note_id
stringlengths 13
15
| subject_id
int64 10M
20M
| hadm_id
int64 20M
30M
| note_type
stringclasses 1
value | note_seq
int64 2
133
| charttime
stringlengths 19
19
| storetime
stringlengths 19
19
| text
stringlengths 1.56k
52.7k
|
|---|---|---|---|---|---|---|---|
10425960-DS-16 | 10,425,960 | 21,379,443 | DS | 16 | 2116-01-26 00:00:00 | 2116-02-04 09:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Demerol
Attending: ___.
Chief Complaint:
Polytrauma s/p fall down 12 stairs
Major Surgical or Invasive Procedure:
___: Chest Tube placement
History of Present Illness:
This patient is a ___ year old female who is transferred from OSH
for a fall. She fell down 12 stairs. Outside hospital, she had
CT C-spine and torso which showed rib fractures, small
pneumothorax, pulmonary contusion, T10 fracture. On arrival she
complains of lower back pain.
Past Medical History:
___, breast cancer
Social History:
___
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAMINATION
HR: 106 BP: 107/80 Resp: 16 O(2)Sat: 95 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Chest: Clear to auscultation, left ribs tender, no flail
chest
Cardiovascular: Tachycardic
Abdominal: Soft, Nontender
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent, diffuse choreoathetotic movements,
moving arms and legs equally
Psych: Normal mentation
___: No petechiae
Pertinent Results:
___ 05:15PM BLOOD Hct-30.5*
___ 02:40PM BLOOD WBC-9.0 RBC-3.31* Hgb-10.1* Hct-28.9*
MCV-87 MCH-30.6 MCHC-35.0 RDW-13.0 Plt ___
___ 02:31AM BLOOD Hct-25.1*
___ 06:50PM BLOOD Hct-27.4*
___ 08:52AM BLOOD WBC-8.1 RBC-3.94* Hgb-11.9* Hct-34.3*
MCV-87 MCH-30.3 MCHC-34.9 RDW-13.2 Plt ___
___ 12:08AM BLOOD WBC-15.2*# RBC-4.19* Hgb-12.8 Hct-36.3
MCV-87 MCH-30.5 MCHC-35.2* RDW-13.0 Plt ___
___ 12:08AM BLOOD Glucose-115* UreaN-15 Creat-0.5 Na-130*
K-4.2 Cl-93* HCO3-28 AnGap-13
Radiology:
___: Chest radiograph: There are numerous minimally
displaced posterior left-sided rib fractures of at least the
___ robs. No significant pneumothorax is seen. Lungs are
clear of focal consolidation or pleural effusions. The cardiac
and mediastinal silhouette is normal. IMPRESSION: Numerous left
posterior rib fractures. No pneumothorax, though assessment is
limited by supine positioning.
___: Head CT: The examination is somewhat limited by motion
artifact and was repeated. There is no evidence of acute
intracranial hemorrhage, edema, mass effect, or large
vascular territorial infarction. The ventricles and sulci are
normal in size and configuration. The basal cisterns appear
patent, and there is preservation of normal gray-white matter
differentiation. No fracture is identified.The globes are
intact. IMPRESSION: No acute intracranial hemorrhage or mass
effect or obvious infarct. Study somewhat limited due to motion
related artifacts. Correlate clinically to decide on the need
for
further workup or follow-up.
___: Chest radiograph: Multiple left sided posterior rib
fractures are again seen. There is a tiny left apical
pneumothorax. The lungs are clear of focal consolidation or
pleural effusion. The heart and mediastinal silhouette is
normal.
IMPRESSION: Multiple posterior left-sided rib fractures. Tiny
left apical pneumothorax.
___: Persistent left hemidiaphragmatic elevation and
moderate left lower lobe atelectasis reflecting respiratory
splinting from known left-sided rib fractures. New right basilar
opacity which could represent aspiration versus new
consolidation.
Brief Hospital Course:
Pt is a ___ y/o F admitted from OSH on ___ s/p
posterolateral ___ rib fractures, T10 compression fracture, and
pneumothorax. Pt reports that she slipped and fell backwards
down 12 stairs. At the time of the fall, pt was unsure if she
hit her head but did not sustain loss of consciousness. She
denied having any weakness or paresthesias, but did report
having midback pain. She was transported to an OSH where
initial imaging was taken, and the pt was transferred to ___
for possible emergent surgery, which was not ultimately required
after consulting neurology. Neurology reported that pt does not
require bracing at this time either. On Hospital day #4, the
patient had worsening respiratory status and CXR revealed a
worsening left sided pleuarl effusion. Interventional
Pulmonology was consulted and a CT was placed with over 1L of
fluid in return. The patient was hemodynamically stable and the
CT was removed 24 hours later. On ___, Acute Pain Service
was consulted due to poor pain control and an epidural was
placed, but was subsequently removed the following day due to
hypotension. At that time, the pt's pain was controlled by a
PCA. Physical therapy was consulted due to the nature of the
injuries complicated by an exasperation of the patient's
___ disease. The physical therapists recommended a
rehabillitation to regain her baseline functionality.
The patient was converted to oral pain medication with continued
good effect. Diet was progressively advanced as tolerated to a
regular diet with good tolerability. The patient voided without
problem. During this hospitalization, the patient had difficulty
with ambulation due to her Parkinsons but worked with the
Physical Therapists, was adherent with respiratory toilet and
incentive spirometry, and actively participated in the plan of
care. The patient received subcutaneous heparin and venodyne
boots were used during this stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with assist, voiding without assistance, and
pain was well controlled. The patient was discharged to rehab.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
___:
MAXZIDE 37.5-25 mg tablet daily
levothyroxine 150 mcg daily
ranitidine 150 mg BID
lisinopril 40 mg daily
labetalol 100 mg BID
rOPINIRole 1.5-2.0mg TID/PRN (parkinsons)
amantadine 50-100 mg TID/PRN(parkinsons)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Amantadine 100 mg PO QAM parkinsonism
3. Amantadine 50 mg PO DAILY
4. Amantadine 50 mg PO DAILY
5. Baclofen 10 mg PO TID
6. Bisacodyl ___AILY:PRN constipation
7. Carbidopa-Levodopa (___) 1.5 TAB PO Q3H
8. Docusate Sodium 100 mg PO BID
9. Heparin 5000 UNIT SC BID
10. Ibuprofen 600 mg PO Q8H:PRN pain
11. Labetalol 100 mg PO BID
12. Levothyroxine Sodium 150 mcg PO DAILY
13. Lidocaine 5% Patch 1 PTCH TD QPM
14. Lisinopril 40 mg PO DAILY
15. Lorazepam 1 mg PO HS:PRN insomnia
16. Lorazepam 0.5 mg PO Q4H:PRN dyskinesia
17. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
18. Ranitidine 150 mg PO BID
19. Ropinirole 2 mg PO QAM parkinsonism
20. Ropinirole 1.5 mg PO DAILY
21. Ropinirole 1.5 mg PO QPM
22. Senna 17.2 mg PO BID
23. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Polytrauma:
1. Left ___ posterolateral rib fractures
2. T10 compression fracture
3. Left pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms ___,
You were admitted to ___ for pain control and management of
your injuries after falling down stairs. You sustained injuries
to your ribs, your spine, and your lung. The Spine doctors saw
___ and determined there was no surgical intervention necessary
for the thoracic spine fracture and you could be weight bearing
as tolerated. You had a chest tube placed to into your left lung
to drain a pleural effusion. You were also given an epidural for
pain control. You were evaluated by the physical therapists, who
felt you needed a short term rehab to regain your strength and
get back to your baseline functioning. You are now stable and
your pain is under control. You are ready to be discharged to
rehab to continue your recovery. Please note the following
discharge instructions:
* Your injury caused 5 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.
* 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:
___
|
10425960-DS-17 | 10,425,960 | 20,746,210 | DS | 17 | 2120-12-24 00:00:00 | 2120-12-24 20:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Demerol / indomethacin / meperidine
Attending: ___.
Chief Complaint:
Lumbar stenosis
Major Surgical or Invasive Procedure:
L4 laminectomy
History of Present Illness:
___ y/o female with a PMH significant for ___ disease
and hypertension who was transferred from ___ for urinary
retention and MRI findings demonstrating L4 spinal stenosis. The
patient states that approximately one week ago the patient felt
as if she pulled something in her back when she stood up. She
remained active and did not experience a lot of pain but the
pain
worsened 4 days ago while she was stretching. She was able to
control the lumbar back pain this week with motrin. A couple of
days ago she noted numbness localized to the sole of her left
foot and last night the numbness started in the sole of the
right
foot which made ambulating difficult. She describes the back
pain
as lumbar back pain which radiates both to the left and right.
She endorses left lower extremity pain which radiates laterally
to the ankle and right lower extremity pain which radiates
posteriorly down her leg and into the calf. She denies any
tingling of the bilateral lower extremities nor weakness.
She denies saddle anesthesia but notes an episode at home 24
hours ago at which time she experienced difficulty initiating a
void. She was finally able to go. She also had difficulty
initiating a void this morning. She denies urinary or rectal
incontinence. Her daughter took her to the ED at ___ given
her symptoms for work-up.
A MRI of the lumbar spine was performed which revealed L4 lumbar
stenosis. She had a PVR at ___ of >500cc and a foley
catheter was placed. She was transferred to the ED at ___ for
further evaluation.
Past Medical History:
___, breast cancer
Social History:
___
Family History:
noncontributory
Physical Exam:
On discharge:
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Speech Fluent: [x]Yes [ ]No
Comprehension intact [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
___
IPQuadHamATEHLGast
___
Sensation intact to light touch. No clonus.
Wound:
[x]Clean, dry, intact
[x]Suture
Pertinent Results:
See OMR for pertinent lab and imaging results
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the neurosurgery team. The patient was found to
have lumbar stenosis and was admitted to the neurosurgery
service. The patient was taken to the operating room on
___ for L4 laminectomy, 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
patient's Foley catheter was removed on postop day 1. She
continued to have urinary retention. Urology was consulted and
they recommended a foley catheter which was replaced on POD 1.
The foley catheter will remain for ___ days, and a void trial
will be done at that time.
It was noted that the patient had asymptomatic hyponatremia to
128 at the lowest recorded which was treated with fluid
restriction and resolved by day of discharge with most recent
sodium at 134.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient has a Foley placed per above and was moving bowels
spontaneously. 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:
Levothyroxine 150mcg PO QPM, Sertraline 100mg PO QAM, Amlodipine
2.5mg PO daily at 12PM, Clonazepam 0.25mg PO QAM (not ordered
post op), Ranitidine 150mg PO BID, Torsemide 10mg PO QD,
Labetalol 400mg PO BID, Lisinopril 40mg PO daily, Valacyclovir
1g PO BID PRN (not ordered), Bisacodyl 10mg PR PRN constipation,
Polyethylene glycol PRN constipation
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
3. Diazepam 5 mg PO Q6H:PRN muscle spasm
Tapered dose - DOWN
RX *diazepam 5 mg 1 ml by mouth every six (6) hours Disp #*15
Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
5. Heparin 5000 UNIT SC BID
RX *heparin, porcine (PF) 5,000 unit/0.5 mL 5000 unit
subcutaneous twice a day Disp #*60 Syringe Refills:*0
6. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by
mouth twice a day Refills:*0
7. Senna 17.2 mg PO QHS
RX *sennosides [senna] 8.6 mg 17.2 mg by mouth at bedtime Disp
#*60 Tablet Refills:*0
8. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*6 Tablet Refills:*0
9. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours as needed Disp #*15 Tablet Refills:*0
10. Amantadine 100 mg PO TID
11. amLODIPine 2.5 mg PO DAILY at 12p
12. ClonazePAM 0.25 mg PO DAILY:PRN anxiety
13. Labetalol 400 mg PO BID
14. Levothyroxine Sodium 150 mcg PO DAILY
15. Lisinopril 40 mg PO DAILY
16. pramipexole 0.75 mg oral QPM
17. Pramipexole 0.75 mg PO DAILY
18. Pramipexole 0.5 mg PO DAILY
19. Ranitidine 150 mg PO BID
20. Rytary (carbidopa-levodopa) 4 CAP ORAL BID 4 tabs
21. Rytary (carbidopa-levodopa) 3 CAP ORAL BID 3 tabs
22. Sertraline 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Lumbar stenosis
Urinary retention
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:
Spine Surgery without Fusion
Surgery
* Your incision is closed with sutures. You will need suture
removal. Please keep your incision dry until suture removal.
* Do not apply any lotions or creams to the site.
* Please avoid swimming for two weeks after suture removal.
* Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
* We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
* You make take leisurely walks and slowly increase your
activity at your own pace. ___ 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.
Medications
* Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) or anti-inflammatories (Aleve,
Advil, Ibuprofen etc) until cleared by the 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.
*** You had urinary retention requiring a foley catheter.
Urology has recommended keeping the foley catheter in place for
___ days and then trying a voiding trial. This was placed on
___ ***
Followup Instructions:
___
|
10426177-DS-10 | 10,426,177 | 20,649,795 | DS | 10 | 2193-04-22 00:00:00 | 2193-05-04 15:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ EXPLORATORY LAPAROTOMY; APPENDECTOMY
History of Present Illness:
___ otherwise healthy who presents with abdominal pain and
distention. He started to have epigastric abdominal pain 4 days
ago with one episode of emesis, but this all improved by night
time. However, the pain recurred the next day and worsened. He
has had minimal PO intake since then secondary to nausea and he
had another episode of emesis yesterday. He has not had a bowel
movement or passed gas since 4 days ago. He describes the pain
as a "nerve pulling" type of pain every time he lies flat or
straightens his body. He denies fevers or chills or changes in
urination.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory.
Physical Exam:
On presentation to the hospital:
Vitals: 71 132/84 15 99%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l
ABD: distended, tympanitic, diffusely tender with voluntary
guarding, no rebound
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
On discharge from the hospital:
Vitals: 75 124/80, 16, 99/RA
GEN: A&Ox4, NAD.
HEENT:No scleral icterus, mucus membranes moist
CV: RRR, Normal S1, S2. No MRG
PULM: Lungs CTA bilaterally
ABD: Soft/mildly distended/TTP around incision. + flatus
EXT: + pedal pulses. No edema, cyanosis, clubbing.
Pertinent Results:
___:
WBC-13.4*# RBC-5.07 Hgb-15.1 Hct-46.3 MCV-91 MCH-29.8 MCHC-32.6
RDW-12.9 Plt ___ ALT-44* AST-44* AlkPhos-81 TotBili-1.1
___
WBC-6.9 RBC-4.03* Hgb-12.1* Hct-36.3* MCV-90 MCH-29.9 MCHC-33.2
RDW-12.5 Plt ___ Glucose-123* UreaN-8 Creat-0.5 Na-137 K-3.7
Cl-105 HCO3-27 AnGap-9 Calcium-8.0* Phos-1.8* Mg-2.2
KUB: Findings concerning for an early or partial small bowel
obstruction, although an obstructive lesion in the mid
descending
colon cannot be excluded. Recommend further evaluation with CT.
CT A/P: Dilated fluid-filled loops of small bowel with probable
decompressed loops seen in the right lower quadrant, findings
concerning for early or partial small bowel obstruction.
Brief Hospital Course:
___ presents with abdominal pain and distention. He started to
have epigastric abdominal pain 4 days ago with one episode of
emesis, but this all improved by night
time. He was admitted to the Acute Care Service and taken to the
OR for an exploratory laparotomy and appedenectomy on ___.
Post-operatively, patient remained NPO and had a nasogastric
tube that was discontinued on POD #1 due to minimal output and
improvement in nausea. Patient's pain was well controlled with
Dilaudid PCA and he was transitioned to PO oxycodone upon
discharge. On POD 2, patient was advanced to sips and tolerated
well. On POD 3, patient was advanced to regular diet which he
tolerated well and was passing flatus. Vitals were stable and
patient remained afebrile upon discharge.
Medications on Admission:
none
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
Followup Instructions:
___
|
10426541-DS-18 | 10,426,541 | 28,967,988 | DS | 18 | 2162-01-28 00:00:00 | 2162-01-29 07:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ceftin / Bactrim / clarithromycin
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ woman with diastolic dysfunction, CAD, hypertension,
dyslipidemia, and chronic hyponatremia, who presented with
shortness of breath.
Patient reports progressive shortness of breath for the last
week, which she associates with the humidity because it improves
when she's inside with the AC on. She often has dyspnea on
exertion, but this is slightly worse than usual. She was brought
to ___, where EKG was read as concerning for ST
elevations in the inferior and septal leads. At ___ she was
started on heparin gtt, given 300 mg Plavix and a full-dose
asprin. She was also given 40 mg IV Lasix. Her first troponin at
___ was negative. She was transferred to ___ for further
management of a possible STEMI. However, on arrival to ___,
the EKG was read without any ST changes, as well as repeat EKG
at ___. The heparin gtt was stopped after consultation with
cardiology. Of note, the patient expressed her wishes to not
have a cardiac cath if it were recommended.
In the ___:
- Initial vitals were: 98.0 68 151/42 24 96% Nasal Cannula
- Exam notable for: BLE edema
- Labs notable for: troponin < 0.01 x1 (also negative at
___, lactate 1.2, Na 129 (baseline), K 5.2, BNP 2739
- EKG: Regular rhythm at a ventricular rate of 70, atrial wave
are noted at a rate of 300, suggestive of atrial flutter with
3:1 conduction delay, ST elevation is noted in V2 through V3
similar to prior ECG in ___.
- Imaging notable for: Chest xray: Lung volumes are low. Small
left pleural effusion again noted. Bibasal compressive lower
lobe atelectasis. There is hilar congestion and mild
interstitial edema. Patient is rightward rotated.
Cardiomediastinal silhouette is unchanged. Bony structures are
intact.
- Vitals prior to transfer: 98.2 78 157/53 21 96% Nasal Cannula
On the floor, pt reports her breathing is much better-- better
than it was on arrival to the ___, and better than it was a week
ago. She believes that the humidity worsens her breathing, and
that the air conditioning improves it.
Past Medical History:
CAD
Carotid Stenosis
TIA x 3
Anemia
Hypertension
Hyperlipidemia
Hypothyroidism
Glaucoma
S/P Hysterectomy ___
Peripheral Vascular disease with claudication
Squamous cell carcinoma s/p excision
Social History:
___
Family History:
Brother with CAD and CABG at age ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: 97.8 165/57 82 18 96% 2L
Wt: 64 kg standing
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: regular, no murmurs appreciated
Lungs: bilateral crackles up to have the lungs
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: 1+ edema to mid shin
Neuro: CNII-XII intact, normal gait with walker to the bathroom
DISCHARGE PHYSICAL EXAM:
=======================
Vital Signs: 98.6 133/62 76 18 97RA
Wt: 64 kg standing
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: regular, no murmurs appreciated
Lungs: clear to auscultation bilaterally-- no wheezes, no
crackles
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: 1+ edema to mid shin
Neuro: CNII-XII intact, normal gait with walker to the bathroom
Pertinent Results:
ADMISSION LABS:
===============
___ 09:16PM BLOOD WBC-10.5* RBC-3.73* Hgb-10.4* Hct-32.0*
MCV-86 MCH-27.9 MCHC-32.5 RDW-15.5 RDWSD-48.6* Plt ___
___ 09:16PM BLOOD Neuts-74.5* Lymphs-14.9* Monos-9.3
Eos-0.4* Baso-0.3 Im ___ AbsNeut-7.85* AbsLymp-1.57
AbsMono-0.98* AbsEos-0.04 AbsBaso-0.03
___ 09:16PM BLOOD ___ PTT-150* ___
___ 09:16PM BLOOD Glucose-122* UreaN-29* Creat-1.0 Na-129*
K-5.2* Cl-90* HCO3-17* AnGap-27*
___ 09:16PM BLOOD proBNP-2739*
___ 09:16PM BLOOD cTropnT-<0.01
___ 06:35AM BLOOD cTropnT-<0.01
___ 06:35AM BLOOD Calcium-9.2 Phos-4.2 Mg-1.9
DISCHARGE LABS:
===============
___ 07:45AM BLOOD WBC-11.8* RBC-3.18* Hgb-8.9* Hct-27.7*
MCV-87 MCH-28.0 MCHC-32.1 RDW-15.7* RDWSD-50.1* Plt ___
___ 07:45AM BLOOD Plt ___
___ 07:45AM BLOOD ___ PTT-29.6 ___
___ 07:45AM BLOOD Glucose-100 UreaN-44* Creat-1.1 Na-134
K-3.7 Cl-92* HCO3-28 AnGap-18
___ 07:45AM BLOOD Calcium-9.5 Phos-4.4 Mg-1.9
IMAGING:
=========
___ Imaging CT HEAD W/O CONTRAST
1. No acute intracranial abnormality. Specifically no
intracranial
hemorrhage.
2. Evidence of chronic microvascular ischemic changes with
symmetric cortical atrophy.
3. There is opacification of the right sphenoid sinus with
air-fluid level (not previously seen in ___ CT head without
contrast).
___ Imaging HIP (UNILAT 2 VIEW) W/P
There are no signs for acute fractures or dislocations involving
the left hip. There is generalized demineralization. Severe
degenerative changes and scoliosis of the lower lumbar spine are
seen. Old healed fracture deformities of the right superior and
inferior pubic rami are seen.There are 3 cannulated screws
fixating a healed fracture of the right femoral neck.
___ Imaging FOOT AP,LAT & OBL LEFT
No acute fractures or dislocations are seen. There is
generalized
demineralization. There are degenerative changes particularly at
the first MTP joint and several DIP and PIP joints.No bony
erosions are identified. Vascular calcifications are seen.
___ Imaging KNEE (AP, LAT & OBLIQUE
There is no joint effusion. No displaced fractures or
dislocations are seen. There are degenerative changes with
moderate medial compartmental joint space narrowing. There is
generalized demineralization. Vascular calcifications are seen.
There is soft tissue swelling anterior to the patellar tendon.
No focal lytic or blastic lesions are seen.
___ Cardiovascular ECHO: LVEF >55%
The left atrium is elongated. 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. Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. There are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of ___, the
rhythm has changed and the degree of pulmonary hypertension
detected has increased.
Brief Hospital Course:
Mrs. ___ is an ___ woman with diastolic
dysfunction, CAD, hypertension, dyslipidemia, chronic
hyponatremia who was admitted with shortness of breath.
# CORONARIES: LM 40% tapering lesion, LAD 50% mid stenosis after
the first diagonal branch, CFX was a small vessel with no flow
limitations, RCA had 50% ostial lesion with 25% pressure
dampening (cath ___
# PUMP: LVEF >55%
# RHYTHM: Atrial fibrillation/flutter
# Atrial flutter: During this admission, patient had well rate
controlled rates but had declined anticoagulation in the past
except for full-dose aspirin. EP was consulted on this admission
for potential ablation to treat her Afib, but patient declined
ablation for aflutter on this admission. Due to her CHADSvasc
score of 5, patient was started on Apixaban 5mg BID and her
aspirin was downtitrated to aspirin 81mg daily. She was further
started on metoprolol 12.5 BID. She was started on metoprolol
succ 25mg Daily Patient tolerated her new medication regimen,
and at the time of discharge was doing well.
# Shortness of breath: On presentation, patient complained of
shortness of breath, most likely secondary acute-on-chronic
diastolic heart failure, given hx of increasing ___ edema,
elevated BNP, chest xray with pulmonary edema, and dramatic
improvement after 40 IV Lasix at OSH. On PO 40 Lasix daily at
home, and often eats a high salt diet secondary to low
BPs/hyponatremia. Unlikely ACS given trop negative x2, no
reported chest pain, and EKG without ischemic changes. On this
admission, concern remained for aflutter ( Aflutter in 3:1 block
) causing her acute on chronic HF exacerbation. Patient was
diuresed on IV lasix, and then transitioned to po Torsemide
which she tolerated well. Her daily I/Os were recorded, and her
daily weights were monitored. She was further maintained on
metoprolol 12.5 BID, Lisonopril 20mg BID. Following diuresis,
patient had markedly improved shortness of breath, and at the
time of discharge was able to ambulate and lie flat without
subjective shortness of breath.
#Fall, no LOC: On ___, patient fell while in the bathroom,
injuring her L thigh, L knee and L great toe. Patient did not
have any prodromal symptoms, denied light-headedness, dizziness
or palpitations at this time. Patient was assessed and found to
have stable VSS and small bruising over thigh and knee which was
marked. Patient suffered no head injury, no LOC. A noncontrast
CT of the head was performed, which showed no intracranial
hemorrhage or acute process. Hgb was stable at 8.2, and plan was
made to trend pts Hgb. Physical therapy was further consulted on
this admission.
# CAD: patient initially had concerns for ST changes at OSH, but
low suspicion on arrival to ___. Patient did have
mild-moderate CAD on ___ c. cath, but per her history she has
not had any chest pain, and shortness of breath is not
particularly new. Patient was maintained as aspirin 81mg daily
and atorvastatin 20 QPM.
# Metabolic acidosis: on admission, patient had anion gap
metabolic acidosis, lactate not elevated and no kidney injury,
with unclear etiology, perhaps secondary to poor PO intake over
several days prior to admission. Patients metabolic acidosis
resolved on this admission.
# Hypertension: during this admission, patient was maintained on
her home amlodipine 5mg BID, lisinopril 20mg BID.
# Hyponatremia, chronic: patient was found to be hyponatremic on
this admission, which is a chronic issue for her. She is
followed by Dr. ___ hyponatremia is thought to be
secondary to SIADH and low solute intake, with a low urine
sodium level. Na at baseline on admission, and improved with
diuresis.
# Hyperkalemia: on this admission, patient had chronic mild
hyperkalemia, perhaps secondary to lisinopril, however in
combination with hyponatremia raises concerns for adrenal
insufficiency. Her AM cortisol was checked on this admission,
which was noted to be within normal limits, with low concern for
adrenal insufficiency during this hospital admission.
#Anemia: patient has known chronic anemia at baseline. Per OMR,
she carries halassemia trait. Patients Hgb was trended on this
admission, which was stable at the time of discharge.
- continue to monitor
TRANSITIONAL ISSUES:
====================
- Patient will need Chem 10 drawn on ___
and sent to her PCP ___ (FAX: ___) since she has
changed diuretic medications (see scrip)
- Please re-address benefit of ablation with EP to treat
patients Aflutter. EP ablation was offered to patient on this
admission but it was declined by patient.
- Patient was started on Apixaban on this admission for
aflutter. Please continue to monitor patient with regards to
bleeding risk on this medication
- Patient was started on metoprolol on this admission for rate
control. Please continue to monitor patients vital signs and
titrate her betablocker on this medication
- Please continue to monitor patients serum lytes (chem 10) as
patient was discharged on torsemide 20mg
- Please continue to monitor patients hyponatremia. Patients
serum Na improved with diuresis on this admission. Due to
concern for acute heart failure exacerbation, patient should
have balanced salt vs low salt diet intake to balance risk of
acute heart failure exacerbation as compared to her known,
chronic hyponatremia.
- Please continue to monitor patients weights, as she was
discharged on torsemide
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
2. Multivitamins 1 TAB PO DAILY
3. Docusate Sodium 100 mg PO DAILY
4. Furosemide 20 mg PO BID
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Travatan Z (travoprost) 0.004 % ophthalmic QPM
7. amLODIPine 5 mg PO BID
8. Aspirin 325 mg PO DAILY
9. Atorvastatin 20 mg PO QPM
10. Vitamin D 1000 UNIT PO DAILY
11. Hydrocortisone Cream 2.5% 1 Appl TP DAILY itchy ears
12. Lisinopril 20 mg PO BID
13. metroNIDAZOLE 0.75 % topical QPM
14. PARoxetine 10 mg PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
3. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. amLODIPine 5 mg PO BID
6. Atorvastatin 20 mg PO QPM
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
8. Docusate Sodium 100 mg PO DAILY
9. Hydrocortisone Cream 2.5% 1 Appl TP DAILY itchy ears
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Lisinopril 20 mg PO BID
12. metroNIDAZOLE 0.75 % topical QPM
13. Multivitamins 1 TAB PO DAILY
14. PARoxetine 10 mg PO DAILY
15. Travatan Z (travoprost) 0.004 % ophthalmic QPM
16. Vitamin D 1000 UNIT PO DAILY
17.Outpatient Lab Work
Chem 10 (Na, K, Cl, CO3, BUN, Cr, Mag, Phos, Calcium)
Please fax results to ___. ___ (FAX: ___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute on chronic heart failure exacerbation
Atrial flutter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you during your admission to
___.
You presented to the hospital with worsening shortness of
breath. You were assessed in the ___, and thought to have an
acute heart failure exacerbation due to your increased lower leg
swelling, evidence of increased fluid on your chest xray and
labs that were notable for an elevated marker related to heart
failure exacerbation. Furthermore, you improved markedly after
receiving a medication to help you urinate some of the extra
volume related to your heart failure exacerbation. There was a
low concern for an ischemic cardiac event, as you had negative
labs and a reassuring EKG. However, you were noted to have
atrial flutter on EKG, which may have caused your acute heart
failure exacerbation.
During this admission, you were diuresed with Lasix to help you
urinate the extra volume you had retained. You improved markedly
on IV Lasix, and you were transitioned to oral torsemide, which
you tolerated well. The use of these medications caused your
shortness of breath to markedly improve, and at the time of
discharge you were able to ambulate and lie flat with minimal
shortness of breath.
Furthermore, on this admission you were offered an intervention
to treat the Aflutter that was noted on your EKG, and which may
have precipitated this whole episode. You declined this
treatment on this admission, however, you will continue to
followup in clinic and you have the option to have this
procedure at a later date.
Lastly, you were started on a new oral anticoagulation
medication called Apixiban, which was given to you to reduce
your risk of stroke related to your Aflutter cardiac arrhythmia.
You tolerated this medication well, and your aspirin dose was
reduced on this admission.
Several of your home medications have changed on this admission,
so please refer to the medication list below to ensure that you
are taking your prescribed medications correctly.
Please also followup at the following appointments that have
been arranged on your behalf.
Once again, it was a pleasure taking care of you during your
stay at ___. We wish you the best of luck!
Your ___ care team
Followup Instructions:
___
|
10426650-DS-3 | 10,426,650 | 28,656,452 | DS | 3 | 2129-10-22 00:00:00 | 2129-10-29 15:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
heparin
Attending: ___.
Chief Complaint:
Trauma: ___
Major Surgical or Invasive Procedure:
suturing left arm laceration
History of Present Illness:
This patient is a ___ year old male who complains of MVC.
The patient is transferred from ___. He
was the restrained driver in an ___. He ran into a fence and
then the fence hit him in the left chest. There was no
penetrating injury. At the outside hospital the patient
initially had a GCS of 15. On CT scan he was diagnosed with
a left flail chest, left renal laceration, rib fractures #4
and 5, pulmonary contusion, C5-6 fracture, left subdural
hematoma, bilateral pneumothoraces that are small. He does
have a left hemothorax. He had a left chest tube placed and
was intubated for airway protection. He was transferred by
med flight ground. He was started on levo fed for
hypotension en route. He also was on propofol en route. At
the outside hospital initially he was noted to be
hemodynamically stable. Therefore a trauma basic was called
prior to arrival.
Past Medical History:
none
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION: upon admission ___
HR: 120 BP: 70/ O(2)Sat: 100
Constitutional: Intubated
HEENT: Right forehead abrasion
Cervical collar in place
Chest: Left chest it in place, left anterolateral chest
abrasion
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
Pelvic: Pelvis is stable.
Extr/Back: Right hip abrasion. Left upper arm 2 cm
laceration. There is no obvious deformity. Normal pulses in
all 4 extremities
Neuro: The patient initially is moving all extremities
vigorously.
Pertinent Results:
___ 05:00AM BLOOD WBC-7.9 RBC-3.53* Hgb-10.5* Hct-30.9*
MCV-88 MCH-29.8 MCHC-34.0 RDW-13.3 Plt ___
___ 06:25AM BLOOD WBC-8.2 RBC-3.54* Hgb-10.4* Hct-31.5*
MCV-89 MCH-29.4 MCHC-33.0 RDW-12.7 Plt ___
___ 03:36AM BLOOD WBC-9.5 RBC-3.78* Hgb-10.7* Hct-33.0*
MCV-87 MCH-28.3 MCHC-32.4 RDW-12.3 Plt Ct-93*
___ 02:41AM BLOOD WBC-10.8 RBC-4.02* Hgb-11.3* Hct-34.4*
MCV-85 MCH-28.0 MCHC-32.7 RDW-12.6 Plt Ct-65*
___ 08:05AM BLOOD WBC-23.2* RBC-4.38* Hgb-12.7* Hct-38.0*
MCV-87 MCH-29.0 MCHC-33.4 RDW-12.1 Plt ___
___ 03:18PM BLOOD ___ PTT-36.4 ___
___ 07:14AM BLOOD PTT-51.5*
___ 03:18PM BLOOD ___
___ 06:25AM BLOOD Glucose-92 UreaN-14 Creat-0.6 Na-140
K-3.6 Cl-103 HCO3-29 AnGap-12
___ 01:11PM BLOOD Glucose-119* UreaN-12 Creat-0.8 Na-126*
K-4.2 Cl-95* HCO3-24 AnGap-11
___ 06:14AM BLOOD CK-MB-11* MB Indx-0.6 cTropnT-0.61*
___ 06:25AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.0
___ 08:05AM BLOOD ASA-NEG Ethanol-69* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:24AM BLOOD freeCa-1.11*
___: A-gram:
No evidence of arterial injury to the left kidney, liver, or
spleen
___: Cat scan of the head:
1. Stable posterior parafalcine subdural hemorrhage since 5 hrs
prior.
2. There is a newly apparent contusion in the inferior left
temporal lobe
adjacent to the petrous apex.
___: chest x-ray:
In comparison with the earlier study of this date, with the
chest tube on
water seal there is no definite pneumothorax. Increased
opacification at the left base could reflect pulmonary
hemorrhage or developing aspiration or pneumonia. Less prominent
area of increased opacification is seen at the right base
medially. There is still dilatation of the gas-filled stomach
after removal of the nasogastric tube.
___: esophagram:
No evidence of esophageal leak.
___: ECHO:
IMPRESSION: Normal right ventricular size with mild free wall
hypokinesis. Normal left ventricular global/regional systolic
function. Mild posterior leaflet mitral valve prolapse with mild
to moderate mitral regurgitation. Suggestion of pulmonary
hypertension.
___: EKG:
Sinus tachycardia. Extensive ST segment elevation, most
pronounced across the anterior precordial leads up to four
millimeters and extending to leads I, II, and aVL concerning for
injury pattern with subtle ST segment depression in lead III.
Possible PR segment depression in lead II which may indicate a
component of pericarditis. Clinical correlation is suggested.
Compared to the previous tracing of ___
segment elevation is new
___: chest x-ray:
In comparison with the study of ___, there appears to be
a small left apical pneumothorax. Otherwise, little change in
the appearance of the heart and lungs.
___: CTA of chest:
. No evidence of pulmonary embolism.
2. New moderate right pleural fluid collection there is mildly
hyperdense that may be related to complex fluid.
3. Small left hydro pneumothorax status post interval chest tube
insertion.
4. Bibasilar consolidation/ contusions, left greater than right.
___: chest x-ray:
In comparison with the study of ___, there again is a
small left
apical pneumothorax despite the presence of a chest tube. Hazy
opacification of the hemithoraces, especially on the left, is
consistent with layering pleural effusions and compressive
basilar atelectasis.
___: chest x-ray:
In comparison with the earlier study of this date, of the left
chest tube is been removed. Small apical pneumothorax persists.
Increased opacification at the left base is most consistent with
pleural effusion and compressive basilar atelectasis, although
in the appropriate clinical setting superimposed
pneumonia would have to be considered. Less prominent changes
are seen at the right base.
___: chest x-ray:
In comparison with the study of ___, the apical
pneumothorax on the
left appears to be decreasing. Little change in the bibasilar
opacifications, most likely reflecting pleural effusion and
compressive atelectasis. As previously, in the appropriate
clinical setting, superimposed pneumonia
___: ___:
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
Brief Hospital Course:
___ year old male, restrained driver, who was involved in a MVC
after his vehicle struck a pole or fence. The pole or fence
penetrated the car through the driver's side and struck the
patient's left chest with no penetration (blunt injury only). At
the OSH, he was found to have left hemo-thorax for which he had
a chest tube placed. He also sustained a small right
pneumothorax, a grade 3 left renal laceration, a small right
occipital SDH, 2 left rib fractures(L4-5), and a nondisplaced C6
fracture.
Prior to his transfer here, he was intubated and sedated, on
levophed, fentanyl, and propofol. In the emergency room, his
systolic blood pressure was in the 70's and he was tachycardic.
This was thought to be due to under resuscitation so he was
given 3L NS bolus and 2 units prbcs with improving hemodynamics.
His hematocrit went from 38 to 42. He was reported to be moving
all of his extremities. His FAST examination was reported to be
negative. He had a reportedly traumatic foley insertion with
hematuria that quickly cleared. Because of the extent of his
injuries, he was taken to ___ and found to have a negative left
renal, celiac, and aortic angiogram. This procedure was
complicated by a iatrogenic right groin hematoma. An additional
injury related to the accident was a left arm laceration, which
was sutured in the emergency room.
The Neurosurgery service was consulted because of the patient's
head injury. No surgical intervention was indicated and the
patient was placed on a 7 day course of keppra. He was also
placed in a cervical collar for stabilization of the C6 cervical
fracture. His neurological status continued to be monitored and
a repeat head cat scan was reported to be unchanged.
During his ICU course, the patient was weaned and extubated
within 24 hours. He required additional intravenous fluids for
bouts of tachycardia. His nasogastric tube was removed and the
chest tube was placed to water seal. He underwent an esophagram
to evaluate for an esophageal perforation which was reported as
negative. On HD #3, the patient was reported to have a decrease
in his platelet count. A HIT panel was sent and the
subcutaneous heparin was discontinued until the results of the
HIT panel returned. While in the intensive care unit, the
patient continued to be tachycardic with STE. During this time,
he was noted to have a positive troponin. The Cardiology
service was consulted. The patient underwent an echocardiogram
on ___ which showed RV free wall hypokineis, MR, and mitral
prolapse. After consultation with cardiology, the patient was
reported to have pericarditis. He was placed on telemetry and
started on ibuprofen.
The patient was transferred to the surgical floor on ___. At
his time, his chest tube was removed. The HIT panel returned
slightly positive and the patient was started on an argatraban
drip with a goal PTT of 50-70. The patient was evaluated by the
Hematology/Oncology service who determined that the patient had
a low likelihood of HIT and the argantraban was discontinued.
The patient underwent lower extremity ultrasound which showed no
evidence of deep vein thrombosis. No further anticoagulants were
indicated.
During the remainder of the hospital course, the patient was
evaluated by physical therapy in preparation for discharge. The
social worker met with the patient to assess his social support
systems. On the day of discharge, the patient was tolerating a
regular diet and voiding without difficulty. His vital signs
were stable and he was afebrile. His hematocrit has stabilized
at 30. His neck was supported in an Aspen collar. Appointments
for follow-up were made with the acute care service and with the
Neurology service. An appointment for follow-up with a new
primary care provider, Dr. ___ was scheduled for ___. His
sister was informed of the appointments.
Medications on Admission:
none
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN constipaton
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 50 mg/5 mL 10 cc liquid(s) by mouth twice a
day Disp ___ Milliliter Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
4. Senna 8.6 mg PO BID constipation
RX *sennosides [senna] 8.8 mg/5 mL 5 cc by mouth twice a day
Disp ___ Milliliter Refills:*0
5. Famotidine 20 mg PO BID
until your follow-up visit in the acute care clinic
RX *famotidine 40 mg/5 mL 2.5 cc suspension(s) by mouth twice a
day Disp ___ Milliliter Refills:*0
6. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg/20.3 mL 20.3 cc solution(s) by mouth
every six (6) hours Disp #*500 Milliliter Refills:*0
7. Ibuprofen Suspension 600 mg PO Q6H:PRN pain
take with food
RX *ibuprofen 100 mg/5 mL 30 cc by mouth every six (6) hours
Disp #*240 Milliliter Refills:*0
8. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 3
hours Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Trauma: MVC:
small rigth occipital SDH
Left hemothorax
Left rib fractures x2 with flail segment
Left renal injury grade III
pneumomediastinum
C6 fracture nondisplaced
small right 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 hospital after you were involved in a
MVA in which you sustained fractured ribs, a small bleed in your
head, a a frature to your cervical vertebrae and a renal injury.
You had a laceration on your left arm which was sutured. There
was concern about an allergy to heparin, but after consultation
with the Hematologist, there was no indication needed for a
blood thinner. You are slowly recovering from your injuries and
you are preparing for discharge home with 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.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus
You also sustained a bleed in your head, please report:
*sever headache
*visual changes
*difficulty speaking
*drooping on one side of your body
*weakness on on side of your body
Because of your injury to your neck, it is important to wear the
cervical collar at all times
Please report: any weakness in upper extremities, shoulder
weakness, and difficulty with hand grasps, numbness in hands
Followup Instructions:
___
|
10426690-DS-24 | 10,426,690 | 29,378,920 | DS | 24 | 2159-06-21 00:00:00 | 2159-06-21 18:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Desipramine / Sulfa (Sulfonamide Antibiotics) / Vicodin /
Codeine / Percocet
Attending: ___.
Chief Complaint:
Accidental removal on GJ tube
Major Surgical or Invasive Procedure:
___: ___ replacement of 22 ___ MIC GJ tube through the
existing opening
PROCEDURE:
After risks benefits and alternatives and the procedure were
explained to the patient a written informed consent was
obtained. The patient was brought to the angiography suite and
placed supine on the table. The upper abdomen was prepped and
draped in usual sterile fashion. Time out was performed per
hospital protocol.
Moderate sedation was provided by administering divided doses of
1 mg Versed and 50 mcg fentanyl throughout total intra service
time of 25 min during which patient's hemodynamic parameters
were continuously monitored.
Initial scout images demonstrated pyloric metal stent and
multiple metallic clips in the upper abdomen. The existing
opening in the upper abdomen was accessed these 5 ___ Kumpe
catheter and a glidewire. Access was obtained to port to the
jejunum. Glidewire was replaced with ___ J-wire. The Kumpe
catheter was removed. Over the new wire annular 22 ___ MIC
gastrojejunal tube was placed. The balloon was inflated in the
stomach. Contrast injection through the jejunal port
demonstrated appropriate location of the jejunal
port.
Patient tolerated procedure well. No immediate postprocedure
complications noted.
Significant breakdown of the skin at the access site was noted.
Wound consult is recommended.
FINDINGS:
Pyloric metal stent in the appropriate location.
IMPRESSION:
Successful replacement of 22 ___ MIC GJ tube through the
existing opening.
History of Present Illness:
This is a very pleasant ___ yo female with PMH of multiple
abdominal surgeries including open roux-en-y gastric bypass ___
years prior with subsequent
complications of gastric outlet obstruction from pyloric
stenosis, requiring
decompressive gastrotomy and pyloric stent; recently admitted
for failure
to thrive in rehab with weight loss and placement of GJ tube.
Patient presented to Emergency Department for accidental removal
of GJ tube. She eats a
regular diet and is keeping her weight up currently without tube
feeds, although she has been on them in the past. Pt reports
mild
abd distension. Denies f/c, ab. pain, n/v/d, melena, BRBPR, CP,
SOB, or any other symptoms.
Past Medical History:
esophageal ring, ___ syndrome, englobulin clot
lysis requiring DDAVP before invasive procedures, colonic
polyps, esophageal stricture s/p multiple dilations, pyloric
stenosis, detached retina, vWF, hypothyroid, gout, tremor, LGIB,
PE, HTN/hypotension in setting of autonomic instability, stage
III kidney disease
Social History:
___
Family History:
MI in father age ___ and mother age ___, daughter died from MRSA,
3 of her children had congenital pyloric stenosis
Physical Exam:
Upon admission:
V: 98.0 72 162/62 18 100% RA
Gen: NAD, comfortable, A and O X3
CV: RRR, no murmur
Pulm: CTAB, no wheezing
Ab.: G tube site present without drainage. Soft, NT/ND, BS+, no
rebound/guarding or masses.
Ext: WWP, no cyanosis, no edema, 2+ DP pulses.
On discharge:
VITALS: 98.1 152/74 (191/107) 90 20 99% RA
General: well appearing elderly woman, AAOx3, in NAD
HEENT: left eye with cataract, otherwise unremarkable
CV: no m/r/g RRR
Lungs: CTAB
Abdomen: Soft, non-distended, non-tender. GJ tube in place with
a surrounding erythematous lesion, mildly tender to palpation,
non-edematous, no discharge
Ext: 1+ edema to knees bilaterally. No rash
Rest is otherwise unremarkable
Brief Hospital Course:
This is a very pleasant ___ yo female with PMH of multiple
abdominal surgeries including open roux-en-y gastric bypass ___
years prior with subsequent
complications of gastric outlet obstruction from pyloric
stenosis, requiring
decompressive gastrotomy and pyloric stent; recently admitted
for failure
to thrive in rehab with weight loss and placement of GJ tube.
Patient presented to Emergency Department for accidental removal
of GJ tube. She eats a
regular diet and is keeping her weight up currently without tube
feeds, although she has been on them in the past. Pt reports
mild
abd distension. Denies f/c, ab. pain, n/v/d, melena, BRBPR, CP,
SOB, or any other symptoms.
Neuro: The patient was alert and oriented throughout the
hospitalization; pain was well controlled with minimal
acetaminophen.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. However,
blood pressure did vary during this hospitalization. Internal
medicine team was consulted prior to discharge and they
concurred that this was likely secondary to patient's underlying
___ syndrome. She received
her home regimen of hydrocortisone and pyridostigmine. There was
one episode with SBP greater than 200 which was treated with
hydralazine IV.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, frequent ambulation and incentive spirometry were
encouraged throughout hospitalization.
FEN/GI: Patient was admitted for accidental removal of GJ tube.
Patient was kept NPO and on IV fluids until replacement of tube
was completed. She successfully underwent ___ replacement
of 22 ___ MIC GJ tube through the existing opening. On the
same procedure, the pyloric metal stent was found to be in the
appropriate location. She tolerated the procedure well and
quickly thereafter resumed regular diet. Tube feeds were held
given the fact that patient had Suplena cans at home, not
available at the hospital. At the time of discharge patient was
instructed to resume tube feed regimen as in the past.
Abdominal wound: The skin arouund the opening was found to be
erythematous and tender, likely the cause of the irritating
effect of gastric contents. Wound care was consulted and patient
received recommendations on appropriate wound care including
securing the tube at all times to prevent tension/enlargement on
tract, which can be done with tape or flexitrac. Also, cleanse
site with warm water then dry well and apply thin layer of
critic aid clear barrier ointment and cover with dry precut
gauze.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with assistance, 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:
1. Citalopram 10 mg PO DAILY
2. Docusate Sodium 50 mg PO BID
3. Ferrous Sulfate 325 mg PO DAILY
4. ClonazePAM 1 mg PO Q4H:PRN anxiety
5. Pyridostigmine Bromide 60 mg PO TID
6. Senna 1 TAB PO BID
7. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
8. Acetaminophen 325-650 mg PO Q6H:PRN pain
9. Allopurinol ___ mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Furosemide 20 mg PO DAILY
12. Hydrocortisone 20 mg PO DAILY
13. Levothyroxine Sodium 88 mcg PO DAILY
14. Midodrine 5 mg PO DAILY:PRN low blood pressure
15. Pantoprazole 40 mg PO Q24H
16. TraZODone 50 mg PO HS
Discharge Medications:
1. Citalopram 10 mg PO DAILY
2. Docusate Sodium 50 mg PO BID
3. Ferrous Sulfate 325 mg PO DAILY
4. ClonazePAM 1 mg PO Q4H:PRN anxiety
5. Pyridostigmine Bromide 60 mg PO TID
6. Senna 1 TAB PO BID
7. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
8. Acetaminophen 325-650 mg PO Q6H:PRN pain
9. Allopurinol ___ mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Furosemide 20 mg PO DAILY
12. Hydrocortisone 20 mg PO DAILY
13. Levothyroxine Sodium 88 mcg PO DAILY
14. Midodrine 5 mg PO DAILY:PRN low blood pressure
15. Pantoprazole 40 mg PO Q24H
16. TraZODone 50 mg PO HS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Accidental removal of GJ tube s/p ___ replacement
2. Autonomic dysfunction: Shy ___ syndrome
3. Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
- Please resume taking all your home medications
- Please follow-up with your primary ___ physician (Dr.
___ the next couple of days
- Take care of your wound as instructed: Secure tube at all
times to prevent tension/enlargement on tract; this can be done
with tape or Flexitrac. Cleanse site with warm water then dry
well, apply thin layer of critic aid clear barrier ointment and
cover with dry precut gauze
Followup Instructions:
___
|
10426710-DS-16 | 10,426,710 | 25,088,000 | DS | 16 | 2188-03-15 00:00:00 | 2188-03-15 14:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Right hand, face droop, word-finding difficulties
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Neurology at bedside for evaluation after code stroke activation
within: 5 minutes
Time (and date) the patient was last known well: 2:30pm(24h
clock)
___ Stroke Scale Score: 2
t-PA given: No Reason t-PA was not given or considered: patient
anticoagulated with Coumadin, low NIHSS
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
___ Stroke Scale score was 2:
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: 1
10. Dysarthria: 0
11. Extinction and Neglect: 0
Reason for consult: code stroke
HPI:
___ with PMHx of AFIB on Coumadin, HTN, CAD, presents after
sudden onset of right arm weakness and language difficulties.
She
was at home in bed because she was feeling poorly when she had
the sudden onset of right arm 'hanging down' as if it was
becoming longer, the inability to use her right fingers, and
word
finding difficulty. She immediately pulled a cord to alert the
building caregivers who immediately called ___ and brought her
to
___. She states that she believes her speech sounded funny to
the caregiver but reports understanding everything that was said
to her. By arrival her deficits were already resolving although
she received a NIHSS of 2 for inability to remember ___ even
though her birthday was only two days ago and poor performance
with naming (unable to name the objects on the stroke card). She
states that she had a sudden onset of gait difficult
approximately ___ months ago requiring her to buy a cane for
ambulation. She pays her own bills but does not cook for herself
or go to the grocery alone because of her difficulty with gait.
On neuro ROS, (+) right arm/hand weakness (+) word finding
issues
(+) chronic balance and gait issues (+) occasional ___
headaches, chronic insomnia, (+) chronic vision loss secondary
to
glaucoma, (+) occasional lightheadedness, (+) chronic hearing
loss. The pt denies diplopia, dysphagia, vertigo, tinnitus.
