedure, and follow up with urology ___ weeks after discharge
which was set up with her primary urologist.
- Abx: zosyn for 14 day course (___)
- Pain control: Tylenol, oxycodone PO, discontinue Dilaudid PRN
- L PICC placed ___, CXR confirmed placement
- ECHO for enterococcus bacteremia - neg.
- urine cx @OSH - E.Coli, Enterococcus, GNRs
- blood cultures- GNRs, enterococcus
- sputum cx
- Abdominal US to evaluate for hematoma.
CHRONIC ISSUES:
# History of PE
- Cont apixaban on ___
# Anxiety
- cont alprazolam 0.25 mg qhs PRN: anxiety
# Dementia
- cont olanzapine 10 mg qhs
- cont 1000 mcg cyanocobalamin daily
# Depression
- cont sertraline 75 MG DAILY
# Chronic back pain
- held fentanyl patch initially with low dose PRN Dilaudid given
initially as needed, then transitioned to home medication
Transitional issues:
#Anticoagulation- Apixaban restarted on ___, needs follow up
for when to complete course for PR
#Antibiotics/Infectious Disease- Will continue zosyn 4.5g Q8h
for 14days from when L PCN was placed (___), end date = ___.
She will need suppressive Abx until definitive management for
stones with urology.
#Definitive management for stones - needs urologist outpatient
follow up as indicated
#PICC in left arm, will need removal post-completion of
antibiotics
# Communication: HCP: ___, ___ (alternative
___ ___
# Code: Full, confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. cranberry 425 mg oral DAILY *AST Approval Required*
2. Potassium Chloride 10 mEq PO DAILY
3. Norco (HYDROcodone-acetaminophen) ___ mg oral Q6H:PRN PAIN
4. Hydrocortisone Cream 1% 1 Appl TP BID:PRN rash
5. Docusate Sodium 100 mg PO BID
6. Sertraline 75 mg PO DAILY
7. Loratadine 10 mg PO DAILY
8. Magnesium Oxide 400 mg PO BID
9. Cyanocobalamin 1000 mcg PO DAILY
10. Fluticasone Propionate NASAL 2 SPRY NU BID
11. Omeprazole 20 mg PO DAILY
12. Ferrous Sulfate 325 mg PO TID
13. Vitamin D 1000 UNIT PO DAILY
14. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
15. FoLIC Acid 1 mg PO DAILY
16. Milk of Magnesia 30 mL PO Q12H:PRN constipatoin
17. Cyclobenzaprine 5 mg PO TID
18. Fentanyl Patch 25 mcg/h TD Q72H
19. OLANZapine 10 mg PO QHS
20. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
21. Apixaban 5 mg PO BID
22. ALPRAZolam 0.25 mg PO QHS
Discharge Medications:
1. Piperacillin-Tazobactam 4.5 g IV Q8H
Please continue up to and on ___ to complete 14 day course
RX *piperacillin-tazobactam 4.5 gram 4.5 gm IV every eight (8)
hours Disp #*8 Vial Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild *AST Approval
Required*
3. ALPRAZolam 0.25 mg PO QHS
4. Apixaban 5 mg PO BID
5. cranberry 425 mg oral DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Cyclobenzaprine 5 mg PO TID
8. Docusate Sodium 100 mg PO BID
9. Fentanyl Patch 25 mcg/h TD Q72H
10. Ferrous Sulfate 325 mg PO TID
11. Fluticasone Propionate NASAL 2 SPRY NU BID
12. FoLIC Acid 1 mg PO DAILY
13. Hydrocortisone Cream 1% 1 Appl TP BID:PRN rash
14. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
15. Loratadine 10 mg PO DAILY
16. Magnesium Oxide 400 mg PO BID
17. Milk of Magnesia 30 mL PO Q12H:PRN constipatoin
18. Norco (HYDROcodone-acetaminophen) ___ mg oral Q6H:PRN
PAIN
19. OLANZapine 10 mg PO QHS
20. Omeprazole 20 mg PO DAILY
21. Potassium Chloride 10 mEq PO DAILY
22. Sertraline 75 mg PO DAILY
23. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Severe sepsis
Pyelonephritis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___
(___) because you had severe sepsis due to pyelonephritis,
which is an infection of your kidney. Sepsis is an infection in
your bloodstream. We treated you with antibiotics and fluids. We
believe your pyelonephritis may have been a result of an
obstruction of your urinary tract making it difficult for urine
to drain from your kidney normally. To relieve the obstruction,
we had to put a drain in your left kidney. You have ureteral
stents for your previous kidney stones that may have been the
potential cause of the obstruction. You will leave the hospital
with the kidney drain and it will stay in place until you can
get the ureteral stents and stones treated and removed with
Urology.
In terms of your infection, you are being treated with zosyn. We
placed a PICC line in your left arm so that you can receive the
antibiotics outside of the hospital. The total course of your
antibiotics is 14 days, making the last day of antibiotics on
___. Please note, because your kidney stones may still ___
bacteria, you will need to be on some sort of antibiotics to
prevent an infection once you complete the course of zosyn. You
will follow up in infectious disease clinic to determine what
new antibiotics you will be put on.
Please ensure to follow up with your scheduled outpatient
appointments with Urology and Infectious Disease especially, and
any others as well. Thank you for allowing us to be a part of
your care.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10402762-DS-17 | 10,402,762 | 25,868,862 | DS | 17 | 2137-08-16 00:00:00 | 2137-08-16 17:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Relafen / Colace / Androderm
Attending: ___.
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
flex sigmoidoscopy
History of Present Illness:
Mr. ___ is a ___ yo man with PMH of ulcerative colitis s/p
proctocolectomy with J-pouch-anal anastomosis complicated by
pouchitis, CAD, ___, severe MR presenting with 1 day of BRBPR.
He has been in USOH until about 0600 this AM when he noticed
blood in the toilet bowl. He reports that he has a little bit of
bleeding from rectum on occasion with intermittent rectal pain
for which he uses lidocaine and cholestyramine ointment but this
was more than usual. He moved his bowels twice subsequently
today
with progressive decline in the amount of blood. Mostly recently
at about 1600 he said there was only some pink on the paper and
specks of blood in the stool but no blood in the bowl/water.
He also notes that when he awoke this morning he felt slightly
lightheaded on his way to the bathroom in the AM. When he went
to
the bathroom he cleared his throat and produced some blood. He
did this two more times and noticed that there was less blood
each time. He has not had any more episodes like this during the
day. This made him very nervous as he has not had this happen
before. He notes that he felt asleep in an atypical position
(sitting up a bit instead of lying flat) as he fell asleep
watching TV. He also notes that his apartment is very dry and he
has had a dry throat.
He denies f/c, abd pain, change in frequency of BMs (moving
bowels ___ at baseline), n/v, cough, change in urination.
He
has had intermittent SOB over the past ___ years with his CHF
but
states that he does a lot of walking without issue and has had
no
orthopnea/SOB recently. He actually feels like his breathing was
better today. He reports that he always has a runny nose, but
denies any bleeding from the nose.
He also noticed subconjunctival hemorrhage in left eye today. He
has seen this before in his other eye but not recently. He
denies
hard sneeze/cough but does note that he often strains for as
long
as an hour to move his bowels. He reports a history of ITP many
years ago but has had no issues subsequently. He denies easy
bruising or bleeding.
Per outpatient GI note from ___, ___ has not been working
well for pouchitis so he was switched to Lialda 4 tabs/day. He
had some bleeding which was improving so was kept on home cipro
dose 500mg bid which has helped his pouchitis in the past though
unclear if helping now. Per her note, he may have Crohn's
disease
instead of just ulcerative colitis as he has had ulcerations in
the neoterminal ileum. Her recommendation at the time was
flexible sigmoidoscopy if he is still bleeding.
In ED, initial vitals 97.9 76 117/71 18 98% RA. Exam notable for
brown stool with blood mixed in, holosystolic murmur. Labs
notable for lactate 1.1, trop 0.02, negative UA, Hgb 9.1 (last
value 9.6 ___, baseline around 10), INR 1.0, Cr 1.3 (at
baseline), BNP 1080. Imaging notable for unremarkable CXR.
Crossmatched for two units.
Vitals on transfer 97.6 69 129/75 19 96% RA
On arrival to floor, patient feels well and is interested in how
soon he can go home. He does not currently have lightheadedness,
SOB, CP, or other sx.
ROS: Positive as per HPI, all systems reviewed and otherwise
negative
Past Medical History:
-Ulcerative colitis diagnosed ___ status post total
proctocolectomy with J-pouch and ileostomy takedown in ___.
-Severe mitral valve regurgitation.
-Moderate aortic stenosis.
-Three-vessel coronary artery disease with NSTEMI in the
setting of heart failure exacerbation in ___
-___, currently ___ Class II.
-Hypertension
-Hyperlipidemia
-GERD
-Osteoporosis
-Obstructive sleep apnea, not currently using CPAP as prescribed
-Spinal stenosis
-Anemia
-Myxoid smooth muscle neoplasm resected ___ years ago
-Osteoarthritis s/p right total hip arthroplasty on ___.
-History of ITP "many years ago"
Social History:
___
Family History:
Father died at ___, had a stroke. Mother died at
___, had diabetes.
Physical Exam:
Admission Physical Exam:
VS: 98.1 134 / 66 65 18 99 RA
General: Well appearing elderly man lying in bed in NAD
Eyes: PERLL, EOMI, sclera anicteric, subconjunctival hemorrhage
on lateral aspect of left eye
ENT: MMM, oropharynx clear without exudate or lesions, no
evidence of posterior oropharynx irritation/inflammation or
bleeding
Respiratory: CTAB without crackles, wheeze, rhonchi.
Cardiovascular: RRR, normal S1 and S2, III/VI holosystolic
murmur
radiating to axilla
Gastrointestinal: Soft, nontender, nondistended, +BS, no masses
or HSM
Extremities: Warm and well perfused, no peripheral edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert and oriented x3, motor and sensory exam
grossly intact
Pertinent Results:
Admission labs:
___ 02:28PM ___ COMMENTS-GREEN TOP
___ 02:28PM LACTATE-1.1
___ 02:08PM URINE HOURS-RANDOM
___ 02:08PM URINE UHOLD-HOLD
___ 02:08PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:08PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 12:41PM GLUCOSE-100 UREA N-27* CREAT-1.3* SODIUM-140
POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-28 ANION GAP-17
___ 12:41PM estGFR-Using this
___ 12:41PM CK-MB-8 cTropnT-0.02* proBNP-1080*
___ 12:41PM CALCIUM-9.1 PHOSPHATE-4.0 MAGNESIUM-1.8
___ 12:41PM WBC-7.6 RBC-3.44* HGB-9.1* HCT-30.0* MCV-87
MCH-26.5 MCHC-30.3* RDW-19.0* RDWSD-60.5*
___ 12:41PM NEUTS-45.8 ___ MONOS-10.1 EOS-0.7*
BASOS-0.3 IM ___ AbsNeut-3.48 AbsLymp-3.25 AbsMono-0.77
AbsEos-0.05 AbsBaso-0.02
___ 12:41PM PLT COUNT-187
___ 12:41PM ___ PTT-28.8 ___
Imaging:
CXR ___
IMPRESSION:
No acute cardiopulmonary process.
___ EGD
Impression: Normal mucosa in the whole examined duodenum
(biopsy)
Normal mucosa in the whole stomach
Normal mucosa in the whole esophagus
Small hiatal hernia
Polyps in the stomach body
Otherwise normal EGD to third part of the duodenum
___ Sigmoidoscopy
Impression: Abnormal mucosa in the colon (biopsy, biopsy,
biopsy)
There were 2 polypoid lesions with the appearance of
hyperplastic
polyps or pseudopolyps. One was biopsied in the pouch biopsy.
Otherwise normal sigmoidoscopy to 35cm into neoterminal ileum
ECG: NSR rate 67, probable left atrial enlargement; compared to
prior for ___ probably left atrial enlargement is new,
otherwise unchanged.
flImpression: Friability and erosions in the J-pouch compatible
with pouchitis (biopsy)
The proximal ileum was normal. The blind end of the efferent
limb was not visualized.
Otherwise normal sigmoidoscopy to ileum
Recommendations: Continue cipro BID and Lialda
Follow-up c.diff PCR
Follow-up inpatient GI team
ex sig:
ct CHEST:
IMPRESSION:
1. No acute cardiopulmonary process.
2. 0.8 cm sub solid nodule in the right upper lobe with 0.2 cm
solid
component, may be inflammatory or infectious etiology.
Follow-up chest CT
without contrast in 3 months recommended. Additional small
pulmonary nodules.
3. Cholelithiasis.
RECOMMENDATION(S): Chest CT without contrast in 3 months.
Multiple predominantly chronic rib fractures
Brief Hospital Course:
___ yo man with PMH of ulcerative colitis s/p proctocolectomy
with
J-pouch-anal anastomosis complicated by pouchitis, CAD, ___,
severe MR presenting with 1 day of BRBPR.
#IBD/pouchitis/BRBPR/anemia: As noted above, patient has had
complicated course, thought to be UC but with some concern for
Crohn's given ulcers in nonterminal ileum, with proctocolectomy
and J pouch complicated by pouchitis. He has had intermittent
rectal pain and bleeding which has been managed with topical
treatments, Welchol, and Cipro, though was recently switched to
Lialda from Welchol and has not yet filled rx. He was seen in GI
clinic before admission with recommendation for flex sig if
bleeding
persisted. Remained stable without sx, stable CBC,
stable VS. Has had slow downtrend in Hgb about about 1g over 11
months, likely due to intermittent bleeding. He had a flex
sigmoidoscopy that revealed ulcerations but improved from prior.
THe GI team recommended to continue cipro and lialda for
pouchitis. No further bleeding episodes during admission. BIOPSY
PENDING ON DISCHARGE.
#Possible oropharyngeal bleeding: Patient reports clearing
through and spitting out blood prior to admission. He has had no
further
episodes and exam shows no evidence of oral lesions,
orpharyngeal
irritation or bleeding. Lungs clear, no coughing so hemoptysis
unlikely. Given hx of dry throat and dry air in house, likely
had
some mild nasopharyngeal mucosal bleeding overnight and cleared.
CXR unrevealing. CT scan unrevealing other than pulmonary nodule
for which pt will require follow up with repeat scan in 3
months.
#Chronic compensated diastolic CHF/mitral regurgitation/CAD/HTN:
BNP slightly elevated above prior at 1000, CXR unremarkable,
clinically stable without evidence of decompensation at this
time
given lack of crackles on exam, ___ edema, or dyspnea. Continued
home furosemide, metoprolol, atorvastatin.
#TRANSITIONAL ISSUE/PULMONARY NODULE-REPEAT CT SCAN NEEDED IN 3
MONTHS
#Osteoporosis: Continued calcium and alendronate.
#Insomnia: Continued home zolpidem
#OSA: Patient used CPAP in the past, is not actively using.
Discussed with patient that he should restart as outpatient
#Code Status: [x] Full [] DNR/DNI (confirmed)
#Contact: Wife ___ ___ (h), ___ (c)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO QPM
2. Alendronate Sodium 70 mg PO QSUN
3. Ascorbic Acid ___ mg PO DAILY
4. Calcium Carbonate 1000 mg PO DAILY
5. Ranitidine 150 mg PO HS
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO DAILY
8. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral DAILY
9. Ciprofloxacin HCl 500 mg PO BID
10. Acetaminophen 500 mg PO QAM
11. lidocaine 5 % topical TID:PRN rectal pain
12. cholestyramine (bulk) 10 % topical TID:PRN rectal pain
13. Furosemide 40 mg PO DAILY
14. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR TID:PRN rectal
pain
15. Lidocaine Jelly 2% 1 Appl TP TID:PRN rectal pain
16. Lialda (mesalamine) 4.8 g oral DAILY
17. Metoprolol Succinate XL 150 mg PO DAILY
18. Zolpidem Tartrate 7.5 mg PO QHS
19. Multivitamins 1 TAB PO DAILY
20. LOPERamide 4 mg PO QID:PRN diarrhea
21. flaxseed oil 1,000 mg oral DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q24H
take based on GI doctor's recommendations.
2. Acetaminophen 650 mg PO QPM
3. Acetaminophen 500 mg PO QAM
4. Alendronate Sodium 70 mg PO QSUN
5. Ascorbic Acid ___ mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO DAILY
8. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral DAILY
9. Calcium Carbonate 1000 mg PO DAILY
10. cholestyramine (bulk) 10 % topical TID:PRN rectal pain
11. flaxseed oil 1,000 mg oral DAILY
12. Furosemide 40 mg PO DAILY
13. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR TID:PRN rectal
pain
14. Lialda (mesalamine) 4.8 g oral DAILY
15. Lidocaine Jelly 2% 1 Appl TP TID:PRN rectal pain
16. Lidocaine 5 % topical TID:PRN rectal pain
17. LOPERamide 4 mg PO QID:PRN diarrhea
18. Metoprolol Succinate XL 150 mg PO DAILY
19. Multivitamins 1 TAB PO DAILY
20. Ranitidine 150 mg PO HS
21. Zolpidem Tartrate 7.5 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
ulcerative colitis
anemia
?hemoptysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for evaluation of bloody stools and possible
coughing of blood. You underwent an flexible sigmoidoscopy which
showed ulcerations but better than before. The GI doctors have
recommended that you continue your medications. For your
possible coughing of blood you had an unrevealing chest xray and
CT scan that showed a pulmonary nodule that will require a
repeat CT scan in 3 month's time.
You biopsy is still PENDING at the time of discharge. The GI
doctors ___ need to follow up with you regarding the results.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10402810-DS-19 | 10,402,810 | 23,951,807 | DS | 19 | 2142-09-03 00:00:00 | 2142-09-05 07:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Abdominal pain, altered mental status
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
Mr ___ is a ___ gentleman with a history of h/o CAD
s/p CABG, s/p aortic root repair, Afib (on Coumadin), and ESRD
on HD(TThSat) who was transferred from an OSH for concern for
cholangitis after presenting from rehab with jaundice, abdominal
pain, and altered mental status.
He has been staying at rehab for unclear reasons and was noted
to be jaundiced x 1 day and febrile to ___ on the day prior to
admission. He was also confused and reported abdominal pain. At
baseline, he is AAOx3. He was brought to ___ on
___ for further evaluation. Labs were notable for WBC 8.5,
H/H 10.5/34.2, plt 200, INR 3.5, Cr 3.3, TBili 5.2, DBili 4.4,
AP 308, AST 67, ALT 80. CT A/P and RUQ were performed, which
showed findings concerning for acute cholecystitis (mild
gallbladder wall thickening, stranding in
the adjacent fat consistent with inflammatory change) and a
mildly dilated common bile duct at 11 mm. He received Zosyn at
the OSH ___ and was transferred to ___ for further management.
In the ___, initial vitals: T 98.0, HR 105, BP 129/76, RR 18,
SpO2 92% RA.
- Labs were notable for: WBC 7.1, H/H 10.2/33.3, plts 212, Na
136, K 3.4, Cl 94, HCO3 28, BUN 27, glucose 87. ALT 73, AST 60,
AP 296, TBili 5.1, albumin 3.4, lipase 19, lactate 1.4, INR 3.9.
- Imaging: OSH reviewed.
- Patient was given:
___ 00:42 IVF 1000 mL NS 1000 mL
___ 00:42 IV Piperacillin-Tazobactam 4.5 g
___ 00:45 IV Phytonadione 5 mg
- Consults: ERCP (recommended IVF, NPO, reversal of INR, plan
for ERCP tomorrow) and surgery (not a candidate for CCY at this
time)
On arrival to the MICU, patient was initially awake/alert and
conversant but then fell asleep.
Review of systems:
(+) Per HPI
(-) Unable to obtain
Past Medical History:
- CAD s/p CABG in ___
- Aortic root repair in ___
- AFib on Coumadin
- HLD
- ESRD on HD (TThSa), AV fistula in right arm
- Hypothyroid
- TIA
- GERD
- Osteoarthritis
- Peripheral neuropathy
- Hyperlipidemia
- Bilateral hip replacements
- Hernia repair
- Rotator cuff repair
Social History:
___
Family History:
Father: Type 2 DM, aneurysm
Mother: ___
Sister: ___
Physical Exam:
ADMISSION EXAM:
================
Vitals: T 97.9, HR 99, BP 107/71, RR 18, SaO2 93% 3L NC
GENERAL: Sleeping but arousable, NAD
HEENT: +Scleral icterus
NECK: Supple
LUNGS: Clear to auscultation anteriorly
CV: Irregular rhythm, slightly tachycardic, systolic murmur
ABD: +BS, slightly distended, tender in RUQ with guarding
EXT: Warm, well-perfused, 2+ peripheral pulses, RUE AV fistula
SKIN: Slightly jaundiced, scattered bruising on arms
NEURO: Arousable, unable to assess remainder of neuro exam
ACCESS: PIV
DISCHARGE EXAM:
================
VS: 97.3 118/68 102 18 98/RA
General: NAD
HEENT: sclera anicteric
Neck: no lymphadenopathy, supple
CV: irregular rhythm, S1/S2, no m/r/g
Lungs: CTA /b/l
Abdomen: mild ttp in RUQ, no HSM, sntnd
GU: no Foley
Ext: wwp, 2+ pulses
Pertinent Results:
ADMISSION LABS:
================
___ 11:55PM BLOOD WBC-7.1 RBC-3.74* Hgb-10.2* Hct-33.3*
MCV-89 MCH-27.3 MCHC-30.6* RDW-17.4* RDWSD-57.0* Plt ___
___ 11:55PM BLOOD Neuts-78.9* Lymphs-5.6* Monos-11.1
Eos-3.0 Baso-0.8 Im ___ AbsNeut-5.59 AbsLymp-0.40*
AbsMono-0.79 AbsEos-0.21 AbsBaso-0.06
___ 11:55PM BLOOD ___ PTT-41.8* ___
___ 11:55PM BLOOD Glucose-87 UreaN-27* Creat-3.0* Na-136
K-3.4 Cl-94* HCO3-28 AnGap-17
___ 11:55PM BLOOD ALT-73* AST-60* AlkPhos-296* TotBili-5.1*
___ 11:55PM BLOOD Lipase-19
___ 11:55PM BLOOD Albumin-3.4*
___ 05:29AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.1 Iron-46
___ 05:29AM BLOOD calTIBC-190* Ferritn-1190* TRF-146*
___ 12:12AM BLOOD Lactate-1.4
DISCHARGE LABS:
================
___ 07:30AM BLOOD WBC-6.3 RBC-3.34* Hgb-9.2* Hct-29.7*
MCV-89 MCH-27.5 MCHC-31.0* RDW-17.9* RDWSD-57.1* Plt ___
___ 09:35AM BLOOD ___ PTT-30.6 ___
___ 07:30AM BLOOD Glucose-117* UreaN-22* Creat-3.4* Na-138
K-3.6 Cl-101 HCO3-25 AnGap-16
___ 07:30AM BLOOD ALT-23 AST-22 AlkPhos-181* TotBili-1.5
___ 07:30AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.1
MICROBIOLOGY:
==============
___: Blood cultures x 2 pending
IMAGING:
=========
Brief Hospital Course:
Mr. ___ is a ___ gentleman with a history of h/o CAD
s/p CABG, s/p aortic root repair, Afib (on Coumadin), and ESRD
on HD(TThSat) who was transferred from an OSH for concern for
cholangitis and acute cholecystitis after presenting with
jaundice, abdominal pain, and altered mental status.
ACTIVE ISSUES:
===============
# Septic shock from biliary source:
On admission, patient had evidence of acute cholecystitis on CT
A/P with elevated LFTs, fever, and RUQ tenderness. RUQ showed
mildly dilated CBD and given degree of TBili elevation there was
concern for choledocholithiasis/cholangitis. ERCP was performed
on ___ which showed sludge, biliary dilation but no
obstruction. Sphincterotomy was performed. Pt was briefly
started on levophed on ___ s/p ERCP for BPs ___ not fluid
responsive to 2L but weaned off after ~9 hours. For acute
cholecystitis, ACS was consulted and plan is to wait for
interval CCY until patient clinical stable. Pt initially placed
on cefepine/flagyl on ___ admission but planned to cipro and
flagyl on ___ with plan for total course 7 days (end on ___.
Initially held warfarin s/p ERCP with plan for 5 days, ASA
continued given CABG 5 months prior as per surgery. LFTs at time
of discharge were within normal limits and patient was
asymptomatic. Pt is to make an appointment with surgery
outpatient in two weeks after discharge from rehab with Dr. ___
___ possible elective cholecystectomy.
# Afib with RVR:
Pt went into RVR on afternoon of ___. His home metoprolol and
diltiazem were previously held on ___ for hypotension. He was
given several doses of metoprolol and diltiazem during the
afternoon for goal HR < 110. He was on metoprolol and diltiazem
(initially fractionated, later on extended release) for rate
control with patient subsequently resumed on home rate control
agents. Started on home Coumadin after 5 days per above.
#CHF: ECHO ___ showed ___, about 50% in ___, started on
lisinopril 2.5mg qd at time of discharge. Will need close
monitoring of BPs, has a cardiology followup shortly.
# Delirium superimposed on chronic dementia:
Patient reportedly oriented x 1 in the ___ with a normal baseline
mental status though would wax and wane during admission likely
secondary to infection with some improvement during hospital
course. Seroquel was started at bedtime. Any deviation from
baseline was probably ___ to infection. Mental status improved
since admission per wife but patient has had progressive decline
since prior illnesses.
# CAD s/p CABG in ___:
Pt continued on aspirin, metoprolol. Added atorvastatin 80mg as
new medication, will follow up with PCP regarding why he was not
on this previously. PCP's office has been made aware of this new
med. ECHO was obtained prior to discharge for future
pre-operative evaluation with read pending upon discharge. Pt is
to follow up with cardiology at ___. Appt has been made for
patient.
# Hypoxia:
Resolved, on admission to ICU patient was satting low ___ on 3L
NC while sleeping. ___ have been secondary to mild volume
overload in the setting of ESRD. Otherwise had been maintained
on RA at time of discharge.
#Edematous and erythematous right shoulder:
Noted during ICU admission. Xray reveals suture anchors in
humeral head, narrowing of space between superior aspect of
humeral head and undersurface of the acromion, suggesting
possible disease tendons of rotator cuff. No acute intervention
warranted at this time
CHRONIC ISSUES:
===============
# ESRD on HD:
On ___ schedule, on dialysis while hospitalized. Sevelamer
with meals when able to eat while hospitalized.
# Anemia:
Stable during admission with unknown baseline (though per rehab
records, recent Hg between 11 and 12). Most likely ___ anemia of
chronic disease in the setting of ESRD. On folic acid/B12 while
hospitalized.
# Hypothyroidism:
Known h/o, pt Continued on levothyroxine 175 mcg daily.
TRANSITIONAL
================
- Continue cipro/flagyl until ___ for 7 day course.
- Need outpatient INR check on ___.
- Pt discharged on atorvastatin 80mg, will follow-up with PCP
regarding statin use, unclear why he was not on this previously.
- Follow up with outpatient cardiology regarding coronary artery
disease and atrial fibrillation with continued pre-operative
assessment for possibility of future cholecystectomy.
- Follow up with surgery, pt will need to make appointment in 2
weeks after discharge from rehab with Dr. ___
cholecystectomy.
- Pre-operative Echo obtained, read EF ___, pulmonary HTn, at
least 2+ MR. ___ changing dilt regimen.
- Do not resuscitate (DNR/DNI) per MOLST in patient chart and
spoke with patients wife ___. (wife) ___ (h),
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 120 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. ClonazePAM 0.25 mg PO BID:PRN anxiety/insomnia
4. Levothyroxine Sodium 175 mcg PO DAILY
5. Midodrine 10 mg PO TID
6. Metoprolol Tartrate 25 mg PO BID
7. Cyanocobalamin 1000 mcg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. ClonazePAM 0.25 mg PO Q6H:PRN anxiety
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
12. sevelamer CARBONATE 1600 mg PO TID W/MEALS
13. Warfarin Dose is Unknown PO DAILY16
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once at night Disp
#*30 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth daily
Disp #*2 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*6 Tablet Refills:*0
4. QUEtiapine Fumarate 25 mg PO QHS agitation
5. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
6. Aspirin 81 mg PO DAILY
7. ClonazePAM 0.25 mg PO BID:PRN anxiety/insomnia
8. ClonazePAM 0.25 mg PO Q6H:PRN anxiety
9. Cyanocobalamin 1000 mcg PO DAILY
10. Diltiazem Extended-Release 120 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Levothyroxine Sodium 175 mcg PO DAILY
13. Metoprolol Tartrate 25 mg PO BID
14. Midodrine 10 mg PO TID
15. Ondansetron 4 mg PO Q8H:PRN nausea
16. sevelamer CARBONATE 1600 mg PO TID W/MEALS
17. Warfarin 5 mg PO DAILY16
18.Outpatient Lab Work
INR check
427.31
___ Dr. ___ clinic
___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
sepsis from biliary source, cholangitis
SECONDARY DIAGNOSIS
atrial fibrillation with RVR
coronary artery disease s/p CABG
end-stage renal disease
delirium superimposed on baseline dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted for your infection in your biliary system.
There was initial consideration of removing your gallbladder but
decided this will be done at another time given your high risk
from a previous heart operation.
You improved with regards to your pain and infection and were
deemed stable at the time of your discharge. You completed your
antibiotic course on ___ and were restarted on your Coumadin.
Please follow up with ___ Cardiology with NP ___
___ Floor ___
You are to follow-up with Dr. ___ surgery ___ in
two weeks.
If you have worsening symptoms of abdominal pain, abnormal
stools, nausea/vomiting, please return for immediate evaluation.
It was a pleasure taking care of you at ___!
Your ___ Team
Followup Instructions:
___
|
10402903-DS-9 | 10,402,903 | 23,904,659 | DS | 9 | 2148-11-08 00:00:00 | 2148-11-06 16:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo man with HTN, HLD, AAA s/p repair, AFib on apixaban, CHF
s/p CABGx3 ___, presenting with worsening dyspnea. He has
had
a dry cough for the past week. Two days ago (___), he had
difficulty sleeping at night due to shortness of breath. This
morning his breathing looked more labored to his daughter. In
clinic, his O2 sat was noted to be low so he was sent to the ED.
He has not noticed any fevers at home, no chest pain, N/V, abd
pain, diarrhea, dysuria.
His weight has been stable 136-139 lb at home before admission,
checked daily, though 145 lb here on admission. He has not been
on any oral diuretics at home. He had orthopnea on ___ but none
for the 2 weeks prior. He has had some swelling on bilateral
ankles.
In the ED, vitals were: T 101.0 HR 88 BP 126/52 RR 20 O2 83% RA
Exam: Mild respiratory distress requiring supplemental oxygen,
lungs CTAB
Labs: WBC 15.7, proBNP 3467, trop <0.01, lactate 1.7, flu
negative
Studies: EKG - NSR w/ poor R wave progression
CXR - R lung patchy opacities, moderate L pleural effusion
Received: IV vancomycin, piperacillin-tazobactam, and
azithromycin
Past Medical History:
CAD s/p CABG ___ (LIMA-LAD,Diag; RA-RCA)
NSTEMI ___
AFib s/p MAZE and L atrial appendage ligation ___
Congestive Heart Failure, EF 45-50% (___)
Abdominal Aortic Aneurysm
Carotid Artery Stenosis s/p bilateral CEA
Chronic Kidney Disease, baseline Cr 1.2
Hearing Loss
Hyperlipidemia
Hypertension
Peripheral Vascular Disease
Cholecystectomy
Social History:
___
Family History:
Mother - CAD, MI at ___
Father - renal failure
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ ___)
Temp: 98.2 (Tm 98.2), BP: 107/65, HR: 70, RR: 18, O2 sat:
93%, O2 delivery: 4L, Wt: 145.2 lb/65.86 kg
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: JVP not visualized at 30 degrees. Carotidectomy scar.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Crackles and rhonchi to upper lung on R, decreased breath
sounds and crackles to mid lung on L. No wheezes.
BACK: No CVA or spinal tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: Warm. ___ pitting edema to lower shins
bilaterally.
No clubbing or cyanosis.
SKIN: Warm. No rash.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously.
DISCHARGE PHYSICAL EXAM:
==========================
GENERAL: trying to get out of bed, not responding to questions
or
commands
HEENT: PERRLA. MMM.
NECK: no JVD. Carotidectomy scar.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: CTAB. No wheezes.
BACK: No CVA or spinal tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: Warm. No edema. No clubbing or cyanosis.
SKIN: Warm. No rash.
NEUROLOGIC: AOx2. Moving all 4 limbs spontaneously.
Pertinent Results:
ADMISSION LABS:
===============
___ 05:55PM BLOOD WBC-15.7* RBC-3.08* Hgb-9.3* Hct-29.3*
MCV-95 MCH-30.2 MCHC-31.7* RDW-15.5 RDWSD-53.4* Plt ___
___ 05:55PM BLOOD Neuts-79.3* Lymphs-8.5* Monos-10.8
Eos-0.4* Baso-0.4 Im ___ AbsNeut-12.45* AbsLymp-1.34
AbsMono-1.70* AbsEos-0.07 AbsBaso-0.07
___ 05:55PM BLOOD ___ PTT-29.9 ___
___ 05:55PM BLOOD Glucose-114* UreaN-19 Creat-0.9 Na-135
K-4.4 Cl-100 HCO3-21* AnGap-14
___ 05:55PM BLOOD cTropnT-<0.01
___ 05:55PM BLOOD proBNP-3467*
___ 04:39AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.1
___ 05:59PM BLOOD ___ Temp-36.8 pO2-34* pCO2-37
pH-7.39 calTCO2-23 Base XS--1
___ 05:59PM BLOOD Lactate-1.7
IMAGING:
========
Sniff Test (___)
Negative sniff test, no evidence of paradoxical upward
diaphragmatic motion. Mild relative elevation of the left
hemidiaphragm in relation to the right, probably explained by
volume loss from left lower lobe atelectasis as seen on CT Chest
from 1 hour prior.
Video Swallow Study (___)
Penetration with thin and nectar thick liquids. No aspiration.
CT Chest with and without contrast (___)
1. Extensive right lung and left perihilar ground-glass opacity
is favored to represent pulmonary edema.
2. Moderate left pleural effusion with moderate associated left
basilar
atelectasis.
3. Slight heterogeneity involving enhancement of left lung base
collapse may suggest superimposed infection.
CT Chest with and without contrast (___)
Improvement in the prior collapse of the left lower lobe with
better aeration now and smaller left-sided pleural effusion.
Redemonstration of mild traction bronchiectasis noted in both
lower lobes with mild interlobular septal thickening, likely
related to the patient's chronic aspiration episodes. Extensive
superimposed ground-glass to the right lungs have improved in
the upper lobe, likely improving edema, and are slightly worse
in the lower lobe, likely due to a new aspiration episode.
TTE ___:
The left atrial volume index is normal. There is normal left
ventricular wall thickness with a normal cavity size.
There is mild regional left ventricular systolic dysfunction
with basal inferior hypokinesis (see schematic) and
preserved/normal contractility of the remaining segments. The
visually estimated left ventricular
ejection fraction is 50%. There is no resting left ventricular
outflow tract gradient. Normal right ventricular
cavity size with normal free wall motion. Tricuspid annular
plane systolic excursion (TAPSE) is normal. The
aortic sinus diameter is normal for gender. The aortic arch
diameter is normal with a normal descending aorta
diameter. The aortic valve leaflets (3) are moderately
thickened. There is no aortic valve stenosis. There is
trace aortic regurgitation. The mitral valve leaflets are mildly
thickened with no mitral valve prolapse. There is
an eccentric jet of mild [1+] mitral regurgitation. Due to the
Coanda effect, the severity of mitral regurgitation
could be UNDERestimated. The pulmonic valve leaflets are normal.
The tricuspid valve leaflets appear
structurally normal. There is mild to moderate [___] tricuspid
regurgitation. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild mitral
regurgitation. Moderate pulmonary hypertension.
MICROBIOLOGY:
==============
NEGATIVE BLOOD CULTURES, URINE CULTURE, FLU STUDIES, LEGIONELLA,
STREPTOCOCCAL PNEUMONIAE.
DISCHARGE LABS:
================
___ 06:31AM BLOOD WBC-11.9* RBC-3.29* Hgb-9.7* Hct-30.3*
MCV-92 MCH-29.5 MCHC-32.0 RDW-15.4 RDWSD-51.8* Plt ___
___ 06:31AM BLOOD Glucose-167* UreaN-31* Creat-0.9 Na-133*
K-4.0 Cl-89* HCO3-32 AnGap-12
___ 06:31AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.2
Brief Hospital Course:
PATIENT SUMMARY FOR ADMISSION:
==============================
___ yo man with HTN, CAD s/p CABGx3 (___), HFpEF (EF 45-50%),
AF on apixaban, AAA s/p repair, presenting with dyspnea and
hypoxia.
TRANSITIONAL ISSUES:
=====================
[] DISCHARGE DIURETIC: furosemide 20 mg by mouth daily.
[] DISCHARGE WEIGHT: 123.5 pounds -- please correlate with scale
at rehab on admission.
[] DISCHARGE CREATININE: 0.9
[] The patient should be weighed daily, and if there are changes
in weight of ___ pounds in either direction, he should be
evaluated for signs of over-diuresis or fluid overload.
[] He will have Pulmonary follow up at ___.
ISSUES ADDRESSED:
=================
#Acute hypoxemic respiratory failure:
He presented with dyspnea and was found to be hypoxic to the ___
on room air, initially requiring up to 6 L of oxygen. On exam,
he appeared fluid overloaded secondary to known heart failure
with preserved ejection fraction, and also appeared to have a
superimposed pneumonia. He was diuresed extensively with IV
furosemide and had improvement in his oxygen requirements to 2 L
by the time of discharge. He suffered a mild ___ with creatinine
peak of 1.6 due to overdiuresis. At first, given slow
improvement, the Pulmonary consult team involved and recommended
continued diuresis. A CT scan of his lungs showed extensive
right and left perihilar groundglass opacities thought to
represent pulmonary edema, along with a moderate left pleural
effusion with atelectasis and heterogeneity of the left lung
which was thought to represent infection. As for antibiotics, he
was initially given vancomycin and cefepime on ___, which
was transitioned to ceftriaxone ___, and then back to
vancomycin and ceftazidime ___. The change was made
because of slowly resolving hypoxia. He was also treated with
atypical coverage for azithromycin from ___ and then again
___. He had an SLP evaluation which did not show
significant aspiration. He also had evaluation by the
interventional pulmonary team to see if he could have fluid
drained from his effusions, but they were deemed too small to
evacuate. He was also noted to have elevation of the left
hemidiaphragm, and it was thought that possibly he had suffered
phrenic nerve injury during his recent CABG. However, a sniff
test showed normal diaphragmatic function. He worked with
physical therapy and did well, though still required 2 L of
oxygen. The pulmonary team felt comfortable discharging him with
plan for reimaging within ___ weeks and outpatient pulmonary
follow-up. A repeat CT scan while in house showed interval
improvement of his previous lung findings. On discharge, he will
be discharged on no antibiotics, but will be on furosemide 20 mg
by mouth daily, which she had tolerated well for 3 days prior to
admission with stable weights and stable respiratory
requirements.
# Encephalopathy:
Prior to discharge, the patient had periods of waxing and waning
orientation and agitation, which is that his reported was quite
consistent with previous hospitalizations during which she
suffered hospital-related delirium. With reorientation, he was
calm. No further work-up was undertaken.
# Hyponatremia:
Occurred in the setting of diuresis. Stable on discharge.
# Hypertension:
-Continued home isosorbide fractionated.
# Coronary artery disease s/p CABGx3 (___):
-Continued home aspirin and statin.
# pAF
-Continued home metoprolol fractionated.
-Continue home apixaban.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
3. Apixaban 5 mg PO BID
4. Aspirin 81 mg PO DAILY
5. Miconazole Powder 2% 1 Appl TP QID:PRN Rash
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Medications:
1. Furosemide 20 mg PO DAILY
2. Polyethylene Glycol 17 g PO BID
3. Senna 17.2 mg PO BID
4. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
5. Apixaban 5 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Miconazole Powder 2% 1 Appl TP QID:PRN Rash
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
=========
dyspnea
SECONDARY:
===========
Acute heart failure exacerbation
Community-acquired pneumonia
Hyponatremia
Discharge Condition:
Mental Status: Some delirium.
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 WERE YOU ADMITTED?
-You had shortness of breath.
WHAT HAPPENED WHEN YOU WERE HERE?
-We think that your shortness of breath was coming from fluid,
so we gave you intravenous medications to make you pee off
fluid. We also treated you with antibiotics.
-You met with our Pulmonary doctors to ___ you are
feeling shortness of breath.
-You had a CT scan of your lungs which showed lots of fluid and
may be a pneumonia.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
-Continue to take all of your medications as prescribed.
-Go to all of your appointments as shown below.
We wish you the best!
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10403474-DS-7 | 10,403,474 | 21,895,839 | DS | 7 | 2166-04-19 00:00:00 | 2166-04-19 14:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
motor vehicle collision
Major Surgical or Invasive Procedure:
___: PEG PLACEMENT
History of Present Illness:
The pt is a ___ year-old F w/ hx of HLD, COPD, and
Depression/Anxiety who presents s/p MVC from OSH for apparent CT
findings. Hx obtained from pt and family at bedside.
Patient reports that she was driving earlier in the afternoon at
25 mph when, while she was wearing her sunglasses, she noticed
glare from the sun that temporarily blinded her. Due to this
visual obscuration, patient was unable to see stopped car in
front of her and crashed into it. Her airbag deployed although
it is unclear if she only sustained trauma to her chest or also
to her head. She denies loss of consciousness. She remained in
the car until EMS arrived and was brought to outside hospital.
While at OSH, patient underwent NCHCT which showed a R parietal
occipital hemorrhage. She was subsequently transferred to ___
for further evaluation.
At time of interview, patient endorsed left-sided headache
described as aching in nature. No f/c, n/v, or diplopia. She
felt
that she could see car in front of her until glare from sun. Per
pt's daughter, she had recently stated that she would no longer
drive at night. Pt lives alone and is able to perform all of her
ADLs/IADLs. No reported hx of strokes or seizures in past.
Neuro ROS negative except as noted above
General ROS+ for chest pain ___ trauma
Past Medical History:
hyperlipidemia
chronic obstructive pulmonary disease
depression
anxiety
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Exam:
=============
Vitals:
T:98.3 P: 89 BP: 116/97 RR: 18 O2sat: 96% RA
General: Awake, cooperative, NAD, towel over forehead.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, C-collar in place
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward with
mild difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Apparent difficulty with naming due to pt stating her eyes were
"blurry" and couldn't pick out objects. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Pt was able to register 3 objects and recall ___ at 5
minutes.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. R gaze preference w/ apparent L homonymous
hemianopsia, although difficult to assess due to pt's position
in
bed. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, or proprioception throughout. Extinction
present
to L hemibody.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 1
R 2 2 2 1 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor noted. No dysmetria on FNF
over R field of vision, on L field pt does not overshoot but
aberrant in vertical plane.
-Gait: Deferred due to C-Collar
DISCHARGE PHYSICAL EXAM
=======================
Temp: 99.1 PO BP: 116/68 HR: 94 RR: 18 O2 sat: 91% O2 delivery:
RA
General: awakens easily, cooperative
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple
Pulmonary: no increased WOB
Cardiac: RRR
Abdomen: soft, non-distended
Extremities: WWP
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Sitting in bed, regards examiner. Not oriented
to
name. ___ verbal output, says "yes". Follow commands to
stick out tongue and raise arms, follows intermittently
-Cranial Nerves:
PERRL 3 to 2mm and brisk. Gaze R preference, does not easily
cross midline. There is a left visual field cut.
No facial droop (mild R NLF), facial musculature symmetric with
activation. Hearing intact to speech.
-Motor: She moves all extremities easily antigravity. ___
strength lower extremities.
-Sensory: DSS.
-DTRs: right toe up
-Coordination: deferred
-Gait: Deferred
Pertinent Results:
Admission Labs:
============
___ 04:20PM BLOOD WBC-10.0 RBC-3.95 Hgb-11.0* Hct-34.4
MCV-87 MCH-27.8 MCHC-32.0 RDW-13.7 RDWSD-43.9 Plt ___
___ 04:20PM BLOOD ___ PTT-27.3 ___
___ 04:20PM BLOOD ___ 05:20PM BLOOD Glucose-112* UreaN-21* Creat-0.8 Na-137
K-3.6 Cl-103 HCO3-21* AnGap-13
___ 05:20PM BLOOD estGFR-Using this
___ 05:20PM BLOOD
___ 04:32PM BLOOD Glucose-121* Lactate-1.3 Na-138 K-4.6
Cl-104 calHCO3-27
Discharge Labs:
============
___ 05:45AM BLOOD WBC-7.9 RBC-3.63* Hgb-10.1* Hct-31.9*
MCV-88 MCH-27.8 MCHC-31.7* RDW-14.2 RDWSD-44.5 Plt ___
___ 05:45AM BLOOD ___ PTT-26.0 ___
___ 05:45AM BLOOD Glucose-119* UreaN-13 Creat-0.5 Na-146
K-4.6 Cl-101 HCO3-30 AnGap-15
___ 05:45AM BLOOD Calcium-9.8 Phos-3.8 Mg-2.2
Imaging:
======
___ CTA HEAD AND CTA NECK:
1. No significant change in size of a large right
parieto-occipital
intraparenchymal hemorrhage compared to the earlier same-day CT,
with stable
degree of surrounding vasogenic edema and stable mass effect on
the occipital
horn of the right lateral ventricle.
2. Web-like calcified plaque in the mid right internal carotid
artery,
approximately 2.5-3 cm distal to its origin, with approximately
60% stenosis
by NASCET criteria. Mild calcified plaque within bilateral
proximal internal
carotid arteries is not associated with stenosis by NASCET
criteria.
3. No evidence for an arteriovenous malformation at the site of
the right
parenchymal hematoma. No evidence for an intracranial aneurysm.
___ CT CHEST/ABD/PELVIS W/CONTRAST:
1. Acute mildly displaced comminuted sternal fracture with a
small amount of
hematoma in the anterior mediastinum.
2. Minimally displaced fractures of the right anterior second
and third ribs.
3. Age-indeterminate compression fracture T10.
4. No other acute sequelae of trauma.
___ MR HEAD W/O CONTRAST:
1. Large right parietal/occipital parenchymal hematoma is again
demonstrated,
with stable mass effect compared to the ___ CT.
Crescent of slow
diffusion along the medial and anterior margins of the hematoma
raises the
question of underlying parenchymal ischemia. However, evidence
of siderosis
in the left inferior parietal sulci, as well as punctate chronic
micro
hemorrhages in the right cerebellum and right occipital lobe,
are compatible
with underlying amyloid angiopathy.
2. Possible small arachnoid cyst inferior to the left cerebellar
hemisphere is
again demonstrated.
___ MR HEAD W/ CONTRAST:
1. No significant change in size of a large right
parietal/occipital
parenchymal hematoma with stable mass effect.
2. No definite enhancing mass within the hematoma on
postcontrast images.
Although, recommend attention on follow-up imaging as the
hematoma may
partially obscure and underlying mass.
___ CT HEAD W/O CONTRAST:
1. Large right parieto-occipital intraparenchymal hemorrhage now
measures 4.9
x 2.9 cm (previously 4.6 x 2.6 cm), with a similar amount of
surrounding
vasogenic edema. There is persistent mass effect on the
occipital horn with
overall unchanged configuration of the ventricles. No
suggestion of new
hemorrhage.
2. Unchanged areas of low attenuation in the subcortical white
matter, which
are nonspecific, likely sequela of chronic microvascular
ischemic disease.
___ ___
IMPRESSION:
No significant interval change in approximately 4.7 x 2.9 cm
right
parieto-occipital intraparenchymal hematoma, with surrounding
vasogenic edema
resulting in effacement of adjacent sulci and right lateral
ventricle. No new
hemorrhage.
___ CXR
IMPRESSION
There is somewhat low lung volumes. There is pulmonary venous
congestion.
Right infrahilar opacification has decreased in the interim.
There may be a
small left effusion. The cardiomediastinal silhouette is
unchanged. The
aorta is atherosclerotic peer
Brief Hospital Course:
Ms ___ is an ___ year-old woman with a history of
hyperlipidemia, COPD, and depression/anxiety who was originally
admitted to the surgery service after a motor vehicle accident.
Briefly, she was driving home on ___ when she was unable to
see due to a glare of sunlight, causing her to rear-end the car
in front of her. Airbags deployed but she did not lose
consciousness. A non-contrast head CT showed a right parietal
intraparenchymal hemorrhage. She was also found to have
fractures of the sternum, ribs, and a T10 compression fracture.
All of her fractures were non-operative, per the recommendations
of the ACS/orthopedics service. She has been stable from a
respiratory and cardiovascular perspective. Pain has been
controlled with
acetaminophen and oxycodone.
Regarding the etiology of the hemorrhage, there was thought
initially that it was traumatic. However, the appearance of the
hemorrhage was somewhat atypical for a traumatic bleed.
Furthermore, her accident occurred at relatively low speed.
She was transferred to Neurology for further evaluation of her
intraparenchymal hemorrhage.
# Intraparenchymal hemorrhage:
An MRI of the brain without contrast re-demonstrated a large
right parietal and occipital parenchymal hematoma. It also
exhibited evidence of siderosis in the left inferior parietal
sulci as well as punctate chronic microhemorrhages in the right
cerebellum and right occipital lobe. An MRI brain with contrast
did not show an underlying brain mass though follow-up imaging
was recommended. The MRI findings were consistent with cerebral
amyloid angiopathy. Of note the daughter of the patient had
observed a cognitive decline over the last one and a half years.
Ms. ___ was started on lisinopril for blood pressure control.
She underwent PEG placement on ___. Persistent drowsiness
on POD#1 from PEG placement prompted a repeat non-contrast CT
head which displayed a stable hematoma and no new intracranial
pathology. Patient's mental status has since improved although
an element of hypoactive delirium persists.
# fever.
On ___ Ms. ___ spiked a fever and was pan-cultured. The
WBC was normal. A CXR showed left basal opacification. This was
most likely pleural effusion with compressive atelectasis but an
infiltrate couldn't be excluded. She was started empirically on
vancomycin and cefepime on ___. She was again febrile on
___. Though as the WBC remained normal and the cultures
sterile antibiotics were discontinued on ___. Central fever
is the most likely casue of the fever.
# sternal and right-sided rib fractures
Pain control was achieved with tylenol, lidocaine patch and
oxycodone.
Transitional Issues:
- MRI brain w/wo contrast scheduled as opt in 3 months
- Resume oxybutynin as needed
- Resume symbicort as tolerated
- Neurology follow up as below
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Oxybutynin 15 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Sertraline 150 mg PO DAILY
4. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Docusate Sodium 100 mg PO BID
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Lisinopril 30 mg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Senna 8.6 mg PO BID:PRN constipation
9. Atorvastatin 20 mg PO QPM
10. Sertraline 150 mg PO DAILY
11. HELD- Oxybutynin 15 mg PO DAILY This medication was held.
Do not restart Oxybutynin until needed at rehab
12. HELD- Symbicort (budesonide-formoterol) 160-4.5
mcg/actuation inhalation BID This medication was held. Do not
restart Symbicort until able to participate with inhaler at
rehab
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right parieto-occipital intraparenchymal hemorrhage
sternal fracture (managed non-operatively)
right-sided rib fractures ___ and ___ managed non-operatively)
age-indetermined T10 compression fracture (managed
non-operatively)
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized after you were involved in a motor vehicle
accident. You were diagnosed with an ACUTE HEMORRHAGIC STROKE, a
condition from bleeding into the brain. The brain is the part of
your body that controls and directs all the other parts of your
body, so damage to the brain from being deprived of its blood
supply or bleeding 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:
[] arterial hypertension
[] cerebral amyloid angiopathy
We are changing your medications as follows:
You were started on lisinopril 20 mg by mouth daily for blood
pressure control.
Please take your other medications as prescribed.
Please follow up with Neurology as listed below. Please follow
up with your regular doctor within 14 days of discharge.
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:
___
|
10404210-DS-18 | 10,404,210 | 22,880,512 | DS | 18 | 2161-03-05 00:00:00 | 2161-03-05 22:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
iodine / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / aspirin
/ Avelox / moxifloxacin / diphenhydramine / Benadryl / Fioricet
/ morphine / Penicillins / Ambien / Benzodiazepines
Attending: ___.
Chief Complaint:
Ptosis, right sided weakness, lethargy
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ year old female hx cavernous malformation in ___ with
hemorrhage and had surgery in ___, subsequently
re-hemmorhaged and had surgery with Dr. ___ in ___ at ___.
Per Dr. ___ patient has residual cav mal affecting her
medulla and pons area which are inoperable. The patient has had
subsequent hemorrhages in ___ and ___ which presented with R
sides symptoms. She presents to the ED today with right sided
(upper and lower) weakness x 1 day, right lid ptosis, headache
yesterday and increased fatigue x 3days. On ROS she denies CP,
SOB, fevers, chills, or dizziness. She also reports that she has
had more difficulty swallowing her secretions than normal and is
more aware of this motion than she normally is.
Past Medical History:
PMHx:
- 3 intracranial cavernomas: pontine, right cerebellar
cavernoma,
and medulla. Operated on years ago in ___ (Dr. ___ and
more recently at ___.
- sleep apnea
Social History:
___
Family History:
Family Hx: NC
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
PHYSICAL EXAM:
O: T:98.6 BP: 123/65 HR: 91 R: 16 O2Sats: 96% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4-3 mm bilaterally EOMs intact. Slight R lid
ptosis.
Neck: Supple,
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech Thick.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Right tongue deviation
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Right IP 4+/5, otherwise strength full power ___
throughout. No pronator drift
Sensation: Intact to light touch
Coordination: Right finger to nose dysmetria, bilateral heel to
shin dysmetria.
PHYSICAL EXAMINATION ON DISCHARGE:
Aox3, PERRL ___, ___, right tongue deviation, slight R ptosis, no
drift, RUE ___, IP 4+/5 otherwise MAE ___, LUE/LLE ___
Pertinent Results:
Please see OMR for pertinent lab and imaging results.
Brief Hospital Course:
#Cavernous Malformation
The patient presented to the ED on ___ with complaints of
right sided weakness and headache. She underwent a non-contrast
head CT which was concerning for a possible hemorrhage within
the cerebellum versus residual cavernous malformation.
On ___, the patient remained neurologically stable on
examination. On ___, she underwent a MRI which was stable. She
was evaluated by Physical Therapy who recommended continued
therapy at her outpatient center.
#Dysphagia
On ___, the patient was evaluated by the Speech Pathologist who
placed the patient on a strict NPO order while the MRI was
pending. The patient was discharged to home and remained NPO;
she has a follow-up appointment with the Speech-Language
Pathologist she sees regularly at the clinic in ___.
#Tube Feeds
On ___, the patient was started on tube feeds per nutrition
recommendations. She has a PEG tube at baseline.
Medications on Admission:
___: -Proventil HFA 90mcg/actuation inhaler
-midodrine 5 mg TID
-Topamax 25 mg sprinkles BID
-Omeprazole 20 mg daily
-Jevity 1 cal 0.04 gram-10.6kcal/ml 6 times/day (6am, 9am, 12pm,
3pm, 6pm, 9pm)
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q4H:PRN sob
2. Midodrine 5 mg PO TID
3. Omeprazole 20 mg PO DAILY
4. Topiramate (Topamax) 25 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Pontine, Medullary, and Right Cerebellar Cavernous
Malformations.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(walker).
Discharge Instructions:
Activity:
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon.
Medications:
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common 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.
** You may not take in food or drink by mouth until you are
cleared by the outpatient Speech-Language Pathologist you are
scheduled to see next week in ___.
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:
___
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10404360-DS-24 | 10,404,360 | 29,293,024 | DS | 24 | 2206-06-13 00:00:00 | 2206-06-14 08:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year old female with CAD s/p CABG ___, complex
partial seizures, and pulmonary hypertension who presents with
two weeks of cough that has become productive of thick green
sputum. She saw her PCP today who obtained a CXR that was
negative for pna and recommended allergy regimen. OVernight she
developed worsening fever and rigors and came to the ED.
In the ED, initial vitals were T 101.2 91 145/40 24 90%RA. Her
labs were notable for Na 129, WBC 11.0 with 85% poly, UA with
few bact and 15 WBC. CXR showed LLL atelectasis. Here pressures
remained in mid 90___ despite 2L LR and she was given
ceftriaxone, azithro and transferred to ICU.
Review of systems:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies headache, sinus
tenderness. Denies chest pain, chest pressure, palpitations, or
weakness. Denies vomiting, diarrhea, constipation, abdominal
pain, or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
C3, C4, C5 Cervical Laminectomy ___
Asthma
Pulmonary hypertension
Myocardial Infarction ___ yrs ago, s/p RCA stent, CABG ___
Paorxysmal atrial fibrillation
Hypercholesterolemia
Exertional dyspnea
Complex partial seizures-pt describes absence seizures in last
___ months
s/p complete hysterectomy
hyponatremia
appendectomy ___ years ago
tonsillectomy as a child
cataract (bilateral) surgery
Colonoscopy ___ internal hemorrhoids.
pneumonia in the end of ___ hospitalized.
Colonoscopy ___ okay.
Social History:
___
Family History:
Father died of his ___ MI at age ___ in ___. Mother died in
early
___ of emphysema.
Physical Exam:
On Admission:
Vitals- T99.1 104/56 64 18 95%2LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diffusely wheezy, insp wheezes left base, good air
movment
CV: Regular rate and rhythm, distant heart soudns
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
DISCHARGE EXAM
Vitals: T:98.3 BP:120/52 P:66 R:18 O2:95%ra
PAIN: 0
General: nad
Lungs: faint wheezing mid L lung, crackles at L base
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Pertinent Results:
On Admission:
___ 01:50AM BLOOD WBC-11.0# RBC-3.96* Hgb-11.5* Hct-37.1
MCV-94 MCH-29.2 MCHC-31.1 RDW-13.9 Plt ___
___ 01:50AM BLOOD Neuts-85.8* Lymphs-5.7* Monos-7.9 Eos-0.4
Baso-0.1
___ 01:50AM BLOOD Glucose-127* UreaN-20 Creat-0.8 Na-129*
K-4.9 Cl-93* HCO3-25 AnGap-16
___ 09:24AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.1
___ 01:50AM BLOOD Osmolal-270*
___ 04:53AM BLOOD ___ pO2-65* pCO2-40 pH-7.40
calTCO2-26 Base XS-0
___ 01:59AM BLOOD Lactate-1.7
Microbiology:
___ Blood cultures -
___ Urine culture - negative
___ Sputum culture - moderate commensal respiratory flora
___ Respiratory viral screen - inadequate for analysis x 2
Imaging/Studies:
___ Echocardiogram
The left atrium is markedly dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is ___
mmHg. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF = 60%). However, the inferior
wall is hypokinetic, with focal inferobasal akinesis. Right
ventricular chamber size and free wall motion are normal.
[Intrinsic right ventricular systolic function is likely more
depressed given the severity of tricuspid regurgitation.] The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is mild
posterior leaflet mitral valve prolapse. An eccentric,
posteriorly directed jet of Mild to moderate (___) mitral
regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). The tricuspid valve leaflets are
mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. [In the setting of at least moderate to severe
tricuspid regurgitation, the estimated pulmonary artery systolic
pressure may be underestimated due to a very high right atrial
pressure.] There is no pericardial effusion.
___ Chest XRay
A single portable upright view of the chest was obtained.
Cardiomediastinal silhouette including moderate cardiomegaly is
unchanged. Lungs are persistently hyperinflated, reflecting
chronic small airway obstruction and/or emphysema. A streaky
left basilar opacity likely represents atelectasis. There is no
focal consolidation, pleural effusion or pneumothorax.
Brief Hospital Course:
___ F with CAD s/p CABG, COPD, pulm HTN who presented with fever
and productive cough. Felt to have a viral bronchitis versus
community acquired pneumonia. She was covered with levofloxacin.
Her symptoms improved without positive culture data.
Active Issuews
# Fever, cough
Most likely viral bronchitis with baseline asthma versus
community acquired pneumonia given slight CXR findings and
inspiratory wheeze on left base. She also had a new oxygen
requirement. On admission she met ___ SIRS criteria. Viral
respiratory swab was unable to be obtained x2. She was continued
on levofloxacin for a 5 day community acqured pneumonia course.
Her symptoms slowly improved, and she was weaned off oxygen with
an ambulatory SaO2 91-93%.
# Hypotension
Her BP at baseline in OMR are in the ___. Her presenting
pressure of 145/40 in ED may be aberrant and her hypotension in
the ED may have just been her baseline. She was volume
resuscitated with crystalloid. Although her EF was 50%, she had
moderate MR and moderate-severe TR so futher resuscitation was
done jucidiously. Home lisinopril and metoprolol were held
initally and resumed prior to discharge.
# Hyponatremia
Presented with Na+ 129, most likely hypovolemic. This resolved
with IV fluids.
# Pyuria
UA had WBC, she was asymptomatic, and urine culture was negative
so she was not treated.
Chronic Issues
# CAD s/p CABG
Continued home aspirin and atorvastatin. Metoprolol and
lisinopril were initially held.
# Atrial Fibrillation
CHADS2 vasc = 4, paroxysmal, was in sinus rhythm on admission,
not on warfarin. She was continued on amiodarone and aspirin.
Metoprolol was initially held as above.
# Seizures
Per patient, has absance seizures with lip smacking, no seizures
for over ___ year. Was continued on lamotrigine.
# Hypothyroidism
Stable, continued on levothyroxine.
Transitional Issues
- chronic anemia at baseline, unclear if prior work up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN fever; pain
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB; wheezing
3. Amiodarone 200 mg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. LaMOTrigine 100 mg PO BID
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Lisinopril 2.5 mg PO DAILY
9. Neurontin (gabapentin) 400 mg Oral TID
10. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
11. Aspirin 325 mg PO DAILY
12. Ondansetron 4 mg IV Q8H:PRN nausea; vomiting
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Atorvastatin 40 mg PO HS
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB; wheezing
2. Amiodarone 200 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 40 mg PO HS
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. LaMOTrigine 100 mg PO BID
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Lisinopril 2.5 mg PO DAILY
10. Neurontin (gabapentin) 400 mg Oral TID
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
13. Acetaminophen 325-650 mg PO Q6H:PRN fever; pain
14. Levofloxacin 500 mg PO DAILY Duration: 10 Days
RX *levofloxacin 500 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
15. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
16. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with cough, fever and low blood pressure. This
was found to be due to a pneumonia. You were initially treated
in the ICU due to low blood pressure but this improved and you
did not requrire supplimental oxygen at the time of discharge.
Followup Instructions:
___
|
10404360-DS-27 | 10,404,360 | 26,963,149 | DS | 27 | 2207-12-05 00:00:00 | 2207-12-05 19:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
cats / house dust
Attending: ___.
Chief Complaint:
gait instability
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs ___ is a ___ old woman right handed woman
with a history of MI s/p CABG, atrial fibrillation on aspirin,
epilepsy, and frequent falls who presents acute gait instability
in the setting of medication error.
History gathered from the patient and her husband who disagree
with each other on several different points.
Of note, Mrs. ___ has chronic gait unsteadiness and
frequent
falls. At baseline, she uses a cane, but is unstead.
Initially the patient states that she has had worsened gait for
the past 4 days, but later states this is not the case. Late
yesterday evening, Mrs. ___ accidentally took an extra dose
of her Lamictal and Gabapentin, as she had forgotten she already
took her day's dose. She otherwise went to bed feeling well and
there are no other known medication errors.
This morning, upon awakening, she noticed a clear change in her
gait. She was able to get up and out of bed without assistance
and was able to walk to the kitchen to make herself oatmeal.
However, she felt very unsteady and had to use the furniture and
the walls to stabilize herself. When asked what she felt like,
she states "dizzy", but denies vertigo or presyncopal symptoms.
She cannot clarify this further.
Shortly following her breakfast, he had an episode of emesis,
and
later in the day some dry heaves. She attempted to remain at
home. However, she continued to be extremely unsteady.
She had at least 1 mechanical fall today (possibly 2), which her
husband had to help her up from. There were no pre-syncopal
symptoms prior to these and no LoC. When she was sat in the
chair, her husband states the patient was very unsteady sitting
upright and had to "flop" back for support (though the patient
denies this). She required essential "total" assistance to
walk,
much different from her intermittently cane dependent baseline.
She was otherwise without symptoms- no weakness, sensory change,
speech or language change, etc.
Due to this gait change, she presented to an Urgent Care where
her Lamictal level was drawn (pending). She was subsequently
referred to our ED for further evaluation. In our ED,
Orthostatic vitals were negative and gait was very unstable.
Lab
work notable for a pre-renal azotemia, without clear underlying
toxic-metabolic derangement to explain her gait change.
Neurology was consulted for ? posterior circulation ischemia..
Of note, the patient had a very similar presentation in ___
(in addition to many ED visits for falls), with acute (and very
similar) gait change. This occurred in the setting of a
relatively recent increase in her Lamictal (from 300-->400) and
possibly a concurrent UTI. She was initially treated with
antibiotics, but urine culture subsequently returned as
negative.
Per Dr. ___ from ___: "Regarding her seizure
history she is seen by Dr. ___. She has complex partial and
simple partial seizures and has once had a GTC. In the past her
semiology has been behavioral arrest with swallowing however
recently she is reporting episodes of "dreamlike" sensations of
being in another place such as a house or a garden; of feeling
warm on one side of her body; or of a feeling of death and
beauty
and enjoyable sadness when looking at the color green. She has
not had any witnessed events which are clearly seizures, but
because of these events her lamictal dose was increased last
month.
Seizure history:
Semiology:
1. simple partial: "subjective feelings with no alteration of
consciousness", ___
2. complex partial seizure: "swallowing", impending doom, and
unawareness
3. GTC (once in lifetime while pregnant)
EEG findings:
Independent bilateral temporal and parietal epileptiform
discharges.
___
Four episodes: brief, less than 10 second duration, rhythmic
delta bursts from the left temporal that would suggest perhaps
an
underlying brief electrographic seizure "
The patient reports her last seizure roughly ___ months ago.
On neuro ROS, the pt 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 new or changing bowel or bladder
incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain
or
tightness, palpitations. Denies diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- Complex partial seizures as above
- Asthma
- Pulmonary hypertension
- Myocardial Infarction ___ yrs ago, s/p RCA stent, CABG ___
- Paroxysmal atrial fibrillation
- Hypercholesterolemia
- Cervical spine fracture ___
- C3, C4, C5 Cervical Laminectomy ___
- C2 Laminectomy, C2-6 Fusion ___
- s/p appendectomy, tonsillectomy
- s/p complete hysterectomy
- cataract (bilateral) surgery
- Tremor
Social History:
___
Family History:
Father deceased at the age of ___ ___ MI. Mother deceased in
her ___ emphysema. Mother may have had a seizure, details
unclear. Otherwise no family neurologic history.
Physical Exam:
Admission Physical Exam:
Vitals: 72 127/49 18 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM
Neck: Supple. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: S1S2, no M/R/G noted
Abdomen: soft, NT/ND.
Extremities: WWP
Neurologic:
-Mental Status: Keeps her eyes closed for most of the
examination
while talking with the provider, though opens them to commands.
Alert, oriented x 3. She provides her own history, but often
changes her timeline or story. Attentive to examiner, but makes
errors with ___ backward (misses ___. Language is fluent
with intact repetition and comprehension. Normal prosody. There
was a single paraphasic error. Pt was able to name high
frequency
objects, but some difficulty with low frequency (called pointer
finger "pointing finger) objects. Speech was not dysarthric.
Able to follow both midline and appendicular commands. Pt was
able to register 3 objects and recall ___ at 5 minutes. There
was
no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3mm on left, 3.5 on right. Briskly
reactive. EOMI without nystagmus. Normal saccades. VFF to
confrontation.
V: Facial sensation intact to light touch.
VII: Subtle right NLF flattening, but otherwise no facial droop,
facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk. Mildly increased tone in upper ext, ___
with
mild to moderate spasticity. No pronator drift bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5- ___ ___ 5 5- 5 5 5
R 5- 5 4+ ___ 5 5 5- 5 5 5
-Sensory: Difficult exam. No deficits to light touch. Patient
endorses patchy sensory decrease to pinprick in her lower ext
below the thighs, and less frequently her face and arms. She is
inconsistent with this. Pinprick intact at the feet.
Proprioception intact at feet to large movements. No extinction
to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 2
R 2 2 2 3 2
Plantar response was flexor bilaterally.
+ ___ b/l
- Jaw Jerk.
-Coordination: No truncal Ataxia, able to sit up in bed without
difficulty. Significant postural and intention tremor in the
upper and lower extremities. Mildly clumsy RAM bilaterally.
With eyes closed she consistently misses her nose with both
hands
to the right side. This does not change or improve with
repetition. RAM are mild-moderately clumsy bilaterally in her
upper extremities, slightly worse with the right. FNF with
significant tremor, but no clear dysmetria. Heel shin is jerky,
but improved with repetition. No cerebellar rebound.
-Gait: Wide based unsteady stance. She holds her hands out
infront of her (palms out) as if afraid. On wide based
standing,
sways, but does not fall. Any attempt to walk is extremely
unsafe, with a staggering, lurching gait (clearly altered from
baseline per husband). No clear side fall preference.
===============
.
Discharge physical exam
========================
98 120/47 61 18 94RA
Gen NAD
HEENT bruise over R chin
Pulm CTAB
Abd NTND
Extr no cce
awake, alert, oriented
motor: strength intact throughout
sensory: proprioception intact, intact to touch bilaterally
coordination: FNF intact w action tremor
gait: somewhat unsteady using assistive walker
Pertinent Results:
Imaging:
Echo
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function.Moderate to
severe tricuspid regurgitation. Moderate pulmonary artery
hypertension. Mild-moderate mitral regurgitation. Compared with
the prior study (images reviewed) of ___, the severity of
tricuspid regurgitation is now slightly greater.
CTA head and neck:
1. An equivocal 2-3 mm rounded enhancement of the right
parafalcine frontal lobe in the distribution of a right
callosomarginal branch (series 2, image 321). This is likely
secondary to a confluence of vessels or a venous structure,
however a small aneurysm is not entirely excluded. Close
attention on followup examination is recommended.
2. There is approximately 25 percent stenosis of the bilateral
cervical
internal carotid arteries by NASCET criteria. Otherwise, the
remainder of the CTA neck is essentially unremarkable.
3. CTA of the head does not demonstrate high-grade stenosis.
CXR:
Possible trace left pleural effusion. No focal consolidation.
MRI:
1. Study is mildly degraded by motion.
2. No acute intracranial abnormality.
3. No evidence of acute infarct.
4. Ventricular prominence suggested to be disproportionally
increased relative to sulcal prominence, increased compared to
___ prior exam. While findings may reflect central
volume loss, normal pressure hydrocephalus is not excluded on
the basis of this examination. Recommend clinical correlation.
5. Stable 4 mm posterior left cingulate gyrus remote
microhemorrhage versus cavernoma.
6. Known right sphenoid wing probable meningioma not visualized
on current
noncontrast study.
7. Paranasal sinus disease as described.
LABS:
___ 05:40AM BLOOD WBC-6.4 RBC-3.57* Hgb-9.8* Hct-31.2*
MCV-87 MCH-27.5 MCHC-31.4* RDW-14.7 RDWSD-47.3* Plt ___
___ 07:42AM BLOOD WBC-5.5 RBC-3.54* Hgb-9.8* Hct-31.0*
MCV-88 MCH-27.7 MCHC-31.6* RDW-14.8 RDWSD-47.6* Plt ___
___ 01:57PM BLOOD WBC-6.1 RBC-3.59* Hgb-10.0* Hct-31.8*
MCV-89 MCH-27.9 MCHC-31.4* RDW-14.8 RDWSD-48.0* Plt ___
___ 01:57PM BLOOD Neuts-81.5* Lymphs-9.6* Monos-7.0 Eos-1.1
Baso-0.5 Im ___ AbsNeut-5.00 AbsLymp-0.59* AbsMono-0.43
AbsEos-0.07 AbsBaso-0.03
___ 06:35AM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND
K-PND Cl-PND HCO3-PND
___ 05:40AM BLOOD Glucose-88 UreaN-17 Creat-0.9 Na-136
K-4.2 Cl-102 HCO3-27 AnGap-11
___ 07:42AM BLOOD Glucose-93 UreaN-17 Creat-0.8 Na-136
K-4.0 Cl-101 HCO3-26 AnGap-13
___ 01:57PM BLOOD Glucose-117* UreaN-26* Creat-0.7 Na-133
K-4.6 Cl-96 HCO3-27 AnGap-15
___ 07:42AM BLOOD ALT-31 AST-50* LD(LDH)-275* AlkPhos-97
TotBili-0.4
___ 01:57PM BLOOD Lipase-25
___ 04:35PM BLOOD cTropnT-<0.01
___ 06:35AM BLOOD Calcium-PND Phos-PND Mg-PND
___ 07:42AM BLOOD Albumin-4.0 Calcium-10.1 Phos-3.1 Mg-2.1
Cholest-194
___ 01:57PM BLOOD Albumin-4.1 Calcium-9.9 Phos-3.7 Mg-2.4
___ 07:42AM BLOOD %HbA1c-5.9 eAG-123
___ 07:42AM BLOOD Triglyc-51 HDL-86 CHOL/HD-2.3 LDLcalc-98
___ 01:57PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Brief Hospital Course:
=======================
BRIEF HOSPITAL COURSE
=======================
Mrs ___ is a ___ old woman right handed woman
with a history of MI s/p CABG, atrial fibrillation on aspirin,
epilepsy, and frequent falls who presents acute gait instability
in the setting of medication error. Differential diagnosis
included stroke vs medication overdose. MRI brain did not show
infarct; CTA head and neck without evidence of high grade ICA
stenosis. Consistent with diagnosis of overdose, gait and
symptoms improved with time. There was no evidence of a
underlying toxic-metabolic or infectious insult. Patient
evaluated by ___ and recommended for discharge to rehab
facility.
.
=======================
TRANSITIONAL ISSUES
=======================
- CTA showed possible R ACA supracallosal/marginal artery
rounded enhancement - confluence vs small aneurysm 2-3 mm.
- Consider MR ___ for ? Adenoma
- Follow QTc; read as 412 on EKG but cardiology read with a QT
interval as long as 480
- Patient reports depression; please assess as outpatient with
possible psycho/pharmacologic therapy
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Amiodarone 200 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Dulera (mometasone-formoterol) 100-5 mcg/actuation inhalation
1- 2 inhalations once or twice a day, followed by rinsing mouth
& gargling with H20
5. Gabapentin 400 mg PO TID
6. LaMOTrigine 300 mg EXTENDED RELEASE PO QHS
7. Atorvastatin 20 mg PO QPM
8. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Gabapentin 400 mg PO TID
3. LaMOTrigine 300 mg EXTENDED RELEASE PO QHS
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Aspirin 325 mg PO DAILY
7. Dulera (mometasone-formoterol) 100-5 mcg/actuation inhalation
1- 2 inhalations once or twice a day, followed by rinsing mouth
& gargling with H20
8. Atorvastatin 40 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Medication Error
Lamotrigine and gabapentin overdose
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 ___
___ were admitted to ___ with worsened gait instability after
taking too much lamotrigine and gabapentin. Given your risk
factors for stroke, we did do an MRI scan of your head to rule
out other causes, such as stroke. We did not find any evidence
of stroke and attributed this worsening of your gait to your
unintentional medication overdose.
We did not make any changes to your medication regimen. Please
continue to take your medications as prescribed and follow up
with your epilepsy doctor.
Followup Instructions:
___
|
10404360-DS-29 | 10,404,360 | 25,791,092 | DS | 29 | 2209-02-13 00:00:00 | 2209-02-13 17:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
cats / house dust
Attending: ___
Chief Complaint:
weakness, productive cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ h/o CAD s/p CABG, asthma, seizure d/o, afib, and
hypothyroidism p/w 1w productive cough and progressively
increasing weakness. Pt reports sxs similar to previous
pneumonia. Contacted PCP who started azithromycin yesterday, but
sxs worsened and she was too weak to stand on her own so she
came to the ED. Denies f/c/ns, n/v/d, cp, sob, dysuria,
lightheadedness, HA. Husband is present and notes this morning
patient slid off bed to floor, witnessed, and no head strike.
In the ED, initial vitals: 98.0 115 126/79 20 95%NC
Labs were significant for:
WBC 10.2
Hgb 10.3
Imaging showed CXR IMPRESSION:
Comparison 2 ___. The lung volumes have decreased.
Moderate cardiomegaly. Normal alignment of sternal wires.
Clips of the CABG. New retrocardiac opacity with air
bronchograms, potentially reflecting pneumonia in the
appropriate clinical setting. In addition, there are
generalized interstitial markings and bronchial cuffing,
suggesting mild interstitial pulmonary edema.
EKG: Afib w/ RVR to 120
In the ED, she received:
1L NS
ASA 325 mg
ceftriaxone 1 g IV
azithromycin 500 mg IV
metoprolol succinate 25 mg PO
levothyroxine 100 mcg PO
Vitals prior to transfer: 98.1 112 106/60 23 93%NC
Currently, AVSS, lying comfortably in bed and speaking with a
mild stutter. Tremulous at baseline. Breathing comfortably on
RA.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing. No chest pain or palpitations. No nausea
or vomiting. No diarrhea or constipation. No dysuria or
hematuria. No hematochezia, no melena. No numbness, no focal
deficits.
Past Medical History:
- Complex partial seizures as above
- Asthma
- Pulmonary hypertension
- Myocardial Infarction ___ yrs ago, s/p RCA stent, CABG ___
- Paroxysmal atrial fibrillation
- Hypercholesterolemia
- Cervical spine fracture ___
- C3, C4, C5 Cervical Laminectomy ___
- C2 Laminectomy, C2-6 Fusion ___
- s/p appendectomy, tonsillectomy
- s/p complete hysterectomy
- cataract (bilateral) surgery
- Tremor
Social History:
___
Family History:
Father deceased at the age of ___ ___ MI. Mother deceased in her
___ emphysema. Mother may have had a seizure, details
unclear. Otherwise no family neurologic history.
Physical Exam:
Admission Exam:
================
VS: 97.9 ___ 20 95%RA
GEN: Alert, lying in bed, no acute distress, appears slightly
tremulous
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: faint wheeze on LLL, faint rhonchi RLL; possibly
transmitted breath sounds
COR: irregularly irregular rhythm, nl s1/s2, no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal.
resting tremor b/l UE
.
Discharge Exam:
================
VS: 98.0 108 100/64 19 92%RA
GEN: Alert, no acute distress, appears slightly tremulous
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: CTAB
COR: irregularly irregular rhythm, nl s1/s2, no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal.
resting tremor b/l UE
Pertinent Results:
Admission labs:
=============
___ 08:25AM BLOOD WBC-10.2* RBC-3.95 Hgb-10.3* Hct-33.2*
MCV-84 MCH-26.1 MCHC-31.0* RDW-16.5* RDWSD-50.9* Plt ___
___ 08:25AM BLOOD Neuts-80.9* Lymphs-6.4* Monos-11.9
Eos-0.0* Baso-0.2 Im ___ AbsNeut-8.28*# AbsLymp-0.65*
AbsMono-1.22* AbsEos-0.00* AbsBaso-0.02
___ 08:25AM BLOOD Plt ___
___ 08:25AM BLOOD Glucose-114* UreaN-14 Creat-0.5 Na-137
K-4.0 Cl-99 HCO3-22 AnGap-20
___ 08:25AM BLOOD Calcium-9.4 Phos-2.9 Mg-2.2
___ 08:34AM BLOOD Lactate-1.3
.
Imaging/reports:
=============
CXR
IMPRESSION:
Comparison 2 ___. The lung volumes have decreased.
Moderate
cardiomegaly. Normal alignment of sternal wires. Clips of the
CABG. New
retrocardiac opacity with air bronchograms, potentially
reflecting pneumonia
in the appropriate clinical setting. In addition, there are
generalized
interstitial markings and bronchial cuffing, suggesting mild
interstitial
pulmonary edema.
.
Microbiology:
=============
___ - BCx x 2 - NGTD
.
Discharge Labs:
=============
___ 04:45AM BLOOD WBC-5.9 RBC-3.58* Hgb-9.6* Hct-30.8*
MCV-86 MCH-26.8 MCHC-31.2* RDW-16.7* RDWSD-52.7* Plt ___
___ 04:45AM BLOOD Glucose-82 UreaN-10 Creat-0.5 Na-137
K-4.1 Cl-99 HCO3-27 AnGap-15
___ 04:45AM BLOOD Calcium-9.5 Phos-2.9 Mg-2.1
___ 04:45AM BLOOD TSH-0.21*
Brief Hospital Course:
___ female with CAD s/p CABG, asthma, seizure disorder, afib, and
hypothyroidism presented with 1 week of productive cough and
progressively increasing weakness, found to have community
acquired pneumonia with course complicated by atrial
fibrillation with rapid ventricular response. Started on
azithromycin and ceftriaxone with rapid clinical improvement and
transitioned to PO azithromycin and amoxicillin for a total of 7
days of antibiotics. Her atrial fibrillation was treated with
increased metoprolol succinate. Patient was at her goal heart
rate of less than ___nd ambulation and was stable
on room air prior to discharge.
# Community acquired pneumonia: presented with productive cough,
weakness and with intermittent oxygen requirement with LLL
pneumonia on CXR. Treated with azithromycin and ceftriaxone
initially but transitioned to azithromycin and amoxicillin for a
7 day total antibiotic course ending ___. Patient improved
and was stable on room air without fevers or leukocytosis.
# Atrial fibrillation: course complicated by rapid ventricular
response to the 140s. Likely trigger was respiratory infection.
Home metoprolol was increased with guidance of cardiology
consult. Discharge dose is metoprolol succinate 150mg QD.
Recommend titration of this dose as needed with goal heart rate
less than 110 bpm. Workup notable for depressed TSH in the
setting of illness. Recommend rechecking TSH after resolution of
illness and dose adjustment of levothyroxine as appropriate.
# Weakness: evaluated by Physical therapy and recommended
rehabilitation. Patient ambulated with rolling walker.
CHRONIC ISSUES
# Seizure d/o: no evidence of seizure while hospitalized.
Continued home gabapentin and lamotrigine.
# Asthma: treated with home Advair, albuterol and ipratropium
nebulizers.
# CAD s/p CABG: continued home aspirin, atorvastatin and
lisinopril
# Hypothyroidism: TSH was low in the setting of illness,
continued home levothyroxine dose and recommend repeating TSH
after resolution of illness.
# Anemia: near baseline according to previous labs for last
several years.
TRANSITIONAL ISSUES:
[ ] Metoprolol succinate was increased from 25 mg PO daily to
150 mg PO daily in setting of afib w/ RVR to the 140s. Monitor
BP/HR and adjust dosage as appropriate
[ ] Goal heart rate is less than 110 bpm
[ ] complete course of antibiotics with amoxicillin 500mg Q8H
and azithromycin 250mg QD through ___
[ ] TSH obtained in the setting of uncontrolled atrial
fibrillation, recommend repeating after complete resolution of
illness and consideration of reduction of levothyroxine dose if
appropriate
# CODE STATUS: Full
# CONTACT:
Name of health care proxy: ___
Relationship: Husband
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 2.5 mg PO DAILY
2. Gabapentin 400 mg PO TID
3. LamoTRIgine 300 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Atorvastatin 40 mg PO QPM
7. Aspirin 325 mg PO DAILY
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
Discharge Medications:
1. Amoxicillin 500 mg PO Q8H Duration: 4 Days
2. Azithromycin 250 mg PO Q24H
3. Metoprolol Succinate XL 150 mg PO DAILY
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
5. Aspirin 325 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Docusate Sodium 100 mg PO BID
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Gabapentin 400 mg PO TID
10. LamoTRIgine 300 mg PO DAILY
11. Levothyroxine Sodium 100 mcg PO DAILY
12. Lisinopril 2.5 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary:
Pneumonia
Secondary:
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 part in your care during your recent
hospitalization at ___. You
were admitted for cough and increasing weakness. You were found
to have a pneumonia, and treated with antibiotics for this. You
were evaluated by the physical therapy team, and it was
determined that it would be most safe to temporarily go to
rehabilitation to gain back strength.
Please continue to take your medications as prescribed. Should
you note any new or concerning symptoms, please seek medication.
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
10404360-DS-30 | 10,404,360 | 21,412,350 | DS | 30 | 2210-03-03 00:00:00 | 2210-03-03 18:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
cats / house dust
Attending: ___.
Chief Complaint:
Hypotension
Falls
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH Afib, HFpEF, seizure disorder, CAD s/p CABG,
hypothyroidism complaining of hypotension, AMS and frequent
falls. Per her husband she has been falling more at home and has
fallen at least twice in the past 2 days with head strike. The
falls have been an ongoing problem according to the patient,
husband and records review. Per gerontology notes, the etiology
of the falls is believed to be multifactorial. Her gerontologist
has suggested use of a walker instead of a cane for better
balance and her BP meds have been adjusted to address ongoing
hypotension and orthostasis, including discontinuation of
furosemide.
Most recently, her visiting nurse measured her systolic blood
pressures in the ___. Per husband, there has been difficulty
managing her Afib with rate control without dropping her
pressures, so Dr. ___ made the decision to start her
on digoxin with the hopes of downtitrating her metoprolol; day 1
of digoxin was ___.
Per husband she is not currently at her baseline mental status
and her nursing needs have increased significantly and he is
worried about her being at home. Neuro was consulted in the ED
for the AMS and felt presentation most suggestive of functional
decline ___ UTI. Pt does have known seizure disorder but this
appears to be stable and at baseline. They will follow her while
inpatient for a non urgent workup for subclinical activity.
Past Medical History:
- Complex partial seizures as above
- Asthma
- Pulmonary hypertension
- Myocardial Infarction ___ yrs ago, s/p RCA stent, CABG ___
- Paroxysmal atrial fibrillation
- Hypercholesterolemia
- Cervical spine fracture ___
- C3, C4, C5 Cervical Laminectomy ___
- C2 Laminectomy, C2-6 Fusion ___
- s/p appendectomy, tonsillectomy
- s/p complete hysterectomy
- cataract (bilateral) surgery
- Tremor
Social History:
___
Family History:
Father deceased at the age of ___ ___ MI. Mother deceased in her
___ emphysema. Mother may have had a seizure, details
unclear. Otherwise no family neurologic history.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.1 149 / 69 75 16 95 Ra
GENERAL: Oriented to person and place, cannot recall year/month.
Slowed responses but alert. Appears comfortable.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, holosysotlic murmur throughout precordium, no
carotid bruit
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN 11-XII intact. Moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS: 97.6PO 112 / 63 77 18 99 RA
GENERAL: Oriented to person, place, month and day, but not year
(able to say ___ but not which year specifically). Alert.
Speech is normal. Appears comfortable. Has resting tremor
bilaterally.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, holosysotlic murmur throughout precordium,
no carotid bruit
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, somewhat
firm, no rebound/guarding, no hepatosplenomegaly, medium sized
RLQ incisional hernia
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN 11-XII intact. Moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LAB RESULTS:
==========================
___ 12:45PM BLOOD WBC-5.0 RBC-3.53* Hgb-10.0* Hct-32.3*
MCV-92 MCH-28.3 MCHC-31.0* RDW-15.9* RDWSD-53.2* Plt ___
___ 12:45PM BLOOD Neuts-65.4 Lymphs-17.8* Monos-14.0*
Eos-1.6 Baso-0.8 Im ___ AbsNeut-3.27 AbsLymp-0.89*
AbsMono-0.70 AbsEos-0.08 AbsBaso-0.04
___ 12:45PM BLOOD ___ PTT-31.2 ___
___ 12:45PM BLOOD Plt ___
___ 12:45PM BLOOD Glucose-90 UreaN-20 Creat-0.7 Na-137
K-4.8 Cl-99 HCO3-26 AnGap-12
___ 12:45PM BLOOD ALT-25 AST-35 CK(CPK)-137 AlkPhos-92
TotBili-0.6
___ 12:45PM BLOOD Lipase-28
___ 08:10AM BLOOD cTropnT-<0.01
___ 12:45PM BLOOD cTropnT-<0.01
___ 12:45PM BLOOD Albumin-3.9 Calcium-10.0 Phos-3.2 Mg-2.3
___ 12:45PM BLOOD VitB12-550
___ 12:45PM BLOOD TSH-1.6
___ 12:45PM BLOOD Digoxin-0.5*
___ 12:45PM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
___ 12:50PM BLOOD Lactate-1.3
___ 01:45PM URINE BLOOD-NEG NITRITE-POS* PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM*
___ 01:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 01:45PM URINE COLOR-Straw APPEAR-Hazy* SP ___
___ 01:45PM URINE RBC-1 WBC-12* BACTERIA-FEW* YEAST-NONE
EPI-1
INTERVAL LABS:
==================
___ LAMOTRIGINE 14.0 ref 4.0-18.0 mcg/mL
MICROBIOLOGY:
===============
___ 1:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
NITROFURANTOIN-------- <=16 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=0.5 S
BLOOD CX X2 ___ NGTD
DISCHARGE LAB RESULTS:
=======================
___ 06:41AM BLOOD WBC-4.1 RBC-4.07 Hgb-11.4 Hct-37.0 MCV-91
MCH-28.0 MCHC-30.8* RDW-15.7* RDWSD-52.0* Plt ___
___ 06:41AM BLOOD ___ PTT-34.0 ___
___ 06:41AM BLOOD Glucose-81 UreaN-12 Creat-0.7 Na-142
K-4.4 Cl-101 HCO3-28 AnGap-13
___ 06:41AM BLOOD Calcium-9.9 Phos-3.2 Mg-2.3
IMAGING:
=========
EEG ___: IMPRESSION: This is an abnormal waking EEG because
of multifocal independent broad based sharp waves more frequent
on the left than the right side, suggestive of multifocal
cortical hyperexcitability. There is diffuse generalized
background slowing with occasional generalized suppressions and
triphasic waves, consistent with a moderate encephalopathy. This
finding is nonspecific in regards to etiology but can be seen in
the setting of toxic/metabolic derangements, anoxia, and
medication affect. There are no electrographic seizures.
CT head without contrast ___ IMPRESSION: No acute
intracranial abnormality.
XRAY Chest PA and Lateral ___: IMPRESSION: Persistent mild
pulmonary edema, without focal consolidation to suggest
pneumonia.
Brief Hospital Course:
___ with PMH Afib, HFpEF, seizure disorder, CAD s/p CABG,
hypothyroidism complaining of hypotension, AMS and frequent
falls, found to have UTI and orthostatic hypotension.
ACUTE ISSUES:
==============
#AMS: Presented with disorientation and somnolence. NCHCT
negative for acute process in ED. Ultimately thought to have
toxic-metabolic encephalopathy due to multifactorial process.
Possible culprits included AED toxicity, UTI, subclinical
seizure activity, vs medication induced (patient on gabapentin,
digoxin) vs. worsening of underlying dementia or a combination
of all of the above. She has experienced increased falls in the
past when AED levels were elevated so this was a consideration
as she was falling prior to admission. Metabolic workup was
negative and an extended EEG (___) was negative for seizures,
showed diffuse slowing consistent with encephalopathy. The
patient was continued on her home gabapentin and lamotrigine
(lamotrigine level 14 WNL, gabapentin level pending at
discharge) and she was treated with macrobid for her UTI with
improvement in her mental status (see below).
#Falls: Per her husband, she had been falling more at home with
at least 2 falls in the past 2 days with head strike prior to
admission. Possible etiologies included deconditioning, poorly
rate controlled AF, as well as orthostatic hypotension as this
has been issue in the past requiring discontinuation of
antihypertensives. During her stay we continued digoxin at her
home dose, reduced metoprolol succinate to 50 mg (from 150 mg
daily) reduced Sertroline to 25 mg daily (from 50 mg) for
resting tremor. Orthostasis resolved with IV fluids and
compression stockings. ___ recommended discharge to rehab.
#UTI: Patient endorsed urinary frequency without other symptoms.
UA was positive for pan-sensitive staph (coag neg) and she was
treated with macrobid (D1 = ___, D7 = ___.
#Seizure disorder: She has a history of simple partial and
complex partial seizures. She did not have any seizure activity
just prior or during this admission. Her extended EEG was
negative for seizure activity. We continued her home lamotrigine
and gabapentin.
#Afib: Permanent with recent difficulty with rate control though
rates in ___ this admission. Recently started on digoxin to
reduce BB given hypotension and falls. We continued digoxin
0.125mg and reduced metoprolol succinate to 50 mg daily from 150
mg daily. She is not on anticoagulation, reportedly due to
frequent falls with injury, patient's husband says she has never
been offered anticoagulation. CHADSVASC 6 on this admission,
suggesting moderate-high risk category for stroke. This was
discussed with patient and HCP who opted to defer decision to
outpatient setting.
CHRONIC ISSUES:
================
#CAD: s/p CABGx3 in ___. No CP, no acute changes on EKG.
negative troponins x2. On full-dose aspirin.
#HFpEF: TTE ___ showing mod-severe MR, TR and e/o pulm HTN. Has
had exacerbations in past but was intolerant of furosemide ___
hypotension so it was discontinued. No e/o exacerbation on this
admission.
#Hypothyroidism: TSH 1.6 on admission. Continued home
levothyroxine.
#Asthma: Advair substituted for Dulera while inpatient;
continued home albuterol PRN.
Total time spent seeing, examining patient, discussing discharge
with pt, husband, and ___ and coordinating discharge took
43min.
TRANSITIONAL ISSUES:
================
[ ] f/u gabapentin level
[ ] consider reducing aspirin 325 to 81 mg daily for primary
stroke prevention
[ ] consider readdressing anticoagulation for Atrial
Fibrillation as CHA2DS2-VASc is 6
[ ] Metoprolol succinate dose reduced from 150 mg daily to 50
mg daily
[ ] Sertraline dose reduced from 50 to 25 mg daily
[ ] Please f/u orthostasis in outpatient setting and encourage
use of compression stockings and adequate fluid intake
[ ] Started on miralax on day of discharge for constipation.
Please monitor as patient may need increased bowel regimen and
may not report symptoms.
#CODE: Full (confirmed)
#CONTACT: Name of health care proxy: ___
Relationship: Husband Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 400 mg PO TID
2. LamoTRIgine 300 mg PO DAILY
3. Metoprolol Succinate XL 150 mg PO DAILY
4. Digoxin 0.125 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Atorvastatin 40 mg PO QPM
7. selenium sulfide 2.25 % topical ONCE MR1
8. mometasone-formoterol 200-5 mcg/actuation inhalation bid
9. Aspirin 325 mg PO DAILY
10. albuterol sulfate 90 mcg/actuation inhalation q4h prn
11. Sertraline 50 mg PO DAILY
12. Levothyroxine Sodium 50 mcg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H UTI
last day ___. Polyethylene Glycol 17 g PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Sertraline 25 mg PO DAILY
5. albuterol sulfate 90 mcg/actuation inhalation q4h prn
6. Aspirin 325 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Digoxin 0.125 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Gabapentin 400 mg PO TID
11. LamoTRIgine 300 mg PO DAILY
12. Levothyroxine Sodium 50 mcg PO DAILY
13. mometasone-formoterol 200-5 mcg/actuation inhalation bid
14. selenium sulfide 2.25 % topical ONCE MR1
15. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Urinary tract infection
Altered Mental Status
Orthostatic Hypotension
Falls
Seizure disorder
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 ___,
___ was a pleasure to take care for you at ___.
You came to the hospital because you fell at home and were
confused.
At the hospital, we found you have a urinary tract infection.
You have low blood pressure when you stand up. You felt a lot
better after you got fluids through the IV, and we decreased
your heart medicine (metoprolol), and you got antibiotics for
your infection. You also had some tests done of your head that
showed no stroke and no seizures.
When you leave the hospital, please work on getting stronger at
rehab!
See below for all of your medicines and doctors ___.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10404381-DS-18 | 10,404,381 | 27,627,781 | DS | 18 | 2125-01-25 00:00:00 | 2125-01-25 11:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left tibial plateau fracture
Major Surgical or Invasive Procedure:
Removal of external fixator and open reduction internal fixation
of the left tibial plateau
History of Present Illness:
Patient is a pleasant gentleman who sustained a
complex proximal tibia fracture, placed in an external
fixator on ___. He was discharged to rehab and followed
up in clinic for resolution of swelling. His swelling has
improved significantly and he is plan for surgical repair.
Past Medical History:
Bipolar disorder, alcohol use disorder
Social History:
___
Family History:
NC
Physical Exam:
GEN: AOx3, WN, in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR
PULM: unlabored breathing with symmetric chest rise, no
respiratory distress
EXT:
Left lower extremity:
Dressing keep clean, dry, intact. In hinged knee brace,
unlocked
Compartments soft
Fires ___
SILT sural, saphenous, superficial peroneal, deep peroneal and
tibial distributions
Distal digits warm and well perfused
Pertinent Results:
See OMR
Brief Hospital Course:
The patient presented as a same day admission for surgery. The
patient was taken to the operating room on ___ for removal
of external fixator and open reduction internal fixation of the
left tibial plateau, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. His apixaban was restarted
postoperatively. He had weak dorsiflexion postoperively that was
treated conservatively in an AFO. We will continue to monitor
the dorsiflexion weakness. 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
touchdown weightbearing in the left lower extremity, and will be
discharged on apixaban for treatment of his segmental PEs. 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:
Acamprosate 666 mg PO TID
Apixaban 5 mg PO BID
ChlorproMAZINE 25 mg PO BID:PRN anxiety
Divalproex (EXTended Release) 1000 mg PO QHS
FLUoxetine 40 mg PO DAILY
HydrOXYzine 50 mg PO QID:PRN anxiety
Lithium Carbonate 300 mg PO QAM
Lithium Carbonate 600 mg PO QHS
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
2. Docusate Sodium 100 mg PO BID:PRN Constipation - Second Line
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: other order is PACU only
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
5. TraZODone 50 mg PO QHS
6. Acamprosate 666 mg PO TID
7. Acetaminophen 1000 mg PO Q8H
8. Apixaban 5 mg PO BID
9. ChlorproMAZINE 25 mg PO BID:PRN anxiety
10. Divalproex (EXTended Release) 1000 mg PO QHS
11. FLUoxetine 40 mg PO DAILY
12. HydrOXYzine 50 mg PO QID:PRN anxiety
13. Lithium Carbonate 300 mg PO QAM
14. Lithium Carbonate 600 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left tibial plateau 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:
-Touchdown weightbearing in the right lower extremity in an
unlocked hinged knee brace
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is an
over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean off
this medication in 1 week or sooner. This is an example on how
to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and continue following
the bowel regimen as stated on your medication prescription
list. These meds (senna, colace, miralax) are over the counter
and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your physicians
at discharge.
8) Continue all home medications unless specifically instructed
to stop by your surgeon.
ANTICOAGULATION:
- Please take apixaban daily for 3 months
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
TREATMENT/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 after POD3. If draining,
you may apply a gauze dressing secured with paper tape. You may
shower and allow water to run over the wound, but please refrain
from bathing for at least 4 weeks postoperatively.
Call your surgeon's office with any questions.
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 greater than 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 LESS THAN 30 DAYS OF REHAB
Physical Therapy:
Activity: Activity: Out of bed w/ assist
Right lower extremity: Full weight bearing
Left lower extremity: Touchdown weight bearing in an unlocked
hinged knee brace
Encourage turning, deep breathing and coughing qhour when awake.
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 after POD3. If draining,
you may apply a gauze dressing secured with paper tape. You may
shower and allow water to run over the wound, but please refrain
from bathing for at least 4 weeks postoperatively.
Call your surgeon's office with any questions.
Followup Instructions:
___
|
10404382-DS-21 | 10,404,382 | 26,297,178 | DS | 21 | 2188-09-20 00:00:00 | 2188-09-20 13:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Diplopia
Major Surgical or Invasive Procedure:
___: Whole brain radiation begun
History of Present Illness:
HISTORY OF PRESENT ILLNESS: Mr. ___ is a ___ with wide
spread progression of his metastatic small cell lung cancer,
depression, bipolar disorder, and polysubstance abuse (tobacco,
EtOH, marijuana) who presents with a significant functional
decline over the last 3 weeks, severe L-sided rib pain,
pleuritic chest pain, diplopia, malaise, depression, passive
suicidality, and current alcohol abuse.
Please refer to Dr. ___ note from ___ for
more details.
Briefly, ___ is being admitted for pain control (severe L. rib
pain and pleuritic chest pain), assessment and management of his
depression and passive suicidality, alcohol detoxification, work
up of his diplopia (brain MRI given concern for new brain
metastasis), medication reconciliation (patient unsure what he
is taking), and ultimately to arrange home services for improved
support.
REVIEW OF SYSTEMS:
+frequent N/V, orthostatic hypotension resulting in syncope,
irregular bowels (loose stools x ___ years), difficulty sleeping
secondary to pain, significant weight loss, hiccups (frequent),
cough; denies change in appetite, hemoptysis, SOB/DOE, fevers,
chills
PAST ONCOLOGIC HISTORY (per OMR):
Mr. ___ initially presented to care in early ___ with a
right hilar mass, with biopsy-proven small cell carcinoma on
bronchoscopic biopsy.
He was treated for limited stage disease with definitive
concurrent chemoradiation with Carboplatin (AUC 5, D1)/Etoposide
(80mg/m2, D1-3) given IV every 21 days x 4 cycles ___. Cycle 4 was abbreviated after D1 chemotherapy due to
patient nonadherence. RT was given under Dr. ___.
Mr. ___ completed definitive chemoradiation in ___.
Unfortunately his recent PET scan on ___ showed disease
progression with multiple metastases to the lungs, bones, liver,
R adrenal gland and pelvic lymph nodes.
Past Medical History:
Polysubstance abuse
Depression, bipolar disorder
Colon polyps
Lactose intolerance, mild
Osteoarthritis
Internuclear ophthalmoplegia
Social History:
___
Family History:
Mother is alive and healthy
Father died from leukemia
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 98.0 90 / 64 100 16 96% RA
GENERAL: cachectic, mildly intoxicated (etoh), pleasant with
good insight
HEENT: MMM, sclera anicteric, non pallor conjunctiva, no
mucosal lesions, clear OM, no teeth (wears upper and lower
dentures)
NECK: supple, no palpable LAD, no thyromegaly
LUNGS: Decreased breath sounds at the right base, otherwise CTAB
HEART: RRR, no m/r/g
ABD: soft, +BS, NT, ND, no palpable hepatomegaly
EXT: cachectic, dry skin, wwp, no edema
SKIN: neck with patchy areas of pale discoloration, flaky dry
skin along lower extremities
NEURO: PERRLA, EOMI, left lower extremity ___ weakness,
otherwise non focal exam. AOx3, able to recite the days of the
week backwards
ACCESS: right PIV
DISCHARGE PHYSICAL EXAM:
VITALS: 98.0 PO 114 / 70 98 18 91 RA
GENERAL: cachectic, sad affect, good insight
HEENT: MMM
LUNGS: Deferred, easy work of breathing
HEART: Deferred
ABD: Deferred
EXT: cachectic, dry skin, wwp, no edema
SKIN: neck with patchy areas of pale discoloration, flaky dry
skin along lower extremities
NEURO: PERRLA, EOMI, left lower extremity ___ weakness, head
bobbing. AOx3, able to recite the days of the week backwards
ACCESS: r. PIV
Pertinent Results:
ADMISSION LABS:
___ 12:15PM BLOOD WBC-7.1 RBC-4.14* Hgb-UNABLE TO Hct-40.0
MCV-89 MCH-UNABLE TO MCHC-UNABLE TO RDW-12.0 RDWSD-39.2 Plt
___
___ 12:15PM BLOOD UreaN-11 Creat-0.6 Na-121* K-3.9 Cl-71*
HCO3-24 AnGap-26*
___ 12:15PM BLOOD ALT-45* AST-64* AlkPhos-135* TotBili-0.9
___ 12:15PM BLOOD Calcium-9.4 Phos-3.7 Mg-1.8
___ 09:17PM BLOOD Osmolal-306
___ 10:45AM BLOOD TSH-0.91
___ 07:02AM BLOOD Cortsol-1.6*
___ 11:06AM BLOOD Lactate-2.1*
DISCHARGE LABS (STOPPED TAKING LABS SEVERAL DAYS PRIOR TO D/C):
___ 07:05AM BLOOD WBC-7.0 RBC-3.37* Hgb-11.4* Hct-30.7*
MCV-91 MCH-33.8* MCHC-37.1* RDW-12.1 RDWSD-40.2 Plt ___
___ 07:05AM BLOOD Glucose-133* UreaN-11 Creat-0.7 Na-129*
K-3.9 Cl-84* HCO3-29 AnGap-16
___ 07:05AM BLOOD Albumin-4.6 Calcium-9.8 Phos-2.8 Mg-1.8
IMAGING:
___ CXR:
FINDINGS:
There is right perihilar opacity with increased soft tissue at
the hilum as well compatible with patient's known underlying
malignancy. Since prior chest x-ray but similar to recent
PET-CT is parenchymal opacity in the right infrahilar region
worrisome for superimposed infection. There is a small right
pleural effusion. Lungs are otherwise grossly clear.
Cardiomediastinal silhouette is within normal limits. No acute
osseous abnormalities.
IMPRESSION:
Changes at the right hilum compatible with known underlying
malignancy. Superimposed right infrahilar parenchymal opacity
as seen on PET-CT from two days prior which is suspicious for
superimposed infection.
___ MRI BRAIN
IMPRESSION:
1. New, 8 x 7 mm enhancing pontine lesion, worrisome for
metastatic disease.
2. New, 8 x 6 mm extra-axial, dural based enhancing lesion along
the medial aspect of the right parietal lobe, compatible with an
additional site of metastatic disease.
3. Subtle, punctate focus of enhancement with surrounding FLAIR
hyperintensity in the right paramedian parietal lobe, which may
represent an additional site of disease.
4. No evidence for infarction or acute intracranial hemorrhage.
Brief Hospital Course:
SUMMARY:
============================
Mr. ___ is a ___ with wide spread progression of his
metastatic small cell lung cancer and multiple physical and
depressive symptoms, alcohol detoxification and failure to
thrive, here for optimization of symptom management and advanced
care planning, confirmed home with hospice.
ACTIVE ISSUES:
============================
#PROGRESSIVE METASTATIC SMALL CELL CARCINOMA
Patient with progressive and severely metastatic small cell
carcinoma, with wide spread metastasis. Most recently to the
brain leading to diplopia.
1. DIPLOPIA, BLURRY VISION, NEW BRAIN METASTASIS
Found to have 2 new brain metastasis. These symptoms are quite
disabling and bothersome but improving following 1 dose of
radiation (___).
- Dexamethasone 4mg PO BID
- Radiation onc, plan for a total of 5 fractions (___)
2. NAUSEA/VOMITING: denies
- Zofran 4mg q8h PRN
3. PAIN: severe left sided rib pain, pleuritic chest pain and
leg pain, related to disease burden. Improving significantly
- Continue home brace
- APAP 1gm q8h
- Lidocaine 5% patch applied to the left rib cage, left chest
and left hip
- MS ___ 30mg PO BID, Morphine sulfate ___ 15mg q4h PRN
- Naproxen 500mg PO BID
- Bowel regimen PRN (not standing given chronic diarrhea)
- Sent home with nasal spray naloxone
4. INSOMNIA: Finally sleeping well. QTc < 450 (___)
- Ramelteon 8mg QHS
- Seroquel 200mg PO QHS
- Pain control as above
5. FATIGUE, MALAISE: related to disease burden, insomnia and
depression. TSH wnl. AM cortisol very low (has adrenal mets)
- Dexamethasone 4mg PO BID (8AM, 4PM)
6) GOALS OF CARE: MOLST signed ___, DNR/DNI, transfer to
hospital, no artificial nutrition. Patient with great insight
into illness and prognosis. Home with hospice, ___
#DEPRESSION/BIPOLAR DISORDER
#PASSIVE SUICIDAL IDEATION
Patient has had depression and passive suicidal ideation for his
entire life, has not tried to commit suicide in over ___ years.
Symptoms are severe right now, exacerbated by terminal illness.
On Seroquel 200mg PO QHS, Sertraline 50mg qd, Psychiatry
consult, SW consult
#POLYSUBSTANCE ABUSE
#ALCOHOL INTOXCATION
Did not score on CIWA. Psychiatry consult for alcohol
detoxification Uptitrated to Acamprosate 666mg TID for alcohol
cravings (note that the patient was sober at one point in the
past while taking this medication). Dronabinol for nausea,
appetite stimulation
#ACTIVE TOBACCO USE
Smoking 6 cigarettes daily, lower than usual. Prefers lozenges.
Advised patient not to leave the building to smoke. Using
Nicotine lozenges q2h PRN and Nicotine patch
#CHRONIC DIARRHEA
___ years, likely related to known diagnosis of lactose
intolerance, as patient does not follow a lactose-free diet.
EtOH may contribute. Recommended the patient avoid lactose and
alcohol. Imodium is okay to use outpatient as needed.
#MEDICATION RECONCILIATION:
Please note that the patient has not been accurately taking his
medications as prescribed, and is unable to state what he takes
and when he takes it. He had a medication list with him from
___ dated ___ which I am using as a
guide, especially when it related to his psychiatric
medications. Of note, he had a pill bottle with tramadol 50mg
q6h PRN pain, but this was not listed on his verified medication
list and I have not started it here.
TRANSITIONAL ISSUES:
[ ] Patient will continue whole brain radiation until ___
[ ] F/U pain and nausea control
[ ] Going home with home hospice
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H SOB
2. azelastine 137 mcg (0.1 %) nasal BID:PRN rhinitis
3. Vitamin D ___ UNIT PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 300 mg PO BID
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. QUEtiapine Fumarate 200 mg PO QHS
9. Sertraline 50 mg PO DAILY
10. Thiamine 100 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. Benzonatate 200 mg PO TID:PRN cough
Discharge Medications:
1. Acamprosate 666 mg PO TID
RX *acamprosate 333 mg 2 tablet(s) by mouth every 8 hours Disp
#*168 Tablet Refills:*0
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg 2 capsule(s) by mouth every 8 hours
Disp #*168 Capsule Refills:*0
3. Dexamethasone 4 mg PO BID
RX *dexamethasone 4 mg 1 tablet(s) by mouth twice daily (8AM,
4PM) Disp #*56 Tablet Refills:*0
4. Dronabinol 2.5 mg PO BID
RX *dronabinol 2.5 mg 1 capsule(s) by mouth twice daily Disp
#*56 Capsule Refills:*0
5. Lidocaine 5% Patch 3 PTCH TD QAM
on for 12 hours - left chest, left rib cage, left thigh
RX *lidocaine 5 % apply three patches 12 hours a day Disp #*84
Patch Refills:*0
6. Morphine SR (MS ___ 30 mg PO Q12H
RX *morphine 30 mg 1 tablet(s) by mouth every 12 hours Disp #*56
Tablet Refills:*0
7. Morphine Sulfate ___ 15 mg PO Q4H:PRN Pain - Moderate
RX *morphine 15 mg 1 tablet(s) by mouth every 4 hours Disp #*168
Tablet Refills:*0
8. Naproxen 500 mg PO Q12H
RX *naproxen 500 mg 1 tablet(s) by mouth twice daily with food
Disp #*56 Tablet Refills:*0
9. Narcan (naloxone) 4 mg/actuation nasal PRN
RX *naloxone [Narcan] 4 mg/actuation 1 spray nasal once Disp #*5
Spray Refills:*0
10. Nicotine Patch 21 mg TD DAILY
please do not use if you are continuing to smoke
RX *nicotine 21 mg/24 hour (28)-14 mg/24 hour (14)-7 mg/24 hour
(14) Please apply 1 patch to skin for 12 hours a day Disp #*30
Patch Refills:*0
11. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*84 Tablet Refills:*0
12. Ramelteon 8 mg PO QHS insomnia
Should be given 30 minutes before bedtime
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
13. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs inh every 6
hours Disp #*1 Inhaler Refills:*0
14. azelastine 137 mcg (0.1 %) nasal BID:PRN rhinitis
RX *azelastine 137 mcg (0.1 %) 1 spray intranasally twice daily
Disp #*1 Spray Refills:*0
15. Benzonatate 200 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times daily
Disp #*84 Capsule Refills:*0
16. Gabapentin 300 mg PO BID
RX *gabapentin 300 mg 1 capsule(s) by mouth twice daily Disp
#*60 Capsule Refills:*0
17. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth 30 minutes before
breakfast Disp #*30 Capsule Refills:*0
18. QUEtiapine Fumarate 200 mg PO QHS
RX *quetiapine 200 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
19. Sertraline 50 mg PO DAILY
RX *sertraline 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
20. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1
capsule inh daily Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
====================
Metastatic small cell lung cancer, with new CNS metastasis
SECONDARY:
====================
Diplopia
Malnutrition, cachexia
Insomnia, uncontrolled pain, nausea
Chronic diarrhea
Depression/Bipolar disorder
Passive suicidal ideation
Alcohol use disorder
Tobacco abuse
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___
because you were having double vision and pain.
Unfortunately, we learned that your lung cancer has spread to
your brain, which is why you are having double vision. You had
one round of whole brain radiationYou are scheduled for 4 more
days of whole brain radiation.
While you were here, you were given medication to help treat
your pain, nausea, and improve your sleep.
When you go home, you will be set up with home hospice, meaning
that they come to your house. They will be available to you for
any needs, including improved pain control or nausea medication.
Please take your medications as prescribed; we will fax over a
list to Season's Hospice so that they know what has been helping
and will fax the medications ahead of time to your pharmacy so
that you can go straight to the pharmacy and pick them up.
It was a pleasure taking part in your care and we wish you all
the best with your health.
Sincerely,
The team at ___
Followup Instructions:
___
|
10405076-DS-7 | 10,405,076 | 26,821,833 | DS | 7 | 2135-05-25 00:00:00 | 2135-05-25 19:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Deplin / tocilizumab
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Percutaneous cholecystostomy tube placement
History of Present Illness:
___ with h/o morbid obesity, cholelithiasis, autoimmune
polychondritis on chronic steroids, and several other
comorbidities who presents with abdominal pain that started
after colonoscopy ___, had fever that same day. Describes pain
as RUQ radiating to LUQ, band-like distribution, unchanged since
___. Not a/w meals. +nausea, no emesis. Upright KUB neg for free
air. Has seen Dr. ___ in the past for cholelithiasis, but at
the time was asymptomatic. Has bariatric surgery planned at ___
for ___. Was hoping that her surgeon could remove her GB at
that time. She was told that he would try, but if it looked too
challenging, he would not do it at that time. She has two large
known gallstones within her gallbladder, one at the neck of the
GB, that were seen again today on RUQUS and CT a/p. Her
gallbladder wall was described as more thickened today than it
had been in the past, but prior imaging for comparison is a poor
quality CT a/p.
Past Medical History:
___: bari surg planned for ___ at ___, was denied surg at ___
for chronic steroid use. Polychondritis on steroids. Morbid
obesity. h/o IPMNs seen on MRCP one year ago, due for repeat
MRCP
this ___ to eval for interval change.
Other medical problems
ALLERGIC RHINITIS
CATARACT
COLONIC POLYPS
DEPRESSION
EPILEPSY (seizure d/o well controlled, none in years)
HYPERCHOLESTEROLEMIA
KNEE DERANGEMENT, INTERNAL
PALPITATIONS
RELAPSING POLYCHONDRITIS
RIGHT BUNDLE BRANCH BLOCK
SLEEP APNEA
THYROID NODULE
VITAMIN D DEFICIENCY
RAYNAUD'S SYNDROME
GLAUCOMA
POSITIVE INHIBITOR SCREEN
SYMPTOMATIC PVCS
MICROALBINURIA
GASTROESOPHAGEAL REFLUX
HYPOGAMMAGLOBULINEMIA
BENIGN POSITIONAL VERTIGO
OSTEOARTHRITIS
Past Surgical History:
TONSILLECTOMY ___
PARTIAL HYSTERECTOMY ___
LUMPECTOMY
POSTPARTUM TUBAL LIGATION
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission Physical Exam:
Vitals: 98.1/98.1 77 134/74 16 97%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: no respiratory distress
ABD: Soft, nondistended, obese, TTP RUQ, ___, no rebound
or
guarding, palpable gallbladder
Ext: B/L ___ edema, ___ warm and well perfused
Discharge Physical Exam
GEN: AOx3, NAD
CV: RRR no MRG
PULM: CTAB no WRC
ABD: Obese, soft, mildly tender to deep palpation, ND,
cholecystostomy tube site CDI with thin bilious fluid in the
bag, draining to gravity
Ext: b/l pedal edema, pulses 2+ symmetrical, WWP
Pertinent Results:
RUQ US ___
1. Cholelithiasis, without specific evidence of acute
cholecystitis.
2. Echogenic liver consistent with steatosis. Other forms of
liver disease
and more advanced liver disease including steatohepatitis or
significant
hepatic fibrosis/cirrhosis cannot be excluded on this study.
CXR ___
No acute cardiopulmonary abnormality. No subdiaphragmatic free
air.
CT A/P with contrast ___
Cholelithiasis with mild gallbladder wall edema, which was not
seen on prior ultrasound. While this finding is nonspecific, it
can be seen with acute cholecystitis. Clinical correlation is
recommended.
HIDA ___
Nonvisualization of the gallbladder both initially and after
morphine, consistent with acute cholecystitis.
Percutaneous Gallbladder Drainage ___
Successful ultrasound-guided placement of ___ pigtail
catheter into the gallbladder. Sample was sent for microbiology
evaluation.