Denies difficulties comprehending speech. Denies focal
numbness.
On general review of systems, (+) chronic urinary frequency, (+)
recent URI, (+) 1 lb weight loss over the last month. The pt
denies recent fever or chills. No night sweats. Denies chest
pain or tightness, palpitations. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. Denies arthralgias or
myalgias. Denies rash.
Past Medical History:
Hypercholesterolemia
OSTEOPOROSIS, UNSPEC
Psoriasis
HEARING LOSS - SENSORINEURAL, UNSPEC
DERMATITIS - ATOPIC
IRRITABLE BOWEL SYNDROME
DEPRESSIVE DISORDER
Low tension glaucoma
One eye: moderate vision impairment; other eye: near-normal
vision
Ganglion; R thumb MCP joint
Osteoarthrosis, generalized, hand
Severe stage glaucoma
Atrial fibrillation
CAD (coronary artery disease)
Screening for colon cancer
Anticoagulant long-term use
Vitreous detachment
Dry eye syndrome
Essential hypertension, benign
ITP (idiopathic thrombocytopenic purpura)
Primary open angle glaucoma
Blepharitis of both eyes
Restless leg syndrome
Chronic atrial fibrillation
Social History:
___
Family History:
No stroke, seizure
Physical Exam:
=================
Admission Exam
=================
GENERAL EXAM:
- Vitals: 97.8 52 158/125 16 99RA
- General: Awake, cooperative, HOH
- HEENT: NC/AT
- Neck: Supple. No nuchal rigidity
- Pulmonary: CTABL
- Cardiac: irregularly irregular, no murmurs
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
.
NEURO EXAM:
- Mental Status: When re-examined ~2 hours after initial stroke
scale: Awake, alert, oriented to date, month, year. Able to
relate history with no difficulty. Attentive, MOYB except forgot
___ and mixed up ___ and ___. Language fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Able to name high frequency objects,
difficulty with low frequency objects (face, clasp) secondary to
___ = primary language. Able to read without difficulty.
Speech was not dysarthric. Able to follow both midline and
appendicular commands. Able to register 3 objects and recall ___
at 5 minutes.
- Cranial Nerves:
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to loud voice only, unable to hear
whispered
word at 3 foot distance.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
- Motor: Decreased bulk and increased tone throughout. No
pronator drift bilaterally. No adventitious movements such as
tremor or 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 decreased by ___ when compared to the examiner.
Impaired proprioception bilaterally at the big toes, intact at
the ankles. No extinction to DSS.
- DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was extensor bilaterally.
- Coordination: No intention tremor. Mild dysmetria on FNF, hand
wave, and past pointing L>R.
- Gait: Poor balance, small steps, leaned on the examiner for
entire exam, fell to the left when attempting to turn.
.
.
.
=================
Discharge Exam: Normal. No residual weakness or speech
abnormalities.
=================
Pertinent Results:
=====================
LABS
=====================
___ 03:10PM BLOOD WBC-5.6 RBC-5.17 Hgb-15.2 Hct-44.5 MCV-86
MCH-29.4 MCHC-34.2 RDW-14.2 RDWSD-45.1 Plt ___
___ 03:10PM BLOOD Plt ___
___ 03:10PM BLOOD ___ PTT-32.8 ___
___ 06:52AM BLOOD ___ PTT-32.6 ___
___ 06:52AM BLOOD Glucose-107* UreaN-16 Creat-0.7 Na-133
K-4.2 Cl-96 HCO3-29 AnGap-12
___ 06:52AM BLOOD ALT-25 AST-26 LD(LDH)-201 AlkPhos-57
TotBili-0.8
___ 06:52AM BLOOD CK-MB-3 cTropnT-<0.01
___ 03:10PM BLOOD cTropnT-<0.01
___ 06:52AM BLOOD Albumin-3.7 Calcium-9.2 Phos-3.5 Mg-1.7
Cholest-PND
___ 06:52AM BLOOD %HbA1c-PND
___ 06:52AM BLOOD Triglyc-PND HDL-PND
___ 06:52AM BLOOD TSH-PND
.
.
=====================
IMAGING
=====================
MRI brain ___: Small acute infarction in the posterior left
frontal lobe, within the left motor cortex.
.
CTA head/neck ___ (prelim): No definite evidence of
stenosis, or aneurysm greater than 3 mm. No definite evidence of
dissection. Reformats pending. Incidental note is made of a lung
nodule within left upper lobe measuring 4 mm.
.
CXR ___: No infiltrate
Brief Hospital Course:
==============================
BRIEF HOSPITAL COURSE
==============================
Mrs. ___ was admitted with word-finding difficulty, right
facial droop, and right arm weakness which was attributable to a
very small stroke to the left MCA territory. There may have
initially been ischemia to a wider area, acconting for all the
above MCA symptoms, but by the time MRI was done there was only
a small area of restricted diffusion within the cortical hand
representation. By several hours post-admission, she had
recovered fully suggesting rapid recanalization spontaneously.
She was not given tPA due to anticoagulation. Her CTA head/neck
did not show any critical stenoses or acute
cut-offs/dissections.
.
She tells me that she has 2.5mg warfarin pills and that she
takes 1.5 pills daily. She did take 3.75mg warfarin on ___, the
day of her stroke. Early on ___, she was given 5mg. She was
instructed to continue her home dose on ___ with INR checks to
going forward to be dictated by PCP/cardiology. She is already
managed on a statin and her sugars were normal, so we discharged
her home with A1c, lipids, and TSH pending.
.
==============================
TRANSITIONAL ISSUES
==============================
# Stroke:
- Please schedule ___ neurology follow-up within the next
___ months. If no one is available, please feel free to refer
her back to ___ in the ___ stroke division.
- The patient was given 5mg coumadin early on ___ but on ___
(before she came in) she took her normal home dose (per her,
3.75mg - 1.5 tabs where each tab is 2.5mg). We discharged her
with instructions to continue on her home dose since she arrived
within therapeutic INR window.
- Please follow up A1c, TSH, LDL which are pending at time of
discharge
- Please order outpatient TTE to complete the stroke work-up
.
# Occupational therapy:
- We gave the patient a prescription for outpatient
occupational therapy. After an initial evaluation, we hope that
they will be able to send someone to her home to help optimize
her living situation (e.g. how to more easily open the windows
that stick, etc).
.
# Left upper lobe lung nodule: Measured 4mm. Incidentally
discovered on CTA head/neck. Not commented on in CXR read.
Please follow up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 15 mg PO QPM
2. Pilocarpine 4% 1 DROP BOTH EYES Q6H
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
5. Lisinopril 40 mg PO DAILY
6. Nitroglycerin SL 0.4 mg SL ASDIR angina
7. Fluocinolone Acetonide 0.01% Cream 1 Appl TP ASDIR
8. melatonin 1 mg oral QHS
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Warfarin 3.75 mg PO DAILY16
12. Vitamin D 1000 UNIT PO DAILY
13. Artificial Tears Dose is Unknown BOTH EYES ASDIR
14. Calcium+D (calcium carbonate-vitamin D3) 2 tabs oral DAILY
Discharge Medications:
1. Calcium+D (calcium carbonate-vitamin D3) 2 tabs oral DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Fluocinolone Acetonide 0.01% Cream 1 Appl TP ASDIR
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. melatonin 1 mg oral QHS
7. Nitroglycerin SL 0.4 mg SL ASDIR angina
8. Vitamin D 1000 UNIT PO DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Pilocarpine 4% 1 DROP BOTH EYES Q6H
11. Warfarin 3.75 mg PO DAILY16
12. Pravastatin 15 mg PO QPM
13. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
14. Artificial Tears ___ DROP BOTH EYES ASDIR
15. Outpatient Occupational Therapy
ICD ___ Stroke
Please evaluate and treat
Patient has difficulty with some ADLs
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Stroke (fully recovered)
Secondary diagnoses: Atrial fibrillation, hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure caring for you while you were admitted to the
stroke service at the ___. You were
admitted because, for a short while, your right face and right
arm were not working well. This was due to a small stroke (which
we confirmed with an MRI of your brain) but luckily you have
fully recovered.
We have not changed *any* of your medications. You should
continue to take all of your medications as previously directed.
You have already received coumadin for ___ so please do not
take any today (on the day of your discharge). Please take your
lisinopril as soon as you get home (if your blood pressure is
normal) and tomorrow morning, take your Imdur first. Please
continue to check your blood pressure as you do normally to make
sure it is not too low. At your doctor's appointment tomorrow,
you can discuss potentially switching coumadin to a drug called
apixaban (which is a drug that works just as well as coumadin
but with a lower bleeding risk and does not require lab
monitoring). In the meantime, you should continue on your
coumadin as normal. You have a follow-up appointment with your
PCP tomorrow who can arrange your next INR level to be drawn.
Your INR was within therapeutic range while you were here.
There are a few studies that are pending at the time of your
discharge. Your primary care doctor can follow these up. They
include cholesterol, thyroid function, and hemoglobin A1c (a
measure of long-term blood sugar levels). You can also discuss
the need for a heart ultrasound (TTE) with your PCP and
cardiologist, Dr. ___.
You should ___ back to the emergency room immediately if you
have recurrence of your symptoms or new neurologic symptoms. We
will ask your primary care provider to arrange for follow-up
with a neurologist in the ___ system.
We have also given you a prescription for occupational therapy.
You can bring this prescription to a center recommended by your
PCP (please discuss this tomorrow at your appointment) and if
needed, they can send someone to evaluate your living situation
at home and help where possible.
Followup Instructions:
___
|
10426710-DS-17 | 10,426,710 | 29,529,017 | DS | 17 | 2188-04-01 00:00:00 | 2188-04-02 21:45:00 |
Name: ___ Unit 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:
This is a ___ hx of afib on coumadin, recent stroke proven on
MRI with complete recovery, presenting today s/p mechanical fall
after slipping on rug. States she hit her head, but no LOC.
Denying neck pain but endorsing back pain that is worse on the
left. Denies prodromal chest pain, sob, palpitations or
dizziness/lightheadedness. Denies symptoms similar to her stroke
presentation. Denies abdominal pain, incontinence to
urine/bowel. Endorses a headache that began after the fall.
Denies vision/hearing changes.
Past Medical History:
Hypercholesterolemia
OSTEOPOROSIS, UNSPEC
Psoriasis
HEARING LOSS - SENSORINEURAL, UNSPEC
DERMATITIS - ATOPIC
IRRITABLE BOWEL SYNDROME
DEPRESSIVE DISORDER
Low tension glaucoma
One eye: moderate vision impairment; other eye: near-normal
vision
Ganglion; R thumb MCP joint
Osteoarthrosis, generalized, hand
Severe stage glaucoma
Atrial fibrillation
CAD (coronary artery disease)
Screening for colon cancer
Anticoagulant long-term use
Vitreous detachment
Dry eye syndrome
Essential hypertension, benign
ITP (idiopathic thrombocytopenic purpura)
Primary open angle glaucoma
Blepharitis of both eyes
Restless leg syndrome
Chronic atrial fibrillation
Social History:
___
Family History:
No stroke, seizure
Physical Exam:
Admit Physical Exam:
alert and oriented x3
head with small bump on left occiput, no open wound
CNII-XII intact, finger to nose intact; strength limited by pain
from back
irregularly irregular
CTAB, equal chest rise, tenderness over posterior left ribs
abd s/nd/diffusely tender on palpation though mild
pelvis stable
good nonpainful ROM of bilateral hips
no other deformities noted on exam
Discharge Physical Exam:
Tm 98.5 Tc 98 110-160s/60-90s 50-70s ___ 02 100%RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally but with decreased
ability given pain with inspiration. no wheezes, rales, rhonchi
CV: Irreguarly irregular, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs
___ 05:40AM GLUCOSE-113* UREA N-17 CREAT-0.7 SODIUM-127*
POTASSIUM-4.2 CHLORIDE-91* TOTAL CO2-25 ANION GAP-15
___ 05:40AM CALCIUM-8.9 PHOSPHATE-3.0 MAGNESIUM-1.6
___ 05:40AM WBC-8.7 RBC-4.69 HGB-14.0 HCT-41.0 MCV-87
MCH-29.9 MCHC-34.1 RDW-14.5 RDWSD-46.0
___ 05:40AM PLT COUNT-137*
___ 05:40AM ___ PTT-48.6* ___
___ 01:42AM HCT-39.8
Discharge Labs
___ 04:00AM BLOOD WBC-9.2 RBC-4.59 Hgb-13.7 Hct-40.0 MCV-87
MCH-29.8 MCHC-34.3 RDW-14.2 RDWSD-45.2 Plt ___
___ 04:00AM BLOOD ___ PTT-31.6 ___
___ 04:00AM BLOOD Glucose-124* UreaN-20 Creat-0.6 Na-128*
K-3.9 Cl-92* ___ AnG___
Brief Hospital Course:
Ms. ___ is a ___ with a history of atrial fibrillation, on
Coumadin, and a recent history of stroke, who presented to the
ED on ___ after mechanical fall (tripped on rug). No loss
of consciousness. CT of head neck neg reveal T7-10 transverse
process fractures, L3 burst fracture, ___ and 4th rib fractures,
and a small left hemothorax with pulmonary contusion. Patient
was accepted to ___ service on ___ and Neurosurgery was
consulted. Patient was kept on bed rest until chronicity of
fracture could be determined. An MRI of the spine was obtained
to evaluate the chronicity of the burst fracture and need for a
brace. MRI demonstrated acute compression fracture of L3 with
40% loss of height of the vertebra. LSO was ordered and placed
per neurosurgery recommendations. On the morning of the
___ patient experienced chest pain and hypertension. Her
chest pain resolved with Nitro x2. EKG was obtained and showed
no change from that obtained in the ED. Troponins were trended
and all <0.01. Cardiology was consulted and reccomended only
increasing Imdur for better blood pressure control. Of note
patient is hyponatremic at baseline and cardiology did not
recommend aggressively addressing this.
Transitional Issues
-She should follow up in 6 weeks with Dr. ___ with a
CT
of the lumbar spine. This appointment can be made by calling
___
-Imdur was increased to 45 from 30 daily, can consider
increasing to 60 if patient consistently hypertensive with 3
readings of SBP>150.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Isosorbide Mononitrate 30 mg PO DAILY
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
4. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
5. Pilocarpine 4% 1 DROP BOTH EYES Q6H
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Vitamin D 1000 UNIT PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. Lisinopril 40 mg PO DAILY
10. Pravastatin 15 mg PO QPM
11. Multivitamins 1 TAB PO DAILY
12. Senna 8.6 mg PO QHS
13. Docusate Sodium 100 mg PO BID
14. Warfarin 3.75 mg PO DAILY16
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Docusate Sodium 200 mg PO BID
3. Isosorbide Mononitrate (Extended Release) 45 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Lisinopril 40 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
8. Pilocarpine 4% 1 DROP BOTH EYES Q6H
9. Pravastatin 15 mg PO QPM
10. Senna 8.6 mg PO QHS
11. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
12. Vitamin D 1000 UNIT PO DAILY
13. Warfarin 3.75 mg PO DAILY16
14. Acetaminophen 1000 mg PO TID
15. Benzonatate 100 mg PO BID:PRN cough
16. Milk of Magnesia 30 mL PO Q8H
17. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Rib fractures
Pneumothorax
T7-T10 fracture
Burst fx of L3 with retropulsion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to us becaseu of a fall. Your head CT was negative, but
CT of your back showed you have joint changes of old age and
multiple fractures of your ribs and vertebra. You were
evaluated by our orthopedic and they found no reason to to
interevene surgically. They recommended a brace to be worn at
all times and for the head of your bed to always remain below 30
degrees of incline. The fractures you have need the compression
and support of the brace to heal properly.
Followup Instructions:
___
|
10426710-DS-18 | 10,426,710 | 24,537,130 | DS | 18 | 2188-11-03 00:00:00 | 2188-11-04 09:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
___: Right femoral hernia repair with mesh
History of Present Illness:
___ with afib on Coumadin p/w nausea, vomiting, abdominal
pressure x 1 day. Patient reports usual state of health until
this afternoon when she developed increasing abdominal bloating
and epigastric pain. Describes pain as moderate in severity.
Non-localized. Constant. Unable to tolerate po. Had ___ episodes
of emesis. This was accompanied by mild dyspnea. Came to ED for
evaluation. CT scan showed right groin hernia. Surgery
consulted.
On surgery eval, reports persistent mild vague abdominal pain.
Nausea improved with anti-emetics. Passing flatus. Last BM in
AM. Denies fever, chills, chest pain, diarrhea, dysuria, blood
per rectum.
Past Medical History:
Hypercholesterolemia
OSTEOPOROSIS, UNSPEC
Psoriasis
HEARING LOSS - SENSORINEURAL, UNSPEC
DERMATITIS - ATOPIC
IRRITABLE BOWEL SYNDROME
DEPRESSIVE DISORDER
Low tension glaucoma
One eye: moderate vision impairment; other eye: near-normal
vision
Ganglion; R thumb MCP joint
Osteoarthrosis, generalized, hand
Severe stage glaucoma
Atrial fibrillation
CAD (coronary artery disease)
Screening for colon cancer
Anticoagulant long-term use
Vitreous detachment
Dry eye syndrome
Essential hypertension, benign
ITP (idiopathic thrombocytopenic purpura)
Primary open angle glaucoma
Blepharitis of both eyes
Restless leg syndrome
Chronic atrial fibrillation
Social History:
___
Family History:
No stroke, seizure
Physical Exam:
Vital Signs on Admission:
97.7 72 142/77 16 97% RA
GEN: WD, WN in NAD
HEENT: NCAT, anicteric
CV: RRR
PULM: non-labored, no respiratory distress
ABD: soft, mild epigastric tenderness to palpation, mildly
distended, well healed McBurney incision, +non-reducible femoral
hernia R groin
PELVIS: deferred
EXT: WWP, no CCE
NEURO: A&Ox3, no focal neurologic deficits
Physical Exam on Discharge:
VS: 97.6, 68, 144/55, 20, 94%ra
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+) BS x 4 quadrants, soft, mildly tender to palpation
incisionally, non-distended. Incisions: clean, dry and intact,
dressed and closed with dermabond.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
Pertinent Results:
___ 09:30AM BLOOD WBC-6.6 RBC-4.90 Hgb-13.9 Hct-43.3 MCV-88
MCH-28.4 MCHC-32.1 RDW-14.9 RDWSD-48.0* Plt ___
___ 07:40AM BLOOD WBC-6.4 RBC-4.32 Hgb-12.6 Hct-37.5 MCV-87
MCH-29.2 MCHC-33.6 RDW-14.8 RDWSD-46.8* Plt ___
___ 06:55AM BLOOD WBC-6.7 RBC-4.57 Hgb-13.4 Hct-39.8 MCV-87
MCH-29.3 MCHC-33.7 RDW-15.0 RDWSD-47.3* Plt ___
___ 12:12AM BLOOD WBC-7.2 RBC-4.22 Hgb-12.3# Hct-36.3
MCV-86 MCH-29.1 MCHC-33.9 RDW-14.8 RDWSD-46.1 Plt ___
___ 12:25AM BLOOD WBC-11.3* RBC-5.44* Hgb-15.7 Hct-46.0*
MCV-85 MCH-28.9 MCHC-34.1 RDW-14.4 RDWSD-43.6 Plt ___
___ 09:30AM BLOOD Glucose-128* UreaN-17 Creat-0.7 Na-136
K-4.4 Cl-97 HCO3-29 AnGap-14
___ 07:40AM BLOOD Glucose-109* UreaN-21* Creat-0.7 Na-134
K-4.3 Cl-99 HCO3-27 AnGap-12
___ 06:55AM BLOOD Glucose-108* UreaN-15 Creat-0.8 Na-129*
K-4.2 Cl-91* HCO3-27 AnGap-15
___ 12:12AM BLOOD Glucose-126* UreaN-19 Creat-0.8 Na-126*
K-4.4 Cl-92* HCO3-23 AnGap-15
___ 09:53AM BLOOD Glucose-146* UreaN-14 Creat-0.7 Na-128*
K-4.1 Cl-92* HCO3-25 AnGap-15
___ 09:30AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.6
___ 07:40AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.8
___ 01:30PM BLOOD TSH-2.2
___ 10:45AM BLOOD ___
___ 01:25AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___: CT A/P
Fluid-filled small bowel loops reflecting small bowel
obstruction secondary to a right femoral hernia.
___: CXR
Severe cardiomegaly is a stable. The aorta is tortuous.
Vascular congestion has improved. There is no pneumothorax or
enlarging pleural effusions. The lungs are hyperinflated
suggesting COPD. There is no evidence of pneumonia
Brief Hospital Course:
Ms. ___ is a ___ yo F admitted to the Acute Care Surgery
service on ___ with abdominal pain. She had a CT scan that
revealed fluid-filled small bowel loops reflecting small bowel
obstruction secondary to a right femoral hernia. Informed
consent was obtained and she was taken to the operating room for
a right femoral hernia repair with mesh. Please see operative
report for details. After a brief, uneventful stay in the PACU,
the patient arrived on the floor on IV fluids, and IV pain
medication.
On POD 0 her diet was advanced progressively to regular which
she tolerated well. Pain was well controlled on oral
medications. The patient voided without problem. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
She was seen and evaluated by physical therapy who recommended
discharge to home with continued physical therapy.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home with visiting
nursing and physical therapy. Her Coumadin was restarted and her
INR was therapeutic at 2.8 upon discharge. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. Follow up
appointments were scheduled.
Medications on Admission:
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Docusate Sodium 200 mg PO BID
3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Lisinopril 40 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
8. Pilocarpine 4% 1 DROP BOTH EYES Q6H
9. Atorvastatin 20 mg PO QPM
10. Senna 8.6 mg PO QHS
11. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
12. Vitamin D 1000 UNIT PO DAILY
13. Warfarin 3.75 mg PO DAILY16
14. Acetaminophen 1000 mg PO TID
15. Benzonatate 100 mg PO BID:PRN cough
16. Milk of Magnesia 30 mL PO Q8H
17. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
18. solifenacin 5'
Discharge Medications:
1. Acetaminophen 650 mg PO TID
RX *acetaminophen 325 mg 2 tablet(s) by mouth three times a day
Disp #*40 Tablet Refills:*0
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Atorvastatin 20 mg PO QPM
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Senna 8.6 mg PO BID
9. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. Vitamin D 1000 UNIT PO DAILY
12. Warfarin 4 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Small bowel obstruction due to incarcerated right femoral hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___
___ presented to ___ with abdominal pain, nausea, and
vomiting. ___ were found to have a small bowel obstruction
secondary to a right inguinal hernia. ___ were taken to the
operating room for repair of the hernia with mesh. ___ tolerated
this procedure well and are ready to be discharged home to
continue your recovery. ___ will have home ___ services set up.
Please note the following discharge instructions:
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until ___ have stopped taking pain medicine and
feel ___ could respond in an emergency.
o ___ may climb stairs.
o ___ may go outside, but avoid traveling long distances until
___ 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 ___ may start some light exercise when ___ feel comfortable.
o ___ will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when ___
can resume tub baths or swimming.
HOW ___ MAY FEEL:
o ___ may feel weak or "washed out" for a couple of weeks. ___
might want to nap often. Simple tasks may exhaust ___.
o ___ may have a sore throat because of a tube that was in your
throat during surgery.
o ___ might have trouble concentrating or difficulty sleeping.
___ might feel somewhat depressed.
o ___ could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow ___ may shower and remove the gauzes over your
incisions. Under these dressing ___ have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o ___ 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 ___ were told
otherwise.
o ___ 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 ___ may shower. As noted above, ask your doctor when ___ may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, ___ may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. ___ can get both of these
medicines without a prescription.
o If ___ 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 ___ find the pain
is getting worse instead of better, please contact your surgeon.
o ___ 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 ___ take it before your
pain gets too severe.
o Talk with your surgeon about how long ___ 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 ___ are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when ___
cough or when ___ are doing your deep breathing exercises.
If ___ 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 ___ were on before the operation just as
___ did before, unless ___ have been told differently.
If ___ have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10426859-DS-17 | 10,426,859 | 29,233,013 | DS | 17 | 2191-09-22 00:00:00 | 2191-09-22 17:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Antibiotic / Prilosec / atorvastatin
Attending: ___.
Chief Complaint:
Lower abdominal pain, fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ only woman with history of CAD, HTN, TIA,
HL, SVT, anxiety who presents with lower abdominal pain and
fevers.
She was seen at ___ the day prior to admission and complained
of vertigo, for which she was prescribed meclizine. Her symptoms
resolved today without taking any of the meclizine, but she did
have one episode of diarrhea, along with RLQ discomfort and
fevers, so went to her PCP who referred her to the ED. Otherwise
she feels fine and did not want to come in.
In the ED initial vitals were: 98.4 67 100/60 20 96% RA, tmax in
ED ___.
- Labs were significant for UA with 30WBC, lactate 1.2, INR 1.2,
normal chemistry, LFTs, and CBC. CT revealed urteral stricture
with hydronephrosis and hydroureter. Urology was consulted and
recommended IV antibiotics and outpatient urology follow up
- Patient was given Macrobid and then ceftriaxone and
acetaminophen,1L NS.
Vitals prior to transfer were: 98.9 88 109/69 14 96% RA
On the floor, patient is without complaints except that she is
cold and tired and would like her QHS ativan as soon as possible
for sleep. She no longer has RUQ pain.
Past Medical History:
CAD s/p MI ___
R/o TIA ___
Depression
R supraspinatus rupture with rotator cuff arthropathy
HTN
SVT
Anxiety
Hypercholesterolemia
Glucose intolerance
GERD
Social History:
___
Family History:
Mother ___ @___, COPD and Meniere___ disease
Father ___ @___ gastric cancer
Physical Exam:
Admitting Physical Exam:
Vitals - T:98.1 BP:160/86 HR:71 RR:71 02 sat:95% RA
GENERAL: NAD, laying flat comfortably in bed
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, injected
conjunctiva, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: tender with 1+ ankle edema
NEURO: CN II-XII intact, A&Ox3, good historian, moving all
extremties
SKIN:warm no rashes
Discharge Physical Exam:
Vitals- Tm 98.6 Tc 98.2 HR 78 BP 130/68 RR 18 Sa02 97% RA
GENERAL: NAD, lying flat comfortably in bed
NECK: no JVD.
CARDIAC: RRR, S1/S2, no murmurs, rubs, ___
LUNG: CTAB, no wheezes, rales, or rhonchi.
ABDOMEN: Soft, nontender, nondistended, normoactive bowel
sounds, no rebound/guarding; no suprapubic tenderness
MSK: mild tenderness at right flank to percussion
EXTREMITIES: Warm, well perfused. No clubbing or cyanosis. 1+
ankle edema.
NEURO: CN II-XII grossly intact, A&Ox3, moving all extremties.
Pertinent Results:
Admitting Labs:
___ 01:15PM BLOOD WBC-8.1# RBC-4.23 Hgb-13.6 Hct-41.4
MCV-98 MCH-32.2* MCHC-32.8 RDW-13.1 Plt ___
___ 01:15PM BLOOD Neuts-80.9* Lymphs-12.7* Monos-5.4
Eos-0.7 Baso-0.2
___ 01:15PM BLOOD Plt ___
___ 01:15PM BLOOD Glucose-98 UreaN-14 Creat-0.8 Na-133
K-3.8 Cl-99 HCO3-29 AnGap-9
___ 01:15PM BLOOD ALT-15 AST-25 AlkPhos-93 TotBili-0.4
___ 01:15PM BLOOD Lipase-15
___ 01:15PM BLOOD Albumin-3.3*
___ 01:33PM BLOOD Lactate-1.2
___ 04:00PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-MOD
___ 04:00PM URINE RBC-132* WBC-18* Bacteri-FEW Yeast-NONE
Epi-<1
___ 04:00PM URINE CastHy-2*
Relevant Labs:
___ 06:00AM BLOOD WBC-5.2 RBC-4.15* Hgb-13.0 Hct-40.7
MCV-98 MCH-31.3 MCHC-31.9 RDW-12.5 Plt ___
___ 10:15AM BLOOD WBC-7.1 RBC-4.12* Hgb-13.1 Hct-40.5
MCV-98 MCH-31.8 MCHC-32.4 RDW-12.7 Plt ___
___ 03:15PM URINE RBC-10* WBC-30* Bacteri-FEW Yeast-NONE
Epi-1
___ 03:15PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
Discharge Labs:
___ 05:45AM BLOOD WBC-5.2 RBC-4.17* Hgb-13.2 Hct-41.1
MCV-99* MCH-31.6 MCHC-32.0 RDW-12.5 Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD Glucose-98 UreaN-12 Creat-0.7 Na-139
K-4.1 Cl-104 HCO3-29 AnGap-10
Pertinent Micro/Path:
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
PREDOMINATING ORGANISM.
INTERPRET RESULTS WITH CAUTION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
Pertinent Imaging:
___ Chest x-ray PA & Lateral
No acute cardiopulmonary process.
___ CT abdomen/pelvis w contrast
1. New moderate right hydronephrosis and hydroureter with new
1.8 cm segment of narrowing in the distal ureter concerning for
a stricture. An underlying malignant stricture is possible.
Recommend workup starting with urine cytology.
2. 5 mm calcification in close proximity to the distal right
ureter; although, not definitively within the ureter.
3. No evidence of diverticulitis.
4. Stable ventral fat containing hernia.
5. Unchanged L1 compression deformity.
Brief Hospital Course:
___ with history of CAD, HTN, TIA, HL, SVT, anxiety who
presented with subjective fevers (Tmax 101.1 in ED) and
abdominal pain. Found to have cystitis and new right ureteral
stricture with associated hydroureteronephrosis.
Active Diagnoses:
# Complicated cystitis:
Patient presented with positive UA, consistent with cystitis.
However given fevers and abdominal pain, pyelonephritis was also
possible, although no leukocytosis. Outpatient UCx from ___
grew enterococcus, among other flora, but this was felt to be a
posible culprit organism given negative nitrites on admission
UA. CT scan showed a right ureteral stricture that could prevent
adequate clearance of urine and therefore require a longer
course of antibiotics, but there was no evidence of current
complete obstruction. She was treated initially with ceftriaxone
then switched to Augmentin based on urine culture from ___
growing enteroccus. She remained afebrile and was discharged to
complete a 7-day course of Augmentin (d7 = ___.
# Right ureteral stricture with moderate right
hydroureteronephrosis:
This was newly discovered on CT A/P. Most concerning for
malignancy given age and risk factors. Urology consulted in the
ED and wants to see her in outpatient follow-up in 2 weeks with
Dr. ___. Urine cytology was collected but has not been posted
as pending, so may need repeat urine cytology as an outpatient.
Chronic Diagnoses:
# Hyperlipidemia: continued home atorvastatin.
# Hypertension: continued home atenolol.
# Depression/anxiety: continued home citalopram and lorazepam.
# HCM: continued home vitamin D and aspirin.
Transitional Issues:
1. Patient discharged with two pills of Augmentin - take one at
bedtime on ___ and one the morning of ___. Then once her
prescription is filled she will continue to take this medicaiton
three times daily.
2. If any evidence of new or worsening infection, given the
ureteral stricture there would be a concern for a nidus of
infection.
3. Needs to follow-up with urology as ouptatient for further
workup of ureteral stricture.
4. Urine cytology ordered during this hospitalization. This was
collected but has not yet been posted as pending, so she may
require recollection as an outpatient. 5. Emergency Contact: HCP
___ (son) at ___
6. Code status: DNR/DNI confirmed with patient, HCP not aware,
patient says she does not talk to him.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO BID
2. Atorvastatin 10 mg PO DAILY
3. Citalopram 10 mg PO DAILY
4. Vitamin D ___ UNIT PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Lorazepam 0.5 mg PO HS:PRN insomnia
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Acetaminophen 650 mg PO Q8H:PRN pain
10. Aspirin 81 mg PO DAILY
11. Artificial Tear Ointment 1 Appl BOTH EYES TID:PRN dry eyes
12. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Artificial Tear Ointment 1 Appl BOTH EYES TID:PRN dry eyes
3. Aspirin 81 mg PO DAILY
4. Atenolol 25 mg PO BID
5. Atorvastatin 10 mg PO DAILY
6. Citalopram 10 mg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Lorazepam 0.5 mg PO HS:PRN insomnia
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO BID:PRN constipation
11. Vitamin D ___ UNIT PO DAILY
12. Fluticasone Propionate NASAL 2 SPRY NU DAILY
13. Amoxicillin-Clavulanic Acid ___ mg PO Q8H
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth every eight (8) hours Disp #*2 Tablet Refills:*0
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth every eight (8) hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: complicated cystitis
Secondary: ureteral stricture, right hydroureteronephrosis
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 fevers and abdominal
pain. You were found to have a urinary tract infection. You were
treated with IV antibiotics, and your urine culture grew
enterococcus so you are being discharged on
amoxicillin-clavulanate which you will take for 5 more days.
You were also found to have a narrowing of one of the tubes that
connects your kidney to your bladder. This may make you more
likely to have an infection in the future. If you have any
recurrent fevers, abdominal pain, or burning when you urinate,
this could indicate a more serious infection and please seek
medical care.
Because of this narrowing ("stricture"), it is important that
you follow-up with urology after discharge for further
evaluation (see below).
Followup Instructions:
___
|
10426859-DS-18 | 10,426,859 | 25,245,894 | DS | 18 | 2193-12-21 00:00:00 | 2193-12-21 21:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Antibiotic / Prilosec / atorvastatin
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with H/O hypertension, hyperlipidemia, ? CAD (possible MI in
the ___, former tobacco use, remote TIA and untreated
urothelial cell carcinoma who presents with one day of chest
pain. She began having left sided chest pain on the night prior
to admission. She described the pain as sharp and located in the
left chest and going to the shoulder. It was worsened by lying
flat, better when she got up and walked around. There was no
associated shortness of breath or nausea. She presented to a
pain clinic appointment and reported the chest pain in the
waiting room, so was sent via EMS to the ED. By the time of
arrival to the ED, she said her pain had resolved, and it has
not recurred. Of note, at baseline, she walks around her
apartment, goes to the bank, runs light errands, all without
chest pain.
In the ED initial vitals were: T 97.8 HR 78 BP 102/68 RR 20 SaO2
93% on RA. EKG at 1230: NSR, rate 73, ST elevations in II, III,
aVF, V1-V6. ST depression aVR unchanged from ___. Q waves II,
III, aVF, V2-V6. ST elevations in III, aVF, and precordial leads
are more prominent than prior, as are the q waves in precordial
leads.
1800: Above ST changes are less prominent and more similar to
___.
Labs/studies notable for: two negative troponin-T 3 hours apart
at 1200 and 1500. A stat portable echo was performed that did
not show regional wall motion abnormalities (though windows were
suboptimal).
Patient was given aspirin, atorvastatin 80 mg (patient unaware
of prior allergy to atorvastatin) and a heparin gtt. Cardiology
was consulted and initially was considering coronary
angiography. According to the ED resident, the patient at first
was very resistant to going for coronary angiography. Her
symptoms improved while in the ED, and given absence of wall
motion abnormalities on TTE and improvement in her symptoms,
decision was made to manage her medically.
After arrival to the cardiology ward, she denied any chest pain,
shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, or
lower extremity edema.
Past Medical History:
-CAD, s/p MI ? ___
-? TIA ___
-Depression
-R supraspinatus rupture with rotator cuff arthropathy
-Hypertension
-Hyperlipidemia
-SVT
-Anxiety
-Glucose intolerance
-GERD
Social History:
___
Family History:
Mother ___ @___, COPD and Meniere's disease
Father ___ @___ gastric cancer
Physical Exam:
On admission
GENERAL: elderly white woman woman in NAD, comfortable lying
nearly flat in bed. ___ speaking
VS: T 98.2 PO BP 154/79 Left arm supine HR 57 RR 18 SaO2 94% on
RA
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with no JVD
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs, rubs, gallops. No thrills,
lifts. Tender to palpation left lateral chest, with no crepitus.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness.
EXTREMITIES: No clubbing, cyanosis or edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
At discharge
GENERAL: ___ speaking elderly woman in NAD, comfortable
lying nearly flat in bed.
VS: T 98.3 PO BP 169/88 supine HR 64 RR 18 SaO2 96% on RA
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with no JVD
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs, rubs, gallops. No thrills,
lifts. No tenderness to palpation of the left chest.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness.
EXTREMITIES: No clubbing, cyanosis or edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
___ 12:47PM WBC-7.4 RBC-4.57 HGB-13.7 HCT-43.9 MCV-96
MCH-30.0 MCHC-31.2* RDW-12.6 RDWSD-44.8
___ 12:47PM NEUTS-78.1* LYMPHS-15.1* MONOS-5.6 EOS-0.5*
BASOS-0.4 IM ___ AbsNeut-5.75 AbsLymp-1.11* AbsMono-0.41
AbsEos-0.04 AbsBaso-0.03
___ 12:47PM PLT COUNT-244
___ 12:47PM ___ PTT-26.7 ___
___ 12:47PM GLUCOSE-102* UREA N-23* CREAT-0.9 SODIUM-137
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-27 ANION GAP-15
___ 03:44PM cTropnT-<0.01
___ 12:47PM cTropnT-<0.01
___ 10:00PM CK-MB-2 cTropnT-<0.01
ECG ___ 12:28:10 ___
Sinus rhythm. ST segment elevation in leads II, III, aVF, and
V4-V6. Q waves in leads II, III, and aVF. Prominent Q waves in
leads V4-V6. ST segment elevation is more prominent as compared
to the previous tracing of ___. There are more established
Q waves in these leads, as well as more prominent ST segment
elevation in leads V4-V6. These findings are consistent with
active inferolateral ischemic process, perhaps superimposed on
prior injury in that area. There is prominent voltage for left
ventricular hypertrophy. Followup and clinical correlation are
suggested. Rule out myocardial infarction.
ECG ___ 3:28:56 ___
Sinus rhythm. Compared to the previous tracing of ___ there
is evidence for prior or ongoing inferior wall myocardial
infarction superimposed on prior similar findings with apparent
acute exacerbation. Followup and clinical correlation are
suggested.
ECG ___ 8:52:07 AM
Sinus bradycardia with slowing of the rate as compared to the
previous tracing of ___. The previously recorded ST segment
elevation in leads II, III, aVF, and V4-V6 appears improved as
compared to the previous tracing consistent with resolution in
the context of slowing of the rate. Rule out myocardial
infarction. Followup and clinical correlation are suggested.
CXR ___:
Shallow inspiration accentuates heart size, pulmonary
vascularity. Prominent main pulmonary artery, suggests pulmonary
artery hypertension. Tortuous, calcified aorta measuring 4.0 cm
in diameter. Mild interstitial prominence in the lower lungs,
similar, likely represent scarring. No pleural effusion. No
consolidation. Thoracic curve convex to the right.
Echocardiogram ___
The left atrium is normal in size. 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%). 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 but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
Compared with the report of the prior study (images
unavailable for review) of ___, no clear change.
Brief Hospital Course:
___ yo woman with history of hypertension, hyperlipidemia and CAD
(echocardiogram with possible wall motion abnormality in the
___ who presents with one day of chest pain.
# Chest Pain: Patient reported one day of chest pain in left
chest with radiation to left shoulder which began at rest. Pain
was positional--worse with lying down--and was relieved by
walking. She denied associated shortness of breath, dyspnea on
exertion, nausea or diaphoresis. She subsequently presented to a
pain clinic appointment and reported the chest pain in the
waiting room, so was sent via EMS to the ED. By the time of
arrival to the ED, she said her pain had resolved, and it did
not recur. In the emergency department, her EKG showed NSR at a
rate of 73; ST depression aVR; Q waves II, III, aVF, V2-V6; ST
elevations in III, aVF, and precordial leads consistent with
previous EKGs, but possibly more prominent than prior. Bedside
echocardiogram showed no wall motion abnormality, although study
quality was suboptimal. Initially, patient was given
atorvastatin, ASA and started on a heparin drip for concern for
ACS. She was admitted to the cardiology service for further
care. Patient remained chest pain free and troponin-T was
negative x 4. Given patient's chest pain with qualities
inconsistent with ischemia and given resolution of symptoms
prior to ED intervention, this presentation is more consistent
with pericarditis or musculoskeletal etiology rather than ACS.
However, given patient's questionable history of CAD, it may be
reasonable to consider stress testing as an outpatient. She was
prescribed ASA 650 mg TID for 3 days to treat possible
pericarditis.
# Hypertension: Initially, patient's SBP was in the 100s, so a
low dose of metoprolol was initiated rather than patient's home
atenolol (which she is on for SVT). However, upon arrival to the
floor, patient had several SBP readings in 160s. She reported
she had run out of her home atenolol. Patient was given
prescription for atenolol (eGFR 58). Recommend outpatient
follow-up of blood pressure.
TRANSITIONAL ISSUES
[] Please consider metoprolol or carvedilol over atenolol as
atenolol is renally excreted and can therefore be risky in
elderly patients with CKD.
[] Consider stress test. Continue discussion with patient about
possible implications if stress test undertaken given that she
does not wish to have invasive procedures
# Code status: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Artificial Tear Ointment 1 Appl BOTH EYES BID:PRN dry eyes
3. Aspirin 81 mg PO DAILY
4. Atenolol 25 mg PO BID
5. Citalopram 10 mg PO DAILY
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Lorazepam 0.5 mg PO HS:PRN insomnia
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 8.6 mg PO BID:PRN constipation
10. Vitamin D ___ UNIT PO DAILY
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY
12. ___ (cranberry extract) 500 mg oral DAILY
13. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic QID
14. Rosuvastatin Calcium 5 mg PO QPM
15. diclofenac sodium 1 % topical BID:PRN
16. ammonium lactate 12 % topical BID
Discharge Medications:
1. Aspirin 650 mg PO TID
After 3 days of high dose aspirin, then resume taking one 81 mg
aspirin a day.
RX *aspirin 325 mg 2 tablet(s) by mouth three times a day Disp
#*18 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q8H:PRN pain
3. ammonium lactate 12 % topical BID
4. Artificial Tear Ointment 1 Appl BOTH EYES BID:PRN dry eyes
5. Atenolol 25 mg PO BID
RX *atenolol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
6. Citalopram 10 mg PO DAILY
7. ___ (cranberry extract) 500 mg oral DAILY
8. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic QID
9. diclofenac sodium 1 % topical BID:PRN pain
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. Lorazepam 0.5 mg PO HS:PRN insomnia
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Rosuvastatin Calcium 5 mg PO QPM
15. Senna 8.6 mg PO BID:PRN constipation
16. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
-Chest pain atypical for ischemia with no biomarker evidence of
cardiac myonecrosis and some self-remitting localized tenderness
to palpation
-Hypertension
-Stage 3 chronic kidney disease
-Hyperlipidemia
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Ms. ___,
You were in the hospital because you had pain in your chest, but
your lab work showed that you were not having a heart attack.
Your pain could have been from inflammation around the heart. We
are giving you extra aspirin for 3 days that would treat this
type of inflammation.
What was done while I was in the hospital?
==========================================
- You had lab work done that showed you were not having a heart
attack
- You were started on high dose aspirin to help inflammation
around the heart
What should I do now that I am leaving the hospital?
====================================================
- Please see your cardiologist within ___ weeks of leaving the
hospital to ensure your symptoms are gone. We are working on
getting you an appointment with Dr. ___. Please call
___ if you have not heard about a scheduled appointment
within 2 days of discharge.
- Please take high dose aspirin three times a day, for three
days. Then, you can continue to take low dose aspirin as you
were doing.
Thank you for allowing us to participate in your care!
-Your ___ Cardiology Team
Followup Instructions:
___
|
10426859-DS-19 | 10,426,859 | 21,013,288 | DS | 19 | 2194-05-02 00:00:00 | 2194-05-02 19:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Antibiotic / Prilosec / atorvastatin
Attending: ___
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with H/O CAD, TIA, depression, hypertension, hyperlipidemia,
SVT, and anxiety who presented with several days of dyspnea and
tachycardia and was found to be in a SVT in the ED. She also had
a fall earlier this week and landed on her chest and right knee
had "multiple images" and tests done after her fall. Since that
time she has noted some knee pain and chest pain which
subsequently worsened the morning of presentation with
associated dyspnea and malaise. This did not feel like any
symptoms she has had before. She denied fevers, chills or
diarrhea. Reportedly, her HR was noted to be 140s at her
assisted living facility.
On arrival to the ED, initial vitals notable for T 98.9, BP
90/60, HR 144, RR 34, SaO2 98% on O2 4 Lpm via NC. Exam
reportedly with clear lungs, benign abdomen and bruise on her
right knee. Labs notable for EKG showing SVT. She was given
adenosine 6 mg which slowed her rate to the ___ in NSR for ~5
mins but then she returned to ___ with HR in the 140s. EP was
consulted who felt the EKGs represented possible AVNRT, and the
patient was given metoprolol 5 mg IV. EP also recommended oral
beta-blockdage which was ordered but the patient did not
receive. CXR notable for RML opacity which could be consistent
with pneumonia. She was monitored on telemetry and also received
1 L IVF and was admitted to the ___ service for further
evaluation.
In regards to her SVT, she was reportedly hospitalized for this
in the remote past, however she refused ablation at that time
and was reportedly taking propranolol PRN for symptoms
associated with this. She had a Holter monitor in ___ which
showed ___ during night time hours. Her outpatient
cardiologist felt that her symptoms of palpitations and
dizziness was likely due to the Wenckebach rather than an atrial
arrhythmia and she was continued on atenolol BID with
improvement in her symptoms.
Per the patient's daughter in law, the patient's SVT has become
more frequent with multiple hospital presentations. She
previously tried metoprolol instead of atenolol but did not like
how it made her feel. She also has repeatedly refused ablation
or PPM. Her daughter in law feels this current episode has been
going on for several days.
REVIEW OF SYSTEMS: Positive per HPI. 10 point review of symptoms
reviewed and otherwise negative.
Past Medical History:
-CAD, s/p MI ? 90s
-? TIA ___
-Depression
-Right supraspinatus rupture S/p rotator cuff arthropathy
-Hypertension
-Hyperlipidemia
-SVT
-Anxiety
-Glucose intolerance
-GERD
Social History:
___
Family History:
Mother ___ @___, COPD and Meniere's disease
Father ___ @___ gastric cancer
Physical Exam:
On admission
GENERAL: Elderly white woman in NAD.
VS: 53.1 kg; T 97.5; BP 103/76; HR 79; RR 18; SaO2 95% on RA
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP not elevated
CARDIAC: RRR. No murmurs, rubs or gallops appreciated
LUNGS: Faint bibasilar crackles
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: Ecchymosis over right knee and lateral right chest wall
PULSES: Distal pulses palpable and symmetric.
At discharge
GENERAL: Elderly woman in NAD.
VS: T 98.2 BP 130-140s/60-90s HR ___ RR ___ SaO2 98% on RA
HEENT: Normocephalic atraumatic. Sclera anicteric. Conjunctiva
were pink. No pallor or cyanosis of the oral mucosa. No
xanthelasma.
NECK: Supple. JVP not elevated
CARDIAC: RRR. No murmurs, rubs or gallops appreciated
LUNGS: Faint bibasilar crackles
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: Ecchymosis over right knee and lateral right chest wall
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
___ 01:50PM BLOOD WBC-9.1 RBC-4.98 Hgb-14.9 Hct-46.7*
MCV-94 MCH-29.9 MCHC-31.9* RDW-13.1 RDWSD-44.4 Plt ___
___ 01:50PM BLOOD ___ PTT-26.9 ___
___ 01:50PM BLOOD Glucose-140* UreaN-21* Creat-0.9 Na-135
K-4.4 Cl-99 HCO3-19* AnGap-21*
___ 02:38PM BLOOD Lactate-2.1*
___ 07:11AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0
___ 07:11AM BLOOD TSH-3.6
___ 01:50PM BLOOD proBNP-937*
___ 01:50PM BLOOD cTropnT-0.01
___ 07:11AM BLOOD CK-MB-3 cTropnT-0.03*
___ 12:45PM BLOOD CK-MB-2 cTropnT-0.02*
___ 04:40AM BLOOD WBC-6.5 RBC-4.14 Hgb-12.4 Hct-38.4 MCV-93
MCH-30.0 MCHC-32.3 RDW-12.9 RDWSD-43.8 Plt ___
___ 04:40AM BLOOD Glucose-80 UreaN-12 Creat-0.7 Na-141
K-3.4 Cl-106 HCO3-24 AnGap-14
___ 04:40AM BLOOD Calcium-9.3 Phos-3.0 Mg-2.1
ECG ___ 6:24:36 ___
Sinus rhythm with first degree A-V conduction delay. Inferior
infarction with possible lateral involvement, age indeterminate.
Compared to the previous tracing of ___ bradycardia is
absent.
CXR ___
Increased opacification at the medial right lung base, which is
concerning for pneumonia. There is also streaky retrocardiac
opacification, which may represent atelectasis. No pulmonary
edema. Stable enlargement of the cardiomediastinal silhouette
with tortuosity of the thoracic aorta and calcifications of the
aortic knob. No pleural effusion. No pneumothorax.
IMPRESSION: Opacification at the medial right lung base, which
is concerning for pneumonia.
Rib films ___
Moderate cardiomegaly and severely tortuous and dilated
thoracic aorta chronic and unchanged. Lungs are clear. No
pleural effusion. No pneumothorax.
Left second rib anterolaterally is deformed but not fractured.
All other ribs are intact.
Brief Hospital Course:
___ with history of coronary artery disease, transient ischemic
attacks, depression, hypertension, hyperlipidemia, known SVT
medically managed on atenolol, and anxiety who presents with
several days of dyspnea and tachycardia found to be in SVT in
the ED, resolved with adenosine and IV Metoprolol.
# SVT: This resolved in the ED after adenosine initially with
recurrence and successfully treated with metoprolol 5 mg IV.
Patient has remote history of this and was taking atenolol BID.
Patient declined EP procedure for ablation, not within goals of
care. Atenolol discontinued in the setting of eGFR 58 (stage 3
CKD). Verapamil started and tolerated well. She had brief
episodes of 1st degree AV block and type I 2nd degree AV
Wenckebach but was asymptomatic.
# Dyspnea/Malaise: Likely secondary to SVT. While patient
initially with new O2 requirement on presentation, this resolved
with resolution of the SVT making a primary lung pathlogy less
likely. There was, however, an opacity on CXR. Patient remained
afebrile and stable with no elevated WBC, cough or shortness of
breath, so antibiotics were deferred.
# Knee Pain: Secondary to recent fall with complete work up
done. She had reportedly full trauma work up at ___
___ earlier this week which was negative,
particularly images of her knee were negative for fracture.