___ 3:30 pm BILE GALL BLADDER SENSITIVITIES REQUESTED.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
___ 03:30PM BLOOD WBC-7.3 RBC-5.14 Hgb-14.0 Hct-43.7 MCV-85
MCH-27.2 MCHC-32.0 RDW-13.9 RDWSD-42.8 Plt ___
___ 03:30PM BLOOD Glucose-105* UreaN-23* Creat-1.0 Na-136
K-4.2 Cl-95* HCO3-25 AnGap-20
___ 03:30PM BLOOD ALT-27 AST-19 AlkPhos-79 TotBili-0.3
___ 03:30PM BLOOD Lipase-28
___ 09:00AM BLOOD WBC-3.2* RBC-4.82 Hgb-13.0 Hct-41.9
MCV-87 MCH-27.0 MCHC-31.0* RDW-14.0 RDWSD-43.9 Plt ___
___ 04:44AM BLOOD ___
___ 09:00AM BLOOD Glucose-110* UreaN-13 Creat-0.9 Na-139
K-4.0 Cl-104 HCO3-26 AnGap-13
___ 09:00AM BLOOD ALT-33 AST-27 AlkPhos-71 TotBili-0.3
___ 11:25PM BLOOD Lipase-31
___ 09:00AM BLOOD Calcium-9.4 Phos-2.8 Mg-2.3
Brief Hospital Course:
Ms. ___ was admitted from the ED on ___ with symptomatic
cholelithiasis diagnosed by RUQ US and CT A/P. She was made NPO,
given IV maintenance fluids and her pain and nausea controlled
with IV medication. She was started on IV ciprofloxacin and
metronidazole for empiric antibiotic coverage. She then
underwent a morphine-enhanced HIDA scan that showed no filling
of the gallbladder and confirmed the prospective diagnosis of
chronic cholecystitis. Given her >5 days of symptoms she was
deemed to be a poor candidate for same-admission
cholecystectomy, so ___ was consulted for a percutaneous
cholecystostomy, which they performed. They were able to
cannulate the gallbladder without complication and the tube put
out 30cc of bilious fluid upon placement before continuing to
drain the same. Following placement of the tube Ms. ___ had
resolution of her symptoms and was able to tolerate a regular
diet, void spontaneously, and ambulate. She had positive bowel
function and her pain was well-controlled on PO medication. Her
bariatric surgeon at ___, Dr. ___, was contacted by phone
and made aware of her course given her plans for gastric bypass
in the next month. If tenable her interval cholecystectomy may
be completed at the same time as her bariatric procedure,
pending further discussion between Dr. ___ Ms. ___.
On ___ having met all goals of care and remained in
excellent condition, Ms. ___ was discharged home with ___
for her drain and plans to follow up as an outpatient in clinic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Methylprednisolone 3 mg PO DAILY
2. Acetaminophen 650 mg PO Q8H:PRN Pain
3. LaMOTrigine 150 mg PO BID
4. BuPROPion (Sustained Release) 200 mg PO BID
5. ARIPiprazole 5 mg PO DAILY
6. clotrimazole-betamethasone ___ % topical PRN Rash
7. ALPRAZolam 0.25 mg PO QHS:PRN insomnia or anxiety
8. Docusate Sodium 100 mg PO BID
9. Ranitidine 150 mg PO BID
10. Simvastatin 20 mg PO QPM
11. Mycophenolate Mofetil 1500 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Ibuprofen 200 mg PO Q8H:PRN Pain
14. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
16. Methylphenidate SR 36 mg PO DAILY
17. Aspirin 81 mg PO DAILY
18. desvenlafaxine succinate 150 mg oral DAILY
19. cholecalciferol (vitamin D3) 5,000 unit/mL oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain
2. ALPRAZolam 0.25 mg PO QHS:PRN insomnia or anxiety
3. ARIPiprazole 5 mg PO DAILY
4. BuPROPion (Sustained Release) 200 mg PO BID
5. LaMOTrigine 150 mg PO BID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Methylprednisolone 3 mg PO DAILY
8. Mycophenolate Mofetil 1500 mg PO DAILY
9. Ranitidine 150 mg PO BID
10. Simvastatin 20 mg PO QPM
11. Aspirin 81 mg PO DAILY
12. cholecalciferol (vitamin D3) 5,000 unit/mL oral DAILY
13. clotrimazole-betamethasone ___ % topical PRN Rash
14. desvenlafaxine succinate 150 mg ORAL DAILY
15. Docusate Sodium 100 mg PO BID
16. Ibuprofen 200 mg PO Q8H:PRN Pain
17. Methylphenidate SR 36 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
20. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Doses
Finish course on ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*7 Tablet Refills:*0
21. MetRONIDAZOLE (FLagyl) 500 mg PO TID Duration: 10 Doses
Finish course on ___
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Chronic Cholelithiasis
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
abdominal pain from your chronic gallbladder inflammation and
underwent placement of a drainage tube to relieve the pressure
and infection. You 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:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
10405440-DS-13 | 10,405,440 | 25,034,252 | DS | 13 | 2189-06-12 00:00:00 | 2189-06-12 12:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left ankle pain.
Major Surgical or Invasive Procedure:
Open Reduction and Internal Fixation of Left Bimalleolar ankle
fracture
History of Present Illness:
HPI: ___ female presenting with left suspected by
bimalleolar fracture.
Patient states that she only has depression and anxiety. She
denies any other diagnoses. Per chart review, patient also with
a
questionable diagnosis of COPD. She is a current smoker. She is
not on any blood thinners.
Patient had a syncopal episode today resulting in a head strike.
Patient inverted her left ankle during the syncopal episode. She
believe this may have been secondary to taking too much Xanax.
Patient presented to the emergency department with significant
deformity and skin tenting in association with this left ankle.
Her foot was noted to be dusky and pulses could not be palpated.
Patient was immediately reduced in the emergency department and
placed in a splint. Post splint images were obtained.
Past Medical History:
PMH/PSH:
Problems (Last Verified - None on file):
ANEMIA
ANXIETY
ARTHRITIS LEFT HAND
BILATERAL KNEE PAIN
GERD
INSOMNIA
LOW BACK PAIN
PAP NORMAL ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: 24 HR Data (last updated ___ @ 2227)
Temp: 97.9 (Tm 97.9), BP: 141/76 (141-144/76-79), HR: 73
(72-73), RR: 16, O2 sat: 96%, O2 delivery: ra
General: Well-appearing, breathing comfortably
MSK:LLE in posterior splint. DP pulse intact WWP, SILT intact in
LLE dermatomes. Due to nerve block, unable to move toes or
ankle.
Pertinent Results:
___ 05:27AM BLOOD WBC-14.1* RBC-4.43 Hgb-13.3 Hct-41.0
MCV-93 MCH-30.0 MCHC-32.4 RDW-13.2 RDWSD-44.9 Plt ___
___ 05:18AM BLOOD Neuts-78.8* Lymphs-13.1* Monos-6.8
Eos-0.3* Baso-0.2 Im ___ AbsNeut-11.52* AbsLymp-1.91
AbsMono-1.00* AbsEos-0.04 AbsBaso-0.03
___ 05:27AM BLOOD Plt ___
___ 05:27AM BLOOD Glucose-126* UreaN-8 Creat-0.7 Na-143
K-4.3 Cl-102 HCO3-22 AnGap-19*
___ 05:18AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.9
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left bimalleolar fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for Left ankle ORIF, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non-weight bearing in the left lower extremity, and will be
discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ 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:
Medications - Prescription
ALPRAZOLAM - alprazolam 1 mg tablet. 1 Tablet(s) by mouth three
times a day
ATENOLOL - atenolol 25 mg tablet. 1 Tablet(s) by mouth once a
day
CYCLOBENZAPRINE - cyclobenzaprine 10 mg tablet. 1 tablet(s) by
mouth twice a day 1 tab am, 1 later in day, but not same time as
xanax
IBUPROFEN - ibuprofen 800 mg tablet. 1 Tablet(s) by mouth twice
a
day as needed with food
RANITIDINE HCL - ranitidine 150 mg capsule. 1 Capsule(s) by
mouth
twice a day
Medications - OTC
FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron)
tablet,delayed release. 1 tablet(s) by mouth once a day
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Atenolol 25 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 40 mg SC QHS
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
7. ALPRAZolam 1 mg PO QHS
8. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Left ankle bimalleolar ankle 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:
- Non weight bearing of the left lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is an
over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean off
this medication in 1 week or sooner. This is an example on how
to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and continue following
the bowel regimen as stated on your medication prescription
list. These meds (senna, colace, miralax) are over the counter
and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your physicians
at discharge.
8) Continue all home medications unless specifically instructed
to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
Physical Therapy:
Activity: Activity: Activity as tolerated
Left lower extremity: Non weight bearing
Encourage turn, cough and deep breathe q2h when awake
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 after POD3. 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.
Pin Site Care Instructions for Patient and ___:
For patients discharged with external fixators in place, the
initial dressing may have Xeroform wrapped at the pin site with
surrounding gauze.
Often, the Xeroform is used in the immediate post-op phase to
allow for control of the bleeding. The Xeroform can be removed
___ days after surgery.
If the pin sites are clean and dry, keep them open to air. If
they are still draining slightly, cover with clean dry gauze
until draining stops.
If they need to be cleaned, use ___ strength Hydrogen Peroxide
with a Q-tip to the site.
Call your surgeon's office with any questions.
Followup Instructions:
___
|
10405646-DS-7 | 10,405,646 | 20,915,480 | DS | 7 | 2166-12-28 00:00:00 | 2166-12-29 07:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Overdose
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ with history of epilepsy and depression presents from ___
for overdose. The patient's mother at ___ stated that he took
his normal dose of paroxetine the evening of ___ but then
around 7PM took more than 30 tabs of 300mg oxcarbazapine and
___ ibuprofen of unknown dose in a suicide attempt. He denied
alcohol or other drugs. He was taken to ___ where he reportedly
had normal vitals. He was given activated charcoal at 10:15PM
and transferred to ___ for further care. Labs at ___ including
CBC, chem7, LFTs and coags were reportedly normal, and a
carbamazapine level came back at 8.2
In the ED at ___ he was reportedly somnolent but arousable
with normal vitals and no hyperreflexivity or clonus on exam.
Toxicology was consulted and advised close monitoring. Psych saw
him and recommended making the patient ___ and will be
searching for an inpatient admission once medically clear.
At 0530 this morning, he started to vomit black vomitus. He was
confused and mental status changed tremendously. Agitated and
confused with intermittent leg shaking. There was concern that
this may represent a seizure. 2mg Ativan was given and he
improved almost immediately. Repeat labs drawn at that time and
were pending upon admission.
Repeat CXR to rule out aspiration.
___ peripheral IVs
In the ED, initial vitals: 97.5 76 ___ 98% RA
On transfer, vitals were: 70s, 100s, 97 RA, calm, gag reflex
Past Medical History:
Epilepsy
Depression
Cannot move R side of his body well from infantile meningitis
Social History:
___
Family History:
Maternal grandmother= depression
No suicide attempts
No addiction problems
Physical Exam:
On ADMISSION:
GENERAL: sedated, awakes to loud voice but quickly falls back
asleep
HEENT: Sclera anicteric, MMM, black/charcoal around mouth
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No rashes, warm, multiple tatoos
Neuro: patient has proximal right upper extremity muscle
weakness and slight right hand deformity
On Discharge:
PHYSICAL EXAM:
Vitals: 97.3 115/63 16 84 98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes, legions or scars; patient has mutiple tatoos
Neuro: patient has proximal right upper extremity muscle
weakness and slight right hand deformity; balance normal
Pertinent Results:
On Admission:
___ 11:25PM BLOOD WBC-10.9 RBC-4.58* Hgb-14.1 Hct-38.8*
MCV-85 MCH-30.8 MCHC-36.4* RDW-13.7 Plt ___
___ 11:25PM BLOOD Neuts-76.1* Lymphs-16.9* Monos-5.9
Eos-0.8 Baso-0.4
___ 11:25PM BLOOD Glucose-113* UreaN-9 Creat-0.7 Na-134
K-3.5 Cl-98 HCO3-25 AnGap-15
___ 11:25PM BLOOD ALT-32 AST-25 AlkPhos-60 TotBili-0.3
___ 11:25PM BLOOD Albumin-4.4 Calcium-9.0 Phos-3.3 Mg-1.9
___ 11:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:57AM BLOOD ___ pO2-60* pCO2-44 pH-7.34*
calTCO2-25 Base XS--2
___ 06:57AM BLOOD Lactate-3.0*
Other Important Labs:
___ 10:50AM BLOOD Carbamz-6.5
___ 02:57AM BLOOD Carbamz-3.1*
___ 07:12AM BLOOD Carbamz-3.5*
ON DISCHARGE:
___ 07:14AM BLOOD WBC-5.1 RBC-5.47 Hgb-17.3 Hct-48.8 MCV-89
MCH-31.5 MCHC-35.4* RDW-13.8 Plt ___
___ 07:14AM BLOOD Plt ___
___ 07:14AM BLOOD Glucose-86 UreaN-8 Creat-0.6 Na-140 K-5.0
Cl-104 HCO3-23 AnGap-18
___ 02:57AM BLOOD ALT-27 AST-21 AlkPhos-65 TotBili-0.5
___ 07:14AM BLOOD Carbamz-3.9*
IMAGING:
CXR ___: No evidence of acute cardiopulmonary process.
Brief Hospital Course:
___ s/p overdose on his oxcarbazapine and ibuprofen transferred
from ___ with AMS. Patient reportedly had question of seizure in
the ED and vomited much of the charcoal he was given at OSH. The
patient was transferred to the Medical ICU for monitoring for
concern of possible co-ingestion with TCAs or SSRI. Patient had
close EKG monitoring for signs of QRS widening and for signs of
Seratonin syndrome. The patient was stable throughout his stay
and his Mental status returned to baseline. Patient was
restarted on his carbazapine and it was dosed by level. Patient
was evaluated by psych, placed on a 1:1, ___, and
transferred to inpatient psych facility. Patient has follow up
scheduled with his Neurologist after discharge from the
hospital, for adjustment of his Carbazapine as an outpatient.
ACUTE ISSUES
# Oxcarbazapine overdose: Patient was hemodynamically stable on
arrival to ICU, but sedated. Side effects of this poisoning
include QRS widening, seizures and hyponatremia and for this
reason he was initially admitted to the ICU. He was monitored
and without any evidence of seizure or QRS widening. He had very
mild hyponatremia to 131 which resolved with 1L IVF. His
oxcarbazapine level decreased to normal level within 24 hours
and he was more alert and called out to floor. He was evaluated
by psychiatry, placed on 1:1 ___, and recommended for
psychiatry admission when medically cleared. Patient was
medically cleared on ___ and restarted on his carbamazpine,
which was dosed by level. He will f/u with his Neurologist after
leaving the hospital and will need PCP follow up after discharge
from his psychiatric facility.
# Seizure + vomiting: Occured at OSH. This may have represented
a baseline seizure, or could indicate a side effect from the
overdose. Monitored and no further seizures at ___. He was
restarted on oxcarbazepine when levels trended down. Patient
carbazepine level at discharge was 3.9. Patient will f/u with
Neurologist (Dr. ___ after discharge.
# AMS: Likely secondary to Ativan given at OSH for seizure and
overdose. Resolved quickly.
# Depression: Patient overdosed on home AEMs in a reported
suicide attempt. He waws placed on ___, 1:1 supervision,
and psychiatry consulted. Recommended for psychiatric
hospitalization once medically cleared. Patient medically
cleared on ___. Patient transferred to inpatient psych on ___
for evaluation and treatment.
TRANSITIONAL ISSUES
=======================
-patient off of all anti-depressants at this time; will need
inpatient psych evaluation and treatment for severe depression
-carbazapine level was 3.9 at time of discharge (on dosage of
200 mg PO BID); he will need a level drawn and follow up on ___
and result faxed to Dr. ___ patient will f/u with his
neurologist on ___
-patient will also need f/u with a PCP after he is discharged
from his psychiatric facility
- Trileptal level pending on discharge returned as 11. 7 which
is therapeutic
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Paroxetine 30 mg PO DAILY
2. Carbamazepine (Extended-Release) 400 mg PO BID
Discharge Medications:
1. Carbamazepine (Extended-Release) 200 mg PO BID
2. Acetaminophen 650 mg PO Q6H:PRN pain/discomfort
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY: Suicide attempt/Intentional overdose of Oxcarbazapine;
Depression
SECONDARY: Epilepsy, Congenital Menigitis with proximal right
upper extremity weakness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take part in your care during your stay
here at ___. You were transferred to our hospital after you
ingested a large quantity of your anti-seizure medication. You
were monitorred closely in the ICU for one day after you
arrived. You recovered well. You were restarted on your
medication for prevention of the seizures at a lower dose and
will continue on that medication after leaving the hospital.
You were seen by our psychiatric team in the hospital and they
determined you will need to be evaluated and treated at an
inpatient psychiatric facility after leaving the hospital for
treatment of your depression.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10405655-DS-9 | 10,405,655 | 21,654,192 | DS | 9 | 2130-02-04 00:00:00 | 2130-02-11 16:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Oxycodone / oxycodone-acetaminophen
Attending: ___.
Chief Complaint:
mechanical fall w/ T10-11 Right Transverse Process fracture,
Right ___ rib fracture, T9 Spinous process fracture, w/ Chance
fracture T10
Major Surgical or Invasive Procedure:
___ T7-11 arthrodesis and open treatment of chance fracture
with orthopedic spine surgery
History of Present Illness:
Mr. ___ is an ___ year old man with a history of a fib
on warfarin, CHF, Crohn's disease, who presents after mechanical
fall. Patient says around 1:45pm he was standing and purchasing
a
food item at ___, when he lost balance and fell
over, hitting his back on one of the chairs. He does not think
there was a head strike but is unsure, denies LoC. He denies any
preceding dizziness, chest pain, or other symptoms. He complains
of bilateral lower rib pain and lower back pain. He does note
that over the past few days he has felt unwell with some
shortness
of breath on exertion.
In the ED his work up was significant for a CT head (negative),
CT C spine (no acute injury), CT Torso that showed comminuted
and
mildly displaced Chance type fracture through all three columns
of T10 vertebral body with surrounding prevertebral hematomawith
2mm of bony retropulsion into spinal canal causing mild central
canal stenosis, as well as mildly displaced R ___ rib
fractures, T9 spinous process fracture, T10-11 R TP fractures.
He
also had a left humerus plain film that showed no evidence of
fractureor traumatic subluxation. Patient does have pain with
inspiration.
Spine surgery was consulted who recommended obtaining MRI spine
and to keep patient NPO pending imaging.
Past Medical History:
atrial fibrillation, HTN, diastolic CHF, ___ edema, HLD
Social History:
___
Family History:
not pertinent to HPI
Physical Exam:
Admission Physical Exam
Vitals - T 98.7; BP 97/31; HR 66; RR 16; SPO2 98%2L NC
GEN - Well appearing, no acute distress
HEENT - NCAT, EOMI, sclera anicteric. Pupils 3mm bilaterally
and
reactive to light. Trachea midline.
CV - HDS
PULM - No signs of respiratory distress. Lower chest wall
tenderness bilaterally without gross deformity. No chest wall
crepitus.
ABD - soft, nontender, nondistended
PELVIS - stable, nontender
EXT - superficial 4-5cm laceration approximated with
steristrips
at left arm level of elbow with underlying ecchymosis, no
significant hematoma. No other lacerations, contusions, gross
deformity at upper and lower bilateral extremities.
NEURO - A&Ox3, no focal neurologic deficits. Motor strength ___
bilateral upper and lower extremities. Sensory in tact bilateral
upper and lower extremities. T spine tenderness, no step offs or
deformity. No C or L spine tenderness, step offs, or
deformities.
----------
Discharge Physical Exam ___:
vital signs: 98.7, hr=77, bp=101/58, rr=18, 94% room air
GENERAL: sitting in chair, NAD
CV: Ns1, s2
LUNGS: clear
ABDOMEN: soft, mild distention, non-tender
EXT: no pedal edema bil., no calf tenderness bil
BACK: DSD applied, erythema along staple line, skin excoriation
along staple and upper aspect of suture line
NEURO: alert and oriented x 3, speech clear, no tremors
Pertinent Results:
___ 06:24AM BLOOD WBC-10.1* RBC-2.56* Hgb-8.1* Hct-24.5*
MCV-96 MCH-31.6 MCHC-33.1 RDW-13.8 RDWSD-47.9* Plt ___
___ 12:08AM BLOOD WBC-11.5* RBC-2.61* Hgb-8.2* Hct-25.1*
MCV-96 MCH-31.4 MCHC-32.7 RDW-14.0 RDWSD-49.3* Plt ___
___ 03:09AM BLOOD WBC-8.6 RBC-2.71* Hgb-8.5* Hct-25.6*
MCV-95 MCH-31.4 MCHC-33.2 RDW-13.7 RDWSD-47.2* Plt ___
___ 03:51AM BLOOD WBC-6.2 RBC-3.10* Hgb-9.8* Hct-29.8*
MCV-96 MCH-31.6 MCHC-32.9 RDW-13.8 RDWSD-48.5* Plt ___
___ 03:55AM BLOOD WBC-6.1 RBC-3.04* Hgb-9.5* Hct-29.7*
MCV-98 MCH-31.3 MCHC-32.0 RDW-14.2 RDWSD-50.5* Plt ___
___ 02:30PM BLOOD WBC-5.5 RBC-3.11* Hgb-9.9* Hct-30.0*
MCV-97 MCH-31.8 MCHC-33.0 RDW-14.0 RDWSD-49.1* Plt ___
___ 03:51AM BLOOD Neuts-76.6* Lymphs-7.5* Monos-14.8*
Eos-0.5* Baso-0.3 Im ___ AbsNeut-4.71 AbsLymp-0.46*
AbsMono-0.91* AbsEos-0.03* AbsBaso-0.02
___ 03:55AM BLOOD Neuts-79.7* Lymphs-7.1* Monos-12.5
Eos-0.2* Baso-0.2 Im ___ AbsNeut-4.83 AbsLymp-0.43*
AbsMono-0.76 AbsEos-0.01* AbsBaso-0.01
___ 02:30PM BLOOD Neuts-72.0* Lymphs-12.2* Monos-13.7*
Eos-0.5* Baso-0.7 Im ___ AbsNeut-3.94 AbsLymp-0.67*
AbsMono-0.75 AbsEos-0.03* AbsBaso-0.04
___ 06:24AM BLOOD Plt ___
___ 06:24AM BLOOD ___ PTT-32.2 ___
___ 12:08AM BLOOD Plt ___
___ 03:09AM BLOOD Plt ___
___ 03:09AM BLOOD ___ PTT-27.7 ___
___ 03:55AM BLOOD Plt ___
___ 02:30PM BLOOD Plt ___
___ 06:24AM BLOOD Glucose-93 UreaN-33* Creat-1.0 Na-132*
K-4.2 Cl-97 HCO3-27 AnGap-8*
___: CXR:
In comparison with the study of ___, there again is
substantial
enlargement of the cardiac silhouette without appreciable
vascular congestion.
This discordance raises the possibility cardiomyopathy or
pericardial
effusion. No evidence of acute focal pneumonia or vascular
congestion.
Rounded opacification adjacent to the lateral aspect of the
humeral head on the right could reflect calcification in tendons
of the rotator cuff.
___: CT T spine:
. Motion and diffuse osteopenia limits examination.
2. Transitional anatomy with lumbarization of S1.
3. Re-demonstration of an obliquely oriented, comminuted Chance
type fracture through the T10 vertebral body, transverse
process, and spinous process.
4. See same-day full spine MRI for description of multilevel
degenerative
changes and ligamentous injury.
5. Grossly stable probable bilateral S1-2 pars fractures.
6. Right T11 transverse process fracture.
7. Right proximal T10 and T11 rib fractures.
___: T Spine:
Status post posterior fixation from T7 to T11. No evidence of
hardware
related complications. Known fractures were better evaluated on
prior
cross-sectional imaging.
Brief Hospital Course:
___ year old male who presented to the Emergency Department on
___ after a mechanical fall. Upon admission to the hospital,
the patient was made NPO, given intravenous fluids, and
underwent imaging. A head CT was negative for intracranial
process. CT torso revealed comminuted and mildly displaced
Chance type fracture through all three columns of T10 vertebral
body with surrounding prevertebral hematoma with 2mm of bony
retropulsion into spinal canal causing mild central
canal stenosis, as well as mildly displaced R ___ rib
fractures, T9 spinous process fracture, and T10-11 R transverse
process fractures. Given findings, patient was transferred the
ICU and made NPO in anticipation of surgery. Patient was given
vitamin K to reverse anticoagulation from his home warfarin. on
___ he received more vitamin K to further reverse the warfarin
in preparation for surgery with spine orthopedic surgery.
On ___ the patient was taken to the operating room where he
underwent T7-T11 posterior spine instrumented fusion. There were
no adverse events in the operating room; please see the
operative note for details. Pt was extubated, taken to the PACU
until stable, then transferred to the ICU for observation. The
patient was then bridged with SQH until therapeutic on home dose
heparin.
On ___ the patient was transferred to the surgical floor. He
was found to be hypotensive to ___, however asymptomatic. He
was given additional intravenous fluids with little effect. He
was then transfused with a unit of pRBCs. The patient's blood
pressure stabilized with additional intravenous fluids. The
patient resumed his daily Coumadin with monitoring of his
___. INR at the time of discharge was 2.6. During the
patient's hospitalization, he was evaluated by physical therapy
and recommendations made for discharge to a rehabilitation
facility where the patient could further regain his strength and
mobility.
At the time of discharge, the patient was tolerating a regular
diet. He was voiding without difficulty and had return of bowel
function. His hematocrit was stable at 27. His back dressing
was changed prior to discharge with application of an absorbent
dressing which can remain in place for 1 week. The patient was
discharged to a rehabilitation facility on POD #5 in stable
condition. Discharge instructions were reviewed and questions
answered. A follow-up appointment was made in the acute care
clinic and with the spine service.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Atorvastatin 40 mg PO QPM
2. Atenolol 50 mg PO DAILY
3. amLODIPine 5 mg PO DAILY
4. Warfarin 2.5 mg PO 5X/WEEK (___)
5. Warfarin 7.5 mg PO 2X/WEEK (MO,TH)
6. Lisinopril 20 mg PO DAILY
7. Torsemide 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl ___AILY:PRN Constipation - Second Line
3. Docusate Sodium 100 mg PO BID
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
7. Pravastatin 40 mg PO QPM
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
9. Tamsulosin 0.4 mg PO QHS
10. Warfarin 5 mg PO 3X/WEEK (___)
11. Warfarin 3.75 mg PO 4X/WEEK (___)
12. amLODIPine 5 mg PO DAILY
13. Atenolol 50 mg PO DAILY
14. Atorvastatin 40 mg PO QPM
15. Lisinopril 20 mg PO DAILY
16. Torsemide 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
mechanical fall
right T10-11 transverse process fracture,
right ___ rib fracture,
T9 spinous process fracture with chance fracture of T10
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 ___ due to
fall that caused several fractures including rib and spine
fractures and underwent a T7-T11 arthrodesis spine surgery. You
are recovering well and are now ready for discharge. Please
follow the instructions below to continue your recovery:
* Your injury caused ___ right rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10405772-DS-18 | 10,405,772 | 28,040,797 | DS | 18 | 2202-09-17 00:00:00 | 2202-09-17 15:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o F with h/o breast CA in the 1990s, HTN, HL, and spinal
stenosis p/w cough x3 wks and productive with yellow sputum. Pt
states her roommate came down with a cold and then pt and her
other roommate also developed a cold. The other roommate is in
the hospital admitted today with pneumonia. Pt had 3 wks of wet
cough but minimal sputum production. In the last 3 days the
cough worsened in frequency. Pt denies ever having nasal
congestion or sore throat. Also denies
fevers/chills/dyspnea/hemoptysis/chest pain/abd pain/n/v. No
rashes. Saw PCP yesterday and was started on z-pack, cough did
not improve (or worsen) overnight and PCP recommended she come
to the ED.
.
Of note, pt w/ br CA dx in ___, underwent tamoxifen therapy and
right modified mastectomy w/o reconstruction. ___ new mass
noted and pt underwent chest radiation. No recurrence since.
.
In the ED, initial vital signs 96.1 67 ___ 96%. CXR prelim
read was for "Subtle opacity at right lung base which may
represent pneumonia. Possible small pleural effusion or
thickening. No CHF." Labs showed WBC of 7, (76%) PMNs, HCT 34.3,
Bicarb of 34, BUN/cr ___, K 3.4, AG 11, lactate 1.0. Pt was
given one dose of levofloxacin 750mg IV. Blood and urine
cultures were sent. On transfer, vitals were 99.1, 155/68, RR
16, O2 sat 92% on RA.
.
On the floor, pt is walking around the room, up in chair,
appears very comfortable. V/S 99.1 143/66 77 20 94% RA. Endorses
cough, stable and not worsening. Conversing and joking
comfortably.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, shortness of
breath, chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
1. HTN
2. Hyperlipidemia
3. Macular degeneration
4. Cholecystectomy
5. Breast cancer, s/p right mastectomy ___ years ago)
6. Left knee replacement (___)
7. Right knee replacement ___ years ago)
Social History:
___
Family History:
NC - parents lived into their ___. 8 siblings, 2 sisters still
living, ___ and ___ y/o.
Physical Exam:
ON ADMISSION
VS - 99.1 BP 143/66 HR 77 RR20 94%RA
GENERAL - well-appearing female in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
Left eyelid drooping but pt feels this is residual from eyelid
surgery.
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 - protuberant, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, tr pitting edema bilaterally at the ankles,
2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions, but occasional bruises
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait. NO asterixis.
.
AT DISCHARGE
pt continues to cough, exam unchanged.
Pertinent Results:
BLOOD:
___ 03:10PM BLOOD WBC-7.0# RBC-3.76* Hgb-11.7* Hct-34.3*
MCV-91 MCH-31.1 MCHC-34.2 RDW-12.6 Plt ___
___ 07:05AM BLOOD WBC-6.2 RBC-3.71* Hgb-11.5* Hct-33.7*
MCV-91 MCH-31.0 MCHC-34.2 RDW-12.6 Plt ___
___ 03:10PM BLOOD Neuts-76.2* ___ Monos-4.1 Eos-0.7
Baso-0.4
___ 07:05AM BLOOD Neuts-74.1* ___ Monos-4.4 Eos-1.8
Baso-0.5
___ 03:10PM BLOOD Glucose-102* UreaN-17 Creat-0.6 Na-138
K-3.4 Cl-96 HCO3-34* AnGap-11
___ 07:05AM BLOOD Glucose-158* UreaN-12 Creat-0.6 Na-140
K-4.0 Cl-99 HCO3-31 AnGap-14
___ 03:18PM BLOOD Lactate-1.0
.
URINE:
___ 05:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 05:40PM URINE Color-Yellow Appear-Clear Sp ___
Urine legionella antigen negative
.
IMAGING:
CXR ___:
wet read: Subtle opacity at right lung base which may represent
pneumonia. Recommend follow up to resolution. Possible small
pleural effusion or thickening. No CHF.
Brief Hospital Course:
___ y/o F with h/o breast CA in the 1990s, HTN, HL p/w cough x3
wks now worsening in last 3 days.
.
#cough - pt with 3 wks of cough and some, minimal, yellow
sputum. s/p 1d azithro ___ and 1d levo on ___. Afebrile
without leukocytosis. Most likely post-viral bronchitis given
duration and no convincing infiltrate on CXR vs atypical
pneumonia. CURB65 only 1 point. urine legionella negative.
Sputum culture was contaminated. Pt remained afebrile with
normal ___ count and felt well the morning after admission
although cough continued. She was sent home with
dextromethorphan prn and benzononate and with the plan to
complete a 5 day course of levofloxacin. Pt felt well and was
eager to go home.
.
# elevated bicarb - pt with bicarb of 34 on admission. Likely
contraction alkalosis in setting of decreased PO intake. Still,
BUN/cr not elevated which would be expected in that case.
Possible pt is retaining CO2 and bicarb is accumulating as
compensatory - but pt without h/o COPD and past bicarb levels
normal. Pt has AG of 11 and lactate 1.0. Renal function is
normal, no history of kidney disease. Bicarb improved overnight
with PO fluid resuscitation, was felt to be in the setting of
some dehydration.
.
#hypertension - continued home atenolol, amlodipine.
.
#hyperlipidemia - continued statin
.
#arthritis/cervical stenosis - continued home tylenol/codeine
.
#h/o malignancy - stable without recurrence.
.
# CONTACT: ___, friend ___
.
Pt was maintained as full code throughout this hospitalization.
Medications on Admission:
per PCP note the day prior to ___
ACETAMINOPHEN-CODEINE - 300 mg-30 mg Tablet - 1 Tablet(s) by
mouth every four (4) to six (6) hours as needed for pain
AMLODIPINE [NORVASC] - 5 mg Tablet - one Tablet(s) by mouth
daily
ATENOLOL - 25 mg Tablet - one Tablet(s) by mouth daily
ATORVASTATIN [LIPITOR] - 10 mg Tablet - 1 tab po daily
AZITHROMYCIN [ZITHROMAX Z-PAK] - 250 mg Tablet - 2 Tablet(s) by
mouth for 1 day then 1 tablet qd for 4 days
HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth daily
OCCUVITE - (Prescribed by Other Provider) - Dosage uncertain
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider) - 325 mg Tablet
-
2 Tablet(s) by mouth twice a day
LIDOCAINE [LIDOCREAM] - (Prescribed by Other Provider) - Dosage
uncertain
MV-FA-CA-FE-MIN-LYCOPEN-LUTEIN [CENTRUM] - (OTC) - Dosage
uncertain
VIT B COMPLEX ___ COMBO NO.2 - (Prescribed by Other Provider) -
Dosage uncertain
VIT C-BIOFLAV-HESP-RUTIN-HB111 - (OTC) - Dosage uncertain
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
6. acetaminophen-codeine 300-30 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for pain.
7. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*40 Capsule(s)* Refills:*0*
8. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every other
day for 2 doses: take one pill on ___ and the other pill on
___.
Disp:*2 Tablet(s)* Refills:*0*
9. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. dextromethorphan HBr 5 mg Lozenge Sig: One (1) lozenge PO
every ___ hours for 4 days: this medication can make you sleepy.
Disp:*20 lozenges* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
bronchitis
.
SECONDARY
spinal stenosis
history of breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during this
hospitalization. You came in with a cough and were admitted for
bronchitis and possible pneumonia. We treated you with
antibiotics.
We made the following changes to your medications:
ADDED levofloxacin
ADDED benzononate (for cough)
ADDED dextromethorphan (for cough) - this can make you sleepy
All other meds stay the same.
Followup Instructions:
___
|
10405894-DS-6 | 10,405,894 | 21,051,577 | DS | 6 | 2150-04-01 00:00:00 | 2150-04-02 10:50:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Fall and Flank Pain
Major Surgical or Invasive Procedure:
___: Chest Tube/Pigtail Placement
History of Present Illness:
___ w/ h/o afib on Coumadin, hypertensive heart disease (EF
55% ___ CKD stage 4 (baseline Cr), dementia/memory loss, and
recurrent falls, who now presents with suspected unwitnessed
fall a day ago and worsening right flank ecchymosis and found to
have a hct 17. Per patient's son who is accompanying the
patient, he first noted bruising around right flank/lower
abdomen yesterday
when he was helping the patient shower, but then today noticed
it was worse. Therefore, he called to make an appointment with
the patient's PCP, who told him to go to the emergency room. The
patient does not remember falling although he states it is
possible. Currently, he does not complain of any pain,
lightheadedness, shortness of breath, or chest pain. His son
said he has been falling more recently, and most notably had a
fall in ___ and was found to be in new fib, and he has had
a fall last ___ as well. He has not had a good appetite
recently and has not taken in much PO.
Past Medical History:
AAA, diverticulosis, hip fractures, hypercholesterolemia,
HTN, memory loss, CKD stage IV, rosacea, seborrheic dermatitis,
ventral hernia, popliteal aneurysms, h/o syncope, afib,
hypertensive heart disease without heart failure (Echo ___ EF
55%), anemia, right inguinal hernia, hyperparathyroidism, wrist
fracture
PSH: AAA repair ___
Social History:
___
Family History:
Family history is significant for his mother having had some
sort of cancer.
Physical Exam:
-------------------
ADMISSION EXAM
-------------------
PE: 97.6 66 115/59 18 94% RA
Gen: NAD, A&OX1-2
CV: regular rate, 2+ bilateral lower extremity edema
Resp: decreased breath sounds at bases, otherwise equal
GI: soft, NTND; ecchymosis right flank, nontender
Extrem: warm
Neuro: intact ROM, motor/sensory; no TTP CTLS spine
-------------------
DISCHARGE EXAM
-------------------
Vitals: 97.7 154/69 62 18 95 RA
General Appearance: NAD, resting comfortably
Chest: bibasilar crackles
Cardiovascular: reg rate, nl S1/S2, no MRG
Abdomen: soft, NT/ND, NABS, no HSM
Extremities: bilateral ___ bruising, no edema
Neurological: A&O x0
Pertinent Results:
-------------------
ADMISSION LABS
-------------------
___ 02:54PM BLOOD WBC-11.2*# RBC-1.84*# Hgb-5.7*#
Hct-17.4*# MCV-95 MCH-31.0 MCHC-32.8 RDW-15.9* RDWSD-54.3* Plt
___
___ 02:54PM BLOOD Neuts-78.4* Lymphs-8.7* Monos-10.9
Eos-1.1 Baso-0.1 NRBC-0.3* Im ___ AbsNeut-8.78*
AbsLymp-0.97* AbsMono-1.22* AbsEos-0.12 AbsBaso-0.01
___ 02:54PM BLOOD ___ PTT-38.1* ___
___ 02:54PM BLOOD Glucose-141* UreaN-105* Creat-6.5*#
Na-137 K-4.4 Cl-96 HCO3-21* AnGap-24*
___ 02:54PM BLOOD CK-MB-3
___ 02:54PM BLOOD cTropnT-0.11*
___ 07:00AM BLOOD ___
___ 07:00AM BLOOD Calcium-8.4 Phos-4.9* Mg-2.9*
___ 04:49PM BLOOD ___ pO2-183* pCO2-33* pH-7.40
calTCO2-21 Base XS--2
___ 09:57PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:57PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:57PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
___ 09:57PM URINE CastHy-1*
-------------
IMAGING
-------------
___ TTE
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. The right ventricular cavity is
mildly dilated with borderline normal free wall function. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
(___) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
------------
___ ImagingCHEST (PORTABLE AP)
In comparison with the study of ___, the patient has taken a
better
inspiration. There is no evidence of post procedure
pneumothorax or
reaccumulation of pleural fluid. Atelectatic changes are again
seen at the right base.
The remainder of the study is unchanged. Substantial
enlargement of the
cardiac silhouette is again seen with stable degree of pulmonary
vascular
congestion. Opacification at the left base is consistent with
volume loss in left lower lobe and small pleural effusion.
------------
___ (PORTABLE AP)
In comparison with the earlier study of this date, there has
been placement of a right chest tube with removal of some
pleural fluid. Atelectatic changes are again seen at the right
base. Specifically, no evidence of post procedure pneumothorax.
------------
___ ImagingCHEST (PORTABLE AP)
In comparison with the study of ___, there appear to be
increasing pleural effusions, more prominent on the right, with
underlying compressive
atelectasis. The right basilar consolidation seen on CT is more
difficult to assess on plain radiographs. Continued enlargement
of the cardiac silhouette with mild elevation of pulmonary
venous pressure. No evidence of pneumothorax.
------------
___ (SINGLE VIEW)
Diffuse osteopenia. No acute fracture seen.
------------
___ (UNILAT 2 VIEW) W/P
------------
___ CHEST W/O CONTRAST
1. No evidence of acute aortic injury or mediastinal hematoma.
2. Moderate bilateral pleural effusions (right greater than
left).
3. Bilateral lower lobe atelectasis (right greater than left).
4. Right posterior tenth and eleventh rib minimally displaced
acute fractures.
5. Large subcapsular hematoma of the right kidney with
right-sided
retroperitoneal hematoma.
6. 2.9 x 2.9 x 1.7 cm heterogeneous high-density mass projecting
from the
superior pole of the which right kidney, raises suspicion for
right kidney
malignancy (2:145, 601b:89).
------------
___ ABD & PELVIS W/O CON
1. No evidence of acute aortic injury or mediastinal hematoma.
2. Moderate bilateral pleural effusions (right greater than
left).
3. Bilateral lower lobe atelectasis (right greater than left).
4. Right posterior tenth and eleventh rib minimally displaced
acute fractures.
5. Large subcapsular hematoma of the right kidney with
right-sided
retroperitoneal hematoma.
6. 2.9 x 2.9 x 1.7 cm heterogeneous high-density mass projecting
from the
superior pole of the which right kidney, raises suspicion for
right kidney
malignancy (2:145, 601b:89).
------------
___ C-SPINE W/O CONTRAST
1. Mild loss of height of the superior endplates of the T1 and
T2 vertebral
bodies are of indeterminate age, no priors available for
comparison. If
further assessment for acute injury is desired, MRI is more
sensitive. No
evidence of acute fracture seen elsewhere.
2. Multilevel degenerative changes. Minimal retrolisthesis of
C3 over C4 isof indeterminate age, but may be degenerative.
------------
___ ImagingCT HEAD W/O CONTRAST
No acute intracranial hemorrhage. No acute intracranial
process. Chronic
changes.
-------------------
DISCHARGE LABS
-------------------
___ 07:20AM BLOOD WBC-9.9 RBC-3.14* Hgb-9.2* Hct-28.8*
MCV-92 MCH-29.3 MCHC-31.9* RDW-17.2* RDWSD-56.5* Plt ___
___ 07:20AM BLOOD Glucose-95 UreaN-104* Creat-5.3* Na-131*
K-3.8 Cl-98 HCO3-21* AnGap-16
___ 07:20AM BLOOD Calcium-8.6 Phos-5.7* Mg-2.7*
Brief Hospital Course:
___ y/o M A fib on Coumadin, vascular dementia w/ a history of
falls p/w an RP bleed and acute anemia in the setting of a
recent unwitnessed fall, with course complicated by hypoxemic
respiratory failure ___ volume overload.
#Hypoxemic respiratory failure: New O2 requirement up to 6L.
Likely multifactorial related to multiple transfusions (3u
pRBCs) in setting of an acute bleed with superimposed ___ and a
probable component of undiagnosed heart failure given elevated
BNP to >32K. Bilateral pleural effusions seen on CXR s/p R CT
placement by IP, discontinued on discharge. Also with a ? RLL on
CXR so empirically started on CTX and azithro for CAP but this
was discontinued as patient was afebrile without leukocytosis.
Also with posterior rib fractures from fall at home could
further be impairing respiratory mechanics. Pleural studies
suggested a transudative effusion from renal failure vs. heart
failure. Repeat TTE with EF >55%, mild TR/MR, moderate PAH.
Patient was weaned to RA with IV diuresis 120 mg BID and
transitioned to torsemide 60 mg daily on discharge.
___ on Stage IV CKD: Cr up to 6.5 on presentation, baseline
3.0. Secondary to long-standing history of vascular disease and
HTN. Initial concern for cardiorenal, though noted minimal
improvement with diuretics. Urine studies suggested ATN with
FeUrea 55% though no granular casts seen on urine microscopy.
Also concern for renal malignancy with a R superior pole kidney
mass seen on CT. Patient seen by Dr. ___ and prior
notes delinate that patient not amenable to RRT.
#RP hematoma
#S/p fall: CT showing a subcapsular hematoma of the right kidney
with right-sided retroperitoneal hematoma suspected to be due to
an unwitnessed fall. H/H on presentation 5.7/17.4 with
supratherapeutic INR at 5.1. H/H remained stable after 3u pRBC
and INR reversal throughout hospital stay. He was on Tylenol and
oxycodone for pain control while inpatient. Family meeting held
and decision made to discontinue Coumadin given high risk of
falls.
CHRONIC ISSUES:
#Vascular dementia: Continued Aricept.
#Atrial fibrillation: Continue metoprolol PO XL for rate
control. Discontinued Coumadin as above.
#HTN: Continued home amlodipine, torsemide as above.
#Gout: Held colchicine iso ___. Continued to hold on discharge.
TRANSITIONAL ISSUES
===================
- Discharge weight: 78.7 kg
- Discharge creatinine: 5.3
- Check next BMP on ___
- Check next CBC on ___
- Discontinued Coumadin after discussion of risks and benefits
with the patient and family.
- Holding colchicine due to ATN. Resume when able.
- Ongoing discussion with family regarding patient disposition
after rehab. Family considering nursing home vs. home with
nursing services.
- Discontinued furosemide, switched to torsemide 60 mg daily on
discharge. Please weight patient daily and adjust as necessary.
- Mass seen on the superior pole of the R kidney on CT A/P
concerning for malignancy. Consider further work-up outpatient.
The patient will follow up with urology. The patient and family
were informed.
- Please check CBC in 1 week to ensure it is stable. H/H on day
of discharge 9.2/___.8. Restart aspirin if stable.
- Patient had a chest tube placed and subsequently removed for
pleural effusion. The patient will follow up with interventional
pulmonology as an outpatient and will have a repeat CXR then.
DNR/DNI - MOLST signed
Name of health care proxy: ___
Relationship: son
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Colchicine 0.6 mg PO BID PRN Gout flare
2. amLODIPine 5 mg PO DAILY
3. Donepezil 10 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. LORazepam 0.5-1 mg PO DAILY PRN Anxiety
6. Aspirin ___AILY
7. Warfarin 2.5 mg PO 4X/WEEK (___)
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Warfarin 5 mg PO 3X/WEEK (___)
10. Multivitamins 1 TAB PO DAILY
11. Vitamin E 400 UNIT PO DAILY
Discharge Medications:
1. Torsemide 60 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Donepezil 10 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Vitamin E 400 UNIT PO DAILY
7. HELD- Aspirin ___AILY This medication was held. Do
not restart Aspirin until cleared by your primary care physician
8. HELD- Colchicine 0.6 mg PO BID PRN Gout flare This
medication was held. Do not restart Colchicine until cleared by
your primary care physician.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Retroperitoneal Hematoma
Acute on chronic kidney disease
Hypoxemic respiratory failure
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 the hospital after a fall and flank pain.
You were found to have some internal bleeding due to the fall.
We gave you blood transfusions to improve your blood counts. You
then developed shortness of breath due to all the fluid you were
getting through the transfusions. We gave you diuretics to allow
you to pee out the extra fluid. Your breathing improved. We
discussed the risks and benefits of continuing the Coumadin and
we made a decision to stop the medication. You will need to go
to rehab for a short period of time to regain your strength. It
was a pleasure caring for you.
Wishing you the ___,
Your ___ Team
Followup Instructions:
___
|
10405980-DS-13 | 10,405,980 | 29,103,966 | DS | 13 | 2190-06-07 00:00:00 | 2190-06-08 12:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Dilaudid
Attending: ___.
Chief Complaint:
presyncope, chest and arm tightness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of poorly controlled DM2 (not on meds) who
presented with presyncopal symptoms. He reports that he was
driving suddenly felt lightheaded. He describes a feeling of
warmth and "fading out" that was "like it feels to die". He
reports associated transient chest, left jaw and left arm
tightness. He denies any associated pain, dyspnea, nausea or
vomiting. He denies any recent fevers or chills. He does report
that he was been feeling "sluggish" for the past few weeks. Of
note, his wife reports finding him on the ground in the living
room 2 weeks ago; he says he felt nauseous and dizzy and fell.
Had ___ cyst removed 3 months ago, otherwise no risk factors
for PE. Last stress test in our system was ___ and was
normal. Patient has not taken his diabetes medications for about
___ year; he was previously on metformin but had GI side effects.
He reports that his blood sugars have been quite high in the
past, even as high as 500. He does reports increased thirst and
urinary frequency, and the toilet that he uses gets black (urine
is clear, but something seems different and it needs more
frequent cleaning for the past 6+ months)
In the ED, initial vital signs were 98.0 72 123/91 18 97% 3L.
Patient was given aspirin 81mg. Troponin <0.01. EKG with no
significant changes from prior. LLE ultrasound negative for DVT
and showed no residual Bakers cystevidence of fistula, mass, or
fluid collection in the area of concern on the anterior thigh.
UA showed large amount of glucose and trace ketones.
.
On the floor, patient reports feeling low energy, but denies
chest pain, dyspnea, nausea.
Past Medical History:
-GERD
-diabetes (type 2)
-cholecystectomy
-nephrolithiasis
-umbilical hernia repair ___ years ago
-L knee ___ cyst removal
Social History:
___
Family History:
mother with diabetes. brother recently diagnosed with thyroid
cancer. grandmother with some sort of heart problem. No known
family history of early MI or sudden cardiac death.
Physical Exam:
Admission exam:
Vitals- 97.6 123/75 75 20 95%/RA FSG 186
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear. small,
non-tender mobile lump (<1cm) on left scalp
Neck- supple, JVP not elevated (but difficult to assess due to
body habitus), approx 1 cm rubbery mobile node on right side
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
Discharge exam:
Vitals- 97.4 127/90 65 18 97%/RA FSG 176
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear. small,
non-tender mobile lump (<1cm) on left scalp
Neck- supple, JVP not elevated (but difficult to assess due to
body habitus), approx 1 cm rubbery mobile node on right side
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:
Pertinent labs:
___ 12:20PM BLOOD WBC-7.3 RBC-5.62 Hgb-16.6 Hct-48.9 MCV-87
MCH-29.5 MCHC-33.9 RDW-13.2 Plt ___
___ 12:20PM BLOOD Glucose-296* UreaN-14 Creat-0.7 Na-137
K-3.9 Cl-101 HCO3-26 AnGap-14
___ 12:20PM BLOOD cTropnT-<0.01
___ 07:30PM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:02AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:02AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.0 Cholest-209*
___ 07:02AM BLOOD Triglyc-276* HDL-31 CHOL/HD-6.7
LDLcalc-123 (still pending at time of discharge)
___ 07:30PM BLOOD %HbA1c-11.2* eAG-275* (still pending at
time of discharge)
EKG:
Sinus rhythm. Compared to the previous tracing of ___ the
findings are
similar.
Imaging:
Ultrasound of left lower extremity:
IMPRESSION:
1. No evidence the left lower extremity deep vein thrombosis.
2. No evidence of fistula, mass, or fluid collection in the
area of concern.
Stress test:
INTERPRETATION: This ___ year old NIDDM man was referred to the
lab
for evaluation of chest pain and pre-syncope. The patient
exercised for
11 minutes of a modified ___ protocol (~ ___ METS),
representing an
average exercise tolerance for his age. The test was stopped due
to
fatigue. No chest, neck, back, or arm discomforts were reported
by the
patient throughout the study. There were no significant ST
segment
changes throughout the study. The rhythm was sinus with no
ectopy
throughout the study. Appropriate blood pressure and heart rate
responses to exercise. Slightly exaggerated blood pressure
response
noted in early recovery (210/86).
IMPRESSION: No anginal type symptoms or ischemic EKG changes. BP
response as noted.
Chest X-ray:
In comparison with the study of ___, there is little change
and no evidence of acute cardiopulmonary disease. Minimal
streaks of
atelectasis at the left base. No pneumonia, vascular
congestion, or pleural
effusion.
Brief Hospital Course:
___ male with untreated type 2 diabetes presenting following
presyncopal episode associated with chest and left arm
tightness.
# Presyncope: concern for cardiac etiology given untreated type
2 diabetes and associated chest and left arm pressure, however
no EKG changes in the ED and cardiac enzymes were negative.
Stress test ___ year ago was normal. Stress test done, which
showed slightly exaggerated blood pressure response in early
recovery but was otherwise unremarkable. Chest X-ray
unremarkable. Symptoms may have been due to volume depletion in
the setting of elevated blood sugars vs vagal (although unclear
what inciting factor would have been)
# Type 2 diabetes: Patient has not been on medication at home.
Reports history of very high blood sugars. UA on admission
showed 1000 glucose and trace ketones. HbA1c (which returned
after patient discharged) found to be 11.2. Patient was
discharged on 500mg metformin BID and a daily baby aspirin and
was counseled extensively on the importance of establishing care
with a PCP to follow up on diabetes control.
- checked lipid panel for risk stratification. Would consider
statin initiation in the outpatient setting.
Transitional issues:
- establish care with PCP (reports that he has not seen his
insurance PCP in years)
- titrate outpatient diabetes regimen
- address lipid panel (was still pending at time of discharge):
showed cholesterol 209, HDL 31, triglycerides 279
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Glucometer
Please dispense 1 blood glucose meter
4. Lancets
Please dispense 1 box of lancets
Instructions for use: please check blood sugars twice daily
5. Test strips
Please dispense 1 box of glucometer test strips
Instructions for use: please check blood sugars twice daily
Discharge Disposition:
Home
Discharge Diagnosis:
Presyncope
Uncontrolled type 2 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with dizziness and an episode
of chest tightness. You were monitored overnight and your heart
rhythm was normal. Your blood tests did not show any sign of a
heart attack and you had a stress test of your heart which was
normal. A chest X-ray was also normal. Your blood sugars have
been very high, which may have contributed to your symptoms.
At home you should:
-start metformin 500mg twice a day for your diabetes
-check your blood sugars twice a day (once first thing in the
morning, once before dinner) and keep a record of the results
-take 1 baby aspirin (81mg) daily
You should follow up with your new primary care doctor within
the next week or so to see how you are doing with this
medication and adjust things as needed. They can also discuss
the results from some tests (cholesterol levels and HbA1c) which
were still pending at discharge.
It was a pleasure taking care of you during your hospitalization
and we wish you the best going forward.
Followup Instructions:
___
|
10405980-DS-14 | 10,405,980 | 22,727,957 | DS | 14 | 2191-01-27 00:00:00 | 2191-02-12 16:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Dilaudid
Attending: ___.
Chief Complaint:
Presyncope and chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMHx DM and recent admission (___) for presyncope and
negative workup presents with presyncope and chest discomfort.
He said he was at his usual state of health until yesterday
morning when he became lightheaded and dizzy (narrowing field of
vision) while working on his boat. Notably, the patient hydrates
exclusively with Diet Coke often "for days at a time". He notes
that he was unaware that it contained caffeine. This was the
case in the days leading up to his presentation. On the day of
admission, he felt lightheaded and nauseated upon rising from a
supine position. These symptoms were accompanied by fleeting
substernal chest pressure. No blurry vision or sweats. He called
EMS out of concern for ACS.
Past Medical History:
-GERD
-diabetes (type 2)
-cholecystectomy
-nephrolithiasis
-umbilical hernia repair ___ years ago
-L knee ___ cyst removal
Social History:
___
Family History:
(Per OMR)
mother with diabetes. brother recently diagnosed with thyroid
cancer. grandmother with some sort of heart problem. No known
family history of early MI or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL:
Vitals- T97.6 Bp 132/76 HR 68 RR 16 O2 97%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL:
Vitals- 97.6 68 132/75 16 97RA
General- AOx3, NAD
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
------------------
ADMISSION LABS:
___ 08:52PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:52PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 06:06PM GLUCOSE-195* UREA N-19 CREAT-0.9 SODIUM-137
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-22 ANION GAP-18
___ 06:06PM cTropnT-<0.01
___ 06:06PM WBC-10.6 RBC-5.18 HGB-15.8 HCT-43.7 MCV-84
MCH-30.5 MCHC-36.2* RDW-13.4
___ 06:06PM PLT COUNT-186
___ CHEST (PA & LAT)- IMPRESSION: No pulmonary embolism or
evidence of acute aortic pathology. No findings to account for
patient's symptoms.
___ CTA CHEST W&W/O C&RECON - IMPRESSION: No pulmonary
embolism or evidence of acute aortic pathology. No findings to
account for patient's symptoms.
----------------
IMAGING:
___ CTA CHEST
CTA: The aorta and pulmonary arteries are well opacified. The
aorta
maintains a normal contour without evidence of dissection or
intramural
hematoma. There is no pulmonary embolism in the main, right,
left, lobar, segmental or subsegmental pulmonary arteries. The
heart is normal size without pericardial effusion. The thyroid
is normal. The airways are patent to the subsegmental level.
There is no mediastinal, hilar, axillary, or supraclavicular
lymphadenopathy. There is no concerning pulmonary nodule, mass,
or confluent consolidation. Bibasilar atelectasis is present.
There is no pleural effusion or pneumothorax. The imaged portion
of the upper abdomen is unremarkable. No suspicious lesion is
seen in the visualized osseous structures.
IMPRESSION:
No pulmonary embolism or evidence of acute aortic pathology. No
findings to account for patient's symptoms.
Brief Hospital Course:
___ with PMHx significant for DM2 and GERD presents with
lightheadedness due to hypovolemic orthostasis and chest
pressure due to GERD.
.
-------------
ACTIVE ISSUES:
.
#Pre-syncope DUE TO HYPOVOLEMIC ORTHOSTASIS: RESOLVED. Due to
dehydration in the setting exclusive caffeinated cola
consumption for multiple days. Resolved after 2L IVF bolus,
confirmed with negative orthostatics.
.
#CHEST PRESSURE: RESOLVED. Due to GERD. Evidenced by subjective
historical similarity to prior GERD episodes. Started omeprazole
40mg daily. Alternate diagnoses include 1) ACS, which is less
likely given absence of serum troponins and ECG without evidence
of ischemia despite his risk factor (DM); 2) PE, which is less
likely given normal CTA without evidence of perfusion defect.
.
-------------
CHRONIC ISSUES:
.
#DM2 uncontrolled with complications: Pt. checks sugars BID and
usually run 140-150mg/dl. Within the last 2 weeks sugars were
around 280 mg/dl. Pt. endorses taking 2 metformin daily (one in
AM and one in ___. Sugar this AM 151mg/dl. Symptoms returned to
baseline with home metformin dose.
.
#GERD: Pt. h/o GERD. Pt. endorses to feeling dehydrated and
"chugging" a glass of Ice Tea prior to developing the
substernal chest pressure and pre-syncopal episode. Chest
pressure resolved with viscous lidocaine in ED. Prescribed
Omeprazole 40mg QD x 3 weeks and f/u with PCP regarding GERD.
.
--------------
TRANSITIONAL ISSUES:
.
#DIET: Patient plans to decrease soda intake and hydrate with
H20.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Atorvastatin 10 mg PO HS
4. Omeprazole 40 mg PO DAILY
RX *omeprazole 20 mg 1 tablet,delayed release (___) by
mouth Daily Disp #*14 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Presyncope due to dehydration
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 participating in your care at ___. You were
admitted to the hospital for chest pain and lightheadedness.
Based on your lab results and studies, you did not have a heart
attack. Your symptoms were most likely due to acid reflux
(heartburn) and dehydration. We recommend drinking plenty of
water and avoiding caffeinated beverages. We have prescribed you
a medication called omeprazole for your acid reflux.
Please follow up with your primary care doctor and continue to
take all of your medications as prescribed.
Followup Instructions:
___
|
10406393-DS-17 | 10,406,393 | 27,415,949 | DS | 17 | 2154-10-28 00:00:00 | 2154-10-28 18:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male presents with the above fracture s/p motor vehicle
crash. The patient was the unrestrained passenger of a vehicle
traveling at approximately ___ pmh which collided with another
vehicle. The patient suffered multiple traumatic injuries as a
result of this MVC including a closed injury of his right ankle
and spine fractures.