Patient was given Tylenol ___ mg TID standing for pain. Rib
films were negative for fracture.
CHRONIC ISSUES:
# Insomnia - Continued home lorazepam 0.5mg qHS. While this is
not best agent for patient of this age or for insomnia, she has
been chronically stable on this medication.
# Depression - Continued home citalopram 10mg daily
# Hyperlipidemia/CAD - Changed home rosuvastatin 5 mg qHS to 10
mg qHS, continued ASA 81 mg.
# Alergic Rhinitis - Continued home Flonase
# Deficiency - Continued home Vit D 2000U daily
Transitional issues:
- New medication: Verapamil
Code: DNR/DNI
Contact: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Artificial Tear Ointment 1 Appl BOTH EYES BID:PRN dry eyes
3. Aspirin 81 mg PO DAILY
4. Citalopram 10 mg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Rosuvastatin Calcium 5 mg PO QPM
7. Senna 17.2 mg PO BID:PRN constipation
8. Vitamin D ___ UNIT PO DAILY
9. ammonium lactate 12 % topical BID
10. Atenolol 25 mg PO BID
11. ___ (cranberry extract) 500 mg oral DAILY
12. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic QID
13. diclofenac sodium 1 % topical BID:PRN pain
14. Fluticasone Propionate NASAL 2 SPRY NU DAILY
15. Lorazepam 0.5 mg PO HS:PRN insomnia
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Verapamil SR 240 mg PO Q24H
RX *verapamil 240 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
2. Aspirin 81 mg PO DAILY
3. Rosuvastatin Calcium 10 mg PO QPM
RX *rosuvastatin 10 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet
Refills:*1
4. Acetaminophen 650 mg PO Q8H:PRN pain
5. ammonium lactate 12 % topical BID
6. Artificial Tear Ointment 1 Appl BOTH EYES BID:PRN dry eyes
7. Citalopram 10 mg PO DAILY
8. ___ (cranberry extract) 500 mg oral DAILY
9. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic QID
10. diclofenac sodium 1 % topical BID:PRN pain
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. Lorazepam 0.5 mg PO HS:PRN insomnia
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Senna 17.2 mg PO BID:PRN constipation
16. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Supraventricular tachycardia
-Hyperlipidemia
-Reported history of coronary artery disease and transient
ischemic attack
-Dyspnea
-Malaise
-Depression
-Constipation
-Allergic rhinitis
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 here at ___.
You were admitted because you were experiencing heart
palpitations and weakness. An EKG was done of your heart which
showed your heart was beating very fast. You were given
medications to slow down your heart rate and you did very well.
You informed us that you did not want a procedure done that can
prevent further of these episodes from happening. We respect
your decision. We are discharging you with medication that can
manage your fast heart rates.
We are happy to see you feeling better.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10426859-DS-20 | 10,426,859 | 29,908,281 | DS | 20 | 2194-05-25 00:00:00 | 2194-05-26 10:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Antibiotic / Prilosec / atorvastatin
Attending: ___.
Chief Complaint:
Lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ female with past medical history
significant for SVT, with recent admission for SVT presents with
palpitations, lightheadedness, headache. Patient called EMS for
the symptoms earlier of lightheadedness and palpitations at
home. She was found to be in supraventricular tachycardia to
150s, and was cardioverted in ambulance with 6 mg of adenosine.
The patient continued to complain of palpitations and in the ED,
she was again in SVT and was given another 6 mg of adenosine,
which converted her to sinus rhythm. She again went into SVT,
and was then given 2.5mg IV Verapamil x 2. Patient endorsed
taking her home Verapamil ER 240mg this AM.
Her BPs were briefly ___ with her tachycardia of 160,
however she improved after the IV verapamil boluses, which
slowed her heart rate. Patient denied chest pain, shortness of
breath, fevers, chills, cough.
Patient also endorsed having had a fall when she felt
lightheaded but no head strike. She fell on her right side and
caught her fall with her arm.
During last admission for SVT, patient's atenolol was stopped
and Verapamil was started. Patient declined ablation as not
within goals of care.
In the ED, initial vitals were: 99.1 109 140/80 30 96% RA
- Labs notable for: WBC 12.2, other wise CBC WNL. Cr 1 (baseline
) HCO3 17. Trop 0.02.
- Imaging was notable for: CXR: Low lung volumes with mild
pulmonary vascular congestion but no frank pulmonary edema. Mild
bibasilar atelectasis.
- Patient was given:
___ 22:12 IVF NS ( 1000 mL ordered) ___ Started
Stop
___ 22:12 IV Adenosine 6 mg ___
___ 22:12 IV Ondansetron 4 mg ___
___ 22:36 IV Verapamil 2.5 mg ___
___ 23:09 PO Aspirin 324 mg ___
___ 23:13 IV Verapamil 2.5 mg ___
Upon arrival to the floor, patient reports no chest pain, no
chest pressure, no palpitations, no shortness of breath. She is
very comfortable and just want to sleep.
However, when nurse tried to reposition her, patient had pain in
her right hip. She then endorsed that when she stood up earlier
she had felt pain in her entire right leg - her foot, ankle,
leg, hip.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
-CAD, s/p MI ? 90s
-? TIA ___
-Depression
-R supraspinatus rupture with rotator cuff arthropathy
-Hypertension
-Hyperlipidemia
-SVT
-Anxiety
-Glucose intolerance
-GERD
Social History:
___
Family History:
Mother ___ @___, COPD and Meniere's disease
Father ___ @___ gastric cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 97.4 101/59 82 22 95% 2L
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated.
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally on anterior side.
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 edema
Neuro: ___ strength upper/lower extremities. Grossly normal
sensation.
MSK: Right hip non tender to palpation, no echymoses. Right leg
warm, 2+ pulses. Tenderness with hip flexion and cross leg test.
DISCHARGE PHYSICAL EXAM:
VS: 98.5, BP 97/61, HR 69, RR 22, O2 99% on 2L
Weight: 51.7kg
GENERAL: well appearing, no acute distress
HEENT: sclera anicteric
NECK: no JVD visualized
CARDIAC: RRR, nl S1 S2, systolic murmur LUSB, no rubs/gallops
LUNGS: clear to auscultation bilaterally
ABDOMEN: Soft, NTND
EXTREMITIES: WWP, no edema
SKIN: no rash visualized
PULSES: DP 2+ b/l
NEURO/MSK: moving ___ spontaneously against gravity
Pertinent Results:
ADMISSION LABS:
___ 09:46PM BLOOD WBC-12.2*# RBC-4.71 Hgb-14.3 Hct-44.0
MCV-93 MCH-30.4 MCHC-32.5 RDW-13.2 RDWSD-44.7 Plt ___
___ 09:46PM BLOOD Neuts-83.3* Lymphs-10.6* Monos-5.0
Eos-0.2* Baso-0.2 Im ___ AbsNeut-10.17* AbsLymp-1.30
AbsMono-0.61 AbsEos-0.02* AbsBaso-0.03
___ 07:50AM BLOOD ___ PTT-25.2 ___
___ 09:46PM BLOOD Glucose-155* UreaN-15 Creat-1.0 Na-135
K-3.9 Cl-99 HCO3-17* AnGap-23*
___ 09:46PM BLOOD cTropnT-0.02*
___ 07:50AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.0
PERTINENT INTERVAL LABS:
___ 07:50AM BLOOD CK-MB-2 cTropnT-0.09*
___ 07:50AM BLOOD TSH-3.7
DISCHARGE LABS:
___ 04:20AM BLOOD WBC-6.8 RBC-3.89* Hgb-12.1 Hct-36.8
MCV-95 MCH-31.1 MCHC-32.9 RDW-13.4 RDWSD-45.9 Plt ___
___ 04:20AM BLOOD Glucose-82 UreaN-13 Creat-0.7 Na-138
K-3.9 Cl-102 HCO3-25 AnGap-15
___ 04:20AM BLOOD Calcium-9.2 Phos-3.1 Mg-2.1
IMAGING/STUDIES:
CXR ___
Low lung volumes with mild pulmonary vascular congestion but no
frank
pulmonary edema. Mild bibasilar atelectasis.
HIP XRAY ___
There is a nondisplaced comminuted fracture in the right
superior pubic ramus. The patient is s/p right total hip
prosthesis, with non-cemented femoral stem in overall anatomic
alignment. The femoral head component is symmetrically seated
within the acetabular component. No periprosthetic lucency to
suggest loosening and no osteolysis is detected. No heterotopic
ossification is seen. No evidence of dislocation. There are
vascular calcifications. There are minimal degenerative change
is in the left hip.
IMPRESSION: nondisplaced comminuted fracture in the right
superior pubic ramus
CT HEAD ___. No acute intracranial abnormalities.
2. Small chronic infarct.
MICROBIOLOGY
UCx ___ MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN AND/OR GENITAL CONTAMINATION.
BCx ___ NGTD
Brief Hospital Course:
___ with PMH of SVT, CAD, TIA, HTN, HLD, anxiety, likely
undiagnosed uroepithelial carcinoma for which she has declined
further work-up, transitioning to hospice at home, who presents
with lightheadedness and falls, found to have recurrence of her
SVT and small hip fracture.
# SVT: Patient presents with episodes of lightheadedness, found
by EMS and in the ED to be in SVT, likely similar to her prior.
She was treated with adenosine and IV verapamil with return to
NSR. The patient had previously declined further work-up and
management of her SVT including ablation and PPM. The trigger of
her recurrent SVT remained unclear. CXR showed no evidence of
infection. Though UA showed pyuria, this likely represents
underlying uroepithelial carcinoma and patient denied
symptomatic dysuria. In discussion with patient and family, the
patient again declined invasive management including PPM and
ablation for her SVT. The patient's verapamil was increased to
120mg q8hrs with good HR control. The patient did have some
episodes of Wenckebach on higher dose verapamil, though this was
also present on her outpatient Holter recordings on other nodal
blocking agents. The patient should f/u with cardiology as
outpatient for further management.
# Type II NSTEMI: troponin 0.02 in the ED, likely demand in the
setting of tachycardia. ECG with baseline STE in II, III, V1-V3,
ST depression in AvR, Qwaves in II, III, no TWI, unchanged from
prior. The patient's troponin trended to 0.09 though MB was not
elevated. This most likely represents demand in the setting of
tachycardia. Further work-up was not pursued given goals of
care.
# Right leg pain, s/p fall: Patient endorses falls due to
lightheadedness, most likely related to her SVT. The patient's
family reported she had been complaining of progressive headache
since her fall, so she was evaluated with CT head, which showed
no acute change. Hip x-ray notable for non-displaced, comminuted
right superior pubic ramus fracture. The patient was evaluated
by orthopedics who recommended conservative management with pain
control and WBAT. Pain well controlled on acetaminophen and low
dose oxycodone.
# Insomnia: Continued home lorazepam 0.5mg qHS
# Depression: Continued home citalopram 10mg daily
# HLD/CAD:
- Continued home Rosuvastatin 10mg qHS
- Continued home ASA 81mg
# Allergic Rhinitis: Continued home flonase
# Primary prevention: Continued home Vit D 2000U daily
Transitional Issues:
- Patient recently transitioned to hospice as outpatient as she
has likely uroepithelial carcinoma, noted on urine cytology, for
which she has declined further work-up. Consider transition to
hospice after discharge from rehab
- Continue oxycodone and acetaminophen for pain control given
hip fracture
- Continue to monitor HR on increased dose verapamil.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Citalopram 10 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Lorazepam 0.5 mg PO HS:PRN insomnia
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Rosuvastatin Calcium 10 mg PO QPM
9. Senna 17.2 mg PO BID:PRN constipation
10. Vitamin D ___ UNIT PO DAILY
11. ammonium lactate 12 % topical BID
12. Artificial Tear Ointment 1 Appl BOTH EYES BID:PRN dry eyes
13. ___ (cranberry extract) 500 mg oral DAILY
14. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic QID
15. diclofenac sodium 1 % topical BID:PRN pain
16. Verapamil SR 240 mg PO Q24H
Discharge Medications:
1. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain -
Severe
2. Aspirin 81 mg PO DAILY
3. Acetaminophen 650 mg PO Q8H:PRN pain
4. ammonium lactate 12 % topical BID
5. Artificial Tear Ointment 1 Appl BOTH EYES BID:PRN dry eyes
6. Citalopram 10 mg PO DAILY
7. ___ (cranberry extract) 500 mg oral DAILY
8. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic QID
9. diclofenac sodium 1 % topical BID:PRN pain
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. Lorazepam 0.5 mg PO HS:PRN insomnia
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Rosuvastatin Calcium 10 mg PO QPM
15. Senna 17.2 mg PO BID:PRN constipation
16. Vitamin D ___ UNIT PO DAILY
17. Verapamil 120 mg po q8 hours
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: supraventricular tachycardia, non-displaced
comminuted fracture in the right superior pubic ramus, NSTEMI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for allowing us to participate in your care at ___!
You were admitted to the hospital with fast heart rates due to
your known supraventricular tachycardia. We increased your dose
of verapamil and your symptoms improved.
You reported falls in the past, so we evaluated you with a CT
scan of your head, which showed no acute changes. We also
evaluated you with an x-ray of your hip. This showed a small
fracture. We treated you with pain medication, which you may
continue after discharge.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10426922-DS-19 | 10,426,922 | 29,019,056 | DS | 19 | 2158-07-22 00:00:00 | 2158-07-22 15:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
fluoxetine
Attending: ___
___ Complaint:
bright red blood per rectum, chronic diarrhea
Major Surgical or Invasive Procedure:
Segmental resection of the transverse
colon with laparoscopic assistance.
History of Present Illness:
This is a ___ old Female with PMH significant for
cerebrovascular disease ___ years prior, without residual
deficits), hearing loss in right ear (history of acoustic
neuroma), recurrent DVTs (on anticoagulation), history of (?)
ulcerative colitis, total thyroidectomy for thyroid cancer,
history of breast cancer (s/p breast conserving therapy),
history of acoustic neuroma (resected), and depression who
presents with bright red blood per rectum from her nursing
facility in the setting of several weeks of worsening diarrhea.
Per the nursing records, she awoke with dizziness and difficulty
with ambulation the morning of admission. She had large amounts
of diarrhea which were reportedly intermixed with fresh blood.
She had an appointment scheduled with Dr. ___ tomorrow in
___ clinic for colitis concerns, as noted below.
Per he son ___, she has had about 6-months of loose,
non-bloody stools over the course of 6-weeks. The episodes were
increasing in frequency and now occurring twice daily. Her son
reports a colonoscopy last performed at ___ ___ ago and
thinks her GI doctor previously noted a diagnosis of ulcerative
colitis for which she is no longer on medications. Her son
mentions no weight loss, nausea or emesis; appetite is
questionable but her son attributes that to depression. Her SSRI
dose (sertraline) was recently increased from 150 mg to 200 mg
PO daily.
ED course:
- initial VS: 97.0 72 121/56 18 100% RA
- Labs notable for hemoblogin 7.3, platelets 248, INR 9.6
- Creatinine 0.7
- CT abdomen and pelvis obtained
- Received 10 mg vitamin K IV
- 2 units of FFP given
- GI consulted
REVIEW OF SYSTEMS: See HPI for pertinent details. Denies fevers
or chills; no nightsweats. No headaches or visual changes. No
chest pain or difficulty breathing. No notable upper respiratory
symptoms or cough. Denies nausea and emesis or abdominal pain.
(+) loose stools and diarrhea; denies constipation. No dysuria
or hematuria. No new rashes, lesions or ulcers. No extremity
swelling, athralgias or joint complaints. No pertinent weight
loss or gain.
Past Medical History:
PAST MEDICAL HISTORY:
- ? Dementia (cognitive deficits and issues with executive
functioning - episodic paranoia)
- Cerebrovascular disease (no neurologic deficits)
- Recurrent deep venous thrombosis (on anticoagulation), IVC
filter placed ___ ago
- History of (?) ulcerative colitis
- History of thyroid cancer
- Depression
- Breast cancer (s/p radiation, hormone therapy - Dr. ___
at ___, completed treatment ___ ago)
- History of 'hole in her heart' (never repaired)
- History of osteomyelitis with MRSA infection (after elbow
injury)
- Uterine fibroids
- History of hyperglycemia (without a diagnosis of diabetes
mellitus)
PAST SURGICAL HISTORY:
- Acoustic neuroma (resected ___ ago at ___
- Total thyroidectomy (resected > ___ ago)
- Hysterectomy ___ ago)
Social History:
___
Family History:
The patient denies a history of premature cardiac disease such
as MI, arrhythmia or sudden cardiac death. No significant
malignancy history. Mother died at age ___ from cerebral
aneurysm, father died in his ___ due old age. Son with ___
lymphoma. Daughter with spina ___. Family history of Crohn
colitis (cousin).
Physical Exam:
ADMISSION EXAM:
Vitals: 97.6 126/67 62 18 97% RA
Weight: 70.7 kg
General: patient appears in NAD. Appears stated age. Non-toxic
appearing. Pleasant.
HEENT: normocephalic, atraumatic. Hard of hearing on the right.
PERRL. EOMI. Oropharynx with no notable lesions, plaques or
exudates. Dentures noted. Neck supple.
___: regular rate and rhythm. II/VI early systolic murmur at
___ without radiation. S1 and S2.
Respiratory: demonstrates unlabored breathing. Clear to
auscultation bilaterally without adventitious sounds such as
wheezing, rhonchi or rales.
Abdomen: soft, tender to palpation in epigastric region only,
non-distended with normoactive bowel sounds; no significant
abdominal scars
Extremities: warm, well-perfused distally; 2+ distal pulses
bilaterally with no cyanosis, clubbing, trace peripheral edema
to mid-shins noted bilaterally
Derm: skin appears intact with no significant rashes or lesions;
multiple seborrheic keratoses
Neuro: alert and oriented to self, place and time. Normal bulk
and tone. Motor and sensory function are grossly normal. Gait
deferred.
Rectal (my exam): external exam normal with multiple kin tags,
but no fissures or lesions; no palpable masses. Digital exam
notable for normal tone, no palpable mass in the rectal vault
with liquid brown stool present. Guaiac positive.
DISCHARGE EXAM:
V.S. 98.6, 97.6, 61, 141/89, 24, 95RA
General Alert and oriented to self
Cardiac RRR . II/VI early systolic murmur at ___ without
radiation. S1 and S2.
Respi Decreased breath sounds at bases, remaining lung field
CTAB
Abd: Soft, slightly distended, appropriately tender to palpation
around incision sites.
Extremities: warm, well-perfused distally; 2+ distal pulses
bilaterally with no cyanosis, clubbing, trace peripheral edema
to mid-shins noted bilaterally
Derm: skin appears intact with no significant rashes or lesions;
multiple seborrheic keratoses
Neuro: alert and oriented to self, place and time. Normal bulk
and tone. Motor and sensory function are grossly normal. Gait
deferred.
Pertinent Results:
ADMISSION LABS:
___ 11:00AM BLOOD WBC-7.8 RBC-2.91* Hgb-7.3* Hct-25.5*
MCV-88 MCH-24.9* MCHC-28.5* RDW-16.9* Plt ___
___ 11:00AM BLOOD Neuts-86.4* Lymphs-9.3* Monos-2.7 Eos-1.3
Baso-0.3
___ 11:00AM BLOOD Plt ___
___ 11:58AM BLOOD ___ PTT-73.2* ___
___ 07:00PM BLOOD ___ PTT-32.2 ___
___ 11:00AM BLOOD Glucose-109* UreaN-21* Creat-0.7 Na-143
K-3.7 Cl-110* HCO3-29 AnGap-8
___ 11:00AM BLOOD cTropnT-<0.01
___ 11:00AM BLOOD Calcium-8.9 Phos-2.2* Mg-2.1
DISCHARGE LABS:
MICROBIOLOGY: None
ECG (___): NSR @ 67 bpm. Normal axis and intervals. TWI in
lead V2. 0.5-mm lateral ST-depressions in leads V4-6 are noted.
No comparison available.
IMAGING STUDIES:
___ CT ABD & PELVIS WITH CONTRAST - Small segment of
thickening with surrounding inflammatory changes in the
mid-transverse colon may be secondary to colitis. No other acute
intra-abdominal abnormalities identified. (preliminary)
EGD:
Impression: Normal mucosa in the whole esophagus
Large inflammatory pedunculated polyp in the stomach. This polyp
had stigmata of recent bleeding. Two clips were placed to
attempt to stragulate polyp and reduce risk of bleeding. The
polyp was not removed due to a likely high risk of bleeding and
difficult position high in the fundus for obtaining hemostasis
should there be post-polypectomy bleeding. (biopsy, endoclip)
Angioectasia in the duodenum (thermal therapy)
Otherwise normal EGD to third part of the duodenum
Recommendations:
-Please continue daily PPI
-Would hold anticoagulation for at least 24 hours
Colonoscopy:
Findings:
Protruding Lesions A single sessile 1 cm polyp of benign
appearance was found in the descending colon. The polyp was not
removed at this time in the setting of bleeding work-up. A
ulcerated mass of malignant appearance was found in the
transverse colon (precise location uncertain due to scope
looping). The mass caused a partial obstruction. The scope could
not traverse the lesion and the examination was interrupted.
Cold forceps biopsies were performed for histology at the colon
mass. The mucosa just distal to the lesion was tattooed with 4mL
of SPOT ink.
Impression:
- Mass in the transverse colon (precise location uncertain due
to scope looping) (biopsy, injection)
- Polyp in the descending colon
Recommendations: We will follow-up biopsies and inform patient.
Brief Hospital Course:
___ with PMH significant for cerebrovascular disease ___ years
prior, without residual deficits), hearing loss in right ear
(history of acoustic neuroma), recurrent DVTs (on
anticoagulation), history of (?) ulcerative colitis, total
thyroidectomy for thyroid cancer, history of breast cancer (s/p
breast conserving therapy), history of acoustic neuroma
(resected), and depression who presents with bright red blood
per rectum from her nursing facility in the setting of several
weeks of worsening diarrhea with CT evidence of transverse
colitis.
# Lower GI bleeding - Presumed lower source given transverse
colonic thickening and inflammatory changes now with BRBPR. Has
reported history of colitis NOS from many years ago, no current
management. We suspect that possible exacerbation in the
setting of supratherapeutic INR has resulted in bleeding. C diff
negative. Hemodynamics stable. Hb 7.3 g/dL on admission,
baseline unclear. Hb dropped to 6.7 ___, transfused 1 unit ___
evening with good response. EGD revealed pedunculated polyp in
the stomach, no evidence of bleeding. Colonoscopy revealed
large mass in the transverse colon concerning for malignancy.
Colorectal Surgery recommended partial colectomy to remove the
involved segment to reduce the risk of obstruction.
# Supratherapeutic INR - On coumadin for DVT history. Notable
CVA history and ? PFO vs. ASD. Recent change in SSRI dosing and
addition of probiotic noted, and poor PO intake from depression,
which likely all contribute to change in coumadin metabolism.
Evidence of active lower GI bleeding in the setting of colitis.
INR 9.6 on admission. Received vitamin K 10 mg IV x 1 and 2
units of FFP for reversal with decrease in INR to 1.7. Given
colon mass, anticoagulation now contraindicated. Once resection
has been completed, it may be possible to restart coumadin for
stroke Px.
# Non-specific EKG changes - Resolved. Pain-free. 0.5-mm
ST-depression noted in lateral leads. No baseline available. No
reported cardiac history. Troponin negative x2. EKG this
morning with near resolution of ST changes. No concern for ACS,
possible mild strain in the context of bleeding.
# Recurrent deep venous thrombosis - Recurrent DVTs with IVC
filter in place. Now with active bleeding concerns, thus
anticoagulation stopped.
# Cerebrovascular disease - No residual focal deficits. Has some
cognitive concerns, ? vascular dementia. Continued statin and
held anticoagulation.
# History of thyroid carcinoma - Continue levothyroxine
# Depression - Stable mood. Continue sertraline
# Dementia - continue donepezil
TRANSITIONAL ISSUES:
- timing to restart ___
- medical oncology follow-up to discuss biopsy results, possible
chemotherapy options
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 80 mg PO DAILY
2. Warfarin 2 mg PO DAILY16
3. Sertraline 200 mg PO DAILY
4. Donepezil 10 mg PO HS
5. Omeprazole 40 mg PO DAILY
6. Ferrous GLUCONATE 324 mg PO DAILY
7. Levothyroxine Sodium 125 mcg PO DAILY
8. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 10 billion cell
oral DAILY
Discharge Medications:
1. Donepezil 10 mg PO HS
2. Levothyroxine Sodium 125 mcg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Sertraline 200 mg PO DAILY
5. Warfarin 2 mg PO DAILY16
6. Acetaminophen 1000 mg PO Q8H:PRN pain
7. Docusate Sodium 100 mg PO BID
8. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
9. Senna 8.6 mg PO BID:PRN constipation
10. Ferrous GLUCONATE 324 mg PO DAILY
11. Pravastatin 80 mg PO DAILY
12. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 10 billion cell
oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Large cancer of the mid transverse
colon with impending obstruction.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure caring for you at ___
___. You came to the hospital with diarrhea and
blood in your stool. We learned that this was due to a mass in
your colon. This was removed.
You were admitted to the hospital on ___ for a Laparoscopic
Colectomy for surgical management of your colon mass. You have
recovered from this procedure well and you are now ready to
return home. Samples from your colon were taken and this tissue
has been sent to the pathology department for analysis. You will
receive these pathology results at your follow-up appointment.
If there is an urgent need for the surgeon to contact you
regarding these results they will contact you before this time.
You have tolerated a regular diet, are passing gas and your pain
is controlled with pain medications by mouth. You may return
home to finish your recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel
movement prior to your discharge which is acceptable, however it
is important that you have a bowel movement in the next ___
days. After anesthesia it is not uncommon for patients to have
some decrease in bowel function but you should not have
prolonged constipation. Some loose stool and passing of small
amounts of dark, old appearing blood are expected. However, if
you notice that you are passing bright red blood with bowel
movements or having loose stool without improvement please call
the office or go to the emergency room if the symptoms are
severe. If you are taking narcotic pain medications there is a
risk that you will have some constipation. Please take an over
the counter stool softener such as Colace, and if the symptoms
do not improve call the office. If you have any of the following
symptoms please call the office for advice or go to the
emergency room if severe: increasing abdominal distension,
increasing abdominal pain, nausea, vomiting, inability to
tolerate food or liquids, prolonged loose stool, or extended
constipation.
You have ___ laparoscopic surgical incisions on your abdomen
which are closed with internal sutures and a skin glue called
Dermabond. These are healing well however it is important that
you monitor these areas for signs and symptoms of infection
including: increasing redness of the incision lines,
white/green/yellow/malodorous drainage, increased pain at the
incision, increased warmth of the skin at the incision, or
swelling of the area. Please call the office if you develop any
of these symptoms or a fever. You may go to the emergency room
if your symptoms are severe.
You may shower; pat the incisions dry with a towel, do not rub.
The small incisions may be left open to the air. If closed with
steri-strips (little white adhesive strips) instead of
Dermabond, these will fall off over time, please do not remove
them. Please no baths or swimming for 6 weeks after surgery
unless told otherwise by Dr. ___ Dr. ___.
You will be prescribed a small amount of the pain medication
oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
No heavy lifting greater than 6 lbs for until your first
post-operative visit after surgery. Please no strenuous activity
until this time unless instructed otherwise by Dr. ___ Dr.
___.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Your coumadin has been stopped for a short time to allow you to
heal from the surgery. You should discuss when to start this
medicine again with your primary care doctor.
The mass in your colon may be a cancer. Biopsies of the mass
will be available in a few days. You should set up an
appointment with one of our GI Oncologists to discuss these
results and decide if you should have chemotherapy or other
treatment.
Followup Instructions:
___
|
10427102-DS-8 | 10,427,102 | 20,338,824 | DS | 8 | 2170-06-18 00:00:00 | 2170-06-18 16:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
recurrent left pneumothorax
Major Surgical or Invasive Procedure:
___
Left VATS LUL blebectomy
History of Present Illness:
___ M recently d/c from ___ ___ for L spontaneous ptx
presents for L new spontaneos ptx. States that since his d/c
___ he was feeling better, though had a lingering cough. The
morning of presentation, he played ___ and ___ well. While
he was watching a game of dodgeball at 3PM ___, he began
feeling pleuritic chest pain similar to his presentation the
previous week. He denies any trauma preceeding this event. He
walked and drank some water, in an attempt to determine if the
pain was similar to his first pneumothorax. States pain
plateaued and he had difficulty taking a deep breath and felt
certian this was similar to previous event. Denies any fevers,
syncope, dizziness,SOB, productive cough, and rest of ROS was
neg. Presented to ___ where placed a pigtail
anterior chest midclavicular, above second rib. Placed in a
pneumostat and transferred to ___ for continued care.
Past Medical History:
None
Social History:
___
Family History:
Father: Previous history of pleurisy.
Siblings: significant for brother spont ptx age ___ (now ___), d/c
from ___ after 3 hrs obs, no CT, no surgery.
Physical Exam:
Temp: 97.8 HR: 80 BP:120/76 RR: 14 O2 Sat: 99%RA
GENERAL
[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:
HEENT
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[x] Tongue midline [x] Neck supple/NT/without mass [x] Trachea
midline
[ ] Abnormal findings:
RESPIRATORY
[] CTA/P [] Excursion normal [x] No fremitus
[x] No egophony
[ ] Abnormal findings: Mildly decreased breath sounds L,
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] No JVD [x] No edema
[x] Peripheral pulses nl [x] No abd/carotid bruit
[ ] Abnormal findings:
GI
[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia
[ ] Abnormal findings:
GU [x] Deferred
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO
[x] No facial asymmetry [x] Cognition intact
[ ] Abnormal findings:
SKIN
[x] No rashes/lesions/ulcers
[x] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC
[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
___ 12:05PM WBC-7.2 RBC-4.95 HGB-14.6 HCT-43.8 MCV-89
MCH-29.5 MCHC-33.3 RDW-11.9 RDWSD-38.3
___ 12:05PM NEUTS-56.3 ___ MONOS-8.1 EOS-2.4
BASOS-0.7 IM ___ AbsNeut-4.06 AbsLymp-2.33 AbsMono-0.58
AbsEos-0.17 AbsBaso-0.05
___ 12:05PM PLT COUNT-225
___ 12:05PM ___ PTT-33.7 ___
___ 12:05PM GLUCOSE-91 UREA N-15 CREAT-1.1 SODIUM-140
POTASSIUM-5.1 CHLORIDE-101 TOTAL CO2-31 ANION GAP-13
___ Chest CT :
There is a small, trace left apical pneumothorax (4:29), and
left chest tube terminates left upper pleural space (4:86). No
evidence of tension. No large bleb identified. The airways are
otherwise patent to the subsegmental level. There is no focal
consolidation or pleural effusion. Multiple sub-4-mm pulmonary
nodules are identified and are of doubtful clinical significance
in a patient of this age.
___ CXR :
A left-sided chest tube is noted with tip projecting over the
left apex. A tiny residual left apical pneumothorax is noted.
Opacity within the medial aspect of the left apex likely
reflects postoperative hemorrhage. Cardiac, mediastinal and
hilar contours are normal. Pulmonary vasculature is normal. No
shift of mediastinal structures is present. There are no acute
osseous abnormalities. Please note that the extreme right
costophrenic angle is excluded from the field of view.
Brief Hospital Course:
___ was evaluated by the Thoracic Surgery service in
the Emergency Room and admitted to the hospital for further
management of his left pneumothorax. Due to the fact that this
was his second left pneumothorax within 2 weeks, surgery was
recommended.
He was taken to the Operating Room on ___ and underwent a
Left VATS blebectomy. He tolerated the procedure well and
returned to the PACU in stable condition. His chest tube
remained on suction and he had a small air leak. His pain was
controlled with Dilaudid and Tylenol and he was able to use his
incentive spirometer effectively. His room air saturations were
97%. His port sites were dry.
The air leak resolved on ___ and his chest tube was
removed. His post pull chest xray revealed a small left apical
pneumothorax and his room air saturations were excellent. The
film was repeated 3 hours later and remained stable.
He was discharged to home on ___ and will follow up with
Dr. ___ at ___ on ___. His sutures will be removed
at that time.
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
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*2
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrent left 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 hospital with a recurrent
pneumothorax and you required surgery for definitive treatment.
You've recovered well and are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol ___ mg every 6 hours in between your narcotic.
If your doctor allows you may also take Ibuprofen to help
relieve the pain.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
___
|
10427288-DS-21 | 10,427,288 | 27,075,708 | DS | 21 | 2179-05-10 00:00:00 | 2179-05-02 08:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending: ___.
Chief Complaint:
Right ankle pain
Major Surgical or Invasive Procedure:
Status post right ankle I&D/open reduction internal fixation
___, ___
History of Present Illness:
___ female with Diabetes, CHF, COPD, CAD status post CABG (per
the
patient's daughter), GERD, gout, fibromyalgia, CKD who presents
with right ankle fracture dislocation. There are 2 transverse
lacerations approximately 5 cm above the medial malleolus. It
is
difficult on exam to tell if these probes deeply and communicate
with the fracture. She was given Ancef in the ED and tetanus
was
confirmed. She underwent closed reduction with propofol
sedation. this injury will require surgical fixation.
Past Medical History:
Diabetes, high cholesterol, morbid obese, smoker, kidney
disease, stents on the leg, stroke, heart attack, asthma,
arthritis, gout, thyroid problems.
Social History:
___
Family History:
n/c
Physical Exam:
General: Well-appearing female in no acute distress.
Right lower extremity:
-There are 2 horizontal lacerations approximately 5 cm proximal
to the medial malleolus. More proximal laceration is
approximately 4 cm in length. More distal laceration is
approximately 2 cm. There is scattered ecchymosis
- Fires weak ___
- SILT S/S/SP/DP/T distributions though she does have decreased
sensation in her great toe
- 2+ palpable DP, 2+ ___ pulse by Doppler, WWP
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right open ankle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for I&D as well as open reduction
internal fixation of 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 ___ anticoagulation per
routine. While inpatient, the patient was continued on IV Ancef
for prophylaxis against surgical site infection. This was
converted to p.o. Keflex at discharge.
Pain control was somewhat of an issue during this
hospitalization. The patient reported poor pain control and on
___ her narcotic pain regimen was increased slightly. At this
time the patient had a spell where she stared blankly forward
for roughly 1 minute as witnessed by her family members. Her
family was concerned about a possible seizure and neurology was
consulted. Neurology was not concerned for a seizure and
recommended no further workup. They suggested the patient
follow-up in neurology clinic as desired. The pain service also
saw the patient after this event and suggested achieving pain
control through gabapentin and Flexeril in addition to Tylenol
and, if needed, oxycodone used sparingly. With this regimen,
her pain was well controlled.
The patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact. She did
have some difficulty with urination postoperatively. She was
straight cathed multiple times and ultimately a Foley was
placed. A trial of removal of this Foley should occur in ___
days. The patient is NWB in the right 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:
Gabapentin 300 mg nightly
Allopurinol ___ mg PO DAILY
Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H:PRN dry
eyes
Atorvastatin 40 mg PO QPM
Furosemide 80 mg PO DAILY
Insulin SC Sliding Scale
Ipratropium-Albuterol Neb 1 NEB NEB TID:PRN wheezing
Levothyroxine Sodium 175 mcg PO DAILY
Losartan Potassium 25 mg PO DAILY
Omeprazole 20 mg PO DAILY
Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H:PRN wheezing
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
2. Cephalexin 500 mg PO Q6H Duration: 14 Days
3. Cyclobenzaprine 5 mg PO TID:PRN Muscle spasms
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth q8 PRN Disp #*40
Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL 40 mg Subcutaneously at bedtime Disp
#*30 Syringe Refills:*0
6. Gabapentin 300 mg PO BID
RX *gabapentin 300 mg 1 capsule(s) by mouth twice a day Disp
#*40 Capsule Refills:*0
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth q4 PRN Disp #*40
Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
10. Allopurinol ___ mg PO DAILY
11. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H:PRN
dry eyes
12. Atorvastatin 40 mg PO QPM
13. Furosemide 80 mg PO DAILY
14. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
15. Ipratropium-Albuterol Neb 1 NEB NEB TID:PRN wheezing
16. Levothyroxine Sodium 175 mcg PO DAILY
17. Losartan Potassium 25 mg PO DAILY
18. Omeprazole 20 mg PO DAILY
19. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H:PRN
wheezing
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right open ankle fracture
Discharge Condition:
AVSS
NAD, A&Ox3
RLE: Foot resting in short leg splint that is clean, dry, and
intact. Fires exposed toes, sensation intact light touch and
exposed toes, warm and well-perfused exposed
Foley catheter in place
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:
-Nonweightbearing right lower extremity in splint
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add gabapentin, Flexeril, and as a last resort 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
URINARY STATUS:
- Patient experienced difficulty voiding postoperatively. She
was straight cathed multiple times with failure to void post
straight cath. A foley was ultimately placed, with plans for a
void trial at rehab in ___ days.
Physical Therapy:
Nonweightbearing right lower extremity in splint
Treatments Frequency:
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.
- Unless you are in a splint, incision may be left open to air
unless actively draining. If draining, you may apply a gauze
dressing secured with paper tape.
- If splinted, splint must be left on until follow up
appointment unless otherwise instructed. Do NOT get splint wet.
Followup Instructions:
___
|
10427288-DS-22 | 10,427,288 | 21,258,955 | DS | 22 | 2179-11-13 00:00:00 | 2179-11-13 21:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine
Attending: ___
Chief Complaint:
Right ankle pain c/f hardware failure
Major Surgical or Invasive Procedure:
___: Excisional Debridement of Compromised Tissue, Sinus,
Removal of Hardware Both Lateral and Medial from Tibia and
Fibula, Placement of Antibiotic PMMA Spacer, Closure with
Superficial Vacuum Sponge System
___: Right PICC line placement
___: Staged Right Foot Debridement and Irrigation, Removal of
Antibiotic Spacer
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
===========================
___ y/o female with PMH of DM on insulin, HFpEF (EF 55%), COPD,
CAD s/p CABG x3, and CKD (bl Cr 1.2-1.6) with recent open R
ankle bimall fracture s/p I&D and ORIF on ___ with Dr.
___ presents as a transfer from ___ for
worsening ankle pain and hardware malfunction and non-healing
fracture on x-ray.
Patient had been doing well following operation in ___ but
noticed that over the past month, she has not been able to bear
weight on the RLE with worsening of pain for the past 2 weeks.
No recent falls or trauma. Uses walker at baseline for
ambulation though has been unable to bear weight now. She has
been evaluated by wound care nurses who noted development of
ulcers on the dorsum of the right foot as well as the posterior
aspect of the right calf with surrounding erythema on the ankle.
Reportedly, a line was drawn around the erythematous region
though there has
been expansion of erythema from these markings. She denies
fever/chills, night sweats, vomiting, abdominal pain, diarrhea
or dysuria. She has had ongoing fibromyalgia pain with
significant discomfort to light palpation of bilateral ___.
Patient presented to the ED in ___ with x-ray results as
below, concerning for hardware malfunction as well as
non-healing fracture. She was transferred to ___ for
orthopedic evaluation. Ortho was consulted in the ED though
deferred urgent surgical intervention given concern for
overlying cellulitis with planned admission to medicine for
optimization.
Past Medical History:
IDDM II
HFpEF (EF 55%)
COPD/asthma
CAD s/p CABG
HLD
Tobacco use disorder
CKD
Gout
Fibromyalgia
Arthritis
Hypothyroidism
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
T 98.4 BP 165/84 HR 95 RR 18 Sat 92% RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. MMM.
CARDIAC: Regular rhythm, normal rate. No murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES/SKIN: Significant tenderness with mild palpation of
bilateral legs (chronic) with non-pitting edema down to the feet
(exam limited by pain), RLE with significant pain with movement
of the ankle, Erythema on the anterior and lateral aspect of the
ankle with extension beyond prior marking and warmth, ~1cm open
wound with packing on the dorsum of the right foot with mild
surrounding erythema, posterior leg wound is covered and c/d/I,
feet warm with normal cap refill and sensation
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. Normal sensation.
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 558)
Temp: 98.1 (Tm 98.3), BP: 127/72 (119-161/59-72), HR: 78
(78-84), RR: 18 (___), O2 sat: 93% (90-93), O2 delivery: 1L
(1L-2L), Wt: 278.22 lb/126.2 kg
GENERAL: laying in bed, sleepy, NAD
HEENT: PERRL, EOMI. MMM. JVP unable to be assessed due to body
habitus
CARDIAC: RRR, S1 + S2 present, no mrg
LUNGS: Upper lung fields clear to auscultation, diffuse crackles
in bilateral bases
ABDOMEN: Non-tender to palpation, non-distended
EXTREMITIES/SKIN: 2+ edema in legs bilaterally. R foot in
bivalve
cast
NEUROLOGIC: AOx3. CN2-12 grossly intact. Moving all 4 limbs
spontaneously. No tremors on outstretched hands.
Pertinent Results:
ADMISSION LABS:
===============
___ 08:45PM BLOOD WBC-8.9 RBC-3.13* Hgb-9.2* Hct-30.6*
MCV-98 MCH-29.4 MCHC-30.1* RDW-15.4 RDWSD-54.0* Plt ___
___ 08:45PM BLOOD ___ PTT-32.2 ___
___ 08:45PM BLOOD Glucose-202* UreaN-45* Creat-1.3* Na-133*
K-5.1 Cl-100 HCO3-24 AnGap-9*
___ 08:45PM BLOOD calTIBC-194* VitB12-956* Ferritn-250*
TRF-149*
INTERVAL LABS:
==============
___ 06:43PM BLOOD Ret Aut-2.7* Abs Ret-0.06
___ 06:43PM BLOOD ALT-<5 AST-13 LD(LDH)-177 AlkPhos-82
TotBili-<0.2
___ 05:22AM BLOOD proBNP-3618*
___ 08:45PM BLOOD hsCRP-186.2
___ 06:43PM BLOOD Hapto-213*
___ 04:52AM BLOOD calTIBC-196* Ferritn-168* TRF-151*
___ 08:45PM BLOOD calTIBC-194* VitB12-956* Ferritn-250*
TRF-149*
___ 05:13AM BLOOD TSH-17*
___ 05:13AM BLOOD Free T4-0.9*
___ 05:16AM BLOOD CRP-38.8*
___ 05:13AM BLOOD CRP-17.2*
___ 06:04AM BLOOD CRP-54.2*
DISCHARGE LABS:
===============
___ 05:16AM BLOOD WBC-5.8 RBC-2.88* Hgb-8.4* Hct-28.0*
MCV-97 MCH-29.2 MCHC-30.0* RDW-15.4 RDWSD-54.7* Plt ___
___ 05:16AM BLOOD ___ PTT-30.0 ___
___ 05:16AM BLOOD Glucose-211* UreaN-60* Creat-1.5* Na-138
K-5.4 Cl-97 HCO3-30 AnGap-11
___ 05:16AM BLOOD Calcium-9.7 Phos-4.1 Mg-2.2
___ 08:45PM BLOOD hsCRP-186.2
___ 10:57AM BLOOD Vanco-18.2
___ 05:16AM BLOOD CRP-38.8*
MICRO:
======
- ___ Foreign Body - Sonication Culture Sonication
culture, prosthetic joint-FINAL {CORYNEBACTERIUM SPECIES
(DIPHTHEROIDS)}; ANAEROBIC CULTURE-FINAL
- ___ TISSUE GRAM STAIN-FINAL; TISSUE-PRELIMINARY
{CORYNEBACTERIUM SPECIES (DIPHTHEROIDS)}; ANAEROBIC
CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY; POTASSIUM
HYDROXIDE PREPARATION-FINAL
- ___ TISSUE GRAM STAIN-FINAL; TISSUE-FINAL
{CORYNEBACTERIUM SPECIES (DIPHTHEROIDS), ESCHERICHIA COLI};
ANAEROBIC CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY; POTASSIUM
HYDROXIDE PREPARATION-FINAL INPATIENT
- ___ TISSUE GRAM STAIN-FINAL; TISSUE-FINAL; ANAEROBIC
CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY; POTASSIUM
HYDROXIDE PREPARATION-FINAL
- ___ SWAB GRAM STAIN-FINAL; WOUND
CULTURE-FINAL {STAPHYLOCOCCUS CAPITIS, CORYNEBACTERIUM SPECIES
(DIPHTHEROIDS)}; ANAEROBIC CULTURE-FINAL INPATIENT
IMAGING:
========
CHEST X-RAY (___)
FINDINGS: AP upright and lateral views of the chest provided.
Midline sternotomy wires and mediastinal clips are again noted.
There is no focal consolidation concerning for pneumonia. There
is possible mild pulmonary vascular congestion. No frank edema.
No large effusion or pneumothorax. Linear densities in the
left midlung may represent atelectasis. The overall
cardiomediastinal silhouette is stable. Bony structures are
intact. IMPRESSION: Suspect mild pulmonary vascular congestion.
CHEST PORT. LINE PLACEMENT (___)
IMPRESSION: Comparison to ___. The patient has
received the new right PICC line. The course of the line is
unremarkable, the tip of the line projects over the cavoatrial
junction. No complications, notably no pneumothorax. Lung
volumes are low. The presence of small bilateral pleural
effusions is likely. No pulmonary edema. Stable moderate
cardiomegaly.
UNILATERAL RIGHT UPPER EXTREMITY VEINS ___
FINDINGS: There is normal flow with respiratory variation in the
right subclavian veins. The right internal jugular, axillary,
and brachial veins are patent, show normal color flow, spectral
doppler, and compressibility. The right basilic, and cephalic
veins are patent, compressible and show normal color flow.
There is an intravenous seen in the right brachiocephalic vein
with flow around it. IMPRESSION: No evidence of deep vein
thrombosis in the right upper extremity.
CHEST X-RAY (___)
IMPRESSION: In comparison with the study of ___, there is
continued enlargement of the cardiac silhouette with stable
elevation in pulmonary venous pressure. Bilateral pleural
effusions with basilar atelectasis, more prominent on the left.
No evidence of acute focal consolidation.
CHEST X-RAY (___)
FINDINGS: Redemonstration of a right-sided PICC, which
terminates at the cavoatrial junction. Redemonstration of
several sternotomy wires. Low lung volumes with crowding of the
bronchovascular markings. No focal consolidations or pulmonary
edema. No large pleural effusions or pneumothorax. Dense left
basilar atelectasis-unchanged. Cardiomediastinal silhouette is
unchanged and the cardiac silhouette remains enlarged.
IMPRESSION: No pulmonary edema. Overall unchanged appearance of
the cardiopulmonary structures compared to most recent chest
radiographs. Unchanged cardiomegaly.
CHEST X-RAY (___)
IMPRESSION: In comparison with study of ___, there again are
low lung volumes with little change in the appearance of the
cardiomediastinal silhouette. There is increased engorgement of
ill defined pulmonary vessels consistent with increasing
pulmonary venous pressure. Poor definition of the left
hemidiaphragm suggests small pleural effusion and atelectatic
changes at the left base.
Brief Hospital Course:
___ with hx of open R ankle fx s/p R ankle I&D/ORIF in ___,
T2D, HFpEF, and CAD s/p CABG transfer from ___ with R leg
cellulitis and hardware malpositioning/infection, now s/p R
ankle hardware removal and placement of antibiotic spacer
(___), repeat surgery for removal of antibiotic spacer (___),
continues to be on IV antibiotics (CTX/Vanc), course c/b acute
decompensated heart failure, s/p Lasix gtt, c/b ___, now stable.
ACUTE/ACTIVE ISSUES:
====================
# RIGHT LOWER EXTREMITY HARDWARE INFECTION: Right calf ulcer and
right shin surgical site was likely source of infection. Wound
swab (___) grew corynebacterium, E.coli, and Staph
Capitus. S/p hardware removal and antibiotic spacer placement
(___) and removal (___). Cultures grew corynebacterium, E.
coli, and Staph capitus. PICC line placed ___. On antibiotics
vancomycin 1g Q48H and ceftriaxone 2g IV QD until ___ for full 6
week course. Required daily wound dressing changes. Wound was
clean/dry/intact on discharge. CRP ___ was 38.
# RIGHT ANKLE FRACTURE S/P ORIF: S/p hardware removal ___ with
antibiotic spacer placement. Antibiotic spacer removal on ___.
Bivalve cast in place, will f/u with foot/ankle specialist and
rehab before operative fusion or revision.
# ACUTE HFPEF EXACERBATION: Patient developed volume overload,
likely secondary to receiving 2L IVF intra-op on ___ and having
Lasix held. No other acute causes for decompensation identified.
TSH was elevated, but free T4 only mildly low. Initially
diuresed with IV Lasix, transitioned to Lasix drip 15 mg/hr
___. CXR from ___ showed resolution of pulmonary edema
that was seen on CXR from ___. Lasix drip stopped on ___ given
increasing Cr discussed below and appeared to be at dry weight
(274 lbs). TTE (___) showed no interval worsening of cardiac
function (EF 55%). Although patient remained volume up on exam
with diffuse bibasilar crackles and 2+ lower extremity
bilaterally, given that bedweight of 270 lbs was similar to dry
weight and given presumed pre-renal ___ discussed below, ___
80 mg QD and losartan 50 mg PO QD were held on discharge.
# ___ ON CKD: Cr rose to to peak of 1.8 from baseline of 1.2-1.5
in setting of diuresis with Lasix gtt discussed above. Cr
downtrended to 1.5 on discharge. Lasix was held on discharge
with plan to restart within short time frame pending stable Cr.
# HYPOXIA: Persistent ___ O2 requirement likely multifactorial
in setting of resolving pulmonary edema/atelectasis given,
underlying COPD. Additionally given transient desaturations
during sleep that improve upon awakening, likely component of
obesity hypoventilation syndrome given body habitus.
# COSTOCHONDRITIS: Patient had numerous episodes of atypical
chest pain and tenderness on palpation of chest wall, suggesting
costochondritis. Numerous EKG were obtained, all were
unremarkable. Lidocaine patch was used to good effect.
# RIGHT ARM SWELLING/TINGLING: Patient had persistent tingling
in right hand without neurologic deficits on exam. She was
thought to have spinal stenosis given intermittent neck pain.
Reassuringly right upper extremity ultrasound was normal without
DVT. Gabapentin was reduced in setting of ___, and was
discharged on gabapentin 200 mg BID only.
# NORMOCYTIC FE DEFICIENCY ANEMIA: Patient had baseline
hemoglobin of ___. Transferrin saturation of 14%, consistent
with iron deficiency anemia. She is s/p 4 units of pRBC ___
x1, ___ x1, ___ x2). Hemolysis labs were normal. Iron
supplementation was held in setting of active infection.
# DVT: Per family, patient developed DVT at ___
during hospitalization in ___. Patient does not prefer
surgery. She was continued on apixaban 5 mg BID.
CHRONIC/STABLE ISSUES:
======================
# TREMORS: Tremors on ___, right worse than left. Resolved on
its own. Likely due to deconditioning after prolonged hospital
stay. Neurologic exam is at baseline without focal deficits.
# IDDM: Lantus uptitrated to 25U qHS from 15U and with insulin
sliding scale. Held home Victoza.
# HYPOTHYROIDISM: Continued home levothyroxine 200 mcg.
Increased to 225 mcg QD on ___ given TSH of 17 and FT4 of 0.9.
Patient has been taking levothyroxine correctly (every morning
on empty stomach >1h prior to breakfast, with no concurrent
intake of calcium or iron products).
# GERD: Continued home omeprazole 20 mg PO QD.
# CAD: Continued home aspirin 81 mg QD, rosuvastatin 20 mg QPM.
# GOUT: Continued home allopurinol ___ mg QD.
# COPD: Continued nebulizers Q6h PRN.
# CONSTIPATION: Requiring regular enema and suppository. Managed
with senna, bisacodyl, and miralax PRN.
TRANSITIONAL ISSUES
===================
[ ] Please recheck Cr on ___, if Cr is stable or downtrending,
please restart Lasix at reduced dose of 40 mg PO and increase to
80 mg if weight gain ___ lbs/day
[ ] Please continue vancomycin and ceftriaxone until ___
[ ] Please follow up weekly OPAT labs (next due ___
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
WEEKLY: CBC with differential, BUN, Cr, AST, ALT, Total Bili,
ALK PHOS, Vancomycin trough, CRP
[ ] Please recheck TSH in ___ weeks, as levothyroxine was
increased from 200 to 225 mg on ___
[ ] Please follow up patient's anemia with outpatient iron
studies. Please resume PO iron supplementation when infection
has resolved
[ ] Please confirm course of apixaban for DVT (diagnosed
___ per PCP recommendations and ensure discontinuing
apixaban when course is completed
[ ] Please refer patient for outpatient sleep study for OSA
evaluation
[ ] Please have goals of care conversation and confirm code
status
[ ] Please consider starting a beta-blocker for patient's heart
failure as she is not on any neurohormonal blockade
[ ] Please reevaluate her pain and if needed may add back on
gabapentin 400 mg QHS if patient is non-somnolent as renal
function permits
[ ] Continue recheck hemoglobin at follow up appointments given
transfusion requirements while inpatient
[ ] F/u pending wound culture data
DIURETIC ON DISCHARGE: NONE (HELD ISO ___
DRY WEIGHT ON DISCHARGE: 278 lbS
CREATININE ON DISCHARGE: 1.5
# CODE: Full presumed
# CONTACT: ___ ___
Ms. ___ was seen and examined on ___ with exam reflected
in this discharge summary. She is medically ready for discharge.
time spent on discharge > 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
2. Allopurinol ___ mg PO DAILY
3. amLODIPine 5 mg PO DAILY
4. Apixaban 5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Gabapentin 200 mg PO BID
8. Gabapentin 400 mg PO QHS
9. Glargine 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. Levothyroxine Sodium 200 mcg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. risedronate 35 mg oral 1X/WEEK
13. Senna 8.6 mg PO BID
14. Losartan Potassium 50 mg PO DAILY
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN CP
16. Victoza 3-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous DAILY
17. salmeterol 50 mcg/dose inhalation Q12H
18. Furosemide 80 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth q8hrs Disp #*90 Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
RX *bisacodyl [Laxative (bisacodyl)] 5 mg 2 tablet(s) by mouth
once a day Disp #*60 Tablet Refills:*0
3. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g IV q24hrs
Disp #*33 Intravenous Bag Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Multivitamins 1 TAB PO DAILY
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by
mouth once a day Refills:*0
7. Rosuvastatin Calcium 20 mg PO QPM
RX *rosuvastatin 20 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet
Refills:*0
8. Vancomycin 1000 mg IV Q48H
RX *vancomycin 1 gram 1000 mg IV q48hrs Disp #*17 Vial
Refills:*0
9. Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. Levothyroxine Sodium 225 mcg PO DAILY
11. Senna 17.2 mg PO HS
12. TraMADol 25 mg PO BID:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
13. Allopurinol ___ mg PO DAILY
14. amLODIPine 5 mg PO DAILY
15. Apixaban 5 mg PO BID
16. Aspirin 81 mg PO DAILY
17. Docusate Sodium 100 mg PO BID
18. Gabapentin 200 mg PO BID
19. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN CP
20. Omeprazole 20 mg PO DAILY
21. risedronate 35 mg oral 1X/WEEK
22. salmeterol 50 mcg/dose inhalation Q12H
23. HELD- Furosemide 80 mg PO DAILY This medication was held.
Do not restart Furosemide until discuss with PCP
24. HELD- Gabapentin 400 mg PO QHS This medication was held. Do
not restart Gabapentin until discuss with PCP
25. HELD- Gabapentin 400 mg PO QHS This medication was held. Do
not restart Gabapentin until discuss with PCP
26. HELD- Gabapentin 400 mg PO QHS This medication was held. Do
not restart Gabapentin until discuss with PCP
27. HELD- Losartan Potassium 50 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until discuss with PCP
28.Outpatient Lab Work
ICD: L03.90
DATE: ___
Weekly CBC with differential, BUN, Cr, AST, ALT, Total Bili, ALK
PHOS, Vancomycin trough, CRP
ATTN: ___ CLINIC - FAX: ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Right lower extremity joint infection
Secondary Diagnosis:
Acute Heart Failure with preserved ejection fraction
exacerbation
Iron Deficiency Anemia
Thrombocytosis
Insulin Dependent Type 2 DM
Chronic Kidney Disease
Gastroesophageal Reflux Disease
Deep Venous Thrombosis
Hypothyroidism
Coronary Artery Disease
Gout
Chronic Obstructive Pulmonary Disorder
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 WAS I IN THE HOSPITAL?
You were in the hospital because you had an infection in your
right foot. You also had extra fluid in your lungs.
WHAT WAS DONE WHILE I WAS HERE?
You had surgery to remove the infected hardware in your right
foot. We also gave you antibiotic medications through your IV to
help with the infection. Lastly, we gave you IV medications,
furosemide (Lasix), to help remove excess fluid from your body.
WHAT SHOULD I DO WHEN I GO TO REHAB?
-You should avoid placing any weight on your right foot unless
instructed to do so.
-You should take your medications as instructed. You should go
to your doctors ___ as below.
-Weigh yourself every morning, call your doctor if your weight
goes up or down more than 5 lbs in two days or more than 5 lbs
in one week.
-Try to limit your salt intake
We wish you the best!
-Your ___ Care Team
Followup Instructions:
___
|
10427443-DS-6 | 10,427,443 | 26,245,059 | DS | 6 | 2116-05-04 00:00:00 | 2116-05-06 15:51:00 |
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:
s/p cardiac catheterization with DES to the LAD ___
s/p ICD placement on ___
History of Present Illness:
Mr. ___ is a ___ with PMH of HTN, poorly controlled diabetes
who was admitted to CCU for management of LAD STEMI. Patient
reports episodes of severe chest pain associated with shortness
of breath, palpitations, diaphoresis and nausea about three
weeks ago. He went to ___ at that time and was
treated with Levaquin for pneumonia. He reports not being able
to sleep for 3 nights due to chest pain and shortness of breath.
His symptoms then improved however he was still not back to his
baseline. He overall felt more tired and fatigue. Then last
night he had recurrence of his chest chest tightness of ___
associated with tachycardia and shortness of breath. He then
presented to ___ this morning and was found to have
wide-complex tachycardia and HR in the 190s. He was then given 2
doses of adenosine and 1 dose of amiodarone with no relief of
symptoms. He was then cardioverted successfuly with 200J then
360J. Repeat EKG showed sinus rhythm with ST Elevations of 2mm
in V2, 0.5mm in V1 and 1mm in V3. He was then asymptomatic with
no chest pain or shortness of breath. He was given aspirin and
started on Heparin gtt. He was then transferred to ___ for
further evaluation and management.
He was taken directly to cath lab for concern of STEMI. In the
cath lab, he was found to have complete occlusion of mid LAD
which was stented with DES through right radial access. He was
started on Tirofiban and was 600mg plavix loaded. Subsequently
admitted to the CCU for further monitoring.
Currently patient reports shortness of breath and chest pain has
resolved. He reports episodes of shortness of breath, orthopnea
and PND in the past three weeks.
Past Medical History:
Hypertension
Diabetes Mellitus
Retinitis Pigmentosa
Social History:
___
Family History:
Father had a 6way heart bypass at age ___
Mother passed away of stroke at age ___
Physical Exam:
ADMISSION EXAM:
VS: T=98.1 BP=130/87 (SBP=130-153/DBP=86-106) HR=109-114
___ O2sat= 96-99% on 4L
Gen: Well appearing gentleman not in acute distress
HEENT: PER, No cervical lymphadenopathy
NECK: JVP at around 14
CV: RRR, II/VI systolic murmur at apex
LUNGS: Mild bilateral basal crackles
ABD: Normal bowel sounds, soft, no tenderness
EXT: 2+ Bilateral lower extremity edema
PULSES: Full and equal
SKIN: Warm and moist
NEURO: Oriented
DISCHARGE EXAM:
VS: Tmax/Tcurrent: Afebrile, 120-138/78-101, HR 86-92sinus, 97%
RA. I/O: 24h: 600/375 8h: 440/525 +++
Weight: 134kg (136.3kg)
Gen: Well-appearing gentleman sitting up in bed, speaking
comfortably in full sentences, not in acute distress.
HEENT: No cervical lymphadenopathy
NECK: Cannot appreciate JVD.
CV: RRR, II/VI systolic murmur at apex
LUNGS: CTAB
ABD: Normal bowel sounds, soft, no tenderness
EXT: trace lower extremity edema. right wrist with normal CSM.
PULSES: Full and equal
SKIN: Warm and moist. Left chest wall with patent gauze/tegaderm
dssing. No bleeding/hematoma. Normal CSM to left arm
NEURO: Oriented
Pertinent Results:
ADMISSION LABS:
=================
___ 07:30AM BLOOD WBC-11.8* RBC-5.46 Hgb-15.5 Hct-46.4
MCV-85 MCH-28.4 MCHC-33.4 RDW-13.8 Plt ___
___ 07:30AM BLOOD Neuts-68.2 ___ Monos-5.3 Eos-1.6
Baso-0.4
___ 07:30AM BLOOD ___ PTT-83.8* ___
___ 07:30AM BLOOD Glucose-433* UreaN-14 Creat-0.9 Na-136
K-4.8 Cl-99 HCO3-21* AnGap-21*
___ 03:37AM BLOOD ALT-27 AST-18 LD(LDH)-261* AlkPhos-90
TotBili-0.6
___ 07:30AM BLOOD cTropnT-0.23*
___ 07:30AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.8
PERTINENT LABS:
=================
___ 05:27PM BLOOD cTropnT-0.30*
___ 03:37AM BLOOD cTropnT-0.32*
___ 07:30AM BLOOD %HbA1c-12.6* eAG-315*
___ 05:27PM BLOOD Triglyc-165* HDL-43 CHOL/HD-5.2
LDLcalc-148*
___ 05:27PM BLOOD TSH-1.9
DISCHARGE LABS:
=================
___ 05:00AM BLOOD WBC-9.6 RBC-5.14 Hgb-14.9 Hct-43.0 MCV-84
MCH-29.0 MCHC-34.7 RDW-14.1 Plt ___
___ 05:00AM BLOOD ___ PTT-41.5* ___
___ 05:00AM BLOOD Glucose-184* UreaN-13 Creat-0.9 Na-137
K-4.1 Cl-100 HCO3-28 AnGap-13
___ 05:00AM BLOOD Calcium-8.7 Phos-4.1 Mg-1.9
MICROBIOLOGY:
=================
___ 10:23 am MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Final ___: No MRSA isolated.
STUDIES:
=================
ECGStudy Date of ___ 12:00:42 ___
Sinus tachycardia. Leftward axis. Inferior wall myocardial
infarction of indeterminate age. Anterior wall myocardial
infarction of indeterminate age with ST segment elevation in the
mid-precordial leads consistent with ST elevation myocardial
infarction. Low voltage in the limb leads. Clinical correlation
for ST elevation myocardial infarction is suggested. No previous
tracing available for comparison.
IntervalsAxes
___
___
CARDIAC CATH (___):
- Dominance: Right
- LMCA: normal
- LAD: totally occluded after D1
- LCX: normal
- RCA: normal
- Using an XBLAD 3.5 guide, the LAD occlusion was crossed with a
Pilot 50 wire and dilated with a 2.5 balloon restoring flow.
This was then stented with a 2.75 x 22 Resolute ___
postdilated to 3.0 mm with no residual and restoration of near
normal flow. The mid and distal LAD had diffuse disease to 60%.
Time to intervention was delayed due to initial ventricular
tachycardia and transfer from ___.
RECOMMENDATIONS:
- Monitor in CCU
- Follow enzymes. Cardiac ECHO.
- Continue aspirin indefinitely, clopidogrel minimum ___ year.
ECG Study Date of ___ 7:38:44 AM
Sinus tachycardia. Probable inferior wall myocardial infarction
of
indeterminate age. Loss of R waves in the anterolateral leads
suggests
extensive myocardial infarction of indeterminate age. Low QRS
voltages in the limb leads. Modest diffuse ST-T wave changes.
TRACING #1
Intervals Axes
Rate PR QRS QT/QTc P QRS T
112 166 74 332/423 35 -13 145
Portable TTE (Complete) Done ___ at 4:02:31 ___ FINAL
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Overall left
ventricular systolic function is moderately depressed (Biplane
LVEF= 30%) secondary to akinesis of the apex, septum, and distal
anterior and inferior walls. A large (2.7 x 2.3 cm) apical
thrombus is seen in the left ventricle. Two smaller thrombi are
also appreciated along the distal inferior wall. The ascending
aorta is mildly dilated. The aortic arch is mildly dilated. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
moderate-severe regional and global systolic dysfunction c/w
CAD. Multiple LV thrombi as described above. Restrictive LV
filling. No significant valvular disease.
ECG Study Date of ___ 7:46:30 AM
Sinus tachycardia. Compared to tracing #1 multiple described
abnormalities persist. TRACING #2
Intervals Axes
Rate PR QRS QT/QTc P QRS T
111 162 76 336/425 37 -10 147
ECG Study Date of ___ 9:26:30 AM
Sinus tachycardia. Compared to tracing ___
segment appears to be elevated with more biphasic T waves
suggestive of acute myocardial injury pattern. Compared to
tracing ___ segment elevation appears more
pronounced. Clinical correlation is suggested. TRACING #3
Intervals Axes
Rate PR QRS QT/QTc P QRS T
110 174 80 340/427 57 -9 141
CHEST (PORTABLE AP) Study Date of ___ 9:47 ___
IMPRESSION:
The lung volumes are low. Minimal blunting of the left
costophrenic sinus
could be caused by a minimal pleural effusion. The retrocardiac
atelectasis is visualized. Mild pulmonary edema is present. No
evidence of pneumonia. No pneumothorax. Borderline size of the
cardiac silhouette.
ECG Study Date of ___ 4:04:56 ___
Sinus tachycardia. Inferior myocardial infarction of
indeteminate age.
Anterior wall myocardial infarction which could be recent/acute.
Low
QRS voltage in the limb leads. Compared to the previous tracing
of ___ no significant change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
113 160 86 330/422 31 -24 135
ECG Study Date of ___ 8:49:52 AM
Sinus rhythmm. Left atrial abnormality. Prior inferior
myocardial infarction and prior anteroseptal and lateral
myocardial infarction with continued ST segment elevation which
is upward coved in leads V1-V6 consistent with ongoing or recent
anteroseptal, lateral and apical myocardial infarction. Followup
and clinical correlation are suggested. Compared to the previous
tracing of ___ no diagnostic interim change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
96 158 82 370/433 23 -9 161
CHEST (PA & LAT) Study Date of ___ 9:38 AM
IMPRESSION:
Small left pleural effusion and moderate left lower lobe
atelectasis are
probably unchanged since ___. There is no pneumothorax.
Transvenous right atrial pacer and right ventricular pacer
defibrillator leads follow their expected courses from the left
pectoral generator. Heart is normal size. There is no
mediastinal widening. Right lung is clear.
Brief Hospital Course:
___ with PMH of HTN, poorly controlled diabetes who was admitted
to CCU for management of LAD STEMI s/p DES. Now s/p ICD for VT
and newly-dx LV thrombi being managed with Coumadin.
#) ACUTE CORONARY SYNDROME: Patient most likely had the LAD
STEMI about three weeks ago as evidenced by his q waves. He had
complete occlusion of his LAD s/p ___ on ___. Was
subsequently treated with tirofiban for 8 hours, and was started
on Aspirin 81mg daily, Clopidogrel 75mg daily (after being
loaded with 600 mg initially), and Atorvastatin 80mg Daily. Also
treated with heparin gtt for multiple LV thrombi seen on ECHO
(as below). Dose of lisinopril increased from 10 mg to 40 mg
daily. Was started on metoprolol succinate 100mg po qam and 50mg
po qpm.
#) APICAL THROMBUS: multiple LV thrombi seen on ___ ECHO - a
large (2.7 x 2.3 cm) apical thrombus, as well as two smaller
thrombi along the distal inferior wall. Heparin gtt started
___. Started on coumadin, which was titrated to 4 mg qd on
discharge. INR on ___ was 3.5. Patient will f/u with Dr. ___
___ for INR management. Will need repeat ECHO in 3 months to
reassess LV thrombi.
#) SYSTOLIC HEART FAILURE, TTE ___ with EF 30%: Patient has
clinical symptoms of heart failure with shortness of breath,
orthopnea and PND for the past three weeks. Patient initially
diuresed with 20 mg IV lasix, and then transitioned to 40 mg PO
lasix daily. Managed with metoprolol and ACEI as above.
#) V TACH: initially presented to ___ on ___ with
ventricular tachycardia @ 205 bpm. VT likely in setting of
infarct. Was cardioverted to sinus rhythm, and transferred to
___ for further management. On ___, a ___
Energen dual-chamber ICD was successfully implanted for
secondary prevention of sudden cardiac death. Patient was
treated with 1 dose of vancomycin, followed by 3 days of
cephalexin. Will f/u with EP and device clinic.
#) DIABETES: Uncontrolled; HbA1c now 12.6. ___ consulted.
Patient treated with lantus + HISS while in-house. Patient will
be discharged with ___ f/u, on Lantus + Humalog ISS, while
continuing metformin.
#)HYPERTENSION: increased dose of lisinopril and started on
metoprolol as above.
TRANSITIONAL ISSUES:
# CODE: Full
# CONTACT: ___ (___)
- ICD placed; will f/u with EP and device clinic
- Started on warfarin for anticoagulation given LV thrombus;
will f/u with Dr. ___ for INR management.
- Will need repeat ECHO in 3 months to reassess LV thrombi.
- Started on Aspirin 81mg daily, Clopidogrel 75mg daily,
Atorvastatin 80mg Daily, Metoprolol succinate 100mg po qam and
50mg po qpm.
- Started on Furosemide 40 mg PO DAILY for ___
- Started on lantus + humalog SSI, in addition to metformin -
for better control of DM
- Dose of lisinopril increased from 10 mg to 40 mg daily
- Needs to complete 3 more doses of cephalexin s/p ICD placement
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
3. Clopidogrel 75 mg PO DAILY
DO NOT STOP unless TOLD TO BY ___
___ *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*11
4. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
5. Glargine 20 Units Breakfast
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 20 Units before
BKFT; Disp #*2 Vial Refills:*1
RX *insulin lispro [Humalog] 100 unit/mL AS DIR Up to 12 Units
QID per sliding scale Disp #*1 Vial Refills:*0
RX *insulin syringe-needle U-100 [BD Insulin Syringe Ultra-Fine]
31 gauge x ___ for insulin injections up to five times a day 5
x daily Disp #*150 Syringe Refills:*1
6. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
7. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily in am
Disp #*30 Tablet Refills:*3
8. Metoprolol Succinate XL 50 mg PO QPM
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily in pm
Disp #*30 Tablet Refills:*3
9. Cephalexin 500 mg PO Q8H Duration: 3 Doses
RX *cephalexin 500 mg 1 capsule(s) by mouth three times a day
Disp #*3 Capsule Refills:*0
10. Outpatient Lab Work
420.0
INR draw ___
RESULTS sent to: Dr. ___: ___ Fax: ___
11. Outpatient Lab Work
420.0
INR/ Chem 7 draw ___
RESULTS sent to: Dr. ___: ___ Fax: ___
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Warfarin 4 mg PO DAILY16
Dr. ___ will call you to tell you what to take after you have
your INR drawn
Discharge Disposition:
Home
Discharge Diagnosis:
ventricular tachycardia
acute coronary syndrome s/p DES to the LAD
poorly controlled diabete Type II
systolic heart failure (EF 30%)
LV thrombus (on coumadin)
s/p ICD placement ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were transferred to ___ for treatment of your chest
pain and arrythmia. You EKG was concerning and upon arrival you
were taken to the cardiac cathterization lab where a blockage
was found in the left anterior descending artery. A ___ was
placed to open the blockage successfully. Following the cardiac
cathterization an ultrasound of the heart called an
echocardiogram was done which revealed a clot in the left
ventricle which puts you at risk for stroke. You were started on
anticoagulation called coumadin which we are monitoring its
effectiveness by drawing a lab called an INR. Dr. ___ will call
you to dose your coumadin appropriately based on these labs. You
will receive lab slips for the outpatient lab work.
Because you had a lethal arrythmia called ventricular
tachycardia you needed an ICD, defibrillator which was placed in
the chest and will activate if you go into another lethal
arrythmia while at home. You have a follow up in the device
clinic to assess the site and the settings.
You now have a history of heart failure and need to weigh
yourself every day. If your weight goes up more than 3 pounds in
1 day or more than 5 pounds in 2 days please call Dr. ___. Your
weight on day of discharge is 295 pounds.
You have been started on insulin for your blood sugars which was
not well controlled on pills alone and have been given injection
teaching and wil have a follow up with ___ for care in the
next week.
You have been given an updated list of the medications you are
taking on discharge.
Activity restrictions per nursing.
It was a pleasure taking care of you this hospitalization. If
you have any queations related to your stay please feel free to
contact the heartline.
Followup Instructions:
___
|
10427568-DS-12 | 10,427,568 | 25,519,272 | DS | 12 | 2190-05-19 00:00:00 | 2190-05-19 13:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Seroquel / Klonopin / Codeine / Prozac / Lipitor
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
From admitting H&P:
___ with a PMH of HTN, HLD, DM, moderate CAD p/w chest pain.
Pt states that CP started at 11 ___. Pt describes CP as ___,
pressure-like, occurring at rest, radiating to left arm,
non-pleuritic. No alleviating/worsening factors. Lasted ___
hours. Associated with nausea without vomiting. Denies
diaphoresis. Resolved spontaneously. Denies associated SOB,
hemoptysis, leg swelling, recent travels/surgeries.
Pt was discharged from ___ unit 1.5
weeks ago for severe depression after the death of his brother.
Since then he has been living in a shelter. Recently had
flu-like symptoms and reports several people at the shelter were
sick. Did not get his flu shot this year.
Pt had a cardiac catheterization in ___ at ___ which
demonstrated 40% RCA stenosis.
Pt had EKG stress ___ that showed no ischemic changes (Duke 9).
In the ED, initial vitals: ___ pain 97.9 41 156/79 16 96% RA
Labs notable for:
1) BMP: Na 136, K 4.6, Cl 102, HCO3 24, BUN 12, Cr 0.8, glucose
486
2) CBC: WBC 7.5, Hb 13.2, plt 207
3) Troponin <0.01
4) UA: +glucose, no ketones
Imaging notable for:
1) EKG: SR, TE/Biphasic T waves/dynamic T wave changes in
anterior leads
2) CXR: No acute abnormality
Pt given:
___ 01:36 Aspirin 324 mg
___ 02:12 LR ( 1000 mL ordered)
Upon arrival to the floor, the patient reports no chest pain."
Past Medical History:
T2DM
CAD
NSTEMI
Hypertension
Social History:
___
Family History:
Mother - CHF, angina, cardiac arrest
Father - heart attack in ___
Physical Exam:
On day of discharge:
Vitals: Temp: 98.1 (Tm 98.9), BP: 154/76 (146-156/73-77), HR: 62
(62-69), RR: 18 (___), O2 sat: 98% (94-98), O2 delivery: RA,
Wt: 157.85 lb/71.6 kg
Weight on admission: 74kg
General: lying in bed, NAD
HEENT: NC/AT
Neck: trachea midline
CV: RRR, no m/r/g
Lungs: CTA in all lung fields
Abd: Nondistended
Neuro: moves all extremities appropriately
Psych: affect blunted, but more reactive than on prior exam
Pertinent Results:
On day of admission:
___ 11:50PM BLOOD WBC-7.5 RBC-4.61 Hgb-13.2* Hct-39.3*
MCV-85 MCH-28.6 MCHC-33.6 RDW-12.9 RDWSD-39.7 Plt ___
___ 11:50PM BLOOD Plt ___
___ 07:28AM BLOOD ___ PTT-29.2 ___
___ 11:50PM BLOOD Glucose-486* UreaN-12 Creat-0.8 Na-136
K-4.6 Cl-102 HCO3-24 AnGap-10
___ 11:50PM BLOOD cTropnT-<0.01
___ 07:28AM BLOOD cTropnT-<0.01
___ 11:50PM BLOOD TSH-11*
EKG ___: ST eleavations in V1-V3. Biphasic T waves in V2-V3
with dynamic T wave changes in anterior leads concerning for LAD
involvement
Brief Hospital Course:
___ with a PMH of HTN, HLD, DM, moderate CAD (cath in ___ with
40% stenosis of RCA) who presented with chest pain.
# Chest Pain: EKG on arrival demonstrated <___levations
and biphasic T waves in the anterior leads, highly concerning
for CAD involving the LAD. Troponins were negative x2. He was
treated with 48 hours of heparin gtt. Plan was for cardiac
catheterization, but patient refused this intervention without
explanation of this decision. Also declined stress testing,
labs, vital sign measurement, blood sugar assessment, and thus
adding on cardiac medications was deemed unsafe. Psychiatry was
consulted and felt that patient had demonstrated capacity to
refuse intervention despite high concern for cardiac ischemia.
He was discharged AGAINST MEDICAL ADVICE. Home aspirin and
ezetimibe were continued.
#Depression: Prior to admission to ___, the patient was
recently discharged from ___ for severe depression after
the death of brother. Psychiatry was consulted, as above. He
was continued on his home citalopram 40mg daily and divalproex
___ twice daily.
#Type 2 diabetes mellitus/Hyperglycemia: On arrival, the patient
was found to have a blood glucose of greater than 450. No AG, no
ketones in UA c/f DKA. A1C 11.1% (___). Pt reports his
medications were stolen at his shelter and hasn't taken
medications for 1 week. Insulin sliding scale was given in
house. Metformin, glipizide, and Januvia restarted on discharge.
Transitional Issues:
[] If patient amenable for workup of ischemic disease, he would
benefit from diagnostic catheterization.
[] Admission labs notable for TSH 11 and T4 4.3 (slightly below
normal). Repeat TSH while hospitalized was normal at 4.1.
Recommend repeat testing and possible initiation of
levothyroxine if indicated as outpatient.
[] Will need ongoing social support for homelessness and
depression.
[] Pt reported all his medications were stolen, so he was given
30 day scripts for all of his home meds, as documented in the
discharge summary
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Divalproex (DELayed Release) 500 mg PO BID
2. Citalopram 40 mg PO DAILY
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. GlipiZIDE 10 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Januvia (SITagliptin) 25 mg oral daily
7. Ezetimibe 10 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Citalopram 40 mg PO DAILY
RX *citalopram 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Divalproex (DELayed Release) 500 mg PO BID
RX *divalproex ___ mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Ezetimibe 10 mg PO DAILY
RX *ezetimibe 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. GlipiZIDE 10 mg PO BID
RX *glipizide 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Januvia (SITagliptin) 25 mg oral daily
RX *sitagliptin [Januvia] 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
7. MetFORMIN (Glucophage) 1000 mg PO BID
RX *metformin 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Unstable angina
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because of chest pain, which
was concerning for a heart attack.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You had an EKG in the emergency room that showed signs
suggestive of a heart damage, though blood tests were reassuring
against a heart attack.
- We recommended a procedure to look for and clear blockages
from the arteries of your heart, but you refused this procedure.
- You also did not want to have any further tests to look for
heart disease.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- It is very important to seek medical attention if you have new
or concerning symptoms or you develop thoughts of hurting
yourself or others, chest pain, swelling in your legs, abdominal
distention, or shortness of breath at night.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10427568-DS-8 | 10,427,568 | 24,893,415 | DS | 8 | 2184-08-29 00:00:00 | 2184-08-29 22:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Seroquel / Klonopin / Codeine / Prozac / Lipitor
Attending: ___.
Chief Complaint:
Fever and suicide ideations
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Date: ___
Time: ___
_
________________________________________________________________
PCP:
Dr ___ in ___.
_
________________________________________________________________
HPI:
___ with bipolar and depression presents for suicidal ideation.
Patient seen here last week for same thing and discharged.
Patient states tonight he has thoughts of suicidal ideation
states he cut himself with a knife. Patient states this is all
due to his son's death about a month ago. Patient does not have
any access to guns. Patient denies any recreational drug use,
EtOH abuse or cigarettes. Patient has no medical complaints.
Patient seen by ___ and he was cleared by them for d/c to a
day program.
He reports chills while eating dinner this pm. He does not
report cough/chest pain/sob. No sick contacts. He does not work
and is on disability. He lives alone.
In ER: (Triage Vitals:101.5 103 149/72 20 99% )
Meds Given:
Yest 23:27 Acetaminophen 500mg Tablet 2 ___.
Yest 23:46 GlipiZIDE 5 mg Tab 2 ___.
Yest ___ MetFORMIN (Glucophage) 500mg Tablet 2 ___.
Today 02:27 CeftriaXONE 1g Frozen Bag 1 ___.
Today 02:28 Azithromycin 500mg Vial 1 ___.
Today 02:53 Insulin Human Regular 100 Units / mL - 10 mL Vial 8
___.
Fluids given: 1 LNS
Radiology Studies: CXR
consults called: Psych
.
PAIN SCALE: ___ pain on skin for sunburn
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[ ] Fever [ +] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[ ] _____ lbs. weight loss/gain over _____ months
Eyes
[X] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT [X]WNL
[ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat
[] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [X] All Normal
[ ] Shortness of breath [ ] Dyspnea on exertion [ ] Can't
walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum
[ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [X] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ]
Chest Pain [ ] Dyspnea on exertion [ ] Other:
GI: [X] All Normal
[ ] Nausea [] Vomiting [] Abd pain [] Abdominal swelling [
] Diarrhea [ ] Constipation [ ] Hematemesis
[ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [X] All Normal
[ ] Dysuria [ ] Incontinence or retention [ ] Frequency
[ ] Hematuria []Discharge []Menorrhagia
SKIN: [] All Normal
[ ] Rash [ ] Pruritus [+] sunburn
PSYCH: [] All Normal
[ ] Mood change [+]Suicidal Ideation [ ] Other:
[X]all other systems negative except as noted above
Past Medical History:
DMII, Hyperlipidemia
BPAD with previous pysch admissions.
Last admitted to a medical unit in ___ at ___ for
chest pain during which cath showed blockages but no stents
placed.
Social History:
___
Family History:
- Per OMR: Mother, reported d/o bipolar disorder. Sister and
niece have depression.
Physical Exam:
PHYSICAL EXAM: I3 - PE >8
PAIN SCORE ___ skin pain from sunburn
1. VS 98.8 P 93 BP 118/64 RR 18 O2Sat on __98% on RA
GENERAL: Obese male laying in bed.
Nourishment: good
Grooming: good
Mentation: alert, speaking in full sentences
2. Eyes: [X] WNL
PERRL, EOMI without nystagmus, Conjunctiva:
clear/injection/exudates/icteric Ears/Nose/Mouth/Throat: MMM, no
lesions noted in OP
3. ENT [] WNL
[X] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____
cm
[] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [] WNL
[X] Regular [] Tachy [X] S1 [X] S2 [-] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[x] Edema RLE None
[x] Edema LLE None
2+ DPP pulses b/l
[] Vascular access [X] Peripheral [] Central site:
5. Respiratory [X ]
[X] CTA bilaterally [ ] Rales [ ] Diminshed
[] Comfortable [ ] Rhonchi [ ] Dullness
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [ X] WNL
[x] Soft, non-tender
[] Non distended [] distended [] bowel sounds Yes/No []
guiac: positive/negative
7. Musculoskeletal-Extremities [x] WNL
[ ] Tone WNL [X ]Upper extremity strength ___ and symmetrical
[ ]Other:
[ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica
[ ] Other:
[] Normal gait []No cyanosis [ ] No clubbing [] No joint
swelling
8. Neurological [X] WNL
[X ] Alert and Oriented x 3
+ resting tremor
9. Integument [X] WNL
[x] Warm [] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
[ ] Cool [] Moist [] Mottled [] Ulcer:
None/decubitus/sacral/heel: Right/Left
10. Psychiatric [] WNL
[X] Appropriate [] Flat affect [] Anxious [] Manic []
Intoxicated [] Pleasant [] Depressed [] Agitated [] Psychotic
[] Combative
Discharge:
Afebrile VSS
GEN: Non-toxic
RESP: Breathing comfortably. No WRR.
CV: RRR.
Pertinent Results:
___ 10:00PM URINE HOURS-RANDOM
___ 10:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 10:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 09:45PM GLUCOSE-448* UREA N-14 CREAT-0.7 SODIUM-134
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-22 ANION GAP-18
___ 09:45PM estGFR-Using this
___ 09:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:45PM WBC-14.0*# RBC-4.81 HGB-14.6 HCT-41.4 MCV-86
MCH-30.3 MCHC-35.2* RDW-13.1
___ 09:45PM NEUTS-74.9* LYMPHS-16.3* MONOS-7.3 EOS-1.0
BASOS-0.3
___ 09:45PM PLT COUNT-220
CXR:
IMPRESSION: Opacity within the right lower lobe is concerning
for pneumonia, given the clinical history.
Brief Hospital Course:
The patient is a ___ year old male with h/o BPAD, HTN, HLD, DM
who presents with CAP and suicide ideations. He is now denying
SI but does endorse depression.
----------
FEVER AND INFILTRATE ON XRAY: CAP
Pt was continued on Azithromycin and ceftriaxone on the floor.
Shortly after hospitalization, pt decided to leave the hospital
against medical advice. Pt was given a dose of levofloxacin and
was provided a prescription for a total 5 day course.
Levofloxacin was chosen to maximize probability of compliance.
.
HYPERGLYCEMIA:
- SSI
- DM diet
- home regimen.
.
BPAD and suicide ideations
- continued o/p meds
Pt was evaluated by Psychiatry and determined to have capacity
to leave against medical advice. Pt was recommended partial day
program, which patient declined. Pt was provided contact
information in discharge paperwork.
Discharged Against Medical Advice.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Divalproex (DELayed Release) 500 mg PO BID
2. Citalopram 40 mg PO DAILY
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. GlipiZIDE 10 mg PO BID
5. Ezetimibe 10 mg PO DAILY
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Citalopram 40 mg PO DAILY
3. Divalproex (DELayed Release) 500 mg PO BID
4. Ezetimibe 10 mg PO DAILY
5. GlipiZIDE 10 mg PO BID
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Levofloxacin 750 mg PO Q24H Duration: 4 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
# Probable community acquired pneumonia
# Chronic suicidal ideation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized with fever from suspected pneumonia. You
were treated with antibiotics, but you decided to leave the
hospital against medical advice. Your antibiotic was changed to
a more convenient antibiotic after discharge.
You were also evaluated by Psychiatry for complaints of suicidal
ideation. They recommended a partial day program, but you
declined.
Followup Instructions:
___
|
10427677-DS-2 | 10,427,677 | 23,641,430 | DS | 2 | 2114-07-21 00:00:00 | 2114-07-21 18:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers, salmonella typhi bacteremia
Major Surgical or Invasive Procedure:
___ line placement
History of Present Illness:
___ yo man, returned from ___ after a wedding celebration with
his family, with fevers, and found to have salmonella typhi
bacteremia. He went to ___ for 2 weeks, and returned on ___.
He was born in ___, and took no precautions and no
prophylaxis. 1 week after his return, on ___, he developed
high fevers, to 103, as well as chills. He had no abdominal
pain, no diarrhea, no palpitations, no dizziness, no rash. He
had headaches 2 days ago.
.
He saw his pcp ___ ___. Blood cultures were drawn and one was
positive for GNRs, and he was started on ciprofloxacin 500 mg po
bid on ___. Despite the initiation of treatment, he had no
improvement in his fever curve. He believes he might have lost
weight since his return, at least according to our scale.
.
He otherwise is well, with full review of 9 other systems and
negative.
Past Medical History:
Positive ppd, negative cxr, not treated
Social History:
___
Family History:
No family history of diabetes, hypertension, CAD as far as he
knows.
Physical Exam:
Exam
VS T current 100.3 BP 128/75 HR 87 RR 18 100 O2sat
.
Gen: In NAD. Diaphoretic.
HEENT: PERRL, EOMI. No scleral icterus. No conjunctival
injection. Mucous membranes moist. No oral ulcers.
Neck: Supple, no LAD, no JVP elevation.
Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal
respiratory effort.
CV: RRR, no murmurs, rubs, gallops.
Abdomen: soft, NT, ND, NABS, no splenomegaly appreciated.
Extremities: warm and well perfused, no cyanosis, clubbing,
edema.
Neurological: alert and oriented X 3, face symmetric. Moves all
extremities.
Skin: No rashes appreciated.
Psychiatric: Appropriate.
GU: deferred.
Pertinent Results:
.
Microbiology:
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-final
{GRAM NEGATIVE ROD(S)}; Aerobic Bottle Gram Stain-FINAL
EMERGENCY WARD
___ 1:15 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
Reported to and read back by ___. ___ ___ 10:12AM.
SALMONELLA SPECIES. FINAL SENSITIVITIES.
Presumptive identification pending confirmation by
___
Laboratory.
(This isolate is resistant to nalidixic acid;
therefore, it may
not be eradicated by fluoroqinolone treatment. Consider
Infectious
Disease consultation.).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SALMONELLA SPECIES
|
AMPICILLIN------------ <=2 S
CEFTRIAXONE----------- <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {GRAM NEGATIVE ROD(S)}; Aerobic Bottle Gram
Stain-FINAL
___ 07:38AM BLOOD WBC-6.0 RBC-4.41* Hgb-12.6* Hct-35.3*
MCV-80* MCH-28.6 MCHC-35.8* RDW-12.3 Plt ___
___ 06:45AM BLOOD WBC-6.6 RBC-4.71 Hgb-13.7* Hct-39.0*
MCV-83 MCH-29.1 MCHC-35.1* RDW-12.3 Plt ___
___ 06:15AM BLOOD WBC-7.5 RBC-4.85 Hgb-13.8* Hct-39.8*
MCV-82 MCH-28.5 MCHC-34.8 RDW-12.4 Plt ___
___ 01:00PM BLOOD WBC-8.5 RBC-4.72 Hgb-14.0 Hct-38.6*
MCV-82 MCH-29.8 MCHC-36.4* RDW-12.1 Plt ___
___ 01:00PM BLOOD Neuts-67.6 ___ Monos-6.3 Eos-0
Baso-0.8
___ 07:38AM BLOOD Creat-0.8
___ 06:15AM BLOOD Glucose-86 UreaN-6 Creat-0.9 Na-140 K-4.1
Cl-105 HCO3-27 AnGap-12
___ 01:00PM BLOOD Glucose-95 UreaN-9 Creat-0.9 Na-136 K-4.0
Cl-100 HCO3-27 AnGap-13
___ 07:38AM BLOOD ALT-118* AST-88*
___ 06:15AM BLOOD ALT-87* AST-63* LD(LDH)-368* AlkPhos-45
TotBili-0.4
___ 06:15AM BLOOD Hapto-31
___ 01:02PM BLOOD Lactate-1.3
___ 01:34PM BLOOD Hct-35.7*
Brief Hospital Course:
Pt is a ___ y.o male with h.o positive PPD, recent travel to
___, who presented with S.typhi bacteremia and continued fever
despite outpatient treatment with ciprofloxacin.
.
#S.typhi bacteremia/typhoid fever-Pt with recent travel to
___. Outpt cultures were positive for S.typhi reportedly
sensitive to cipro, but nalidixic acid testing was not
performed. Lack of clinical improvement despite outpatient
treatment suggested resistance to cipro. No other concurrent
source of infection thus far found. Per report outpatient w/u
for malaria negative. Per ID, relative bradycardia with fever,
classic for S.typhi. Pt was started on IV ceftriaxone and fever
curve trended down to tmax in last 24 hrs prior to DC 100.8. Pt
did not have any other localizing source of infection. Bcx at
___ grew salmonella species that were resistant to nalidixic
acid testing, but sensitive to ampicillin, ceftriaxone, bactrim.
Therefore, ID's final recommendation was for a 2 week total
course of IV ceftriaxone given that he had clinically improved
on this regimen. Last day of therapy ___. Pt will need weekly
cbc with diff, Chem-7 and LFTs send to Dr. ___ ID-see #
below. PICC placed on ___ evening, heparin dependent.
.
#transaminitis-mild, likely due to above. Pt did not have any
clinical signs of hepatitis. LFTs to be continually monitored
weekly after discharge.
.
#mild normocytic anemia-could be due to current
inflammation/infection. No suggestion of active bleeding. LDH
was elevated, but haptoglobin was normal. HCT upon discharge
was stable at 35.7
.
FEN: regular diet
.
DVT PPx: ambulation
.
CODE: FULL
Medications on Admission:
Ciprofloxacin 500 mg po bid
Discharge Medications:
1. ceftriaxone 2 gram Recon Soln Sig: One (1) infusion
Intravenous once a day for 11 days: last day of therapy ___.
Disp:*11 * Refills:*0*
2. Outpatient Lab Work
OPAT labs.
Weekly CBC with Diff, chem-7, LFTs to be faxed to Dr. ___ at
___
3. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
samonella typhi bacteremia/thyphoid fever
anemia
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 fever and bacteria in the
blood (Samonella Typhi). For this, you were evaluated by the
infectious disease team and started on new antibiotic therapy
(IV ceftriaxone) with good effect. You will need to continue
antibiotic therapy for a total of a 2 week course. Last dose on
___.
.
Medication changes:
1.start ceftriaxone IV daily for a total of 11 more days, last
day ___
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
___
|
10428356-DS-16 | 10,428,356 | 29,671,382 | DS | 16 | 2112-08-21 00:00:00 | 2112-08-21 15:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
nausea, vomiting, headache, right facial droop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ right-handed man with a history of
vascular dementia, hypothyroidism, unspecified dysphagia,
hypertension, and hyperlipidemia who presented to the local ___
hospital with headache, malaise, and vomiting, and was found to
have right facial droop so transferred for stroke evaluation.
He reports 2 weeks of large volume urinary frequency every 2
hours, causing him to wake up frequently throughout the night.
He
denies dysuria. This morning after breakfast he developed a
left-frontal headache, pressure-like quality, ___ intensity,
along with generalized malaise (reports only that he didn't
"feel
good"). He was taken to the ___ hospital by a social worker from
his group home and vomited while being triaged. He reported
feeling dizzy and was cradling his head in his hands. He was
also
noted to be diaphoretic and pale. He was able to stand to obtain
orthostatics wherein his HR rose from 60 to 90, with SBP
remaining steady in 160s. He was transferred due to concern for
stroke given right facial droop seen on evaluation.
At ___, he vomited while on the CT scanner table. On my
evaluation, NIHSS was 2 for disorientation to month and right
lower facial weakness. He was able to provide some of his own
history, including that he had a remote stroke, but he could not
recall details.
ROS:
+ Urinary frequency
+ Nausea, vomiting
+ Malaise
+ Headache
Denies difficulties producing or comprehending speech, loss of
vision, diplopia, dysarthria, vertigo, focal weakness, numbness,
or parasthesiae. Denies difficulty with gait.
Past Medical History:
- Vascular dementia
- Mood disorder with major depressive-like episode due to
general
medical condition.
- Hypertension
- Hyperlipidemia
- Cataract
- Hypothyroidism
- Squamous cell carcinoma of lip
- Dysphagia, unspecified (on pureed diet)
Per barium swallow ___ able to swallow puree, ground
soft solid, and honey consistency without difficulty.
- History of colon polyps (tubular adenomas, hyperplastic, and
adenomatous polyps).
- Left inguinal hernia
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
Vitals: T:97.1 HR:71 BP:145/112 RR:17 SaO2:100%
General: Awake, cooperative, NAD.
HEENT: NC/AT.
Neck: Supple. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: Warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to person, age, place, year not
month, and reason for presentation. Able to relate history
though
details vague. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects (hammock,
cactus). Able to read without difficulty. No dysarthria. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to threat.
V: Facial sensation intact to light touch.
VII: Right lower facial droop.
VIII: Hearing intact to speech.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch throughout. No extinction
to
DSS.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 1 1 2
R 2 1 2 2
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF bilaterally.
-Gait: Deferred.
DISCHARGE PHYSICAL EXAM
===========================
General: Awake, cooperative, NAD.
HEENT: NC/AT.
Neck: Supple. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: Warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to person, age, place, year not
month, and reason for presentation. Able to relate history
though
details vague. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects (hammock,
cactus). Able to read without difficulty. No dysarthria. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to threat.
V: Facial sensation intact to light touch.
VII: Right lower facial droop.
VIII: Hearing intact to speech.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch throughout. No extinction
to
DSS.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 1 1 2
R 2 1 2 2
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF bilaterally.
-Gait: Deferred.
Pertinent Results:
ADMISSION LABS
================
___ 03:41PM BLOOD WBC-11.5* RBC-4.81 Hgb-14.9 Hct-43.3
MCV-90 MCH-31.0 MCHC-34.4 RDW-12.6 RDWSD-41.6 Plt ___
___ 03:41PM BLOOD Neuts-86.9* Lymphs-6.4* Monos-5.8
Eos-0.2* Baso-0.4 Im ___ AbsNeut-9.97* AbsLymp-0.74*
AbsMono-0.67 AbsEos-0.02* AbsBaso-0.05
___ 03:41PM BLOOD Plt ___
___ 03:41PM BLOOD ___ PTT-26.2 ___
___ 03:41PM BLOOD Glucose-165* UreaN-15 Creat-0.7 Na-141
K-4.3 Cl-99 HCO3-23 AnGap-19*
___ 03:41PM BLOOD ALT-18 AST-16 AlkPhos-112 TotBili-1.1
___ 06:20AM BLOOD CK-MB-5 cTropnT-<0.01
___ 03:41PM BLOOD cTropnT-<0.01
___ 03:41PM BLOOD Albumin-4.5 Calcium-9.0 Phos-3.5 Mg-2.1
___ 03:41PM BLOOD TSH-2.4
___ 03:41PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE LABS
=================
___ 06:20AM BLOOD WBC-10.2* RBC-4.82 Hgb-14.7 Hct-43.5
MCV-90 MCH-30.5 MCHC-33.8 RDW-12.6 RDWSD-41.3 Plt ___
___ 06:20AM BLOOD Neuts-84.1* Lymphs-7.3* Monos-7.7
Eos-0.3* Baso-0.3 Im ___ AbsNeut-8.54* AbsLymp-0.74*
AbsMono-0.78 AbsEos-0.03* AbsBaso-0.03
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD ___ PTT-27.7 ___
___ 06:20AM BLOOD Glucose-112* UreaN-12 Creat-0.7 Na-141
K-4.0 Cl-100 HCO3-29 AnGap-12
___ 06:20AM BLOOD ALT-18 AST-17 LD(LDH)-223 CK(CPK)-198
AlkPhos-120 TotBili-1.5
___ 12:14AM BLOOD Lipase-26
___ 06:20AM BLOOD CK-MB-5 cTropnT-<0.01
___ 06:20AM BLOOD %HbA1c-5.5 eAG-111
___ 12:22AM BLOOD ___ pO2-85 pCO2-40 pH-7.45
calTCO2-29 Base XS-3
___ 12:22AM BLOOD Lactate-1.5
IMAGING
==========
CTA HEAD W&W/O C & RECONS Study Date of ___
CTA HEAD:
The anterior and middle cerebral arteries are patent
bilaterally. There is a possible slight narrowing of the left
middle cerebral artery but there is no occlusion. The posterior
communicating artery is diminutive bilaterally. There is a
large ophthalmic artery bilaterally which likely represents
collapse collateral pathway. The dural venous sinuses are
patent.
The posterior circulation is patent and without stenosis,
occlusion, or
aneurysm.
CTA NECK:
There is bilateral occlusion of the internal carotid arteries.
The origin of the left common carotid artery is diminished in
caliber. There is no visualized flow in the left external
carotid artery. There is occlusion of the left internal carotid
artery just distal to the area of the bifurcation. There is
distal likely retrograde flow in the supraclinoid segment of the
left ICA.
The right common carotid artery is normal in caliber, however
there is
occlusion of the internal carotid artery immediately distal to
the
bifurcation. There is distal likely retrograde flow in the
supraclinoid
segment of the right ICA. The right external carotid artery is
patent
There is no evidence of stenosis, occlusion, or aneurysm the
vertebral or
basilar arteries.
OTHER:
The visualized portion of the lungs are clear. The visualized
portion of the thyroid gland is within normal limits. There is
no lymphadenopathy by CT size criteria.
Brief Hospital Course:
Mr. ___ is a ___ year old right-handed man with a history of
vascular dementia, chronic left frontal infarct with residual
right facial droop, unspecified dysphagia, hypertension, and
hyperlipidemia who presented to OSH with headache, malaise, and
vomiting, and was noted to have right facial droop. He was
transferred to ___ for stroke evaluation. He did have an acute
stroke.
#Chronic left frontal infarct
#Chronic right facial droop:
Presented with left frontal headache, general malaise. Taken to
___ hospital where right lower facial droop was noted, SBP 200,
prompting transfer to ___. Here, initial NIHSS 2
(disorientation to month, right lower facial weakness).