Past Medical History:
No significant past medical history
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Constitutional: Abrasions on face
Oropharynx within normal limits
Chest: No respiratory distress., Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
Extr/Back: = DPs and PTs. R ankle with obvious deformity,
able to range toes
Skin: No rash, Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
___: No petechiae
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: 98.1 138/74 68 18 98RA
Gen: Well-appearing, NAD
HEENT: abrasions on face, right facial laceration s/p suturing
Neck: ___ J collar in place
CV: RRR
Resp: CTA b/l, no respiratory distress
Abd: soft, NTND, no rebound or guarding
Ext: right lower extremity with bulky ___ dressing
Pertinent Results:
Admission Labs:
================
___ 10:55AM BLOOD WBC-25.8* RBC-4.60 Hgb-13.9 Hct-42.7
MCV-93 MCH-30.2 MCHC-32.6 RDW-13.4 RDWSD-45.7 Plt ___
___ 10:55AM BLOOD ___ PTT-28.4 ___
___ 10:55AM BLOOD UreaN-12 Creat-0.8
___ 10:55AM BLOOD Lipase-25
___ 10:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:22PM BLOOD Glucose-139* Lactate-2.6* Na-138 K-3.3
Cl-106 calHCO3-21
Discharge Labs:
===============
___ 06:35AM BLOOD WBC-12.7* RBC-4.07* Hgb-12.5* Hct-37.4*
MCV-92 MCH-30.7 MCHC-33.4 RDW-13.2 RDWSD-44.7 Plt ___
___ 06:35AM BLOOD Glucose-98 UreaN-11 Creat-0.7 Na-138
K-3.9 Cl-103 HCO3-22 AnGap-17
___ 06:35AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.0
Imaging:
=========
___ Imaging MR HEAD W/O CONTRAST
1. No evidence of infarction or intracranial hemorrhage.
2. Prominent flow void corresponding to the enlarged right
parietal vascular structure seen on the recent CTA, possibly
representing vascular malformation with associated mild
surrounding edema.
3. There are additional nonspecific periventricular and
subcortical FLAIR
hyperintensities, which may be a sequela of chronic small vessel
ischemic
disease.
___ Imaging CT LOW EXT W/O C RIGHT
1. Comminuted laterally displaced and mildly distracted fracture
of the
calcaneus with intra-articular extension to the anterior and
middle facet of the subtalar joints as well as the
calcaneocuboid articulation and
sustentaculum tali. Additional fractures involving the anterior
calcaneal
process. Small osseous fracture fragments are noted along the
calcaneocuboid articulation.
2. Comminuted distal fibular tip fracture with small osseous
fracture fragments along the talofibular joint.
___ Imaging DX KNEE & TIB/FIB
No previous images. There is soft tissue swelling about the
lateral malleolus with an unusual appearance of the distal
fibula laterally. Additional dedicated ankle views are
recommended to determine whether this represents an acute or old
fracture.
Otherwise, no evidence of acute fracture or dislocation. Views
of the knee show minimal hypertrophic spurring medially without
definite joint effusion.
___ Imaging ANKLE (AP, MORTISE & LA
1. Likely acute, oblique fracture of the lateral aspect of the
distal fibula.
2. Navicular fracture better described on dedicated foot
radiograph from same day. Please refer to foot radiograph
report for further details.
3. Soft tissue swelling.
___ Imaging FOOT AP,LAT & OBL RIGHT
1. Acute, comminuted calcaneal fracture with intra-articular
extension
involving the cuboid calcaneal articulation.
2. Surrounding soft tissue swelling.
3. Possible distal fibular fracture is better described on ankle
radiograph from same day, please refer to report for further
details.
___ Imaging CTA HEAD AND CTA NECK
1. No evidence of infarction, intracranial hemorrhage, vascular
dissection, occlusion, stenosis, or aneurysm greater than 3 mm.
2. Enlarged draining cortical vein in the posterior right
frontal lobe
consistent with a DVA. Associated enlargement of the right MCA
suggests an associated arteriovenous malformation. Angiography
is recommended for
confirmation.
3. Mostly well corticated ossific density adjacent to the left
C6 uncinate
process may represent a fragmented osteophyte or remote prior
fracture. This contacts the left vertebral artery without
evidence of associated acute vascular injury.
4. Unchanged appearance of the inferior endplate avulsion
fracture of C4 with associated prevertebral edema.
5. 4 mm right upper lobe pulmonary nodule. Comparison with
prior studies, if available, is recommended. If the patient has
risk factors for primary lung malignancy, including a history of
smoking, ___ year followup chest CT is recommended.
___ Imaging MR CERVICAL SPINE W/O C
1. Moderately motion degraded study.
2. Prevertebral fluid without definite disruption of the
anterior longitudinal ligament.
3. However, findings worrisome for anterior longitudinal
ligament injury.
4. Increased signal on the water ideal images involving the
interspinous an interlaminar ligaments at C5-6, also suggesting
ligamentous injury.
5. Minimal retrolisthesis of C5 on C6 with associated
interspinous ligament edema at this level.
6. Multilevel degenerative changes as described above, worst at
C5-C6 where there is severe bilateral neural foraminal stenosis
and C6-C7 where a posterior osteophyte compresses the spinal
cord without associated signal abnormality.
___ Imaging ANKLE (AP, MORTISE & LA
There is an acute fracture of the postero- lateral tip of the
distal right
fibula with mild lateral displacement and minimal proximal
retraction. There is associated mild soft tissue swelling
around the ankle. No other fracture is identified. There are
no significant degenerative changes. The mortise is congruent on
this non stress view. The tibial talar joint space is preserved
and no talar dome osteochondral lesion is identified. No
suspicious lytic or sclerotic lesion is identified. No soft
tissue calcification or radiopaque foreign body is identified.
___ Imaging CHEST (PORTABLE AP)
No acute intrathoracic process
___-SPINE W/O CONTRAST
Hyperextension fracture of the anterior inferior endplate of C4
vertebral body with associated prevertebral soft tissue
swelling. No alignment abnormality.
___ Imaging CT HEAD W/O CONTRAST
Small right periorbital preseptal hematoma and soft tissue
swelling is noted. No acute intracranial hemorrhage. No
fracture.
Brief Hospital Course:
The patient presented to the Emergency Department on ___ via
EMS after being an unrestrained driver in a ___. Upon arrival to
ED, patient underwent primary and secondary surveys, which found
an ankle fracture and cervical spine tenderness. Given
findings, the patient was scanned and found to have right distal
tibula fracture, calcaneus fracture, and C4 fracture.
Neurosurgery was consulted for the C4 fracture and recommended
___ collar for 4 weeks with follow up in clinic. Orthopedics
was consulted for the distal tibula and calcaneus fractures,
placed patient in bulky ___ dressing with air cast boot, and
recommended close follow up in clinic for potential surgical
repair of calcaneus fracture.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with PO oxycodone
and then changed to PO tramadol upon patient's request. Patient
initially complained of dizziness and nausea, his head imaging
was notable for chronic/stable DVA with possible AVM.
Non-emergent angiography was recommended for further evaluation
and patient instructed to follow up with PCP. Patient's
dizziness and nausea resolved on its own and at time of
discharge patient was no longer symptomatic.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. On imaging patient was
found to have 1cm lung nodule. Given smoking history, patient
was counseled on smoking cessation and instructed to follow up
with PCP for repeat imaging in ___ year.
GI/GU/FEN: The patient was on a regular diet. He experienced
intermittent nausea, which self-resolved (see above). His
regular diet was well tolerated. Patient's intake and output
were closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth q6h prn Disp #*90 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
Continue to take this medication to avoid constipation while on
pain medications
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour 1 patch daily Disp #*28 Patch
Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
Continue to take this medication to avoid constipation while on
pain medications
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
daily Refills:*0
5. TraMADol ___ mg PO Q4H:PRN Pain - Moderate
RX *tramadol 50 mg ___ tablet(s) by mouth q4h PRN Disp #*20
Tablet Refills:*0
6.Crutches
Dx: right fibula and calcaneus fractures
Px: good
___: 13 months
ICD 10 Code: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Right distal fibula fracture
Right calcaneus fracture
C4 fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(crutches).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you. You were recently admitted
to the ___ after a car
accident. You were found to have a fracture in your neck and 2
fractures in your right ankle.
For the neck fracture, you are to wear the neck collar until you
follow up with the spine surgeons in clinic in 4 weeks.
For the right ankle fractures, you were placed in a dressing and
given an air cast boot. Please do not put any pressure on the
foot and keep it elevated as much as possible. Please follow up
with the orthopedic surgeons in clinic on ___.
You also had dizziness and nausea. You had a scan of your head
that did not show any acute causes for your symptoms. You were
evaluated by the physical therapists without any problems and
were cleared to return home with the use of crutches.
On your head scans, you were found to have a vascular
abnormality. It was stable and looked like it had been there for
a long time. Please follow up with your primary care doctor for
further management.
On the scans of your chest, you were found to have a small lung
nodule. Given your history of smoking, you should follow up with
your primary care doctor for ___ repeat scan of your chest in ___
year.
Please follow the below instructions to complete your recovery
at home:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, keep your right foot elevated as much
as possible, do not put pressure on your right foot, and drink
adequate amounts of fluids.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10406570-DS-22 | 10,406,570 | 28,294,847 | DS | 22 | 2184-01-17 00:00:00 | 2184-01-19 20:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / simvastatin
Attending: ___.
Chief Complaint:
yspnea, rapid heart rate
Major Surgical or Invasive Procedure:
___: 200j synchronized cardioversion for afib w/
RVR(hemodynamically stable)
History of Present Illness:
___ female, DM on metformin, HTN, PAF on metoprolol and
warfarin, PEA ___ who presented to the ED in mild respiratory
distress and progressive DoE over last week. Pt notes having ___
minutes of palpitations 2x per week over the last 8 months.
Patient reports she felt herself go into afib ~1 week ago.
Denies palpitations today but notes a little tightness in chest.
She reports cough with productive white phlegm for past month
and denies orthopnea. No fever/chills. Some chest tightness
today associated with sob. No pleuritic pain. No orthopnea. No
increase in baseline leg edema. History of rapid afib req
cardioversion in past. Did not take her AM metoprolol today.
In the ED, initial vitals were 98.2 46 151/85 22 97%. Exam was
significant for visible SOB in mild respiratory distress with
some chest tightness and pedal edema. Labs were significant for
a BUN/Cr of ___ and an otherwise unremarkable BMP, BNP of
2729 (no baseline), CBC showing H&H of 11.3/35.2 (b/l 38-39)
with some evidence of hemolysis on RBC morphology, 182k
platelets, nl WBC, INR of 4.0. TnT 0.01 (no baseline), UA
unremarkable. TSH 2.9. CXR was done showing pulmonary edema. EKG
showed Rapid Afib without ischemic changes. No cultures are
pending. Patient was given 5mg IV metoprolol x2, given 25mg
metoprolol tartrate x1, Pt was cardioverted in the ED (Patient
sedated with 80mg Propofol and fentanyl, cardioverted to sinus
with 200j sync cardioversion). She also received Lasix 20mg IV x
1. Patent was admitted for CHF exacerbation in the setting of
AFib. VS prior to transfer were 57 138/88 16 99% RA.
On arrival to the floor, patient is breathing comfortably in NAD
and conversing easily.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, hemoptysis, black stools or red
stools. She denies recent fevers, chills or rigors. She denies
exertional buttock or calf pain. All of the other review of
systems were negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema outside of
baseline, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- Negative chemical stress test in ___
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
CHF (EF in ___ 51%)
PAF on warfarin
DMII
GERD
s/p hysterectomy
L breast cyst removed
osteoarthritis
Vit D deficiency
Distant hx of PE after hysterectomy
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Mom died of colon ca in her ___, Dad had prostate ___ and died of
MI in ___. 5 siblings, all ok except oldest sister with ___.
Physical Exam:
PE on admission
VS: 98.2 127-145/79-107 ___ 20 95-100% on RA
GENERAL: NAD, awake and alert, conversing
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender and supple, no LAD, no JVP
BACK: no spinal process tenderness, no CVA tenderness
CARDIAC: RRR, no M/R/G, nl s1 and s2
LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding, no HSM
EXT: warm and well-perfused, no cyanosis, clubbing, trace edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII Grossly intact, strength ___ throughout,
sensation grossly normal
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
PE on discharge
VS: 98.8 124-151/68-101 ___ 16 95-100% on RA
GENERAL: NAD, awake and alert, conversing
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender and supple, no LAD, no JVP
BACK: no spinal process tenderness, no CVA tenderness
CARDIAC: RRR, no M/R/G, nl s1 and s2
LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding, no HSM
EXT: warm and well-perfused, no cyanosis, clubbing, trace edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII Grossly intact, strength ___ throughout,
sensation grossly normal
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Labs on Admission
___ 10:50AM BLOOD WBC-4.8 RBC-3.81* Hgb-11.3* Hct-35.2*
MCV-92 MCH-29.7 MCHC-32.1 RDW-14.3 Plt ___
___ 10:50AM BLOOD Neuts-60 Bands-0 ___ Monos-11 Eos-1
Baso-0 ___ Myelos-0
___ 10:50AM BLOOD ___ PTT-41.2* ___
___ 10:50AM BLOOD Plt Smr-NORMAL Plt ___
___ 10:50AM BLOOD Glucose-102* UreaN-16 Creat-1.0 Na-143
K-4.0 Cl-109* HCO3-22 AnGap-16
___ 07:00PM BLOOD CK(CPK)-153
___ 10:50AM BLOOD proBNP-2729*
___ 10:50AM BLOOD cTropnT-<0.01
___ 07:00PM BLOOD CK-MB-3 cTropnT-<0.01
___ 10:50AM BLOOD Mg-1.4*
___ 10:50AM BLOOD TSH-2.9
Labs on discharge
___ 06:25AM BLOOD WBC-4.1 RBC-3.41* Hgb-10.3* Hct-31.7*
MCV-93 MCH-30.2 MCHC-32.5 RDW-14.4 Plt ___
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD ___ PTT-37.8* ___
___ 06:25AM BLOOD Glucose-105* UreaN-18 Creat-1.0 Na-144
K-3.8 Cl-106 HCO3-24 AnGap-18
___ 06:25AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.0
EKG ___
The rhythm appears to be atrial fibrillation with rapid
ventricular response
of about 150. The rapid rate and the low voltage in the limb and
the
precordial leads make interpretation difficult in addition to
the baseline
artifact. However, no major abnormalities are noted except for
poor R wave
progression across the precordium and non-specific ST-T wave
changes. Compared
to the previous tracing the atrial fibrillation is new. Clinical
correlation
is highly suggested.
EKG ___
The rhythm has reverted back to sinus rhythm with marked left
atrial
abnormality and no significant change compared to the previous
tracing in ___
except for a slightly longer Q-T interval.
EKG ___
No significant change compared to tracing #2
CXR ___
Single frontal view of the chest shows increased air space
opacity at the
right lung base compatible with lobar pneumonia. The heart size
is mildly
enlarged, possibly due to technique. Mediastinal and hilar
contours are
grossly normal. No pleural effusion or pneumothorax.
IMPRESSION: Right lower lobe pneumonia.
Brief Hospital Course:
___ year old female with history of paroxysmal afib on metoprolol
and coumadin, HTN, DM, here with 1 week of worsening dyspnea and
palpitations found to have afib w/ RVR s/p cardioversion with
mild CHF euvolemic on d/c s/p gentle diuresis.
# Afib w/ RVR - S/p cardioversion in the ED. In house metoprolol
tartrate was continued, convert to tartrate 12.5mg BID while in
house. Pt was loaded on Amiodarone per EP with 400mg IV, then
will get 400mg BID ___ and ___, 400mg QD from ___,
then 200mg QD thereafter. Because pt's INR was 4.0 on admission,
warfarin was held x2 days and pt was d/c'd on ___ dose of
warfarin ___ amiodarone interaction.
# acute diastolic CHF - Nuclear stress ___ shows EF of 51%.
Prior echo was in ___ which showed no diastolic dysfxn and nl
EF. Patient was noted to clinically have acute CHF, BNP 2700, on
admission and was given Lasix 20mg IV x 2. JVD elevated and pulm
edema on CXR (not thought to be PNA despite official report as
pt was afebrile, had no cough or other symptoms of PNA). Pt was
d/c'd euvolemic on exam, with ambulatory O2 sats of 95-96%
HTN - metoprolol, valsartan were continued in house
Gerd - pantoprazole BID was continued in house
DMII - Last A1c in ___ was 6.1%. Held oral meds, put on
ISS while in house.
Vitamin D deficiency - cholecalciferol continued
# Transitional Issues
- consider outpatient echo given last echo was in ___
- consider outpatient sleep study, given suspicion for OSA
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO DAILY
2. Fluocinolone Acetonide 0.01% Cream 1 Appl TP BID:PRN affected
area
3. MetFORMIN (Glucophage) 850 mg PO BID
4. Metoprolol Succinate XL 25 mg PO DAILY
5. NIFEdipine CR 90 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID PRN
affected area
8. Valsartan 240 mg PO DAILY
9. Warfarin 2.5 mg PO 2X/WEEK (___)
10. Warfarin 5 mg PO 5X/WEEK (MO,WE,TH,FR,SA)
11. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. Fluocinolone Acetonide 0.01% Cream 1 Appl TP BID:PRN affected
area
3. NIFEdipine CR 90 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID PRN
affected area
6. Valsartan 240 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. MetFORMIN (Glucophage) 850 mg PO BID
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Warfarin 1 mg PO 2X/WEEK (___)
Start taking your coumadin again on ___.
RX *warfarin [Coumadin] 1 mg 1 tablet(s) by mouth twice per week
on ___ and ___ Disp #*30 Tablet Refills:*0
11. Warfarin 2.5 mg PO 5X/WEEK (MO,WE,TH,FR,SA)
Start taking your coumadin again on ___.
RX *warfarin [Coumadin] 2.5 mg 1 tablet(s) by mouth 5 times per
week on ___, ___, ___ and ___ Disp #*30 Tablet Refills:*0
12. Amiodarone 400 mg PO DAILY
Take once daily starting ___.
RX *amiodarone 400 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
13. Amiodarone 400 mg PO BID Duration: 5 Doses
Please take twice a day ___ and ___.
RX *amiodarone 400 mg 1 tablet(s) by mouth twice a day Disp #*5
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- atrial fibrillation
- acute exacerbation of systolic heart failure
Secondary Diagnosis
- diabetes
- ___ edema
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 in the hospital. You came
in because you were short of breath and were having
palpitations. We discovered that you were in Atrial Fibrillation
and required cardioversion in order to get your heart beating
normally again. The cardioversion procedure went well and your
heart was beating normally again; however, you had excess fluid
related to heart failure that was causing you to be so short of
breath. This probably happened because if the fast heart rate
you had. We gave you medicine that makes you pee out that extra
fluid and your breathing recovered. We also started you on a
medication that will help keep you from having palpitations
again called Amiodarone. You will need to continue taking this
medication as directed and keep your appointments with your
___ clinic. As we discussed, ___ usually causes
people to need much less coumadin than usual, so following your
INR will be very important while you take these two medications.
You will need to call your cardiologist Dr. ___ office
to make an appointment at this number: ___. Tell them
that you were just discharged from the hospital and need a
follow-up appointment with him within two weeks.
I also recommend that you continue the discussion about being
DNR/DNI with your primary care provider as well as letting your
family and Health Care Proxy know about your wishes.
Followup Instructions:
___
|
10406570-DS-23 | 10,406,570 | 22,991,369 | DS | 23 | 2184-10-13 00:00:00 | 2184-10-13 19:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / simvastatin
Attending: ___.
Chief Complaint:
Progressive Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of ___, Afib s/p DCCV in ___, HTN, DM2 who
presents with progressive dyspnea and orthopnea. She reports for
the past 3 weeks she has had these symptoms but have
progressively been worse over the past few days. She did
recently return from a trip to ___ the ___ prior to
admission (___) and had various foods with high sodium
potential including fried fish, baked potatoes with butter, and
gravy. Although her symptoms started before her trip, she
reports worsening in the days since she returned. Specifically,
she noticed increased edema of the lower extremities, inability
to lay flat on her back, and waking up at night with a
"rattling" in her chest. She was unable to walk short distances
without getting extremely short of breath. Since returning from
her trip, she has gained about ___ lbs.
On 4L NC
In the ED, initial vitals were 59 170/100 34 96% 15L
Non-Rebreather. Patient was started on nitro drip, given 20mg IV
lasix. CXR showed pulmonary edema. Vitals prior to transfer
were: 47 169/76 22 95% Nasal Cannula.
On arrival to the floor, she is stable, in NAD, but is reporting
a headache similar to the one she had when the EMS used nitro
spray prior to her transfer.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- Negative chemical stress test in ___
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
CHF (EF in ___ 51%)
PAF on warfarin
DMII
GERD
s/p hysterectomy
L breast cyst removed
osteoarthritis
Vit D deficiency
Distant hx of PE after hysterectomy
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Mom died of colon ca in her ___, Dad had prostate ___ and died of
MI in ___. 5 siblings, all ok except oldest sister with ___.
Physical Exam:
Admissions Physical:
VS: 98 180s/80s-90s ___ 20 95%RA
General: NAD, comfortable, pleasant woman appearing younger than
stated age
HEENT: NCAT, nonicteric sclera
Neck: supple, JVP elevated to 10 cm
CV: regular rhythm, no m/r/g
Lungs: Good air movement. Crackles at the bases, no wheezes,
rhonchi, rales
Abdomen: soft, NT/ND, BS+
Ext: WWP,3+ pitting edema in lower extremities extending up to
the knee
Neuro: moving all extremities grossly
Discharge Physical:
VS: 98.1 139-162/60s-70s ___ 20 100%RA
General: NAD, comfortable, pleasant woman appearing younger than
stated age
HEENT: NCAT, nonicteric sclera
Neck: supple, JVP elevated to 9 cm
CV: regular rhythm, no m/r/g
Lungs: Good air movement. No crackles at the bases, no wheezes,
rhonchi, rales
Abdomen: soft, NT/ND, BS+
Ext: WWP, No edema in lower extremities
Pertinent Results:
Admissions Labs:
___ 09:40AM BLOOD WBC-5.6 RBC-3.71* Hgb-11.1* Hct-34.4*
MCV-93 MCH-29.8 MCHC-32.2 RDW-14.2 Plt ___
___ 09:40AM BLOOD Plt ___
___ 10:16AM BLOOD ___
___ 09:40AM BLOOD Glucose-107* UreaN-22* Creat-1.2* Na-143
K-4.6 Cl-108 HCO3-22 AnGap-18
___ 09:40AM BLOOD CK(CPK)-243*
___ 08:20AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.7
___ 09:40AM BLOOD CK-MB-4 proBNP-1035*
___ 09:40AM BLOOD cTropnT-<0.01
___ 06:12AM BLOOD CK-MB-1 cTropnT-<0.01
Discharge Labs:
___ 06:12AM BLOOD WBC-4.0 RBC-3.84* Hgb-11.3* Hct-34.4*
MCV-90 MCH-29.5 MCHC-32.9 RDW-14.0 Plt ___
___ 06:12AM BLOOD ___ PTT-33.0 ___
___ 06:12AM BLOOD Glucose-82 UreaN-26* Creat-1.3* Na-141
K-3.9 Cl-105 HCO3-27 AnGap-13
___ 06:12AM BLOOD ALT-34 AST-38 LD(LDH)-272* AlkPhos-72
TotBili-0.3
___ 06:12AM BLOOD Calcium-8.9 Phos-4.5 Mg-1.9
___ 11:15AM BLOOD PEP-NO SPECIFI ___ FreeLam-20.1
Fr K/L-0.90
Cardiac MRI
IMPRESSION:
Mildly enlarged left atrium. Moderately enlarged right atrium.
Mildly
increased left ventricular cavity size (normal when indexed for
size) with
normal wall thickness and overall mass. Normal regional/global
left
ventricular systolic function. No evidence of gadolinium
enhancement,
consistent with the absence of fibrosis or scar. Appropriate
nulling of the
myocardium. Normal right ventricular cavity size and systolic
function. Normal
ascending and descending aorta diameters. Moderately enlarged
main pulmonary
artery size . Trileaflet aortic valve with no evidence of
stenosis. Visual
mitral regurgitation. Trace pericardial effusion.
CONCLUSION: Preserved biventricular regional/global systolic
function with
normal wall thickness. No evidence of gadolinium enahncement.
Moderately
enlarged main pulmonary artery size. Visual mitral
regurgitation. No evidence
of cardiac amyloid.
Brief Hospital Course:
Ms. ___ is a ___ with history of dCHF, Afib s/p DCCV in
___, HTN, DM2 who presents with progressive dyspnea and
orthopnea likely due to an acute exacerbation of her chronic
dCHF.
#Acute dCHF exacerbation: Ms. ___ presented with increased
lower extremity edema, progressive shortness of breath, and
sensation of "rattling" in her chest that would wake her at
night about 3 hours after falling asleep. Chest X ray showed
pulmonary edema. She reported a recent trip where she ate foods
that perhaps contained more salt than she would normally
consume. Her symptoms had predated this trip but were
significantly worse after returning. While in the hospital, she
was diuresed with IV lasix 20 mg. Her lower extremity edema
improved significantly and the crackles that had been present on
pulmonary exam also resolved. She was discharged on 20 mg of
furosemide. Since she does not have a history of CAD and the
cause of her dCHF has not yet been described, there was thought
that amyloid could be contributing to her presentation. She had
a cardiac MR that was not suggestive of amyloid. SPEP and UPEP
were also negative. She had a normal kappa/lambda ratio. On the
last day of admission, the patient reported some chest pressure
that she had not previously experienced. This was not exertional
and self resolved. An additional episode was brought to the care
team's attention. EKG at the time was unchanged from normal and
trops/CK-MB were normal. It was thought to be related to her
GERD.
#HTN: The patient presented to the ED and was hypertensive with
systolics in the 180s. Her pressures improved some what after
receiving her home medication which she had not gotten in the
emergency department however throughout her hospital stay, her
blood pressure was less than ideally controlled. She was started
on losartan 25 with better control. This was uptitrated to
losartan 50 mg on discharge. She was bradycardic to the high ___
while admitted which did limit ability to be aggressive with
pharmacologic agents for bp control.
#afib: The patient was in sinus while admitted. She was kept on
her home warfarin dose of 2.5 daily and maintained a therapeutic
INR.
# DM2: maintained on ISS.
# GERD: Stable. Home PPI was continued.
Transitional Issues:
-Ms. ___ need a follow up Chem 7 to ensure stable
creatinine 1 week after discharge given that she was started on
losartan.
- Ms. ___ need a follow up with Dr. ___ on
discharge.
- Pt has follow up scheduled with PCP. Please monitor for
adequate blood pressure control.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Fluocinolone Acetonide 0.01% Solution 1 Appl TP DAILY:PRN
irritation
5. Furosemide 20 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID:PRN
irritation
9. Warfarin 2.5-5.0 mg PO ASDIR
10. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
3. Atorvastatin 40 mg PO QPM
4. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Vitamin D 1000 UNIT PO DAILY
8. Warfarin 2.5-5.0 mg PO ASDIR
9. Losartan Potassium 50 mg PO DAILY
RX *losartan 50 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
10. Fluocinolone Acetonide 0.01% Solution 1 Appl TP DAILY:PRN
irritation
11. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID:PRN
irritation
12. Outpatient Lab Work
Please draw a Chem 7 (Na, K, Cl, Bicarb, BUN, Cr, Glucose) and
INR
ICD-9: ___
Please fax results to Dr. ___ at ___ and
___ clinic at ___
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary diagnosis: Acute Diastolic heart failure exacerbation
Secondary diagnoses: Hypertension, hyperlipidemia, diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because of increased shortness
of breath and swelling related to your heart failure. While you
were here, we also noticed that your blood pressures were high
which was probably also related to having extra fluid in your
body. We gave you lasix to help you get rid of the fluid and
added another blood pressure medication. We also performed a
cardiac MRI to see whether your heart had protein deposition
called amyloid that could decrease its function however the test
showed that your heart function was normal.
You are now ready to be discharged. Please follow up with your
providers (listed below) and continue to take your medications
as prescribed. Weigh yourself as soon as you get home from the
hospital and then again every morning and call your doctor if
weight goes up more than 3 lbs.
Followup Instructions:
___
|
10406825-DS-19 | 10,406,825 | 21,543,423 | DS | 19 | 2172-02-10 00:00:00 | 2172-02-10 14:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics) / amoxicillin / Keflex /
trazodone / nabumetone / Macrolide Antibiotics / nitrofurantoin
Attending: ___.
Chief Complaint:
left subtrochanteric femur fracture
Major Surgical or Invasive Procedure:
left long trochanteric fixation nail
History of Present Illness:
From Admission Note (___):
___ w/ hypothyroidism and HTN, "skin condition", on low dose
chronic prednisone although she is not sure why, generally very
healthy and ambulates with a cane, s/p fall with unclear
circumstances now w/ L subtrochanteric femoral fracture,
transferred from ___ for further evaluation. In terms of her
fall, she recalls she was out in the garden "likely watering my
plants" and then she "passed out and woke up on the ground". At
___ she was c/o L hip pain and was reportedly somewhat altered
from her baseline. CT neck/head negative for acute process.
Pelvis and L full femoral XR revealing L ST fem fx.
Currently, she continues to endorse pain at the left hip. No
back pain, chest pain, shortness of breath, abd pain, naus, vom,
diarrhea, blurry vision, cough, ST, rhinorrhea. No numbness,
weakness, or tingling distally in either leg. Denies dysuria or
frequency. She is unsure why she fell this morning. She is back
to her baseline MS, per family at the bedside.
Past Medical History:
hypothyroidism
HTN
anxiety
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
General: well appearing lady lying in bed with family at
bedside, pleasant and conversant, no acute distress
Vitals:
97.8
88
137/81
16
97% RA
Right upper extremity:
- Skin thin but intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender arm and forearm
- Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Left upper extremity:
- Skin thin with scattered skin tears, however generally intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender arm and forearm
- Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Right lower extremity:
- Skin thin but intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Left lower extremity:
- Skin thin but intact
- LLE shortened and externally rotated without gross deformity
at the hip
- No erythema, edema, induration or ecchymosis
- Tender to palpation around the proximal left hip, otherwise
nontender
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
DISCHARGE PHYSICAL EXAM:
Vitals: AVSS
Gen: AOx3, NAD
CV: RRR
Pulm: CTAB
Left lower extremity:
- Skin thin but intact, incisions clean, dry, and intact
- No erythema, edema, induration
- Mild ecchymosis
- Tender to palpation around the proximal left hip, otherwise
nontender
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 04:45PM GLUCOSE-138* UREA N-42* CREAT-1.4* SODIUM-136
POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-21* ANION GAP-17
___ 04:45PM WBC-15.5* RBC-3.92 HGB-12.8 HCT-39.8 MCV-102*
MCH-32.7* MCHC-32.2 RDW-13.5 RDWSD-50.4*
___ 04:45PM NEUTS-88.3* LYMPHS-2.8* MONOS-8.1 EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-13.69* AbsLymp-0.43* AbsMono-1.25*
AbsEos-0.00* AbsBaso-0.03
___ 04:45PM PLT COUNT-200
___ 04:45PM ___ PTT-22.4* ___
___ 04:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 04:30PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 04:30PM URINE HYALINE-1*
Femur Fluoroscopy XR ___:
IMPRESSION:
Fluoroscopic images from the operating suite show placement of a
fixation
device about fracture of the proximal femur. Further
information can be
gathered from the operative report.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left subtrochanteric fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for placement of a long
trochanteric fixation nail, which the patient tolerated well.
For full details of the procedure please see the separately
dictated operative report. The patient was taken from the OR to
the PACU in stable condition and after satisfactory recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the <left lower extremity, and
will be discharged on Lovenox 40mg every day for 2 weeks for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Spironolactone 25 mg PO DAILY
2. Albuterol Inhaler 1 PUFF IH Q6H
3. Enalapril Maleate 10 mg PO BID
4. Verapamil SR 180 mg PO Q24H
5. PredniSONE 3 mg PO DAILY
6. LORazepam 0.5-1 mg PO BID
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Enoxaparin Sodium 40 mg SC Q24H Duration: 14 Doses
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*14 Syringe
Refills:*0
3. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
4. Albuterol Inhaler 1 PUFF IH Q6H
5. Enalapril Maleate 10 mg PO BID
6. LORazepam 0.5-1 mg PO BID
7. PredniSONE 3 mg PO DAILY
8. Spironolactone 25 mg PO DAILY
9. Verapamil SR 180 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left subtrochanteric 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:
- Weight bearing as tolerated in the left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
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
Physical Therapy:
Weight bearing and range of motion as tolerated in the left
lower extremity
Treatments Frequency:
Staples will be removed 2 weeks after the surgery in clinic.
Please keep incisions clean and dry. If there is any soak
through, a clean gauze dressing may be applied and changed as
necessary.
Followup Instructions:
___
|
10407143-DS-14 | 10,407,143 | 21,296,439 | DS | 14 | 2161-02-14 00:00:00 | 2161-02-14 13:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
heparin
Attending: ___.
Chief Complaint:
Bleeding from puncture site in Lt groin
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with hx of afib on Coumadin, diabetes, CHF,
complete heart block with pacemaker, heparin allergy (?HIT), and
PVD s/p bilateral common iliac stents who recently presented
with
worsening symptoms of buttock and thigh claudication. He was
hospitalized from ___ where he underwent a diagnostic RLE
angiogram via a ___ sheath, showing severe right SFA stenosis
and diseased ___ runoff to the foot. We had recommended a lower
extremity bypass procedure to help alleviate his symptoms
however
the patient deferred. He was discharge home yesterday and asked
to restart his home dose Coumadin today. He had been doing well
this morning, ambulating around his yard through the day. He
took
an afternoon nap around 1pm and when he woke up at 4pm, he found
himself covered with blood from the left groin access site. He
was brought to ___ where they placed Gelfoam gauze and a sandbag
over his left groin in attempts to stop his bleeding. He was
then
transferred to ___ for further evaluation.
Past Medical History:
Afib, AVR on warfarin, DM, CHF, complete heart block with
ICD/pacer, HIT/left arm thrombosis, carotid stenosis, PVD,
adenomatous colonic polyps, fall with right maxillary fracture
(___)
PSH:
- CABG/AVR with bioprosthetic valve ___ ___
- Bilateral iliac stents, unverified ___ ___
- Pacemaker
Social History:
___
Family History:
FH:
Father - CAD
Physical ___:
Physical Exam:
Vitals: 98.0 62 147/78 18 100%RA
GEN: AOx3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: irregularly irregular
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm, no active ulcers
Left groin: hemostatic after manual pressure, no palpable
hematoma or pseudoaneruysm, mild surrounding ecchymosis around
puncture site
R: p/d/-/d L: p/d/-/d
Pertinent Results:
___ 07:05AM BLOOD WBC-6.9 RBC-3.16* Hgb-9.8* Hct-29.9*
MCV-95 MCH-31.0 MCHC-32.8 RDW-14.9 RDWSD-51.3* Plt ___
___ 07:05AM BLOOD Glucose-93 UreaN-28* Creat-1.3* Na-138
K-4.2 Cl-103 HCO3-26 AnGap-13
Brief Hospital Course:
Mr. ___ was discharged from our service two days prior to his
current admission. e had a angiograph ___ d/t bilateral R>L
buttock claudication.
the puncture site on his left groin started to bleed he was
transferred from ___ for further evaluation and treatment. On
arrival to the ED, patient was hemodynamically stable and had
slow continued amounts of bleeding from the left groin. 20
minutes of manual pressure was held on the groin with complete
hemostasis. Hct ___. INR 1.6 (the patient was sent home to
cont his Coumadin however have not started it yet at) An US
duplex of his groin r/o pseudo aneurism of the Lt fem artery. Cr
1.4 at admission trended down.
He is being discharged for further f/u in the out patient
setting.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Carvedilol 12.5 mg PO TID
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Lisinopril 2.5 mg PO DAILY
7. Warfarin 2 mg PO 5X/WEEK (___)
8. Warfarin 2.5 mg PO 2X/WEEK (MO,WE)
9. Humalog 4 Units Breakfast
Humalog 4 Units Dinner
NPH 15 Units Breakfast
NPH 6 Units Dinner
Discharge Medications:
1. Humalog 4 Units Breakfast
Humalog 4 Units Dinner
NPH 15 Units Breakfast
NPH 6 Units Dinner
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Carvedilol 12.5 mg PO TID
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Lisinopril 2.5 mg PO DAILY
8. Warfarin 2 mg PO 5X/WEEK (___)
9. Warfarin 2.5 mg PO 2X/WEEK (MO,WE)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bleeding from lt groin angiopuncture site
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 to the hospital in your last
visit after a peripheral angiogram. To do the test, a small
puncture was made in one of your arteries. The puncture site
heals on its own: there are no stitches to remove. You tolerated
the procedure well and were discharged from the hospital. the
day after you were discharged , you were re admitted due to
bleeding from the puncture site. the bleeding stopped
spontaneously with local pressure.
you are now being discharged with the following recommendations:
Puncture Site Care
For one week:
Do not take a tub bath, go swimming or use a Jacuzzi or hot
tub.
Use only mild soap and water to gently clean the area around
the puncture site.
Gently pat the puncture site dry after showering.
Do not use powders, lotions, or ointments in the area of the
puncture site.
You may shower .
You may have a small bruise around the puncture site. This is
normal and will go away one-two weeks.
Activity
For the next ___ hours:
Do not drive.
For the first week:
Do not lift, push , pull or carry anything heavier than 10
pounds
Do not do any exercises or activity that causes you to hold
your breath or bear down with abdominal muscles. Take care not
to put strain on your abdominal muscles when coughing, sneezing,
or moving your bowels.
After one week:
You may go back to all your regular activities, including
sexual activity. We suggest you begin your exercise program at
half of your usual routine for the first few days. You may then
gradually work back to your full routine.
Medications:
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
For Problems or Questions:
Call ___ in an emergency such as:
Sudden, brisk bleeding or swelling at the groin puncture site
that does not stop after applying pressure for ___ minutes
Bleeding that is associated with nausea, weakness, or
fainting.
Call the vascular surgery office (___) right away if
you have any of the following. (Please note that someone is
available 24 hours a day, 7 days a week)
Swelling, re-bleeding, drainage, or discomfort at the puncture
site that is new or increasing since discharge from the
hospital.
Any change in sensation or temperature in your legs
Fever of 101 or greater
Any questions or concerns about recovery from your angiogram
Followup Instructions:
___
|
10407265-DS-19 | 10,407,265 | 26,267,945 | DS | 19 | 2136-06-15 00:00:00 | 2136-06-15 23:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PLASTIC
Allergies:
Keflex
Attending: ___.
Chief Complaint:
weakness, increased bleeding from bilateral lower abdominal JP
drains
Major Surgical or Invasive Procedure:
Evacuation of abdominal hematoma
History of Present Illness:
___ year old male ___ s/p panniculectomy at ___ presenting
with weakness and concern about increased JP drain output. Left
drain output 110, right 70 overnight. Output is dark and bloody
in appearance. Patient has continued to put out a steady amount
of blood into his JP drains as well as oozzing around the site
while in the ED. States gradual worsening of lightheadedness
since operation. Patient describes feeling as though his "legs
went weak" but patient lowered himself to the ground and denies
head trauma or LOC. Patient reports minimal diffuse abdominal
pain worst in left lower quadrant. Reports nausea, no emesis,
diarrhea, blood in stool, chest pain, or shortness of breath.
Patient has not urinated since yesterday and reports feeling as
though he cannot initiate voiding. Patient hypotensive to 98/61
at time of presentation to the ED, pt is afebrile (rectal temp
98.8). Pt is not tachycardic, no hypoxia and no unilateral lower
extremity swelling.
Past Medical History:
prior laparoscopic gastric bypass surgery in ___ ___s a
right hip replacement in ___.
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission PE: 98.4 83 98/61 18 97% (rectal temp 98.8)
Gen: pale, shivering, fluent speech and cooperative
CV: RRR
Pulm: CTAB
Abd: Transverse abd incision clean and intact with bloody
drainage from the lateral aspects around the JP drain sites.
Mildly tender to palpation with no rebound or guarding.
Extrems: +radial pulses, +DP pulses b/l
Neuro: speech fluent, no lateralizing motor or sensory deficits
Pertinent Results:
ADMISSION LABS:
___ 11:50AM GLUCOSE-133* UREA N-23* CREAT-1.0 SODIUM-139
POTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-20* ANION GAP-18
___ 11:50AM CALCIUM-7.8* PHOSPHATE-4.4 MAGNESIUM-1.4*
___ 11:50AM WBC-11.0 RBC-3.59* HGB-10.3* HCT-31.9* MCV-89
MCH-28.6 MCHC-32.2 RDW-13.7
___ 11:50AM PLT COUNT-157
___ 06:45AM LACTATE-4.9*
___ 06:25AM GLUCOSE-199* UREA N-28* CREAT-1.6* SODIUM-133
POTASSIUM-6.6* CHLORIDE-96 TOTAL CO2-24 ANION GAP-20
___ 06:25AM estGFR-Using this
___ 06:25AM WBC-15.2* RBC-4.44* HGB-12.6* HCT-39.7*
MCV-89 MCH-28.5 MCHC-31.8 RDW-13.9
___ 06:25AM NEUTS-87.2* LYMPHS-5.5* MONOS-6.9 EOS-0.2
BASOS-0.2
___ 06:25AM PLT COUNT-203
___ 06:25AM ___ PTT-25.8 ___
Brief Hospital Course:
The patient was re-admitted to the plastic surgery service on
___ and had an evacuation of an abdominal hematoma. The
patient tolerated the procedure well.
.
Neuro: Post-operatively, the patient received IV pain medication
with good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: Pre and post-operatively, the patient was given IV fluids
for volume support and then until tolerating oral intake. His
diet was advanced when appropriate, which was tolerated well. He
was also started on a bowel regimen to encourage bowel movement.
A foley insertion was attempted in the ED s/p patient report
that the last time he voided was "yesterday around 4pm" and that
he was trying to urinate most of the night but was unable.
Foley was unable to be advanced in the ED due to resistance so
it was again attempted in the OR but again there was resistance.
A coude catheter was then successfully inserted with immediate
drainage of 900cc of clear yellow urine. The patient was
commenced on Flomax that he will continue at home x 1 week. The
foley was kept in place upon discharge and patient is to follow
up with Urology on ___ for a voiding trial. Intake and output
were closely monitored.
.
ID: Post-operatively, the patient was continued on clindamycin
PO. The patient's temperature was closely watched for signs of
infection.
.
At the time of discharge on POD#3, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating with assistance, voiding without assistance, and pain
was well controlled. Lower abdominal incision was intact with
developing ___ and suprapubic ecchymosis. Bilateral
lower abdominal JP drains with thin bloody fluid draining.
Abdominal binder in place. Patient has sister and niece at
bedside that will safely escort him home and stay with home
while he recovers. Pt was d/c'ed on 5d of cipro for +UA
Medications on Admission:
1. Atenolol 25 mg PO DAILY
2. Clindamycin 300 mg PO Q6H
3. Gabapentin 1200 mg PO HS
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Nortriptyline 25 mg PO HS
6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Clindamycin 300 mg PO Q6H
3. Gabapentin 1200 mg PO HS
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
6. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule,extended release 24hr(s) by
mouth at bedtime Disp #*7 Capsule Refills:*0
7. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth q12hrs
Disp #*10 Tablet Refills:*0
8. Nortriptyline 150 mg PO QAM
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
1) Post-operative bleeding, abdominal hematoma
2) urinary retention
3) UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Personal Care:
1. Leave your abdominal incision open without a dressing.
2. Clean around the drain site(s), where the tubing exits the
skin, with soap and water.
3. Strip drain tubing, empty bulb(s), and record output(s) ___
times per day.
4. A written record of the daily output from each drain should
be brought to every follow-up appointment. your drains will be
removed as soon as possible when the daily output tapers off to
an acceptable amount.
5. You may shower daily at 48 hours after surgery. No baths
until instructed to do so by Dr. ___.
6. Wear your abdominal binder at all times.
7. You will keep your urinary catheter in place until your
Urology appointment for a 'void trial' on ___.
.
Activity:
1. You may resume your regular diet.
2. DO NOT lift anything heavier than 5 pounds or engage in
strenuous activity until instructed by Dr. ___.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging.
3. Take prescription pain medications for pain not relieved by
tylenol.
4. Take 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. You have been given a prescription for 'Flomax/Tamsulosin'
which should help you to urinate freely once the catheter comes
out. Your script is for one week only. Please ask Urology if
you should continue this medication and if so, request a new
prescription.
.
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. Separation of the incision.
4. Severe nausea and vomiting and lack of bowel movement or gas
for several days.
5. Fever greater than 101.5 oF
6. Severe pain NOT relieved by your medication.
7. Severe diarrhea.
.
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.
.
DRAIN DISCHARGE INSTRUCTIONS
You are being discharged with drains in place. Drain care is a
clean procedure. Wash your hands thoroughly with soap and warm
water before performing drain care. Perform drainage care twice
a day. Try to empty the drain at the same time each day. Pull
the stopper out of the drainage bottle and empty the drainage
fluid into the measuring cup. Record the amount of drainage
fluid on the record sheet. Reestablish drain suction.
Followup Instructions:
___
|
10407275-DS-13 | 10,407,275 | 22,053,460 | DS | 13 | 2159-01-29 00:00:00 | 2159-02-01 12:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Penicillins
Attending: ___.
Chief Complaint:
Pre-syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with history of hypertension,
hyperlipidemia, diabetes mellitus, asthma, abdominal hernia, and
intra-abdominal infections (___) who presented to her
cardiologist's office today with episodes of pre-syncope, and
tachycardia to 140s. She has had episodes which occur when
rising from seated, and feel like 'blood is draining from my
face.' She has not fully lost consciousness. She also reports
intermittent nausea and NBNB vomiting, last emesis one week ago.
She has no appetite today, and appetite has been generally
decreased. Denies abdominal pain, but says her hernia has been
increasing in size, and she was planning to see a surgeon on
___ for this. She has had increased thirst and has been
drinking quite a bit of water. She has not had fever or chills.
Ms ___ was seen by her cardiologist Dr. ___ ___. She
follows with a cardiologist only as of recently, and her major
cardiac problem is a heart murmur which was identified in recent
hospital stay. In clinic, vagal maneuvers did not break the
tachycardia. She is unable to take beta blockers because it
worsens her asthma. TTE in the office today revealed normal LV
function with EF 55-60% per written report.
Patient also reports episodic sweating, DOE, heart pounding,
and increasing dizziness for the past couple of months, as well
as loss of appetite with 65lb intentional weight loss over the
last year, and 100-lb over the last year and a half. She is a
competitive ballroom dancer, and has been affected over the past
year by worsening fatigue. She has tried to lose weight via diet
and dance training, but still feels the weight is "pouring off"
quite rapidly.
Ms. ___ was recently admitted at ___ ___ for
hypertensive urgency. She presented for that admission with
near-syncope and elevated HR similar to this current episode.
During that hospitalization she was noted to have SBPs>200 with
headache, mild ___ with Cr 1.13. Troponin was 0.055, which was
ultimately attributed to demand ischemia in setting of
hypertensive emergency given normal stress echo (though poor
quality study). On discharge, patient was taking 50 mg losartan
and 25 hctz, but was later switched to 100mg losartan daily
(hctz was dc'ed due to hypercalcemia and metabolic alkalosis)
per Nephrology who saw her outpatient on ___. She also takes
Amlodipine 10mg.
In the ED, initial vitals were: T 96.4,HR 128,BP 137/91,RR
16,99%RA. After 2L of IVF, HR improved to 90's.
Labs notable for:
D-Dimer: 278
Trop-T: 0.04; proBNP: 363
133|91|45 / AGap=23
-----------272
5.0|24|1.5\
Ca: 10.9 Mg: 1.9 P: 4.9
WBC: 18.3 Hgb: 12.6 Plt:409
___: 10.2 PTT: 27.4 INR: 0.9
Imaging notable for benign CXR. EKG showed sinus tachycardia
@117 bpm, LAE, LVH, nonspecific T wave abnormalities.
Patient was given 2L NS, 324mg ASA. EP was consulted and
requested medicine admission and workup for sinus tach. Decision
was made to admit for workup of tachycardia on medicine service.
Vitals prior to transfer: 98.2, HR97, 143/69, RR 18, 97% RA
On the floor, pt felt overwhelmed by everything going on, but
had no new complaint.
ROS:
(+) Per HPI. Also has had a headache x2 days,
(-) Denies fever, chills, night sweats. Denies sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath. Denies chest pain or tightness, palpitations.
Deniesdiarrhea, constipation or abdominal pain. No recent change
in bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias.
Past Medical History:
Hypertension
Hyperlipidemia
T2DM - last A1C 6.9% per pt
Migraines
Asthma
s/p umbilical hernia repair ___ c/b intra-abd Staph infection,
requiring mesh removal
s/p TAH ___ for endometriosis c/b intra-abd infection with
"open wound"
Social History:
___
Family History:
Father - CAD s/p CABG, DM, HLD
Brother - HTN
No premature CAD, arrhythmia, cardiomyopathy, or sudden cardiac
death.
Physical Exam:
ADMISSION EXAM:
Vital Signs: 98.9, 88/51, HR 64, RR 20, 99 RA
Manual BP: 120/64
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, ___ systolic
murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
surgical scars present. Abdominal incisional hernia nontender
and reducible, but grossly visible.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing or edema
Neuro: CNII-XII intact, finger to nose normal, ___ strength in
___ ___.
DISCHARGE EXAM:
VS Tm 98.3 Tc 98.1 BP 151-170/69-83 HR 72-114 RR 18 02 99%RA I/O
2900/1600
GENERAL: Well appearing, NAD
HEENT: MMM, EOMI
HEART: rrr, no m/r/g
Lungs: CTAB, breathing comfortably
Abdomen: soft, nontender, nondistended, no HSM appreciated
GU: deferred
Ext: warm and well perfused, pulses, no edema
Neuro: grossly normal
Pertinent Results:
ADMISSION LABS:
___ 04:00PM ___ PTT-27.4 ___
___ 04:00PM WBC-18.3* RBC-4.58 HGB-12.6 HCT-39.3 MCV-86
MCH-27.5 MCHC-32.1 RDW-14.5 RDWSD-45.2
___ 04:00PM TSH-1.5
___ 04:00PM ALBUMIN-4.7 CALCIUM-10.9* PHOSPHATE-4.9*
MAGNESIUM-1.9
___ 04:00PM cTropnT-0.04* proBNP-363*
___ 04:00PM CK(CPK)-70
___ 04:00PM GLUCOSE-272* UREA N-45* CREAT-1.5* SODIUM-133
POTASSIUM-5.0 CHLORIDE-91* TOTAL CO2-24 ANION GAP-23*
___ 06:12PM D-DIMER-278
___ 07:41PM URINE RBC-2 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-0
___ 07:41PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-70 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
PERTINENT LABS:
As noted in admission and discharge labs. Short stay.
DISCHARGE LABS:
___ 08:00AM BLOOD WBC-10.0 RBC-3.82* Hgb-10.5* Hct-33.4*
MCV-87 MCH-27.5 MCHC-31.4* RDW-14.5 RDWSD-46.4* Plt ___
___ 08:00AM BLOOD Glucose-412* UreaN-16 Creat-1.1 Na-132*
K-4.2 Cl-90* HCO3-25 AnGap-21*
___ 08:00AM BLOOD ALT-26 AST-23 AlkPhos-117* TotBili-0.2
___ 08:00AM BLOOD Calcium-9.8 Phos-3.6 Mg-1.7
MICRO:
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
STUDIES:
CT A/P ___
1. No pulmonary emboli to the subsegmental level.
2. Left adrenal 3 cm heterogeneous mass is concerning for
pheochromocytoma
taking into account the patient's symptoms. Recommend further
evaluation with
CT abdomen adrenal mass protocol or MRI.
3. Moderate right paraumbilical hernia with herniated loops of
nonobstructive
small bowel.
4. Simple left renal cyst.
Brief Hospital Course:
ACTIVE PROBLEMS:
#PRE-SYNCOPE
Acutely was likely due to hypovolemia. Hypovolemia was supported
by exam findings, symptoms exacerabated during standing, BUN/Cr
> 20, hypotension, UA with numerous hyaline casts, and response
of BUN/Cr/BP to IV fluids. Chronically, possible
pheochromocytoma may be contributing in light of recent CT
abdomen findings. Infection seemed less likely to be
contributing, as abdominal pain had resolved, patient reportedly
has high baseline WBC (current WBC 10K), and was not febrile or
tender to palpation. However, patient had had symptoms for about
a year now, and hypovolemia chronically would have led to ATN.
ACS unlikely with negative trops, Aortic stenosis unlikely with
negative TTE, PE unlikely with negative D-dimer, hyperthyroidism
unlikely with normal TSH and T4.
- Outpatient work-up of pheo: serum metanephrines (or urine),
renin and aldosterone
- f/u cultures
- Telemetry
#SINUS TACHYCARDIA
Likely due to possible pheochromocytoma and sympathetic response
to hypovolemia, given lack of tachycardia following IV fluids.
- Outpatient work-up as above
___
Admission Cr 1.5 then to 1.1 after IV fluids, stable for 1 day,
still elevated from baseline. Likely pre-renal given response to
IV fluids and numerous hyaline casts in setting of hypotension.
- IV fluids as needed
- Monitor BUN, Cr
- Hold home losartan
- Avoid NSAIDs and nephrotoxins
#LEUKOCYTOSIS
Initial leukocytosis on admission of 18.3 then to 10.0 after IV
fluids, likely hemoconcentrated. Patient reported to have high
WBC at baseline. Concern for recurrent infection of hernia given
history.
- Outpatient follow up of WBC
- CBC w/ diff
#ABDOMINAL PAIN
Resolved
- Monitor in outpatient setting
#HTN:
SBPs vary greatly and are as high as 180.
- Restarted home losartan with stable Cr
- Continued home amlodipine given suspicion for pheo
CHRONIC/STABLE PROBLEMS:
#DM:
Currently on outpatient Metformin and Exenatide, no longer on
Insulin but had previously been on Lantus. Last A1C 6.9% per pt.
- ISS with Humalog
- Held home metformin, exenatide during admission
#HLD
- Continued ASA 81 mg
- Continued simvastatin 40mg PO daily
#Asthma
- Continued home albuterol and fluticasone
- Avoided beta blockers (exacerbate her asthma)
# Chronic pain:
- Continued home tramadol 50 mg PO q6hr:PRN
- Tylenol PRN
- Avoided Fioricet given caffeine content and sinus tachycardia
(pt states she is no longer taking)
- Avoided NSAIDs for pain in setting of renal dysfunction
# FEN: IVF as above, replete electrolytes, low salt diet
# PPX: Subcutaneous heparin, Senna/Colace, analgesics as above
# ACCESS: PIVs
# CODE: Full, confirmed
# CONTACT: Daughter ___ ___
# DISPO: HMED pending further workup
TRANSITIONAL ISSUES:
#?PHEOCHROMOCYTOMA: Recommend sending plasma metanephrines,
serum metanephrines & serum ___. Consider dedicated CT
adrenal protocol
#Early satiety: Unclear etiology. Consider EGD
#HTN: Discharged with losartan/amlodipine with BPs in 150-160s
# CODE: Full, confirmed
# CONTACT: Daughter ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL
subcutaneous BID
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN SOB
9. Simvastatin 40 mg PO QPM
10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL
subcutaneous BID
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Losartan Potassium 100 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN SOB
9. Simvastatin 40 mg PO QPM
10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Sinus Tachycardia, Acute Kidney Injury due to Hypovolemia
Secondary Diagnosis:
Hypertension, Hyperlipidemia, Diabetes Mellitus
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 time at ___.
Why was I in the hospital?
- You were admitted because of symptoms of fast heart rate,
sweating, large weight loss in a short period of time, and
sensitivity to heat
- We were also concerned about your abdominal pain
What did we do while you were here?
- We did many lab tests, which showed that you were dehydrated.
We gave you fluids, which helped
- We did a CT, which showed a small mass on your adrenal glands.
We think this could be the cause of your symptoms
What should I do now?
- Make sure to go to your scheduled appointments, especially
with endocrinology who will be following up on your adrenal
gland mass
- Take all of your medications as prescribed. We haven't changed
any of your medications
We wish you the best of health!
Your ___ Medicine Team
Followup Instructions:
___
|
10407303-DS-14 | 10,407,303 | 29,346,679 | DS | 14 | 2138-12-25 00:00:00 | 2138-12-26 18:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zetia / Crestor / metformin / glipizide
Attending: ___.
Chief Complaint:
Chest pain, dizziness
Major Surgical or Invasive Procedure:
___ EGD
History of Present Illness:
Ms ___ is a ___ y/o woman with PMH significant for HTN, DM,
and arthritis who presents with DOE, orthostatic dizziness, and
substernal chest pain when walking upstairs, found to be
severely
anemic.
She presented to her PCP ___ ___ with dyspnea on exertion,
dizziness and chest pain. She was referred to ___, where her
hemoglobin was found to be 5.5. She also endorses melenic
stools
for 2 weeks. Denies BRBPR or hematochezia. Denies nausea or
vomiting.
She has had unintentional weight loss over many years, slowly
dropping from a
weight of about 250 pounds to 140 pounds. She has not noted any
accelerated weight loss over the past few months. The weight
loss was unintentional. She denies any recent change in the
caliber or frequency of her stools.
When her arthritis acts up she sometimes takes Aleve, although
she notes that she uses it rarely. She reports using ___
over-the-counter strength tabs a week. She denies significant
alcohol use, she denies a history of H. pylori in her or her
family, she denies aspirin or blood thinner use, she denies
liverdisease.
She reports she has never had an endoscopy or colonoscopy. She
denies any history of reflux, dyspepsia, dysphagia, odynophagia.
She states that she did stool cards instead of colonoscopy for
colorectal cancer screening.
ROS: Negative except per HPI.
In the ED
=============
Initial vitals: 99.4 102 134/62 16 100% RA
Exam notable for: Well-appearing woman lying back in bed, RRR,
grade IV/VI systolic murmur appreciated across precordium, JVD
to
mid-neck, no edema, PERRL, EOMI
Labs were significant for
5.5 MCV=91
4.8>-------<254
18.3
MB: 3 Trop-T: <0.01
proBNP: ___ AGap=17
------------< 147
4.5 21 1.0
Ca: 9.6
EKG: NSR, normal axis, ? ST depressions on the lateral lead
(stress pattern), ? LVH.
Imaging showed
CXR: Streaky left lower lobe opacity could reflect atelectasis
though infection is not excluded in the correct clinical
setting.
No pneumothorax.
The patient received:
- Esomeprazole sodium 40 mg IV Q12H
- 2u PRBCs
Past Medical History:
MEDICAL HISTORY:
HYPERTENSION
HYPERLIPIDEMIA
ARTHRITIS
DIABETES MELLITUS
SURGICAL HISTORY:
CARPAL TUNNEL SURGERY ___
CESAREAN SECTION ___
VAGINAL BIRTH ___
Social History:
___
Family History:
Mother ___ ___ HYPERTENSION
Father ___ young LIGHTENING
Sister Living HEALTHY
Brother ___ HEALTHY
Daughter Living HEALTHY
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.3 PO 135 / 70 R Lying 88 16 99 Ra
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, mild conjunctival pallor.
PERRLA, EOMI.
NECK: Supple without LAD
PULM: full air entry bilaterally, no crackle. no wheeze. no
rhonchi
HEART: ___ crescendo/decrescendo murmur best ausculatated at
base
of the heart
ABD: Soft, non-distended, non-tender. No rebound/guarding. BS+
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII intact, strength ___ in b/l ___
DISCHARGE PHYSICAL EXAM:
========================
VS: 98.6 PO 109 / 67 82 18 98 RA
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, mild conjunctival pallor.
PERRLA, EOMI.