Neurologic exam otherwise unremarkable. CT with left frontal
chronic infarct, bilateral internal carotid occlusions. Patient
was shown picture of his face and stated that there was no
change in his chronic right lower facial droop. His presenting
headache may have been in the setting of hypertension, as it
improved with better pressure control. Given low suspicion for
acute stroke, MRI was not performed. Stroke risk factors were
notable for: HgA1C: 5.5, LDL pending at discharge. Received
aspirin 325 mg x1, initiated aspirin 81 mg daily. Changed home
pravastatin 60 mg daily to atorvastatin 80 mg daily.
#Nausea
#Vomiting
Etiology unclear. Developed over approximately one day. Was
notably orthostatic per heart rate criteria (HR 60-->90) at the
___, likely in setting of dehydration from GI losses. His
symptoms were initially concerning for posterior circulation
disease, however ruled out acute stroke as above. Possibly had
transient viral illness. Improved with IV fluids. At time of
discharge, symptoms resolved.
#Hypothyroidism:
Continued home levothyroxine.
#HTN:
held home amlodipine, resumed at discharge.
#Depression:
Held home bupropion, resumed at discharge.
TRANSITIONAL ISSUES:
=======================
[] f/u lipid panel, pending at discharge
[] initiated aspirin, changed pravastatin to atorvastatin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Docusate Sodium 100 mg PO DAILY
3. Levothyroxine Sodium 112 mcg PO DAILY
4. Pravastatin 60 mg PO QPM
5. BuPROPion XL (Once Daily) 150 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. amLODIPine 10 mg PO DAILY
4. BuPROPion XL (Once Daily) 150 mg PO DAILY
5. Docusate Sodium 100 mg PO DAILY
6. Levothyroxine Sodium 112 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#chronic left frontal infarct
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
You came to the hospital because you developed nausea, vomiting,
and headaches. The right side of your face was also drooped.
These symptoms were concerning for a stroke. We evaluated you
with blood tests and imaging of your brain and determined that
you did not have a new stroke. Your facial droop appears to be
chronic from your old stroke. Your nausea, vomiting, and
headaches got better with fluids.
Please continue to take your medications as prescribed and
___ with your doctors as ___.
We wish you all the best,
Your ___ care team
Followup Instructions:
___
|
10428958-DS-7 | 10,428,958 | 24,405,180 | DS | 7 | 2112-05-11 00:00:00 | 2112-05-14 09:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Jaw pain
Major Surgical or Invasive Procedure:
Open reduction and internal fixation of mandible fracture
History of Present Illness:
___ year old female with no significant PMH s/p assault last
night sustained L ramus, R body fracture in line of #s 29,___enies LOC. Evaluated at ___ where
she was found to have bilateral mandibular fractures.
Transferred to ___ ED for management. ___ consulted for
mandible fractures. Denies dysphagia, odynophagia, respiratory
distress. Denies parasthesia.
Past Medical History:
None
Social History:
___
Family History:
Noncontributory
Physical Exam:
EXAM ON ADMISSION:
General: Alert, oriented x3, NAD
Head: Normocephalic, atraumatic
Eyes: EOM intact, PERRLA, no double vision, no changes to vision
Ears: No changes to hearing, gross hearing intact, no battle
sign
Nose: Septum midline, no septal hematoma, no rhinorrhea, no
epistaxis
Extraoral: Mouth opening of 30 mm, no TMJ pain
Intraoral: Right buccal ecchymosis. Step deformity at right
mandible body in line of #s 29 and 30. Mobility of segments
noted. Malocclusion with open bite. FOM/tongue non-elevated,
pharynx clear, uvula midline. Dentition grossly intact.
Neck: Soft, FROM
Neuro: CN2-12 intact
.
EXAM ON DISCHARGE:
General: Alert, oriented x3, NAD
Head: Normocephalic, atraumatic
Eyes: EOM intact, PERRLA, no double vision, no changes to vision
Ears: No changes to hearing, gross hearing intact, no battle
sign
Nose: Septum midline, no septal hematoma, no rhinorrhea, no
epistaxis
Extraoral: Mouth opening of 30 mm, no TMJ pain, right V3
paresthesia,
Intraoral: arch bars intact, incision intact FOM/tongue
non-elevated,pharynx clear, uvula midline. Dentition grossly
intact.Elastics intact, occlusion intact, stable and repeatable
Neck: Soft, FROM
Neuro: CN2-12 intact except right V3 paresthesia
Pertinent Results:
___ 07:00PM GLUCOSE-78 UREA N-13 CREAT-0.7 SODIUM-138
POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-24 ANION GAP-21*
___ 07:00PM estGFR-Using this
___ 07:00PM WBC-10.1 RBC-4.23 HGB-13.7 HCT-42.8 MCV-101*
MCH-32.3* MCHC-31.9 RDW-13.0
___ 07:00PM NEUTS-81.5* LYMPHS-14.2* MONOS-3.5 EOS-0.5
BASOS-0.4
___ 07:00PM PLT COUNT-325
___ 07:00PM ___ PTT-28.0 ___
.
PANOREX: Acute fractures through the mandibular body onthe right
and the
ramus on the left as detailed above.
Brief Hospital Course:
Ms. ___ was found to have a mandible fracture. She was
admitted to the ___ service in order to be taken to the
operating room by the ___ service. While awaiting OR
availability, she was seen by social work due to concern of the
nature of her trauma, and they felt that the patient was safe to
return to her usual living situation.
.
She was taken to the OR with ___ where she underwent open
reduction, internal fixation of right mandibular body fracture
with closed reduction of the left subcondylar fracture. The
details of the procedure are in the operative report. She
tolerated the procedure well and was extubated without incident.
She was taken to the PACU for recovery.
.
The patient remained hemodynamically stable in the PACU and her
pain was controlled so she was transferred to the surgical
floor. She was started on a liquid diet and her pain was
adequately controlled with PO medications. She was evaluated by
the ___ serrvice prior to discharge who placed elastic bands to
hold the fracture in reduction. She will follow up in ___
clinic as scheduled.
Medications on Admission:
None
Discharge Medications:
1. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane BID (2 times a day).
Disp:*900 ML(s)* Refills:*0*
2. oxycodone-acetaminophen ___ mg/5 mL Solution Sig: ___ MLs
PO Q4H (every 4 hours) as needed for pain: Do not drive while
taking this medication.
Disp:*300 ML(s)* Refills:*0*
3. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO three
times a day for 5 days.
Disp:*15 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Mandibular fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at ___. You were
admitted to the hospital for a fractured mandible. You had
surgery to repair the fracture performed by the oral surgeons.
They placed elastic bands to help hold the bones in place, and
you will need to follow up with them in their clinic as
scheduled. You need to use the prescribed mouthwash and you
should take the pain medication and antibiotics as prescribed.
You should stay on a liquid diet until you see them in clinic.
You should also apply ice to your face twice a day to help
reduce the swelling.
Followup Instructions:
___
|
10429531-DS-18 | 10,429,531 | 20,213,153 | DS | 18 | 2116-02-04 00:00:00 | 2116-02-05 10:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year old gentleman with PMH of HTN with recent CVA
who presents with abdominal pain and concern for vasculitis.
One week ago, he started experiencing generalized abdominal pain
without n/v as well as diarrhea up to 4 episodes per day.
Associated symptoms of subjective fevers, night sweats. No
recent travel, new exposures. New meds are rivaroxaban,
olmesartan, aspirin which were started after a recent stroke
that he was told was embolic from "the neck" (discharge summary
from admission for stroke was en route to ___ at the time of this
note).
He went to his PCP's office where he had labs showing WBC 25,
35% eosinophils, then was sent over to ___ for
further w/u. There, CT abd/pelvis was concerning for vasculitis
vs diffuse atherosclerotic disease, sigmoid colitis, dilated
CBD. They then obtained a CTA with similar findings including
occlusion of the left external iliac artery. As a result, he was
transferred to ___.
This morning he reports ongoing ___ diffuse abdominal pain.
Pain is not associated with eating. Denies any other complaints.
Denies any recent rash, joint pains, visual changes (though does
note that his stroke presented with unilateral R sided vision
loss). He does endorse ongoing weakness, w/o pain or stiffness,
of the proximal legs bilaterally, for which his statin was
recently stopped. No shoulder girdle weakness or stiffness.
Denies recent weight loss (confirmed by PCP).
Past Medical History:
Hypertension
CVA ___
Social History:
___
Family History:
FATHER S/p 3v CABG at age ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 97.4 146/74 HR 72 RR20 100%
GENERAL: Alert and oriented x 3. In no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes
or rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
DISCHARGE PHYSICAL EXAM:
PHYSICAL EXAM:
VITALS: 98 120s/60s-80s ___ 18 98 RA
GENERAL: Alert and oriented x 3. In no apparent distress. Thin.
Normal affect, able to tell a relatively detailed history.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Thin, non tender, soft.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal speech and
gait
Pertinent Results:
ADMISSION LABS
___ 08:16PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:16PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:16PM URINE GR HOLD-HOLD
___ 08:16PM URINE UHOLD-HOLD
___ 08:16PM URINE HOURS-RANDOM CREAT-65 TOT PROT-6
PROT/CREA-0.1
___ 09:22PM PLT SMR-NORMAL PLT COUNT-332
___ 09:22PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-NORMAL BURR-OCCASIONAL FRAGMENT-OCCASIONAL
___ 09:22PM NEUTS-41.3 ___ MONOS-6.1 EOS-32.3*
BASOS-0.4 IM ___ AbsNeut-7.95* AbsLymp-3.69 AbsMono-1.18*
AbsEos-6.22* AbsBaso-0.08
___ 09:22PM WBC-19.3* RBC-4.30* HGB-11.9* HCT-36.8*
MCV-86 MCH-27.7 MCHC-32.3 RDW-13.9 RDWSD-42.9
___ 09:22PM HCV Ab-Negative
___ 09:22PM b2micro-2.7*
___ 09:22PM CRP-2.2
___ 09:22PM HBsAg-Negative HBs Ab-Negative HBc
Ab-Negative
___ 09:22PM ALBUMIN-3.4*
___ 09:22PM LIPASE-18
___ 09:22PM ALT(SGPT)-85* AST(SGOT)-52* ALK PHOS-307* TOT
BILI-0.2
___ 09:22PM GLUCOSE-86 UREA N-14 CREAT-0.9 SODIUM-136
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-23 ANION GAP-13
___ 10:09PM ___ PTT-31.6 ___
___ 10:42PM LACTATE-0.8
___ 10:45PM ___
___ 11:26PM URINE MUCOUS-RARE
___ 11:26PM URINE RBC-<1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 11:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 11:26PM URINE COLOR-Straw APPEAR-Clear SP ___
PERTINENT LABS:
EOSINOPHIL TREND:
___ 09:22PM BLOOD Neuts-41.3 ___ Monos-6.1
Eos-32.3* Baso-0.4 Im ___ AbsNeut-7.95* AbsLymp-3.69
AbsMono-1.18* AbsEos-6.22* AbsBaso-0.08
___ 05:50AM BLOOD Neuts-56 Bands-0 Lymphs-14* Monos-6
Eos-23* Baso-0 ___ Metas-1* Myelos-0 AbsNeut-9.35*
AbsLymp-2.34 AbsMono-1.00* AbsEos-3.84* AbsBaso-0.00*
LFT TREND:
___ 09:22PM BLOOD ALT-85* AST-52* AlkPhos-307* TotBili-0.2
___ 05:50AM BLOOD ALT-87* AST-57* CK(CPK)-33* AlkPhos-295*
TotBili-0.2
___ 06:55AM BLOOD ALT-87* AST-54* LD(LDH)-214 CK(CPK)-38*
AlkPhos-276* TotBili-0.2
STUDIES PENDING AT DISCHARGE:
___ 10:45PM BLOOD ANCA-PND
___ 10:45PM BLOOD C1 INHIBITOR-PND
___ 10:49PM BLOOD SED RATE-Test
SCHISTOSOMA AB
STRONGYLOIDES AB
STOOL STUDIES:
___ 2:24 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
MICROSPORIDIA STAIN (Pending):
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Pending):
Cryptosporidium/Giardia (DFA) (Pending):
IMAGING/STUDIES:
CTA FROM ___ (RE-READ BY ___ RADIOLOGY):
FINDINGS:
LOWER CHEST: Mild dependent atelectasis. There is no evidence of
pleural or
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepatic
biliary dilatation. A common bile duct measures up to 11 mm
with distal
tapering. No visualized choledocholithiasis. The gallbladder
distended and
demonstrates minimal focal enhancement in the region of the
fundus that may
reflect presence of adenomyomatosis (series 2c, image 35).
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: There is moderate dilatation of the left collecting
system calyces
and pelves ureteric junction with abrupt transition seen just
distal to the
UPJ. There is slight delay of corticomedullary differentiation
of the left
kidney. However excreted contrast is seen within the collecting
system. No
focal solid renal masses. No visualized stones.
GASTROINTESTINAL: Oral contrast passes to the level of the
rectum. The
stomach is unremarkable. Small bowel loops demonstrate normal
caliber, wall
thickness, and enhancement throughout. The sigmoid colon is
poorly distended
which may overestimate the degree of wall thickening. No
substantial
pericolonic fat stranding. The walls of the remaining colon are
poorly
assessed due to the presence of oral contrast. The appendix is
not
visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR:
There is no abdominal aortic aneurysm.
Mild scattered atherosclerotic calcifications are present
throughout the
abdominal aorta and its branches. There are non contiguous
areas of mild
concentric and eccentric wall thickening of the abdominal aorta
and its
branches.
The celiac artery, SMA, renal arteries and ___ are patent.
There is focal short segment stenosis of the right renal artery
approximately
7 mm beyond its origin (series 8, image 38). There are no
pseudoaneurysms
noted on either side. There is no irregularity of the wall of
any of the
intrarenal renal arteries on either side. No dissections
present. There is
no evidence of a beaded appearance of the medium-sized arteries.
The left external iliac artery is occluded right from its origin
up to the
left common femoral artery which is reconstituted by collaterals
suggestive of
a chronic occlusion. The left internal iliac artery is patent.
The right
external and internal iliac arteries are patent. There is
reconstitution at
the left common femoral artery.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Complete, likely chronic occlusion of the left external iliac
artery with
reconstitution of the left common femoral artery via
collaterals.
2. Concentric and eccentric non contiguous wall thickening of
the abdominal
aorta with mild narrowing of the left common iliac artery.
Scattered
calcified atherosclerotic plaques are seen throughout the
abdominal aorta and
its branches with areas of luminal irregularity. No dissection
or aneurysm
formation. No penetrating atherosclerotic ulcers.
3. Focal short segment stenosis of the right renal artery
approximately 7 mm
beyond its origin without renal parenchymal ischemia.
4. These findings may reflect changes secondary to
atherosclerosis, however in
the right clinical scenario, medium and large vessel vasculitis
may be
considered.
5. Left moderate ureteropelvic junction obstruction caused by a
crossing
vessel, the left renal artery branch and vein.
CXR ___ NO ACUTE PROCCESS
CAROTID ULTRASOUNDS ___. Significant narrowing of the left carotid artery resulting
in 60-69%
stenosis.
2. Mild heterogeneous plaque and intimal thickening in the
right carotid
artery resulting in 40-59% stenosis.
ABI/PVRS:
R ABI: 0.91
L ABI: 0.45
PVRS monophasic
Significant aortoiliac disease in the left and significant right
superficial
femoral artery disease at rest. The patient was unable to
exercise due to
intravenous line in the left antecubital fossa.
Brief Hospital Course:
ASSESSMENT & PLAN: This is a ___ year old gentleman ith PMH of
HTN and stroke, presenting with abdominal pain, eosinophilia and
findings c/f diffuse atherosclerosis vs vasculitis on imaging.
# Abdominal pain: Presented with 1 week of abdominal pain,
diarrhea, subjective fevers. CT showed diffuse atherosclerotic
disease, less likely vasculitis according to radiology. Colitis
was reported on intial read but on re-read this was due to
underdistention of the sigmoid colon. The cause of his pain
remained somewhat unclear: rheumatology was consulted and in
setting of normal ESR and CRP, absence of other symptoms of
vasculitis, did not think vasculitis explained his abdominal
pain. Differential includes chronic non occlusive mesenteric
ischemia given postprandial worsening (though would not expect
swift improvement, and his pain improved throughout his stay).
GERD remained in differential as he did describe pain as burning
in quality (htough more diffuse), and he was started on
ranitidine. Stool studies for parasitic GI infection as well as
schistosoma Ab, strongyloides Ab were sent given eosinophlia,
most of which were still pending on discharge. Pain was much
improved on discharge, tolerating full diet.
#Eosinophilia: Absolute eos count during admission trended
6.22->3.84->2.15->2.6. The etiology was unclear. As above,
vasculiitis was felt to be less likely, ___ negative, normal
ESR/CRP. ANCA pending on discharge. There was no LAD on exam or
imaging to suggest heme malignancy, no lab or VS e/o adrenal
insufficiency. As above, parasitic antibodies were sent and
pending at discharge. Reaciton to new med e.g. aspirin was
considered but his count improved without changing these meds.
Given improvement of eosinophil count he was dsicharged with
plan for close follow up and monitoring.
#Recent CVA: Likely embolic from R carotid stenosis (see my note
dated ___ for review of OSH data). No indication for Xa
inhibitor given there is no indication that his stroke was from
a central embolic source. He had no afib and a normal TTE at OSH
and normal telemetry during this admission as well. Symptoms and
CT head findings, on review of outside records, all indicated a
R sided stroke likely embolic from R carotid artery origin which
has confirmed stenosis on imaging. Thus there was no indication
for systemic anticoagulation with rivaroxaban and this was
discontinued on ___ after discussion with patient who was in
agreement. Aspirin was continued and rosuvastatin was started.
#Vascular disease: He was seen by vascular surgery given
findings of chronic left sided iliac occlusion w/ reconstitution
by collaterals. L ABI 0.4 at rest, no symptoms or signs of
active limb ischemia. Carotids also showed b/l stenosis. He will
follow up as an outpatient to discuss carotid disease and iliac
occlusion, no inpatient intervention was required.
CHRONIC ISSUES:
#HTN: continued home olmesartan.
TRANSITIONAL ISSUES:
[] Absolute eosinophil count at discharge was 2.69. Trend while
inpatient was: 6.22->3.84->2.15-> 2.69. Please check CBC with
diff within 1 week of discharge and would recommend referral to
hematology/oncology if eosinophil count is rising.
[] Studies pending at discharge: ___, b2 glycoprotein,
complement, schistosoma, strongyloidies, stool studies. The
inpatient team will communicate with the PCP if any of these
return positive.
[] Rivaroxaban was stopped while inaptient. There was no
indication that his stroke was from a central embolic source, as
he had no afib and a normal TTE at OSH and normal telemetry
during this admission. Symptoms and CT head findings, on review
of outside records, all indicated a R sided stroke likely
embolic from R carotid artery origin. Thus there was no
indication for systemic anticoagulation with rivaroxaban.
Aspirin was continued.
[] New meds: Zantac 150 BID started prior to discharge. Started
Rosuvastatin in place of Atorvastatin given complaint of muscle
weakness on atorva. Needs to be on high dose statin given
vascular disease and stroke history.
[] Abdominal pain was improving at the time of discharge, and
there was some indication that symptoms were related to GERD.
Please follow up symptoms on newly started H2 blocker.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benicar (olmesartan) 10 mg oral DAILY
2. Rivaroxaban 20 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. TraMADol 50 mg PO Q8H:PRN PAIN
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. TraMADol 50 mg PO Q8H:PRN PAIN
3. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Rosuvastatin Calcium 40 mg PO QPM
RX *rosuvastatin [Crestor] 40 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Benicar (olmesartan) 10 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
eosinophilia
dyspepsia
atherosclerosis
SECONDARY DIAGNOSES:
hypertension
s/p CVA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___:
You were admitted to ___ because you had abdominal pain and
had some abnormalities in your labs (one type of your white
blood cells was very elevated). We did a number of tests to rule
out dangerous reasons for this number to be elevated, and these
all came back negative. You were seen by the vascular surgery
team because you had narrowing of some of your blood vessels.
You should follow up with them about this as an outpatient.
We stopped the medication rivaroxaban (xarelto) because this
medication is not recommend for the type of stroke that you had.
It was a pleasure to care for you!
Your ___ Team
Followup Instructions:
___
|
10429638-DS-5 | 10,429,638 | 23,236,921 | DS | 5 | 2129-02-18 00:00:00 | 2129-02-19 10:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dysuria, fevers, flank pain
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
This patient is a ___ year old female with a history of recurrent
UTI/Pyelonephritis who presented to the ED on ___ with a 24
hour history of nausea, vomting, dysuria, fevers, subsequently
discharged home with prescription for ciprofloxacin. The
patient returned to the ED on ___ complaining of worsening
falnk pain, fevers and persistent urinary symptoms and had a CT
a/p done at that time that showed severe right sided
pyelonephritis with low denisty areas concerning for early
abscess versus infarct. She was initially admitted to the
medicine floor for further management. On the evening of ___
the patient was complaining of fevers, worsening shortness of
breath and with increasing O2 requirement between ___ on
facemask. Per nursing, the patient would desat into low ___
on room air. she had a portable chest xray performed that was
concerning for mild worsening pulmonary edema as compared to
film from ED. Although she was mentating appropriately, speaking
in full sentences and in no obvious respiratory distress, she
was transferred to the ICU for further management of her
hypoxia. The patient denied any chest pain, pleurisy, cough, ___
___ or calf tenderness.
Past Medical History:
- Recurrent UTI/Pyelo
- depression
- ADHD
Social History:
___
Family History:
no history of kidney disease or cancer
Physical Exam:
ADMISSION EXAM
===============
Vitals: HR 101, BP 129/84 RR 15 Sp02 95% 5L NC
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: speaking in full sentences, not in resp distress.
crackles to mid lung fields on right. Left lung fields clear. no
wheezes/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
FLANK: R CVAT. No L CVAT
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No calf tenderness.
SKIN: no rash
DISCHARGE EXAM
===============
Vitals: T 100.3, BP 116/69, HR 89, RR 20, 98% on RA
GENERAL: Well-appearing, sleeping young lady in NAD, pleasant
HEENT: NC/AT, PERRL, MMM, mild periorbital edema
CARDIAC: RRR, S1 S2, faint SEM, no r/g
LUNG: Faint bibasilar rales, no w/r
ABDOMEN: Soft, minimally TTP in RLQ without rebound/guarding.
+mild Right CVAT, no left CVAT
EXTREMITIES: Warm, well perfused, no edema
NEURO: Alert, oriented, speech fluent, face symmetric, moves all
extremities
SKIN: No rashes
Pertinent Results:
ADMISSION LABS
===============
___ 04:56PM BLOOD WBC-15.5* RBC-3.88* Hgb-12.3 Hct-38.8
MCV-100* MCH-31.8 MCHC-31.8 RDW-13.4 Plt ___
___ 04:56PM BLOOD Neuts-90.6* Lymphs-5.9* Monos-2.6 Eos-0.6
Baso-0.3
___ 04:56PM BLOOD Glucose-105* UreaN-14 Creat-1.0 Na-137
K-3.3 Cl-100 HCO3-25 AnGap-15
___ 01:10PM BLOOD ALT-17 AST-30 AlkPhos-108* TotBili-0.1
___ 01:10PM BLOOD Albumin-3.2*
___ 09:10AM BLOOD Calcium-7.9* Phos-3.1 Mg-1.7
___ 09:44PM BLOOD Type-ART pO2-91 pCO2-35 pH-7.35
calTCO2-20* Base XS--5
___ 05:04PM BLOOD Lactate-2.8*
___ 09:44PM BLOOD O2 Sat-96
DISCHARGE LABS
===============
___ 07:55AM BLOOD WBC-9.2 RBC-3.82* Hgb-11.7* Hct-38.5
MCV-101* MCH-30.7 MCHC-30.5* RDW-14.0 Plt ___
___ 03:59AM BLOOD Glucose-87 UreaN-11 Creat-1.1 Na-139
K-3.4 Cl-106 HCO3-25 AnGap-11
___ 03:59AM BLOOD Calcium-8.0* Phos-4.2 Mg-1.7
MICROBIOLOGY
=============
___ Urine gonorrhea, chlamydia urine NAAT - pending
___ Blood cultures - pending
___ Urine culture - pan-sensitive E.coli
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/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 STUDIES
================
___ CHEST (PA & LAT) - Fluid overload with interstitial
edema. No focal opacification concerning for pneumonia. No
large pleural effusion.
___ CT ABD & PELVIS WITH CO - Severe right-sided
pyelonephritis. No focal perinephric fluid collection
identified. However, there are multiple areas of
hypoattenuation superimposed on striated nephrogram, including 8
mm rounded low density within the upper pole and peripheral
wedge-shaped low-density areas within the lower pole. Findings
may represent combination of developing abscess and/or infarct.
Multiple findings attributable to fluid overload including a
small right
non-hemorrhagic layering pleural effusion, faint bibasilar
ground-glass
opacification with smooth septal thickening suggesting pulmonary
edema,
periportal edema, enlarged IVC, small to moderate intrabdominal
ascites, and diffuse superficial soft tissue edema.
___ ECHO - The left atrium is normal in size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF = 65%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
leaflets are structurally normal. Mild to moderate (___) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
___ RENAL U.S. PORT - No drainable fluid collection is
identified. Mildly heterogeneous appearing right kidney likely
relates to the patient's acute pyelonephritis. 4-mm
nonobstructing left renal calculi. No evidence of
hydronephrosis.
Brief Hospital Course:
BRIEF HOSPITAL COURSE: ___ with PMH significant for recurrent
urinary tract infections, depression and ADHD now presenting
with acute right-sided pyelonephritis complicated by urosepsis
and hypoxemia.
ACTIVE ISSUES
# SEPSIS secondary to PYELONEPHRITIS- Evidence of fever and
tachycardia with positive urinalysis and evidence of
pan-sensitive E. coli urinary tract infection. CT imaging
demonstrated right sided pyelonephritis with possible evidence
of a developing abscess. However, a renal ultrasound conducted
~2 days later did not reveal an abscess or fluid collection. She
was treated with ceftriaxone during the initial stages of the
hospitalization and was switched to oral antibiotics prior to
discharge. She was evaluated by the urology consult team who
recommended outpatient follow-up.
# ACUTE HYPOXEMIA - CXR and exam consistent with interstital
pulmonary edema with echocardiogram demonstrating normal
biventricular cardiac function. She responded to intermittent IV
diuresis. Her oxygen saturations were 95% on 5L NC on arrival to
MICU and improved with diuresis. Mild pleural effusion noted on
CXR was attributed to leaky pulmonary vasculature.
#PAIN: Nonspecific headache and neck pain resolved with tylenol,
oxycodone, and occasional IV morphine. Pt did not have evidence
of meningismus.
#CONSTIPATION: Patient was maintained on a bowel regimen of
senna, docusate and Miralax.
# MACROCYTIC ANEMIA: B12 studies were normal.
CHRONIC ISSUES
===============
# DEPRESSION/PSYCH: Continued home sertraline. Home vyvanse
held given occasional tachycardia.
TRANSITIONAL ISSUES:
-------------------
Emergency Contact: ___ (boyfriend): ___
Pending studies: Blood cultures collected on ___ and ___
New medications: Bactrim DS BID (to be continued until ___
Follow-up: Meet with outpatient urology to evaluate causes of
recurrent UTI's (e.g., VCUG), and to re-image the kidneys in ~10
days from discharge. Meet with PCP to conduct ___ repeat chest X
ray (~10 days following discharge), to ensure pulmonary edema
has resolved.
This discharge summary was faxed to Dr. ___ in ___,
___, at ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 50 mg PO DAILY
2. Gianvi (28) (drospirenone-ethinyl estradiol) ___ mg-mcg oral
daily
3. Vyvanse (lisdexamfetamine) 60 mg oral daily
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Pain
5. Ciprofloxacin HCl 250 mg PO Q12H
Discharge Medications:
1. Sertraline 50 mg PO DAILY
2. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 10 Days
Please continue to take the antibiotics until ___, even if
your symptoms resolve before then.
3. Gianvi (28) (drospirenone-ethinyl estradiol) ___ mg-mcg oral
daily
4. Vyvanse (lisdexamfetamine) 60 mg oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
Sepsis
Pulmonary 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 on the SIRS 4 service of
___. You were admitted to us
after developing pyelonephritis (an infection of the kidney),
accompanied by an infection of your blood stream. We treated you
with antibiotics and IV fluids. During your hospitalization your
oxygen levels dropped because of fluid accumulating in your
lungs, requiring you to go to the ICU. However, this resolved
when we corrected your fluid levels.
Upon returning home, please follow-up with a primary care
physician in ___, who will ensure that your lungs have
adequately recovered. Please also follow-up a urologist in
___, who will help to determine the cause of your repeated
UTI's, and who may decide to re-image your kidneys ~10 days
after discharge from the hospital. Please call the urologist at
___ to reschedule the appointment before you leave for
___.
Please continue to take Bactrim (the antibiotics), twice a day,
until ___. It is important that you continue the
antibiotics until this date, even if your symptoms resolve
beforehand.
Please take your home Miralax for constipation. You may take up
to two doses a day, if necessary.
Sincerely,
The ___ 4 Medical Team
Followup Instructions:
___
|
10429729-DS-13 | 10,429,729 | 26,929,922 | DS | 13 | 2123-01-16 00:00:00 | 2123-01-21 14:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
dysphagia
Major Surgical or Invasive Procedure:
___: Esophageal stent placement
History of Present Illness:
___ with metastatic lung cancer, initial dx in ___ at
stage IIIA who underwent chemo and radiation therapy through
___ (details not available) with dx of esophageal cancer in ___ who presents with progressive dysphagia over past 1 month
now with inability to swallow any solid or liquid. Up till two
weeks ago she was consuming purees and liquids and for past week
she has not been able to swallow liquids. Shas lost over 10 lbs
in past week. She has had chills and chronic worsened couhg
wiht yellow/green phlegm. She was given Rx for levofloxacin
last week for cough but only able to take 2 days of this
medication. She also filled Rx for dexamethasone 4mg PO daily
yesterday. Due to progressive dysphagia her cancer providers,
Dr. ___ Dr. ___ referred her to ___ via ___
___ ED.
She received IV dilaudid 1mg x3doses in ED which has not
relieved any of her cancer related chest pain. She has not been
able to swallow her pain medication as prescribed and pain
across chest is worsened. She also has tingling of her R arm
which is related to probable neuropathy due to supraclavicular
tumor
Past Medical History:
lung cancer, seen by IP at ___ in ___
Social History:
___
Family History:
not pertinent to current admit
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
98.1 122/71 18 93 2L
thin, pale female lying in bed and frequently coughing
clear/yellow phlegm into basin, fatigued
heent with dry oral mucosa and symmetric facial features
hard firm, enlarged R supraclavicular lymph node
clear breath sounds without rales or wheezes
L chest port
regular s1 and s2
soft abdomen
no peripheral edema
aox3 fluent speech, calm
Pertinent Results:
ADMISSION LABS
================
___ 02:40PM BLOOD WBC-13.1*# RBC-2.33*# Hgb-7.5*#
Hct-23.5*# MCV-101* MCH-32.1* MCHC-31.9 RDW-17.3* Plt ___
___ 02:40PM BLOOD Neuts-90.3* Lymphs-4.5* Monos-4.8 Eos-0.3
Baso-0.1
___ 02:40PM BLOOD Glucose-75 UreaN-11 Creat-0.5 Na-136
K-3.3 Cl-99 HCO3-24 AnGap-16
DISCHARGE LABS
================
RADIOLOGY
=========
___ Endoscopy Report
A malignant 6 cm long stricture was found at 22 cm from the
incisors. The regular upper endoscope could not traverse the
lesion.
In the middle of the completely obstructing mass, an opening was
noted. Traversing the opening, visualization of cavity, lung
parenchyma and brochi was noted. This is consistent with the
esophagopleural fistula.
Initially, under fluoroscopic guidance a standard 15 mm biliary
extraction balloon was passed through the standard upper
endoscope into the proximal obstructing mass. After the wire
could not travese the stricture, contrast was injected opacifing
the tight stricture and extravasating into the mediatinum.
Subsequently, a pediatric endoscope was inserted for evaluation.
With the assistance of the pediatric endoscope, the stricture
was traversed after carefull manipulation with minimal forward
pressure.
A 0.035 in x ___ cm Jagwire was left in place within the gastric
body and the endoscope removed.
An esophageal stent was slowly advanced over the guidewire
through the stricture under fluoroscopic visualization in
between the 2 radiographic markers indicating proximal and
distal borders of the stricture.
A 15.3cm by 18mm WallFlex Esophageal Fully Covered Metal stent
(REF: 1672; LOT: ___ was placed successfully. Final
position of the stent was confirmed endoscopically and
fluoroscopically
___ CXR (after hypoxia event)
New left mid lung patchy opacity consistent with aspiration.
CT CHEST W/O CONTRAST Study Date of ___ 3:01 ___
Cavitated mass or abscess extending from mediastinal tumor at
the level of the carina to the right hilus, presumably
originating from the stented
esophagotracheal fistula but clearly communicating with the
right lower lobe superior segmental bronchus. To be effective in
preventing aspiration, the esophageal stent needs to prevent
communication of the esophagus with both the trachea and this
cavity since the cavity communicates with the right lung. It ___
also be necessary to obturate the fistula with the superior
segmental bronchus.
Liquid pools in the otherwise patent stent the esophageal stent
running from the thoracic inlet to the gastroesophageal juction
with a small hiatus hernia.
Extensive mediastinal tumor is continuous from the right lower
paratracheal station through the subcarinal and paraesophageal
stations as far as the level of the left atrium, and extends
into both hila, severely narrowing the proximal left main
bronchus. The right upper lobe bronchus is obliterated,
presumably ligated in a right upper lobectomy.
Extensive aspiration, predominantly left lower lobe. Small
pericardial
effusion not clinically significant.
CHEST (PORTABLE AP) Study Date of ___ 1:29 ___
Patient is still extubated, ET tube tip just below the thoracic
inlet in
standard placement. The large esophageal stent has not migrated.
Heterogeneous peribronchial opacification in the left lower lung
on ___ has improved. This could be due to improvement in
any aspiration of esophageal contents following esophageal
stenting. Enlarged right hilus ___ be smaller although right
perihilar infiltration remains the same. Small right pleural
effusion is new or slightly larger. Heart size is normal. No
pneumothorax.
ESOPHAGUS Study Date of ___ 2:10 ___
No evidence of esophageal leak or fistula.
Brief Hospital Course:
___ with metastatic NSCLC who presented with dysphagia and
aspiration pneumonia due to tracheo- and bronchioesophageal
fistulas secondary to erosive esophageal metastases. The patient
is now s/p esophageal and tracheal stenting and is cleared to
resume eating. She will require a 14 day course of
amoxicillin-clavulanate, as detailed below.
ACTIVE ISSUES:
--------
# ASPIRATION PNEUMONIA: RESOLVING. Due to tracheoesophageal
fistula and tracheobronchial fistula.
- Discontinue vancomycin for MRSA coverage (___) given
negative MRSA swab.
- Discontinue pip-tazo for broad gram negative coverage
including pseudomonas (___)
- Transition to amoxicillin-clavulanate ___, total 14 day
course from ___ with broad gram negative and anaerobic
coverage given frank gastric contents observed within bronchial
tree. No pseudomonal or atypical coverage, but these organisms
are far less likely.
# BRONCHIO-ESOPHAGEAL FISTULA S/P ESOPHAGEAL STENTING ___, S/P
BMS RIGHT MAINSTEM BRONCHUS ___: RESOLVED. Likely only a
temporizing solution. Gastrografin swallow ___ did not show
evidence of aspirated radiocontrast. The patient was cleared to
eat. She was instructed on the importance and details regarding
her nubilzer treatments to maintain bronchial stent patency.
- Nebulized acetylcysteine BID to prevent bronchial stent
stenosis
- Guafenesin 1200mg BID to prevent bronchial stent stenosis.
- Patient scheduled to followup in interventional pulmonology
clinic.
- Discontinued outpatient dexamethasone, which the patient did
not fill before presentation to ___.
# Hypoxemic respiratory failure: RESOLVED. Due to aspiration
pneumonia. Patient required intubation for several days to
support respiratory status.
# Metastatic non small cell lung cancer: Diffusely metastatic.
EXG did not show evidence of QTc prolongation due to methadone.
Palliative care followed the patient; however, the patient
remained remiss to fully engage at this juncture.
- Continued home pain regimen
-- Methadone 60 PO QID
-- Hydromorphone ___ PO Q3:PRN, with holding parameters
# HYPOKALEMIA: WORSENED. TTKG consistent with renal losses.
Initiated on standing potassium, 20 mEQ daily.
- Followup with primary oncologist.
# ANEMIA: Due to anemia of chronic disease in the setting of
metastatic cancer.
# RIGHT ARM NEUROPATHY: Due to supraclavicular tumor. No ptosis,
meiosis, or anhydrosis.
- Resumed gabapentin, 300mg TID.
TRANSITIONAL ISSUES:
-------
# PLEASE DISCONTINUE OXYCODONE LIQUID PRESCRIPTION, NEVER MIX
MULTIPLE NARCOTICS AS THESE CAN LEAD TO RESPIRATORY DEPRESSION.
# AEROSOLIZED N-ACETYLCYSTEINE AND SODIUM CHLORIDE
# BRONCHUS, BIOPSY (TRANSBRONCHIAL /ENDOBRONCHIAL)
# REPEAT SERUM POTASSIUM IN THE SETTING OF ONGOING RENAL LOSSES
# CODE: DNR/ OK TO INTUBATE FOR BRONCHIAL STENT ADJUSTMENT, IF
NEEDED
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Methadone 60 mg PO QID
2. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
3. Dexamethasone 4 mg PO DAILY
4. Docusate Sodium (Liquid) 100 mg PO BID
5. Gabapentin 100 mg PO TID
6. Sertraline 50 mg PO DAILY
7. Prochlorperazine 5 mg PO Q8H:PRN n/v
8. Ondansetron 8 mg PO Q8H:PRN n/v
9. Multivitamins 1 TAB PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. OxycoDONE Liquid 2.5-20 mg PO Q2-4 PRN pain
Discharge Medications:
1. Acetylcysteine Inhaled For interventional pulmonary use
only 4 mL NEB BID
mix with albuterol
2. Albuterol 0.083% Neb Soln 1 NEB IH BID mix with
Acetylcysteine
5. Docusate Sodium (Liquid) 100 mg PO BID
6. Gabapentin 300 mg PO Q8H
7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain
Do not take if sedated
8. Methadone 60 mg PO QID
9. Amoxicillin-Clavulanic Acid ___ mg PO Q12H (through ___
10. Guaifenesin ER 1200 mg PO Q12H stent
___. Magnesium Oxide 400 mg PO BID
12. Potassium Chloride 20 mEq PO DAILY
13. FoLIC Acid 1 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Sertraline 50 mg PO DAILY
16. Pantoprazole 40 mg PO Q12H
17. Ondansetron 8 mg PO Q8H:PRN n/v
18. Prochlorperazine 5 mg PO Q8H:PRN n/v
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
------------
ASPIRATION PNEUMONIA
TRACHEOESOPHAGEAL FISTULA
TRACHEOBRONCHIAL FISTULA
ESOPHAGEAL STRICTURE
SECONDARY DIAGNOSES:
----------
METASTATIC NON-SMALL CELL LUNG CANCER
MALNUTRITION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted with pneumonia caused by a hole between your
esophagus and your lungs, a process which itself is due to your
metastatic lung cancer. You underwent procedures to place stents
which sealed these holes, to the extent that it is possible.
This should reduce the risk of passing stomach contents directly
into your lungs in the near term. You will need to followup with
the interventional pulmonologists who placed the stents in your
lungs. You will also need to continue taking the antibiotics
prescribed to you, which continue to treat your lung infection.
Followup Instructions:
___
|
10430116-DS-9 | 10,430,116 | 23,416,381 | DS | 9 | 2144-02-04 00:00:00 | 2144-02-16 11:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Crestor
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy
History of Present Illness:
___ F who presents with abd pain since 9pm last
night, epigastric, w/ several episodes of emesis. No other
associated symptoms. She reports she has had this pain once
before, and was told at that time that her symptoms were likely
viral.
Past Medical History:
VOMITING (ICD-787.03)
GOITER, NONTOXIC MULTINODULAR (ICD-241.1)
HYPERCHOLESTEROLEMIA (ICD-272.0)
HYPERTENSION, BENIGN ESSENTIAL (ICD-401.1)
AODM (ICD-250.00)
HEMOCCULT POSITIVE STOOL--S/P EGD, COLONOSCOPY (ICD-578.1)
HELICOBACTER PYLORI GASTRITIS S/P RX (ICD-041.86)
Renal insufficiency
Social History:
___
Family History:
Pt's mother had had "a stomach illness" at one time, but was
apparently successfully treated with herbal medicine.
Physical Exam:
Admission Physical Exam:
Vitals: 99.5, 78, 135/60, 20, 96% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: unlabored on RA
ABD: Soft, nondistended, TTP in epigastrium/RUQ, no palpable
masses
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical exam:
VS: 98.2, 152/77, 68, 16, 90 RA
Gen: A&O x3 lying in bed in NAD
CV: HRR
Pulm: LS ctab
Abd: soft, NT/ND lap sites with dermabond CDI minimal bruising
Ext: trace pedal edema
Pertinent Results:
___ 06:10AM BLOOD WBC-9.1 RBC-3.00* Hgb-9.1* Hct-28.4*
MCV-95 MCH-30.3 MCHC-32.0 RDW-13.0 RDWSD-44.5 Plt ___
___ 04:06AM BLOOD WBC-16.8* RBC-3.33* Hgb-10.5* Hct-32.2*
MCV-97 MCH-31.5 MCHC-32.6 RDW-13.0 RDWSD-45.5 Plt ___
___ 03:30PM BLOOD WBC-19.1* RBC-3.50* Hgb-10.7* Hct-31.8*
MCV-91 MCH-30.6 MCHC-33.6 RDW-12.7 RDWSD-41.5 Plt ___
___ 06:15AM BLOOD WBC-15.6* RBC-3.91 Hgb-12.1 Hct-37.6
MCV-96 MCH-30.9 MCHC-32.2 RDW-12.8 RDWSD-44.8 Plt ___
___ 06:10AM BLOOD Glucose-117* UreaN-24* Creat-2.7* Na-141
K-3.7 Cl-105 HCO3-22 AnGap-14
___ 04:06AM BLOOD Glucose-124* UreaN-29* Creat-2.6* Na-140
K-4.2 Cl-102 HCO3-22 AnGap-16
___ 06:15AM BLOOD Glucose-194* UreaN-38* Creat-2.8*# Na-143
K-4.9 Cl-105 HCO3-20* AnGap-18
___ 06:10AM BLOOD ALT-17 AST-31 AlkPhos-49 TotBili-0.2
___ 04:06AM BLOOD ALT-14 AST-24 AlkPhos-62 TotBili-0.7
___ 06:15AM BLOOD ALT-16 AST-26 AlkPhos-74 TotBili-0.3
___ 06:10AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.9
Imaging:
CT abdomen / pelvis:
1. Distended gallbladder with multiple gallstones and mild
gallbladder wall edema, findings concerning for acute
cholecystitis in the correct clinical setting. If further
evaluation is needed, consider ultrasound.
2. No evidence of bowel obstruction or appendicitis.
3. Trace bilateral pleural effusions and mild bibasilar
atelectasis.
RUQ US:
1. Mild common bile duct dilation to 9 mm. Although no distal
obstructing
stone is visualized, choledocholithiasis is not excluded. MRCP
can be
obtained at this time for further assessment.
2. Incidental 1 cm cyst in the pancreatic body, potentially
side-branch IPMN. Follow up with MRCP or ultrasound is
recommended in ___ year given age and size
SURGICAL PATHOLOGY REPORT - Final
PATHOLOGIC DIAGNOSIS:
Gallbladder, cholecystecomy:
- Marked acute-on-chronic cholecystitis with ulceration,
necrosis and abscess formation.
- Cholelithiasis.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on ___
for evaluation and treatment of abdominal pain. Admission
abdominal ultra-sound showed mild common bile duct dilation to 9
mm and abdominal/pelvic CT revealed distended gallbladder with
multiple gallstones and mild gallbladder wall edema, concerning
for acute cholecystitis. The patient underwent laparoscopic
cholecystectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
tolerating sips, on IV fluids, and oral analgesia for pain
control. The patient was hemodynamically stable.
.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*20 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*5 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*10 Packet Refills:*0
5. Senna 17.2 mg PO HS
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:
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10430213-DS-14 | 10,430,213 | 24,147,065 | DS | 14 | 2163-09-02 00:00:00 | 2163-09-03 09:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Iodinated Contrast Media - IV Dye / Gentamicin /
Levofloxacin / Nitrofurantoin / Penicillins / Quinolones / Sulfa
(Sulfonamide Antibiotics) / Tetracyclines / daptomycin /
mupirocin / potassium clav
Attending: ___.
Chief Complaint:
Ulcer
Major Surgical or Invasive Procedure:
Bone Biopsy
PICC Line placed
Removal of Power Port
History of Present Illness:
In brief this is a ___ with PMH paraplegia since ___,
Neurogenic bladder with chronic MDR UTIs, bilateral ___ DVTs s/p
IVC filter, chronic hyponatremia of unclear etiology transferred
from OSH for evaluation of new left ischial decubitus ulcer
evaluation. Patient had left AKA in ___ for extensive
osteomyelitis c/b stump hematoma and wound dehiscence as well as
and osteomyelitis of stump requiring redo of left AKA in ___.
Since then, there has been growing concern about worsening PVD
of the RLE, but given the complicated course that he had with
the left leg, surgical intervention for the RLE was deferred to
sometime this year. A few weeks ago, he was noted to have
worsening RLE swelling and had been elevating his right leg to
promote reabsorption of the extra fluid. Subsequently,
approximately 2 weeks ago his ___ noticed a new left ischial
ulcer. His PCP was contacted who tried to arrange inpatient
evaluation at several OSH in his area, but pt was denied for
some reason. He then received the recommendation to present to
the ED for further evaluation.
At OSH ED, pt presenting with concerns for UTI with increased
discomfort around his foley and lower abdomen. Labs were
significant for a leukocytosis with neutrophilic predominance,
WBC 17.9 (83.5% PMNs), Thrombocytosis 560, Na 130, Cr 0.8. U/A
consistent with pyuria. Pt had no complaints feels nothing
below the abdomen so did not know about the new ulcer before his
___ saw him. Denies fevers, chills, CP, SOB, ___ edema.
Past Medical History:
Paraplegia s/p ?spinal cord injury "shock of spinal cord"
GERD
chronic anemia
AKA
IVC filter
Social History:
___
Family History:
None contributory
Physical Exam:
ADMISSION EXAM:
VS: 98.2 86 118/62 20 97 on RA
GENERAL: well appearing, NAD, able to turn round freely
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, JVD:
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: AKA on L, R side multiple ulcers with dry scabs
over dorsal and medial aspects, medial lesion is new, erythema
spread proximally to mid shin
Sacrum: two 5 cm ulcers over left buttock and hip, with
superficial nacrotic tissue. The one over hip joint tracks to
bone.
NEURO: awake, A&Ox3, ___ muscle strength over ___, sensation none
upto hip bilaterally
DISCHARGE EXAM:
Vitals: T BP P RR %RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, rhonchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, +BS, no rebound
tenderness or guarding, no organomegaly
Ext: Left ischium with ~4x4cm ulcer, able to probe to bone with
surrounding necrotic tissue, left stump without warm, erythema.
RLE erythema markedly improved from prior exams, elevated, right
foot w/eschars wrapped, pulses non-dopplerable
Skin: No other rashes areas of erythema appreciated, no obvious
warmth
Neuro: CN II-XII grossly intact, UE strength/sensation WNL
Pertinent Results:
ADMISSION LABS:
___ 08:55PM BLOOD WBC-14.7* RBC-4.09* Hgb-12.4* Hct-39.5*
MCV-97 MCH-30.3 MCHC-31.4 RDW-13.6 Plt ___
___ 08:55PM BLOOD Neuts-82.7* Lymphs-11.2* Monos-4.5
Eos-0.9 Baso-0.8
___ 10:30AM BLOOD ___ PTT-33.8 ___
___ 10:30AM BLOOD ESR-96*
___ 08:55PM BLOOD Glucose-83 UreaN-9 Creat-0.7 Na-128*
K-4.8 Cl-93* HCO3-21* AnGap-19
___ 07:30AM BLOOD ALT-12 AST-19 LD(LDH)-127 AlkPhos-70
TotBili-0.4
___ 06:50AM BLOOD Calcium-7.6* Phos-2.3* Mg-1.9
___ 07:30AM BLOOD Albumin-2.4* Calcium-8.3* Phos-3.3 Mg-2.0
___ 10:30AM BLOOD CRP-184.9*
___ 08:55PM BLOOD Lactate-1.1 K-3.8
IMAGING:
Lower extremity ultrasound ___:
IMPRESSION:
1. Partially occlusive DVT in the right CFV and proximal SFV.
Findings are age indeterminate.
2. Partially occlusive DVT in the left CFV and proximal SFV.
Findings are age indeterminate.
CXR ___:
FINDINGS: No previous images. The tip of the Port-A-Cath
extends to the
medial aspect of the brachiocephalic vein on the left before its
junction with the superior vena cava.
No evidence of acute pneumonia or vascular congestion.
Left Ischium tissue biopsy ___:
Ischium, biopsy (A):
Acute osteomyelitis, focal.
Surrounding fibrous tissue with mild chronic inflammation.
CTA chest/aorta/iliac with runoffs ___
IMPRESSION:
1. 15 cm-long infrarenal abdominal aortic aneurysm measuring up
to 4.4 cm.
2. Extensive peripheral vascular disease, including complete
occlusion of the right common and external iliac arteries, as
described above. Reconstituted RCFA, occluded SFA,
reconstituted above knee popliteal artery and two-vessel right
lower extremity runoff.
3. Atrophic left kidney with multiple cortical defects, likely
the sequelae of chronic ischemia, given left main renal artery
stenosis.
4. Mild narrowing at the take-off of the celiac trunk.
5. Cholelithiasis.
6. Large hiatal hernia.
7. Left Port-A-Cath terminating at the left brachiocephalic
vein.
MICRO:
Left Ischium Bone bx:
___ 5:30 pm TISSUE (L) ISCHIUM.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
Reported to and read back by ___ ___ 11:21AM
___.
VIRIDANS STREPTOCOCCI. SPARSE GROWTH.
STREPTOCOCCUS ANGINOSUS (___) GROUP. SPARSE GROWTH.