NECK: Supple without LAD, midline trachea
PULM: full air entry bilaterally, no crackles. no wheezes. no
rhonchi
HEART: ___ crescendo/decrescendo murmur ULSB, RRR
ABD: Soft, non-distended, non-tender. No rebound/guarding. BS+
EXTREM: Warm, well-perfused, no edema, 2+ DP
NEURO: CN II-XII intact, strength ___ in b/l ___
Pertinent Results:
ADMISSION LABS:
===============
___ 01:20PM BLOOD WBC-4.8 RBC-2.02*# Hgb-5.5*# Hct-18.3*#
MCV-91 MCH-27.2# MCHC-30.1* RDW-14.9 RDWSD-50.0* Plt ___
___ 06:37PM BLOOD Neuts-64.3 ___ Monos-6.7 Eos-1.4
Baso-0.2 Im ___ AbsNeut-2.78 AbsLymp-1.16* AbsMono-0.29
AbsEos-0.06 AbsBaso-0.01
___ 01:20PM BLOOD Glucose-147* UreaN-24* Creat-1.0 Na-147
K-4.5 Cl-109* HCO3-21* AnGap-17
PERTINENT LABS:
===============
___ 06:37PM BLOOD Ret Aut-2.8* Abs Ret-0.05
___ 06:56AM BLOOD TotBili-1.9* DirBili-0.2 IndBili-1.7
___ 06:37PM BLOOD LD(LDH)-326*
___ 01:20PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-229
___ 06:37PM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:37PM BLOOD calTIBC-404 VitB12-300 Hapto-162
Ferritn-10* TRF-311
DISCHARGE LABS:
===============
___ 07:22AM BLOOD WBC-4.8 RBC-3.12* Hgb-9.0* Hct-28.5*
MCV-91 MCH-28.8 MCHC-31.6* RDW-15.2 RDWSD-50.1* Plt ___
___ 07:22AM BLOOD ___ PTT-28.6 ___
___ 07:22AM BLOOD Glucose-85 UreaN-11 Creat-0.8 Na-144
K-4.1 Cl-106 HCO3-20* AnGap-18
___ 07:22AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.0
RELEVANT IMAGING:
=================
CXR ___
Cardiac silhouette size is mild to moderately enlarged. The
mediastinal and hilar contours are unremarkable. Pulmonary
vasculature is not engorged. Streaky opacities in the left
lower lobe may reflect atelectasis, though infection is not
excluded. Right lung is clear. No pleural effusion or
pneumothorax is demonstrated. Mild degenerative changes are
noted involving the imaged thoracic spine. Moderate
degenerative changes are seen involving the right glenohumeral
and acromioclavicular joints.
IMPRESSION:
Streaky left lower lobe opacity could reflect atelectasis though
infection is not excluded in the correct clinical setting. No
pneumothorax.
Brief Hospital Course:
This is a ___ with history of HTN, DM and osteoarthritis,
presenting with chest pain thought to be secondary to severe
anemia (5.3), with two weeks of melena concerning for an upper
GI bleed found to have non bleeding duodenal ulcer which may
represent culprit though colonoscopy deferred until outpt given
stability.
#SEVERE ANEMIA
#MELENA - Bleeding Duodenal Ulcer
Patient presented with dizziness, fatigue, and chest pressure
with exertion found to have Hb 5.3 on admission c/w symptomatic
anemia. Trops negative x2. Hemolysis negative, iron deficient.
Found to have duodenal ulcer on ___ EGD. She is from ___
so probability of h pylori quite high. Colonoscopy was deferred
to outpatient setting given stability of Hb after 3 total units
and no recurrent bleeding. Slow large bowel GIB or AVM is still
on ddx. Transitioned to BID PO PPI prior to discharge. She will
have outpatient GI follow up with Dr. ___. Her H pylori
stool antigen and duodenal biopsies should be followed.
#SUBSTERNAL CHEST PAIN
#HEART MURMUR
Likely flow murmur from anemia. And chest pain from ulcer vs
demand. No e/o ischemia. She should follow up with her PCP for
possible ECHO.
# HTN
Restarted home lisinopril at d/c
# DM
Diet controlled at home. Patient was on glipizide, but it gave
her a rash. Most recent A1c ___ 6.7. ___ benefit from
metformin regardless given relative stability of renal function
and lack of overt cardiac comorbidities.
Transitional issues:
====================
[] Patient should have a CBC checked in ___ days after discharge
[] ___ biopsy results for Hpylori, treat if positive
[] Patient should follow up with Dr. ___ in 1 month ___ )
[] Patient was started on pantoprazole 40 mg BID this should be
continued
[] Patient was noted to have a large systolic ejection murmur
which may be flow related with her anemia, but should be
followed with an ECHO as an outpatient
[] NSAIDS including aleve for her arthritis should no longer be
used
[] ___ benefit from cardioprotective aspects of Metformin.
Consider starting as outpatient.
Code Status: DNR, ok to intubate, discussed with patient
HCP: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. amLODIPine 2.5 mg PO DAILY
3. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pressure
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
2. amLODIPine 2.5 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pressure
5.Outpatient Lab Work
ICD 10: K26.0
Lab: cbc, chem 7 by ___
Fax to: ___, MD
___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
==================
duodenal ulcer
Secondary Diagnosis:
====================
iron deficiency anemia
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 dizzy and
having chest pain.
What did we do while you were here?
- Your blood counts and found them to be low
- We think you were bleeding so we did an endoscopy (EGD)
- There was an ulcer in your small intestine, we took biopsies
to sample the area and make sure you do not have an infection
contributing to the ulcer
- Your blood counts were monitored and found to be stable
- We ensured you could eat before you could leave
What do you need to do when you go home?
- Call your doctor if you become dizzy or experience chest pain
again
- Follow up with Dr. ___ in 1 month ___ )
- You should have your blood checked in 1 week
- Take all of your medications as prescribed. We added
pantoprazole 40 mg twice a day.
- Please do not take any more Aleve or other NSAIDS which can
contribute to your bleeding risk.
- You should have your blood levels checked in the next ___
days.
- We recommend an ultrasound (ECHO) of your heart because of
your murmur.
It was a pleasure taking care of you!
Your ___ Care team
Followup Instructions:
___
|
10407303-DS-15 | 10,407,303 | 29,022,574 | DS | 15 | 2139-05-12 00:00:00 | 2139-05-12 17:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zetia / Crestor / metformin / glipizide
Attending: ___.
Chief Complaint:
chest pain and presyncope
Major Surgical or Invasive Procedure:
___: EGD
___: colonoscopy
___: capsule endoscopy
History of Present Illness:
Mrs. ___ is a ___ woman with PMH of duodenal ulcer
w/ positive H pylori treated in ___, HTN, HLD, DM who
presents with chest pain and presyncope.
Of note, the patient was admitted in ___ with similar
symptoms. She was found to be anemic with Hgb ~5. She underwent
EGD with finding of duodenal ulcer. She was also found to be H
pylori positive and was treated with amoxicillin and
metronidazole for two weeks.
The patient began experiencing chest pain several days ago. She
describes the chest pain as sharp, worse with activity,
improving
with rest, non-pleuritic, non-positional, and non-reproducible
with palpation. She feels that the pain has been occurring
increasingly over the past several weeks. Additionally, the
patient reports that she has been experiencing episodes of near
blacking out, during which she will need to steady herself
before
her vision returns. The patient also endorses black tarry stools
and an 8lb unintentional weight loss over an uncertain time
period. Otherwise, she denies bloody stools, abdominal pain, or
nausea/vomiting.
In the ED, initial vitals were T 98.1F, HR 96, BP 153/79, RR 18,
satting 100% RA. Labs were notable for Hgb 5.2. Otherwise, CBC,
chem-7, and cardiac enzymes were unremarkable. She was admitted
to Medicine service for further management.
On arrival to the floor, the patient's vitals were T 98.3F, HR
___ BP 161/73, RR 20, 99% RA. The patient confirmed the above
history.
Past Medical History:
MEDICAL HISTORY:
HYPERTENSION
HYPERLIPIDEMIA
ARTHRITIS
DIABETES MELLITUS
SURGICAL HISTORY:
CARPAL TUNNEL SURGERY ___
CESAREAN SECTION ___
VAGINAL BIRTH ___
Social History:
___
Family History:
Mother ___ ___ HYPERTENSION
Father ___ young LIGHTENING
Sister Living HEALTHY
Brother ___ HEALTHY
Daughter Living HEALTHY
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: T 98.3F, HR ___ BP 161/73, RR 20, 99% RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: Normocephalic, atraumatic.
CARDIAC: Grade III/VI holosystolic murmur auscultated best in
apex.
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.
SKIN: Warm.
NEUROLOGIC: Patient is alert and responding to questions
appropriately. Patient is able to move all four extremities. No
facial asymmetry noted.
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 24 HR Data (last updated ___ @ 635)
Temp: 98.0 (Tm 98.1), BP: 127/66 (126-168/46-87), HR: 76
(71-90), RR: 20 (___), O2 sat: 99% (97-100), O2 delivery: RA,
Wt: 125.22 lb/56.8 kg
GENERAL: Alert and interactive. In no acute distress.
HEENT: Normocephalic, atraumatic.
CARDIAC: Grade III/VI harsh ejection murmur heard best at ___.
No
change appreciated with Valsalva maneuver.
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.
SKIN: Warm.
NEUROLOGIC: Patient is alert and responding to questions
appropriately. Patient is able to move all four extremities. No
facial asymmetry noted.
Pertinent Results:
ADMISSION LABS
==============
___ 12:00PM BLOOD WBC-4.5 RBC-1.96* Hgb-5.4* Hct-17.2*
MCV-88 MCH-27.6 MCHC-31.4* RDW-15.4 RDWSD-49.2* Plt ___
___ 12:00PM BLOOD Plt ___
___ 11:55PM BLOOD Ret Aut-1.8 Abs Ret-0.05
___ 12:00PM BLOOD Glucose-93 UreaN-20 Creat-0.9 Na-143
K-4.3 Cl-106 HCO3-23 AnGap-14
___ 11:55PM BLOOD CK-MB-2 cTropnT-<0.01
___ 03:55PM BLOOD cTropnT-<0.01
___ 11:55PM BLOOD calTIBC-345 Ferritn-11* TRF-265
DISCHARGE LABS
==============
___ 07:00AM BLOOD WBC-3.5* RBC-2.63* Hgb-7.6* Hct-23.8*
MCV-91 MCH-28.9 MCHC-31.9* RDW-14.9 RDWSD-48.9* Plt ___
___ 07:00AM BLOOD Glucose-86 UreaN-7 Creat-0.8 Na-147 K-3.5
Cl-111* HCO3-22 AnGap-14
RELEVANT MICRO
==============
___ 07:22AM STOOL HELICOBACTER ANTIGEN DETECTION, STOOL-PND
RELEVANT IMAGING
================
EGD (___):
IMPRESSIONS:
- Normal esophagus
- Normal stomach
- Erythema, edema, and heaped up mucosa with a small erosion in
the D1. Finding could be related to GI blood loss but not
definitive.
Colonoscopy (___):
- Normal mucosa in the whole colon and 10 cm into the terminal
ileum
- No fresh blood, old blood or potential source of bleeding was
identified
Brief Hospital Course:
Mrs. ___ is a ___ woman with PMH of duodenal ulcer
w/ positive H pylori treated in ___, HTN, HLD, DM who
presented with chest pain, presyncope, melena, and hemoglobin of
5.2, consistent with GI bleed. EGD and colonoscopy were
unrevealing of obvious bleeding sources. Capsule endoscopy was
performed with results pending. Clinically, patient remained
stable after receiving 2U pRBCs, with no further melena,
resolution of chest pain, and stable vital signs/hemoglobin.
Discharged for outpatient follow-up.
=============
ACUTE ISSUES:
=============
# GI bleed:
# Anemia:
# Presyncope:
Patient had large drop in hemoglobin to 5.2 at presentation,
associated with presyncopal symptoms. Patient endorsed melena,
consistent with likely GI bleed. No hx NSAID use. She received
2U pRBCs starting in the ED and maintained hemoglobin >7 and
hemodynamic stability throughout the rest of her stay with no
further melena. Diagnostically, there was concern for recurrence
of ulcer and H pylori infection (stool antigen pending).
However, EGD ___ AM showed minimal duodenal irritation unlikely
to be cause of acute blood loss. ___ colonoscopy was
unrevealing. Capsule endoscopy performed ___ ___ but unlikely to
be read until ___. Given absence of obvious sources of
bleeding on imaging, most likely due to angiodysplasia. ___
syndrome should be considered given heart murmur and recent echo
with evidence of AS. Given no evidence of active bleeding,
discharged with plan for outpatient GI follow-up.
# Chest pain:
On presentation, patient endorsed exertional chest pain over the
past several days
improving with rest. Normal CK-MB, troponin x3. EKG not
concerning. Possibly related
to demand ischemia I/s/o anemia, although no biochemical
evidence. Chest pain now resolved after transfusion.
# Hypernatremia:
Resolved. Na of 154 ___ AM -> after 1L ___, down to 147 on
___. Likely due to fluid losses from bowel prep beginning on ___
___ with no free water intake due to NPO status.
# Systolic murmur:
Harsh ejection murmur most c/w LVOT obstruction in the setting
of
hyperdynamic cardiac function due to anemia. Echo from ___
shows evidence of intracavitary gradient as well as mild AS.
===============
CHRONIC ISSUES:
===============
# HTN: held home amlodipine and lisinopril given acute bleed and
normotension throughout stay
# DM: ISS, received total of 1 unit of insulin throughout stay
====================
TRANSITIONAL ISSUES:
====================
- HELD amlodipine and lisinopril
- Patient will need follow-up with GI to review diagnostic
results and further management plan
-------------
Communication
-------------
#CODE: DNR/DNI
#CONTACT: ___ (daughter, ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 2.5 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. amLODIPine 2.5 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
================================================
MEDICINE Discharge Worksheet
================================================
Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You presented with symptoms of bloody stool, dizziness, and
chest pain and were admitted to the hospital to evaluate and
treat bleeding in your gastrointestinal tract.
What was done for me while I was in the hospital?
- You were given a blood transfusion. An upper endoscopy, a
colonoscopy, and a capsule endoscopy were performed to locate
the source of the bleeding. The upper endoscopy and colonoscopy
did not show any likely bleeding sources, and the results of the
capsule endoscopy are not back yet. Because your vital signs and
hemoglobin levels were stable, and you did not have any more
bloody stool, it is probable that the bleeding stopped on its
own while you were in the hospital.
What should I do when I leave the hospital?
- Please take your medications and go to your follow-up
appointments as listed below. Make sure to eat and drink well to
prevent dizziness as your body works to replace the rest of the
blood that you lost.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10407582-DS-26 | 10,407,582 | 26,661,560 | DS | 26 | 2179-12-25 00:00:00 | 2179-12-25 17:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / simvastatin
Attending: ___.
Chief Complaint:
anemia, volume overload
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
Mr ___ is a ___ with h/o advanced alcoholic cirrhosis,
complicated by esophageal varices and recurrent hepatic
encephalopathy, diabetes, peptic ulcer disease/portal
gastropathy, who presents with anemia and volume overload.He
endorses a 20lb weight gain (dry weight 150Ibs), dyspnea on
exertion and orthopnea which has worsened in the last 2 weeks.
These symptoms have also been associated with fatigue. Approx. 1
month ago he had admission for hepatic encephalopathy at ___
___ where "his medications were changed." Since then
he has gained weight and developed dyspnea. Approx. 2 weeks ago
he was diagnosed with pneumonia which was treated with
Azihromycin with completed course approx. 1 week ago. Currently
he denies any chest pain, productive cough, fevers, myalgias, ___
pain, rhinorrhea, sore throat, palpitations. He has been
compliant with a low salt diet and sompliant with his home
medications listed below. He has no drank alcohol.
.
He Has hx of chronic anemia and denies any recent abdominal
pain, melena, hematochezia, confusion, dyspepsia, nausea or
vomiting. He passes ___ dark brown stool per day.
.
In the ED, triage vitals were 97.5 °F (36.4 °C), Pulse: 67, RR:
15, BP: 136/79, O2Sat: 99. F. Hct was 20.5, down from 23.4 2
weeks ago and 30, 1 month ago (gradual decline). Given lasix
80mg IV x1. Troponin 0.15, but CK-MB . He recieved 1 unit in
blood in ER
.
Currently, vitals on transfer 161/74 61 98% 16rr 97.8
.
ROS: per HPI, denies fever,night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Alcohol-induced cirrhosis
- no EtOH ___ years
- history 2 cords of grade 1 varices on EGD ___
- EGD ___ - 1 cords of grade I varices were seen in the
lower third of the esophagus; Friability, erythema and petechiae
in the antrum compatible with portal hypertensive gastropathy;
area of antrum with active bleeding likely either from a
Dielofay or just from portal hypertensive gastropathy.
(injection, thermal therapy)
Otherwise normal EGD to second part of the duodenum
Duodenal Ulcer (seen on EGD ___
Renal cell carcinoma s/p CyberKnife therapy ___ and ___
H/o renal failure
T2DM
Hypertension
H/o VRE bacteriuria
Social History:
___
Family History:
Significant for diabetes mellitus in his mother and father.
There is no history of coronary artery disease.
Physical Exam:
PHYSICAL EXAMINATION:
VS: 150/82, 13 96% RA P-95 170Ibs
GENERAL: Well appearing in NAD. Jaundiced
HEENT: Sclera icteric. MMM.
CARDIAC: RRR with no excess sounds appreciated
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: Distended but Soft, non-tender to palpation. Dullness
to percussion over dependent areas but tympanic anteriorly. No
HSM or tenderness appreciated.
EXTREMITIES: 1+ edema b/l. Warm and well perfused, no clubbing
or cyanosis.
NEUROLOGY: asterixis
Pertinent Results:
Pertinent Labs:
___ 11:15AM BLOOD WBC-3.7* RBC-2.16* Hgb-6.7* Hct-20.5*
MCV-95 MCH-31.2 MCHC-32.8 RDW-16.8* Plt ___
___ 02:23PM BLOOD ___ PTT-33.8 ___
___ 11:15AM BLOOD UreaN-52* Creat-2.4* Na-142 K-4.5 Cl-111*
HCO3-21* AnGap-15
___ 01:00PM BLOOD ALT-19 AST-30 AlkPhos-191* TotBili-0.5
___ 01:00PM BLOOD Lipase-51
___ 01:00PM BLOOD CK-MB-6
___ 01:00PM BLOOD cTropnT-0.15*
___ 05:33AM BLOOD CK-MB-5 cTropnT-0.13*
___ 11:15AM BLOOD Albumin-3.0* Calcium-7.9* Phos-3.2
___ 11:15AM BLOOD PTH-118*
___ 01:00PM URINE Hours-RANDOM Creat-79 TotProt-226
Prot/Cr-2.9*
CHEST (PA & LAT)
IMPRESSION: New bilateral pleural effusions, left greater than
right. Left lower lobe opacity may represent atelectasis or, in
the correct clinical setting, pneumonia.
EGD-
Polyps in the stomach
There was evidence of a very mild 'snake-skin' appearance in the
proximal stomach compatible with mild portal gastropathy.
In the antrum, there was significant linear/nodular erythema
compatible with GAVE.
Argon-Plasma Coagulation was applied for treatment of GAVE.
Otherwise normal EGD to ___ portion of duodenum.
RUQ U/S:
IMPRESSION:
1. Antegrade flow in the main and right portal veins. Probable
slow,
intermittent, reversed flow in the left portal vein. Reversal of
flow in the splenic vein.
2. Coarse and nodular liver consistent with cirrhosis with no
suspicious
focal hepatic lesions.
3. Splenomegaly.
4. Gallstones.
Brief Hospital Course:
Mr ___ is a ___ with h/o advanced alcoholic cirrhosis,
complicated by esophageal varices and recurrent hepatic
encephalopathy, diabetes, peptic ulcer disease/portal
gastropathy, who p/w anemia and volume overload.
.
# GI bleed: On admission pt's HCT was 20 significantly lower
than baseline of 30. He did not respond appropriately to 2U
prbcs. His stool was occult positive for blood on admission. He
underwent EGD and found to have GAVE which was treated with
argon plasma coagulation. He will need repeat EGD w/ APC in
___. Post EGD his H/H stabilized and no further bleeding
occurred. He will continue on Pantoprazole 40mg bid until next
EGD.
.
# Volume overload: likely related to underlying cirrhosis and
recent medication adjustments made at OSH. He was 15 lbs above
his dry wt on admission to the hospital. Pt responded well to
80mg IV Lasix with brisk diuresis. After discussion with his out
pt nephrologist in conjunction with the hepatology team we
decided to restart his prior home medications including
Furosemide 40mg BID and HCTZ 12.5mg daily before adjustments
were made a the OSH.
.
# Troponinemia: troponin 0.15 on admission, CK-MB 6. EKG w/o
changes. Repeat troponin trended down and CK-MB remained flat
throughout this hospitalization. This was attributed to CKD and
possible demand ischemia from the significant GI bleed the pt
experienced.
.
# ETOH Cirrhosis: Pt has h/o recurrent hepatic encephalopathy.
Mental status was clear and oriented during this admission. A
RUQ u/s showed possible reversal of flow in L hepatic vein and
complete reversal of flow to splenic vein. He was not
encephalopathic during this admission. We discontinued
propranolol after EDG did not show varices We continued the
following out pt medications:
- continue lactulose 30 mL PO TID
- continue rifaximin 550mg PO BID
.
# CKD: baseline Cr ~2.7. On admission, Cr 2.4. No evidence of
acute renal failure. We restarted Valsartan and diuresis and his
kidney function did not significantly fluctuate.
.
# DM2: continue home glargine 15 units at breakfast, and use
HISS in house
.
# HTN: Continued home amlodipine 5mg daily. We added Valsartan
and HCTZ back to his regimen. His Lasix dose was changed to 40mg
bid and propranolol was discontinued as mentioned above.
# Transitional:
1. Out pt lab work prescription was given to the pt and the
results will be sent to PCP
2. f/u appts w/ PCP, hepatology and nephrology
3. pt instructed to weigh himself daily and call PCP if weight
fluctuates more than 3lbs
4. pt will need repeat EGD for GAVE in ___ weeks w/ Dr. ___
___ on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs(s) orally three times a day as needed for cough please
dispense with spacer and instruct
AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth once a day
BD INSULIN SYRINGES ___, 12.7MM, 30GUAGE -
Entered by MA/Other Staff - - use one syringe a day to inject
insulin once daily
FUROSEMIDE - 80 mg Tablet in AM and 40mg ___
HUMALOG PEN - 300 unit/3 mL Insulin Pen - as directed
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - Inject 15
units daily or as directed
Humalog 100 unit/ml daily use as directed
LACTULOSE - 10 gram/15 mL Solution - 30 mL(s) by mouth three
times a day titrate to ___ BMs daily.
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day
PROPRANOLOL - 10 mg Tablet - 1 Tablet(s) by mouth twice a day
RIFAXIMIN [XIFAXAN] - 550 mg Tablet - 1 Tablet(s) by mouth twice
a day - No Substitution
SUCRALFATE [CARAFATE] - (discharge med) - 1 gram Tablet - 1
Tablet(s) by mouth four times a day
TRAZODONE - 150 mg Tablet - 0.5 (One half) Tablet(s) by mouth at
bedtime
Medications - OTC
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - test up
to 4 times daily as directed
MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth once
daily
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q8H:PRN wheeze
2. HumAPEN Luxura HD *NF* (insulin admin supplies) use as
directed Subcutaneous with meals diabetes
3. Glargine 15 Units Breakfast
4. Lactulose 30 mL PO TID
Titrate to ___ BMs daily. ___ MD if change in mental status.
5. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 Tablet(s) by mouth q12 Disp #*60 Tablet
Refills:*0
6. Rifaximin 550 mg PO BID
7. Sucralfate 1 gm PO QID
8. traZODONE 75 mg PO HS:PRN insomnia
9. Amlodipine 5 mg PO DAILY
hold for SBP<90 and HR<55
10. Furosemide 40 mg PO BID
hold for sbp <95
RX *furosemide 40 mg 1 Tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
11. valsartan-hydrochlorothiazide *NF* 160-12.5 mg Oral daily
RX *Diovan HCT ___ mg-12.5 mg 1 Tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
12. Outpatient Lab Work
Chem-7
Please Fax lab results to Dr. ___ @ ___
Discharge Disposition:
Home
Discharge Diagnosis:
Liver Cirrhosis
Acute upper GI Bleed
chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital for anemia and
significant weight gain. Your anemia was found to be due to a
stomach bleed that we had to coagulate in order to get it to
stop. You will need to have this procedure performed again in
___ weeks post discharge. Your weight gain most likely was due
to the recent medication changes that were made to your daily
regimen. We have once again adjusted your regimen and would like
you to weigh yourself on a daily basis. If your weight increases
by more than 3 lbs please call your doctor. Please have your
blood drawn prior to your primary care appointment and the
results will be faxed to them for review.
The following changes have been made to your medications:
STOP:
Omeprazole
START:
Pantoprazole for you GI bleed
Valsartan/Hydrochlorothiazide a blood pressure medicine you were
taking prior
CHANGE:
Furosemide 40mg twice per day
Followup Instructions:
___
|
10407582-DS-28 | 10,407,582 | 22,572,780 | DS | 28 | 2180-12-15 00:00:00 | 2180-12-24 23:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / simvastatin
Attending: ___
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ gentleman who has stage IV chronic kidney disease,
known renal cell carcinoma, EtOH cirrhosis c/b encephalopathy,
hepatocellular carcinoma status post CyberKnife therapy (last
treatment ___ for both lesions presenting with confusion.
Patient was recently seen at ___ clinic on ___ where
he has reported repeated episodes of nausea and vomiting, a poor
appetite, early satiety and inability to tolerate food with
resultant three kg weight loss; weight at that visit 250 pounds.
At that time dronabinol was started as an appetite stimulant;
patient starting taking med on ___ morning; otherwise no
medication changes.
Since that visit wife and patient note at least ___ episodes of
confusion with last episode at 3am this morning which lasted
~10am and cleared somewhat with extra dose of lactulose.
Decision made to present to the ED for evaluation of underlying
infection leading to confusion as wife and patient note that UTI
had triggered encephalopathy in the past. With the exception of
limited PO intake no other identifiable trigger to confusion. No
recent fevers, sick contacts, travel, melena, BRBPR, or
additional localizing symptoms of infection. Wife states nausea
has been an intermittent problem over preceding months however
no overt vomiting. Has been staying up late in the preceding
weeks to watch the ___ games and questions if this is
throwing off his schedule and contributing to insomnia and
confusion.
In the ED, initial VS: 99.1 74 143/60 16 99%. Exam notable for
alert, oriented mental status; brown stool, guaiac negative. CXR
without opacity. UA negative. FAST negative with no tappable
ascites. Decision made to admit to ET for further evaluation
VS prior to transfer: 97.6 81 136/69 16 100
On arrival to ET, patient without complaint and feels "clear".
He denies any localizing signs/symptoms currently: no fevers,
chills, sweats, abdominal pain. Notes he has intermittent
dysuria and ?presence of UTI. No change in urinary frequency.
Past Medical History:
Alcohol-induced cirrhosis
- no EtOH ___ years
- history 2 cords of grade 1 varices on EGD ___
- EGD ___ - 1 cords of grade I varices were seen in the
lower third of the esophagus; Friability, erythema and petechiae
in the antrum compatible with portal hypertensive gastropathy;
area of antrum with active bleeding likely either from a
Dielofay or just from portal hypertensive gastropathy.
(injection, thermal therapy)
Otherwise normal EGD to second part of the duodenum
Duodenal Ulcer (seen on EGD ___
Renal cell carcinoma s/p CyberKnife therapy ___ and ___
H/o renal failure
T2DM
Hypertension
H/o VRE bacteriuria
Social History:
___
Family History:
Significant for diabetes mellitus in his mother and father.
There is no history of coronary artery disease.
Physical Exam:
Physical Exam on Admission:
Vitals: 98.0 152/80 80 18 100%RA
General: Alert, oriented, pleasant
HEENT: dry MM, no icterus
Neck: supple, no LAD, no thryomegaly
Heart: RRR, ___ SEM heard throughout the precordium but best
appreciated at RUSB
Lungs: Clear throughout; no crackles, no wheeze
Abdomen: soft, nontender, nondistended, no fluid wave, +BS
Extremities: WWP, 2+ pulses
Neurological: intact, CNII-XII intact bilaterally, strength ___
in upper and lower flexors/extensors bilaterally, reflexes ~1+
symmetric; mild flap; able to say the days of the week backwards
Physical Exam on Discharge:
VS: T98.3, BP162/65, HR87, RR20, O2sat100%RA
Neuro: no asterixis, A+Ox3
Exam otherwise unchanged from admission
Pertinent Results:
Lab Results on Admission:
___ 02:30PM BLOOD WBC-2.9* RBC-2.51* Hgb-8.2* Hct-23.1*
MCV-92 MCH-32.7* MCHC-35.6* RDW-13.9 Plt ___
___ 02:30PM BLOOD Neuts-64.8 Lymphs-16.9* Monos-8.3
Eos-9.1* Baso-0.9
___ 05:35AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
___ 02:30PM BLOOD ___ PTT-32.6 ___
___ 02:30PM BLOOD Glucose-297* UreaN-60* Creat-3.3* Na-137
K-3.4 Cl-107 HCO3-15* AnGap-18
___ 02:30PM BLOOD ALT-27 AST-25 LD(LDH)-261* CK(CPK)-146
AlkPhos-184* TotBili-0.6
___ 02:30PM BLOOD Lipase-61*
___ 02:30PM BLOOD CK-MB-4
___ 02:30PM BLOOD Albumin-3.7 Calcium-8.7 Phos-4.0 Mg-2.5
___ 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:36PM BLOOD Lactate-1.6
___ 03:35PM URINE Color-Yellow Appear-Clear Sp ___
___ 03:35PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 03:35PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
___ 03:35PM URINE Eos-NEGATIVE
___ 02:45PM URINE Hours-RANDOM UreaN-344 Creat-72 Na-43
K-23 Cl-34
___ 02:45PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Microbiology:
___ 4:45 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 4:27 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
Studies:
Cardiovascular ReportECGStudy Date of ___ 2:21:34 ___
Sinus rhythm. Within normal limits.
Radiology ReportCHEST (PA & LAT)Study Date of ___ 2:49 ___
IMPRESSION: No acute cardiopulmonary process.
Radiology ReportDUPLEX DOP ABD/PEL LIMITEDStudy Date of
___ 8:18 AM
IMPRESSION:
1. No portal vein thrombus identified. Limited visualization of
the LPV due to technical limitations.
2. Nodular coarsened hepatic architecture. The known hepatic
mass is not
visualized.
3. Splenomegaly.
4. Cholelithiasis.
5. Left renal mass.
Radiology ReportCT HEAD W/O CONTRASTStudy Date of ___
2:25 ___
IMPRESSION:
No evidence of an acute intracranial process or large mass. MRI
would be more sensitive for intracranial metastases, if
clinically warranted.
Lab Results on Discharge:
___ 05:50AM BLOOD WBC-2.8* RBC-2.60* Hgb-8.4* Hct-23.5*
MCV-91 MCH-32.2* MCHC-35.5* RDW-15.0 Plt Ct-89*
___ 05:35AM BLOOD Neuts-62 Bands-0 Lymphs-14* Monos-12*
Eos-12* Baso-0 ___ Myelos-0
___ 05:35AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
___ 05:50AM BLOOD ___ PTT-49.9* ___
___ 05:50AM BLOOD Glucose-127* UreaN-51* Creat-2.8* Na-144
K-3.9 Cl-117* HCO3-16* AnGap-15
___ 05:50AM BLOOD ALT-23 AST-24 LD(LDH)-259* AlkPhos-165*
TotBili-1.5
___ 05:50AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.3
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
Mr. ___ is a ___ gentleman who has stage IV chronic
kidney disease, known renal cell carcinoma, EtOH cirrhosis c/b
encephalopathy, and hepatocellular carcinoma status post
CyberKnife therapy (last treatment ___ for RCC and HCC who
presented from home with encephalopathy and acute kidney injury.
He was treated for hypovolemia and anemia with improvement in
renal function and mental status. He was discharged home after
2-units pRBC transfused and renal function corrected.
ACUTE CARE
# Encephalopathy: Mr. ___ presented to the hospital
encephalopathic. He had acute renal insufficiency, anemia, and
poor PO intake with nausea and constipation at home.
Interventions to improve mental status included increased
lactulose dosing to good effect, transfusion of 2U pRBC for
anemia, and holding home lasix and valsartan to treat
hypovolemic ___. He was without appreciable sign of GI bleed as
brown stool in the rectal vault. Infectious etiology unlikely as
patient is without fevers, abdominal pain and work-up revealed
CXR neg, UA neg, no tappable ascites. Tox screen negative. ECG
without signs of ischemia. Portal vein thrombus not seen on
ultrasound. Additionally acute CNS abnl was considered as
patient with known RCC; but neuro exam was non-focal and non-con
head CT was negative (though limited sensitivity). Anemia and
___ improved, and this combined with increased lactulose cleared
his mental status. He was restarted on lower dose of valsartan
on discharge and lasix and HCTZ were held. Lactulose and
rifaximin were continued.
# Acute on chronic renal insuffiency. Patient with known CKD IV
and followed by Dr ___ as an outpatient. On admission
creatinine elevated above recent baseline to 3.3 (creatinine
hovers around 2.6-2.8); UA bland. Patient with history
consistent with pre-renal though spec gravity is not impressive
at 1.008; regarding alternative dx, differential with 9%
eosinophils raising possiblity of AIN though no concurrent
fever, rash, med change; furthermore patient with historically
elevated eos. History not c/w post-renal as with exception of
burning has no symptoms to suggest obstruction. Improved with
volume resuscitation with blood product and holding diuretics.
# Normocytic Anemia. Admission HCT 23. Baseline HCT ~25 but
variable. FAST negative in the ED. Stool brown though guaiac
positive and patient with a history of duodenal ulcer as well as
gastric polyps so bleeding remains in ddx. Improved with pRBC
transfusion. He was continued on PPI and carafate and discharged
to continue outpatient workup.
CHRONIC CARE:
# Nausea. Mr. ___ reports intermittent nausea at home. On home
zofran. ?related to underlying liver disease/malignancy. Zofran
was continued on admission.
# Cirrhosis: EtOH related ___ MELD 19 and Child
___ A)and patient is not active on transplant list in setting
of malignancy. Acute hepatic encephalopathy was treated with
rifaximin and lactulose Q2hrs and decreased frequency as mental
status cleared. He has no ascites, but does have grade 1
esophageal varices seen on OSH EGD>
#RCC, HCC: advanced disease, s/p cyberknife. Continued
supportive care as above.
# Hypertension: Continued amlodipine. Decreased valsartan dosing
and DC'd furosemide and HCTZ owing to hypovolemia on admission.
# DMII. Last A1c 6.1 in ___. Continued lantus and lispro
sliding scale.
TRANSITIONS IN CARE:
# Contact: Patient; wife (cell - ___ (home -
___
# Code Status on this Admission: Full Code
# Medication Changes: furosemide and HCTZ were discontinued
owing to hypovolemia on admission. Valsartan dose was decreased
in the setting of ___.
#Followup appointments: he will be seen in the transplant clinic
and with PCP following discharge. Ongoing issues include ?slow
GI bleed, CKD, and Code status
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Glargine 18 Units Breakfast
4. Multivitamins 1 TAB PO DAILY
5. Pantoprazole 40 mg PO Q12H
6. Rifaximin 550 mg PO BID
7. Sucralfate 1 gm PO QID
8. traZODONE 75 mg PO HS:PRN sleep
9. Lactulose 30 mL PO QID
10. albuterol sulfate *NF* 90 mcg/actuation Inhalation TID
11. Insulin Lispro Desensitization Protocol 8 UNIT SUBCUT ASDIR
12. valsartan-hydrochlorothiazide *NF* 160-12.5 mg Oral daily
13. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Now that the tube is out, you should not need this for more tahn
a day.
14. Dronabinol 2.5 mg PO DAILY
15. Ondansetron 4 mg PO Q12HR nausea
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Glargine 18 Units Breakfast
3. Lactulose 30 mL PO QID
4. Multivitamins 1 TAB PO DAILY
5. Ondansetron 4 mg PO Q12HR nausea
6. Pantoprazole 40 mg PO Q12H
7. Rifaximin 550 mg PO BID
8. albuterol sulfate *NF* 90 mcg/actuation Inhalation TID
9. Dronabinol 2.5 mg PO DAILY
10. Insulin Lispro Desensitization Protocol 8 UNIT SUBCUT ASDIR
11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
12. Sucralfate 1 gm PO QID
13. traZODONE 75 mg PO HS:PRN sleep
14. Valsartan 40 mg PO DAILY
RX *valsartan [Diovan] 40 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
15. Outpatient Lab Work
ICD-9 Diagnosis Code V42.7 Liver replaced by transplant
Please draw CBC, Chem-10
Please fax results to ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hepatic Encephalopathy
Secondary: Anemia, Acute on Chronic Renal Insufficiency
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 part in your care during your stay at
___. You were admitted to the
hospital because of an episode of increased confusion at home.
While in the hospital we also found that your anemia and kidney
function had worsened. While in the hospital, we treated your
confusion with increased lactulose, and treated the anemia with
a blood transfusion. Following the transfusion, your blood
counts improved, as did your kidney function. You likely did not
have enough fluid/blood in your body leading to the
above-mentioned problems.
Please take lactulose regulary and aim for ___ bowel movements
daily.
Please have labs drawn on ___ and faxed to the Transplant
Center.
Please keep all followup appointments.
Followup Instructions:
___
|
10407582-DS-29 | 10,407,582 | 21,407,386 | DS | 29 | 2181-10-21 00:00:00 | 2181-10-21 17:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / simvastatin
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHX alcoholic cirrhosis, ___ s/p cyberknife therapy
and also ___ s/p cyberknife therapy presents with progressive
fatigue and shortness of breath. Patient reports he has been
feeling fatigued for the last several weeks. Says this is
similar to bouts he has had in the past when he was anemic and
required blood transfusions. Howevever, over the last few days,
he has also noted dyspnea on exertion. Over the last couple
weeks, he has had more and more trouble climbing the 2 flights
of stairs in his home. The last 2 days have ___ extremely
difficult, prompting him to come in to the ED.
In the ED, initial vitals were: 98.8, 94, 160/79, 16, 100%RA.
Hct was at baseline 27. Blood in stool vault on eval by ED
resident. On evaluation by GI Fellow, did not have any blood on
rectal exam. In the ED had 2 large-bore IVs placed, IVF, and
crossed for blood and had 1U PRBC. Also given pantoprazole gtt.
Transfer vital signs: 98.0, 87, 167/83, 16, 100%RA
On arrival to the floor, patient reports he feels a little
better since he received 1U PRBC in ED. He denies hematemesis or
bright red blood per rectum. Has no chest pain or abdominal
pain. Denies orthopnea, PND. No fevers or chills, but patient
does feel warm. No recent weight changes or loss of appetitie.
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:
Alcohol-induced cirrhosis
- no EtOH ___ years
- history 2 cords of grade 1 varices on EGD ___
- EGD ___ - 1 cords of grade I varices were seen in the
lower third of the esophagus; Friability, erythema and petechiae
in the antrum compatible with portal hypertensive gastropathy;
area of antrum with active bleeding likely either from a
Dielofay or just from portal hypertensive gastropathy.
(injection, thermal therapy)
Otherwise normal EGD to second part of the duodenum
Duodenal Ulcer (seen on EGD ___
Renal cell carcinoma s/p CyberKnife therapy ___ and ___
H/o renal failure
T2DM
Hypertension
H/o VRE bacteriuria
Social History:
___
Family History:
Significant for diabetes mellitus in his mother and father.
There is no history of coronary artery disease.
Physical Exam:
ADMISSION:
VS: 98, 172/77, 77, 20, 100RA
General: Awake, alert, NAD
HEENT: MMM, No oral lesions
Neck: Supple, no adenopathy, JVP not elevated
CV: RRR, III/VI early peaking crescendo decrescendo murmur heart
best at sortic area, no pulsus parvus ettardus, no drowning of
S2
Lungs: CTA b/l, no wheezes
Abdomen: Normal BS, soft, NT, ND, no ascite appreciated, no
hepatomegaly
GU: Deferred
Rectal: Trace light brown stool faintly guaiac posiive
Ext: Warm, well-perfused, trace ___ pitting edema to lower ankles
Neuro: No asterixis
Skin: Spiders present over anterior chest
DISCHARGE:
VS: 98, 172/77, 77, 20, 100RA
General: Awake, alert, NAD
HEENT: MMM, No oral lesions
Neck: Supple, no adenopathy, JVP not elevated
CV: RRR, III/VI early peaking crescendo decrescendo murmur heart
best at sortic area, no pulsus parvus ettardus, no drowning of
S2
Lungs: CTA b/l, no wheezes
Abdomen: Normal BS, soft, NT, ND, no ascite appreciated, no
hepatomegaly
GU: Deferred
Rectal: Trace light brown stool faintly guaiac posiive
Ext: Warm, well-perfused, trace ___ pitting edema to lower ankles
Neuro: No asterixis
Skin: Spiders present over anterior chest
Pertinent Results:
ADMISSION:
___ 01:00PM BLOOD WBC-3.8* RBC-2.85* Hgb-8.4* Hct-27.2*
MCV-95 MCH-29.4 MCHC-30.8* RDW-16.8* Plt ___
___ 01:00PM BLOOD Neuts-82.5* Lymphs-8.0* Monos-5.0 Eos-3.7
Baso-0.8
___ 01:00PM BLOOD ___ PTT-35.1 ___
___ 01:00PM BLOOD Glucose-420* UreaN-56* Creat-3.1* Na-137
K-4.2 Cl-113* HCO3-19* AnGap-9
___ 01:00PM BLOOD ALT-20 AST-30 AlkPhos-189* TotBili-0.5
___ 01:00PM BLOOD cTropnT-0.10*
___ 07:00PM BLOOD cTropnT-0.09*
___ 01:00PM BLOOD Albumin-2.5* Calcium-8.0* Phos-3.8 Mg-2.0
___ 06:30AM BLOOD Cortsol-17.0
___ 06:30AM BLOOD TSH-1.3
___ 01:20PM BLOOD Lactate-2.0
DISCHARGE:
___ 06:40AM BLOOD WBC-2.8* RBC-2.50* Hgb-7.7* Hct-22.8*
MCV-92 MCH-30.7 MCHC-33.6 RDW-16.7* Plt Ct-82*
___ 06:40AM BLOOD ___
___ 06:40AM BLOOD UreaN-50* Creat-2.8* Na-137 K-3.8 Cl-109*
HCO3-19* AnGap-13
___ 06:30AM BLOOD ALT-17 AST-26 AlkPhos-173* TotBili-0.7
___ 01:00PM BLOOD Lipase-43
___ 06:40AM BLOOD Calcium-7.6* Phos-4.2 Mg-1.9
STUDIES:
CXR -> Subtle scattered opacities could represent multifocal
pneumonia.
Recommend followup to resolution.
ECHO -> The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. There are three
aortic valve leaflets. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. The tricuspid valve
leaflets are mildly thickened. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild calcific aortic stenosis. Trace aortic regurgitation.
Brief Hospital Course:
___ with past medical history of alcoholic cirrhosis
decompensated by non-bleeding Grade I varices and portal
hypertensive gastropathy, CKD, RCC s/p cyberknife therapy, and
HCC s/p cyberknife therapy presents with progressive fatigue and
dyspnea on exertion.
#Dyspnea on Exertion: Progressive for several weeks, but
appearing comfortable at rest without hypoxemia. No cough or
fever to suggest PNA, though question of opacities on CXR prelim
read. No e/o hypervolemia by exam. Does have history of mild AS
with notable AS murmur, so may be secondary to worsening AS.
Also on the differential would be portopulmonary syndrome though
echo was unable to assess pulmonary artery pressures. Unlikely
due to anemia as Hct at his baseline. No history of known
coronary ischemia with negative stress test in ___, with slight
elevation in troponin likely ___ renal dysfunction and
downtrended on repeat. PE's less likely as he is not tachycardic
on exam and no pleuritic chest pain, though he does have hx of
malignancy. Amulatory sats were at 98%.
#Chronic Anemia: From blood loss and chronic disease. Appears to
be at baseline. Report of blood in rectal vault in ED, though
not seen on exam by nightfloat, liver fellow, or us. Received 1u
pRBCs in ED but no appropriate increase in H/H. Has history of
UGIB from Dielofay vs friable gastropathy, known non-bleeding
Grade I varices (EGD ___.
#Fatigue: Unclear cause. Patient says his symptoms feel somewhat
like his previous episodes of anemia, but hct at baseline. No
recent fevers or travel to suggest infection and no recent
changes in weight. Does not appear to be decompensation of liver
disease. Progression of malignancy and occult infection are a
possibility. Infectious work-up Ucx, CXR, Blood cx negative.
TSH and AM cortisol wnl.
#Alcoholic Cirrhosis: Decompensated by non-bleeding Grade I
varices and portal hypertensive gastropathy. Appears stable at
this time with no encephalopathy or ascites on exam. MELD 18.
Continued home furosemide, rifaximin, lactulose.
CHRONIC
#Hypertension - Continued home valsartan and amlodipine.
#Diabetic - continued home insulin regimen and diabetic diet.
#CKD - creatinine at baselin.
TRANSITIONAL
- continued ___
- could consider pulm c/s or RHC to further eval possibility of
pulm htn contributing.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Dronabinol 2.5 mg PO BID
3. Furosemide 40-60 mg PO DAILY
4. Glargine 15 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Lactulose 30 mL PO TID-QID
6. Ondansetron 4 mg PO Q12H:PRN nausea
7. Pantoprazole 40 mg PO Q12H
8. Rifaximin 550 mg PO BID
9. Sucralfate 1 gm PO BID
10. TraZODone 75 mg PO HS
11. Valsartan 80 mg PO HS
12. Vitamin D 1000 UNIT PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Sildenafil 100 mg PO X1:PRN desired effect
15. Acetaminophen 650 mg PO DAILY:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO DAILY:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Dronabinol 2.5 mg PO BID
4. Furosemide 40-60 mg PO DAILY
5. Glargine 15 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
6. Lactulose 30 mL PO TID-QID
7. Multivitamins 1 TAB PO DAILY
8. Ondansetron 4 mg PO Q12H:PRN nausea
9. Pantoprazole 40 mg PO Q12H
10. Rifaximin 550 mg PO BID
11. Sucralfate 1 gm PO BID
12. TraZODone 75 mg PO HS
13. Valsartan 80 mg PO HS
14. Vitamin D 1000 UNIT PO DAILY
15. Sildenafil 100 mg PO X1:PRN desired effect
Discharge Disposition:
Home
Discharge Diagnosis:
Dyspnea, unclear etiology
Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were evaluated at ___ for your dyspnea. Your heart
function looked good and there was no evidence of pneumonia on
your chest xray. You walked well with your nurse and should
continue to follow up with your outpatient providers ___
management of your dyspnea.
Followup Instructions:
___
|
10407693-DS-13 | 10,407,693 | 27,088,322 | DS | 13 | 2123-09-05 00:00:00 | 2123-09-05 17:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending: ___
Chief Complaint:
ataxia, unsteady gait, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is ___ ___ year old man with a history of
schizoaffective disorder, HIV, and hepatitis C who presents with
ataxia, unsteady gait, and altered mental status after ingestion
of unknown types and quantities of medications.
The patient was referred to the ED from his primary care
physician, ___ with chief complaint of altered mental
status/gait. He has hx of schizoaffective d/o, bipolar type, and
is currently on medications which are managed with the
assistance of ___). Pt was in ___ ED recently
with similar complaint which seemed to have been triggered by
marijuana use, and resolved after several hours without
intervention. Today ___ reports pt's symptoms have returned and
seem worse, especially pt's gait which ___ reports is "way off."
___ usually pours pt's meds but the ___ states pt seems to
have taken meds from the bottle and she is unsure what he took.
Also noted lamotrigine w/meds which is not prescribed to pt.
Pt reports he took his meds last night and this AM and thought
he took the correct ones. Denies SI/HI. Unsure which pills he
took. He reports smoking marijuana after taking his pills but
denies any other alcohol or drug use. Reports he feels not like
himself, unsteady. Denies falls but has cuts on chin, forehead,
R elbow, L ankle.
In the ED, initial VS were T 98, HR 65, BP 144/86, RR 18, SPO2
98RA
In the ED pupils were pin-point and reactive, gait was unsteady,
and he was slow to respond.
Labs:
--Normal Chem 10
-- WBC 6.2, Hgb 9.9
-- iron panel: iron 43, ferritin 18, TIBC 438, haptoglobin 389
-- UA: mild proteinuria
-- urine tox: negative
-- serum tox: negative
-- ALT 17, AST 25, AP 87, Tbili 0.2, Alb 4.4
CT head showed no acute intracranial process.
He was evaluated by neurology, who wrote:
___ yo man who presents after ingestion of multiple medications
of unknown type and dose, possibly including lamotrigine. On
exam, he has very mild direction-changing nystagmus and
bilateral dysmetria, in the absence of weakness, ataxia, or
other cerebellar/brainstem findings. He also has asterixis
bilaterally as well as the appearance of jaundice and scleral
icterus although he has a normal bilirubin. Overall, his picture
is consistent with a toxic ingestion and not with a primary
neurological etiology, including posterior circulation stroke."
He was given risperidone 4mg PO, oxcarbazepine 150mg PO, and
benztropine 1mg PO and transferred to the floor.
This morning the patient states that he continues to feel "off"
and confused. He complains of tremor, but denies chest pain,
abdominal pain, nausea, vomiting, fevers, chills, urinary
symptoms. The pain in his right ankle is improved. He is alert
and oriented to person and season, but does not know the year.
He is unable to list the months of the year.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
Schizoaffective disorder
SI attempt w/ ingestion (___)
HIV
Hepatitis C
Social History:
___
Family History:
Mother: ___
Father: ___
Physical Exam:
ADMISSION:
===========
VS - 98.3 115/58 70 18 98% RA
GENERAL: Sitting comfortably in bed eating breakfast, NAD
HEENT: NC/AT, EOMI, anicteric sclera. Has right going nystagmus
when looking to the left.
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, ND, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, negative ___ sign
EXTREMITIES: LLE is warm and erythematous along medial aspect.
Has tinea pedis bilaterally on the feet. Otherwise no edema,
clubbing or cyanosis.
NEURO: AAOx2 (knows name and season; does not know year). Unable
to list the months of the year in order. CN II-XII intact, has
right going nystagmus with left directed gaze, ___ strength in
upper and lower extremities bilaterally, sensation intact to
light touch.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE:
==========
VS - 99.0 134/79 (120-130/70-80) 70 (60-70) 18 100% RA
GENERAL: Sitting comfortably in bed, NAD
HEENT: NC/AT, EOMI, anicteric sclera. Has mild nystagmus upon
lateral gaze
NECK: supple, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: soft, ND, NTTP, +BS
EXTREMITIES: LLE is warm and erythematous along medial aspect
which is improved from prior exam. Has tinea pedis b/l on the
feet. Otherwise no edema, clubbing or cyanosis.
NEURO: AAOx2-3 (knows season, holiday, ___ but thought it
was ___. CN II-XII intact, has right going nystagmus with left
directed gaze, ___ strength in upper and lower extremities
bilaterally, sensation intact to light touch.
SKIN: Has tinea pedis on feet bilaterally. Mild erythema along
the medial aspect of LLE.
Pertinent Results:
ADMISSION:
___ 02:39PM BLOOD WBC-6.2 RBC-3.30* Hgb-9.9* Hct-31.8*
MCV-96 MCH-30.0 MCHC-31.1* RDW-14.0 RDWSD-49.4* Plt ___
___ 02:39PM BLOOD Neuts-42.8 ___ Monos-11.8 Eos-2.4
Baso-1.0 Im ___ AbsNeut-2.66 AbsLymp-2.59 AbsMono-0.73
AbsEos-0.15 AbsBaso-0.06
___ 02:39PM BLOOD ___ PTT-31.2 ___
___ 02:39PM BLOOD Glucose-109* UreaN-10 Creat-0.9 Na-137
K-4.3 Cl-98 HCO3-28 AnGap-15
___ 02:39PM BLOOD ALT-17 AST-25 AlkPhos-87 TotBili-0.2
___ 02:39PM BLOOD Albumin-4.4 Calcium-9.8 Phos-4.3 Mg-2.1
Iron-43*
___ 02:39PM BLOOD calTIBC-438 VitB12-PND Hapto-389*
Ferritn-18* TRF-337
___ 02:39PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE:
___ 06:56AM BLOOD WBC-6.2 RBC-3.39* Hgb-10.2* Hct-32.9*
MCV-97 MCH-30.1 MCHC-31.0* RDW-14.2 RDWSD-50.4* Plt ___
___ 06:56AM BLOOD Glucose-98 UreaN-14 Creat-0.9 Na-139
K-4.1 Cl-104 HCO3-27 AnGap-12
IMAGING:
CT HEAD WITHOUT CONTRAST ___:
There is no intra-axial or extra-axial hemorrhage, mass, midline
shift, or
acute major vascular territorial infarct. Gray-white matter
differentiation is
preserved. Ventricles and sulci are unremarkable. Basilar
cisterns are
patent.
Included paranasal sinuses and mastoids are clear. Skull and
extracranial soft
tissues are unremarkable.
IMPRESSION:
No acute intracranial process.
CXR ___:
No previous images. The cardiac silhouette is within normal
limits and there is no evidence of vascular congestion, pleural
effusion, or acute focal pneumonia.
Left Lower Extremity Ultrasound ___:
Brief Hospital Course:
MR. ___ is ___ ___ year old gentleman with a history of
schizoaffective disorder, HIV, Hepatitis C who presented with
ataxia, unsteady gait, and altered mental status after ingestion
of unknown types and quantities of medications. Patient was
found to have toxic metabolic encephalopathy secondary to
medication ingestion and marijuana. He was also found to have
left lower extremity cellulitis treated with Keflex, tinea pedis
treated with miconazole, and iron deficiency anemia. Patient was
evaluated by psychiatry, medication regimen adjusted, and
determined to be safe for discharge home. He will have a
visiting ___ who will visit daily to ensure compliance with
medications.
ACUTE MEDICAL ISSUES:
=====================
#Toxic Metabolic Encephalopathy, unsteady gait:
Improved and per patient, he is back at baseline. Upon
admission, exam notable for confusion,
disorientation/inattentiveness, slowed speech, nystagmus, upper
extremity dysmetria, without truncal ataxia or weakness. He also
has asterixis; notably ALT/AST and bilirubin normal, and serum
tox screen is negative. CBC and chemistries unremarkable, and CT
head showed no acute process. At home, the patient is on
perphenazine, oxcarbazepine, aripiprazole, benztropine and
risperidone. There was also question of whether or not he took
lamotrigine. Given the patient's history of taking unknown
quantities of unknown medications and then smoking marijuana, it
is likely that his acute presentation is secondary to toxic
ingestion. After further discussion with the patient, there was
concern that he may have intentionally took the medication after
feeling depressed over the holiday when his father told him he
could not go home. His psychiatric medications were initially
held and Neurology and Psychiatry were consulted. Per Neurology,
it was unlikely that he was having a primary neurological event,
but rather his symptoms were a result of the medication misuse.
The psychiatry team adjusted his medications to Abilify 10mg
daily and perphenazine 4mg TID prn. Other psychiatric
medications were held until his mental status cleared. One day
after admission, the patient returned to his baseline mental
status and denied any intentions of hurting himself or others.
After a thorough evaluation with Psychiatry, the patient was
deemed safe to return home with more frequent visitations from
his ___ and placement of medications in a locked box. The
patient was agreeable to this plan and his ___ was updated
frequently throughout his hospital course. He will resume his
home psychiatric medications upon discharge with plans to
follow-up with his psychiatrist at ___.
#LLE Erythema, Cellulitis:
The patient presented with a tender, erythematous and warm LLE
with concern for cellulitis and less likely DVT. His symptoms
improved with Keflex ___ q6hour and ___ was pending at time
of discharge. Given his marked improvement with antibiotics and
low suspicion of DVT, the patient was deemed safe to discharge
home without the final read on the ultrasound. Will email PCP
with results.
#Iron deficiency anemia:
Patient admitted with hemoglobin 9.9 which is decreased from his
prior documented hemoglobin of 12 in ___. Iron studies
demonstrate low iron and ferritin concerning for iron deficiency
anemia. Patient HD stable without signs/symptoms of active
bleed. Last colonoscopy in ___ was normal. Would benefit from
iron supplementation as an out-patient. Was not initiated at
this time due to difficulty obtaining perscriptions over the
holiday.
#Tinea Pedis:
Patient found to have tinea pedis on the feet bilaterally,
started on miconazole cream BID.
CHRONIC MEDICAL ISSUES:
=========================
#HIV: Well controlled with last viral load undetectable.
Followed at ___.
Continued home ___.
#Hepatitis C: The patient has a history of hepatitis C. LFTs on
admission normal and abdominal exam benign. Patient has notable
asterixis, however, this is a known side-effect of multiple of
his anti-psychotics and is less likely due to an underlying
liver pathology. Per ___ records, patient has undergone
successful treatment of his HCV.
=====================
TRANSITIONAL ISSUES:
=====================
[ ] LLE Cellulitis: continue 7 day course of Keflex ___ PO
q6h, d1= ___, last dose ___
[ ] Restarted on home psychiatric medications
[ ] ___ follow-up with Psychiatry pending
[ ] Has iron deficiency anemia and would likely benefit
supplementation and further work-up upon discharge
LABS PENDING AT DISCHARGE: B12, TSH, Lower extremity ultrasound
to evaluate for DVT
# CODE STATUS: Full
# CONTACT: ___: ___ ; ___
(___) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Perphenazine 4 mg PO QAM
2. Perphenazine 12 mg PO QHS
3. RISperidone 4 mg PO DAILY
4. Complera (emtricitab-rilpivirine-tenofov) 200-25-300 mg oral
DAILY
5. Oxcarbazepine 150 mg PO BID
6. Benztropine Mesylate 1 mg PO QHS
7. Multivitamins 1 TAB PO DAILY
8. ARIPiprazole 10 mg PO DAILY
9. Naproxen 500 mg PO Q12H:PRN pain
Discharge Medications:
1. ARIPiprazole 10 mg PO DAILY
RX *aripiprazole [Abilify] 10 mg 1 tablet(s) by mouth daily Disp
#*2 Tablet Refills:*0
2. Multivitamins 1 TAB PO DAILY
3. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours
Disp #*10 Tablet Refills:*0
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*12 Capsule Refills:*0
4. Benztropine Mesylate 1 mg PO QHS
5. Complera (emtricitab-rilpivirine-tenofov) 200-25-300 mg oral
DAILY
6. Naproxen 500 mg PO Q12H:PRN pain
7. RISperidone 4 mg PO DAILY
8. Oxcarbazepine 150 mg PO BID
9. Miconazole 2% Cream 1 Appl TP BID
RX *miconazole nitrate 2 % apply generous amount to both feed
twice a day Refills:*0
10. Perphenazine 12 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute Toxic Metabolic Encephalopathy
Cellulitis (left lower extremity)
Tinea Pedis
Chronic Medical Conditions:
Iron deficiency Anemia
Hepatitis C
HIV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your admission to
___. You came into the hospital
because you were confused and had unsteady gait. We found that
you did not have any infection and a scan of your head was
normal. This is likely due to your medications. You were
evaluated by psychiatry who recommended that you re-start your
Abilify 10mg daily and change your perphenazine to as needed. We
also found that you had an infection of your left leg,
cellulitis, please continue taking the antibiotics (Keflex) for
a total of 7 days, last dose ___.
You will have a visiting ___ to visit you daily to help with
your medications. Additionally there was concern that this may
be a side effect of smoking marijuana. We strongly recommend
that you stop smoking marijuana because of its negative impact
on your health.
Please be sure to take your medications as prescribed and follow
up with your outpatient providers.
Be well and take care.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10407730-DS-24 | 10,407,730 | 29,168,802 | DS | 24 | 2151-02-26 00:00:00 | 2151-02-26 21:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Lipitor
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
___: Tunnel cath placed
___: s/p Cardiac Catheterization
History of Present Illness:
___ with PMH CAD (CABG ___, cardiac cath ___ for angina
showed severe 3-vessel native dx, patent LIMA-LAD with a 30%
stenosis at touchdown and a 50-60% mid vessel stenosis, patent
SVG-OM graft and known occluded SVG-RCA graft with good
collateral flow, s/p Cypher DES to protected LM ___, HFpEF
(last LVEF 65%), CKD (Cr 3.8-4.0), diabetes, hypertension,
hyperlipidemia s/p dual-chamber pacemaker for intermittent
complete heart block in ___, autoimmune hepatitis c/b Child A
cirrhosis, presenting with respiratory distress.
Patient was recently discharged on ___ after hospitalization
for syncope and orthostasis, found to have ulcerations on EGD
___ portal hypertensive gastropathy without evidence of active
bleeding. She was transfused 2 units of PRBCs and 250cc of fluid
for orthostasis. On discharge, amlodipine 5mg was discontinued.
Other BP meds remained the same.
She was seen in ED last night and early this morning with
complaint of not feeling well, found to have a UTI. Given one
dose of p.o. Bactrim and discharged with same. She did not get
any further antibiotic because the ___ nurse felt that her GFR
was too low to use bactrim, and she should be switched to cipro.
Throughout the day today she began having more and more
difficulty breathing and now with a low-grade temperature. She
states she never had chest pain. Her anginal equivalent from
prior to her bypass was pressure in her ears on exertion.
Presents via EMS on a NRB saturating 100%, but is tachypneic and
moaning.
In the ED, initial vitals were: no temp, ___ NRB
She was given 1g ceftriaxone for UTI. CXR showed moderate
interstitial edema, increased from prior imaging at 4AM. She was
given 40mg IV lasix and put on BiPAP. She put out 300cc and was
able to be weaned to 3LNC satting 96% after 30 minutes. She was
started on a nitro drip to reduce BPs. She was also noted to be
in afib with rates in 120s (new, no prior record of afib) with
diffuse STD and LVH with RBBB. She received 10 units insulin for
FSBG 310.
On arrival to the floor, pt very anxious, asking for home
anti-anxiety meds.
Past Medical History:
- CAD (s/p stenting in ___, CABG ___. Cardiac cath ___
for angina showed severe 3-vessel native dx, patent LIMA-LAD
with a 30% stenosis at touchdown and a 50-60% mid vessel
stenosis, patent SVG-OM graft and known occluded SVG-RCA graft
with good collateral flow)
- Diabetes
- Hypertension
- ESRD (per report biopsy-proven diabetic nephropathy. Not yet
on HD)
- 1.1-cm right renal artery aneurysm, stable in size.
- Stents in upper and lower poles of left renal artery (patent
at ___ cath).
- Asthma
- Autoimmune Hepatitis- hepatitis at age ___
- Cholelithiasis
- Pacemaker
- Depression
- Anemia
- Hypothyroidism
- breast cancer s/p L mastectomy and implant
Social History:
___
Family History:
Father died at ___ years old from an MI. She has a brother who
has a history of cardiomyopathy and an MI at age of ___. Oldest
son suffered an MI and had stents at age ___. Youngest son had
stent placed at ___ at age ___.
Physical Exam:
ADMISSION EXAM:
VS: 99.2, 141/72, 86, 20, 97% 3LNC
General: NAD, anxious, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, JVD 5-6cm
CV: regular rhythm, no m/r/g
Lungs: crackles at bases bilaterally
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
DISCHARGE EXAM:
VS:
Tmax/Tcurrent:98.2/97.7 ___ RR:18 ___ O2 sat:
97% RA
I/O:
24hr: 1294/1125
Weight:71.5 kg
Tele: SR
.
Exam:
General: A/O, lying flat in bed during HD. Dry cough noted
HEENT: no JVD, lg neck
CV: RRR, ___ systolic murmur RUSB
Resp: course exp wheezes ant, no crackles
ABD: soft, NT
Extr: no edema
Neuro: A/O x3
Pertinent Results:
ADMISSION LABS:
___ 05:58PM BLOOD WBC-11.9*# RBC-3.15* Hgb-10.2* Hct-30.5*
MCV-97 MCH-32.5* MCHC-33.5 RDW-14.1 Plt ___
___ 05:58PM BLOOD Neuts-71.2* ___ Monos-4.3 Eos-0
Baso-0.4
___ 05:58PM BLOOD ___ PTT-31.4 ___
___ 05:58PM BLOOD Glucose-327* UreaN-44* Creat-3.6* Na-126*
K-3.8 Cl-101 HCO3-17* AnGap-12
___ 05:58PM BLOOD proBNP->70000
___ 05:58PM BLOOD cTropnT-0.84*
___ 05:53PM BLOOD pO2-122* pCO2-35 pH-7.28* calTCO2-17*
Base XS--9 Comment-GREEN TOP
___ 05:53PM BLOOD Lactate-2.2*
___ 05:53PM BLOOD O2 Sat-96
___ 06:10PM URINE Color-Straw Appear-Clear Sp ___
___ 06:10PM URINE Blood-TR Nitrite-NEG Protein-300
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:10PM URINE RBC-<1 WBC-<1 Bacteri-MOD Yeast-NONE
Epi-0
PERTINENT LABS:
___ 05:58PM BLOOD cTropnT-0.84*
___ 01:02AM BLOOD CK-MB-11* MB Indx-6.9*
___ 01:02AM BLOOD cTropnT-1.09*
___ 05:30AM BLOOD CK-MB-11* MB Indx-6.8* cTropnT-1.27*
___ 01:00PM BLOOD CK-MB-10 MB Indx-6.5* cTropnT-1.05*
DISCHARGE LABS:
MICRO:
___ 5:00 am URINE
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 5:42 pm BLOOD CULTURE x2: NO GROWTH.
IMAGING:
EKG (___): Sinus rhythm. Left atrial abnormality. Right
bundle-branch block. Compared to the previous tracing of ___
the rate has increased. The inferolateral ST segment changes
persist without diagnostic interim change.
CXR (___): Moderate interstitial edema, increased compared
to the prior study.
EKG (___): Sinus rhythm. Left atrial abnormality. Right
bundle-branch block. Compared to the previous tracing of ___
the rate has slowed. The ischemic appearing ST segment
abnormalities are somewhat improved. Otherwise, no diagnostic
interim change. Clinical correlation is suggested.
Cardiac Cath (___):
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated three vessel native coronary artery disease. The
___ had
mild disease with a patent stent. The LAD had a 90% stenosis in
the mid
portion. The LCx was occluded in the mid portion with a small
OM. The
RCA was occluded in the proximal portion.
2. Coronary conduit angiography demonstrated a patent LIMA-LAD
with a
90% stenosis in the distal LAD. The SVG to OM was patent
without
angiographically apparent disease. THe SVG to RCA was known
occluded
and not engaged.
3. Limited resting hemodynamics revealed an elevated LVEDP.
The left
ventricular pressure was 195/30 mm/Hg. There was no gradient to
the
aorta. The aorta was 195/72 (mean 122). There was a 50 mm
gradient
between the aortic pressure and the measured right arm
peripheral blood
pressure.
FINAL DIAGNOSIS:
1. Native three vessel coronary artery disease.
2. LIMA - LAD patent with distal 90% stenosis in the LAD.
3. SVG-OM patent.
4. SVG-RCA known occluded.
5. Elevated left sided filling pressure.
6. Possible subclavian stenosis.
Arterial Ultrasound of Left Upper Extremity (___): Patent
brachial and radial arteries with a normal triphasic waveform.
No stenosis.
Renal Ultrasound (___):
1. Patent main renal arteries bilaterally with relatively low
peak
velocities.
2. Absent diastolic flow in the main renal arteries bilaterally
(30-35
cm/sec.), which may reflect extensive calcification.
3. Markedly diminished diastolic flow in the interlobar renal
arteries
bilaterally, consistent with renal parenchymal disease.
4. Normal sized kidneys with multiple cysts bilaterally.
CXR (___): Moderate interstitial edema, decreased since the
prior study. Small bilateral pleural effusions.
Subclavian Ultrasound (___): Bilateral subclavian artery
stenosis.
.
___: GI bleeding study: no active bleed
.
___ ECG:
Sinus rhythm with atrial premature beats. Right bundle-branch
block. Diffuse ST-T wave repolarization abnormalities. Compared
to the previous tracing of ___ the rate is slower.
.
___:
IMPRESSION:
Successful placement of a 19 cm cuff to tip tunneled dialysis
line. The tip of the catheter terminates in the right atrium.
The catheter is ready for use.
.
Labs at discharge:
___ 07:15AM BLOOD WBC-3.4* RBC-2.79* Hgb-9.0* Hct-27.2*
MCV-97 MCH-32.2* MCHC-33.0 RDW-15.8* Plt Ct-93*
___ 07:15AM BLOOD Glucose-158* UreaN-44* Creat-4.2* Na-133
K-3.5 Cl-97
___ 07:15AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.0
___ 04:44PM BLOOD calTIBC-260 Ferritn-325* TRF-200
___ 07:05AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 07:05AM BLOOD HCV Ab-NEGATIVE
Brief Hospital Course:
Ms. ___ is an ___ with known CAD (CABG ___
cath revealing severe 3-vessel native disease, patent LIMA-LAD,
patent SVG-OM graft, and known occluded SVG-RCA graft with good
collateral flow; s/p Cypher DES to protected LM ___, HFpEF
(LVEF 65% prior to admission on ___, dual-chamber pacemaker
for intermittent complete heart block in ___, CKD (Cr 3.8-4.0),
DM, HTN, HLD and autoimmune hepatitis c/b cirrhosis, recently
admitted on for orthostasis/anemia s/p transfusions, who
presented on ___ with an NSTEMI and flash pulmonary edema.
# Flash Pulmonary Edema: Her breathing improved with diuresis.
An echo on ___ revealed LVEF of 30% and severe hypokinesis of
the anterior septum. She was cath'ed on ___, revealing 90%
stenosis of the LAD. Cath also revealed elevated central
pressures (195/72), with SBP ~50 above peripheral RUE pressures.
Blood pressures are inaccurate on her arms and were taken from
her a blood pressure cuff on her left calf throughout her
hospitalization subsequent to this study. On the evening of
___, she developed acute SOB in the setting of severe HTN
(SBP's in 220's); her breathing eased with a nitro drip and 80mg
IV lasix. She was transferred to the CCU and nitro drip was
quickly weaned down and oxygen requirement dropped from
non-rebreather to 3L NC, then to RA the following morning. She
developed flash pulmonary edema a second time ___ in the setting
of blood pressure elevation to the 230s systolic. Her symptoms
improved on a nitro gtt and she received dialysis later in the
day.
# NSTEMI: An echo on ___ revealed LVEF of 30% and severe
hypokinesis of the anterior septum. She was cath'ed on ___,
revealing 90% stenosis of the LAD. She underwent LAD stent
placement on a subsequent cath ___. She is maintained on
carvedilol (to be titrated up with elevated BP), aspirin 81mg,
Imdur 90mg, Rosuvastatin 20mg 4x/week.
# Acute on chronic diastolic/systolic heart failure with mitral
stenosis: CXR on admission showed pulmonary edema and elevated
BNP >6000, likely ___ low compliance from NSTEMI and HTN. Pt has
previously had preserved EF, but current echo shows LVEF of 30%
in setting of hypokinesis. Pt reported a persistent
non-productive cough and had wheezes on exam. A repeat CXR on
___ revealed possible persistent edema. As above, she had an
episode of flash pulmonary edema on the evening of ___ so was
diuresed with 80mg IV lasix with excellent urine output. Out of
concern for worsening her tenuous renal function, she was
maintained on a 2L fluid restriction, losartan and Imdur. Her
antihypertensives were held in the setting of hypotension
associated with acute blood loss and HD. Her antihypertensives
were restarted slowly and she was discharged on coreg and
valsartan.
# Hypertension: Pt was hypertensive at presentation, with
persistent hypertension throughout hospitalization. Cardiac cath
revealed markedly central pressures (195/72), with a SBP ~50
higher than peripheral RUE pressures, raising the question of
subclavian/distal arterial stenoses. BP's were thereafter
collected from the left calf. Pt has history of renal artery
stenosis s/p L renal artery stents. A renal artery doppler on
___ revealed patent main renal arteries, but diminished distal
flow bilaterally. Subclavian ultrasound revealed bilateral
subclavian stenosis. The subclavians were evaluated during her
cath on ___ but the stenoses were not felt to be significant so
no stents were placed. She is being maintained on carvedilol and
valsartan as above. Imdur was held secondary to multiple
hypotensive episodes, particularly during HD. Lasix was
discontinued and her volume status was subsequently managed with
hemodialysis.
# Subclavian stenosis: Significant pressure gradient between
central (measured during cardiac cath) and right upper extremity
pressures raised the question of subclavian stenoses, which was
confirmed by ultrasound. NOTE THAT THE PATIENT'S TRUE BLOOD
PRESSURE IS 50 POINTS HIGHER THAN THAT MEASURED IN HER ARMS. Her
blood pressures were measured in her legs during this admission.
# Anemia: Secondary to witnessed GI bleed with renal failure and
anemia of chronic disease likely contributing. Coombs and
haptoglobin negative for hemolysis. Anemia of chronic disease is
a possibility, given recently elevated ferritin and low-normal
transferrin. Reticulocyte index is below expected at 1.5 (>2%
considered adequate); this may be secondary to iron deficiency
from chronic bleed. She was continued on her home iron. On ___,
she was noted to have a large hematochezic bowel movement
associated with a 5 point crit drop. She was transfused 2 units
pRBCs and transferred back to the CCU. She continued to have
hematochezia while in the CCU but did not require any further
transfusions. She was transitioned to high dose pantoprazole.
Tagged red blood cell scan did not show active bleeding.
# End Stage Renal Disease: Baseline creatinine 3.7-4.0.
Creatinine increased to ~4.6 in the setting of fluid
restriction, diuresis, and poor PO intake at baseline. There was
a concern that the contrast from the catheterization could
worsen her renal function, particular in the setting of volume
depletion from diuresis/fluid restriction for treatment of CHF.
She received 20 cc of contrast during the cath of ___, with
plan to receive an additional 20 cc of contrast during stent
placement. Cr slowly rose and renal recommended tunneled HD
catheter placement which occurred on ___, with initiation of
dialysis on ___. She underwent daily HD/ultrafiltration
treatments ___ for HD initiation and then she was
transitioned to a ___ HD schedule. Weight on day of
discharge was 71.5kg. She was continued on home nephrocaps,
sodium bicarbonate.
# Anxiety: Continued home clonazepam. Geriatric psychiatry
consult was placed. Her home alprazolam was discontinued at the
recommendation of ___ and her clonazepam dose was
increased. She had frequent anxiety attacks while inpatient.
INACTIVE ISSUES:
----------------
# Asthma: She did have wheezing on exam likely related to volume
overload. She was diuresed, as above, and also treated with
DuoNebs. Steroid inhaler was started prior to discharge for
persistent cough and wheezing.
# ?Arrhythmia: Patient not pacing on tele and V paced <1% of
time on recent interrogation. Patient tachy on presentation,
EKG regular and appears sinus tach with PAC. She had a 16 second
episode of an accelerated atrial rhythm during pacer
interrogation ___. She was monitored on telemetry throughout
admission and had an 8 beat run of likely afib during her stay.
She was not started on anticoagulation for afib during her
admission secondary to her bleeding. She should have follow up
outpatient with cardiology to further workup possible afib.
# Diabetes mellitus: Continued home insulin/ sliding scale.
Finger sticks have been elevated, with diet subsequently
switched to a consistent carbohydrate diet, and insulin sliding
scale increased.
# Autoimmune hepatitis: Child's A cirrhosis. Continued home
ursodiol and azathioprine.
# Hypothyroidism: Not symptomatic. Continued home levothyroxine.
TRANSITIONAL ISSUES:
-Initiated dialysis during this admission.
-PATIENT'S TRUE BLOOD PRESSURE IS 50 POINTS HIGHER THAN THAT
MEASURED IN HER ARMS. Her blood pressures were measured in her
legs (left calf) during this admission.
-Needs fistula placement in near future
- needs anticoagulation for AFib during this admission. Not
anticoagulated (CHADS-VASC is 5) due to GI bleed. Will need to
touch base with GI.
-pancytopenic at discharge. if platelets do not return to her
baseline, recommend hematology outpatient consult
-concern for transient episode of brief afib on tele, unclear if
she has an arrhythmia. Recommend outpatient monitoring
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO Q6H:PRN anxiety
2. Azathioprine 100 mg PO DAILY
3. Nephrocaps 1 CAP PO DAILY
4. ClonazePAM 0.25 mg PO BID
5. Vitamin D 50,000 UNIT PO 1X/WEEK (TH)
6. Furosemide 20 mg PO BID
7. NPH 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Nitroglycerin SL 0.3 mg SL PRN chest pain
12. Rosuvastatin Calcium 20 mg PO 4X/WEEK (___)
13. Ursodiol 500 mg PO BID
14. Valsartan 320 mg PO DAILY
15. Aspirin 325 mg PO DAILY
16. Calcium Carbonate 500 mg PO TID
17. Docusate Sodium 100 mg PO BID
18. Ferrous Sulfate 325 mg PO DAILY
19. NPH 5 Units Bedtime
20. Psyllium 1 PKT PO BID
21. Senna 8.6 mg PO BID:PRN constipation
22. Sodium Bicarbonate 650 mg PO BID
23. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Azathioprine 100 mg PO DAILY
2. Calcium Carbonate 500 mg PO TID
3. Docusate Sodium 100 mg PO BID
4. Ferrous Sulfate 325 mg PO DAILY
5. NPH 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Nephrocaps 1 CAP PO DAILY
8. Nitroglycerin SL 0.3 mg SL PRN chest pain
9. Psyllium 1 PKT PO BID
10. Rosuvastatin Calcium 20 mg PO 4X/WEEK (___)
11. Senna 8.6 mg PO BID:PRN constipation
12. Ursodiol 500 mg PO BID
13. Vitamin D 50,000 UNIT PO 1X/WEEK (TH)
14. ClonazePAM 0.25 mg PO BID
15. Valsartan 80 mg PO DAILY
16. Acetaminophen 325-650 mg PO Q6H:PRN pain
17. Carvedilol 25 mg PO BID
18. Heparin Dwell (1000 Units/mL) ___ UNIT DWELL PRN
dialysis
Dwell to CATH Volume
19. Heparin Flush (1000 units/mL) ___ UNIT DWELL PRN line
flush
20. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
21. Pantoprazole 40 mg PO Q12H
22. Sarna Lotion 1 Appl TP QID:PRN itch
23. Sodium Chloride Nasal ___ SPRY NU QID:PRN congestion
24. TraZODone 25 mg PO HS:PRN sleep
25. ALPRAZolam 0.5 mg PO Q6H:PRN anxiety
26. Benzonatate 100 mg PO TID
27. Fluticasone Propionate 110mcg 2 PUFF IH BID
28. Clopidogrel 75 mg PO DAILY
29. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___)
Discharge Diagnosis:
Coronary artery disease: - CAD (s/p stenting in ___, CABG ___.
with good collateral flow)
Acute on chronic diastolic/systolic heart failure
NSTEMI
Bilateral upper extremity subclavian stenosis
ESRD-HD started on ___
Hypertension
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to us for shortness
of breath, which we believe was due to a heart attack, and
subsequent build-up of fluid in your lungs. Your breathing
improved with oxygen, and with additional Lasix to remove some
of the fluid in your body. You were also started on hemodialysis
on ___. You will require hemodialysis three times a week.
Dialysis will help prevent fluid from building up in your lungs.
When your blood pressure goes too high you develop fluid in
your lungs and have a difficult time breathing. Your blood
pressure has been well controlled on carvedilol and a lower dose
of diovan.
For the heart attack, we gave you medications to relieve your
heart and thin your blood. However, your blood levels dropped
slightly, and in case you had bleeding from your GI tract, we
stopped the blood-thinning medications. Your blood counts have
been stable for 4 days now and you have been restarted on iron
and will get an injection in dialysis to help your anemia.
We conducted an echocardiogram of your heart which showed a
decreased pumping action of your heart. You also had a cardiac
catheterization on ___ and had two drug coated stents placed in
your left anterior descending artery (LAD). You will need to
take an antiplatelet, Plavix 75mg daily for a minimum of one
year. Aspirin along with Plavix are taken to reduce the risk of
a blood clot/plaque from forming in your stents. Do not stop
either of these medications unless told by your cardiologist.
Stopping either of these prematurely may put you at risk for a
life threating heart attack. Activity restrictions and care of
your right groin site are listed in your nursing discharge
instructions.
You had two brief episodes of atrial fibrillation during this
hospital stay. It is not safe to give you blood thinners at this
point but it should be considered in the future once your
intestinal bleeding has resolved.
We wish you the best!
Your ___ Team
Followup Instructions:
___
|
10407730-DS-25 | 10,407,730 | 27,903,812 | DS | 25 | 2151-03-14 00:00:00 | 2151-03-14 13:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Lipitor
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Ultafiltrate, Dialysis
History of Present Illness:
Mrs. ___ is an ___ year old woman with CAD (CABG ___,
cardiac cath ___ for angina showed severe 3-vessel native
dx, patent LIMA-LAD with a 30% stenosis at touchdown and a
50-60% mid vessel stenosis, patent SVG-OM graft and known
occluded SVG-RCA graft with good collateral flow, s/p Cypher
DES to protected LM ___, HFpEF
(last LVEF 65%), ESRD on HD, diabetes, hypertension,
hyperlipidemia s/p dual-chamber pacemaker for intermittent
complete heart block in ___, autoimmune hepatitis c/b Child A
cirrhosis, presenting with shortness of breath.
Patient reports one day SOB that began yesterday after dialysis
and worsened throughout the day to the point where the patient
presented to ___ after she was home from
rehabilitation for one day. She reports that she has had no
nausea vomiting fevers chills or chest pain. ECG showing old
RBBB. Trop 1.2 at osh, started on Bipap. She was transferred
here for cards eval.
Of note, patient was recently admitted to ___ ___
for NSTEMI and flash pulmonary edema and underwent cardiac
catheterization with PCI to LAD and tunnel cath placement with
initiation of HD.
In the ED, pt arrived with EMS on CPAP breathing 16 bpm in no
distress, removed from CPAP as per MD at bedside, placed on NC @
3lpm with 02 sats @ 100%. Initial vitals were 97.7 82 144/59 17
100% Nasal Cannula. Vitals prior to transfer were 97.7 82 144/59
17 100% Nasal Cannula.
On the floor, patient is saturating well on room air. She
complains of shortness of breath but is breathing comfortably
without supplemental O2. Pt also with significant fatigue (has
not slept in over 24 hours). No other complaints. Pt
specifically denies CP, palpitations, or pleuritic symptoms. No
nausea or vomiting or diaphoresis. Denies fevers or chills or
cough or URI or UTI
symptoms.
Past Medical History:
- CAD (s/p stenting in ___, CABG ___. Cardiac cath ___
for angina showed severe 3-vessel native dx, patent LIMA-LAD
with a 30% stenosis at touchdown and a 50-60% mid vessel
stenosis, patent SVG-OM graft and known occluded SVG-RCA graft
with good collateral flow)
- Diabetes
- Hypertension
- ESRD (per report biopsy-proven diabetic nephropathy. Not yet
on HD)
- 1.1-cm right renal artery aneurysm, stable in size.
- Stents in upper and lower poles of left renal artery (patent
at ___ cath).
- Asthma
- Autoimmune Hepatitis- hepatitis at age ___
- Cholelithiasis
- Pacemaker
- Depression
- Anemia
- Hypothyroidism
- breast cancer s/p L mastectomy and implant
Social History:
___
Family History:
Father died at ___ years old from an MI. She has a brother who
has a history of cardiomyopathy and an MI at age of ___. Oldest
son suffered an MI and had stents at age ___. Youngest son had
stent placed at ___ at age ___.
Physical Exam:
==========================
PHYSICAL EXAM ON ADMISSION:
==========================
Vitals: T 98, HR 85, BP 153/53
Weight: 70.4
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, JVP 8cm
CV: regular rhythm, no m/r/g
Lungs: bibasilar crackles, normal respiratory rate and effort
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
==========================
PHYSICAL EXAM ON DISCHARGE:
==========================
VS: T=98 (Tmax=98.4), BP=142/52 (99-156/47-109), P=70 (67-81),
RR=14, O2Sat=100%RA, FSGS=216 (172-335), i/o's: 12- 200cc in,
125cc out; 24- 668cc in, 250cc out + 2050cc dialysis out. Weight
= 67.6Kg standing (down from 69.7Kg standing yesterday).
GENERAL: NAD, alert, interactive
HEENT: NC/AT, sclerae anicteric, MMM, JVP 8cm
LUNGS: clear to auscultation, no crackles, rhales, or rhonchi
HEART: RRR, normal S1 & S2, no m/r/g
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: WWP, 2 + pulses distally, no clubbing, cyanosis or
edema
NEURO: awake, A&Ox3
SKIN: no purulence, mild erythema at site of catheter insertion,
no tenderness
Pertinent Results:
===================
LABS ON ADMISSION:
===================
___ 11:00AM BLOOD WBC-5.7 RBC-2.89* Hgb-9.5* Hct-29.1*
MCV-101* MCH-33.0* MCHC-32.8 RDW-16.1* Plt ___
___ 11:00AM BLOOD Neuts-82.9* Lymphs-10.4* Monos-5.8
Eos-0.3 Baso-0.6
___ 11:00AM BLOOD Plt ___
___ 11:00AM BLOOD ___ PTT-28.8 ___
___ 11:00AM BLOOD Glucose-304* UreaN-26* Creat-2.7* Na-131*
K-4.1 Cl-90* HCO3-30 AnGap-15
___ 11:00AM BLOOD cTropnT-0.30*
___ 11:00AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.7
___ 11:04AM BLOOD Lactate-1.6
___ 12:50PM URINE RBC-20* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
___ 12:50PM URINE Blood-SM Nitrite-NEG Protein->600
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-LG
===================
LABS ON DISCHARGE:
===================
___ 06:27AM BLOOD WBC-3.0* RBC-2.64* Hgb-8.6* Hct-26.4*
MCV-100* MCH-32.7* MCHC-32.7 RDW-14.9 Plt ___
___ 06:27AM BLOOD Plt ___
___ 06:27AM BLOOD Glucose-177* UreaN-34* Creat-3.2*# Na-133
K-4.3 Cl-95* HCO3-27 AnGap-15
___ 06:27AM BLOOD Calcium-9.0 Phos-4.2 Mg-1.8
===================
IMAGING:
===================
___ CXR AP IMPRESSION: Moderate cardiomegaly with pulmonary
edema and likely small bilateral pleural effusions.
___ EKG Sinus rhythm. Right bundle-branch block.
Anterolateral ST segment depression consistent with left
ventricular hypertrophy or myocardial ischemia. Compared to the
previous tracing of ___ there is an increase in sinus rate.
___ EKG Sinus rhythm. Right bundle-branch block. Left
ventricular hypertrophy. Anterolateral ST segment abnormalities
most consistent with left ventricular hypertrophy, although
myocardial ischemia cannot be fully excluded. Compared to
tracing #1 the findings are similar.
Brief Hospital Course:
___ with known CAD s/p CABG, sHF(LVEF 30%), dual-chamber
pacemaker for intermittent complete heart block in ___, CKD,
DM, HTN, HLD and autoimmune hepatitis c/b cirrhosis, recently
admitted for NSTEMI and flash pulmonary edema who p/w shortness
of breath and elevated troponin, treated as acute on chronic
systolic HF/Flash Pulmonary Edema in the setting of HTN.
=============
ACUTE ISSUES:
=============
# Acute on chronic systolic heart failure/flash pulmonary edema:
Pt w/sHF (LVEF 30% on echo ___, p/w dyspnea, thought to be ___
flash pulmonary edema in the setting of HTN. Workup significant
for elevated proBNP (>70,000), CXR showing pulmonary edema &
physical exam findings c/w volume overload. Pt's weight on
admission (70.4Kg) was below weight on recent discharge (71.5
kg), & has now downtrended to 67.6Kg. Trialed diuresis with 80
IV lasix without much effect. Pt had 2L's taken off via
ultrafiltrate & 2.5 taken off via HD, w/SBP's trending down to
the 120's-150's. She underwent frequent ultrafiltration using
lower extremity pressures to guide her blood pressure (she has
PAD and a 50mmHg gradient between central aortic pressure and
non-invaive upper extremity cuff pressures). She became
hypotensive when getting weight down below 68.3kg so this is her
dry weight. At that weight crackles improved, breathing felt
better and cough improved. The reason for decompensation and
flash pulmonary edema at the time of admission was hypertensive
emergency because upper extremity pressures were being used to
guide dialysis and she was being under-ultrafiltrated.
# HTN: patient with a history of HTN, presented w/SBP into the
190's. Patient was given nitroglycerin gtt & underwent
ultrafiltrate & HD, with improved of SBP's to the 120's-150's.
Patient was maintained on carvedilol and valsartan as above.
-consider increasing valsartan if blood pressures increase on
home diet
# CAD/NSTEMI: patient with a history of CAD p/w dyspnea, found
to have troponin elevated to 0.3 & downtrending, was 0.82 on
prior admission. In the setting of mild, downtrending
troponemia, absence of chest pain, there was little concern for
ACS. Likely due to demand in setting of hypertension.
-Patient was continued on home doses of ASA,rosuvastatin,
carvedilol, clopidogrel.
# End Stage Renal Disease on HD (TThS): On prior admission, pt
had tunneled HD catheter placed and dialysis initiated. She
underwent ultrafiltrate & HD, & was continued on nephrocaps.
-BP to be taken in LLE
# Anemia: patient with recent GI bleed as well as anemia of
chronic disease, p/w Hct=27.3. Pt endorsed BRBPR & was hemoccult
positive on ED exam, but BRBPR resolved & Hct stable at 28.1 on
discharge. Pt continued on home iron & maintained on
pantoprozole for recent GI bleed.
-Given possibility of CHF exacerbation in the setting of anemia,
continue to monitor Hb/Hct in outpatient setting.
# Anxiety/depression: patient with hx anxiety, reported to be
anxious. Psychiatry consulted & recommended xanax prn anxiety.
Pt became confused when she received ativan, please avoid in the
future. Social work consulted & provided supportive counseling
during hospitalization. Patient was continued on home
clonazepam.
-cont clonazepam at home, xanax 0.25mg rather than ativan for
anxiety
#Complicated UTI: Pt had catheter. UA on admission showed pyuria
w/WBC's>182 and culture grew GBS. Although she was asymptomatic,
given her confusion (concurrent with receiving ativan), she was
treated for complicated UTI with 7 day course of abx,
transitioned to PO ampicillin.
-Discharged on Day___, cont ampicillin 500mg PO BID for 4 more
days, give after dialysis
================
CHRONIC ISSUES:
================
# Asthma: patient with a history of asthma, was not wheezy
during admission. was continued on home ipratropium-albuterol
nebs.
# Diabetes mellitus: pt with history of DM, insulin dependent.
Pt maintained on diabetic diet, home NPH, & humalog sliding
scale during hospital course, with sugars 100s-200s.
# Autoimmune hepatitis: Child's A cirrhosis. Patient maintained
on home doses of ursodiol & azathioprine.
-stopped hydroxyzine given episode of delirium, and pt denied
pruritis
# Hypothyroidism: patient with history of hypothyroidism,
asymptomatic.
-Continued on home levothyroxine during hospital course.
====================
TRANSITIONAL ISSUES:
====================
-Patient w/Bilateral upper extremity subclavian stenosis.
Accurate blood pressure measurements can only be obtained via
measurement in the lower extremities.
-Given possibility of CHF exacerbation in the setting of anemia,
continue to monitor Hb/Hct in outpatient setting.
-Dry weight 68.3kg
-Continue ampicillin 500mg PO BID to complete 7 day course (Day
___ for complicated UTI.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Azathioprine 100 mg PO DAILY
2. Calcium Carbonate 500 mg PO TID
3. Docusate Sodium 100 mg PO BID
4. Ferrous Sulfate 325 mg PO DAILY
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Nephrocaps 1 CAP PO DAILY
7. Psyllium 1 PKT PO BID
8. Rosuvastatin Calcium 20 mg PO 4X/WEEK (___)
9. Senna 8.6 mg PO BID:PRN constipation
10. Vitamin D 50,000 UNIT PO 1X/WEEK (TH)
11. Valsartan 80 mg PO DAILY
12. Carvedilol 25 mg PO BID
13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
14. Pantoprazole 40 mg PO Q12H
15. TraZODone 25 mg PO HS:PRN sleep
16. Benzonatate 100 mg PO TID
17. Fluticasone Propionate 110mcg 2 PUFF IH BID
18. Clopidogrel 75 mg PO DAILY
19. Aspirin 81 mg PO DAILY
20. ClonazePAM 0.5 mg PO BID
21. Sodium Chloride Nasal 1 SPRY NU QID:PRN congestion
22. Guaifenesin 10 mL PO Q6H
23. Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
Humalog 1 Units Bedtime
NPH 19 Units Breakfast
24. hydrOXYzine HCl 12.5 mg oral BID
25. Men-Phor (camphor-menthol) 0.5-0.5 % topical qid:prn itching
26. Nitroglycerin SL 0.4 mg SL PRN chest pain
27. Epoetin Alfa 10,000 UNIT IV DAILY:PRN dialysis
28. Ursodiol 500 mg PO BID
Discharge Medications:
1. Blood Pressure Measurement
Blood pressure measurement must be taken in patient's left leg.
Arm measurements are not accurate.
2. Carvedilol 25 mg PO BID
3. ClonazePAM 0.5 mg PO BID
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Valsartan 80 mg PO DAILY
6. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety
RX *alprazolam 0.25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. Aspirin 81 mg PO DAILY
8. Azathioprine 100 mg PO DAILY
9. Benzonatate 100 mg PO TID
10. Calcium Carbonate 500 mg PO TID
11. Clopidogrel 75 mg PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Ferrous Sulfate 325 mg PO DAILY
14. Fluticasone Propionate 110mcg 2 PUFF IH BID
15. Nephrocaps 1 CAP PO DAILY
16. Pantoprazole 40 mg PO Q12H
17. Ursodiol 500 mg PO BID
18. Vitamin D 50,000 UNIT PO 1X/WEEK (TH)
19. Ampicillin 500 mg PO Q12H Duration: 5 Days
RX *ampicillin 500 mg 1 capsule(s) by mouth twice daily Disp #*8
Capsule Refills:*0
20. Epoetin Alfa 10,000 UNIT IV DAILY:PRN dialysis
21. TraZODone 25 mg PO HS:PRN sleep
22. Rosuvastatin Calcium 20 mg PO 4X/WEEK (___)
23. Senna 8.6 mg PO BID:PRN constipation
24. Psyllium 1 PKT PO BID
25. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
26. Nitroglycerin SL 0.4 mg SL PRN chest pain
27. Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
Humalog 1 Units Bedtime
NPH 19 Units Breakfast
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS:
Acute on Chronic systolic heart failure/Flash Pulmonary Edema
SECONDARY DIADNOSIS:
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted because you
were feeling short of breath. We determined that this was likely
due to fluid in your lungs because of high blood pressure. We
removed 5L of fluid via dialysis, your blood pressures declined
& your shortness of breath resolved.
We treated you for a possible urinary tract infection. Please
continue taking ampicillin 500mg by mouth twice daily for a
total of 7 days.
Going forward, we have included in your discharge work the
recommendation to future care providers that accurate blood
pressures must be taken in your legs due to blockages in the
blood vessels in your arms.
It is important that you continue with your regular schedule of
dialysis, so that you do not have build-up of fluid in your
body. Additionally, please continue to weigh yourself every
morning, and call your physician if your weight increases more
than 3 pounds.
With best wishes,
Your ___ Team
Followup Instructions:
___
|
10407730-DS-26 | 10,407,730 | 22,555,946 | DS | 26 | 2151-04-30 00:00:00 | 2151-04-30 20:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Lipitor / Diovan
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
AV-fistula creation - ___
History of Present Illness:
___ with h/o CAd s/p CABG, SHF (EF=30%), HTN, ESRD on HD
(TThSa), AH c/b cirrhosis, who presents with dyspnea x 2 days.
She started feeling short of breath yesterday, and endorses
cough productive of white phlegm, and worsening orthopnea ___
pillows instead of ___ pillows). She was seen by Dr. ___
___ who noted increased crackles in pulmonary exam and
order a CXR that showed pulm edema. She was dialyzed yesterday
with 3.6L removed, but still c/o dyspnea at rest and orthopnea.
In the ED, initial vitals were: 97.6 65 98/64 18 94% RA
Labs were unremarkable except for Cr of 3.6. CXR: pulmonary
edema, bilat pleural effusions. Renal was consulted and
recommended admission for diuresis and aggressive dialysis. On
transfer vitals were: 97.8 68 124/55 17 100% RA
On arrival to the floor, she reports feeling like she has never
recovered to her baseline since her admission 6 weeks ago. She
feels like she has continued to have dyspnea with exertion
though reports that it is worse than prior now. She endorses
poor sleep secondary to orthopnea but denies PND. She does
report recently discontinuing Valsartan secondary to cough,
which has continued but improved since stopping the medication.
She denies fevers, chills, sick contacts, leg edema, CP,
increased salt intake.
Of note, recently admitted to ___ service for hypertensive
crisis w/ pulm edema.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations.
Denies nausea, vomiting, diarrhea, constipation or abdominal
pain. No dysuria. Denies arthralgias or myalgias. Ten point
review of systems is otherwise negative.
Past Medical History:
- CAD (s/p stenting in ___, CABG ___. Cardiac cath ___
for angina showed severe 3-vessel native dx, patent LIMA-LAD
with a 30% stenosis at touchdown and a 50-60% mid vessel
stenosis, patent SVG-OM graft and known occluded SVG-RCA graft
with good collateral flow)
- Diabetes
- Hypertension
- ESRD (per report biopsy-proven diabetic nephropathy. Not yet
on HD)
- 1.1-cm right renal artery aneurysm, stable in size.
- Stents in upper and lower poles of left renal artery (patent
at ___ cath).
- Asthma
- Autoimmune Hepatitis- hepatitis at age ___
- Cholelithiasis
- Pacemaker
- Depression
- Anemia
- Hypothyroidism
- breast cancer s/p L mastectomy and implant
Social History:
___
Family History:
Father died at ___ years old from an MI. She has a brother who
has a history of cardiomyopathy and an MI at age of ___. Oldest
son suffered an MI and had stents at age ___. Youngest son had
stent placed at ___ at age ___.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.2 146/68 70 20 97RA
General: NAD, comfortable, pleasant. +conversational dyspnea
HEENT: NCAT, PERRL, EOMI
Neck: supple, JVP at 10cm with kussmaul's sign.
CV: regular rhythm, distant heart sounds attenuated by breast
implant. no m/r/g
Lungs: bibasalar crackles extending ___ way up back.
Abdomen: soft, NT/ND, BS+
Ext: WWP, trace edema, ___ pulses intact
Neuro: moving all extremities grossly, AAOx3
DISCHARGE PHYSICAL EXAM:
VS: 98.2 ___ 58-66 16 100RA 66.6 from 65.7(dry weight
65kg)
General: NAD, comfortable, pleasant. Bright affect. Lying in
bed. HEENT: NCAT, PERRL, EOMI
Neck: supple, JVP at 9cm
CV: regular rhythm, distant heart sounds attenuated by breast
implant. no m/r/g
Lungs: CTAB.
Abdomen: soft, NT/ND, BS+
Ext: WWP, no edema, ___ pulses intact
Neuro: moving all extremities grossly, AAOx3
Pertinent Results:
ADMISSION LABS:
___ 12:45PM BLOOD WBC-3.5* RBC-2.56* Hgb-8.5* Hct-26.6*
MCV-104* MCH-33.1* MCHC-31.9 RDW-15.0 Plt ___
___ 12:45PM BLOOD Neuts-57.9 ___ Monos-5.3 Eos-1.2
Baso-0.5
___ 12:45PM BLOOD ___ PTT-27.3 ___
___ 06:22AM BLOOD Ret Aut-3.1
___ 12:45PM BLOOD Glucose-135* UreaN-26* Creat-3.9* Na-134
K-3.8 Cl-94* HCO3-26 AnGap-18
___ 06:22AM BLOOD Albumin-3.6 Calcium-8.9 Phos-3.8 Mg-1.5*
___ 06:22AM BLOOD ALT-16 AST-20 LD(LDH)-190 AlkPhos-101
TotBili-0.5
___ 12:45PM BLOOD proBNP-GREATER TH
___ 06:35AM BLOOD cTropnT-0.08*
___ 10:00AM BLOOD cTropnT-0.05*
___ 02:04PM BLOOD Lactate-1.7
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-3.3* RBC-2.64* Hgb-9.0* Hct-27.8*
MCV-105* MCH-34.1* MCHC-32.4 RDW-14.4 Plt ___
___ 06:30AM BLOOD Glucose-159* UreaN-30* Creat-4.3* Na-130*
K-4.2 Cl-93* HCO3-27 AnGap-14
___ 06:30AM BLOOD Phos-4.1 Mg-1.9
STUDIES:
+ CXR ___: In comparison with the study ___, there
is substantial increase in the degree of pulmonary edema with
continued enlargement of the cardiac silhouette and blunting of
the costophrenic angles. The central catheter and pacer device
remain in place. In the appropriate clinical setting, the
opacification at the left mid and lower zones could reflect
superimposed pneumonia.
+ CXR ___: Right-sided large-bore central venous catheter
is again seen terminating in the right atrium. Dual lead
right-sided pacemaker is stable in position. There is persistent
blunting of the bilateral costophrenic angles suggesting trace
pleural effusions with overlying atelectasis. Perihilar
opacities are consistent with pulmonary edema which appear
grossly stable to possibly minimally decreased as compared to
the prior study. The cardiac silhouette
remains enlarged. The aorta is calcified.
IMPRESSION: Small bilateral pleural effusions again seen.
Pulmonary edema which may be slightly improved since the prior
study. Persistent cardiomegaly.
+ CXR ___: Mild pulmonary edema is slightly improved
compared to the prior exam. Note is made of mild bibasilar
atelectasis. There is no evidence of pneumothorax. No new focal
consolidations concerning for pneumonia are identified.
+ ECG ___: Sinus rhythm. Frequent atrial premature
contractions.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 ___ 77 84 -85
+ TTE ___: The left atrium is moderately dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is moderate global left ventricular hypokinesis (LVEF =
30%). The right ventricular cavity is mildly dilated with mild
global free wall hypokinesis. The ascending aorta is mildly
dilated. The aortic valve leaflets are moderately thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. There is severe mitral annular calcification. There is
mild functional mitral stenosis (mean gradient 5 mmHg at 67 bpm)
due to mitral annular calcification. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Symmetric LVH with moderate global left ventricular
systolic dysfunction. Mild right ventricular systolic
dysfunction. Mild calcific mitral stenosis. At least mild mitral
regurgitation. Mild pulmonary hypertension.
+ TTE - ___: The estimated right atrial pressure is ___
mmHg. There is mild symmetric left ventricular hypertrophy with
normal cavity size. There is moderate regional left ventricular
systolic dysfunction with hypokinesis of the inferior and
inferolateral walls and the distal septum and anterior walls and
apex. The remaining segments contract normally (LVEF = 35 %). No
masses or thrombi are seen in the left ventricle. Right
ventricular chamber size is normal. with mild global free wall
hypokinesis. The aortic valve leaflets are mildly thickened
(?#). Mild (1+) aortic regurgitation is seen. Mitral
regurgitation is present but cannot be quantified.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with regional systolic dysfunction most
c/w multivessel CAD (LAD and PDA distribution).
Compared with the prior study (images reviewed) of ___,
the findings are similar.
Brief Hospital Course:
___ with known CAD s/p CABG, sHF(LVEF 30%), dual-chamber
pacemaker for intermittent complete heart block in ___, CKD,
DM, HTN, HLD and autoimmune hepatitis c/b cirrhosis, recent
NSTEMI and recent admission for acute on chronic systolic HF due
to HTN presenting with acute on chronic heart failure.
# Acute on chronic systolic heart failure: Pt w/ sHF (LVEF 30%
on echo ___, p/w dyspnea x 2 days. CXR with pulmonary edema,
bilateral effusions. She was dialyzed to 65.7 kg, close to her
goal dry weight of 66kg. Her dialysis was complicated initially
by episodes of symptomatic hypotension but this resolved by the
end of the hospitalization. Started losartan 50 mg, which she
will take everyday except for her dialysis days. Will follow-up
with a heart failure specialist
# End Stage Renal Disease on HD (TThS): SOB and orthopnea
improved with aggressive dialysis sessions which were
complicated by hypotension On HD since ___. s/p AV fisutla
creation on ___
# HTN: Recent admission for hypertensive crisis leading to flash
pulmonary edema. BP adequately well controlled now. Recently
stopped valsartan ___ cough. We continued home carvedilol and
started losartan, though held these meds prior to hemodialysis.
# Small Bilateral Pleural Effusions: New pleural effusions noted
on CXR. Likely from decompensated heart failure. However, renal
consulted and says that dialysis not very effective at removing
fluid from pleural space. Likely not large enough to cause her
level of dyspnea. Repeat CXR ___ with improvement.
# CAD s/p CABG with recent NSTEMI: continued home ASA,
rosuvastatin, carvedilol, clopidogrel.
# Diabetes mellitus: pt with history of DM, insulin dependent.
Continued home NPH, & humalog sliding scale
# Anemia: patient with recent GI bleed as well as anemia of
chronic disease, p/w Hct=27.3. Pt endorsed BRBPR & was hemoccult
positive on ED exam, but BRBPR resolved & Hct stable at 28.1 on
discharge. Pt continued on home iron & maintained on
pantoprozole for recent GI bleed.
-Given possibility of CHF exacerbation in the setting of anemia,
continue to monitor Hb/Hct in outpatient setting.
# Asymptomatic UTI: No complaints of dysuria, frequency,
urgency. No
white count or fevers. No confusion. Treated on last recently
for asymptomatic UTI given delirium. Held antibiotics as
clinically stable and asymptomatic.
# Anxiety/depression: Well contolled on home clonazepam and
zoloft.
# Autoimmune hepatitis: Diagnosed at age ___. Child's A cirrhosis.
Continued home doses of ursodiol & azathioprine.
# Hypothyroidism: Continued home levothyroxine during hospital
course.
TRANSITIONAL ISSUES:
- would recommend followup in device clinic for concern about
intermittently not pacing correctly.
- Will need to follow-up in Transplant clinic to monitor
progression of AV fistula.
- Will followup with the Heart failure service.
- No BPs or labs on left arm as has left upper arm AV fistula
- take blood pressure measurements on left leg.
- hold carvedilol and losartan, prior to HD
- Resume outpatient dialysis (___)
# CODE: Full (confirmed)
# EMERGENCY CONTACT: ___ (___) ___ Cell phone:
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 25 mg PO BID
2. ClonazePAM 0.5 mg PO TID
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Azathioprine 100 mg PO DAILY
6. Calcium Carbonate 500 mg PO TID
7. Clopidogrel 75 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Ferrous Sulfate 325 mg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. Pantoprazole 40 mg PO Q12H
12. Ursodiol 500 mg PO BID
13. Vitamin D 50,000 UNIT PO 1X/WEEK (TH)
14. Rosuvastatin Calcium 20 mg PO 4X/WEEK (___)
15. Senna 8.6 mg PO BID:PRN constipation
16. Psyllium 1 PKT PO BID
17. Nitroglycerin SL 0.4 mg SL PRN chest pain
18. NPH 8 Units Breakfast
19. Sertraline 12.5 mg PO DAILY
20. Lunesta (eszopiclone) 3 mg oral QHS insomnia
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Azathioprine 100 mg PO DAILY
3. Calcium Carbonate 500 mg PO TID
4. Carvedilol 25 mg PO BID
5. ClonazePAM 0.5 mg PO TID
6. Clopidogrel 75 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Ferrous Sulfate 325 mg PO DAILY
9. NPH 8 Units Breakfast
RX *NPH insulin human recomb [Humulin N] 100 unit/mL 8 units 8
Units before BKFT; Disp #*1 Vial Refills:*0
10. Levothyroxine Sodium 25 mcg PO DAILY
11. Lunesta (eszopiclone) 3 mg oral QHS insomnia
12. Nephrocaps 1 CAP PO DAILY
13. Pantoprazole 40 mg PO Q12H
14. Psyllium 1 PKT PO BID
15. Rosuvastatin Calcium 20 mg PO 4X/WEEK (___)
16. Senna 8.6 mg PO BID:PRN constipation
17. Sertraline 25 mg PO DAILY
RX *sertraline 25 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
18. Ursodiol 500 mg PO BID
19. Vitamin D 50,000 UNIT PO 1X/WEEK (TH)
20. Acetaminophen 650 mg PO TID
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth PRN Disp #*90 Tablet Refills:*0
21. Nitroglycerin SL 0.4 mg SL PRN chest pain
22. Losartan Potassium 50 mg PO DAILY
Take this medication everyday EXCEPT on dialysis days
RX *losartan 50 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY: Acute on chronic decompensated systolic Heart failure,
End stage renal disease on dialysis, fistula placement
SECONDARY: Diabetes Mellitus, Hypertension, 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 to provide you with care during your stay at
___. You were admitted for
shortness of breath. We felt that your symptoms were due to both
your heart and kidney failure causing a build up of fluid in
your lungs. We removed the fluid with dialyis and lasix, which
improved your symptoms. It is important that you weigh yourself
every morning, and call your doctor if weight goes up more than
3 lbs, if you have any worsened shortness of breath, or if you
notice swelling in your legs.
You had a fistula done on ___ and will need to follow up with
the transplant surgeons.
Also, you will be following up with our heart failure
specialist. In order to better treat your heart failure, you
will also start a new medication called losartan.
Wishing you the very best,
Your team at ___
Followup Instructions:
___
|
10407730-DS-28 | 10,407,730 | 24,033,324 | DS | 28 | 2151-07-24 00:00:00 | 2151-07-29 11:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Lipitor / Diovan / Latex, Natural Rubber
Attending: ___.
Chief Complaint:
Back Pain, Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an ___ female the past history of CAD s/p
CABG and multiple stents, DMII, HTN, ESRD s/p HD fistula,
autoimmune hepatitis c/b cirrhosis who is transferred from
urgent care with bilateral flank pain and fever concerning for
sepsis. She was in her usual state of health until this morning,
when she woke up with an ___ lower back pain. The pain was
described as aching, with a band-like distribution extending
bilaterally across the spinous processes to both flanks. The
quality of the pain does not change with posture or activity.
She denied any associated numbness and tingling or radiation to
the lower extremities. She does not have any history of lower
back pain; this is the first occurrence of this pain.
She also noted that she felt a generalized weakness during this
time. She felt unsteady when standing up and felt physically
weak. She took naproxen with minor relief of symptoms. She then
presented to urgent care. She was found to have a temperature of
99.6. Labs at urgent care were notable for leukocytosis with
left shift and hyponatremia.
She denies any chills, nausea, vomiting, SOB, cough, chest pain,
abdominal pain, diarrhea, dysuria, urinary urgency leading up to
and during this episode. She was in her usual state of health
until this morning. Of note, she began dialysis over the summer
via tunneled catheter. She had a LUE AVF placed on ___, which
was used for HD for the first time yesterday. Multiple
operations were done on the fistula, last one in ___.
She was transferred to ___ for further evaluation. In the ED,
her vitals were: T98.5 HR80 BP121/85 RR18 O2sat 97%/RA. She did
have one fever spike to 101.8 in the ED. Her labs were notable
for: WBC 14.2 w/ left shift (neuts 92.5), Lactate 2.0, Plt 88,
glucose 200, BUN 41, Cr 3.5, Na 129. Cardiac tests were notable
for: TropT 0.02, ___ ___. Liver tests were notable for: ALT
12, AST 22, AlkPhos 201, Tbili 0.6. UA was negative for
infectious source with no WBC, bacteria, yeast but showed 600
protein and 100 glucose in the urine. EKG was negative. CXR
showed improving pulmonary edema with no focal consolidation.
Patient was treated empirically with vancomycin 1g and
ceftriaxone 1g IV and given IVF.
On Transfer Vitals were: 98.4 133/42 70 18 98/RA. She states
that she feels much stronger than this morning and her back pain
has decreased to ___.
Review of Systems:
(+) fever, back pain as per HPI
(-) 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:
- CAD (s/p stenting in ___, CABG ___. Cardiac cath ___
for angina showed severe 3-vessel native dx, patent LIMA-LAD
with a 30% stenosis at touchdown and a 50-60% mid vessel
stenosis, patent SVG-OM graft and known occluded SVG-RCA graft
with good collateral flow)
- Diabetes
- Hypertension
- ESRD (per report biopsy-proven diabetic nephropathy. Not yet
on HD)
- 1.1-cm right renal artery aneurysm, stable in size.
- Stents in upper and lower poles of left renal artery (patent
at ___ cath).
- Asthma
- Autoimmune Hepatitis- hepatitis at age ___
- Cholelithiasis
- Pacemaker
- Depression
- Anemia
- Hypothyroidism
- breast cancer s/p L mastectomy and implant
Social History:
___
Family History:
Father died at ___ years old from an MI. She has a brother who
has a history of cardiomyopathy and an MI at age of ___. Oldest
son suffered an MI and had stents at age ___. Youngest son had
stent placed at ___ at age ___.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.4 133/42 70 18 98/RA
General: awake, alert, NAD
HEENT: NCAT, PERRL, EOMI. No scleral icterus.
Neck, supple, full ROM, No cervical lymphadenopathy. No pain
elicited with neck flexion or extension.
CV: RRR, ns S1+S2, no m/r/g 2+ radial pulses 2+ b/l 1+ DP b/l
Lungs: Basilar crackles heard in lower third of lung in a
symmetric pattern bilaterally. Good air movement b/l in all
fields, no wheezing/rhonchi
Abdomen: Soft, nontender, nondistended. No palpable masses.
Ext: Dry and WWP, no clubbing, cyanosis. trace edema to shins
Neuro: AAOx3. ___ strength throughout upper and lower
extremities. Straight leg test negative. Moving all extremities
with purpose. Cranial nerves grossly intact. Sensation intact
and symmetric to light touch in lower extremities.
Back: No spinous process or paraspinal tenderness. Full ROM of
back flexion and extension. Left-sided, soft moveable mass is
noted which patient states has been unchanged for many years. No
muscle spasm with palpation. No CVA tenderness
==============================
DISCHARGE EXAM:
Vitals: Tmax/Tcurr:98.3 BP146-174/57-67 HR61-64 RR18 O2:100/RA
General: awake, alert, NAD
HEENT: NCAT, PERRL, EOMI. No scleral icterus.
Neck: soft, supple, full ROM, No cervical lymphadenopathy.
CV: RRR, ns S1+S2, no m/r/g
Lungs: Basilar crackles heard R>L. Breathing nonlabored.
Abdomen: Soft, nontender, nondistended.
Ext: Dry and WWP, no clubbing, cyanosis, edema.
Neuro: AAOx3. ___ strength throughout upper and lower
extremities.
Back: Unchanged from admission. No spinous process or paraspinal
tenderness. Full ROM of back flexion and extension. Left-sided,
soft moveable mass is noted which patient states has been
unchanged for many years. No muscle spasm with palpation. No CVA
tenderness.
Pertinent Results:
ADMISSION LABS:
Blood:
___ 10:10AM BLOOD WBC-14.2*# RBC-3.44* Hgb-11.4* Hct-33.6*
MCV-98 MCH-33.1* MCHC-33.9 RDW-15.3 Plt Ct-99*
___ 10:10AM BLOOD Neuts-92.9* Lymphs-2.1* Monos-4.2 Eos-0.1
Baso-0.2 Im ___
___ 10:10AM BLOOD Glucose-200* UreaN-41* Creat-3.5* Na-129*
K-4.1 Cl-91* HCO3-22 AnGap-20
___ 11:40AM BLOOD cTropnT-0.02* ___
___ 11:40AM BLOOD ALT-12 AST-22 AlkPhos-201* TotBili-0.6
___ 11:40AM BLOOD Albumin-3.9 Calcium-9.6 Phos-2.3*# Mg-1.6
Urine:
___ 11:40AM URINE Color-Yellow Appear-Clear Sp ___
___ 11:40AM URINE RBC-0 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
___ 11:40AM URINE Blood-NEG Nitrite-NEG Protein-600
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
IMAGING:
CXR (___):
Minimal to mild pulmonary edema, improved since prior chest
radiograph. Small bilateral pleural effusions and mild
cardiomegaly. No focal consolidation identified.
CT Abd/pelvis ___:
Wet Read: ATRO TUE ___ 7:19 ___
1. Enlarged heart with interlobular septal thickening at the
bases as well as
right nonhemorrhagic pleural effusion, findings suggestive of
hydrostatic
pulmonary edema cardiogenic in origin. Extensive coronary
calcifications
noted.
2. Prominent 1.9 x 1.2 cm paraesophageal node (2:10) noted as
well as a small
hiatal hernia.
3. Cholelithiasis, no evidence to suggest cholecystitis.
4. Nodular liver in keeping with known diagnosis of cirrhosis.
No evidence of
ascites. No focal lesion is seen. Slightly heterogeneous
attenuation of the
liver is noted, possibly to suggest passive hepatic congestion.
5. Diverticular disease without evidence of diverticulitis.
6. Right adnexal 3.7 x 4.___efined oval cystic
structure, present on
prior examination dated ___, for which follow up
ultrasound if
not yet preformed is recommended.
7. Unchanged right renal calcified aneurysm measuring 1.3 x 1.1
cm (2:28).
Additional bilateral renal cortical hypodensities are
statistically most
compatible with simple cysts.
8. Extensive atherosclerotic calcifications involving the
abdominal aorta,
renal arteries and bilateral common iliac arteries extending
into external and
internal iliac arteries. These appear, however, patent.
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-3.0* RBC-3.24* Hgb-10.6* Hct-32.3*
MCV-100* MCH-32.7* MCHC-32.8 RDW-15.7* Plt ___
___ 07:30AM BLOOD Glucose-115* UreaN-32* Creat-3.6*#
Na-131* K-4.2 Cl-90* HCO3-27 AnGap-18
___ 06:14AM BLOOD CRP-82.2*
Brief Hospital Course:
Mrs ___ is ___ female the past history of CAD s/p
CABG and multiple stents, DMII, HTN, ESRD s/p HD fistula,
autoimmune hepatitis c/b cirrhosis who presented with bilateral
back pain and fever to 101.8.
ACUTE ISSUES
# Back Pain and Fever: Patient admitted with bilateral
back/flank pain and fevers. One-time fever of 101.8 in ___ ED.