ANAEROBIC CULTURE (Final ___:
BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH.
BETA LACTAMASE POSITIVE. OF TWO COLONIAL MORPHOLOGIES.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
RLE wound culture:
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
STAPH AUREUS COAG +. SPARSE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
DISCHARGE LABS:
___ 05:27AM BLOOD WBC-10.0 RBC-3.87* Hgb-11.9* Hct-38.6*
MCV-100* MCH-30.8 MCHC-30.9* RDW-15.5 Plt ___
___ 06:21AM BLOOD ___ PTT-31.9 ___
___ 05:27AM BLOOD ESR-75*
___ 05:27AM BLOOD Glucose-90 UreaN-27* Creat-0.8 Na-136
K-4.6 Cl-100 HCO3-29 AnGap-12
___ 07:40AM BLOOD ALT-19 AST-31 AlkPhos-104 TotBili-0.3
___ 05:27AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.1
___ 05:27AM BLOOD Vit___-___
___ 05:27AM BLOOD CRP-24.1*
Brief Hospital Course:
ASSESSMENT AND PLAN: ___ with ___ paraplegia (since ___,
wheelchair-bound/chronic foley), s/p L AKA (___), GERD, chronic
anemia, p/w deep ischial decubitus ulcer and R foot ulcers sent
from ___ ER for surgical consult.
ACTIVE ISSUES:
# Sacral OM: likely ___ pressure ulcer in the setting of
increase pressure on the left ischium over the last several
weeks because of concern for worsening edema in RLE. Pt found
to have elvated ESR/CRP and is now s/p bone bx with cultures
growing strep viridans and Bacteroides in anaerobic bottle.
Superficial swab positive for MSSA and Strep anginosis likely
contaminants. Blood cultures were negative. ID was consulted
and recommended treatment with ceftriaxone and flagyl while
in-house with transition to Ertapenem to continue for 6 weeks
and follow-up with ___ clinic.
# IV ACCESS: Has PortACath that was inserted ___ years ago at OSH
because of frequent need for abx given multiple UTIs. CXR showed
port tip in brachiocephalic. Pt reports trouble in the past
with not being able to draw off his ports. Says that at OSH he
went by "Odd-ball ___ Patient went to ___ and had PICC
line placed and port removed. Given patient has had multiple
infections in the past permanent venous access should be avoided
in this patient.
# RLE PVD: The lesion over his R leg likely ___ vascular and or
neuropathic ulcer and dry gangrene in patient with known PVD and
paraplegia with neuropathy. Pt has dependent rubor and no
pulses, vascular surgery consulted in ED and signed off.
Reconsulted yesterday for documentation and they have
recommended NIAS and toe pressures, CTA with runoffs. CTA
showed occlusion of major vessels, vascular surgery recs local
care and f/u for further discussion/management as an outpatient.
Patient developed worsening drainage of purulent material over
right great toe which was cultured. Abx were also broadened to
Cefepime and Flagyl at this time. Wound culture grew Coag
positive for MSSA and patient was started on vancomycin prior to
discharge, but rehab was called and updated to discontinue
vancomycin.
# UTI: Pt has pyuria in the setting of chronic indwelling foley.
Has hx of MDR UTIs in the past, therefore would favor not
empirically treating at this point. ED culture was obtained
before old catheter was removed, but has subsequently been
changed. Prelim on this cx growing pseudomonas. Pt known to
have very resistant Pseudomonas UTI in the past. Repeat UCx w
polymcrobial E. coli infection, likely ___ chronic foley
colonization would not treat as patient is asymptomatic.
CHRONIC ISSUES:
# HTN: Stable continue home Metoprolol Succinate
# HYPOTHYROID: Stable, continue home levothyroxine
# NEUROPATHY: Stable, continue home gabapentin
# ANEMIA: continue home iron supplmentation and bowel regimen
# CODE: FULL (confirmed)
# CONTACT: ___ (wife, HCP) ___
TRANSITIONAL ISSUES:
- Patient should follow-up with vascular surgery as an
outpatient for further debridement
- Patient should follow-up with Infectious Disease Outpatient
Antibiotic Therapy Clinic upon discharge to rehab for further
evaluation and determination of course of antibiotics
- If wound culture is positive for MRSA patient should continue
with vancomycin IV for 14 days
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
2. Acetaminophen 650 mg PO Q4H:PRN pain, fever
3. Aspirin 81 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. fenofibrate micronized *NF* 145 mg Oral daily
6. Detrol LA *NF* (tolterodine) 4 mg Oral BID
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
Hold for HR<60
9. OxycoDONE (Immediate Release) ___ mg PO TID:PRN pain
10. Oxycodone SR (OxyconTIN) 30 mg PO Q12H
11. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN gas
12. Ascorbic Acid ___ mg PO DAILY
13. Bisacodyl 10 mg PR HS:PRN constipation
14. Cyanocobalamin 1000 mcg PO DAILY
15. Docusate Sodium 100 mg PO BID:PRN constipation
16. Ferrous Sulfate 325 mg PO DAILY
17. Gabapentin 200 mg PO TID
18. Heparin Flush (10 units/ml) Dose is Unknown IV PRN line
flush
19. Lorazepam 0.5 mg PO Q8H:PRN anxiety
20. Milk of Magnesia 30 mL PO Q6H:PRN constipation
21. Nicotine Patch 14 mg TD DAILY
22. Vitamin D 4000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain, fever
2. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN gas
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Bisacodyl 10 mg PR HS:PRN constipation
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Ferrous Sulfate 325 mg PO DAILY
8. Gabapentin 200 mg PO TID
9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
10. Levothyroxine Sodium 100 mcg PO DAILY
11. Lorazepam 0.5 mg PO Q8H:PRN anxiety
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Milk of Magnesia 30 mL PO Q6H:PRN constipation
14. Nicotine Patch 14 mg TD DAILY
15. Omeprazole 20 mg PO DAILY
16. OxycoDONE (Immediate Release) ___ mg PO TID:PRN pain
17. Oxycodone SR (OxyconTIN) 30 mg PO Q12H
18. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
19. Cyanocobalamin 1000 mcg PO DAILY
20. Detrol LA *NF* (tolterodine) 4 mg Oral BID
21. fenofibrate micronized *NF* 145 mg Oral daily
22. Vitamin D 4000 UNIT PO DAILY
23. ertapenem *NF* 1 gram Intravenous Q24H
Continue until ___
24. Vancomycin 1000 mg IV Q 12H
25. ertapenem *NF* 1 gram Injection Q24H Reason for Ordering:
Needs one dose to document tolerance prior to discharge to
facility
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Osteomyelitis
Peripheral vascular disease
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:
Mr. ___, you were admitted to the ___
___ for evaluation of your ulcer. You were found to
have an infection in the bone underr your left buttock and in
your right leg will require intravenous (IV) antibiotics for
several weeks. You will have outpatient follow-up with the
Infectious Disease clinic for further management of your
antibioticts. You were also found to have severe peripheral
artery disease affecting your right leg and should follow-up
with a vascular surgeon after you leave rehab for further
management. Your Port was removed and a PICC line was placed so
you can continue to get antibiotics for your infection.
Please see below for your follow-up appointments.
It was a real pleasure caring for you and we wish you a speedy
recovery!
Followup Instructions:
___
|
10430393-DS-5 | 10,430,393 | 25,174,469 | DS | 5 | 2149-12-21 00:00:00 | 2149-12-21 16:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old female with no significant PMH who
presented to ___ with complaints of headache since ___. The
patient is ___ speaking only and HOH. According to the
patients daughter she began having intermittent headaches which
progressed to persistent headaches, and has been taking Aspirin
___ tabs every 6 hours since ___ for pain control. The
patient
is normally independent and ambulatory at home. This morning she
awoke with slurred speech which has since resolved. The patients
daughter states that she had a fall a "couple weeks ago"
although
denies head strike. Neurosurgery was consulted for further
recommendations and evaluation. On exam the patient denied chest
pain, SOB, fevers, or chills.
Past Medical History:
HTN in the distant past, no longer requires anti-hypertensive
medication.
Social History:
___
Family History:
NC
Physical Exam:
ON ADMISSION:
O: BP: 158/78 HR:85 R:18 O2Sats: 99 RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2-1 mm bilaterally EOMs-Grossly intact (tracks
examiner)
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, "hospital", and ___.
Language: Unable to assess language, ___ speaking only
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1
mm bilaterally.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Very HOH
XII: Tongue midline without fasciculations.
Motor: Moves all extremities x4 antigravity to command. Unable
to
obtain isolated motor exam as pt having difficulty participating
in exam due to language barrier & HOH.
ON DISCHARGE: (exam completed with interpretation by family)
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, "hospital", and ___.
Language: ___ speaking. No dysarthria.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2mm
bilaterally.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to loud voice
XII: Tongue midline without fasciculations.
Motor: Moves all extremities x4 antigravity to command and
against mild resistance. Unable to obtain isolated motor exam
due to language barrier.
Pertinent Results:
___ NCHCT:
Subacute left cerebral subdural hematoma measuring up to 5 mm
without
significant mass effect or midline shift.
___ NCHCT:
1. Dental almalgam and overlying hardware streak artifact limits
study.
2. Stable left subacute subdural hematoma measuring 4-5 mm in
maximal
thickness.
3. Within limits of study, no new acute intracranial hemorrhage.
___ NCHCT
1. Stable, small left subdural hematoma, measuring up to 4 mm
with interval resolution of minimal rightward midline shift.
2. No new, acute intracranial hemorrhage.
___ 05:30AM BLOOD WBC-3.4* RBC-3.68* Hgb-10.8* Hct-33.1*
MCV-90 MCH-29.3 MCHC-32.6 RDW-13.4 RDWSD-44.3 Plt ___
___ 06:10AM BLOOD WBC-3.3* RBC-3.65* Hgb-10.9* Hct-33.1*
MCV-91 MCH-
29.9 MCHC-32.9 RDW-13.3 RDWSD-44.1 Plt ___
___ 02:21AM BLOOD WBC-4.5 RBC-3.78* Hgb-11.2 Hct-34.0
MCV-90 MCH-29.6 MCHC-32.9 RDW-13.5 RDWSD-44.1 Plt Ct-73*
___ 01:48PM BLOOD WBC-5.6 RBC-3.99 Hgb-11.9 Hct-36.2 MCV-91
MCH-29.8 MCHC-32.9 RDW-13.5 RDWSD-45.1 Plt Ct-74*
___ 01:48PM BLOOD Neuts-72* Bands-1 Lymphs-5* Monos-21*
Eos-0 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-4.09
AbsLymp-0.28* AbsMono-1.18* AbsEos-0.00* AbsBaso-0.00*
___ 01:48PM BLOOD Hypochr-OCCASIONAL Anisocy-NORMAL
Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-1+
___ 05:30AM BLOOD Plt Smr-LOW Plt ___
___ 05:30AM BLOOD ___ PTT-29.9 ___
___ 02:21AM BLOOD ___ PTT-30.0 ___
___ 01:48PM BLOOD ___ PTT-30.5 ___
___ 05:30AM BLOOD Glucose-94 UreaN-12 Creat-0.6 Na-139
K-3.9 Cl-106 HCO3-27 AnGap-10
___ 03:24AM BLOOD Glucose-63* UreaN-13 Creat-0.7 Na-134
K-4.1 Cl-103 HCO3-22 AnGap-13
___ 02:21AM BLOOD Glucose-67* UreaN-18 Creat-0.6 Na-135
K-4.2 Cl-101 HCO3-25 AnGap-13
___ 01:48PM BLOOD Glucose-117* UreaN-25* Creat-0.9 Na-134
K-4.2 Cl-96 HCO3-29 AnGap-13
___ 05:30AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.8
___ 03:24AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.8
___ 02:21AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.9
___ 01:48PM BLOOD Calcium-9.1 Phos-2.9 Mg-2.0
___ 03:24AM BLOOD VitB12-___* Folate-14.7
___ 01:48PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:00PM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:00PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-7.5 Leuks-MOD
___ 04:00PM URINE RBC-15* WBC-12* Bacteri-FEW Yeast-NONE
Epi-<1
Brief Hospital Course:
On ___ the patient presented with persistant headache x 3days.
She has been taking Aspirin for pain. On head CT she was found
to have L subacute SDH. She received platelets in ED and 1gm
Keppra. She was admitted to the ICU for further monitoring.
On ___ the patient remained neurologically stable. Hematology
was consulted for thrombocytopenia which is a chronic issue the
patient has been followed for in the past. They recommended the
patient follow up with Atrius Hematology at ___ and the
contact information was provided to the patient's daughter. ___
working with the patient and the recommend rehab. Her IV fluids
were d/c'd. She is tolerating a regular diet.
On ___, the patient remained neurologically stable. ___
continues to work with patient. Family at bedside expressed
interest in rehab if ___ speaking. Case management was
informed of the plan to begin discharge planning. Patient was
called out to the floor.
On ___ patient remained neurologically and hemodynamically
stable. She had a repeat NCHCT which was stable. Heme/Onc
continued to follow for her low platelets, and recommended
outpatient follow-up. She continued to work with physical
therapy, who recommended discharge to rehab.
Medications on Admission:
Calcium with D3
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain/ fever
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. Heparin 5000 UNIT SC BID
5. LevETIRAcetam 500 mg PO BID
6. Senna 8.6 mg PO BID:PRN Constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left subdural hematoma
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:
Brain Hemorrhage without Surgery
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.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10430393-DS-6 | 10,430,393 | 25,422,304 | DS | 6 | 2150-01-24 00:00:00 | 2150-01-24 15:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
prednisone
Attending: ___
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with past medical history of SDH after fall in ___
presents with a single level unwitnessed mechanical fall which
occurred ___. Patient was rising to her walker to ambulate
when she fell, and was assisted by her daughter who came from an
adjacent room after hearing the event. She found her mother on
her buttocks and conscious without suspicion for loss of
consciousness.
She had a fall earlier in the year which resulted in a SDH and a
hospitalization. She was recently discharged from a
rehabilitation facility and returned recently to family
dwelling. She has a distant history of HTN but is not currently
on any anti-hypertensive medications. She speaks ___ and
her history is recounted by her daughter who has served as both
the ___ for her mother during this admission and as a
historian. Per report, the patient denies nausea, emesis, change
in bowel habits, syncopal events. No recent fevers or chills. No
recent bloody stools or melena.
On evaluation in the ED, she has a NCHCT and C Spin CT negative
for acute fractions. Her CT Torso shows a right 9th rib fracture
with a small associated hemothorax. There is no overlying
crepitus or external evidence of injury at that site or
elsewhere on her body. Her VSS and E 4 V 4 or 5 and M 6 for a
total of ___ on exam. Her laboratory values are unremarkable
except for UA concerning for a UTI. On CT Imaging she has a
findings on in her thyroid and thoracic aorta which are non
acute but require outpatient evaluation.
Past Medical History:
HTN in the distant past, no longer requires anti-hypertensive
medication.
Social History:
___
Family History:
NC
Physical Exam:
Admission PE:
VS: 97.6F 59 121/67 19 96% RA
Gen: frail, petite, elderly woman
Neuro: PERRL, EOMI, follows commands, moves all four extremities
no pronator drift
HEENT: atraumatic head, no hemotympanium, no malocclusion, non
tender neck on exam
CV: RRR
Pulm: b/l breath sounds, decreased air movement some minor
crackles R base, no ecchymosis, hematoma or lacerations. Right
chest wall tenderness to palpation, no crepitus
Abd: scaphoid abdomen, soft, non tender, non distended, no
guarding or rebound
Ext: lower and upper extremity pulses palpable, full ROM UE and
___, motor function intact
Thorax: no ecchymosis, no chest wall deformity or tenderness on
exam
Pelvis: stable, no hematomas or lacerations over bony
prominences
Pertinent Results:
___ 08:34PM GLUCOSE-95 UREA N-23* CREAT-0.8 SODIUM-139
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-30 ANION GAP-11
___ 08:34PM CALCIUM-9.2 PHOSPHATE-3.6 MAGNESIUM-2.0
___ 08:34PM WBC-4.9 RBC-3.83* HGB-11.4 HCT-35.2 MCV-92
MCH-29.8 MCHC-32.4 RDW-14.0 RDWSD-47.0*
___ 08:34PM PLT COUNT-62*
___ 08:34PM ___ PTT-30.0 ___
___ 10:10PM URINE HOURS-RANDOM
___ 10:10PM URINE HOURS-RANDOM
___ 10:10PM URINE UHOLD-HOLD
___ 10:10PM URINE GR HOLD-HOLD
___ 10:10PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
___ 10:10PM URINE RBC-9* WBC-24* BACTERIA-FEW YEAST-NONE
EPI-<1
___ 10:10PM URINE HYALINE-3*
___ 08:20PM COMMENTS-GREEN TOP
___ 08:20PM K+-3.7
___ 07:30PM GLUCOSE-141* UREA N-25* CREAT-0.9 SODIUM-134
POTASSIUM-7.1* CHLORIDE-99 TOTAL CO2-26 ANION GAP-16
___ 07:30PM estGFR-Using this
___ 07:30PM ALT(SGPT)-20 AST(SGOT)-62* ALK PHOS-48 TOT
BILI-0.4
___ 07:30PM ALBUMIN-4.2
___ 07:30PM WBC-4.5 RBC-3.89* HGB-11.6 HCT-35.8 MCV-92
MCH-29.8 MCHC-32.4 RDW-14.2 RDWSD-47.7*
___ 07:30PM NEUTS-44.4 ___ MONOS-29.6* EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-1.99# AbsLymp-1.15* AbsMono-1.33*
AbsEos-0.00* AbsBaso-0.01
___ 07:30PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-1+ MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL
POLYCHROM-NORMAL OVALOCYT-1+ TARGET-OCCASIONAL BURR-OCCASIONAL
TEARDROP-OCCASIONAL
___ 07:30PM PLT SMR-VERY LOW PLT COUNT-78*
Brief Hospital Course:
___ w recent ___ admitted to ___ s/p fall while transferring
from ___. Patient is ___ only and information obtained
from medical records and with family. Patient has been under
home ___ care at home for past 2 weeks. On ___, while
attempting to stand up from seated position, she felt leg
weakness, and sat onto the floor; failed to reach ___. There
was no LOC.
In the ED, CT scans were done. UA was positive and treated with
macrobid. She reports increased urinary frequency. She was
unsteady walking in the ED and initial disposition was to rehab.
She had mild increase in her repeat CXR while in ED although
remained stable from respiratory or hemodynamic standpoint.
Given her age and comorbidities she was transferred to ICU for
close monitoring. She also had positive UA in ED and was started
on nitrofurantoin. Her repeat cultures were consistent with
contamination, she completed 3 day course of antibiotic.
She continued to remain clinically stable, her repeat Hct was
stable, on HD 3 she was transferred from ICU to floor. On HD 4,
the patients hematocrit remained stable at 35.6(35.4), and her
CXR was stable to improved. She was weaned off supplemental
oxygen successfully and physical therapy recommended discharge
to rehab. At the time of discharge, the patient was doing well,
afebrile and hemodynamically stable. The patient was tolerating
a diet, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Bisac-Evac 10 mg rectal suppository
Colace 100 mg capsule
Milk of Magnesia 400 mg/5 mL oral suspension
Tylenol ___ mg tablet
Vitamin D3 1,000 unit capsule
bisacodyl 5 mg tablet
levetiracetam 1,000 mg tablet (no longer takes per daughter)
senna 8.6 mg capsule
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. Senna 8.6 mg PO BID:PRN Constipation
5. Milk of Magnesia 30 mL PO Q12H:PRN constipation
6. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Mildly displaced right T9 rib fracture
Small right hemothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
after a fall. Imaging revealed a ___ right sided rib fracture
and some blood in your lung space. You were closely monitored
and your blood levels remained stable. You had chest xrays to
monitor your lung which have remained stable. You were found to
have a urinary tract infection for which you were treated with
antibiotics. You are now breathing comfortably, pain is better
controlled, and you are ready to be discharged to home to
continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up in clinic.
Avoid driving or operating heavy machinery while taking pain
medications.
* 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:
___
|
10430393-DS-7 | 10,430,393 | 23,453,719 | DS | 7 | 2151-01-18 00:00:00 | 2151-01-18 21:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
prednisone
Attending: ___
Chief Complaint:
flank pain/back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ ___ PMHx osteoporosis, known
ascending aortic aneurysm ,and h/o recurrent falls with prior
___ who presents with complaint of back pain and L-sided flank
pain.
She reports that her back pain and L-sided flank pain began ___
weeks ago and has become progressively worse. Her flank pain
radiates from her back to the front. It was initially
exacerbated with movement but now she has pain even at rest.
She and her family deny any recent trauma or falls (last fall
reportedly last year, complicated by ___). She has had no
changes in her BMs and denies any melena or BRBPR. She also
denies any n/v, chest pain, SOB, f/c/ns. Aside from her pain,
she has otherwise been in her USOH. Given her progressive
back/flank pain, she presented to the ED.
In the ED, initial VS 97.7, 69, 153/79, 19, 97% on RA. Her labs
were notable for wnl chemistries, WBC 3.8, wnl Hgb 12.3, Plt
107. UA negative. She underwent CTA torso which showed RLL
subsegmenetal PE, enlargement of her known ascending aortic
aneurytsm to 6.5 cm (from 6.3 cm), and a new T11 compression
fracture with moderate degenerative changes of her spine
including additional compression deformities of T12-L4. She was
evaluated by Cardiac Surgery who felt she was not a candidate
for cardiac surgery re: her known aortic aneurysm. Ortho Spin
erecommended outpatient f/u in Spine clinic and no role for
bracing/surgical intervention at this time. Per ___, her
aortic aneurysm was not a hard contraindication for initiation
of AOC; Neurology was curbsided and discussed that because her
SDH was over ___ year ago, AOC could be initiated safely if
desired.
Upon arrival to the floor, the patient denies any chest pain,
SOB, exertional dyspnea. She endorses only back pain while
lying in bed but states she is currently comfortable. She
states she has had no BMsin 4 days (normally moves BMs daily).
She states she is otherwise in her USOH.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
osteoporosis
thrombocytopenia
AAA
h/o SDH
Social History:
___
Family History:
NC
Physical Exam:
Admission exam:
Vitals- 99.4 144 / 83 70 18 94 Ra
GENERAL: ___, elderly female in NAD
HEENT: MMM, NCAT, EOMI, anicteric sclera
CARDIAC: RRR, nml S1 and S2, no m/r/g, no JVD
LUNGS: CTAB, unlabored respirations
BACK: mild midline spinal TTP of lower thoracic region with mild
TTP of L paraspinal region
ABDOMEN: soft, NTND, normoactive bowel sounds
EXTREMITIES: no pitting edema of BLE
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: AOx3, sensation intact, moving all extremities
purposefully
Discharge exam:
Vitals: 98.5 ___
GENERAL: ___, elderly female sitting up in bed,
eating breakfast, no distress
HEENT: MMM, NCAT, EOMI, anicteric sclera
CARDIAC: RRR, no murmurs
LUNGS: clear bilaterally
ABDOMEN: soft, nontender throughout
EXTREMITIES: no edema
Pertinent Results:
Admission exam:
___ 06:32PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 06:30PM GLUCOSE-84 UREA N-21* CREAT-0.7 SODIUM-139
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-30 ANION GAP-13
___ 06:30PM ALT(SGPT)-6 AST(SGOT)-14 ALK PHOS-53 TOT
BILI-0.5
___ 06:30PM LIPASE-40
___ 06:30PM ALBUMIN-3.9
___ 06:30PM WBC-3.8* RBC-4.12 HGB-12.3 HCT-37.3 MCV-91
MCH-29.9 MCHC-33.0 RDW-13.7 RDWSD-45.4
___ 06:30PM NEUTS-56.0 ___ MONOS-23.3* EOS-0.0*
BASOS-0.0 IM ___ AbsNeut-2.11 AbsLymp-0.74* AbsMono-0.88*
AbsEos-0.00* AbsBaso-0.00*
___ 06:30PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
___ 06:30PM PLT SMR-LOW PLT COUNT-107*
Discharge exam:
___ 06:20AM BLOOD WBC-3.0* RBC-4.11 Hgb-12.0 Hct-36.3
MCV-88 MCH-29.2 MCHC-33.1 RDW-13.9 RDWSD-44.6 Plt Ct-99*
___ 06:20AM BLOOD Glucose-76 UreaN-20 Creat-0.8 Na-140
K-3.9 Cl-102 HCO3-30 AnGap-12
___ 06:20AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.1
Micro:
urine culture pending
Imaging/Studies:
___ CTA TORSO
1. Right lower lobe subsegmental pulmonary embolism.
2. No evidence of aortic dissection. Mild interval increase in
size of large ascending aortic aneurysm now measuring up to 6.5
cm.
3. Focal enhancement along the periphery segment ___ of the
liver, which can be seen in the setting of superior vena cava
syndrome. Clinical correlation is recommended.
4. Upper lobe predominant ground-glass opacities likely reflect
an infectious or inflammatory process.
5. Diffuse enlargement of the thyroid gland, for which
nonemergent thyroid ultrasound is recommended.
6. New T11 superior endplate compression fracture. Moderate to
severe multilevel degenerative changes of the spine, including
compression deformities of T12-L4 with greater than 50% loss of
height.
___ LENIs
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
EKG:
___ sinus bradycardia
Brief Hospital Course:
Ms. ___ is a ___ ___ ___ osteoporosis, known
ascending aortic aneurysm ,and h/o recurrent falls with prior
___ who presents with complaint of back pain and L-sided flank
pain.
# Back pain
# Acute T11 compression fracture
# severe osteoporosis
Back pain likely due to compression fracture, spontaneously
occurred in setting of known severe osteoporosis. No history of
preceding trauma. Ortho spine consulted and did not recommend
any bracing or surgical intervention. Pain was managed with
Tylenol and patient's family instructed to start 1g Q8H to help
manage pain during acute setting. Home vitamin D and calcium
were continued. ___ evaluated patient and recommended home with
home ___. Pain much improved on discharge.
# Subsegmental PE
Patient with new RLL subsegmental PE incidentally noted on CTA.
She is asymptomatic without chest pain, dyspnea, hypoxia, or
tachycardia. Bilateral lower extremity dopplers were also
negative. Extensive counseling regarding risks/benefits of
anticoagulation was pursued with the patient's 4 daughters.
Ultimately, it was determined her risk of bleeding on
anticoagulation would outweigh the benefit, particularly given
the subsegmental nature of the PE. Would recommend surveillance
___ ultrasounds to evaluate for DVT. If any new clots were found,
could readdress anticoagulation risks/benefits.
# Thoracic aortic aneurysm
Dilated to 6.5 cm on CT scan without any complications seen. Per
cardiac surgery, not a surgical candidate. Patient's BP remained
well controlled < 120. Patient's family was counseled regarding
this finding. Recommend outpatient surveillance.
# Constipation. No BM in 4 days. Started on
colace/senna/miralax with good effect.
Transitional issues:
- risk of bleeding thought to outweigh benefit of
anticoagulation of subsegmental PE
- recommend surveillance lower extremity ultrasound to evaluate
for DVT in 6mo
- surveillance for thoracic aortic aneurysm, patient is not
surgical candidate
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 1000 UNIT PO DAILY
2. Calcium Carbonate 600 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*84 Tablet Refills:*0
2. Calcium Carbonate 600 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
subsegmental pulmonary embolus
severe osteoarthritis c/b acute compression 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:
Ms. ___
It was a pleasure caring for you during your stay at ___. You
were admitted for back pain and you were found to have a
compression fracture in your spine, likely due your
osteoarthritis. You were also found to have a small blood clot
in your lung as well as slight enlargement of your aortic
aneurysm. We discussed the risks and benefits of a blood
thinner. The risk of the blood clot causing serious problems is
relatively low. However, the risk of you bleeding while on the
blood thinner is at least moderate to high. Therefore, the risk
of a blood thinner (bleeding) is likely greater than the
benefit.
We would recommend outpatient monitoring for clots, such as
repeat ultrasound of your legs, in about 6 months. You should
have surveillance of your aortic aneurysm as directed by your
PCP.
For your pain, you should take 1000mg (2 extra-strength Tylenol
or acetaminophen) every 8 hours regularly until you see your
PCP. You can also have ___ extra-strength Tylenol as needed for
pain during the day. DO NOT EXCEED 8 EXTRA STRENGTH TYLENOL
PILLS in 1 day.
Take care,
Your ___ Team
Followup Instructions:
___
|
10430459-DS-12 | 10,430,459 | 28,359,567 | DS | 12 | 2188-02-21 00:00:00 | 2188-02-23 09:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lung mass
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an ___ yo M former smoker, h/o tongue/pharynx SCC s/p
resection and radiation, who presents with FTT, weight loss, and
new lung mass on CXR.
Pt presented to PCP ___ ___ with ___ months of 15 lb
unintentional weight loss, generalized weakness, increased
somnolence. He also has had over this time bilateral calf
tightness and a shuffling, more unsteady gait. He has not had
any SOB, chest pain, back pain, hemoptysis, blood in the stools
or urine. He uses a liquid diet after his tongue cancer
resection, with long standing esophageal dysphagia after his
surgery (not new or progressive). He denies frank weakness in
his legs, bowel or bladder incontinence, vision changes, changes
in speech, or headaches.
CXR revealed large left lung mass (different from prior lung
nodule seen on prior CT). Labs with new transaminitis to ___,
new anemia to ___ (baseline ___, Na low 130s (baseline ___
140), WBC 25 with left shift, albumin 2.6, TSH 7, low
iron/TIBC/transferrin and a high ferritin.
In the ED, initial vitals were: 98.2 73 114/53 18 100%. Symptoms
as above, admitted for expedited workup of lung mass
On the floor, pt is without acute complaints.
Review of systems: As above. Also denies
fevers/chills/diarrhea.
Past Medical History:
Peptic ulcer
Osteomyelitis
Osteoarthritis
THYROID NODULE
HYPOTHYROIDISM
Positive PPD (pt unsure of details, denies TB exposure)
MASTOIDITIS - CHRONIC
HEARING LOSS - CONDUCTIVE & SENSORINEURAL
OCULAR HYPERTENSION
HISTORY BCC- l cheek
Polycythemia
Lung nodule
T1, N1, M0, grade II squamous cell carcinoma of the right
retromolar trigone in ___
Left oral tongue tumor, ___
Social History:
___
Family History:
Sister with breast cancer.
Physical Exam:
ADMISSION:
97.5 123/62 66 18 100% RA
General: Cachectic, NAD, speech is dysarthric (per pt baseline)
HEENT: Dry MM, no obvious cervical LAD, surgical scars on
anterior chin
Neck: Supple, no JVD
CV: RRR, no m/r/g
Lungs: CTAB
Abdomen: Soft, scaphoid, no ttp, NABS
GU: No foley
Back: No ttp or step offs on spine
Ext: WWP, no edema
Neuro: CN II-XII intact, nml strength/sensation throughout, nml
FNF, gait deferred
Skin: No rashes on visualized skin
Rectal: Nml rectal tone, sensation, no stool in the vault
DISCHAGE:
Vitals: 98 108/48 70 18 100% RA
General: Cachectic, NAD, speech is dysarthric (per pt baseline)
HEENT: Dry MM, no obvious cervical LAD, surgical scars on
anterior chin
Neck: Supple, no JVD
CV: RRR, no m/r/g
Lungs: CTAB
Abdomen: Soft, scaphoid, no ttp, NABS
GU: No foley
Ext: WWP, no edema
Neuro: CN II-XII intact, nml strength/sensation throughout, nml
FNF, gait deferred
Skin: No rashes on visualized skin
Pertinent Results:
ADMISSION LABS:
___ 01:05PM PLT COUNT-445*
___ 01:05PM NEUTS-93.3* LYMPHS-3.1* MONOS-3.1 EOS-0.3
BASOS-0.2
___ 01:05PM WBC-22.9* RBC-3.47* HGB-10.2* HCT-32.3*
MCV-93 MCH-29.5 MCHC-31.7 RDW-13.9
___ 01:05PM ALBUMIN-3.2* CALCIUM-9.0 PHOSPHATE-3.2
MAGNESIUM-2.6
___ 01:05PM LIPASE-35
___ 01:05PM ALT(SGPT)-55* AST(SGOT)-34 ALK PHOS-89 TOT
BILI-0.4
___ 01:05PM estGFR-Using this
___ 01:05PM GLUCOSE-99 UREA N-12 CREAT-0.6 SODIUM-132*
POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-29 ANION GAP-11
___ 02:30PM ___ PTT-31.0 ___
___ 11:04PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 11:04PM URINE COLOR-Yellow APPEAR-Hazy SP ___
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-19.4* RBC-3.01* Hgb-8.6* Hct-27.9*
MCV-93 MCH-28.6 MCHC-30.8* RDW-13.9 Plt ___
___ 06:25AM BLOOD ALT-40 AST-27 LD(LDH)-316* AlkPhos-74
TotBili-0.3
___ 06:25AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.9 UricAcd-2.4*
___ 06:25AM BLOOD T4-6.6
MICRO:
___ 11:04 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION
___ 6:25 am BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING:
CXR ___: IMPRESSION: Large left perihilar mass;
differential diagnosis includes
malignancy but smooth borders may indicate a cystic or benign
lesion. Chest
CT, preferably with intravenous contrast, is recommended to
characterize
further.
CT ABD/PELVIS W/ CONTRAST ___: IMPRESSION:
1. No evidence of intra-abdominal malignancy.
2. Cholelithiasis without cholecystitis.
3. Abdominal aortic atherosclerotic calcification
moderate-severe stenosis of
the celiac artery ostia.
CT CHEST WITH CONTRAST ___:
IMPRESSION:
1. Large, necrotic lingular mass consistent with primary lung
cancer, likely large cell. The mass abuts the adjacent
pericardium and is associated with mild mass effect on the left
heart and a small pericardial effusion.
2. Contiguous left hilar lymph nodes are enlarged and result in
narrowing of
the lingular bronchus.
3. Trace left pleural effusion.
4. Subcentimeter mixed attenuation lung nodules are not typical
for
metastases, but could represent sites of multicentric lung
cancer.
5. Complete description of subdiaphragmatic findings is
dictated under a
another clip number.
Brief Hospital Course:
This is an ___ yo M former smoker, h/o tongue/pharynx ___ s/p
resection and radiation, who presents with FTT, weight loss, and
new lung mass on CXR.
# Lung mass: C/f primary lung cancer, with associated small
pericardial effusion and mass effect on left heart on CT.
Unclear if nodules on R are mets, multicentric foci, or
incidental. No evidence of intraabdominal metastasis. Atrius
oncology was consulted and plan is for outpatient bronchoscopy
by IP for biopsy, ___ and MRI brain to complete staging, as
well as TTE to characterize pericardial involvement. Pt will ___
in ___ clinic. Functional status is poor, may limit
therapeutic options.
# Leukocytosis: Left shift. Most likely a leukamoid reaction to
his malignancy. There appeared to be compressive atelectasis
from the tumor but no clinical e/o pneumonia so held off on
treating. UA was neg. Blood cultures pending at discharge but
there was low suspicion for infection.
# LFT elevation: Mild. No baseline for comparison. No e/o
obvious mets on CT. No symptoms to suggest active hepatitis or a
biliary process. Normalized at discharge.
# Hyponatremia: Mild, could be hypovolemic from longstanding
poor PO intake or mild SIADH from lung tumor. Encouraged PO
intake and pt will have repeat labs as an outpatient.
# FTT: Likely due to underlying malignancy. Albumin 3.2. Pt will
continue with Ensure supplementation as outpt.
# Anemia: Normocytic. Most c/w anemia of chronic disease, though
iron saturation is low so iron deficiency likely contributing as
well. There was no stool in rectal vault to guiac on exam. Could
also consider marrow infiltration by malignant process. Pt
started on iron supplementation with a bowel regimen and will
have PCP and oncology ___.
# Hypothyroid: Pt with TSH 7, T4 wnl, consistent with
subclinical hypothyroidism. Decision whether to increase thyroid
hormone dosing can be as an outpatient.
# Ocular: H/o glaucoma. Continued home timolol and latonoprost.
Transitional issues:
- Outpt lung biopsy with IP (needs to be scheduled); IP office
will call patient, and patient given IP # as well
- Outpt TTE, ___ MRI for staging (need to be
scheduled, Atrius onc will call pt)
- Outpt Atrius oncology ___
- PCP ___, please check CBC and electrolytes at that visit.
- ___ blood cx
- Suggest trending T4 levels as outpt to assess need to increase
thyroid hormone if overt hypothyroidism develops
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Ranitidine 150 mg PO BID
4. Timolol Maleate 0.5% 1 DROP LEFT EYE BID
Discharge Medications:
1. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Ranitidine 150 mg PO BID
4. Timolol Maleate 0.5% 1 DROP LEFT EYE BID
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
6. Ferrous Sulfate 325 mg PO DAILY
Leave four hours between taking this and levothyroxine
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
7. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*30 Capsule Refills:*0
1. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Ranitidine 150 mg PO BID
4. Timolol Maleate 0.5% 1 DROP LEFT EYE BID
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
6. Ferrous Sulfate 325 mg PO DAILY
Leave four hours between taking this and levothyroxine
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
7. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Lung mass
Failure to thrive
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted
with weakness and a new lung mass. The lung mass, as we
discussed, is concerning for cancer. We think your weakness is
related to this possible cancer as well, as it can cause you to
feel fatigued. We are setting you up with a biopsy procedure
with the pulmonologists as an outpatient, as well additional
imaging to see if there is evidence of cancer elsewhere in your
body. We also would like you to have an echocardiogram, or heart
ultrasound, as the mass is close to your heart.
You will be contacted about these appointments.
We also would like you to see your primary care doctor to have
labs checked next week. We have started you on iron for your
anemia (low blood count), as well as a laxative to prevent
constipation, which can happen with iron. Remember to stay
well-hydrated at home.
Followup Instructions:
___
|
10430776-DS-9 | 10,430,776 | 28,041,745 | DS | 9 | 2146-06-09 00:00:00 | 2146-06-10 21:19:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___ - intubated
___ - R pigtail catheter placed
___ - extubated
History of Present Illness:
Mr. ___ is ___ male with a past medical
history of COPD, CHF, A. fib on Pradaxa, hypertension who
presents to the emergency department as a transfer for a
possible overdose.
History is obtained by EMS and per medical records, patient
presented to ___ on ___ ___ the evening,
complaining of shortness of breath for several days. He endorses
a fall a few days prior to presentation for which he was taking
extra oxycodone for his pain. At the outside hospital, he was
very drowsy and retaining CO2 so he was ___ Narcan. Patient
became alert and agitated at that time. He was also found to be
___ A. fib with RVR. Throughout his ED stay, patient will
continue to be agitated and started to desaturate requiring RSI.
He was intubated with etomidate and succinylcholine.
Subsequently patient had a CAT scan of his head and neck which
were negative for any acute fractures or intracranial processes.
It did show a large right pleural effusion.
Patient was loaded with digoxin and IV magnesium and transferred
to ___ for further care. He also received 10 mg of IV vitamin
K per med flight.
Received propofol, fentanyl, versed at OSH. He was continued on
propofol at ___.
Trauma surgery evaluated him and didn't recommend chest tube
___ that there might be a hemothorax.
Sedation was lightened ___ the ED ___ attempt to do a neuro exam,
but patient was not following commands.
Physical exam ___ ED:
====================
Con: Intubated sedated, GCS 3 T
HEENT: NCAT. pinpoint pupils, no icterus. midline trachea
Neck: no JVD. No step-offs appreciated over cervical, thoracic
or lumbar spine
Resp: No incr WOB, CTAB. Diminished breath sounds ___ the right
lung fields
CV: RRR. Normal S1/S2. 2+ radial pulse bilaterally
Abd: Soft, Nondistended.
MSK: ___ without edema. No joint stability, no focal tenderness
over long bone
Skin: No rash, Warm and dry, No petechiae
Neuro: Intubated and sedated, GCS of 3T. Withdraws to pain to
all 4 extremities
EKG afib, RBBB.
OSH IMAGING
===========
CT Head ___
No evidence of intracranial hemorrhage, mass-effect, or fracture
Small laceration of the right frontal scalp
CT cervical spine ___
No evidence of fracture or traumatic subluxation
CTA of the chest ___
Acute appearing fracture of the ninth right rib, there are old
fractures of the right sixth and seventh ribs Moderate right
pleural effusion, which may represent hemothorax No evidence of
pulmonary thromboembolism. However evaluation of the basal
vessels is limited due to suboptimal bolus of contrast.
On arrival to the MICU, patient is intubated and sedated.
MICU Course: Underwent thoracentesis ___ for R hemothorax,
believed to be caused by rib fx following mechanical fall.
Stepped down to floor on ___.
Past Medical History:
COPD
CHF
A. fib on Pradaxa
Hypertension
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
GENERAL: Intubated and sedated
HEENT: Pupils sluggishly reactive to light, equal, round,
anicteric sclera
NECK: supple, JVP not elevated, no LAD
LUNGS: Diminished breath sounds on right anterior lung field,
throughout
CV: Irregularly irregular, 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, 2+ edema to knees
bilaterally, during on the bottoms of the feet
SKIN: Ecchymosis throughout, mainly on the lateral side of right
knee
NEURO: Withdraws all 4 extremities to pain
DISCHARGE PHYSICAL EXAM
=======================
PHYSICAL EXAM:
___ 0741 Temp: 97.7 PO BP: 123/69 HR: 96 RR: 18 O2 sat: 93%
O2 delivery: Ra
GENERAL: NAD, asleep ___ bed
HEENT: MMM, anicteric sclera
NECK: supple, JVD to 14cm at 45 degrees
CV: RRR, no M/R/G
PULM: CTAB, no wheezes, crackles
GI: soft, NT, ND
EXTREMITIES: 2+ pitting edema b/l to the knee
NEURO: CN ___ grossly intact
GAIT: abnormal gate with decreased leg swinging, but stable and
able to ambulate without assistance
Pertinent Results:
ADMISSION LAB RESULTS
=====================
___ 02:15AM BLOOD WBC-8.7 RBC-3.84* Hgb-9.5* Hct-30.8*
MCV-80* MCH-24.7* MCHC-30.8* RDW-20.0* RDWSD-57.1* Plt Ct-52*
___ 02:15AM BLOOD ___ PTT-47.3* ___
___ 06:56AM BLOOD Glucose-103* UreaN-17 Creat-0.9 Na-142
K-3.4* Cl-93* HCO3-34* AnGap-15
___ 06:56AM BLOOD ALT-25 AST-34 LD(LDH)-360* CK(CPK)-149
AlkPhos-101 TotBili-0.8
___ 06:56AM BLOOD Albumin-3.3* Calcium-8.2* Phos-4.4 Mg-2.6
Iron-19*
___ 02:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LAB RESULTS
=====================
IMAGING
=======
OSH IMAGING
===========
CT Head ___
No evidence of intracranial hemorrhage, mass-effect, or fracture
Small laceration of the right frontal scalp
CT cervical spine ___
No evidence of fracture or traumatic subluxation
CTA of the chest ___
Acute appearing fracture of the ninth right rib, there are old
fractures of the right sixth and seventh ribs
Moderate right pleural effusion, which may represent hemothorax
No evidence of pulmonary thromboembolism. However evaluation of
the basal vessels is limited due to suboptimal bolus of
contrast.
___ IMAGING
=============
US of Left Lower Extremity ___
No evidence of DVT
MICROBIOLOGY
============
___ Blood culture - negative
___ urine culture - negative
___ Sputum culture:
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ CLUSTERS.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). RARE GROWTH.
Brief Hospital Course:
___ with a hx of COPD, HFrEF, Afib (on pradaxa), chronic lumbar
pain previously on long term narcotics who presented for
somnolence ___ the setting of what is suspected to be
unintentional opioid overdose. The patient was administered
narcan, intubated at OSH prior to transfer and was subsequently
admitted to ___ MICU. Course ___ the MICU notable for R sided
hemothorax ___ setting of rib fx s/p thoracentesis by IP,
episodes of afib w/ RVR, as well as ongoing thrombocytopenia.
# Hypoxia
The patient had persistent hypoxia s/p thoracentesis for
hemothorax. Not on home O2. Differential included pulmonary
edema ___ reduced EF and severe MR vs PE ___ ___ of held
anticoagulation and enlarged right sided heart chambers vs less
likely COPD exacerbation. Eventually resolved and pt went home
without any O2 requirements.
# HFrEF
# Severe MR
___ revealing for EF=43% w/ regional wall motion abnormalities
___ inferior segments and severe MR. ___ the severity of MR, EF
likely overestimated. Most likely etiology of cardiomyopathy is
ischemic. Is on home Lasix 40mg BID, although there is some
question as to if the pt is taking this. Held initiation of ACE
inhibitors due to soft BPs, but can consider initiating outpt by
PCP (transitional issue). ___ also need ischemic workup as
outpt.
# R Hemothorax
CT scan at OSH notable for a R sided hemothorax ___ the setting
of rib fracture s/p presumed mechanical fall. IP consulted and
placed pigtail cath w/ bloody output, removed several days after
it was placed.
# Opiate withdrawal
Patient with tachycardia, tremulousness, nausea,
vomiting,restlessness. Likely from opiate withdrawal ___
longstanding use. Pt initially interested ___ discontinuing all
narcotics and addiction psych consulted. However over course of
stay, changed his mind and decided to stay on his prescribed
oxycodone regimen for chronic back pain.
# Urinary retention
Per history, pt takes > ___ hours to urinate at home. Noted to
have significant retention on voiding trial ___ MICU. Resolved;
managed with finasteride 5mg QDaily and tamsulosin 0.4 QDaily.
# Thrombocytopenia
Transient, with unclear cause. Pt w/ concurrent anemia, however
no evidence to suggest active bleeding, splenic sequestration,
or thrombotic microangiopathy. Timing of heparin administration
not consistent w/ HIT. No obvious offending drugs. Consumption
___ the setting of resolving hemothorax may be implicated,
however thrombocytopenia to this degree would be atypical. Per
heme, prior chronic alcohol use may be invoked, though at
present there is a paucity of priorlab values and social history
to confidently attribute his thrombocytopenia to this. Resolved
prior to discharge.
# Microcytic Anemia
Likely multifactorial ___ known blood loss from hemothorax and
long standing nutritional deficiencies. Iron studies suggestive
of iron deficiency. LDH slightly high however may be related to
blood reabsorption from the lung and nml hapto not consistent
w/hemolysis, furthermore there were no schisotcytes on smear.
# A fib
Received digoxin load outside hospital. Currently ___ persistent
afib on telemetry. Rates controlled on home verapamil, though
with episodes of RVR ___ the MICU. Pt refused metoprolol because
of previous adverse effect of memory lost ___ the past so placed
on diltiazem. Patient HR stable so will maintain current dose of
diltiazam and change to long acting. CHADVAS score greater than
4 so will be discharged on dabigatran and ASA.
# COPD
Patient with history of COPD with high PCO2 on ABG and high
calculated bicarb. Remains persistently hypoxic, but no wheezes
on exam. Discharged on home medications.
# Falls, multiple
# Rib fracture
# Sciatic pain
Controlled with standing tylenol, lidocaine patch, gabapentin
was started and uptitrated to 400mg TID. ___ was consulted.
Medical team examined patient and determined his gait to be
stable.
TRANSITIONAL ISSUES
===================
[] Stress Test/Cath ___ revealing for EF=43% w/ regional wall
motion abnormalities ___ inferior segments and severe MR. ___
the severity of MR, EF likely overestimated. Most likely
etiology of cardiomyopathy is ischemic.)
[] Urology follow-up for retention
[] Pre-diabetes, hgbA1c 6.2
[] Heme recommending ___ for anemia
[] Desatting while sleeping, could be attributed to sleep apnea,
may require outpatient workup.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE (Immediate Release) 30 mg PO Q4H:PRN Pain - Severe
2. Aspirin 81 mg PO DAILY
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
4. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
5. Dabigatran Etexilate 150 mg PO BID
6. Furosemide 80 mg PO BID
7. Verapamil 80 mg PO Q8H
8. Tiotropium Bromide 1 CAP IH DAILY
9. Tamsulosin 0.4 mg PO QHS
10. Omeprazole 20 mg PO DAILY
11. Finasteride 5 mg PO DAILY
Discharge Medications:
1. Diltiazem Extended-Release 240 mg PO DAILY
RX *diltiazem HCl 240 mg 1 capsule(s) by mouth once a day Disp
#*30 Capsule Refills:*0
2. Furosemide 40 mg PO BID
RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
4. Aspirin 81 mg PO DAILY
5. Dabigatran Etexilate 150 mg PO BID
6. Finasteride 5 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. OxyCODONE (Immediate Release) 30 mg PO Q4H:PRN Pain - Severe
9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
10. Tamsulosin 0.4 mg PO QHS
11. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hypoxic Respiratory Failure
Hemothorax
Atrial fibrillation
Heart failure with Reduced Ejection Fraction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I ___ THE HOSPITAL?
- You were ___ the hospital because after a fall you broke one of
your ribs, and you had trouble breathing.
WHAT HAPPENED TO ME ___ THE HOSPITAL?
- You were ___ the critical care unit because you needed a
breathing tube to help your breathing.
- A chest tube was placed to help get rid of the blood ___ your
lungs.
- Your medications were adjusted to help control your fast heart
rates.
- You were ___ IV medication to urinate more and remove extra
fluid from your legs.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed.
- Please follow up with your PCP at the time listed below.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10430999-DS-14 | 10,430,999 | 27,875,808 | DS | 14 | 2136-11-29 00:00:00 | 2136-11-29 13:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ M with h/o anxiety/depression, alcohol abuse,
___ esophagus, and esophageal adenocarcinoma s/p radiation
and esophagectomy c/b recurrent strictures, presenting with
abdominal pain.
Patient reports severe "stabbing" epigastric pain that began
this morning when he was brushing his teeth. He states that the
pain feels like it is deep in his abdomen and does not radiate.
Per patient's wife, patient has been having this epigastric pain
every morning since his esophagectomy in ___, but it has been
getting more severe and lasting longer over the past month.
Patient sleeps in a recliner and wakes up early in the morning
with a dry cough that progresses to retching and then this
severe abdominal pain. Patient states that the pain improves
with moving around, Ativan, and alcohol. Patient was supposed to
be on an Ativan taper (end date two weeks ago), per his wife the
taper was not done correctly and he has continued to take Ativan
from his friend, ~1mg total/day. In addition, patient drinks
~12oz wine per day in the morning, which he reports temporarily
helps this abdominal pain.