No point tenderness on MSK exam. Septic workup, including CXR
and UA, performed in the ED were negative for a source. Blood
cultures pending at time of discharge. One dose of vancomycin
and ceftriaxone given in the ED and then discontinued. Initial
concern for osteomyelitis given immunocompromised, but patient
remained afebrile and experienced resolution of her back pain
off antibiotics. Also low likelihood given band-like,
intermittent nature of pain. Abd/pelvis CT scan showed no
potential sources of infection. Given these findings, back pain
was probably MSK related. Fever could have been due to an
inflammatory response or less likely transient bacteremia in the
setting of starting HD through AV fistula site.
CHRONIC ISSUES:
# ESRD: Patient underwent normally scheduled dialysis on
___ while hospitalized. Dialysis was performed on ___
through her AV fistula.
# Chronic syst CHF: Last echo in ___ showed mild global free
wall hypokinesis with an EF of 35%. BNP in the ED was 68,258,
with previous BNPs greater than assay limits. Not volume
overloaded and underwent normally scheduled dialysis.
# Hyponatremia: Patient with sodium chronically around 130.
Patient was placed on 1L fluid restriction and Na level remained
stable throughout admission.
# Thrombocytopenia: Platelet count chronically around 100.
Stable throughout admission.
# Anemia: Stable throughout admission
# Cirrhosis: Patient with CP-A cirrhosis ___ autoimmune
hepatitis. Continued home doses of ursodiol & azathioprine.
# CAD: continued home ASA, rosuvastatin, carvedilol, and
clopidogrel.
# IDDM: Continued home NPH, & humalog sliding scale
# Anxiety/depression: Continued home clonazepam and zoloft.
# Hypothyroidism: Continued home levothyroxine
TRANSITIONAL ISSUES:
- Recommend followup ultrasound exam for right adnexal 3.7 x 4.4
cm cystic structure seen on CT.
-Trend back/abdominal exam
- prominent 1.9 x 1.2 cm paraesophageal node noted on CT
Abd/pelvis
CODE: Full Code
-Have HD cathter removed by ___. Should speak to HD team about
this.
Contact: ___ (Husband - HCP) Home: ___ Cell phone:
___
Medications on Admission:
1. Acetaminophen 650 mg PO TID:PRN Pain
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO TID
4. Carvedilol 25 mg PO BID
5. ClonazePAM 0.5 mg PO TID
6. Clopidogrel 75 mg PO DAILY
7. Docusate Sodium 100 mg PO DAILY
8. eszopiclone 3 mg oral QHS: PRN insomnia
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. Nitroglycerin SL 0.4 mg SL PRN Chest pain
12. Pantoprazole 40 mg PO Q12H
13. Psyllium 1 PKT PO BID
14. Rosuvastatin Calcium 20 mg PO 4X/WEEK (___)
15. Senna 8.6 mg PO BID:PRN Contipation
16. Sertraline 50 mg PO DAILY
17. Vitamin D 50,000 UNIT PO 1X/WEEK (TH)
18. Ursodiol 500 mg PO BID
19. Polyethylene Glycol 17 g PO DAILY
20. FiberCon (calcium polycarbophil) 625 mg oral QDaily PRN
21. Hydrocortisone Cream 1% 1 Appl TP EVERY OTHER DAY
22. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN PRN
23. NPH 8 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
24. Azathioprine 50 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. ClonazePAM 0.5 mg PO TID
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium 100 mg PO DAILY
6. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN PRN
7. Calcium Acetate 667 mg PO TID W/MEALS
8. Azathioprine 50 mg PO DAILY
9. NPH 8 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
10. Levothyroxine Sodium 25 mcg PO DAILY
11. Nephrocaps 1 CAP PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Ursodiol 500 mg PO BID
14. Sertraline 50 mg PO DAILY
15. Senna 8.6 mg PO BID:PRN Contipation
16. Rosuvastatin Calcium 20 mg PO 4X/WEEK (___)
17. Hydrocortisone Cream 1% 1 Appl TP EVERY OTHER DAY
18. FiberCon (calcium polycarbophil) 625 mg oral QDaily PRN
19. eszopiclone 3 mg oral QHS: PRN insomnia
20. Calcium Carbonate 500 mg PO TID
21. Acetaminophen 650 mg PO TID:PRN Pain
22. Nitroglycerin SL 0.4 mg SL PRN Chest pain
23. Polyethylene Glycol 17 g PO DAILY
24. Pantoprazole 40 mg PO Q12H
25. Psyllium 1 PKT PO BID
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary
Back pain
Systemic Inflammatory Response Syndrome
Secondary
CAD (s/p CABG in ___, multiple cardiac caths, most recently in
___: NSTEMI, drug-eluting stents placed)
- IDDM
- Hypertension
- CHE with rEF (EF 35%)
- ESRD (per report biopsy-proven diabetic nephropathy. On HD
since ___, received first HD through AV fistula yesterday)
- Autoimmune Hepatitis - hepatitis at age ___ w/ CP-A cirrhosis
- 1.1-cm right renal artery aneurysm, stable in size.
- Stents in upper and lower poles of left renal artery
- Asthma
- Cholelithiasis
- Pacemaker
- Depression
- Anemia
- Hypothyroidism
- breast cancer s/p L mastectomy and implant in ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to the hospital because ___ had fevers and
back pain. ___ were evaluated with blood tests and imaging of
your abdomen and spine. ___ were treated with a one time dose of
antibiotics and pain medications. Our CT imaging did not show
any concerning area of infection. Your fever and lab
abnormalities resolved with significant improvement in your back
pain.
Please take note of the following:
1. If ___ have any severe worsening of your back pain or new
fevers, please call your PCP or go to the ED immediately for
evaluation.
2. Please continue all your medications as prescribed and
continue your regular ___ dialysis schedule. Speak to your
Dialysis doctors about having your catheter removed.
3. Please make sure to keep all scheduled appointments,
including your appointment with Dr. ___ on ___.
Lastly, as ___ have a history of heart failure, please weigh
yourself every morning, call your doctor if your weight goes up
more than 3 lbs.
It was a pleasure taking care of ___! We all wish ___ the very
best.
- Your ___ Care Team
Followup Instructions:
___
|
10407740-DS-20 | 10,407,740 | 23,788,011 | DS | 20 | 2164-12-17 00:00:00 | 2164-12-19 18:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hyperbilirubinemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man with alcoholic cirrhosis listed for transplant
(decompensated by esophageal variceal bleed s/p banding, HE,
ascites, sober since ___, referred to ED from Transplant
Clinic for asymptomatic hyperbilirubinemia to 17 (up from 7.9 on
___. He reports that he feels well and denies any new
symptoms. No fever or chills, abdominal pain or distension,
nausea, vomiting, melena, hematochezia, anorexia, or confusion.
Patient reports he has been sober since ___ with only one
relapse (2 glasses of wine last ___). However, he has been
drinking significant amounts of non-alcoholic beer -- about ___
bottles per night, and occasionally 5 or 6 bottles. No
acetaminophen use. He did recently start several new
medications:
gabapentin, multivitamin (OTC), and vitamin E (OTC). He also
received a 5-day course of azithromycin for bronchitis about one
month ago.
In the ED, the patient was afebrile and hemodynamically stable.
- Exam was notable for jaundice and mild abdominal distension.
- Labs were notable for markedly elevated bili, Plt 87, INR 1.9,
negative tox screen, CEA 20
- Bedside ultrasound showed no tappable pocket
- Hepatology was consulted and recommended abdominal doppler,
infectious workup, and admission
- Abdominal Doppler was negative for biliary obstruction or PVT
- No medications were given
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise 10-point review of systems was negative.
Past Medical History:
Alcoholic cirrhosis listed for transplant (c/b varices s/p
banding, HE, and ascites)
Alcohol use disorder in remission (sober since ___
DM type 2
HTN
spontaneous pneumothorax in ______
prostate cancer s/p chemo in ___
right ear tumor as child and deaf in right ear
cholelithiasis
right inguinal repair
Social History:
___
Family History:
DM. No history liver disease.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
GENERAL: Jaundiced, friendly, NAD.
HEENT: +Scleral icterus. OP moist and clear.
CV: RRR, soft systolic murmur.
RESP: CTAB.
GI: Soft, distended, non-tender, no fluid wave.
GU: No suprapubic or CVA tenderness.
EXTR: Warm, trace pitting edema bilaterally. Multiple healing
abrasions on shins (patient reports he sustained these after a
fall).
NEURO: Alert, oriented, attentive. No asterixis.
SKIN: +Spider angiomata, +jaundice.
DISCHARGE PHYSICAL EXAMINATION:
===============================
VITALS: ___ 2245 Temp: 98.9 PO BP: 137/66 R Lying HR: 99
RR:
18 O2 sat: 98% O2 delivery: Ra
GENERAL: Jaundiced, NAD.
HEENT: Sclerae icteric. MMM.
NECK: JVP not elevated.
CV: RRR, systolic murmur heard over the LLSB. no m/r/g
RESP: Slight end-expiratory wheezes, no crackles or rhonchi.
Breathing comfortably on room air.
GI: Soft, grossly distended, nontender, no rebound or guarding.
GU: No CVA tenderness.
EXTR: Warm, 1+ edema in BLEs to knees. Multiple annular scaly
lesions on legs and upper extremities.
NEURO: AOx3, + minimal asterixis
SKIN: Spider angiomata on chest.
Pertinent Results:
ADMISSION LABS:
===============
___ 11:10AM BLOOD WBC-6.0 RBC-3.21* Hgb-11.1* Hct-31.3*
MCV-98 MCH-34.6* MCHC-35.5 RDW-15.9* RDWSD-57.1* Plt Ct-87*
___ 04:34AM BLOOD Neuts-60.6 Lymphs-18.6* Monos-16.1*
Eos-3.3 Baso-1.0 Im ___ AbsNeut-2.93 AbsLymp-0.90*
AbsMono-0.78 AbsEos-0.16 AbsBaso-0.05
___ 05:57AM BLOOD Hypochr-1+* Anisocy-1+* Poiklo-1+*
Macrocy-1+* Target-2+* Echino-1+* RBC Mor-SLIDE REVI
___ 11:10AM BLOOD ___
___ 11:10AM BLOOD UreaN-11 Creat-1.0 Na-135 K-3.9 Cl-93*
HCO3-23 AnGap-19*
___ 11:10AM BLOOD ALT-22 AST-94* LD(LDH)-204 AlkPhos-205*
TotBili-17.1* DirBili-9.2* IndBili-7.9
___ 11:10AM BLOOD Albumin-2.9*
___ 11:10AM BLOOD Hapto-41
___ 11:10AM BLOOD CEA-20.2* AFP-3.0
___ 04:34AM BLOOD IgM HAV-NEG
___ 08:57PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___:10AM BLOOD Ethanol-NEG
___ 10:09AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-LG* Urobiln-4* pH-6.5 Leuks-SM*
___ 10:09AM URINE RBC-0 WBC-12* Bacteri-FEW* Yeast-NONE
Epi-0
___ 10:09AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
DISCHARGE LABS:
=================
___ 08:19AM BLOOD WBC-6.9 RBC-2.14* Hgb-7.4* Hct-21.2*
MCV-99* MCH-34.6* MCHC-34.9 RDW-18.4* RDWSD-65.2* Plt Ct-69*
___ 05:45AM BLOOD ___ PTT-53.6* ___
___ 08:19AM BLOOD Glucose-267* UreaN-43* Creat-1.2 Na-134*
K-4.8 Cl-99 HCO3-21* AnGap-14
___ 08:19AM BLOOD ALT-31 AST-61* AlkPhos-123 TotBili-17.9*
___ 08:19AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.7
___ 06:04AM BLOOD Albumin-3.7 Calcium-9.3 Phos-3.7 Mg-1.8
MICROBIOLOGY:
=============
- BLOOD CULTURE - ___: NO GROWTH
- URINE CULTURE (___): VIRIDANS STREPTOCOCCI. >100,000
CFU/mL.
- BLOOD CULTURE (___): NO GROWTH
- BLODD CULTURE (___): NO GROWTH
- URINE CULTURE (___): NO GROWTH
- MRSA SCREEN (___): NO MRSA ISOLATED
- BLOOD CULTURE (___): NO GROWTH
- BLODD CULTURE (___): NO GROWTH
- BLOOD CULTURE (___): NO GROWTH
- BLODD CULTURE (___): NO GROWTH
- URINE CULTURE (___): NO GROWTH
IMAGING:
========
RUQUS - ___
1. Cirrhotic liver with trace ascites.
2. Splenomegaly.
3. Reversal of flow within the main portal vein as well as the
right branches. Flow is hepatopetal within the left portal vein
towards the patent umbilical vein. Apparent reversal of flow
within the SMV.
4. Cholelithiasis without evidence of acute cholecystitis. No
biliary ductal dilation.
CHEST X-RAYS - ___
No acute cardiopulmonary process.
RENAL U/S - ___
No evidence of renal calculus or hydronephrosis.
US ABDOMEN LIMITED - ___
Targeted grayscale ultrasound images were obtained of the 4
quadrants of the abdomen, revealing trace perihepatic ascites,
insufficient for paracentesis.
CHEST X-RAYS - ___
Cardiomediastinal silhouette is within normal limits. There has
been
worsening of the airspace opacities throughout both lungs,
previously only at the lung bases. Findings are suspicious for
worsening pneumonia. Pulmonary edema is felt to be less likely
given the lack of a widened vascular pedicle.
EGD ___
No evidence of esophageal varices
Ring in the distal esophagus
Congestion, petechiae, and mosaic mucosal pattern in the stomach
fundus and stomach body compatible with portal hypertensive
gastropathy
No evidence of gastric varices
Normal mucosa in the whole examined duodenum
NJ tube was placed past the third portion of the duodenum. The
tube was moved from the mouth into the nose and bridled at 110
cm. The tube flushed without difficulty.
CXR ___
Dubhoff tube passes below the diaphragm with its tip not
included in the field of view. Heart size and mediastinum are
stable. Surgical changes in the right apex are stable. Diffuse
opacities are concerning for pulmonary edema, mild and appear to
be similar to previous examination or minimally improved in
particular in the left lung. Small amount of right pleural
effusion cannot be excluded. Underlying infection is a
possibility. No appreciable pneumothorax.
Brief Hospital Course:
TRANSITIONAL ISSUES
=================
[] F/U labs to be drawn on ___ and faxed to Transplant
Hepatology (Fax ___
[] Will need ongoing adjustment of insulin for blood glucose
control while on tube feeds
[] Started on tube feeds for nutritional support to be continued
after leaving the hospital
[] Held spironolactone
BRIEF SUMMARY
=============
Mr. ___ is a ___ year-old male with history of decompensated
alcoholic cirrhosis (inactive on transplant list) who was
referred from outpatient clinic due to hyperbilirubinemia.
Patient found to have alcoholic hepatitis failed trial of 7-day
course of steroids. His hospital course was complicated by UTI
and hospital acquired pneumonia. He was started on tube feeds
for nutrition.
ACTIVE ISSUES
==============
# Alcoholic hepatitis
# Worsening hyperbilirubinemia
# Malnutrition
Patient was referred from outpatient clinic for
hyperbilirubinemia. Reported drinking non-alcoholic beer,
positive ethanol level at ___ on ___. On admission,
there was no evidence of PVT, GI bleed, no tappable ascitic
pocket was found. Blood cultures were negative. CXR was clear.
On admission, his MDF was 50.7. However, patient was not started
on steroids as he had UTI. After completing a 5-day course of
antibiotics and due to continued worsening of his numbers, he
was started on 7-day trial of prednisone 40mg on ___ till
___. His MDF on ___ was 74.3 and 67. Lille score on ___ > 0.45 (discontinued steroids given nonresponse and
hyperglycemia). Patient also had a dobhoff placed but vomited it
out on ___. Dobhoff was replaced on ___ under direct
visualization. Tube feeds were initiated. Rate was increased to
65 cc/hr, unable to tolerate further increases due to emesis.
Continued ursodiol 300mg BID.
# Esophageal varices with h/o bleeding s/p banding
# Portal hypertensive gastropathy
# Hematemesis
EGD ___ with 3 cords of grade I varices in the distal
esophagus. He had a small amount of hematemesis on initiation of
tube feeds with stable CBC which resolved and he was able to
tolerate tube feeds prior to discharge in addition to oral
intake. Nadolol was restarted on discharge.
# Viridans strep UTI (resolved)
UA from ___ showed WBC and bacteria. UCx grew gram positive
bacteria speciated to viridans strep. Patient was treated with
5-day course of ceftriaxone between ___.
# RLL Infiltrate c/f HAP (resolved)
# Leukocytosis
Patient had worsening SOB, mild tachycardia, leukocytosis, and
CXR c/f HAP. Possibly in setting of aspiration ___ emesis. U/A
with negative leuks/nitrites.BCx/UCx were negative. Repeat
abdominal ultrasound showed trace perihepatic ascites. Patient
was converted initially with cefepime for 7 days (D1:
___. Vancomycin was discontinued due to negative MRSA
swab.
# ___
Patient had a rise in his Cr to 1.4 on ___ that was thought to
be pre-renal in the setting of sepsis. He was started on
ceftriaxone as above and albumin challenge with 75g of 25%
albumin with subsequent improvement in kidney function to base
line of 1.0-1.1. Subsequently, patient was another rise in Cr to
1.4 on ___ that was also thought to be related to HAP. Patient
was treated with cefepime for HAP and albumin challenge. Cr was
stable at discharge at 1.5.
# ___
Discussions were held with patient and girlfriend about poor
prognosis with consideration of home hospice. Not eligible for
transplant until 3 months sobriety given recent ethanol level.
After discussion, he expressed his wish to continue with
treatment and placement of feeding tube.
# Metabolic acidosis
Likely due to chronic diarrhea from lactulose and renal
dysfunction. He was trialed on bicarbonate 1300mg TID but mild
acidosis persisted and this was discontinued due to lack of
improvement and concern for sodium load.
# Elevated CEA
Unclear etiology. Recent MRI showed a 5.5x4.5cm liver lesion
that appeared similar to background liver tissue rather than ___
or metastasis. No lesions on colonoscopy ___ at ___ nor
EGD ___ at ___.
# Alcohol use disorder
Counseled patient to avoid non-alcohol beer and continue his
current efforts to maintain sobriety. Multivitamin and thiamine
were started.
# DM2 on insulin
Home basal/bolus insulin regimen was adjusted with increased
requirements while at steroids. Blood glucose increased with
tube feeds and will likely need continued adjustments to insulin
regimen based on po intake.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. FoLIC Acid 1 mg PO DAILY
2. Spironolactone 25 mg PO DAILY
3. Nadolol 20 mg PO DAILY
4. Lactulose 30 mL PO BID hepatic encephalopathy
5. rifAXIMin 550 mg PO BID
6. Toujeo 60 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Gabapentin 300 mg PO QHS
8. Furosemide 20 mg PO DAILY
9. LORazepam 0.5-1 mg PO QHS:PRN insomnia
10. Thiamine 100 mg PO DAILY
11. Omeprazole 20 mg PO BID
12. Ursodiol 300 mg PO BID
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Glargine 30 Units Breakfast
Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Lactulose 30 mL PO TID
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Gabapentin 300 mg PO QHS
7. Nadolol 20 mg PO DAILY
8. Omeprazole 20 mg PO BID
9. rifAXIMin 550 mg PO BID
10. Thiamine 100 mg PO DAILY
11. Ursodiol 300 mg PO BID
12.Outpatient Lab Work
On ___
Please draw CBC, CHEM-10, LFTs, INR
Fax to: ___ TRANSPLANT HEPATOLOGY
FAX # ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
=================
ALCOHOLIC HEPATITIS
SECONDARY DIAGNOSES:
====================
LIVER CIRRHOSIS
___
HEPATIC ___
___
___ ACQUIRED PNEUMONIA
ALCOHOL USE DISORDER
TYPE 2 DIABETES
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 WERE ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because your bilirubin
levels were high.
- WHAT HAPPENED WHILE YOU WERE ADMITTED?
- Due to consumption of alcoholic beverages, you had acute
inflammation of your liver, a condition called alcoholic
hepatitis.
- You were found to have a urinary tract infection for which you
were treated with antibiotics.
- You were treated with a 7 day course of steroids for your
alcoholic hepatitis. However, due to lack of appropriate
response, this was stopped.
- You were found to pneumonia and were treated with IV
antibiotics.
- You had feeding tube placed to help you get enough nutrients
and help your liver to recover.
- WHAT SHOULD YOU DO WHEN LEAVE THE HOSPITAL?
- You should continue to take your medications as prescribed.
- You should attend your follow up appointments listed below.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10408090-DS-13 | 10,408,090 | 20,065,216 | DS | 13 | 2195-12-21 00:00:00 | 2195-12-23 05:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ Hx HTN, mild diastolic dysfunction, who is 2 weeks s/p R
hip replacement on ___, presenting from home with 2 episodes of
BRBPR and transient crampy abdominal pain that has now resolved.
After operation, pt had been started on Warfarin for post-op
anticoagulation. She had two episodes of guiace positive stools
at rehab last week which lead them to stop the warfarin (had
also had one or two black stool in hospital before discharge).
Had improved to the point of discharge home from rehab last
week. While at home at 4pm this afternoon, she had the 2
episodes of BRBPR. Did not have any stool with either episode,
just blood. Max of ___ cup. Never happened before. No history of
hemorrhoids. Reports that since hip surgery had been having
multiple loose BMs/day until 2 days ago. Over last 2 days had to
strain a bit to have a BM and BMs slightly painful. No history
of diverticulosis or diverticulitis. No fevers or chills. No
abdominal pain worth mentioning. Denies nausea, vomiting, chest
pain, cough, shortness of breath, lightheadedness, or dizziness.
When she stood up to walk she was momentary lightheaded but then
able to walk.
In the ED, initial VS: 99.3 74 122/74 16 98%. On rectal pt with
brown stool that was tracely guiac positive - no hemorrhoids
seen, Hgb was down to 11.4 from previous Hgb here of 13.5 in ___
(before the surgery) but reported to be up from most recent
levels, lactate was 1.4. No significant Abd pain and UA showed
boarderline UTI, which combined with elevated WBC lead ER to
give 1g IV CTX. Pt was admitted for serial Hct, VS monitoring,
+/- GI consult.
.
Currently, pt feels fine. No abd pain at all. Doesn't feel the
need to go to bathroom right now. No other complaints. She
reports that area of redness around surgical incision of R hip
is thought to be due to contact allergy with dressings used,
although of note, the surgeon who did the surgery has not seen
it personally.
.
REVIEW OF SYSTEMS:
See HPI. Denies dysuria, hematuria, acute rash, focal weakness.
Past Medical History:
MILD DIASTOLIC DYSFUNCTION
RECENT R HIP REPLACEMENT
HYPERTENSION - ESSENTIAL, UNSPEC
HYPERLIPIDEMIA
TREMOR
OBESITY
INSOMNIA, UNSPEC
MELANOMA - UPPER LIMB
APPENDECTOMY
VENTRAL HERNIA
L PARTIAL KNEE REPLACEMENT
Social History:
___
Family History:
Brother ___ Cancer; Cancer - Colon
Father ___ CAD/PVD
Mother ___ lung cancer
Sister ___ CAD/PVD
Physical Exam:
ADMISSION EXAM
VS - 98.3, BP 110/68, HR 85, RR 18, Sats 97% RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses, R leg has
large surgical incision that is C/D/I on lateral aspect of upper
leg, surrounding incision is ___ in band of erythema with mild
induration, not warm to palp and not tender
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, no focal deficits
DISCHARGE EXAM
- Same as above.
Pertinent Results:
___ 06:30PM WBC-15.6*# RBC-3.60* HGB-11.4* HCT-32.7*
MCV-91 MCH-31.6 MCHC-34.8 RDW-14.0
___ 06:30PM NEUTS-68.6 ___ MONOS-4.4 EOS-5.4*
BASOS-0.6
___ 06:30PM PLT COUNT-389#
___ 06:30PM ___ PTT-29.4 ___
___ 06:30PM proBNP-75
___ 06:30PM GLUCOSE-106* UREA N-21* CREAT-0.8 SODIUM-141
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-26 ANION GAP-15
___ 06:39PM HGB-11.6* calcHCT-35
___ 07:00PM URINE MUCOUS-RARE
___ 07:00PM URINE RBC-0 WBC-7* BACTERIA-FEW YEAST-NONE
EPI-1 TRANS EPI-<1
___ 07:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
___ 07:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:45PM LACTATE-1.3
___ 05:40AM BLOOD WBC-10.0 RBC-3.22* Hgb-9.9* Hct-28.8*
MCV-90 MCH-30.9 MCHC-34.4 RDW-13.5 Plt ___
___ 01:15PM BLOOD Hct-30.5*
___ 05:40AM BLOOD Neuts-59.3 ___ Monos-4.6 Eos-6.1*
Baso-0.6
___ 05:40AM BLOOD ___ PTT-28.3 ___
___ 05:40AM BLOOD Glucose-101* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-23 AnGap-15
URINE CULTURE (Final ___:
BETA STREPTOCOCCUS GROUP B. 10,000-100,000
ORGANISMS/ML..
___ 8:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
RADIOLOGY:
Final Report
INDICATION: Patient with right lower extremity swelling. Assess
for DVT.
COMPARISONS: None available.
FINDINGS:
Grayscale, color Doppler, and spectral analysis images of
bilateral common
femoral, right superficial femoral, and popliteal veins were
obtained. Normal
flow, compressibility, and augmentation is demonstrated
throughout. Color
flow was seen in the posterior tibial and peronal veins in the
right calf.
IMPRESSION:
No evidence of DVT in the right lower extremity.
The study and the report were reviewed by the staff radiologist.
Final Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: ___ female with history of
elevated white blood
cell count.
COMPARISON: ___.
FINDINGS: Frontal and lateral views of the chest were obtained.
Minimal left
base atelectasis is seen. No focal consolidation, pleural
effusion, or
pneumothorax is seen. Cardiac and mediastinal silhouettes are
stable.
IMPRESSION: No acute cardiopulmonary process.
___. ___: TUE ___ 12:30 AM
Brief Hospital Course:
___ w/ Hx HTN, mild diastolic dysfunction, who is 2 weeks s/p R
hip replacement on ___, presenting from home with 2 episodes of
BRBPR and transient crampy abdominal pain that has now resolved.
# BRBPR:
There was no further bleeding during her hospital course. She
had no abdominal pain. She had one formed guaiac negative bowel
movement without pain. It was thought that diverticulosis was
the most likely etiology given the painless nature and history
of constipation and straining. Other likely etiologies included
internal hemorrhoids. Patient remained symptom free and
hemodynamically stable with Hct stable at 32.7 (admission) ->
28.8 -> 30.5. Warfarin and ASA were continued to be held.
.
# Leukocytosis:
Her WBC was 15 at the time of admission without any clear source
of infection or inflammatory process. Repeat WBC 11h later was
10. She remained afebrile. CXR was unremarkable. She was found
to have pyuria and asymptomatic. No additional antibiotics were
given. BCx and UCx were pending at the time of discharge.
(Addendum: urine cx on ___ grew 10,000-100,000K GBS).
.
# HTN:
Patient remained stable on home nadolol and lisinopril.
.
# Recent R Hip Replacement:
The patient was found to have erythema surrounding the incision
site, which was thought to be an allergic reaction to dermabond
per her surgeon at OSH. The incision remained clean, dry, and
intact. Erythema was nontender and remained stable.
.
# Transitional issues
- Full code
- Follow up BCx
- Follow up UCx
- Outpatient colonoscopy versus other work-up for
gastrointestinal bleed as per primary care doctor
Medications on Admission:
MEDICATIONS: confirmed with pt
LIPITOR 80 mg Oral Tablet 1 po qd or as directed
Nadolol 20 mg Oral Tablet 1 po q am
Lisinopril 5 mg Oral Tablet 1 tablet daily
* doesen't remember below meds
Omeprazole 40mg daily
Trazodone 50 mg Oral Tablet ___ tablet at bedtime PRN sleep
Zolpidem 5 mg Oral Tablet ___ po qhs prn insomnia
FISH OIL CAPSULE 120-180MG PO (DOCOSAHEXANOIC ACID/EPA)
VITAMIN D CAPSULE 400 UNIT PO (ERGOCALCIFEROL)
CALCIUM CARBONATE W/VITAMIN D TABLET 600-200
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day as needed for
heartburn.
5. zolpidem 5 mg Tablet Sig: ___ Tablets PO HS (at bedtime).
6. Vitamin D3 Oral
7. multivitamin Oral
8. Glucosamine Sulf-Chondroitin Oral
9. folic acid Oral
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Lower GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to ___ with
rectal bleeding. Your bleeding resolved by the time you were
admitted to the hospital. We suggest that you not take coumadin
or any anticoagulation (blood thinners) as you are now walking
around better.
You should follow-up with your primary care doctor at the
appointment below and with your gastroenterologist about this
problem.
Continue all of your other home medications.
Followup Instructions:
___
|
10408325-DS-19 | 10,408,325 | 29,677,222 | DS | 19 | 2185-06-14 00:00:00 | 2185-06-14 15:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cauda Equina
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man with DM, CKD III, CAD, transferred from ___ ED for concern of cauda equina syndrome.
Approximately 2 weeks ago, he was sitting in a chair when the
legs of the chair broke, causing him to fall backwards and
strike
his back at the level of the shoulder blades on a cabinet.
For the following week he was able to continue walking, but had
pain in his upper/mid back. About one week ago, he developed
weakness of the bilateral lower extremities and urinary
incontinence--he states he has had no sensation of needing to
void. He has not ambulated without assistance since that time.
Two days ago he had another fall when attempting to get out of
bed, sliding out of bed and hitting his right knee. He developed
right knee pain and swelling, prompting evaluation at the
___. He was discharged the same day and was mobilizing
via wheelchair, however due to his continued inability to walk,
he returned to the ___ today, where MR ___ showed
concern for cauda equina impingement. He was also noted to be in
atrial flutter, which is a new diagnosis for him.
He denies any changes in bowel habits, and had a normal bowel
movement yesterday. He complains of numbness in both legs,
present for one week, as well as ongoing right knee pain with
movement. He has pain in the middle of his shoulder blades but
also only with movement. He has had a non-productive cough for
the last ~2 weeks, denies fever/chills, sick contacts. He states
he has been taking his lasix daily (except today) and his weight
has stayed constant around ~250 pounds. He has ___ edema which is
unchanged. He states he has not taken any of his medications
today.
In the ED, initial VS were:
98.4
66
171/62
20
95% 2L NC
Exam notable for:
___ proximal hip flexion strength, hyporeflexive patellar, loose
rectal tone, no saddle anesthesia
ECG: atrial flutter with 3:1 block, rate 69 with PVCs. Isolated
Q
waves avL, avR, submillimetric Q in lead I. Early R-wave
progression.
Labs showed: Cr 2.3 (down from 2.9 at ___, lactate 2.4,
trop 0.03. WBC 12.8, Hb 11.8, INR 1.4.
MR ___ at ___ showed: Tethering of cauda equina nerve
roots at L2-L3, moderate spinal stenosis, marketed right and
moderate to marked left neural for meatal stenosis with
impingement of exiting nerve roots.
CXR with no acute process. R knee X-ray with no fracture.
Code cord was called in the ED and patient was seen by Ortho
spine. They recommended MRI of entire spine, keep patient NPO
for
possible OR tomorrow for L2-S1 decompression/fusion, and admit
to
medicine for "full medical work-up." They felt given duration of
symptoms (~1 week), there was no indication for emergent
surgery.
Patient received no medication in the ED.
Transfer VS were:
98.3
70
178/60
17
100% RA
On arrival to the floor, he reports no pain except with movement
and coughing. He denies dyspnea and orthopnea.
Past Medical History:
NIDDM
Possible history of Afib, on ASA 81 mg qd. (chart history,
patient denied)
History of "mini stroke" in 1990s (chart history, patient
denied)
History of bilateral lower extremity fractures at age ___.
Hypercholesterolemia
CAD
HTN
Obesity
BPH
Social History:
___
Family History:
NC to presenting complaint
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: reviewed in eflowsheets
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, slightly dry MM
NECK: supple, JVP elevated to mid neck with HOB at 30 degrees
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: No rhonchi on anterior exam, scattered wheezes. Posterior
exam limited by pain with movement.
ABDOMEN: moderately distended with umbilical hernia. non-tender
to palpation.
EXTREMITIES: 2+ ___ ___ edema to mid shins
NEURO: A&Ox3. Hyporeflexive patellar reflexes bilaterally. No
clonus. No saddle anesthesia. Decreased rectal tone. Decreased
sensation in bilateral LEs.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 553)
Temp: ___ (Tm 98.6), BP: 161/70 (125-161/62-79), HR: 79
(77-90), RR: 18 (___), O2 sat: 97% (97-100), O2 delivery: Ra,
Wt: 253.09 lb/114.8 kg
General: Alert, oriented, no acute distress
HEENT: NC/AT, Sclera anicteric, oropharynx clear
Neck: supple, JVP not elevated
Lungs: CTAB anteriorly, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, obese, bowel sounds present, no
rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, no pitting ___: condom catheter in place, draining dark yellow
urine without gross hematuria
Skin: hyperpigmentation over bilateral feet
Neuro: AAOX3. fluent speech, no facial droop, CN II-XII grossly
intact. Motor ___ with right hip flexion, ___ with left hip
flexion, ___ with right plantar/dorsal flexion, ___ with left
plantar/dorsal flexion bl. lower extremity SILT.
Pertinent Results:
ADMISSION LABS:
===============
___ 07:40PM BLOOD WBC-12.8* RBC-4.03* Hgb-11.8* Hct-37.0*
MCV-92 MCH-29.3 MCHC-31.9* RDW-11.9 RDWSD-39.9 Plt ___
___ 07:40PM BLOOD Neuts-76.1* Lymphs-16.3* Monos-6.3
Eos-0.5* Baso-0.2 Im ___ AbsNeut-9.72* AbsLymp-2.08
AbsMono-0.80 AbsEos-0.07 AbsBaso-0.03
___ 07:40PM BLOOD ___ PTT-33.9 ___
___ 07:40PM BLOOD Glucose-211* UreaN-56* Creat-2.4* Na-131*
K->10.0* Cl-96 HCO3-26 AnGap-9*
PERTINENT LABS:
===============
___ 07:40PM BLOOD cTropnT-0.03*
___ 10:04AM BLOOD CK-MB-2 cTropnT-0.04*
___ 10:04AM BLOOD ALT-29 AST-28 LD(LDH)-238 CK(CPK)-305
AlkPhos-74 TotBili-0.5
___ 05:50AM BLOOD %HbA1c-8.4* eAG-194*
___ 05:50AM BLOOD TSH-0.65
___ 05:40AM BLOOD PSA-28.1*
MICROBIOLOGY:
=============
___ urine culture negative
blood cultures NGTD
STUDIES:
========
OSH:
MR ___
CT T-SPINE
KNEE (AP, LAT & OBLIQUE) RIGHT Study Date of ___
No acute fracture seen. Moderate osteoarthritic changes.
Moderate
suprapatellar joint effusion.
LUMBO-SACRAL SPINE (AP & LAT) Study Date of ___
No radiographic findings to suggest acute fracture or
dislocation. If concern for spinal stenosis, MRI or CT is more
sensitive and would provide better assessment.
MR CERVICAL SPINE W/O CONTRAST Study Date of ___
1. Degenerative changes of the cervical spine most significant
at C4-C5 where there is mild-to-moderate spinal canal narrowing
and mild ventral indentation of the cord without evidence of
abnormal cord signal.
2. Linear STIR signal along the superior endplate of the T1
vertebral body is favored to represent degenerative signal
change, however, a mild superior endplate compression fracture
is a differential consideration in the appropriate clinical
context.
3. Multilevel severe cervical neural foraminal narrowing as
described above.
4. Findings compatible with diffuse idiopathic skeletal
hyperostosis (DISH) of the cervical and thoracic spine.
5. Degenerative changes of the thoracic spine without
significant spinal canal or neural foraminal narrowing.
6. Blastic lesion in the T10 vertebral body may represent a bone
island but the possibility of a metastasis cannot be excluded.
RECOMMENDATION(S): Consider a radionuclide bone scan to
evaluate the T10
vertebral body blastic lesion.
CHEST (PA & LAT) Study Date of ___
No acute cardiopulmonary abnormality.
TTE ___
1) Moderate symmetric left ventricular hypertrophy wtih normal
biventricular wall thicknesses, cavity sizes, and
regional/global systolic function.
BONE SCAN Study Date of ___
Multiple areas of likely degenerative change without suggestion
of
metastatic disease on bone scan to correlate with finding at T10
on MRI.
DISCHARGE LABS:
===============
___ 05:15AM BLOOD WBC-14.2* RBC-3.56* Hgb-10.3* Hct-31.6*
MCV-89 MCH-28.9 MCHC-32.6 RDW-12.0 RDWSD-38.7 Plt ___
___ 05:15AM BLOOD ___ PTT-35.9 ___
___ 05:15AM BLOOD Glucose-60* UreaN-50* Creat-2.0* Na-144
K-4.3 Cl-104 HCO3-29 AnGap-11
Brief Hospital Course:
Mr. ___ is an ___ man with T2DM, Stage III-IV CKD,
CAD, transferred from ___ ED with 1 week of lower
extremity weakness and difficulty ambulating with initial
concern for cauda equina syndrome after sustaining a mechanical
fall. His strength improved without surgical decompression and
he was able to ambulate with ___ in close coordination with
ortho spine, diagnosis was spinal stenosis with possible disc
herniation post fall, without cauda equina syndrome.
ACUTE ISSUES:
___ weakness
#c/f cauda equina syndrome
MR ___ at ___ showed tethering of nerve roots at L2-L3,
moderate spinal stenosis, marked right and moderate to marked
left neural foraminal stenosis with impingement of exiting nerve
roots. MR of ___ and T-spine did not show compression. There
was initial concern for cauda equina syndrome with plan for OR,
but his motor strength in lower extremities improved without
surgical decompression; ortho spine instead suspected acute
right sided L4/5 disc herniation causing more pronounced right
lower extremity weakness. He ultimately did not require surgery.
He was able to ambulate with a walker with ___. He should follow
up with spine outpatient. He was discharged to rehab.
#Atrial flutter
He was found to have new atrial flutter. No prior history of
this per his PCP. CHADS2VASC of 5 (age, CHF, HTN, DM),
potentially up to 7 if including a question of possible TIA in
___ (per wife, had an aphasic event for a few hours, which PCP
later said may have been a mini-stroke, but did not ever have
neurology work up). He was started on anticoagulation with
warfarin this admission, once determined to be non-operative and
cleared from the spine perspective. He was not bridged. He was
rate controlled with carvedilol, which replaced his home
atenolol. TTE showed LVH and normal regional/global systolic
function, no valvular disease.
#HTN
He was hypertensive up to SBP 200 on admission, but
asymptomatic. This was likely due to him having missed home
meds, with contribution of pain/stress response. His home
irbesartan was stopped, home atenolol was stopped. He was
started on carvedilol 25 BID and amlodipine 10 daily with good
effect.
___ on CKD stage III-IV
Prior baseline creatinine of 2.28 on ___ per PCP records,
with admission Cr of 2.4. This admission he developed an ___.
This was thought initially due obstruction given his urinary
retention, but it did not improve after foley placement, and was
ultimately likely prerenal. Home lasix and irbesartan were held
and creatinine returned to baseline.
#Urinary retention
#Hematuria
He developed hematuria after traumatic foley at presentation.
Foley was re-placed by urology. Urinary retention was thought to
be more likely related to his age and BPH, rather than a
neurologic symptom of possible cord compression. His Foley was
removed and he was able to void on his own for >48 hours prior
to discharge.
#Leukocytosis
#C/f prostate cancer
#Failure to thrive
Pt with leukocytosis w/o fever or localizing infectious symptoms
(other than cough) for infection. Pt stated cough is his
baseline. In the setting of elevated PSA, overall functional
decline, this is concerning for prostate cancer. Bone scan
negative for metastases, however no imaging of pelvis/abdomen
was obtained. He has outpatient follow up with urology in the
prostate cancer clinic scheduled on discharge.
#Cough
Patient with chronic dry cough. CXR negative for pneumonia, no
e/o pulmonary edema. He was treated symptomatically.
#Elevated troponin
Trop mildly elevated at 0.03 in the setting of CKD. EKG with TW
flattening in lateral lead but no STE/STD, and patient did not
have cardiac symptoms.
#c/f T10 blastic lesion
MRI C spine initially showed a possible blastic lesion at T10
that was concerning for bone island vs metastasis. PSA was
elevated at 28 this admission, though this was after traumatic
foley placement in the setting of BPH. Subsequent bone scan was
negative for malignant metastases. He will follow up with ortho
spine as an outpatient.
#T2DM
His home glipizide was changed from 5 mg BID to 10 mg XL daily.
He was started on Lantus as well as HISS. He will need ongoing
titration of both his long acting insulin and his Humalog. He
will be discharged on 5u Lantus qPM.
#Chronic diastolic heart failure
TTE this admission showed moderate LVH with EF 62%. He takes
home home Lasix 40 and 80 every other day (which was recently
increased from 40 daily). Home lasix was held initially as pt
was euvolemic on admission and remained euvolemic without
intervention throughout his stay. He will need continued
re-evaluation for possible diuresis as after discharge.
#CAD
Patient and wife deny having had heart problems or MI in the
past. No record of cath in our system, though he carries the
diagnosis of CAD per chart. This admission he was switched from
home simvastatin to atorvastatin in the setting of being started
no amlodipine.
TRANSITIONAL ISSUES:
- Discharge weight: 114.8 kg, 253.09 lb
- Discharge creatinine: 2.0
- Discharge INR: 1.8
[] Please continue ongoing titration of this patient's insulin
regimen. Pt was newly initiated on insulin during this
admission. HE SHOULD NOT BE DISCHARGED FROM REHAB UNTIL HE
DEMONSTRATES UNDERSTANDING OF HOW TO PROPERLY MEASURE GLUCOSE
AND ADMINISTER INSULIN.
[] Home Lasix held at pt was euvolemic and did not require
diuresis. Please re-start Lasix as clinically indicated
[] Started on anticoagulation with warfarin for atrial flutter
this admission. INR will be managed by rehab facility on
discharge and then by PCP ___.
[] There was initial concern for cauda equina syndrome given
cord compression on MRI and lower extremity weakness, but
ultimately his symptoms improved without intervention and it was
not clinically consistent with cauda equina. He has follow up
outpatient with ortho spine scheduled to evaluate his L4-L5 disc
herniation
[] Please continue ongoing uptitration of antihypertensives
[] Pt with leukocytosis as above, without infectious signs or
symptoms. Please continue to evaluate for infection
[] Pt has elevated PSA, leukocytosis, and recent functional
decline, concerning for prostate cancer. Pt is scheduled to see
urology as an outpatient.
#CODE: Full
#CONTACT: ___
Relationship: WIFE
Phone: ___
Other Phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Furosemide 40 mg PO EVERY OTHER DAY
4. Gabapentin 300 mg PO BID
5. GlipiZIDE 5 mg PO BID
6. irbesartan 150 mg oral DAILY
7. Simvastatin 20 mg PO QPM
8. Calcitriol 0.25 mcg PO 3X/WEEK (___)
9. Aspirin 81 mg PO DAILY
10. Furosemide 80 mg PO EVERY OTHER DAY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Carvedilol 25 mg PO BID
4. Tamsulosin 0.4 mg PO QHS
5. Gabapentin 300 mg PO DAILY
6. GlipiZIDE XL 10 mg PO DAILY
7. irbesartan 75 mg oral DAILY
8. Aspirin 81 mg PO DAILY
9. Calcitriol 0.25 mcg PO 3X/WEEK (___)
10. Finasteride 5 mg PO DAILY
11. HELD- Furosemide 40 mg PO EVERY OTHER DAY This medication
was held. Do not restart Furosemide until another doctor thinks
you need to restart it
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
L4/L5 disc herniation
HTN
___ on stage III-IV CKD
Atrial flutter
Urinary retention
Hematuria
SECONDARY DIAGNOSIS:
Type II diabetes
Chronic diastolic heart failure
CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at ___
___.
WHY WERE YOU ADMITTED?
- You had weakness in your legs and were unable to walk. We were
concerned this was because of compression of your spine after
your fall.
WHAT HAPPENED IN THE HOSPITAL?
- We were initially worried that you might need surgery, but
your symptoms improved on their own and you were able to walk
with physical therapy. You were seen by the spine surgeons many
times and after many discussions, the decision was made to NOT
do surgery.
- You had difficulty urinating, so you had a urine catheter
placed. This was very bloody and you required the catheter for
many days. We were able to take this out. You will see a
urologist (prostate and urinary doctor) after your discharge.
- Your blood pressures were very high initially. We changed your
blood pressure medication regimen so it was better ___ for
you.
- You were found to have an abnormal heart rhythm called "atrial
flutter" or "a flutter". To decrease your risk of strokes caused
by atrial flutter, you were started on a blood thinner
medication (warfarin).
- We also increased your diabetes medications. We added
something called insulin. This is a once a day injectable
medication. Before you leave the rehab, please ensure you and
your wife understand how to use the insulin safely.
WHAT SHOULD YOU DO AT HOME?
- Take your medications as prescribed.
- Go to your follow up appointments as scheduled.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
10408355-DS-19 | 10,408,355 | 26,502,261 | DS | 19 | 2116-07-29 00:00:00 | 2116-08-02 13:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
Diagnositic cerebral angiogram
History of Present Illness:
___ y/o female with history of Chronic headaches who presents
today with c/o progressively worsening dizzyness. Patient has
had
an accompanying headache, she describes the headache as
bandlinke
across her forhead, but expresses that she has had headaches of
this magnitude in the past. She describes her dizzyness as worse
when she is in the supine position, feels that objects are
spinning around her. A CT was done which revealed no
Subarachnoid
hemorrhage but a incidental finding of an ACOM aneurysm.
Past Medical History:
HTN
High cholestrol
Gerd
Social History:
___
Family History:
Mother and 2 brothers with ___ disease.
Brother had a stroke.
Physical Exam:
T:97.3 BP: 148/ 80 HR:97 R18 O2Sats 100ra
Gen: WD/WN, comfortable, NAD.
HEENT: Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
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, propioception, pinprick and
vibration bilaterally.
Pertinent Results:
Admission Labs:
___ 05:45PM BLOOD WBC-9.9 RBC-5.05 Hgb-14.8 Hct-42.7 MCV-85
MCH-29.3 MCHC-34.6 RDW-12.6 Plt ___
___ 05:45PM BLOOD Neuts-67.3 ___ Monos-4.2 Eos-2.2
Baso-0.6
___ 06:19PM BLOOD ___ PTT-23.0 ___
___ 05:45PM BLOOD Glucose-93 UreaN-10 Creat-0.7 Na-141
K-4.2 Cl-106 HCO3-22 AnGap-17
___ 06:10AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.3
___ 11:35PM BLOOD HCG-<5
___ 07:32PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 06:35PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 07:32PM URINE Color-Straw Appear-Clear Sp ___
___ 06:35PM URINE Color-Straw Appear-Clear Sp ___
MICROBIOLOGY
___ 7:32 pm URINE Site: CLEAN CATCH
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
EKG:
Sinus rhythm. RSR' pattern in leads V1-V2, probable normal
variant. Probable intra-atrial conduction delay. No previous
tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
76 184 ___
CTA Head:
IMPRESSION:
1. Large multilobulated anterior communicating artery saccular
aneurysm is
redemonstrated, arising from the junction of the ACom and the A1
and A2
segments of left anterior cerebral artery as described above.
2. Bulbous appearing proximal P1 segment of left posterior
cerebral artery
may represent an infundibulum at origin of hypoplastic PCom or a
small
aneurysm. Attention on cerebral angiogram is suggested.
Brief Hospital Course:
Pt was admitted to the neurosurgery service after she was found
to have acomm aneurysm. Neurology was consulted to help with her
vertigo symptoms. They recommended the Epley maneuver and to
follow up with her outpatient neurologist. She was scheduled for
angiogram on ___ to further evaluate her aneurysm. She was
made NPO on the evening of ___ in preparation of her
procedure.
The angiogram revealed an a-comm aneurysm as noted by the CTA
that is likely amenable to endovascular intervention, per Dr.
___. She did well following the procedure and there were no
acute events in the immediate postprocedure period. She was
discharged home later that evening with instructions to follow
up in the ___ clinic.
Medications on Admission:
Lyrica(dosage unknown), Famotidine 20mg daily,vitamen D,
doxycycline 100 bid, Calcarb wtih D
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for dizziness.
Disp:*30 Tablet(s)* Refills:*0*
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
6. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q4H (every 4 hours) as needed for headache.
Disp:*30 Tablet(s)* Refills:*0*
7. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
8. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
9. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1)
Tablet PO twice a day: Avoid taking with synthroid.
Discharge Disposition:
Home
Discharge Diagnosis:
Acomm aneurysm
Hypothyroidism
Ca/Vit D Deficiency
Fibromyalgia
Daily headaches
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
When you go home, you may walk and go up and down stairs.
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
After 1 week, you may resume sexual activity.
After 1 week, gradually increase your activities and distance
walked as you can tolerate.
No driving until you are no longer taking pain medications
What to report to office:
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call ___ for transfer to closest
Emergency Room
Followup Instructions:
___
|
10408555-DS-2 | 10,408,555 | 24,685,718 | DS | 2 | 2150-10-10 00:00:00 | 2150-10-10 15:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
partial amputation L index finger
Major Surgical or Invasive Procedure:
___ - L index finger washout, revision amputation left index
finger, closed reduction/perc pinning left long finger P1 and
P2, left ring finger P1, repair nailbed lac left ring finger.
History of Present Illness:
___ right-hand dominant presents in transfer from ___
with zone 2 non-dominant index finger partial amputation after
having placed her hand into the chute of her lawnmower around
330p. Denies other injuries. Tetanus shot and ancef given at
OSH. A digital block was also performed for pain control.
Past Medical History:
uterine vs. endometrial ca s/p chemo and hysterectomy
Social History:
___
Family History:
non contributory
Physical Exam:
AFVSS
NAD, A&Ox 3
LUE in splint, c/d/i, no pain, compartments soft
Brief Hospital Course:
You were admitted on ___ for treatment L index finger near
amputation. Please follow these discharge instructions:
1. You should keep the splint on the LUE and keep it dry.
2. You may shower daily keeping the splint dry and protected.
.
Activity:
1. DO NOT use your LUE for any weight lifting until instructed
to do so by Dr. ___.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. Take your antibiotic as prescribed (5 days of keflex)
3. Take Colace, 100 mg by mouth 2 times per ___, to prevent
constipation. You may use a different over-the-counter stool
softener if you wish.
.
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) or open areas.
2. A large amount of bleeding from the incision(s) or open
areas.
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.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever, headache, mild pain
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN moderate to
severe pain
3. Keflex x 5 days
Discharge Disposition:
Home
Discharge Diagnosis:
left index finger partial amputation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted on ___ for treatment of left index finger
partial amputation. You were taken to surgery for washout (lots
of grass in wound), revision amputation left index finger,
closed reduction/perc pinning left long finger P1 and P2, left
ring finger P1, repair nailbed lac left ring finger. Distal lac
of middle finger explored and nerve appears to be in continuity.
Please follow these discharge instructions:
1. You should keep your dressing on until follow up.
2. You may shower daily. No baths until instructed to do so by
Dr. ___.
3. You will need to follow up on ___ in hand clinic for
orthoplast splint
4. You will have k-wires for 6 weeks in the finger.
.
Activity:
1. DO NOT lift anything with your Left hand or engage in
strenuous activity until instructed by Dr. ___.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. Take your antibiotic as prescribed (5 days of Keflex)
3. Take Colace, 100 mg by mouth 2 times per ___, to prevent
constipation. You may use a different over-the-counter stool
softener if you wish.
.
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) or open areas.
2. A large amount of bleeding from the incision(s) or open
areas.
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:
___
|
10408681-DS-6 | 10,408,681 | 26,770,052 | DS | 6 | 2126-04-04 00:00:00 | 2126-04-04 18:56:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
post-arrest
Major Surgical or Invasive Procedure:
Right IJ CVL placement
Right radial arterial line
Endotracheal Intubation
History of Present Illness:
___ is a ___ year old female with past medical history
of CHF, ETOH abuse, Crohn's disease, transferred from ___
___ s/p cardiac arrest with ROSC.
Per records, patient was recently hospitalized at ___
for neutropenic fever (neutropenia thought to be ___
etoh-induced bone marrow suppression), ___ ___ atn, and ETOH
withdrawal ___ - ___. Today she was found by nursing staff at
her rehab facility in cardiac arrest. She was intubated in the
field, had right humeral IO placed, and ACLS protocol was
initiated with 2 shocks given. She presented initially to ___
___ in PEA with CPR in progress; she had ROSC after 1 round
epi given. She was re-intubated with 7.5 ETT (5.0 was placed in
field) without complication. She was started on Levophed for
pressure support, per report she was not following commands
after ROSC. She was academic to 7.19 and hypokalemic to 2.6, and
was given K IV. She was started on therapeutic hypothermia
(estimated at 8:30 am ___ and she was transferred to ___.
In the ED, initial vitals: HR: 70 BP: 113/76 RR: 20. Temp on
arrival was 32.2 C. Her EKG was notable for STE in V1 and AVR,
with diffuse ST depressions concerning for ischemia. On repeat
EKG in ED, ST elevations and depressions apparently resolved,
with T-wave inversions persistent in lateral leads. Cardiology
was consulted and felt that her arrest was likely in the context
of hypokalemia leading to arrest and prolonged cardiac ischemia.
(notably she was hypokalemic to K 2.8 upon presentation to
___ Suspicion for ACS was low given her recovery with
pressure support and resuscitation, and she was not felt to be a
candidate for catheterization.
Had recent admission ___ to ___ for ETOH
withdrawal, mild pancreatitis, refeeding syndrome, neutropenic
fever and ongoing diarrhea ___ Crohn's. She was treated for
withdrawal with CIWA. Had significant abnormalities in
electrolytes (K 1.8 on admission) thought to be ___
malnutrition/GI lossess/refeeding, repleted aggressively. She
had ongoing diarrhea, negative for cdiff x2, evaluated by GI who
started her on pred 40mg. She was also noted to pancytopenic,
heme/onc c/s'd who felt this was ___ malnutrition, ETOH bone
marrow suppression. She did develop fever while neutropenic,
unclear source, covered with vanc/zosyn until neutropenia
resolved (duration unclear). Also developed ___ (Cr peaked at
2.73), resolving at time of discharge (2.4). Discharged to
rehab.
Past Medical History:
ETOH abuse (h/o withdrawal seizure)
fatty liver disease
Crohn's disease
Pancytopenia
Pneumonia
?CHF
Depression
Social History:
___
Family History:
unable to assess
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: sedated, intubated
HEENT: normocephalic, atraumatic
NECK: supple, JVP not elevated, no LAD
LUNGS: equal air movement bilaterally, no crackles
CV: no murmurs
ABD: soft, non-tender, non-distended, bowel sounds present
EXT: 2+ pulses, no pitting edema
SKIN: 3cm area of superficial burn- low sternal and left
inframammary region.
NEURO: a+ox3
DISCHARGE PHYSICAL EXAM:
General: nonresponsive, appears comfortable
RESP: breathing comfortably on room air
SKIN: warm
Pertinent Results:
PERTINENT LABS:
___ 12:43PM BLOOD WBC-37.0* RBC-3.05* Hgb-9.5* Hct-29.0*
MCV-95 MCH-31.1 MCHC-32.8 RDW-20.8* RDWSD-70.6* Plt ___
___ 09:30AM BLOOD Neuts-89* Bands-3 Lymphs-2* Monos-2*
Eos-1 Baso-0 ___ Metas-3* Myelos-0 AbsNeut-27.69*
AbsLymp-0.60* AbsMono-0.60 AbsEos-0.30 AbsBaso-0.00*
___ 12:43PM BLOOD ___ PTT-121.1* ___
___ 12:43PM BLOOD Glucose-322* UreaN-27* Creat-2.3* Na-137
K-3.3 Cl-99 HCO3-22 AnGap-19
___ 12:54PM BLOOD ___ Temp-34.7 Rates-/16 Tidal V-400
PEEP-5 FiO2-100 pO2-44* pCO2-39 pH-7.39 calTCO2-24 Base XS-0
AADO2-638 REQ O2-100 Intubat-INTUBATED Vent-CONTROLLED
___ 06:04PM BLOOD Type-ART Temp-32.8 pO2-103 pCO2-26*
pH-7.56* calTCO2-24 Base XS-2
___ 09:40AM BLOOD Lactate-5.2*
___ 06:04PM BLOOD Lactate-1.5
PERTINENT MICROBIOLOGY:
___ 6:00 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
RARE GROWTH Commensal Respiratory Flora.
PERTINENT RADIOLOGY:
MRI Head ___:
1. Symmetric signal abnormalities in the thalami, subtle
symmetric signal
abnormalities in the basal ganglia, almost symmetric signal
abnormalities and bilateral posterior frontal, parietal, and
occipital cortex, and left greater than right medial temporal
lobe signal abnormalities, are compatible with sequela of
hypoxic ischemic injury. However, some of the cortical signal
abnormalities could be secondary to seizure activity.
Correlation with EEG could be considered if clinically
warranted.
2. No edema or mass effect.
Brief Hospital Course:
___ with history of alcohol abuse, Crohn's disease who presented
s/p cardiac arrest at her nursing home. She initially had a
shockable rhythm. The total duration of down-time was unknown.
The initial post-ROSC labs showed hypokalemia, which was
suspected to be the cause of her arrest. She had a poor initial
post-ROSC exam, so she underwent therapeutic hypothermia. Repeat
examination after re-warming showed a persistently poor
neurologic exam with absent corneal reflexes and gag. She was
breathing spontaneously. An MRI brain was performed for
prognostication, which showed severe hypoxic-ischemic injury.
Given this, her family elected to transition her care to comfort
measures only.
TRANSITIONAL ISSUES:
-continue comfort measures oriented care
# CODE: DNR/DNI, CMO
# Communication: HCP: ___ ___
___ (___) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Potassium Chloride 10 mEq PO BID
2. TraZODone 100 mg PO QHS
3. Magnesium Oxide 400 mg PO BID
4. Calcium Carbonate 500 mg PO BID
5. Ferrous Sulfate 325 mg PO BID
6. Cyanocobalamin 500 mcg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Furosemide 40 mg PO BID
10. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
11. Pantoprazole 40 mg PO Q24H
12. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever
2. Artificial Tears ___ DROP BOTH EYES QID
3. Glycopyrrolate 0.2 mg IV Q6H:PRN secretions
4. HYDROmorphone (Dilaudid) ___ mg IV Q1H:PRN pain, SOB
RX *hydromorphone 1 mg/mL ___ mg IV q1h:PRN Disp #*20 Syringe
Refills:*0
5. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
Discharge Disposition:
Extended Care
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
-cardiac arrest
-global hypoxic-ischemic brain injury
-septic shock
-hypoxic respiratory failure
SECONDARY DIAGNOSIS:
-alchohol abuse
-Crohn's disease
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear family of Ms. ___,
___ was admitted to ___ ___ after
a cardiac arrest. This means that her heart stopped. Because of
this, she sustained brain damage. Given her previous wishes, she
was removed from all machines and care will focus solely on her
comfort.
Our thoughts are with your family during this difficult time.
We wish you all the best,
Your ___ Team
Followup Instructions:
___
|
10408971-DS-23 | 10,408,971 | 26,417,601 | DS | 23 | 2137-11-09 00:00:00 | 2137-11-10 20:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tramadol / codeine
Attending: ___.
Major Surgical or Invasive Procedure:
EGD ___ showed gastritis, possibly secondary to atrophic
gastritis, and duodenitis without active bleeding.
Capsule endoscopy ___ results pending at discharge
attach
Pertinent Results:
ADMISSION LABS:
================
___ 02:30PM BLOOD WBC-7.0 RBC-2.79* Hgb-8.2* Hct-26.0*
MCV-93 MCH-29.4 MCHC-31.5* RDW-14.6 RDWSD-48.0* Plt ___
___ 02:30PM BLOOD Neuts-86.5* Lymphs-8.2* Monos-4.2*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-6.04 AbsLymp-0.57*
AbsMono-0.29 AbsEos-0.00* AbsBaso-0.01
___ 02:30PM BLOOD Plt ___
___ 02:30PM BLOOD Glucose-137* UreaN-40* Creat-1.3* Na-139
K-5.9* Cl-107 HCO3-22 AnGap-10
___ 02:30PM BLOOD CK(CPK)-202*
___ 02:30PM BLOOD CK-MB-4
___ 02:30PM BLOOD cTropnT-0.04*
___ 07:49PM BLOOD CK-MB-4 proBNP-997*
PERTINENT LABS:
================
___ 07:49PM BLOOD CK-MB-4 proBNP-997*
___ 02:30PM BLOOD CK(CPK)-202*
___ 07:49PM BLOOD CK(CPK)-178
___ 02:30PM BLOOD cTropnT-0.04*
___ 07:49PM BLOOD cTropnT-0.05*
___ 07:59AM BLOOD cTropnT-0.04*
___ 10:42AM BLOOD cTropnT-0.05*
___ 11:30PM BLOOD cTropnT-0.07*
IMAGING/PROCEDURES:
====================
EGD ___:
-Normal esophagus
-Linear erythema and congestion in the antrum compatible with
gastritis
-Decreased vascularity and possible atrophy in the stomach
compatible with possible atrophic gastritis
-Mild congestion and erythema in the duodenum compatible with
non-septic, mild duodenitis
CXR ___:
FINDINGS:
Status post median sternotomy and CABG. Mild cardiomegaly is
present. The aorta is tortuous. Mediastinal and hilar contours
are unremarkable. No focal consolidation, pleural effusion, or
pneumothorax. Streaky atelectasis in the lung bases. No acute
osseous abnormality. Moderate degenerative changes of the
thoracic spine.
KUB ___
AP view of the abdomen shows a nonobstructive bowel gas pattern
with air and stool seen throughout the colon. Atherosclerotic
vascular calcifications are seen in the aortoiliac system.
There are new is an endoscopic capsule overlying the right lower
quadrant probably at the level of the cecum.
DISCHARGE PHYSICAL EXAM:
=========================
VITALS: ___ 0716 Temp: 98.1 PO BP: 124/50 R Lying HR: 63
RR:
18 O2 sat: 98% O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
ENT: MMM. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, mild tenderness to
palpation throughout.
EXTREMITIES: No edema. L below knee amputation. R PIV in place.
SKIN: Warm. No rash.
PSYCH: appropriate mood and affect
DISCHARGE LABS:
================
___ 07:04AM BLOOD WBC-4.8 RBC-2.95* Hgb-8.8* Hct-27.3*
MCV-93 MCH-29.8 MCHC-32.2 RDW-15.2 RDWSD-50.2* Plt ___
___ 07:04AM BLOOD Glucose-105* UreaN-23* Creat-1.1 Na-142
K-4.1 Cl-110* HCO3-22 AnGap-10
___ 07:04AM BLOOD cTropnT-0.06*
___ 07:04AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.1 Iron-PND
Brief Hospital Course:
ASSESSMENT AND PLAN:
====================
Ms. ___ is a primarily ___ ___ year old with a
PMH of CAD (CABG ___, PCI in ___ and last PCI in
___ s/p SMA stent on xarelto and ASA, severe 3v CAD with
patent LIMA-LAD, PAD s/p L BKA, CVA, HTN, and current tobacco
use who presented with acute on chronic chest pain and found to
be anemic (Hb 8.2) with dark, guaiac positive stool concerning
for acute GI bleed. Her xarelto was stopped and she was started
on IV PPI BID. She underwent EGD which showed gastritis and
duodenitis without active bleeding and the results of the
capsule endoscopy were still pending at discharge (preliminary
showing retention in the stomach and little footage of small
bowel). Her Hb remained stable at ~8.5 and she did not require
transfusion. During her admission, she continued to have an
acute exacerbation of her chronic chest pain which mildly
improved with SLN. She remained hemodynamically stable without
ischemic changes on EKG and troponin level remained stable at
0.04 to 0.05 and she was discharged home.
TRANSITIONAL ISSUES:
=====================
[ ] Hb 8.8 and SCr 1.1 at discharge. Re-check CBC and BMP at
closest follow-up appointment.
[ ] Holding xarelto in the setting of acute GI bleed and will
need to evaluate re-starting xarelto or plavix at vascular
medicine follow-up with Dr. ___
[ ] Results of capsule endoscopy pending at discharge
[ ] Restarted home lisinopril at discharge given resolution of
___
[ ] Holding home potassium given presented with hyperkalemia
[ ] If she develops additional GI bleed, she will require EGD
with capsule placement with GI
ACUTE ISSUES:
=============
#Melena
#Normocytic anemia
She has a history of gastric antral vascular ectasia and on
presentation she had dark, guaiac positive stool and was found
to be anemic with hemoglobin 8.2, which had decreased from 11.6
two weeks ago. Notably, she had switched from plavix to low-dose
Xarelto on ___ for stent anticoagulation in the setting of
significant atherosclerosis. Her xarelto 2.5 mg BID was stopped
and she was started on IV PPI BID. EGD showed gastritis and
duodenitis without active bleeding. The capsule endoscopy was
performed but the capsule tablet was noted to be in the small
intestines for extended periods of time. KUB obtained prior to
discharge showed capsule pill near the cecum. She remained
hemodynamically stable with Hb ~8.5 and she did not require a
blood transfusion.
#Atypical chest pain
#Acute on chronic chest pain
#3v CAD s/p CABG and PCI
#Elevated troponin
#Poly-vascular disease
She has been having ongoing acute on chronic episodes of chest
pain. She has polyvascular disease with PMH of significant
coronary artery disease and was recently seen by cardiology in
the ___ on ___ where she was instructed to use sublingual
nitro PRN and ranexa in addition to her home Imdur. Her acute on
chronic chest pain mildly improved with nitroglycerin,
suggesting at least a partial cardiac or vasospastic etiology.
However, their is also likely a non-cardiac component of chest
pain as she had a normal nuclear stress test ___ w/o ischemia
and her chest pain has not resolved despite maximizing
antianginal medication. She has been medically managed as she
has difficult vascular access for coronary angiogram and there
was no indication for coronary angiogram during this admission.
She remained hemodynamically stable without ischemic changes on
EKG and stable troponin leak at ~0.05 likely in the setting of
demand ischemia. She will be discharged on ASA alone and
decision to restart clopidogrel vs. trialing rivaroxaban can be
decided on an outpatient basis.
#Hyperkalemia:
On presentation she was hyperkalemic to 5.9 which normalized
after improvement in her ___ and ___ her home 20 mEq
potassium supplementation, which she takes with her furosemide.
She was re-started on her home furosemide 40 mg. Her potassium
supplementation was held at discharge given that she presented
with hyperkalemia.
___
She presented with elevated serum creatinine to 1.3, up from her
baseline of 1.0 from ___ and her home lisinopril was held.
Her ___ was thought to be pre-renal etiology in the setting of
GI bleed and improved with IVF. Her ___ resolved and her SCr was
1.1 at discharge.
CHRONIC ISSUES:
===============
#PAD:
There was no indication for acute intervention and she is
followed by Dr. ___ her chronic occlusions.
#HTN
On initial presentation, she was normotensive and her metoprolol
ER 50 mg was stopped in the setting of GIB and her lisinopril
and furosemide were held in the setting of ___. She was
continued on her home imdur and re-started on metoprolol
tartrate 12.5 mg q6h on ___. She remained hemodynamically
stable with blood pressures in the 130s-150s and she was
discharged home on metoprolol ER 50 mg and 60 mg imdur ER daily.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Ferrous Sulfate 325 mg PO TID
4. Lisinopril 20 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Potassium Chloride 20 mEq PO BID
8. QUEtiapine Fumarate 200 mg PO QHS
9. Vitamin D ___ UNIT PO DAILY
10. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
11. Alendronate Sodium 70 mg PO QWED
12. calcium citrate 200 mg (950 mg) oral QID
13. Furosemide 40 mg PO DAILY
14. Ranolazine ER 500 mg PO BID
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
16. Rivaroxaban 2.5 mg PO BID
Discharge Medications:
1. Alendronate Sodium 70 mg PO QWED
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. calcium citrate 200 mg (950 mg) oral QID
5. Ferrous Sulfate 325 mg PO TID
6. Furosemide 40 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Lisinopril 20 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
11. Omeprazole 40 mg PO DAILY
12. QUEtiapine Fumarate 200 mg PO QHS
13. Ranolazine ER 500 mg PO BID
14. Vitamin D ___ UNIT PO DAILY
15. HELD- Potassium Chloride 20 mEq PO BID This medication was
held. Do not restart Potassium Chloride until your doctor tells
you to
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
=====================
#Melena
#Normocytic anemia
#Atypical chest pain
#Elevated troponin
Secondary diagnosis:
=====================
#Coronary artery disease
#Hypertension
#Acute kidney injury
#Hyperkalemia (resolved)
#Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege taking care of you at ___
___.
Fue un privilegio cuidar de ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
¿POR QUÉ FUE ___ HOSPITAL?
===================================
- You were admitted to the hospital for chest pain and blood in
your stool
- Fue ingresado ___ hospital por dolor en el pecho y sangre en
___ popó
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
¿QUÉ PASÓ MIENTRAS ESTABA ___ HOSPITAL?
==========================================
- You had a procedure (EGD) to look for bleeding in your stomach
and it did not show any bleeding but it did show irritation or
inflammation of your stomach (gastritis). You also swallowed a
camera to look for bleeding in your intestines and we are still
waiting for the results of that study to come back.
- ___ tuvo un procedimiento (EGD) para buscar ___
estómago y no mostró ningún ___ sí mostró irritación
o inflamación ___ estómago (gastritis). También tragó una
cámara para buscar ___ en sus intestinos y todavía estamos
esperando ___ vuelvan ___ ese estudio.
- You were given sublingual nitrogen which made your chest pain
a little better.
- ___ nitrógeno sublingual, lo ___ hizo ___ un
poco el pecho.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
¿QUÉ ___ DESPUÉS DE ___ ___ HOSPITAL?
================================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
- Continúe tomando todos sus ___ un seguimiento
con sus médicos en sus citas programadas.
We wish you all the best!
___ deseamos todo lo mejor!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10409353-DS-4 | 10,409,353 | 29,317,119 | DS | 4 | 2119-02-03 00:00:00 | 2119-02-03 15:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Dilaudid / morphine
Attending: ___.
Chief Complaint:
R heel pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ states he was working at his barn at home when he
lost
his balance jumped off of a second story area and landed on his
right heel and then rolled onto his left side. He had instant
right heel pain, crawled to his house and called for help. He
was
seen at ___ where he was diagnosed with a right calcaneous
fracture and transferred here for further treatment.
He states he feels like he bruised his left hip; otherwise
denies
any other pain. Denies any numbness or tingling. Wears brace
over
left knee for chronic ?patellar tendonitis
Past Medical History:
diverticulitis (admitted 2x in last year)
rotator cuff repair
retinal tear
Social History:
___
Family History:
Non contributory
Physical Exam:
Upon consultation in the ED:
PE:
Vitals: temp 97, HR 70, BP 160/90 RR 16 O2 sat 95% RA
GEN: Calm and comfortable
Neuro: A&O x 3
Neck: Nontender to palpation posteriorly
CV: Regular
CHEST: no acute distress
ABD: Soft, Nontender, Nondistended.
Spine: non-tender to palpation
BUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearms are soft
No pain with passive motion
R M U SILT
EPL FPL EIP EDC FDP intact
1+ radial pulses
LLE skin clean superficial abrasions over thigh
left knee in hinged knee brace
No gross deformity, erythema, edema, induration or ecchymosis.
Thighs and legs are soft
No pain with passive motion
mild tenderness to left hip
Staph Sural DPN SPN SILT
___ FHL ___ TA intact
1+ ___ and DP pulses
RLE skin clean superficial abrasions over thigh
Tender to palpation over R calcaneous. Moderate swelling of
calcaneous.
Non-tender to palpation of knee, proximal tibia, femur
Saph Sural DPN SPN SILT
___ FHL intact
1+ ___ and DP pulses
Pertinent Results:
___ 11:50PM ___ PTT-25.2 ___
___ 11:50PM PLT COUNT-258
___ 11:50PM NEUTS-80.2* LYMPHS-11.2* MONOS-6.5 EOS-1.4
BASOS-0.7
___ 11:50PM WBC-9.4 RBC-4.47* HGB-13.7* HCT-42.8 MCV-96
MCH-30.6 MCHC-32.0 RDW-14.4
___ 11:50PM CALCIUM-9.3 PHOSPHATE-3.1 MAGNESIUM-1.9
___ 11:50PM estGFR-Using this
___ 11:50PM GLUCOSE-127* UREA N-12 CREAT-0.9 SODIUM-141
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-31 ANION GAP-14
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right calcaneus fracture and was admitted to the
orthopedic surgery service. The patient was placed in a well
padded splint with fibroglass reinforcement. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by HD#1.
The patients home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, and the patient was voiding
spontaneously. The patient is NWB in the right lower extremity,
and will be discharged on Lovenox for DVT prophylaxis. The
patient will follow up in in one to two weeks per routine. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course, and all questions
were answered prior to discharge.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC DAILY
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4-6 hours Disp #*45
Tablet Refills:*0
5. Vitamin D 400 UNIT PO DAILY
6. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right calcaneus fracture.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
ACTIVITY AND WEIGHT BEARING:
- NWB RLE
Physical Therapy:
NWB RLE.
Pt wears ___ on LLE for comfort since prior to admission;
recommended by an OSH.
Treatments Frequency:
Please keep splint/cast clean and dry.
Followup Instructions:
___
|
10409830-DS-16 | 10,409,830 | 29,214,311 | DS | 16 | 2159-11-28 00:00:00 | 2159-11-28 16:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Demerol
Attending: ___.
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
Dual chamber pacemaker placement (___)
History of Present Illness:
Mr. ___ is a ___ yo gentleman with hx of atrial fibrillation,
HTN, TIA, and ___ disease who is presenting after a
holter monitor showed several pauses one of which was 5.9
seconds.
The patient says that he has been in overall good health. He
used
to work out several days a week on a treadmill. About 3 weeks
ago
he was at his regular work out and he became extremely dizzy. He
had to slow down his work out and he felt improved. After that
he
had increasing episodes of dizziness with exertion. He never
lost
consciousness or passed out. They were all while he was moving
around. He finally had an episode crossing the road and decided
he needed to be evaluated. He presented to urgent care. At
urgent
care he had an ECG w/ atrial fibrillation and they recommended
the patient see his regular cardiologist.
He saw his cardiologist on ___ and was no longer in atrial
fibrillation but was bradycardia. She had recommended a holter
to
look for pauses. He wore the holter over the weekend and pressed
the button a few times. They called him today and told him to go
to the ED for evaluation because of long pauses on the holter.
In the ED he was afebrile. He had an isolated BP up to 176
otherwise his systolics were in the 140s. He remained 99% on RA.
His exam was non-concerning.
He had a laboratory evaluation that showed a Cr of 1.1, normal
CBC, and a trop < 0.01. INR 2.8 He had a cxr that was normal.
ECG: sinus brady to 47
On the floor he endorsed the above.
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
Parkinsons
TIA
Social History:
___
Family History:
Gfather w/ cancer unknown type
Dad w/ aneurysm at ___ yo
Mom passed at ___ unsure reason
Physical Exam:
ADMISSION EXAM:
VITALS: 24 HR Data (last updated ___ @ 2348)
Temp: 98.3 (Tm 98.3), BP: 152/80, HR: 52, RR: 18, O2 sat:
99%, O2 delivery: RA, Wt: 159.9 lb/72.53 kg
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 with JVD at clavical at 45 degrees
CARDIAC: Sinus brady, normal S1, S2. No murmurs/rubs/gallops.
No
thrills, lifts.
LUNGS: No chest wall deformities. Resp were unlabored, no
accessory muscle use. No crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars
PULSES: Distal pulses palpable and symmetric
DISCHARGE EXAM:
===============
no acute distress, sitting up in bed, alert and oriented,
pleasant and conversant with fluent speech.
Left anterior chest pacemaker site bandaged, clean dry and
intact
without any erythema exudates or tenderness.
Anicteric sclerae, moist mucous membranes.
Clear to auscultation bilaterally without any rales or wheezes.
Regular rate and rhythm, normal S1-S2 without any murmurs rubs
or
gallops.
Abdomen is benign
Extremities are warm and well perfused, without any cyanosis
clubbing or edema.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:10PM BLOOD WBC-5.7 RBC-5.08 Hgb-16.2 Hct-47.8 MCV-94
MCH-31.9 MCHC-33.9 RDW-12.8 RDWSD-44.2 Plt ___
___ 09:10PM BLOOD Neuts-58.3 ___ Monos-8.6 Eos-1.4
Baso-0.2 Im ___ AbsNeut-3.33 AbsLymp-1.77 AbsMono-0.49
AbsEos-0.08 AbsBaso-0.01
___ 09:10PM BLOOD ___ PTT-37.5* ___
___ 09:10PM BLOOD Glucose-147* UreaN-23* Creat-1.1 Na-142
K-4.7 Cl-107 HCO3-23 AnGap-12
___ 09:10PM BLOOD cTropnT-<0.01
___ 07:07AM BLOOD cTropnT-<0.01
___ 07:07AM BLOOD TSH-1.0
DISCHARGE LABS:
================
___ 06:40AM BLOOD WBC-10.0 RBC-5.48 Hgb-17.8* Hct-51.3*
MCV-94 MCH-32.5* MCHC-34.7 RDW-12.4 RDWSD-42.8 Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD ___ PTT-35.2 ___
___ 07:07AM BLOOD ___ PTT-36.8* ___
___ 07:07AM BLOOD Glucose-78 UreaN-22* Creat-1.0 Na-143
K-4.6 Cl-110* HCO3-24 AnGap-9*
___ 07:07AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.1
IMAGING/STUDIES:
=================
___ CXR
IMPRESSION:
Lungs are clear. Heart size is normal. There is no pleural
effusion. No
pneumothorax is seen. No evidence of pneumonia. Left-sided
pacemaker leads project to the right atrium and right ventricle
Brief Hospital Course:
___ year old man with history including paroxysmal atrial
fibrillation (CHADS2-VASc 5, on warfarin), HTN, HLD, ___
disease who presented with symptomatic sinus bradycardia and
conversion pauses most consistent with sinus node
dysfunction/sick sinus syndrome in the setting of longstanding
AF.
Transitional Issues:
====================
[]Patient to follow up with Dr. ___, device clinic
follow-up in 1 week
[]Continued on home Coumadin regimen on discharge, next INR
check ___
[]Replaced home 2.5 bid isradipine with 5 amlodipine qd
Active Issues:
==============
#Atrial fibrillation, Paroxysmal
#Symptomatic Bradycardia
Had episode of presyncope while walking and recurrent exertional
lightheadedness. Holter with paroxysmal atrial fibrillation and
up to 5.9s conversion pauses noted. While symptoms of
lightheadedness do not entirely correlate with time of pauses on
monitor, he clearly has evidence of sinus node dysfunction and
resting sinus rates 40-50s in the absence of nodal agents. EP
consulted and recommend pacemaker implant for sinus node
dysfunction. Patient is in agreement. ___ has been discussed
with his primary cardiologist, Dr. ___ he has been
stable on warfarin and preferred to continue. Dual chamber PPM
placed ___. Interrogated the following day, pacer function
normal with acceptable lead measurements and battery status.
Discharged with the following plan: continue home Coumadin,
repeat INR check at clinic on ___, follow up 1 week
in device clinic.
Chronic Issues:
===============
#Parkinsons - continued home amantadine, ropinirol, rasagiline
#Hypertension - held home isradipine on admission, started on 5
amlodipine. Per patient preference, discharged on amlodipine.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. rOPINIRole 8 mg PO BID
2. Warfarin 2.5 mg PO 5X/WEEK (___)
3. Warfarin 4 mg PO 2X/WEEK (MO,FR)
4. Tamsulosin 0.4 mg PO QHS
5. Rasagiline 1 mg PO DAILY
6. Amantadine 100 mg PO BID
7. isradipine 2.5 mg oral BID
8. Pravastatin 20 mg PO QPM
9. Fish Oil (Omega 3) 1000 mg PO TID
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Amantadine 100 mg PO BID
3. Fish Oil (Omega 3) 1000 mg PO TID
4. Pravastatin 20 mg PO QPM
5. Rasagiline 1 mg PO DAILY
6. rOPINIRole 8 mg PO BID
7. Tamsulosin 0.4 mg PO QHS
8. Warfarin 2.5 mg PO 5X/WEEK (___)
9. Warfarin 4 mg PO 2X/WEEK (MO,FR)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
==================
Atrial Fibrillation, Paroxysmal
Symptomatic bradycardia
Secondary Diagnosis:
====================
Parkinsons Disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted for evaluation of your lightheadedness and
dizziness.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- The cardiology team was involved with your care, and
recommended the placement a pacemaker to help prevent your
symptoms from reoccurring.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please note any changes that may have been made to your
medications.
- Please attend all follow up appointments as listed below.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Followup Instructions:
___
|
10409849-DS-11 | 10,409,849 | 27,766,111 | DS | 11 | 2158-11-01 00:00:00 | 2158-11-01 14:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
lisinopril / seasonal
Attending: ___.
Chief Complaint:
Fall from Stairs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o HTN, CKD, ___ disease, former smoker (35 pack
years), +FH lung cancer, remote history of asthma who is
admitted to the ___ service s/p fall
with multiple fractures. Patient reportedly fell from 12 stairs
and has sustained a C2 fx, multiple L rib fx's, displaced L
humerus fx s/p bedside reduction of humerus.
Past Medical History:
SHORTNESS OF BREATH
OSTEOPENIA
LEG CRAMPS
HYPERTENSION
CHRONIC KIDNEY DISEASE
SEBORRHEIC KERATOSIS
ANEMIA
FALLS
OSTEOPOROSIS
RIB FRACTURE
KYPHOSIS
GAIT DISORDER
Social History:
___
Family History:
father- lung cancer
mother- lymphoma
Physical ___:
Discharge Physical Exam:
Vitals - temp 98.4 / HR 94 / BP 118/72 / RR 16 / O2sat 96%RA
GEN: NAD
HEENT: Cervical collar in place and appropriate, NCAT, EOMI, no
scleral icterus
CV: RRR, no M/R/G
RESP: no respiratory distress, breathing comfortably on room
air, appropriate chest wall TTP
GI: soft, non-TTP, no R/G/D
EXT: WWP, no peripheral edema, appropriate TTP and ecchymoses
overlying the L humerus
Pertinent Results:
___ 06:05AM BLOOD WBC-9.8 RBC-4.35 Hgb-12.8 Hct-38.7 MCV-89
MCH-29.4 MCHC-33.1 RDW-14.4 RDWSD-46.4* Plt ___
___ 05:35AM BLOOD WBC-9.3 RBC-3.91 Hgb-11.7 Hct-35.6 MCV-91
MCH-29.9 MCHC-32.9 RDW-14.4 RDWSD-48.0* Plt ___
___ 05:50AM BLOOD Glucose-119* UreaN-31* Creat-1.1 Na-136
K-4.3 Cl-103 HCO3-21* AnGap-16
___ 12:15AM BLOOD cTropnT-<0.01
___ 05:50AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.1
___: CT TORSO
1. No acute intraperitoneal or intrapelvic abnormalities.
2. 1.0 cm solid pulmonary nodule in the left upper lobe. In
addition to
multiple sub 4 mm nodules and sub solid nodules.
3. Fluid in the endometrium. Further evaluation with
nonemergent pelvic
ultrasound can be considered as clinically indicated.
4. Comminuted and severely angulated left humeral diaphyseal
fracture,
partially imaged.
5. Multiple mildly displaced left rib fractures. No
pneumothorax or pulmonary hemorrhage.
RECOMMENDATION(S): For incidentally detected single solid
pulmonary nodule bigger than 8mm, a follow-up CT in 3 months, a
PET-CT, or tissue sampling is recommended.
___: XR L HUMERUS
Status post close reduction of left mid diaphyseal comminuted
fracture with significantly improved alignment, now near
anatomic.
___: MRI CSPINE
1. Transversely oriented C2 vertebral body fracture with
extension into the
lateral masses.
2. No evidence of cord edema, cord compression, or ischemia.
3. Posterior paraspinal soft tissue edema with injury to the
C2-C6
interspinous and supraspinous ligaments, left greater than
right.
4. Interspinous ligamentous injury at C1-2.
5. Mild prevertebral soft tissue edema without injury to the
anterior
longitudinal ligament.
6. Trace ventral epidural hematoma at C2-C3.
7. Question of nondisplaced superior endplate T2 vertebral body
fracture.
8. Degenerative changes involving the left C4-C5 facets with
small facet joint effusion.
9. Cervical spondylosis with cord remodeling at C4-C5 and C5-C6
without cord edema or deformity.
MR HEAD W/O CONTRAST Study Date of ___ 5:40 ___
IMPRESSION:
1. No evidence of acute infarction or hemorrhage.
2. Diffuse parenchymal volume loss with probable chronic small
vessel ischemic
disease, as above.
Brief Hospital Course:
Following diagnosis of her traumatic injuries, the patient was
admitted to the ACS service at the ___ for further monitoring.
Her injuries include a C2 Fracture with Associated Ligamentous
Injury, a Left Displaced Humerus fracture that was reduced
externally by the Orthopedics team and multiple left sided rib
fractures.
On HD1, patient was evaluated by Orthopedics and injuries were
determined to be nonoperative, recommended ___ J collar, no
need for log-roll. MRI C-spine demonstrated transversely
oriented C2 vertebral body fracture with extension into the
lateral masses. No evidence of cord edema, cord compression, or
ischemia. Posterior paraspinal soft tissue edema with injury to
the C2-C6 interspinous and supraspinous ligaments, left greater
than right. Interspinous ligamentous injury at C1-2. Mild
prevertebral soft tissue edema without injury to the anterior
longitudinal ligament. Trace ventral epidural hematoma at C2-C3.
On HD2, the patient removed her own Foley, UA was sent and wnl.
Patient complained of hallucinations and so her pain medications
were decreased. The patient was tolerating a regular diet and
she was able to void without issue.
On HD3, the patient's blood pressure was elevated to 206/99, she
remained asymptomatic without headaches/dizziness, she was
neurologically intact on exam. Her blood pressure improved with
IV hydralazine.
On HD4, the patient's blood pressure was in the 160s, she
complained of dizziness with ambulation, no LOC. This was
attributed to likely orthostatic hypotension. The patient worked
with physical therapy and recommended for acute rehab.
On HD5, the patient was screened for acute rehab and continued
to receive PO hydralazine for elevated SBP in 170s.
On HD6, the patient complained of spatial neglect with L arm,
neurology was consulted and recommended DW-MRI.
On HD7, the patient's MRI was negative for any acute process.
The patient was deemed to be medically stable for acute rehab.
On HD8, the patient was deemed ready for discharge to acute
rehab. She was hemodynamically stable and tolerating a regular
diet, as well as voiding without issue. Her pain was
well-controlled with PO tramadol. She is A&OX3 and
neurologically intact. She will be discharged on her home
medications as well as PO pain medications. She will follow-up
with ___ clinic in ___ weeks. The patient expressed
understanding and agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO DAILY PRN Pain - Mild
2. amLODIPine 2.5 mg PO DAILY
3. Carbidopa-Levodopa (___) 1.5 TAB PO TID
4. DiphenhydrAMINE Dose is Unknown PO Frequency is Unknown
5. Multivitamins 1 TAB PO DAILY
6. Aspirin 81 mg PO DAILY
7. fluticasone-salmeterol 230-21 mcg/actuation inhalation
DAILY:PRN
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
2. Heparin 5000 UNIT SC TID
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. TraMADol 25 mg PO Q6H:PRN pain
RX *tramadol [Ultram] 50 mg Half tablet(s) by mouth every 6
hours Disp #*20 Tablet Refills:*0
5. Acetaminophen 650 mg PO TID
6. amLODIPine 2.5 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Carbidopa-Levodopa (___) 1.5 TAB PO TID
9. fluticasone-salmeterol 230-21 mcg/actuation inhalation
DAILY:PRN
10. Multivitamins 1 TAB PO DAILY
11. HELD- DiphenhydrAMINE Dose is Unknown PO Frequency is
Unknown This medication was held. Do not restart
DiphenhydrAMINE until You are off of Tramadol
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
C2 Fracture, interspinous ligamentous injury C1-C2
Left Displaced Humerus Fracture
Multiple Left Sided Rib Fracture (left ___ ribs)
pulmonary nodules- 1cm left upper lobe, sub4mm nodules and
subsolid nodules
moderate hiatal hernia
trace ventral epidural hematoma C2-C3
cervical spondylosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
You were admitted to the Acute Care Surgery service at the ___
for management of your traumatic injuries you sustained from
your fall down stairs. Your injuries include a C2 Vertebral
fracture, a left humerus (arm) fracture that was reduced at
bedside and multiple left sided rib fractures. None of your
injuries required any surgical management during your admission.
Your pain has been controlled, you are tolerating a regular
diet, and you are now ready to be discharged to a rehab facility
to continue your recovery.
1. For your vertebral fracture in your neck, you will wear the
___ Cervical Collar at all times until you follow up with
the Orthopedic Spine team as an outpatient in 6 weeks.
(Orthopedic Spine team ___
2. For your left humerus fracture, you should continue to move
your arm as tolerated and may bear weight that is comfortably in
that arm. You will follow up with the General Orthopedic Surgery
team in ___ days for re-evaluation of your humerus fracture.
___ at ___
3. For your rib fractures, it is important that you control your
pain such that you are able to walk and take deep breaths. If
you do not do these activities, you are at a much higher risk of
developing a pneumonia. Use your incentive spirometer as
frequently as possible and walk several times per day to help
your lungs heal. See the following instructions.
* Your injury caused left sided rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician. Take Tylenol as prescribed for minimal
pain, you may take the Narcotic oxycodone when the pain
persists.
* 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
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus)
You were also found to have an incidentally discovered lung
nodule, that is approximately 1 cm in size. We are uncertain
what this nodule represents, but given its size and your history
of smoking, we would like to order a PET/CT Scan to make sure
this is not a malignancy. You will go to rehab to regain your
strength and get your PET Scan as an outpatient once you return
home from rehab.
ACTIVITY:
- If you were driving previously, do not resume drive until you
have stopped taking pain medicine, feel you could respond in an
emergency, no longer have the ___ J neck brace, no longer have
the ___ arm brace, and are cleared by all of your
surgeons.
- You should continue to walk several times a day and follow the
exercises given to you by the therapists.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- Continue to wear your ___ J neck collar on at all times.
Your
Pain control:
- Your pain has been well controlled with Acetaminophen
(Tylenol) and minimal Tramadol. You should continue to take the
Tylenol regularly and the Tramadol as needed for moderate to
severe pain not controlled by the Tylenol.
- Wean off the Tramadol and Tylenol as you are able. Do not
exceed 3000mg per day of Tylenol.
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
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
- weakness, numbness, heaviness, cold/blue extremity
- loss of control of your urine and stool if you had it before
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
Please return to all of your home medications as you were taking
them prior to this hospitalization. You may continue to eat a
regular diet as you were before.
We wish you the best in your recovery and thank you for allowing
us to take part in your care.
- Your ___ care team
Followup Instructions:
___
|
10410021-DS-20 | 10,410,021 | 21,589,182 | DS | 20 | 2135-12-29 00:00:00 | 2136-01-02 20:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Zantac / ciprofloxacin
Attending: ___.
Chief Complaint:
Right lower quadrant abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with Crohn's disease (dx'd ___ now on 6-mercaptopurine and
prednisone, s/p multiple bowel resections, most recently on
___ at ___, who presented with 4
days of RLQ pain, night sweats, and subjective fevers.
On ___ the patient underwent resection of a bypass loop of
bowel (which had been placed several years prior) for
intermittent GI bleed as well as stricturoplasty. His prednisone
dose was tapered to 20mg daily from 60mg daily after discharge.
Four days prior to admission at ___, he began to experience
sharp, localized RLQ abdominal pain that was ___ in
intensity. The pain sometimes waned but felt like a "lightning
bolt" at its worst. Patient reports that when he would bend over
he would feel a sensation in his RLQ of the abdomen. No
association of pain with eating or bowel movements. Has been
tolerating POs at home. During this time he also endorses night
sweats, subjective fevers (his highest measured temp. was ___,
and nausea. No vomiting, no hematochezia or melena.
After reporting his symptoms to his physician his prednisone
dose was increased from 20mg daily to 30mg daily. However the
patient continued to experience significant pain and presented
to the ED under the direction of his Gastroenterologist.
His CT scan of the abdomen/pelvis showed enteroenteric fistulae
and developing sinus tract through the anterior abdominal wall.
No drainable fluid collection. The patient was initially
admitted to the surgery service. He was started on IV
ciprofloxacin and flagyl, and placed on bowel rest.
Currently, he feels his pain is improved (___). It is still
localized to the RLQ. Denies current nausea. Now having ___ BMs
per day, non-bloody. He reports passing gas.
ROS: per HPI, denies chills, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, vomiting, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
1. Crohn's disease: Diagnosed in ___, resection of ___ feet
of jejunum with strictures in ___. s/p GIB from Dieulofoy's
angioectasia ___. s/p GIB ___ requiring embolization. Had
ileal thickening with phlegmon and ileal strictures resulting in
ileal resection and stricturoplasty with intestinal bypass. On
___, patient had resection of 20 cm ileum with sparing of
distal 10 cm and phlegmon was removed. He was initially managed
with ___, prednisone and Pentasa. More recently, just on ___ and
prednisone. When efforts made to taper steroids to prednisone 10
mg in the past, patient had Crohn's flare with ___ BM per day.
Previous admission in ___ for hematochezia thought to be
Crohn's flare based on CTA with jejunal inflammation; ___
without bleeding source, subsequent MR enteroscopy showed
multiple strictures in the ileum. Patient was evaluated by
general surgeon Dr. ___ deferred surgery at that
time, but considered laparotomy with stricturoplasties if
bleeding recurred.
2. Peptic ulcer disease.
3. Anal fissures.
4. Nephrolithiasis status post ureteral stent and extracorporeal
shock wave lithotripsy in ___.
5. Blepharitis.
6. Vitamin B12 deficiency
7. Osteoporosis secondary to longterm steroids, followed by
Endocrinology
8. HTN
Social History:
___
Family History:
HTN, DM, unspecified colitis in grandmother, breast cancer in
mother, no colon cancer
Physical Exam:
Admission physical exam:
VS - Temp 97.9F, BP 101/77 , HR 75, R 16, O2-sat 99% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS+, soft, buldging mass visible in RLQ,
well-healing midline abdominal incision without surrounding
erythema, mild TTP in the RUQ, no rebound or guarding.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, gait deferred
Discharge physical exam:
VS - Tm 98.2, Tc 97.7, BP 114/68 (100s-120s/60s-70s), HR 54, R
18, O2-sat 99% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS+, soft, non-tender, bulging mass on RLQ
significantly reduced, well-healing midline abdominal incision
without surrounding erythema
EXTREMITIES - WWP, no c/c/e
SKIN - no rashes or lesions
NEURO - awake, A&Ox3
Pertinent Results:
___ 10:10AM SED RATE-78*
___ 10:10AM PLT COUNT-574*#
___ 10:10AM WBC-19.3* RBC-4.56* HGB-13.9* HCT-42.2 MCV-93
MCH-30.5 MCHC-33.0 RDW-13.8
___ 10:10AM WBC-19.3* RBC-4.56* HGB-13.9* HCT-42.2 MCV-93
MCH-30.5 MCHC-33.0 RDW-13.8
___ 10:10AM HCV Ab-NEGATIVE
___ 10:10AM CRP->300
___ 10:10AM HBs Ab-NEGATIVE HBc Ab-NEGATIVE IgM
HBc-NEGATIVE
___ 10:10AM ALBUMIN-3.8 CALCIUM-9.7 PHOSPHATE-3.2
MAGNESIUM-2.1
___ 10:10AM LIPASE-26
___ 10:10AM ALT(SGPT)-41* AST(SGOT)-22 ALK PHOS-130 TOT
BILI-0.5
___ 10:10AM estGFR-Using this
___ 10:10AM GLUCOSE-113* UREA N-19 CREAT-0.9 SODIUM-140
POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-27 ANION GAP-18
___ 10:15AM LACTATE-1.8
___ 11:32AM URINE MUCOUS-RARE
___ 11:32AM URINE RBC-0 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 11:32AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.5
LEUK-NEG
___ 11:32AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:30 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ 5:41 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 9:25 am Immunology (CMV) Source: Venipuncture.
**FINAL REPORT ___
CMV Viral Load (Final ___:
CMV DNA not detected.
Performed by PCR.
Detection Range: 600 - 100,000 copies/ml.
FOR RESEARCH USE ONLY..
NOT FOR USE IN DIAGNOSTIC PROCEDURES.
This test has been validated by the Microbiology
laboratory at ___.
___ 3:05 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 9:10 pm BLOOD CULTURE SET#1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 9:20 pm BLOOD CULTURE Source: Venipuncture SET#2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ Abdominal/pelvic CT with PO and IV contrast:
IMPRESSION:
1. Severe terminal ileitis with probable enteroenteric fistulae
and
developing sinus tract through the anterior abdominal wall. No
drainable
fluid collection.
2. Partial small bowel obstruction secondary to inflammatory
changes of the
terminal ileum.
___ MR enterography:
IMPRESSION:
1. Extensive inflammatory mass involving the distal ileum with
a fistula
extending upwards to the anterior abdominal wall where it opens
into a 5.6-cm
air collection immediately deep to the anterior abdominal wall,
with air
tracking into the right rectus muscle and subcutaneous fat. The
fistula also
tracks towards the transverse colon which is thickened and
enhancing. No
bowel obstruction.
2. Separate focal area of thickening in the distal ileum a few
cm proximal to
the above area of gross abnormality, which demonstrates limited
peristalsis
and may be chronic in nature.
3. Shortened small bowel consistent with previous small bowel
resection(s).
Brief Hospital Course:
___ with h/o Crohn's disease presenting with RLQ pain
approximately 2wks after small bowel resection and
stricturoplasty at OS___ and in the setting of tapering of
prednisone dose attributed to a Crohn's Flare.
HOSPITAL COURSE BY PROBLEM
#. Crohn's Flare.
Abdominal CT showing severe terminal ileitis and evidence of
enteroenteric fistulae and developing sinus tract through the
anterior abdominal wall. There was no evidence of
intra-abdominal abscess or anastomatic leak, and patient is s/p
appendectomy so these were thought to be unlikely causes of his
symptoms. Heptatitis B and C serologies were negative for acute
infection. The GI team was consulted and recommended treating
the patient with IV ciprofloxacin and flagyl, giving and IV PPI,
and placing him on IV methylpredinisolone 20mg q6h. The patient
was also placed on bowel rest and given IV morphine for pain
control. The patient experienced improvement in his abdominal
pain. A CMV viral load was sent to evaluate for a possible
infectious cause of his symptoms and was found to be
undetectable. The patient did experience increasingly loose
stools during his hospitalization, so a stool c. diff was sent
and found to be negative. MR enterography was performed, which
showed extensive inflammation of the terminal ileum with a
fistula extending toward the anterior abdominal wall and
tracking towards the transverse colon. After improvement in the
patient's pain, the GI team felt the patient's diet could be
advanced to a low residue diet, which he tolerated well. The day
prior to discharge he was transitioned to PO steroids and PO
antibiotics. He was discharged with a plan for follow up with GI
the following week and with surgery in the following ___ weeks.
#. Positive PPD. During this hospitalization, a PPD was placed
in anticipation of possibly starting Remicade. 48hrs after
placement, a 5mm, dark red, slightly raised patch was noted, and
was considered positive given that the patient was on high-dose
steroids. A quantiferon gold was sent and found to be
indeterminate. The patient was informed of his positive PPD and
told to follow up with his PCP for possible treatment of latent
TB.
#. Bradycardia with prolonged QTc.
The patient was noted to be bradycardic during this admission,
with heart rates as low as the high ___. He remained
asymptomatic, and his heart rates rose with activity. Blood
pressures remained stable in the ___ systolic. An EKG was
performed which showed sinus bradycardia, with prolonged QTc but
no abnormalities within the conduction system. The prolonged QTc
was attributed to ciprofloxacin, and he was switched to
ceftriaxone. His K and Mg remained within normal limits. He was
maintained on telemetry and continued to be bradycardic but was
still asymptomatic. After discontinuing the ciprofloxacin, his
QTc shortened and was 447ms the day before discharge.
#. Fevers and night sweats.
Likely ___ Crohn's flare. The patient remained afebrile while in
the hospital.
#Leukocytosis:
The patient's white count was 19.3 on his admission. This was
thought to be due to his Crohn's flare or the initiation of
steroids. He was treated as above, and his white count decreased
from admission but remained elevated, likely secondary to
steroids.
#Hypertension:
The patient is managed as an outpatient with lisinopril 10mg PO
daily. However, his lisinopril was held during this admission as
his blood pressures were in the ___ systolic. Patient was
instructed to follow-up with his primary care physician
regarding restarting this medication.
Transition of care:
- Follow-up with GI and surgery in regards to further management
of patient's Crohn's Disease
- Follow-up with primary care physician regarding ___ for
latent TB in light of positive PPD and indeterminate quantiferon
gold testing.
Medications on Admission:
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg/mL Solution - twice
monthly
LISINOPRIL - 10mg po daily
MERCAPTOPURINE -75 mg po daily
OMEPRAZOLE - 40mg po BID
PREDNISONE - 30 mg PO daily (increased from 20mg to 30mg 2 days
PTA)
OXYCODONE- ACETOMENOPHEN: ___
CALCIUM CARBONATE [TUMS EXTRA STRENGTH SMOOTHIES] - 300 mg (750
mg) Tablet, Chewable - 2 Tablet(s) by mouth daily
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM-D] - 600 mg-200 unit
Capsule - 1 Capsule(s) by mouth three times a day
FERROUS SULFATE - 325 mg (65 mg iron) Tablet - one Tablet(s) by
mouth daily
MULTIVITAMIN - Tablet - 1Tablet(s) by mouth once a day
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth every 12 hours Disp
#*14 Tablet Refills:*0
2. mercaptopurine *NF* 75 Oral Daily Reason for Ordering: Wish
to maintain preadmission medication while hospitalized, as there
is no acceptable substitute drug product available on formulary.
3. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth Three times daily
Disp #*10 Tablet Refills:*0
4. Omeprazole 40 mg PO BID
5. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*9 Tablet
Refills:*0
6. Cyanocobalamin 1000 mcg IM/SC TWICE PER MONTH
7. Multivitamins 1 TAB PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. calcium carbonate-vitamin D3 *NF* 600 mg(1,500mg) -200 unit
Oral TID
Discharge Disposition:
Home
Discharge Diagnosis:
Crohn's flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at ___.
You were admitted to the hospital for abdominal pain. An
abdominal CT was done which showed severe inflammation of the
small bowel, consistent with a flare of your Crohn's disease.
The gastroenterology team was consulted and recommended treating
you with IV antibiotics, IV steroids, and bowel rest. Your pain
improved during your hospitalization. MR enterography was
obtained during this admission. You were transitioned to oral
medications and an oral diet and were tolerating these well
prior to discharge.
During your hospitalization you were noted to have a slow heart
rate. You were asymptomatic. Please follow up with your primary
care doctor regarding this. Your PPD was positive during this
admission, and a blood test was indeterminate for tuberculosis.
Follow-up with your primary care doctor about under-going
further ___ for this as it can affect treatment of your
Crohn's disease in the future.
Please keep all follow up appointments.
The following medications were changed: You wil be taking oral
flagyl, cefpodoxime, and 60mg prednisone. We STOPPED your
lisinopril in light of normal blood pressures. Talk with your
primary care doctor about restarting lisinopril.
Followup Instructions:
___
|
10410110-DS-6 | 10,410,110 | 21,693,772 | DS | 6 | 2124-08-19 00:00:00 | 2124-08-21 15:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts) / metformin
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an ___ year old man with hypertension, diabetes
mellitus-type II and dementia who presented from his independent
living facility after RN there found him to be 'weak' and
tachycardic to the 110s. The patient reports feeling completely
"normal" and "OK" without any complaints. He endorses some
occasional cough, but cannot qualify or quantify it.
He denies any fevers, chills, sweats, chest pain, shortness of
breath, abdominal pain, nausea, vomiting, diarrhea,
lightheadedness.
In the ED, initial vitals were: T 100.2, "BP and HR - WNL" and
on exam, he was found to have decreased breath sounds at both
lung bases. Labs were significant for WBC 9.3 with neutrophilic
shift, lactate 2.3, Cr 1.4. His EKG was unchanged from prior.
CXR showed right lung infiltrate concerning for pneumonia. Given
his CURB-65 score of 2, he received 1L NS, ceftriaxone 1g,
azithromycin IV 500mg and was admitted to medicine.
On the floor, his vitals were as below. He continued to have no
complaints whatsoever.
Past Medical History:
HTN, DM-II, dementia
Social History:
___
Family History:
None on file
Physical Exam:
EXAM ON ADMISSION
Vitals: T 98.2F, BP 155/68, HR 77, R 18, SpO2 98% on RA, FSG
110 mg/dL
General: Alert, oriented - to name, month, year, city and place
("medical building"), in 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, grade II/VI
systolic murmur
Lungs: Decreased air entry to the lung bases bilaterally, with
rhonchi appreciated over right lower, upper and lateral lung
fields; few scattered wheezes and rhonchi over left upper
posterior lung field
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Extremities: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
EXAM ON DISCHARGE
Vitals: T 97.6 BP 167/61 HR 63 R 16 SpO2 98% on RA ___ 93
General: Alert, oriented - to name, month, year, city and place
("medical building"), in 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, grade II/VI
systolic murmur
Lungs: Good air entry bilaterally, with scattered expiratory
wheezes, greatest over the RLL field
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Extremities: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
Pertinent Results:
LABS ON ADMISSION
___ 11:35AM BLOOD WBC-9.8# RBC-4.10* Hgb-13.8* Hct-40.1
MCV-98 MCH-33.6* MCHC-34.3 RDW-14.4 Plt ___
___ 11:35AM BLOOD Neuts-86.1* Lymphs-8.1* Monos-4.9 Eos-0.8
Baso-0.2
___ 11:35AM BLOOD Glucose-264* UreaN-31* Creat-1.4* Na-138
K-3.9 Cl-99 HCO3-28 AnGap-15
___ 11:35AM BLOOD Calcium-8.4 Phos-2.1* Mg-1.9
___ 11:43AM BLOOD Lactate-2.3*
INTERVAL LABS, IMAGING
___ CXR: Right middle lobe pneumonia. Recommend followup
chest x-ray in ___ weeks after treatment to assure resolution
LABS ON DISCHARGE
___ 06:45AM BLOOD WBC-5.5 RBC-3.62* Hgb-12.3* Hct-36.1*
MCV-100* MCH-34.0* MCHC-34.1 RDW-14.3 Plt ___
___ 06:45AM BLOOD Glucose-93 UreaN-26* Creat-1.3* Na-140
K-3.2* Cl-101 HCO3-33* AnGap-9
___ 06:45AM BLOOD Albumin-3.3* Calcium-8.2* Phos-2.9 Mg-2.0
Brief Hospital Course:
This is an ___ year old man with HTN, DM-II and dementia who
presented without complaints, but history from caretakers of
weakness x1 week, with tachycardia today, found to have a RML
pneumonia on CXR today.
ACTIVE ISSUES
## WEAKNESS: the patient denied any weakness upon admission -
he denied any and all symptoms and reported feeling quite well,
like his usual self. Report of weakness was from caretaker. This
complaint may have been attributed to a linguistic barrier,
given the fact that the patient speaks very little ___.
## PNEUMONIA: upon investigation of weakness, CXR revealed
right middle lobe pneumonia. He denied cough, chest pain,
shortness of breath, fevers, chills or malaise. He remained
afebrile throughout his hospitalization. He never developed
supplemental oxygen requirement nor leucocytosis, however his
first CBC with differential showed a neutrophilic predominance
(>80%), which resolved upon the seconday day, after having
received antibiotics. He was started on ceftriaxone and
azithromycin for treatment for community-acquired pneumonia, to
which he had a good response. In preparation for discharge,
ceftriaxone and azithromycin were discontinued, and the patient
was sent home on levofloxacin for 3 days, to complete a total
course of antibiotics of 5 days in duration.
CHRONIC ISSUES
# DEMENTIA: stable. Currently A&O x2+ (name, city, year, month)
but admits to difficulty with memory. Continued home donepezil
and memantine.
# HYPERTENSION: SBP running in 150s to 160. VS monitored.
Continued home regimen of amlodipine, lisinopril and HCTZ, but
given the patient's GFR, consider stopping HCTZ since effect is
mitigated by decreased GFR and instead increasing amlodipine or
adding a third agent for antihypertensive effect?
# DIABETES MELLITUS - TYPE II: stable. FSGs WNL. Held home
regimen of glipizide and metformin for ISS while hospitalised.
=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=
TRANSITIONAL ISSUES
=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=
-- Given the patient's GFR, HCTZ may be ineffective as
antihypertensive
[] Pt to complete 3 more days of PO levofloxacin for CAP
[] Pt should have follow up CBC at PCP visit given his
macrocytic anemia and thrombocytopenia
[] Vitamin B12 dose increased to 1000 U daily given his recent
B12 deficiency and macrocytic anemia
[] Unclear if pt had previously been taking his B12. B12 recheck
pending at discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 7.5 mg PO DAILY
2. Donepezil 5 mg PO HS
3. Doxazosin 1 mg PO HS
4. GlipiZIDE XL 2.5 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Memantine 10 mg PO BID
8. MetFORMIN (Glucophage) 500 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Cyanocobalamin 100 mcg PO DAILY
11. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Amlodipine 7.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Donepezil 5 mg PO HS
6. Doxazosin 1 mg PO HS
7. Hydrochlorothiazide 25 mg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. Memantine 10 mg PO BID
10. MetFORMIN (Glucophage) 500 mg PO DAILY
11. GlipiZIDE XL 2.5 mg PO DAILY
12. Levofloxacin 500 mg PO Q24H Duration: 3 Days
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: pneumonia
Secondary diagnoses: HTN, DM-II, dementia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Confused - sometimes.
Discharge Instructions:
Dear ___
___ were admitted to ___ for a pneumonia. ___ were feeling
well, and were started on antibiotics for treatment. ___ be
sent home with 3 days of antibiotics to finish a total course of
5 days.
Thank ___ for allowing us to care for ___, it's been our
pleasure.
-- Your team at ___
___
___ ___
___
___
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- ___
___ ___
Followup Instructions:
___
|
10410201-DS-9 | 10,410,201 | 25,050,253 | DS | 9 | 2162-08-08 00:00:00 | 2162-08-08 19:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
symptomatic bradycardia
Major Surgical or Invasive Procedure:
Pacemaker
History of Present Illness:
Mr. ___ is a ___ year old male with HTN, HLD, atrial
fibrillation on coumdin, CKD with baseline creatinine of 1.6 and
multiple myeloma on Velcade/dex/Bortezomib every other week. He
reports doing well until last month. He is usually able to walk
___ feet with a walker but for the past month has noticed
progressive dyspnea on exertion to a point now where he has to
gasp for air if he walks ten feet. He has never felt dizzy, lost
consciousness or had chest discomfort.
Per records, his cardiologist did a holter on ___ which
showed atrial fibrillation with average ventricular rate of 34,
minimal ventricular rate of 25 with chronotopic competence to
maximum heart rate of 63. He had no VPCs recorded. His
cardiologist stopped his carvedilol and was pondering EP consult
for pacemaker placement for symptomatic bradycardia.
He went to his ___ clinic at ___ today where he was
noted to have heart rate in ___ and thus after discussion with
his cardiologist was instructed to present to ED. He did not
receive his chemotherapy today.
In the ED, his initial vitals were 98.0 30 165/60 20 98%RA. ECG
showed atrial fibrillation with likely AV dissociation and
fascicular escape rhythm. EP was consulted who recommended
vitamin K 3 mg oraly for INR of 3.8 and NPO after midnight with
plan to place permanent pacemaker tomorrow by Dr. ___.
On the floor, he reported no complaints.
REVIEW OF SYSTEMS
On review of systems, He denies any prior history of stroke,
TIA, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: N/A
-PERCUTANEOUS CORONARY INTERVENTIONS: N/A
3. OTHER PAST MEDICAL HISTORY:
Atrial fibrillation on coumadin
Multiple myeloma on Velcade/dexamethasone/bortezomib every other
week
CKD stage 3B with baseline creatine of 1.6
Peripheral Neuropathy
GI bleed (pyloric obstruction, gastric ulcers) leading to
stomach resection in ___
Post-surgical DVT which has resolved
Migraines
Anxiety/Depression
Social History:
___
Family History:
Significant for CAD in his dad
Physical Exam:
ADMIT:
VS: 97.9 180/78 29 15 98%RA
GENERAL: Obese male in no acute distress
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No xanthalesma. No
cannon A waves noted
NECK: Supple with JVP of 8 cm
CARDIAC: Bradycardic. Regular rhythm. normal S1, S2. No m/r/g.
No thrills, lifts. No S3 or S4.
LUNGS: Resp unlabored, no accessory muscle use. Bibasilar
crackles
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No femoral bruits. 1+ pedal edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: 2+ Femoral 2+ DP
Left: 2+ Femoral 2+ DP
.
D/C:
Vitals: 97.6 160-170/90 60 18 97 RA
I/O: 1650 since MN UOP
GENERAL: Obese male in no acute distress
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No xanthalesma. No
cannon A waves noted
NECK: Supple with JVP of 8 cm
CARDIAC: Regular rhythm, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: Resp unlabored, no accessory muscle use. Bibasilar
crackles
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No femoral bruits. 1+ pedal edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: 2+ Femoral 2+ DP
Left: 2+ Femoral 2+ DP
Pertinent Results:
___ 11:40PM CK(CPK)-57
___ 11:40PM CK-MB-3 cTropnT-0.02*
___ 04:13PM GLUCOSE-107* UREA N-33* CREAT-2.3* SODIUM-141
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-25 ANION GAP-17
___ 04:13PM estGFR-Using this
___ 04:13PM cTropnT-0.02*
___ 04:13PM proBNP-5034*
___ 04:13PM CALCIUM-9.5 PHOSPHATE-3.7 MAGNESIUM-2.7*
___ 04:13PM WBC-6.0 RBC-4.86 HGB-14.9 HCT-46.5 MCV-96
MCH-30.6 MCHC-31.9 RDW-16.3*
___ 04:13PM CALCIUM-9.5 PHOSPHATE-3.7 MAGNESIUM-2.7*
___ 04:13PM NEUTS-78.4* LYMPHS-12.8* MONOS-5.2 EOS-3.0
BASOS-0.6
___ 04:13PM PLT COUNT-171
___ 04:13PM ___ PTT-53.5* ___
CHEST (PA & LAT) Study Date of ___ 9:49 AM
FINDINGS: As compared to the previous radiograph, the patient
has received a
right pectoral pacemaker. Course of the line is unremarkable,
there is no
fracture. The tip projects over the right ventricle. No
evidence of
pneumothorax or other complication. Borderline size of the
cardiac
silhouette. No pulmonary edema.
Brief Hospital Course:
___ year old male with HTN, HLD, atrial fibrillation on coumdin,
CKD with baseline creatinine of 1.6 and multiple myeloma on
Velcade/Dex/Bortezomib every other week admitted with
symptomatic bradycardia.
.
1. Symptomatic bradycardia: ECG consistent with Afib with AV
dissociation and left anterior fascicular escape rhythm
consistent with high grade AV block. Likely culprit for the high
grade AV block is myeloma as well as age related fibrotic
conduction disorder. Dexamethasone has been associated with
bradycardia though not consistent with his clinical presentation
over past month while he has been getting it since ___.
Underwent single chamber PPM ___ uncomplicated.
.
2. Atrial fibrillation. Not on rate control medications with
high grade AV block. CHADS2 score of 2. s/p 3 mg vitamin K prior
to procedure night before. Continued on home coumadin prior to
D/C.
.
3. ___ on CKD Stage 3B: Creatinine at 2.3 with baseline of 1.6.
Likely progression of his CKD vs prerenal. He is euvolemic if
not her volume overloaded on exam with pedal edema, JVP at 8 cm
and bibasilar crackles.
.
4. HTN: Continued Valsartan 240 mg po qdaily and dyazide 37.5/25
mg po MWF. Restarted on carvedolol for hypertension s/p
pacemaker placement.
.
5. HLD: Continued simvastatin qdaily. Held triplix 135 mg po
qdaily as not formulary and restarted it on discharge.
.
6. Myeloma: Continued Bactrim SS MWF and acylovir 800 mg po
qdaily for prophylaxis.
.
7. Anxiety/Depression: Continued mirtazipine 7.5 mg po qhs and
alprazolom 0.25 mg po qhs prn.
.
#CODE: Full Confirmed
#EMERGENCY CONTACT: HCP ___: ___
.
Transitions of care:
- resume chemotherapy per ___.
Medications on Admission:
Acyclovir 800 mg daily
Trilipix 135 mg daily
Carvedolol 3.125 BID
Coumadin 3.5 mg daily
Bactrim SS MWF
Diovan 240 mg 1.5 tab daily
Diazide 37.5/25 mg MWF
Mirtazipine 7.5 qhs
Alprazolam 0.25 mg qhs prn insomnia
Simvastatin 20 mg daily
Vitamin D 1000 IU daily
MVA daily
Maintainence Velcade/Dex/Bortezomib every other week
Discharge Medications:
1. acyclovir 800 mg Tablet Sig: One (1) Tablet PO once a day.
2. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO MWF (___).
3. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO MWF (___).
4. warfarin 1 mg Tablet Sig: 3.5 Tablets PO once a day: please
take 3.5mg daily.
5. mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
7. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
8. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. valsartan 80 mg Tablet Sig: Three (3) Tablet PO once a day.
10. Trilipix 135 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Coreg 3.125 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
12. cefadroxil 1 gram Tablet Sig: One (1) Tablet PO twice a day
for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
13. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Symptomatic bradycardia
Secondary:
Multiple myeloma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure participating in your care at ___. You were
admitted to the hospital for a slow heart rate. A pacemaker was
placed to fix this problem.
REGARDING YOUR MEDICATIONS...
Medications STARTED that you should continue:
Carvedolol, cefadroxil
Medications STOPPED this admission:
NONE
Medication DOSES CHANGED that you should follow:
NONE
Otherwise, it is very important that you take all of your usual
home medications as directed in your discharge paperwork.
Please followup with your primary care physician ___ ___
days regarding the course of this hospitalization.
Followup Instructions:
___
|
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