Patient's wife also states that patient has anxiety and develops
a cycle of pain and anxiety. In the ED, patient reports anxiety
and vital signs notable for hyperventilation. Per ED note,
patient stated "I'm going to die, something isn't right," "never
having pain like this before," and that he is going to "pass
out." Patient has an appointment scheduled with Behavioral
Health (Atrius) next week.
Patient also endorses nausea, non-bloody non-bilious emesis,
with ~20 episodes today, and chills. Although patient has not
eaten today, he has maintained good PO intake via smaller, more
frequent meals and has no significant weight changes (per wife,
may have gained a few pounds). Patient denies fever, dysphagia,
CP, SOB, hematemesis, diarrhea, hematochezia, melena, dysuria.
His last BM was ___ am, normal and non-bloody. Of note, patient
has not restarted nortriptyline, as suggested by his outpatient
GI doctor ___ below).
Patient's wife reports that she is concerned about Ativan
withdrawal and thinks he needs a supervised facility to properly
wean Ativan.
Patient was recently seen by GI Dr. ___ at ___ on
___, due to complaint of epigastric pain. Per ___ note:
Patient has h/o long segment (12 cm) ___ esophagus, c/b
T3N0 esophageal adenocarcinoma ___ s/p carboplatin/taxol
radiation completed in ___ and MIE (s/p ___
esophagectomy and buttressing of intrathoracic anastomosis with
omental fat) by Dr ___ at ___ in ___. Post operatively,
developed dysphagia, found on EGD ___ to have anastomotic
stricture s/p balloon dilation to 10-12mm. Then presented with
epigastric pain and dysphagia (normal CT ___ and repeat
EGD ___ showed recurrent stricture, s/p dilation to 12mm
and Kenalog injection.
PRIOR WORK UP of his severe epigastric pain
--___ H pylori serology NEGATIVE
--___ EGD with neg H pylori biopsies
--normal LFT ___, normal amylase ___hest and abd (___)
--___ EGD s/p dilation and kenalog injection of anastomotic
stricture, pathology: hyperplastic polyp
PRIOR TREATMENT
--trial of sucralfate qid has not helped
--pantoprazole 40 mg bid (helps with GERD sx)
--nortriptyline 10 mg qhs started ___ took 1 dose and
stopped (not due to s/e of medication)
--he reports lorazepam worked the best for his epigastric pain
In the ED, initial vitals: 98.9 144/97 99 19 98% RA
Of note, tachypnic to 40 per nurse's note
Labs were significant for: Na 123, Cl 83, HC03 21,
LFTs/AP/TBili/Lipase ___
Imaging showed: CXR and CT C/A/P w/ no acute findings
In the ED, pt received:
___ 12:12 IV Morphine Sulfate 4 mg ___
___ 12:12 IV Ondansetron 4 mg ___
___ 12:25 IV Morphine Sulfate 4 mg ___
___ 13:05 IVF NS ( 1000 mL ordered) ___
Started
___ 13:05 IV HYDROmorphone (Dilaudid) 1 mg ___
___ 14:14 IV Ondansetron 4 mg ___
___ 14:48 IV HYDROmorphone (Dilaudid) 1 mg ___
___ 15:46 IV Lorazepam 1 mg ___
Vitals prior to transfer: 97.4 152/101 68 16 100% RA
Currently, patient endorses nausea, emesis, and severe
epigastric pain ___ severity.
ROS:
+ as per HPI above. 10 point ROS o/w negative.
Past Medical History:
GERD
___ esophagus
Esophageal cancer
Colon adenomas
Alcohol abuse
Alcoholic hepatitis without ascites
Depression
Anxiety
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 97.5 ___ 100% RA
GEN: Alert, sitting on side of bed with frequent emesis, in
moderate distress
HEENT: Slightly dry MM, anicteric sclerae, no conjunctival
pallor
NECK: Supple
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, obese, mild TTP even with deep epigastric palpation,
no rebound or guarding, +BS
EXTREM: Warm, well-perfused, no edema
NEURO: Alert and oriented, no FNDs
DISCHARGE PHYSICAL EXAM
Vitals: 98.1 PO 117 / 75 87 18 97 Ra
GEN: Alert, sitting comfortably in bed, NAD
HEENT: MMM, anicteric sclerae, no conjunctival pallor
NECK: Supple w/o LAD
PULM: Generally CTA b/l without wheeze or rhonchi
CAR: rrr (+)S1/S2 no m/r/g
ABD: Soft, obese, non-tender, no rebound or guarding, +BS
Ext: warm, well perfused, no edema
Neuro: A&Ox3, CNs2-12 intact (deaf in L ear, per patient
congenital), strength and sensation grossly intact bilaterally,
no FNDs
Pertinent Results:
ADMISSION LABS
========================
___ 11:40AM BLOOD WBC-8.7 RBC-4.89# Hgb-15.5# Hct-41.3#
MCV-85# MCH-31.7 MCHC-37.5*# RDW-11.0 RDWSD-34.2* Plt ___
___ 11:40AM BLOOD Neuts-82.5* Lymphs-10.0* Monos-6.5
Eos-0.2* Baso-0.3 Im ___ AbsNeut-7.18* AbsLymp-0.87*
AbsMono-0.57 AbsEos-0.02* AbsBaso-0.03
___ 11:40AM BLOOD ___ PTT-31.0 ___
___ 11:40AM BLOOD Glucose-100 UreaN-9 Creat-0.8 Na-123*
K-4.0 Cl-83* HCO3-21* AnGap-23*
___ 11:40AM BLOOD ALT-19 AST-36 AlkPhos-85 TotBili-0.6
___ 11:40AM BLOOD Lipase-16
___ 11:40AM BLOOD Albumin-4.3
___ 11:40AM BLOOD Na-126* K-3.3 Cl-86*
SERUM NA TREND
========================
___ 11:40AM BLOOD Glucose-100 UreaN-9 Creat-0.8 Na-123*
K-4.0 Cl-83* HCO3-21* AnGap-23*
___ 09:35PM BLOOD Glucose-128* UreaN-5* Creat-0.7 Na-117*
K-3.9 Cl-82* HCO3-21* AnGap-18
___ 12:30AM BLOOD Glucose-125* UreaN-6 Creat-0.7 Na-118*
K-4.3 Cl-83* HCO3-22 AnGap-17
___ 06:05AM BLOOD Glucose-96 UreaN-5* Creat-0.8 Na-125*
K-4.2 Cl-88* HCO3-20* AnGap-21*
URINE LYTES TREND
========================
___ 10:59PM URINE Hours-RANDOM Na-97
___ 10:59PM URINE Osmolal-363
___ 05:00AM URINE Hours-RANDOM Na-29
___ 05:00AM URINE Osmolal-141
DISCHARGE LABS:
========================
___ 06:30AM BLOOD WBC-4.3 RBC-4.58* Hgb-14.5 Hct-40.6
MCV-89 MCH-31.7 MCHC-35.7 RDW-11.8 RDWSD-37.4 Plt ___
___ 06:30AM BLOOD Glucose-90 UreaN-8 Creat-1.0 Na-132*
K-4.4 Cl-96 HCO3-27 AnGap-13
___ 06:30AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.1
IMAGING
========================
___ PORTABLE CXR AP
FINDINGS:
AP portable upright view of the chest.
Compared to prior exam, the gastric pull-through appears
relatively
decompressed. No signs of pneumothorax, pneumomediastinum or
free air below the right hemidiaphragm. Lungs are clear without
focal consolidation, large effusion or pneumothorax. Heart size
appears stable and normal. Bony structures are intact.
IMPRESSION:
No acute findings. Status post gastric pull-through and prior
esophagectomy.
___ CT C/A/P W/ CONTRAST
IMPRESSION:
1. Status-post esophagectomy and gastric pull-through without
evidence of
leak.
2. No evidence of recurrence or metastasis.
Brief Hospital Course:
BRIEF SUMMARY STATEMENT:
===========================
___ M with h/o anxiety/depression, alcohol abuse, ___
esophagus, and esophageal adenocarcinoma s/p radiation and
esophagectomy c/b recurrent strictures, presented with abdominal
pain & anxiety.
ACTIVE ISSUES:
===========================
#EPIGASTRIC PAIN: Patient presented with severe epigastric
abdominal pain, which a was progressive worsening of his chronic
epigastric pain. Patient was afebrile and HD stable, and CXR and
CT C/A/P along with labs (LFTs/AP/TBili/Lipase WNL) and recent
endoscopy were reassuring. Per thoracic surgery, no need for
acute surgical intervention. Pain resolved with PPI, GI
cocktail, heat pads, sucralfate, and treatment of anxiety, and
was most likely functional, as it was linked to anxiety.
#Anxiety: He has severe anxiety and develops a cycle of
abdominal pain and anxiety. He was initially treated with
valium, and then tapered off all benzos. He was seen by
psychiatry, who recommended starting nortryptiline, which was
uptitrated to 25mg daily at discharge. Addiction specialists
were also consulted, and provided patient with resources to stop
using ETOH & Ativan to treat his anxiety. At time of discharge,
he was not anxious and had outpatient follow-up scheduled.
#HYPONATREMIA: Patient had hyponatremia on admission, that
resoled with improvement in abdominal pain. Interestingly, the
sodium dropped again when patient became anxious and was
drinking >4L free water daily. He was fluid restricted, and
sodium improved. Educated on importance of not drinking massive
amounts of free water when in pain or anxious, and kept 1.5L
fluid restriction
#Alcohol abuse: Patient was drinking ~12 oz wine daily, and was
placed on CIWA while here. He required Valium for anxiety, but
never had seizures or DT's. Saw Psychiatry and addiction team,
as above. Placed on thiamine, MVI, folate.
CHRONIC STABLE ISSUES:
===========================
#H/O esophageal cancer: Patient denied dysphagia, and thoracic
surgery saw with no indication for acute surgical intervention.
#GERD: continue PPI, encouraged GERD diet, elevating head of bed
TRANSITIONAL ISSUES
===========================
- NEW MEDICATIONS: Patient started on nortriptyline 25mg daily.
Please uptitrate as an outpatient. He was also started on
Tylenol as needed for pain, a GI cocktail with Maalox as needed
for pain, and a multivitamin
- Patient was tapered off benzos, and should NOT be on these
medications.
- Patient has scheduled follow-up with behavioral health on
___, and was given numerous resources to help him manage
alcohol and benzo use
- Please recheck sodium at next PCP appointment, and make sure
patient is adhering to 1.5L fluid restriction
# CODE STATUS: Full (confirmed)
# CONTACT: Girlfriend ___: ___
Cell: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraZODone 50 mg PO QHS
2. Pantoprazole 40 mg PO BID
3. Sucralfate 1 gm PO QID WITH FOOD
4. Thiamine 100 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg 2 tablet(s) by mouth q8 hours prn Disp
#*60 Tablet Refills:*0
2. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN GI
upset
RX *alum-mag hydroxide-simeth [Maalox Advanced] 200 mg-200 mg-20
mg/5 mL 5 mL by mouth q6 hours prn Refills:*0
3. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule
Refills:*0
4. Nortriptyline 25 mg PO QHS
RX *nortriptyline 25 mg 25 mg by mouth daily Disp #*30 Capsule
Refills:*0
5. FoLIC Acid 1 mg PO DAILY
6. Pantoprazole 40 mg PO BID
7. Sucralfate 1 gm PO QID WITH FOOD
8. Thiamine 100 mg PO DAILY
9. TraZODone 50 mg PO QHS
Discharge Disposition:
___
Discharge Diagnosis:
Abdominal Pain
Hyponatremia
Alcohol Abuse
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 ___ due to abdominal pain. We took images
of your abdomen and got laboratory tests from your blood and
urine, which were reassuring. We did not see any evidence of new
injury or inflammation in your abdomen. You were also seen by
the Thoracic Surgery doctors, and did not require any surgical
intervention.
We treated your abdominal pain, nausea, and anxiety with
medications. We started you on a medication called Valium, which
is similar to Ativan but longer acting. It will be important to
follow up with your PCP and ___ at ___.
We also found that your sodium level was low. We gave you
intravenous fluids containing sodium, placed you on a fluid
restriction, and supplemented your meals with sodium-rich
substances like Ensure. We carefully monitored your sodium
levels and your sodium normalized during your admission. Your
sodium was likely low due to not taking in enough sodium from
your diet, and you can continue supplementing your diet with
Ensure if needed.
Please consider alcohol cessation. You were seen by Psychiatry
and Social Work, who recommended XXX.
It was a pleasure to take care of you!
Your ___ team
Followup Instructions:
___
|
10430999-DS-15 | 10,430,999 | 28,459,429 | DS | 15 | 2138-07-08 00:00:00 | 2138-07-08 22:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abd pain, N/V
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ h/o T3N0 esophageal adenocarcinoma
diagnosed in ___ s/p carboplatin/taxol radiation completed
in ___ s/p ___ esophagectomy and buttressing of
intrathoracic anastomosis with omental fat, anxiety, benzo
dependence who is presenting with acute on chronic abdominal
pain.
.
Reports chronic abdominal pain every morning since esophageal
dilation ___ years ago. Notes worsening pain over past few weeks
with acute worsening over past 4 days. He then developed n/v/d
12
hours prior to presentation. Patient describes the pain as
severe, epigastric that does not radiate and is not associated
with eating. Has not taken pain meds at home. Per ED his
girlfriend reports good po intake.
.
In the ED his girlfriend noted increased alcohol consumption
recently. Patient endorsed 3 glasses of wine per night, whereas
his girlfriend thinks this is an underestimate.
There was no blood in the emesis or stool. + dry heaves.
Endorses
headache, shortness of breath. No chest pain, dysuria. Smokes
marijuana daily. He does not use tobacco or illicit drugs.
He was not having diarrhea before his symptoms started.
Of note, pt on trazodone 150mg QHS for sleep for past year.
Decreased to 75mg 6 weeks ago. Patient thinks pain may possibly
have started after decreased dose. He states that he wanted to
get off trazodone completely because his chemical make up didn't
like it. With the trazodone he had to stop drinking because the
combination made him sick. He is ambivalent about whether
cutting
down on the trazodone resulted in more abdominal pain. He has
drinking "a few glasses of wine daily" which he thinks resulted
in abdominal pain. He continually goes back to the fact that his
esophageal cancer surgery was a life changer.
This pain is similar to the chronic pain that he has had in the
past.
He is depressed now becase he has been out of work for a couple
of years but then reports that he builds motorcyles and cars. No
fevers or chills. He had shakes in the ED. He denies SI or HI.
His last drink was on ___. He had withdrawal sx when he
stopped drinking the last time he was in the hospital. He has
gained weight from lack of exercise. Usually he is able to eat
and keep food down.
While in the ED VS on presentation:
8| 97.5|99|174/81|18|100% RA
lipase, LFTs, wnl. He had worsening abdominal pain despite 4mg
morphine x3 and dilaudid. CXR with post surgical changes, no
acute processes. He became hypoxic to ___ on RA, started on 2L
NC. Given worsening abdominal pain and hypoxia, a CT chest and
abdomen with contrast was performed.
His sodium was first 121. IVF were held and it increased to 125
which is his baseline. He was given
Morphine Sulfate 4 mg IV/ Ondansetron 4 mg/Morphine Sulfate 4 mg
Morphine Sulfate 4 mg/Metoclopramide 10 mg/HYDROmorphone
(Dilaudid) .5 mg/HYDROmorphone (Dilaudid) .5 mg/Acetaminophen
1000 mg
LORazepam 1 mg IV /Ondansetron 4 mg
It was thought that he might be withdrawing. Given this, he was
given Ativan.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
GERD
___ esophagus
Esophageal cancer
Colon adenomas
Alcohol abuse
Alcoholic hepatitis without ascites
Depression
Anxiety
Hx of hyponatremia
Social History:
___
Family History:
Brother Alive(2); ___ in a playground accident
Father Alive
Mother Alive
Sister Alive
Physical ___:
ADMISSION EXAM
97.9 ___ R ___%2L Nc
GENERAL: Alert and in no apparent distress. He is asleep when I
enter but awakens easily.
EYES: Anicteric, pupils equally round 3mm not reactive b/l
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM
GEN: Comfortable appearing male, ambulating in hallway
independently
HEENT: MMM
CV: RRR
RESP: CTAB no w.r
ABD: soft, NT, ND, NABS
GU: no foley
EXTR: warm, no edema
AFFECT: calm, appropriate, no agitation
Pertinent Results:
___ 01:36PM BLOOD WBC-8.8 RBC-4.53* Hgb-14.1 Hct-38.2*
MCV-84 MCH-31.1 MCHC-36.9 RDW-11.6 RDWSD-35.2 Plt ___
___ 06:25AM BLOOD WBC-6.9 RBC-4.45* Hgb-13.9 Hct-38.2*
MCV-86 MCH-31.2 MCHC-36.4 RDW-11.8 RDWSD-36.8 Plt ___
___ 08:11PM BLOOD Glucose-148* UreaN-5* Creat-0.7 Na-125*
K-4.5 Cl-88* HCO3-24 AnGap-13
___ 06:25AM BLOOD Glucose-116* UreaN-4* Creat-0.7 Na-127*
K-4.1 Cl-90* HCO3-26 AnGap-11
___ 03:05PM BLOOD Glucose-119* UreaN-5* Creat-1.0 Na-133*
K-3.7 Cl-97 HCO3-25 AnGap-11
___ 01:36PM BLOOD ALT-21 AST-61* AlkPhos-68 TotBili-0.7
___ 01:36PM BLOOD Lipase-21
___ 08:11PM BLOOD cTropnT-<0.01
___ 03:05PM BLOOD Calcium-9.3 Phos-2.6* Mg-1.8
CTA Chest/Abd/pelv:
1. No pulmonary embolism or acute aortic abnormality.
2. Stable postsurgical changes of esophagectomy and gastric
pull-through.
3. Trace right pleural effusion.
4. No acute pathology in the chest, abdomen, or pelvis
Brief Hospital Course:
___ y/o with h/o esophageal cancer s/p XRT followed by resection
with NER, hyponatremia and ongoing alcohol abuse who presents
with n/v/d, abdominal pain and hyponatremia in the setting of
ETOH abuse. Pt was managed supportively in the ED with
antiemetics, pain control and was feeling much better by the
morning of admission
N/V/Abd pain likely ___ Alcoholic gastritis:
Symptoms resolved entirely on the day of admission and pt was
taking po well without N/V or abd pain. He feels this was
likely all precipitated by recent ETOH intake and declined SW
consult. We discussed getting involved a local AA meeting and
pt endorses having a close friend that he plans to attend
meetings with after discharge. He really wants to avoid any
benzos given the difficulty he had weaning from Ativan
previously and felt confident about being discharged home with
his girlfriend/SO. Pt was continued on PPI and was given
Sucralfate 1gram TID for 7 days to help with healing of
gastritis. Pt is scheduled to follow up with his PCPs office in
___ on ___.
Hyponatremia: Acute on chronic issue, likely multifactorial with
ETOH abuse exacerbated by N/V and poor oral intake. The
initial BMP was hemolyzed with Na of 121 while Na was 125 on
whole blood from the same sample. Pt was given some gentle IVF
and sodium improved to 125 on repeat BMP. Afterwards, he was
advanced a diet with 1.5L fluid restriction and his sodium
continued to slowly corrected over the following 24hrs. By the
evening of discharge, Na had recovered to 133 and pt was taking
a regular diet without difficulty. Pt felt back to baseline and
was ambulating in the hallways without any symptoms. He was
encouraged to continued a bland diet/regular salt on discharge
with continued 1.5-2L fluid restriction. Pt was scheduled for
follow up appointment on ___ at 10am with the PCPs NP in
___ with instructions to get a follow up BMP.
Hx of esophageal Ca: CTA chest/abd/pelvis without any signs of
recurrent disease.
Transition issues:
Hyponatremia: acute on chronic issue that resolved over ___ days
of monitoring with regular diet and 1.5L fluid restriction.
Last check at 4pm on ___ was 133. Would recheck BMP on ___
at PCP ___
ETOH abuse: pt declined SW or pharmaceutical help with
abstinence, would continue to discuss AA and supports to avoid
ongoing ETOH abuse.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraZODone 75 mg PO QHS:PRN anxiety
2. Pantoprazole 40 mg PO Q24H
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
4. Multivitamins 1 TAB PO DAILY
5. Thiamine 100 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Sucralfate 1 gm PO QID
Continue taking one tab with each meal for another 7 days
RX *sucralfate 1 gram one tablet(s) by mouth three times a day
Disp #*21 Tablet Refills:*0
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
3. FoLIC Acid 1 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Thiamine 100 mg PO DAILY
7. TraZODone 75 mg PO QHS:PRN anxiety
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Pain
ETOH induced Gastritis
Hyponatremia, likely multifactorial
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abd pain, nausea, vomiting and low sodium
levels in the setting of recent alcohol abuse. You were
treated supportively with rapid improvement in abdominal
symptoms. Your sodium levels have corrected appropriately
without intervention other than 1.5L fluid restriction and
avoidance of ETOH. It is important that you avoid alcohol and
join the support/AA group recommended by your close friend. You
have a follow up appointment scheduled with one of Dr. ___
team at ___ in ___ on ___ to get follow up labs (sodium
check) and discuss this brief admission. We have given you a
prescription for Sucralfate to help with healing of gastritis
but have not made any other changes to your medications.
Best wishes from your team at ___
Followup Instructions:
___
|
10430999-DS-16 | 10,430,999 | 24,370,087 | DS | 16 | 2139-03-18 00:00:00 | 2139-03-22 19:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
===========================
Mr. ___ is a ___ year old male with history significant for
T3N0 esophageal adenocarcinoma s/p chemo and radiation in ___
and esophagectomy, alcohol abuse, and chronic epigastric
discomfort who presents with 1 day of acute epigastric pain, and
multiple episodes of nausea and diarrhea.
Per history obtained in the ED, patient states that he developed
acute onset of epigastric pain, ___ in severity. No
alleviating
or worsening factors. Constant. Sharp. Non-radiating. Never had
pain like this before. Associated with nausea and NBNB emesis,
diarrhea. Drank bottle of white wine before started. Denies
fevers, chills, cp, dysuria. No NSAID use. No blood thinners.
In the ED, initial vitals were: Pain 9, Temp 96.8, HR 93, BP
138/74, RR 20, 100% RA
Exam was notable for:
General: Appears very uncomfortable, in distress from pain
Abd: +epigastric tenderness, soft, distended
CV: Normal
Lungs: CTABL
Labs were notable for:
- CBC wnl (WBCs 9.4)
- BMP: Na 125 -> 123 -> 132 -> 136, Bicarb 20 -> 21 -> 24 -> 28
- Trop <0.01
- Lactate 4.9 -> 4.2 -> 1.6
- Serum tox neg
- LFTs wnl except AST 48
- UA wnl except trace prot, ___ 1.050
Studies were notable for:
- CTA Abd/Chest: no findings to suggest mesenteric ischemia,
aortic dissection
- CXR: no evidence of free air under diaphragm, stable
appearance
of gastric pull-through
The patient was given:
___ 01:10 IV HYDROmorphone (Dilaudid) 1 mg
___ 01:10 IV Ondansetron 4 mg
___ 01:32 IV Pantoprazole 40 mg
___ 01:32 IV Piperacillin-Tazobactam
___ 01:32 IV HYDROmorphone (Dilaudid) 1 mg
___ 02:15 IV HYDROmorphone (Dilaudid) 1 mg
___ 02:40 IV Vancomycin 1500mg
___ 02:40 IV Acetaminophen IV 1000 mg
___ 04:09 IV Ondansetron 4 mg
___ 04:19 IVF D5LR (1000 mL ordered) Started 200 mL/hr
___ 04:31 IVF NS 1000 mL
___ 04:57 IV Diazepam 10 mg
___ 08:33 PO FoLIC Acid 1 mg
___ 08:33 PO Thiamine 100 mg
___ 08:33 PO Multivitamins 1 TAB
___ 09:18 IV Ondansetron 4 mg
___ 09:46 IV Diazepam 5 mg
___ 09:48 IVF NS 1000 mL
___ 10:23 IV Metoclopramide 10 mg
___ 10:23 IV DiphenhydrAMINE 25 mg
___ 16:33 IVF D5LR stopped
Consults:
- None
On arrival to the floor, patient confirmed history as per above,
noting that he developed symptoms of sharp epigastric pain, and
multiple episodes of emesis and diarrhea last night prior to
admission. He stated that his epigastric pain was resolved, no
longer felt nauseous, and had no concerns otherwise. Denied any
confusion, tremors, dysarthria, confusion, paresis, or AVH. No
lightheadedness or dizziness. Patient confirms that his last
alcohol consumption was ~1L Pinot Grigio yesterday (___) at
1500, prior to his acute onset of epigastric pain and
vomiting/diarrhea at ___. He endorses having consumed ___ of
wine for the last few days, and typically consumes this amount
of
wine ___ times a week.
Past Medical History:
GERD
___ esophagus
Esophageal cancer
Colon adenomas
Alcohol abuse
Alcoholic hepatitis without ascites
Depression
Anxiety
Hx of hyponatremia
Social History:
___
Family History:
Brother Alive(2); ___ in a playground accident
Father Alive
Mother Alive
Sister Alive
Physical ___:
ADMISSION PHYSICAL EXAM:
========================
VITALS: Temp 98.1 PO, BP 133/80, HR 83, RR 18, O2 Sat 95% on RA,
Pain ___
GENERAL: Alert and interactive. In no acute distress.
HEENT: Pupils 3 mm and symmetric, nonresponsive to light, EOMI.
Sclera anicteric and without injection. MMM.
NECK: No cervical or supraclavicular lymphadenopathy.
CARDIAC: RRR. Audible S1 and S2. No MRG.
LUNGS: Clear to auscultation bilaterally. No increased work of
breathing.
ABDOMEN: Normoactive BS, NT ND, no hepatosplenomegaly
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
NEUROLOGIC: AOx3. CN2-12 intact. ___ strength in UE and ___.
Moving all limbs spontaneously. Normal sensation.
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 1449)
Temp: 98.5 (Tm 98.5), BP: 152/95 (115-152/78-95), HR: 105
(73-110), RR: 18 (___), O2 sat: 97% (95-97), O2 delivery: RA,
Wt: 196.3 lb/89.04 kg
Otherwise notable for:
Gen: lying comfortably in bed in no apparent distress
HEENT: eyes bloodshot, no scleral icterus
CV: normal rate, regular rhythm, no murmurs
Pulm: CTAB, no increased work of breathing
Abd: soft, nontender, nondistended, no hepatomegaly
Ext: no lower extremity edema
Neuro: alert and oriented, CNII-XII intact, PERRLA, EOMi, ___
strength in bilateral upper and lower extremities
Pertinent Results:
ADMISSION LABS:
==============
___ 12:25AM BLOOD WBC-9.4 RBC-4.90 Hgb-15.2 Hct-42.8 MCV-87
MCH-31.0 MCHC-35.5 RDW-11.1 RDWSD-35.6 Plt ___
___ 12:25AM BLOOD Neuts-80.1* Lymphs-11.7* Monos-7.3
Eos-0.1* Baso-0.4 Im ___ AbsNeut-7.50* AbsLymp-1.10*
AbsMono-0.68 AbsEos-0.01* AbsBaso-0.04
___ 12:29AM BLOOD ___ PTT-26.1 ___
___ 12:25AM BLOOD Glucose-121* UreaN-9 Creat-0.9 Na-125*
K-4.7 Cl-85* HCO3-20* AnGap-20*
___ 12:25AM BLOOD ALT-12 AST-48* AlkPhos-61 TotBili-0.8
___ 12:25AM BLOOD Lipase-18
___ 12:25AM BLOOD cTropnT-<0.01
___ 12:25AM BLOOD Albumin-4.3
___ 12:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 12:28AM BLOOD Lactate-4.9*
___ 07:52AM URINE Color-Straw Appear-Clear Sp ___
___ 07:52AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 07:52AM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 08:22PM URINE Hours-RANDOM Creat-23 Na-<20
___ 08:22PM URINE Osmolal-89
DISCHARGE LABS:
===============
___ 06:02AM BLOOD WBC-4.7 RBC-4.79 Hgb-14.7 Hct-42.4 MCV-89
MCH-30.7 MCHC-34.7 RDW-11.8 RDWSD-37.9 Plt ___
___ 06:02AM BLOOD Neuts-71.1* Lymphs-15.7* Monos-11.3
Eos-0.9* Baso-0.6 Im ___ AbsNeut-3.34 AbsLymp-0.74*
AbsMono-0.53 AbsEos-0.04 AbsBaso-0.03
___ 06:02AM BLOOD Glucose-125* UreaN-7 Creat-1.0 Na-139
K-4.0 Cl-102 HCO3-27 AnGap-10
___ 06:02AM BLOOD ALT-11 AST-24 LD(LDH)-143 AlkPhos-65
TotBili-0.6
___ 06:02AM BLOOD Albumin-3.7 Calcium-9.0 Phos-2.8 Mg-1.8
___ 03:23AM BLOOD Na-135
MICROBIOLOGY:
=============
- ___ Urine culture: No growth
RELEVANT IMAGING:
=================
- ___ Chest XR:
No evidence of free air under the diaphragm. Stable appearance
of gastric
pull-through.
- ___ CTA Torso:
1. No finding to explain the patient's symptoms. Specifically,
no findings to suggest mesenteric ischemia or aortic dissection.
2. Stable post esophagectomy anatomy with gastric pull-through.
- ___ ECG:
Technically difficult study reg rhythm, prob sr Consider
Inferior infarct, old compared to previous ECG ___ the rate
has increased Clinical correlation suggested
- ___ ECG:
Normal sinus rhythm nonspecific low amplitude T waves Otherwise
normal ECG When compared with ECG of ___ 00:15,T
flattening is new
Brief Hospital Course:
Mr. ___ is a ___ year old male with history significant for
T3N0 esophageal adenocarcinoma s/p chemo and radiation in ___
and esophagectomy, alcohol abuse, and chronic epigastric
discomfort who presents with 1 day of acute epigastric pain, and
nausea/vomiting/diarrhea, found to have hyponatremia and was
admitted for management of pain and correction of hyponatremia.
ACTIVE ISSUES:
==============
#Hypotonic Hypovolemic Hyponatremia
Upon admission, the patient was found to be hyponatremic with Na
of 125, likely due to multiple episodes of non-bloody
non-bilious emesis and diarrhea i/s/o heavy alcohol consumption.
Due to initial concern for possible infection, he was treated
with broad spectrum antibiotics, which were quickly discontinued
following further diagnostic workup. He was given normal saline
boluses and D5LR maintenance fluids, with fairly rapid
correction of his Na back into the normal range. He was started
on anti-emetics to prevent further nausea and vomiting. Although
patient remained asymptomatic, due to concern for overly rapid
correction, he was given D5W to slow his continued correction.
At the time of discharge, he was alert and oriented, without
ataxia, with normal extra-ocular movements, and no other
apparent no neurologic sequelae of his resolved hyponatremia.
#Abdominal pain
Upon arrival, the patient endorsed severe epigastric pain
associated with N/V/diarrhea several hours after consuming over
1L of white wine. Most likely ___ alcoholic ketoacidosis vs.
alcohol-induced gastritis/esophagitis. His pain was controlled
initially with Dilaudid, and he remained without significant
abdominal pain throughout rest of admission on PRN Tylenol. He
required no pain medications at the time of discharge.
#Alcohol Use Disorder
Patient has a long history of heavy alcohol use with several
hospital admissions. Has experienced withdrawal in the past. He
experienced no symptoms of alcohol withdrawal during this
admission. He was counseled on the risks of continued alcohol
use, and the patient expressed a strong interest and motivation
to quit drinking and maintain alcohol abstinence. After
discussing with the patient and his partner at length, we
initiated naltrexone, which was prescribed at time of discharge
(and he took first dose prior to leaving the hospital). He was
started on vitamin B12, folate, and thiamine early in admission.
.
.
CHRONIC ISSUES:
===============
#GERD - continued home omeprazole 40 mg po daily.
.
.
TRANSITIONAL ISSUES:
====================
[] Given he was discharged roughly 48 hours after his last drink
of alcohol, he continues to be at risk for alcohol withdrawal
over the next several days. He was counseled on the signs and
symptoms to look out for, and when to seek immediate medical
care.
[] Patient will be discharged with naltrexone for treatment of
alcohol use disorder. We encouraged him to call to schedule an
appointment with his PCP to be seen within 1 week of discharge
in order to follow-up on his alcohol cessation efforts, as this
is the primary etiology of this hospitalization and the most
important thing we can help him with going forward with his
health.
.
.
Code status: full (presumed)
HCP: ___
.
.
.
.
Time in care: >30 minutes in discharge-related activities on the
day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
2. Vitamin B Complex 1 CAP PO DAILY
3. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. naltrexone 50 mg oral DAILY
3. Naltrexone 50 mg PO DAILY
4. Thiamine 100 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Vitamin B Complex 1 CAP PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotonic hypovolemic hyponatremia
Alcohol Use Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You were having severe pain in your stomach along with nausea,
vomiting and diarrhea.
What did you receive in the hospital?
- You received medications to treat your pain and your nausea.
- You also received fluids to help carefully correct the amount
of sodium in your blood, which was quite low when you arrived.
This can be very dangerous if not corrected slowly, which is why
you were admitted to the hospital and monitored carefully.
What should you do once you leave the hospital?
- Please take your medications as prescribed and go to your
future appointments which are listed below.
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10431360-DS-4 | 10,431,360 | 23,535,741 | DS | 4 | 2159-10-16 00:00:00 | 2159-10-16 12:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / oxycodone / prednisone
Attending: ___.
Chief Complaint:
weakness, fevers, paresthesias
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with recent history of
steroid-induced weakness and anxiety/restlessness who presents
with worsening symptoms of weakness, night-drenching sweats,
fevers, cold/hot intolerance and episodes bilateral lower
extremity pain with transient episodic skin changes.
Patient was discharged from rehab on ___ after a recent hospital
admission for steroid-induced weakness and panic attacks. Since
then, and specifically since ___, she has had fevers every
night soaking through her pajamas, requiring her to change. She
is also had "beet red" bilateral lower extremities with burning
paresthesias making it difficult for her to walk. She is also
had
a profound sense of generalized weakness, not being able to
engage in her normal daily activities. On further ROS< patient
reports 4 month history of creamy nipple discharge despite last
having breastfed over ___ years ago. She has also had hair
thinning and more recently thickening behind her neck which she
attributes to the steroids. She was essentially on methylpred
then prednisone on and off for about a month with recent taper
off in the setting of steroid-induced panic attacks and
restlessness. She also notes significant loss of muscle mass
over
the past month where she was previously quite active and now it
requires taxing effort to do anything at all.
___ has had a very stressful past 2 months including
multiple
ED visits and a hospitalization. Brief timeline below:
- ___ - ?anaphylaxis at work. Was sitting at work. A vent
opened above her releasing air. She suddenly developed sensation
of her throat closing, difficulty breathing, increasing
periorbital swelling/fleshiness. Went to bathroom and started
tearing. Coworkers called for help and she was taken to ED.
Concern for anaphylaxis. Given prednisone 125 mg and started on
a
methylprednisolone taper.
- ___ - underwent allergy testing - positive for pollen and
mold, mildly positive for cats/dogs
- ___ - another episode of throat closing,
neck/shoulder/upper
arm swelling - went back to ED, received epinephrine, prednisone
60 mg --> 50 mg x3 days. Told to take prednisone and Benadryl
-->
felt worse.
- ___ - tapering on prednisone; developed swelling in her
feet/legs, sleeplessness, restlessness, anxiety, heat
sensitivity. She was ultimately hospitalized at ___ in ___. Treated for strep throat; given
antibiotics.
Admitted for rapid steroid taper; ___ prednisone 20 mg x1
(this was her most recent dose of prednisone); numbness in
bilateral ___ below knees. Experienced body aches, formication,
back pain, prickliness in feet. MRI showed "mild degenerative
?".
Apparently she was diagnosed with anticholinergic syndrome from
too much Benadryl. Her discharge diagnoses from her discharge
summary also include steroid-induced psychosis, anaphylactic
reaction of unclear etiology, and anxiety and panic attacks.
- ___ - discharged to rehab (___)
- ___ - discharged from rehab
- ___ - seen in ___ clinic at ___.
In the ED:
VS: AFVSS
ECG: within normal limits
PE: Nonfocal neuro exam but for burning paresthesias to the
level
of the knee bilaterally
Patient is ___ with very dark skin, however the
soles of her feet are red and splotchy.
Otherwise benign exam
Labs: CBC/CMP unremarkable except for mild leukopenia to 3.4
Imaging: CXR negative
Impression: Medicine admission for this patient with night
sweats, cyclical fevers, burning paresthesias, and need for
possible endocrine and nutritional workup. Records requested
from
___ and ___ endo note from yesterday
raises
concern for pituitary process and work-up. Notes at bedside
Interventions: none
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Gestational Diabetes
C-section
Tubal Ligation
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
Admission Exam:
VITALS: Temp: 98.6, BP: 116/74, HR: 78, RR: 20, O2 sat: 100%, O2
delivery: RA, Wt: 149.2 lb/67.68 kg
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema. Oropharynx without
visible lesion, erythema or exudate
Does have mild buffalo hump
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly
symmetric with slight muscle wasting
SKIN: No obvious rashes or ulcerations noted on cursory skin
exam
NEURO: Alert, oriented, face symmetric, speech fluent, moves all
limbs
PSYCH: pleasant, appropriate affect, tearful at times
Discharge Exam:
VITALS: ___ 0731 Temp: 98.7 PO BP: 114/76 R Lying HR: 101
RR: 16 O2 sat: 100% O2 delivery: Ra
- Of note, has never been formally febrile in our system on this
admission
GENERAL: Alert and in no apparent distress
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
MSK: Neck supple, moves all extremities, strength grossly
symmetric with slight muscle wasting. Mildly TTP at para-spinal
muscles. No TTP at posterior iliac crests.
SKIN: No obvious rashes or ulcerations noted on exposed skin.
Pt's skin complexion appears homogeneous diffusely, c/w her
___ ethnicity. No "redness" appreciated.
NEURO: Alert, oriented, face symmetric, speech fluent, moves all
limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 07:10PM BLOOD WBC-5.3 RBC-3.52* Hgb-10.6* Hct-32.5*
MCV-92 MCH-30.1 MCHC-32.6 RDW-12.7 RDWSD-42.9 Plt ___
___ 07:10PM BLOOD Glucose-95 UreaN-12 Creat-0.7 Na-143
K-4.0 Cl-104 HCO3-27 AnGap-12
___ 07:10PM BLOOD ALT-11 AST-16 CK(CPK)-73 AlkPhos-43
TotBili-0.2
___ 07:10PM BLOOD Calcium-9.8 Phos-3.8 Mg-2.2
___ 10:30PM BLOOD VitB12-973*
___ 06:24AM BLOOD Cryoglb-NO CRYOGLO
___ 01:15PM BLOOD VitB12-1247*
___ 06:24AM BLOOD FSH-7.0 LH-3.8 Prolact-12 TSH-0.16*
___ 01:15PM BLOOD TSH-0.11*
___ 06:24AM BLOOD T3-99 Free T4-1.5
___ 07:10PM BLOOD 25VitD-22*
___ 06:24AM BLOOD Cortsol-15.5
___ 06:24AM BLOOD Estradl-27
___ 06:24AM BLOOD CRP-0.8
___ 07:10PM BLOOD HCV Ab-NEG
___ 01:48PM BLOOD Lactate-1.2
___ 07:10PM BLOOD MERCURY (WHLE BLD NVY/EDTA)-PND
___ 07:10PM BLOOD LEAD (WHOLE BLOOD)-Test
___ 07:10PM BLOOD CHROMIUM (SPIN NVY/NO ADD)-PND
___ 07:10PM BLOOD DIPHENHYDRAMINE-PND
___ 07:10PM BLOOD THALLIUM, BLOOD-PND
___ 07:10PM BLOOD VITAMIN B6 (SPIN/PLASMA)-PND
___ 07:10PM BLOOD VITAMIN D ___ DIHYDROXY-PND
___ 06:24AM BLOOD ACTH - FROZEN-Test
___ 06:24AM BLOOD SED RATE-Test
___ 06:24AM BLOOD INSULIN-LIKE GROWTH FACTOR-1-Test
Brief Hospital Course:
Ms. ___ is a ___ female with recent
history of steroid-induced weakness and anxiety/restlessness who
presents with worsening symptoms of weakness, night-drenching
sweats, fevers, cold/hot intolerance and episodes bilateral
lower
extremity pain with transient episodic skin changes.
#Fevers
#Night sweats
#Lower extremity pain / Parasthesias
#Galactorhea
#Sick Euthyroid vs hypothyroidism
#Weakness -
#Fevers
#Night sweats
#Lower extremity pain / Parasthesias
#Galactorhea
#Sick Euthyroid vs hypothyroidism
#Weakness -
Etiology unclear. Endocrine consultation from ___ appreciated,
and it appears that an endocrine dx is not a unifying cause for
all her sx. Similarly, Rheumatology consult from ___
appreciated, and appears that it no unifying Rheum-related dx
can
be determined. Extensive discussions with our Toxicology
consultants Dr. ___, with many pending tests (as below
and in prior section). MRI for MS or other neuro pathology
unrevealing on ___. Thus will dispo home today for continued
w/u in outpt setting.
- Ongoing tox workup as per OMR note
- D/c today to home w/ services
- F/u tox studies in outpt setting - I have communicated with
Toxicology Attending Dr. ___ will be following these
and communicating directly with the patient about these results
and their interpretation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth three times a day Disp
#*30 Tablet Refills:*0
2. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Throat pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
We admitted you for various symptoms, and have conducted quite
an extensive workup. We were unable to determine the exact cause
of your symptoms, but having conducted an extensive workup, feel
that you are safe to go home now. There are still multiple tests
pending, and you will hear from us when those results are
available.
We wish you the best with your health.
___ Medicine
Followup Instructions:
___
|
10431522-DS-12 | 10,431,522 | 25,110,842 | DS | 12 | 2148-08-22 00:00:00 | 2148-08-22 18:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Levaquin
Attending: ___.
Chief Complaint:
Weakness, Fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ with h/o polyneuropathy (CMT), HTN, BPH presents with 10
days of weakness and fatigue. He reports that he has
progressively become more weak over the past days to weeks. He
used to be able to use his exercise bike but now feels too weak
to do this and this past week has felt unsteady using his
walker. Today, he asked for a wheelchair before his appt because
he felt so unsteady and this is very unusual for him. His PCP
referred him to the ER.
In the ED, initial vs were: 98.0 83 135/51 18 97% on RA. Labs
showed Cr at baseline of 1.2, CXR with likely L basilar
atelectasis. He was admitted per PCP for infectious ___,
neurology evaluation and out of concern for him being an at-risk
elder.
Currently, the patient appears comfortable and is very pleasant.
Review of sytems:
(+) Per HPI, + sore throat, + joint pans (with weather), + easy
bruising
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies myalgias. Ten point review of
systems is otherwise negative.
Past Medical History:
PAST MEDICAL HISTORY:
___ - familial
hypertension
benign prostatic hypertrophy s/p TURP x2
urinary retention
chronic constipation
GERD with small hiatal hernia
melanoma s/p excision
anxiety
depression
L hip fracture (___)
OA
Restrictive lung disease
Chronic pain
Insomnia
Social History:
___
Family History:
His mother, sister, and maternal uncle have
___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.0 83 135/51 18 97% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: diminished at R base, 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
Back: many SKs, nodule in midline
Ext: Warm, well perfused, no clubbing, cyanosis or edema; distal
atrophy, contractures of his hands
Neuro: CN intact, weak in interosseus muscles/wrist
extension/flexion; unable to plantar/dorsiflex feet but
sensation is intact
PHYSICAL EXAM:
Vitals:Tm 97.7 T 97.3 BP 115/58 (110-130s/50-70s) P67 (60-80s)
RR 18 POx98% RA
General: AAOx3, NAD, pleasant and cooperative, sitting up in bed
watching televesion
HEENT: Sclera anicteric, EOMI, PERRL, 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
Back: many SKs, nodule in midline, no tenderness to palpation
Ext: Warm, well perfused, no clubbing, cyanosis or edema; distal
atrophy, contractures of his hands and toes
Neuro: CN II-XII intact, weak in interosseus muscles/wrist a
extension/flexion; unable to plantar/dorsiflex feet/toes but
sensation is intact
Pertinent Results:
ADMISSION LABS:
___ 06:15PM BLOOD WBC-7.3 RBC-3.94* Hgb-12.4* Hct-35.6*
MCV-90 MCH-31.5 MCHC-34.9 RDW-19.8* Plt ___
___ 06:15PM BLOOD Neuts-74.6* Lymphs-12.9* Monos-4.5
Eos-4.9* Baso-0.8
___ 06:15PM BLOOD ___ PTT-30.5 ___
___ 06:15PM BLOOD Glucose-113* UreaN-23* Creat-1.2 Na-140
K-4.4 Cl-105 HCO3-24 AnGap-15
___ 06:15PM BLOOD ALT-58* AST-46* AlkPhos-54 TotBili-0.5
___ 06:15PM BLOOD Calcium-9.2 Phos-3.1 Mg-2.1
DISCHARGE LABS:
___ 08:10AM BLOOD WBC-5.7 RBC-3.66* Hgb-11.4* Hct-33.2*
MCV-91 MCH-31.0 MCHC-34.2 RDW-19.7* Plt ___
___ 08:10AM BLOOD Plt ___
___ 08:10AM BLOOD Glucose-114* UreaN-28* Creat-1.4* Na-139
K-4.1 Cl-104 HCO3-25 AnGap-14
___ 08:10AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.9
MICRO:
URINE CULTURE (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML.
IMAGING:
___ CHEST (PA+LAT): FINDINGS: PA and lateral views
of the chest are provided. There is left basilar
opacity which is most compatible with atelectasis given
the associated
volume loss. Otherwise, the lungs are clear. No
effusion or pneumothorax. The heart and mediastinal
contour are stable. Old left rib cage deformity is
noted.
Brief Hospital Course:
Mr. ___ is an ___ year-old male with a PMH significant for
polyneuropathy (Charcot ___, HTN, BPH, who presents
with 10 days of weakness and fatigue.
#UTI: Patient presented with weakness, increased frequency, and
dysuria as well as symptoms of bladder spasms on admission.
Initial UA very suggestive of UTI, and cultures revealed
coagulase negative staphylococcus. He was initially started on
IV ceftriaxone and coverage was narrowed to
Sulfameth/Trimethoprim for 7 day course (end date ___
#Weakness/fatigue: Patient seen by PCP who was concerned for
patient's current ability to care for himself as home. His
___ disease is progressing and his ability to
perform ADLs has decreasedd. Recent TSH/B12/folate WNL. LFTs,
cortisol, and electrolytes are with in normal limits. UTI likely
contributory. Patient seen by neurology who noted that motor
examination is at baseline. Recommended follow-up outpatient
with pulmonology and sleep study to understand if other factors
are contributing to fatigue. Patient will continue to be treated
with cymbalta and gabapentin at home doses. Anemia may be
contributing and outpatient work-up recommended. Patient
evaluated by ___ who recommended patient primarily mobilize in
wheel chair until cleared by home ___ for safe ambulation. Also
recommended increased hours of homemaker services.
#Arthritis: Patient is s/p hip and knee transplant, acutely
worse with recent whether and limiting his ambulation. He
receives steroid injections for improvement. He was continued on
home percocet and his pain was noted to be at baseline on
discharge.
# HTN: Patient continued on lisinopril and aspirin.
# Anxiety/Insomnia: Patient continued on lorazepam.
# GERD: Patient continued on omeprazole. sucralfate.
# BPH: Patient continued on terazosin.
# Chronic pain: Patient continued on oxycodone.
# Chronic constipation: Patient continued on standing bowel
regimen.
TRANSITIONAL ISSUES:
[]Continue to treat UTI with sulfameth/trimethoprim for ___nding ___
[]Outpatient Physical Therapy recommended.
[]Pulmonary follow up per neurology recs
[]Sleep study per neurology recs
[]Follow up with PCP
[]Anemia work-up as outpatient
[]Increased homemaker hours
[]Blood cultures pending at time of discharge and will need
follow-up by PCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 100 mg PO BID
2. Lisinopril 10 mg PO DAILY
3. Lorazepam 1 mg PO HS:PRN insomnia
4. Omeprazole 20 mg PO BID
5. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
6. sucralfate *NF* 20 ml Oral BID
7. Terazosin 5 mg PO BID
8. Aspirin 81 mg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 100 mg PO BID
4. Lisinopril 10 mg PO DAILY
5. Lorazepam 1 mg PO HS:PRN insomnia
6. Omeprazole 20 mg PO BID
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
8. Polyethylene Glycol 17 g PO DAILY
9. Terazosin 5 mg PO BID
10. Vitamin D ___ UNIT PO DAILY
11. sucralfate *NF* 20 ml Oral BID
12. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Urinary Tract Infection
Deconditioning
___ Toothe
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___:
It was a pleasure taking care of you during your hospitalization
at ___. You were sent by your primary care physician for
evaluation of generalized weakness. You were noted to have a
urinary tract infection and we started you on antibiotics. It is
important that you complete this antibiotic course at home. We
also had physical therapy evaluate you and they felt you would
benefit from home physical therapy.You were noted to be back
near your baseline and you were discharged home.
We have made some changes to your medication list. Your nurse
___ provide you with a copy of the list and review your
medications with you.
Please follow up with your appointments as outlined below.
Thank you,
Followup Instructions:
___
|
10431522-DS-16 | 10,431,522 | 24,122,555 | DS | 16 | 2151-07-22 00:00:00 | 2151-07-23 13:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / bupropion
Attending: ___.
Chief Complaint:
fevers, suprapubic pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with a history of Charcot ___ and
urinary retention presents to emergency department for
evaluation of fevers and suprapubic pain. Recently treated for
UTI last week with cefpodoxime with a urine culture that
ultimately grew yeast. On ___, he started developing fevers
to ___ and noted suprapubic pain and dysuria. He treated
himself with Tylenol and his fevers resolved. No change in
urinary symptoms. No other localizing infectious symptoms such
as diarrhea (last BM on ___, cough, sore throat, headache,
back pain or skin breakdown. No lower leg edema. No chest pain
or shortness of breath.
In the ED, initial VS were T98.3F HR 79 BP 121/94 RR 16 SpO2 97%
RA.
Exam notable for nontender prostate, abdomen TTP over bladder
and RLQ.
Labs showed BUN:Cr ___, WBCs 5.5 (72% neutrophils), Hgb 10.5,
LFTs wnl, U/A notable for >182 WBCs, 14 RBCs, neg nitrites, 0
Epis.
CXR with no acute cardiopulmonary process. EKG NSR (rate 72),
NA/NI, no ischemic changes.
Received ceftriaxone 1g and oxycodone/acetaminophen.
Transfer VS were 97.9 65 128/59 18 98% RA
Decision was made to admit to medicine for further management
for a UTI.
On arrival to the floor, patient reports feeling "pretty good".
He notes mild dysuria and suprapubic pain. No other symptoms.
Past Medical History:
___ familial
Hypertension
BPH s/p TURP x2
Urinary Retention
Chronic Constipation
GERD w/ small hiatal hernia
Melanoma s/p excision
Anxiety/Depression
L hip fracture (___)
OA
Restrictive lung disease
Chronic pain
Insomnia
Social History:
___
Family History:
His mother, sister, and maternal uncle have ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS - 97.9 65 128/59 18 98% RA
GENERAL: NAD, AOx3, elderly gentleman, in good spirits, nontoxic
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: mildly distended, +BS, nontender in all quadrants, no
rebound/guarding, no CVA tenderness, no hepatosplenomegaly, mild
suprapubic tenderness
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, general muscular atrophy in
extremities, ___ strength in ___, contracted hands and feet.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=======================
VS - 98.1, 128/68, 69, 96%RA
GENERAL: NAD, AOx3, elderly gentleman, in good spirits,
nontoxic, eating breakfast
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: mildly distended, +BS, nontender in all quadrants, no
rebound/guarding, no CVA tenderness, no hepatosplenomegaly, no
objective suprapubic tenderness
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, general muscular atrophy in
extremities, ___ strength in ___, contracted hands and feet.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
--------------
___ 10:14AM BLOOD WBC-5.5 RBC-3.48* Hgb-10.5* Hct-32.9*
MCV-95 MCH-30.2 MCHC-31.9* RDW-17.9* RDWSD-61.0* Plt ___
___ 10:14AM BLOOD Neuts-72.4* Lymphs-14.6* Monos-6.3
Eos-4.5 Baso-0.4 Im ___ AbsNeut-4.00# AbsLymp-0.81*
AbsMono-0.35 AbsEos-0.25 AbsBaso-0.02
___ 10:14AM BLOOD ___ PTT-28.6 ___
___ 10:14AM BLOOD Glucose-127* UreaN-26* Creat-1.5* Na-140
K-3.7 Cl-104 HCO3-25 AnGap-15
___ 10:14AM BLOOD ALT-14 AST-17 AlkPhos-43 TotBili-0.3
___ 10:14AM BLOOD Lipase-23
___ 10:14AM BLOOD Albumin-4.0 Calcium-8.7 Phos-3.3 Mg-1.8
___ 10:16AM BLOOD Lactate-1.5
___ 10:00AM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:00AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 10:00AM URINE RBC-14* WBC->182* Bacteri-MOD Yeast-NONE
Epi-0
___ 10:00AM URINE WBC Clm-FEW Mucous-RARE
DISCHARGE LABS
--------------
___ 06:52AM BLOOD WBC-6.2 RBC-3.45* Hgb-10.4* Hct-32.5*
MCV-94 MCH-30.1 MCHC-32.0 RDW-17.9* RDWSD-61.3* Plt ___
___ 06:52AM BLOOD Glucose-126* UreaN-27* Creat-1.5* Na-141
K-4.1 Cl-105 HCO3-25 AnGap-15
___ 06:52AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.8
IMAGING
-------
___ CXR IMPRESSION: No acute cardiopulmonary process.
MICROBIOLOGY
------------
___ 10:00 am URINE
URINE CULTURE (Preliminary):
ENTEROBACTER CLOACAE COMPLEX. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>___ R
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
___ year-old male with a remote history of multiple UTIs
presenting with suprapubic pain and pyuria.
# Complicated urinary tract infection: male patient, recent
fevers, but no leukocytosis or current symptoms to suggest
ascending infection. Remote history of recurrent UTIs; most
recently treated with cefpodoxime for 7 days (ultimately grew
yeast). No signs of ascending infection given absence of
documented fevers, ___ count or CVA tenderness while admitted.
History of BPH but prostate nontender in ED arguing against
prostatitis. Started on 1g ceftriaxone on ___. Continued on
home terazosin. Transitioned on discharge to PO Bactrim to
complete a 7 day course. Urine culture pending on discharge
(ultimately grew enterobacter, sensitive to Bactrim).
# Anemia: normocytic, chronic, at baseline ___. Monitored with
no significant change.
# Chronic kidney disease, stage III: baseline creatinine
1.3-1.5, currently at baseline. Monitored with no change during
admission.
# Chronic pain: continued home fentanyl patch, gabapentin,
Percocet (reduced dose of oxycodone). Continue home bowel
regimen (senna/Colace/lactulose/Miralax/bisacodyl).
# Depression: continued home paroxetine, trazodone (dose reduced
from 300 to 150mg)
# Gastroesophageal reflux disease: continued home PPI,
sucralfate
# Miscellaneous: continued home vitamin D, prednisone 1mg
Transitional issues
-------------------
- f/u final urine and blood cultures
- decreased trazodone dosing to 150mg qHS prn from 300mg qHS prn
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 1 mg PO DAILY
2. Terazosin 10 mg PO QHS
3. Lactulose 30 mL PO BID constipation
4. Neomycin-Polymyxin-HC Otic Susp 3 DROP BOTH EARS BID
5. Gabapentin 100 mg PO TID
6. Bisacodyl 10 mg PO DAILY:PRN constipation
7. Docusate Sodium 100 mg PO TID
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Fentanyl Patch 50 mcg/h TD Q72H
10. oxyCODONE-acetaminophen 7.5-325 mg oral Q4H:PRN severe pain
11. Sucralfate 1 gm PO BID
12. Omeprazole 20 mg PO BID
13. Aspirin 81 mg PO DAILY
14. PARoxetine 20 mg PO DAILY
15. TraZODone 300 mg PO QHS:PRN insomnia
16. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Docusate Sodium 100 mg PO TID
4. Fentanyl Patch 50 mcg/h TD Q72H
5. Gabapentin 100 mg PO TID
6. Lactulose 30 mL PO BID constipation
7. Neomycin-Polymyxin-HC Otic Susp 3 DROP BOTH EARS BID
8. Omeprazole 20 mg PO BID
9. PARoxetine 20 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. PredniSONE 1 mg PO DAILY
12. Sucralfate 1 gm PO BID
13. Terazosin 10 mg PO QHS
14. Vitamin D ___ UNIT PO DAILY
15. oxyCODONE-acetaminophen 7.5-325 mg ORAL Q4H:PRN severe pain
16. TraZODone 150 mg PO QHS:PRN insomnia
17. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days
start on ___, end ___
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice daily Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Urinary tract infection
SECONDARY DIAGNOSIS:
Charcot ___
Chronic pain
Chronic kidney disease, stage III
Anemia
Depression
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 ___ for treatment of a urinary tract
infection. We gave you IV antibiotics and you will go home with
oral antibiotics to finish your treatment. It is safe to return
home now- please continue to drink plenty of fluids. If you have
any fevers or back pain, please call your Dr. ___.
It was a pleasure taking care of you during your stay- we wish
you all the best!
-Your ___ Medicine Team
Followup Instructions:
___
|
10431522-DS-18 | 10,431,522 | 29,619,050 | DS | 18 | 2153-06-12 00:00:00 | 2153-06-12 15:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / bupropion / cefpodoxime / azithromycin
Attending: ___.
Chief Complaint:
Fever/Rash
Major Surgical or Invasive Procedure:
Skin Biopsy
History of Present Illness:
Mr. ___ is a ___ male with a history of
___, HTN, BPH, chronic constipation, GERD w/
hiatal hernia who presents with fevers.
Patient states that he started having cough congestion 3 days
ago
this progressively worsened with intermittent fevers. He has had
progressive weakness since that time and had decreased oral
intake since yesterday. His cough is only occasionally
productive
of ___ sputum. He denies chest pain, hemoptysis, or shortness
of breath. He has chronic abdominal pain but no increased over
his normal. He denies lower extremity swelling. He states he
went
to his primary care doctor who sent him here for further
testing.
He denies sick contacts or recent travel. He has also been
experiencing a pruritic, red rash on his thighs, chest, and arms
for the past few days. He has had itchy rashes in the past. He
has had several UTIs in the past.
In the ED he was febrile and tachycardic but had good
saturations
on room air. He had a large, watery bowel movement, however
after
which he desaturated. Ceftriaxone and azithromycin were
administered as well as 500 cc NS. Lactate was 2.5.
ROS: A 10-point review of systems was obtained and was otherwise
negative except as per HPI
Past Medical History:
___ familial
Hypertension
BPH s/p TURP x2
Urinary Retention
Chronic Constipation
GERD w/ small hiatal hernia
Melanoma s/p excision
Anxiety/Depression
L hip fracture (___)
OA
Restrictive lung disease
Chronic pain
Insomnia
Social History:
___
Family History:
His mother, sister, and maternal uncle have ___.
Physical Exam:
___ 0729 Temp: 97.4 PO BP: 122/62 HR: 74 RR: 18 O2 sat: 91%
O2 delivery: 1lnc
Gen: non toxic, fluent speech, aox3
HEENT: Moist oral mucosa
Lungs: CTAB no wheezes. Some crackles in bases.
CV: Regular rate and rhythm.
Skin: Patches of discoloration over arm, chest, and abdomen.
many
encircled with skin marker. Seem to be fading.
GU: Skin around shaft somewhat edematous. Exudate under head of
penis. No excoriations. slightly erythematous. No swelling or
rash on scrotum.
Msk: no pitting edema
Abdomen: abd soft non tender, + BS
Pertinent Results:
___
>4.3\10.5\34<198
___
144 | 97 | 42
--------------<
4.5 | 33 | 1.2
Admission UA with WBC>182, Mod Bacteremia, Nitrate Positive, LG
leuks
___ 8:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 CFU/mL.
PRESUMPTIVE IDENTIFICATION.
CEFTRIAXONE test result performed by ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- 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
Brief Hospital Course:
Mr. ___ is a ___ male with a history of
___, HTN, esophageal dysmotility, GERD w/ hiatal
hernia who presents with fevers and cough, ultimately diagnosed
and treated for PNA and e coli UTI.
# Acute hypoxic respiratory failure
# Pneumonia
# Sepsis:
#E coli UTI
Patient presented with fevers, leukocytosis, tachycardia,
tachypnea, and a lactate of 2.5, with new O2 requirement.
While CXR was not very impressive, clinical presentation we
most consistent with PNA and he was ultimately treated with
levofloxacin with improvement. Influenza was negative. Pt does
have a hx of esophageal dysmotility and given this is his second
episode of PNA in the last month he was evaluated by speech and
swallow who found no abnormalities and recommended a regular
diet. Will treat for a total of 14 days to cover complicated UTI
and also pneumonia. Last day of antibiotics is ___. Patient
with ongoing O2 requirements most likely related to his Charcot
___ disease and possible aspiration from weakness and
acute illness. Discussed need for O2 with patient at home for a
short amount of time. Pt is OK with this at this time.
# Rash: Extensive patches across trunk and limbs. No clear
cause without any recent med changes or new contacts. He was
evaluated by dermatology who biopsied the rash and found fixed
drug eruption likely from use of cefpodoxime or azithromycin
that was given in ED in days/week proceeding development of
rash. He should avoid these types of meds.
# ___: Most likely prerenal in setting of infection. Improved
throughout the hospitalization with fluids. On day of discharge,
Cr 1.2
# Chronic pain: he was continued on his home meds
# Depression: Continued home paroxetine 20mg
# Chronic constipation: held regimen given large loose BM in the
ED, restarted on dc
# Insomnia: Continued home trazodone mg PO qhs
# BPH: terazosin 10mg PO qhs held in setting of sepsis, can
continue at home.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Docusate Sodium 100 mg PO TID
4. Fentanyl Patch 50 mcg/h TD Q72H
5. Gabapentin 100 mg PO TID
6. Lactulose 30 mL PO BID constipation
7. Neomycin-Polymyxin-HC Otic Susp 3 DROP BOTH EARS BID
8. oxyCODONE-acetaminophen 7.5-325 mg ORAL Q4H:PRN severe pain
9. PARoxetine 20 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Sucralfate 2 gm PO BID
12. Terazosin 10 mg PO QHS
13. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
14. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Levofloxacin 750 mg PO Q48H Duration: 7 Days
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth Every
other day Disp #*3 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Docusate Sodium 100 mg PO TID
5. Fentanyl Patch 50 mcg/h TD Q72H
6. Gabapentin 100 mg PO TID
7. Lactulose 30 mL PO BID constipation
8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
9. Neomycin-Polymyxin-HC Otic Susp 3 DROP BOTH EARS BID
10. oxyCODONE-acetaminophen 7.5-325 mg ORAL Q4H:PRN severe pain
11. PARoxetine 20 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Sucralfate 2 gm PO BID
14. Terazosin 10 mg PO QHS
15. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
fixed drug eruption
sepsis
e coli uti
pneumonia bacterial nos
Charcot ___ Disease
Hypoxia ___ weakness, pneumonia, and possible aspiration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
you were hospitalized for drug rash caused by either cefpodoxime
or azithromycin, avoid these types of antbitiotics in the
future.
you also had sepsis infection with possible pneumonia and
definite ecoli uti and received antibiotics. You will continue
on antibiotics at home for a total of 14 days. You are
recovering from this pneumonia so your breathing may need a bit
of Oxygen until you are fully recovered.
Thanks for allowing us to take care of you!
The hospitalist team
Followup Instructions:
___
|
10431655-DS-19 | 10,431,655 | 26,995,036 | DS | 19 | 2131-04-02 00:00:00 | 2131-04-02 15:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ PMHx HTN, HLD, depression, and likely
dementia who presents from home with altered mental status.
The patient is a poor historian and the history is taken in bulk
from his family and the ED. According to his family, the patient
was confused while at home today, thinking he was in the
cafeteria where he used to work. He apparently walked to his
upstairs neighbor's apartment to ask for a ride home. The
patient has limited memory of this episode. According to the
patient's children, he has had progressive memory loss over the
past ___ years; it was suggested by his PCP that he may have
Alzheimer's, but the family is seeking a more formal diagnosis.
His son believes he is scheduled for outpatient neurocognitive
testing.
Of note, the patient is a daily drinker, typically ___ beers
daily. He denies any symptoms of withdrawal, and reports having
fallen while previously walking to the liquor store. He states
he fell because he lost his balance and feels that he has been
having more frequent falls. He had no LOC and no head strike. He
denies recent illness, fever, chest pain, difficulty breathing.
He endorses some intermittent burning dysuria. No hematuria. No
nausea, no emesis, no abdominal pain, no diarrhea.
While the patient reports feeling at his mental status baseline,
his family reports that he seems more disoriented and forgetful
than baseline. His son states that the patient has had extremely
poor short term memory for at least ___ years, but that he has
never gotten lost and that is the major change that happened
today.
In the ED, initial VS 98.9, 80, 136/77, 18, 97% on RA. Initial
labs showed wnl chemistries, and CBC notable for Hgb 12.8 (no
known baseline). UA notable for moderate leuks, positive
nitrites, some pyuria. Serum and urine tox screens were
negative. CT head/ CT C-spine and CXR were all unremarkable.
Given family's report of patient being off his normal baseline,
the patient was referred for admission to medicine.
On the floor, the patient reported feeling closer to his usual
self and less confused. He completed a PHQ-9 with a score of 10.
He also completed a MOCA with a score of ___. He requested that
he be able to try again later.
REVIEW OF SYSTEMS:
(+) Dysuria
(-) 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, hematuria.
All other 10-system review negative in detail.
Past Medical History:
HTN
Dementia
Depression
Osteoarthritis of knees
Vitamin B12 deficiency
Alcoholism
Gender identity disorder
Social History:
___
Family History:
Mother and father both died of "cancer related to smoking" more
than ___ years ago. He believes his mother had dementia.
Physical Exam:
Admission Exam
VS: T 98.4, BP 151/82, P 90, RR 16, O2 95 RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
PSYCH: Oriented to person and place. Says it is ___ and
cannot be more specific about date.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Exam
Vitals: 9.4 103/68 58 18
Gen: older man sitting in bed, alert, cooperative, NAD
Chest: equal chest rise,
Neuro speech fluent, aox2, name and month
___: normal affect
Pertinent Results:
LABS:
UA: +leuk (mod), +nitrites, 16 WBCs
CBC:
6.1 > 12.___.4 < 255
(b/l hgb ___
BMP:
136 | 98 | 13 AGap=18
---------------< 93
3.8 | 24 | 0.8
___ 06:48AM BLOOD VitB12-507
___ 06:48AM BLOOD TSH-2.7
___ 12:18AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:46AM BLOOD calTIBC-316 Ferritn-205 TRF-243
MICRO:
___ UCx >100,000 Coag negative staph
___ RPR - pending
IMAGING:
___ CT C-SPINE
-No evidence of acute fracture or traumatic malalignment.
-Multilevel degenerative changes, as described in detail above.
___ CT HEAD
No acute major vascular territory infarction, hemorrhage, or
fracture.
___ CXR
No acute cardiopulmonary process.
EKG:
NSR, unremarkable.
MRI Brain
No acute intracranial abnormality including hemorrhage,
infarct, or
suggestion of mass.
2. Moderate global atrophy without focal predominance. No
disproportionate
medial temporal lobe atrophy.
3. Two punctate areas of nonspecific right frontal white matter
signal
abnormality, likely of no clinical significance, which may
represent the
sequela of chronic small vessel ischemic disease.
4. Paranasal sinus disease, as described.
Discharge Day labs
___ 06:46AM BLOOD WBC-5.7 RBC-3.98* Hgb-12.5* Hct-38.1*
MCV-96 MCH-31.4 MCHC-32.8 RDW-13.2 RDWSD-46.7* Plt ___
___ 06:46AM BLOOD Glucose-82 UreaN-18 Creat-0.7 Na-140
K-3.8 Cl-103 HCO3-28 AnGap-13
___ 06:48AM BLOOD VitB12-507
___ 06:46AM BLOOD calTIBC-316 Ferritn-205 TRF-243
___ 06:48AM BLOOD TSH-2.7
___ 06:25PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
Brief Hospital Course:
___ man brought in for worsening mental status, possible
delirium superimposed on dementia. Initially thought this may
have been precipitated by a UTI, but that's now unclear.
Possible Korsakoff syndrome so also treating with thiamine given
significant confabulation.
Dementia and possible Korsakoff syndrome, w/h/o daily EtOH ___
beers daily), with prior concern for delirium
- causes of delirium have been considered, but none identified
- absence of ataxia on neurologic exam or urinary incontinence
made NPH an unlikely etiology of his dementia, and a PHQ-9 score
of 10 suggested moderate depression which might be contributing,
though pseudodementia unlikely to be primary process
- as a result, Neurology was consulted and agreed with formal
neuropsychiatric testing. He had negative lyme, rpr, b12 and
tsh testing for medical metabolic or infectious causes of
cognitive decline. MRI brain performed showed No acute
intracranial abnormality including hemorrhage, infarct, or
suggestion of mass.
2. Moderate global atrophy without focal predominance. No
disproportionate
medial temporal lobe atrophy. 3. Two punctate areas of
nonspecific right frontal white matter signal abnormality,
likely of no clinical significance, which may represent the
sequela of chronic small vessel ischemic disease. 4. Paranasal
sinus disease, as described.
- dementia is most likely Alzheimer's type, dx by PCP in ___, ___'s could be considered -- Neurologist told the
son that he thought pt had Korsakoff's dementia -- continued
with PO thiamine
- vascular dementia could be considered given impaired executive
function (CT head with small-vessel ischemic disease)
- ___ and OT evaluations indicate that he has very poor safety
awareness, and they both recommend rehab
- per son has ___ appointment for neurocognitive
evaluation (at ___ per report)
He did not have evidence of UTI on repeat UA.
H/o falls - ___ evaluated the patient and recommended rehab
Mild stable normocytic anemia - unclear etiology -- B12 and iron
testing normal
Osteoarthritis of knees and C-spine degenerative joint disease -
continued gabapentin and provided APAP PRN
HTN, HLD - continued metoprolol
Depression - continued citalopram (which patient may easily be
forgetting to take as an outpatient)
Mild constipation - bowel regimen
Insomnia - trazodone
H/o vitamin B12 deficiency -- level normal here
Dispo - deficits in several IADLs and appears unsafe to return
home in
his current state - long term may need more help at home, vs.
getting him into
assisted living, plan has been to discuss ___ application
with case mgmt. - SW consulted for son coping
Advance care planning
- HCP: needs form completed -- is son as per ___
- Care preferences: full code for now
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Gabapentin 200 mg PO QAM
4. TraZODone 50 mg PO QHS:PRN insomnia
5. Gabapentin 300 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Delirium
Dementia, possibly Alzheimer's, ___'s
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with confusion and memory problems. We
determined that you likely had some delirium superimposed on
your dementia, and that your dementia may have worsened
recently. We initially thought you might have a urinary tract
infection, but your urine culture did not end up growing the
type of bacteria we would normally suspect. As a result, we
considered other causes of delirium, and asked for input from
our Neurology colleagues.
We suspect you may have cognitive deficits resulting in memory
troubles.
Followup Instructions:
___
|
10431718-DS-6 | 10,431,718 | 21,761,254 | DS | 6 | 2163-08-17 00:00:00 | 2163-08-18 14:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left lower extremity wound evaluation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with medical history of DMII on insulin, ESRD on dialysis
___ presenting from PCP ___ 2 weeks of left lower
extremity infection. Had been on 10 day course of augmentin
(started ___ but culture came back showing MRSA and referred
in to the ED. Denies fevers or other systemic sx's. Has chronic
mild ___ edema. Denies numbness, tingling, weakness in foot.
In the ED, initial vital signs were: 97.8 71 134/66 16 100% RA.
- Exam was notable for: L foot: dopplerable ___ and DP pulses,
mild edema to knee, macerated skin over anterior shin.
- Labs were notable for: H/H 11.3/36.2, BUN 43, Cr 5 (ESRD),
lactate 1.1, INR 1.3.
- Imaging: L tib/fib xray without findings specific for
osteomyelitis.
- The patient was given: vancomycin and zosyn.
- Consults: none
- Pt was admitted to medicine for: IV abx and HD tomorrow.
Vitals prior to transfer were: 97.8 71 138/78 18 100% RA.
Upon arrival to the floor, he is conversant but cannot provide
details as to how his leg wounds progressed. He says that years
ago he got kicked in the shin and has had problems with that leg
ever since. He was unaware that his HD tunneled line looks
acutely infected, and states that it only itches. He denies
fevers and chills.
REVIEW OF SYSTEMS: a complete ROS was negative except as noted
in HPI
Past Medical History:
CAD s/p CABG
Hypertension
Hyperlipidemia
Diabetes Mellitus
Carotid stenosis
Gastroesophageal reflux disease
Tenosynovitis
Obstructive uropathy, urge incontinence
GI Bleed ___ d/t gastric ulcer
Colonic adenoma s/p polypectomy
ADHD
Psoriasis
Hearing loss
Depression with h/o lithium toxicity-- misses work weekly ___
Chronic low back pain/sciatica
Muscle cramps
Social History:
___
Family History:
Mother with hx of stroke, died of "old age". Father died in his
___ of unknown causes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 158/80, 81, 18, 97% RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes
or rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
DISCHARGE PHYSICAL EXAM:
VITALS: 97.6 124/62 87 20 97RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: LLE with areas of skin wounds with surrounding
erythema, appears mildly improved from yesterday; 2+ pitting
edema up to mid-calves in bilateral lower extremities
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
ACCESS: Left port with mild erythema; no warmth or pus
visualized
Pertinent Results:
LABORATORY STUDIES ON ADMISSION
================================================
___ 04:30PM BLOOD WBC-7.0 RBC-3.60*# Hgb-11.3*# Hct-36.2*#
MCV-101*# MCH-31.4 MCHC-31.2*# RDW-15.3 RDWSD-56.3* Plt ___
___ 04:30PM BLOOD Neuts-65.1 Lymphs-17.6* Monos-12.4
Eos-3.9 Baso-0.7 Im ___ AbsNeut-4.56 AbsLymp-1.23
AbsMono-0.87* AbsEos-0.27 AbsBaso-0.05
___ 04:30PM BLOOD ___ PTT-33.4 ___
___ 04:30PM BLOOD Glucose-182* UreaN-43* Creat-5.0*# Na-133
K-4.6 Cl-94* HCO3-26 AnGap-18
___ 06:55AM BLOOD Calcium-8.9 Phos-5.7*# Mg-2.1
___ 09:06AM BLOOD HBsAg-Negative HBsAb-Positive
HBcAb-Positive*
___ 09:07AM BLOOD Vanco-12.6
___ 09:06AM BLOOD HCV Ab-Negative
___ 04:59PM BLOOD Lactate-1.1
LABORATORY STUDIES ON DISCHARGE
================================================
___ 07:15AM BLOOD WBC-5.3 RBC-3.38* Hgb-10.5* Hct-34.0*
MCV-101* MCH-31.1 MCHC-30.9* RDW-15.5 RDWSD-56.7* Plt ___
___ 07:15AM BLOOD Glucose-87 UreaN-29* Creat-4.1*# Na-135
K-4.0 Cl-95* HCO3-26 AnGap-18
___ 07:15AM BLOOD Calcium-8.8 Phos-4.6* Mg-2.1
IMAGING/REPORTS
================================================
++ ___ TIB/FIB (AP AND LAT) LEFT
No findings specific for osteomyelitis. Radiographs are not as
sensitive as MRI for osteomyelitis
MICROBIOLOGY
================================================
BLOOD CULTURES: PENDING
Brief Hospital Course:
Mr. ___ is a T2DM, ESRD (HD TTS), who was admitted with left
lower extremity cellulitis. He was started on IV Vancomycin with
improvement, and discharged with a plan to complete a 10-day
course (last day ___, to be dosed with HD).
#) CELLULITIS:
Pt presented with left lower extremity cellulitis. Prior to
admission, culture showed MRSA (sensitive to Vancomycin), for
which patient was started on Augmentin (___) with no
improvement so patient was admitted to the hospital. On
admission, pt was afebrile, and left lower extremity had areas
of small skin wounds with surrounding erythema. Pt was treated
with IV Vancomycin (___) with improvement. Pt was
discharged with a plan to complete a 10-day course of IV
Vancomycin (last day ___. Vancomycin to be dosed with HD.
#) ESRD on HD:
Pt has a history of ESRD on HD TTS. On admission, port was noted
to have surrounding erythema but no warmth. Pt reported
associated pruritus but no pain. Per renal, consistent with
contact dermatitis with low suspicion for line infection. Pt
received IV Vancomycin with HD on ___. Pt was
discharged with a plan to complete a course of IV Vancomycin (as
above).
CHRONIC ISSUES
==============
# T2DM: continued home insulin regimen
# CAD: continued home BB, ASA and statin
# Anemia: remained at baseline during admission
TRANSITIONAL ISSUES
=========================================
1. Pt needs to complete a 10-day course of IV Vancomycin (last
day ___. Vancomycin to be dosed with HD.
2. Pt should have close follow up of his left lower extremity
cellulitis to monitor for resolution.
3. Pt needs to have close monitoring of port site. Per renal,
erythema likely secondary to contact dermatitis.
# CONTACT: ___ (son; ___
# CODE STATUS: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 8 Units Breakfast
Insulin SC Sliding Scale using NOVOLOG Insulin
2. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CHEST PAIN
3. Carvedilol 25 mg PO DAILY
4. Divalproex (EXTended Release) 500 mg PO Q12H
5. Atorvastatin 80 mg PO QPM
6. Bisacodyl 10 mg PR QHS:PRN constipation
7. sevelamer CARBONATE 800 mg PO TID W/MEALS
8. Vitamin D ___ UNIT PO DAILY
9. Aspirin 81 mg PO DAILY
10. Calcitriol 0.25 mcg PO DAILY
11. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Bisacodyl 10 mg PR QHS:PRN constipation
4. Carvedilol 25 mg PO DAILY
5. Glargine 8 Units Breakfast
Insulin SC Sliding Scale using NOVOLOG Insulin
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CHEST PAIN
7. Omeprazole 40 mg PO DAILY
8. sevelamer CARBONATE 800 mg PO TID W/MEALS
9. Vitamin D ___ UNIT PO DAILY
10. ___ MD to order daily dose IV HD PROTOCOL
11. Calcitriol 0.25 mcg PO DAILY
12. Divalproex (EXTended Release) 500 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- cellulitis, left lower extremity
SECONDARY:
- ESRD on hemodialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted
because of an infection of your skin on your left leg (called
cellulitis). You were treated with an antibiotic called
Vancomycin. You will complete a 10-day course of Vancomycin,
which you will be given with your hemodialysis (last day
___.
Please call your doctor immediately if you develop fevers or
chills or your rash becomes more red or painful.
Please schedule an appointment with Dr. ___ 1 week
of discharge.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10431934-DS-4 | 10,431,934 | 28,285,584 | DS | 4 | 2168-11-20 00:00:00 | 2168-11-20 09:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OTOLARYNGOLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
neck drainage
Major Surgical or Invasive Procedure:
s/p bedside I&D of right neck
History of Present Illness:
seen as consult from Dr. ___ evaluation of right FOM
cancer. reports this was noticed in ___, persisted at
follow up in ___ at dentist. denies pain, bleeding, dysphagia,
weight loss. smoked socially in the past, drinks ___ glasses of
wine per week. retired OT in ___.
___: irregular lesion seen by hygienist during routine
cleaning
___: returned to dentist for follow up and was referred for
biopsy by oral surgery
___: biopsy right anterior FOM by Dr. ___: fragments
of infiltrating keratinizing SCCA, well to moderately
differentiated, extending to tissue edges
___: Composite resection right floor of mouth mandible
marginal and bilateral neck dissection with radial forearm free
flap reconstruction by Dr. ___ Dr. ___
___: completed adjuvant radiation therapy at ___
with Dr. ___
___: seen on ___ clinic ___ and no issues
___: PET scan at ___- intense uptake in soft tissue anterior
to the right floor of mouth consistent with recurrence, new
uptake left mylohyoid
___: CT neck shows There is peripherally enhancing 2.0
cm x 1.2 cm x 2.3 cm mass at the recipient bed, there is a node
in LEFT level 1a. Mildly prominent left level 2A/periparotid
nodule, level 2b, 4 lymph nodes, similar. Previously seen
mildly prominent bilateral level 5 lymph nodes have decreased.
Consider at least component of inflammatory process.
___- began immunotherapy with ___ adjuvant nivolumab and
lirilumab
___- composite resection of oral cavity, segmental
mandibulectomy (L body to R body), bilateral ND, R FFF, R thigh
STSG by Dr. ___ Dr. ___. Pathology showed one lymph
node negative for tumor, separately submitted tumor bed margins
are negative for invasive tumor, the inferior margin of the
resection specimen is positive for invasive carcinoma.
___- presented to ___ ED with purulent drainage from neck
incision
Past Medical History:
irregular heartbeat on digoxin
Social History:
___
Family History:
Noncontributory.
Physical Exam:
Voice: limited articulation given free flap procedure
Respiratory Effort: unlabored without stridor or stertor
Eyes: Extraocular movements intact
CN: Face moves symmetrically
Face: No gross lesions.
Oral Cavity/Oropharynx: Small area of dehiscence in right
anterior suture line without significant tracking, no visible
dehiscence in posterior suture line. Small volume of dishwater
fluid intraorally at the junction of native tongue and flap on
the right. Midline dorsal native tongue without bleeding, s/p
silver nitrate cautery.
Neck: Right neck dsg over old ___ site right neck, Two small
areas of dehiscence along left lateral suture line. Minimal
serosanguinous/brown
drainage.
Pertinent Results:
___ 07:47AM BLOOD WBC-8.9 RBC-2.77* Hgb-8.3* Hct-26.4*
MCV-95 MCH-30.0 MCHC-31.4* RDW-14.4 RDWSD-48.9* Plt ___
___ 07:28AM BLOOD WBC-9.5 RBC-2.88* Hgb-8.5* Hct-27.5*
MCV-96 MCH-29.5 MCHC-30.9* RDW-14.1 RDWSD-49.0* Plt ___
___ 04:22PM BLOOD WBC-11.3* RBC-2.53* Hgb-7.5* Hct-23.7*
MCV-94 MCH-29.6 MCHC-31.6* RDW-13.9 RDWSD-47.6* Plt ___
___ 07:28AM BLOOD Neuts-71.2* Lymphs-13.0* Monos-9.0
Eos-4.4 Baso-0.4 Im ___ AbsNeut-6.72* AbsLymp-1.23
AbsMono-0.85* AbsEos-0.42 AbsBaso-0.04
___ 10:55AM BLOOD Neuts-72.7* Lymphs-9.5* Monos-11.4
Eos-4.3 Baso-0.4 Im ___ AbsNeut-7.92* AbsLymp-1.03*
AbsMono-1.24* AbsEos-0.47 AbsBaso-0.04
___ 07:47AM BLOOD Plt ___
___ 07:28AM BLOOD Plt ___
___ 07:28AM BLOOD Glucose-89 UreaN-7 Creat-0.4 Na-140 K-4.9
Cl-101 HCO3-29 AnGap-10
___ 04:22PM BLOOD Glucose-118* UreaN-7 Creat-0.4 Na-137
K-4.1 Cl-99 HCO3-26 AnGap-12
___ 10:16AM BLOOD Glucose-99 UreaN-7 Creat-0.5 Na-138 K-4.2
Cl-96 HCO3-28 AnGap-14
___ 07:28AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.7
___ 04:22PM BLOOD Calcium-8.7
___ 10:16AM BLOOD Calcium-9.1 Phos-3.3
___ 10:08AM BLOOD TSH-20*
Brief Hospital Course:
The patient was admitted to the Otolaryngology-Head and Neck
Surgery Service for purulent neck drainage on ___.
Hospital Course by Systems:
Neuro: Pain was well controlled, initially with IV regimen which
was transitioned to oral regimen once tolerating oral intake.
Post-operative anti-emetics were given PRN.
Cardiovascular: Remained hemodynamically stable.
Pulmonary: Oxygen was weaned and the patient was ambulating
independently without supplemental oxygen prior to discharge.
HEENT: The patient initially had purulent drainage intraorally
with applied submental pressure. A CT neck was obtained which
demonstrated a fistulous track to the cutaneous surface. She was
started on antibiotics and wound cultures were sent which
demonstrated mixed oral flora. On HD4, a bedside I&D was
performed with additional purulent fluid expressed. A wick was
placed along her neck where the fistula opened and was serially
packed but was eventually discontinued following the I&D and
continued improvement. On HD5 the patient had oral cavity
bleeding at bedside which was cauterized at bedside with
subsequent improvement. Drainage was reduced during the course
of her hospital stay. ___ was consulted to rule out periapical
sources as a cause of infection. A panorex was obtained which
did not demonstrate any source of caries or periapical lucency.
Peridex was continued while inpatient for intraoral cleaning.
GI: Patient was maintained on tube feeds while inpatient.
GU: Patient was able to void independently.
Heme: Received heparin subcutaneously and pneumatic compression
boots for DVT prophylaxis.
Endocrine: Monitored without any remarkable issues. Patient was
found to be hypothyroid while inpatient and was started on
synthroid to optimize wound healing
ID: WAs initially started on Vancomycin, Cefepime, and Flagyl
for broad spectrum antibiotics while awaiting speciation. Vanc
troughs were followed and adjusted as needed. Infectious
Disease was consulted and she was kept on broad antibiotics with
serial wound cultures. She was discharged on Ceftriaxone and
Flagyl for several weeks. A PICC was placed while inpatient and
was confirmed to be in appropriate location prior to use. The
patient has a scheduled infectious disease outpatient follow up
for continued antibiotic coverage.
At time of discharge, the patient was in stable condition,
ambulating and voiding independently, and with adequate pain
control. The patient was given instructions to follow-up in
clinic with Dr. ___ as scheduled. Pt was given detailed
discharge instructions outlining wound care, activity, diet,
follow-up and the appropriate medication scripts.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Digoxin 0.25 mg PO QHS
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 325 mg PO DAILY
3. CefTRIAXone 1 gm IV Q24H Duration: 16 Days
RX *ceftriaxone in dextrose,iso-os 1 gram/50 mL 1 g IV once a
day Disp #*16 Intravenous Bag Refills:*0
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID
RX *chlorhexidine gluconate 0.12 % Swish and spit 15mL twice a
day Refills:*0
5. Docusate Sodium (Liquid) 100 mg PO BID
6. Fentanyl Patch 25 mcg/h TD Q72H
7. Levothyroxine Sodium 75 mcg PO DAILY
RX *levothyroxine 75 mcg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*1
8. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*48 Tablet Refills:*0
9. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
10. Digoxin 0.25 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
post-op neck infection
oral cavity cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-Take antibiotics as prescribed.
-All feedings and medications through G-tube.
-Follow instructions for ___ line care.
Followup Instructions:
___
|
10431956-DS-3 | 10,431,956 | 27,548,224 | DS | 3 | 2182-06-12 00:00:00 | 2182-06-15 15:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Naprosyn
Attending: ___.
Chief Complaint:
Transient Fluent Aphasia
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
The patient is a ___ with a history of antiphospholipid
antibody syndrome and headaches who presented to the ED after a
transient episode of fluent aphasia in the setting of a
headache.
Neurology was consulted as part of a code stroke in the ED.
The patient was tells me she was last seen well by her coworkers
at ___ when she suddenly started speaking with paraphasic
errors and was making up new words. Her co-workers were quite
alarmed and tape recorded a portion of her speech pattern which
was notable for fluent speech with multiple neologisms and
phonemic paraphasias. The patient herself thought she was
speaking normally. She was able to appropriately follow
commands. No facial droop or other weakness was noted. It was
not until just before noontime that she agreed to come to the ED
with her coworker. On presentation, initial NIHSS was 0 but
code
stroke was activated.
On my arrival, NIHSS was 0. Vitals: 97.8 96 137/71 16 100% RA.
FSG 89. She reported that her language was back to normal, but
also admitted she did not ever notice her language was abnormal
until she was sent the recording from her coworker. Her only
complaint was a ___ left frontotemporal pressure headache with
associated photophobia, phonophobia, and nausea. The headache
started 2 days ago and was initially waxing and waning but has
been persistent over the past 24 hours. The headache
quality/duration was similar to priors which started in the past
___ years and have become slightly more frequent. Headaches do
not
wake her from sleep or worsen with coughing. There was one
other
transient episode of headache and speech disturbance one year
ago
but she does not recall what work-up was pursued, etc. She does
not have an outpatient neurologist.
With regard to her APLS, she was diagnosed at age ___ after
presenting with left foot pain and an ingrown toe nail was
removed and she ultimately had poor wound healing, leading to
work-up showing APLS. She has declined anticoagulation in the
past and takes ASA 81mg x3 daily instead.
ROS as listed above. She also has occasional bright floaters in
her field of view, but not in the scintillating scotoma pattern.
Otherwise, she denies lightheadedness or confusion. Denies
difficulty comprehending speech. Denies blurred vision,
diplopia,
vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia.
Denies focal muscle weakness, numbness, parasthesia. Denies loss
of sensation. Denies bowel or bladder incontinence or retention.
Denies difficulty with gait. No fevers, rigors, night sweats, or
noticeable weight loss. Denies chest pain, palpitations,
dyspnea,
or cough. Denies nausea, vomiting, diarrhea, constipation, or
abdominal pain. No recent change in bowel or bladder habits.
Denies dysuria or hematuria. Denies myalgias, arthralgias, or
rash.
Past Medical History:
- Similar transient speech deficit in ___ with headache, workup
unknown to patient
- Headaches x ___ years with migrainous features, but never
diagnosed with migraines
- Antiphospholipid antibody syndrome, diagnosed at age ___ when
she presented with left foot pain and poor wound healing
- Car accident ___ year ago, cause unclear, lost consciousness
Social History:
___
Family History:
No known family history of hypercoagulability.
Mom passed in early ___, unknown cause. Dad's history unknown.
One brother with alcohol abuse, previously had withdrawal
seizures. Other 4 brothers, 2 sisters with good health. No
heart disease or arrhythmia. No aneurysms.
Physical Exam:
Admission PHYSICAL EXAMINATION
Vitals: 97.8 96 137/71 16 100% RA
General: Obese, AA female, conversational, NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, tatoo on left hand/wrist
Neurologic Examination:
- Mental Status - Awake, alert, oriented x 3. Attention to
examiner easily maintained. Recalls a coherent history, but does
not recall speech problem. Able to recite months of year
backwards. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. There is one
semantic paraphasia during entire interview/exam: substitutes
multigrain for multivitamin. No phonemic paraphasias. Naming
intact, but slightly delayed timing. Normal prosody. No
dysarthria. No apraxia. No evidence of hemineglect. No
left-right
confusion.
- Cranial Nerves - PERRL 4->2 brisk. VF full to finger wiggle.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - No deficits to light touch, temperature or
proprioception bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait - Normal initiation. Narrow base. Normal stride length.
She tandems with ease. Negative Romberg.
# Discharge Physical Exam #
No significant change
Pertinent Results:
___ 12:13PM BLOOD Glucose-106* Na-141 K-4.6 Cl-101
calHCO3-26
___ 12:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:00PM BLOOD HCG-<5
___ 05:35AM BLOOD TSH-1.9
___ 05:35AM BLOOD Triglyc-99 HDL-61 CHOL/HD-3.0 LDLcalc-100
___ 05:35AM BLOOD %HbA1c-5.5 eAG-111
___ 05:35AM BLOOD Cholest-181
___ 12:00PM BLOOD CK-MB-2 cTropnT-<0.01
___ 12:38AM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:00PM BLOOD ALT-37 AST-53* CK(CPK)-260* AlkPhos-75
TotBili-0.2
___ 12:38AM BLOOD CK(CPK)-183
___ 12:00PM BLOOD UreaN-13
___ 12:05PM BLOOD Creat-0.9
___ 12:00PM BLOOD ___ PTT-56.9* ___
___ 12:00PM BLOOD WBC-7.3 RBC-4.56 Hgb-13.7 Hct-41.2 MCV-90
MCH-30.0 MCHC-33.2 RDW-14.6 Plt ___
___ 12:37PM URINE Color-Straw Appear-Clear Sp ___
___ 12:37PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 12:37PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
CTA Head/Neck ___: IMPRESSION:
1. Normal CTA and CTV of the head.
2. Normal CTA of the neck.
3. No hemorrhage or evidence of infarct.
Echocardiogram ___: IMPRESSION: Normal biventricular cavity
sizes with preserved regional and global biventricular systolic
function. Eccentric jet of mild-moderate mitral regurgitation
suggestive of underlying underlying mitral valve prolapse. No
definite cardiac source of embolism identified.
MRI and MRA Brain ___: IMPRESSION:
Normal MRI of the brain, no infarct.
Normal MRV of the brain.
Brief Hospital Course:
Ms. ___ is a ___ right handed woman with a past medical
history of antiphospholipid antibody syndrome on Aspirin and
headaches who presented to the ED after a transient episode of
fluent aphasia felt to be consistent with a TIA.
# TIA
- Patient was treated as a code stroke upon presentation to the
hospital. CT, CTA and CTV imaging was benign. There was no
neurologic deficit on exam and subsequent MRI was benign. Lab
evaluation was unrevealing, though LDL was 100 and A1C was 5.5
Based on her history and prior diagnosis of Antiphospholipid
Antibody syndrome, this was felt to be most consistent with a
TIA due to her hypercoag state.
Her Home aspirin was discontinued and she was bridged to
Coumadin with lovenox (Goal INR ___ with outpatient follow-up
arranged..
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented (required for all patients)? (X) Yes (LDL =
100) - () No
5. Intensive statin therapy administered? () Yes - (X) No
6. Smoking cessation counseling given? (X) Yes - () No [if no,
reason: () non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
() Yes - (X) No [if no, reason not assessed: No
deficits/indication]
9. Discharged on statin therapy? () Yes - (X) No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: ()
Antiplatelet - (X) Anticoagulation] - () No
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 243 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Warfarin 4 mg PO DAILY16
RX *warfarin [Coumadin] 2 mg 2 tablet(s) by mouth at bedtime
Disp #*60 Tablet Refills:*0
2. Multivitamins 1 TAB PO DAILY
3. Enoxaparin Sodium 100 mg SC BID
Start: ___, First Dose: Next Routine Administration Time
Stop this medication when coumadin is therapeutic.
RX *enoxaparin 100 mg/mL 100 mg SQ twice a day Disp #*28 Syringe
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: transient ischemic attack, antiphospholipid
syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of nonsensical speech
resulting from a transient ischemic attack, a condition in which
a blood vessel providing oxygen and nutrients to the brain is
blocked transiently. Damage to the brain from being deprived of
its blood supply can result in a variety of symptoms.
TIA or 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 episodes, we plan to modify
those risk factors. Your risk factors are:
Antiphospholipid syndrome
We are changing your medications as follows:
Start warfarin 4 mg daily. Of note, warfarin is a teratogenic
medication, meaning it can cause deformities in fetus, so it is
very important that you use non-estrogen/hormonal contraceptives
while taking this medication.
Start lovenox (enoxaparin) 100 mg injection twice a day. This
medication can be stopped when your INR is therapeutic.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these 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
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
10432096-DS-19 | 10,432,096 | 25,825,039 | DS | 19 | 2116-11-15 00:00:00 | 2116-11-15 12:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
hypotension, bradycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with PMH of cirrhosis of unclear etiology who
was transferred from ___ for hypotension,
bradycardia, and increased weakness.
Patient complains of ___ days of progressive weakness and
lethargy, which she says prompted her to go to the ED where she
was noted to be hypotensive and bradycardic. Initial BP was
102/47, which decreased to 86/52 and prompted transfer. She was
also noted to be in sinus bradycardia at 48bpm. Troponin was
obtained and was 0.033 (normal 0 to 0.060). She denies any
recent fevers, cough, sore throat, rhinorrhea, headache, or
abdominal pain. Also denies chest pain or dyspnea.
In the ___ ED, initial vitals were: 98.8 48 110/42 20 98% RA.
RUQ US was obtained and showed a patent portal vein with normal
hepatopetal flow. CT head was negative for any acute
intracranial abnormality. CXR showed a R sided pleural effusion
with R basilar atelectasis. She received one dose of
azithromycin in the ED.
On the floor, initial vitals were 97.6 143/56 50 20 95% RA. She
denied any acute complaints and was requesting food.
Past Medical History:
Liver disease of unknown etiology resulting in cirrhosis
HTN
Depression
CVA in ___
Social History:
___
Family History:
no family history of any liver disease
Physical Exam:
Admission Physical Exam:
Vitals: 97.6 143/56 50 20 95% RA
General: Alert, oriented, no acute distress
HEENT: icteric sclerae, MMM
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally with decreased breath
sounds over right base, no wheezes, rales, rhonchi
CV: Regular rhythm, bradycardic, normal S1 + S2, II/VI
crescendo-decrescendo murmurs, no rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pitting edema to b/l thighs, no
clubbing or cyanosis
Neuro: grossly intact, mild asterixis
===========================
Discharge Physical Exam:
Vitals: 98 129/48 73 18 100RA
General: Somnolent but arousable. Seems confused and unable to
lift hands to assess for liver flap. No acute distress
HEENT: icteric sclerae, dry MM
Lungs: Clear to auscultation bilaterally anteriorly
CV: RRR, normal S1 + S2, II/VI crescendo-decrescendo murmur, no
rubs or gallops
Ext: Warm, well perfused, trace to 1+ pitting edema to b/l. LUE
immobile.
Pertinent Results:
Admission Labs:
___ 04:15PM BLOOD WBC-11.1* RBC-4.03* Hgb-13.0 Hct-40.2
MCV-100* MCH-32.3* MCHC-32.4 RDW-19.7* Plt ___
___ 04:15PM BLOOD Neuts-85.1* Lymphs-8.6* Monos-5.5 Eos-0.2
Baso-0.6
___ 04:15PM BLOOD ___ PTT-33.6 ___
___ 04:15PM BLOOD Glucose-96 UreaN-48* Creat-1.7* Na-139
K-3.5 Cl-107 HCO3-23 AnGap-13
___ 04:15PM BLOOD ALT-46* AST-80* CK(CPK)-49 AlkPhos-158*
TotBili-4.7*
___ 04:15PM BLOOD Lipase-55
___ 04:15PM BLOOD CK-MB-2 cTropnT-0.01
___ 04:15PM BLOOD Albumin-2.0* Calcium-9.4 Phos-3.4 Mg-2.4
___ 04:34PM BLOOD Lactate-2.2*
___ 04:15PM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:15PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-MOD
___ 04:15PM URINE RBC-142* WBC-38* Bacteri-FEW Yeast-NONE
Epi-0
___ 04:15PM URINE CastHy-16*
___ 04:15PM URINE Hours-RANDOM UreaN-441 Creat-45 Na-69
K-61 Cl-125
___ 04:15PM URINE Osmolal-449
=====================
Pertinent Labs:
___ 07:30AM BLOOD Fibrino-43*
___ 08:55AM BLOOD ___
___ 07:15AM BLOOD Ret Aut-1.9
___ 10:30AM BLOOD Ret Aut-1.4
___ 07:08AM BLOOD Sickle-NEG
___ 01:23AM BLOOD TSH-1.2
___ 07:08AM BLOOD calTIBC-87* VitB12-GREATER TH Folate-8.0
Ferritn-378* TRF-67*
___ 07:15AM BLOOD IgG-1281 IgA-508* IgM-129
___ 07:15AM BLOOD ___
___ 07:15AM BLOOD AMA-NEGATIVE Smooth-POSITIVE *TITER -
1:20
___ 09:57AM URINE Hemosid-NEGATIVE
=====================
Imaging:
___ CT head:
No acute intracranial abnormality.
___ CXR:
Moderate to large right pleural effusion with right basilar
atelectasis. 2 mild lower thoracic compression deformities, of
indeterminate age.
___ RUQ US:
1. Coarse, macronodular liver suggestive of cirrhosis. Correlate
with clinical history.
2. Patent portal vein with normal hepatopetal flow.
3. Small volume ascites.
4. Right-sided pleural effusion.
___ Echo:
The left atrium is mildly dilated. The left atrium is elongated.
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses and cavity size are normal. There
is mild to moderate regional left ventricular systolic
dysfunction with focal hypokinesis of the basal to mid
inferolateral wall and severe hypo-to-akinesis of the distal ___
of the left ventricle. [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] A possible moderate sized thrombus (1.0 x 1.2
cm) is seen in the left ventricular apex. Doppler parameters are
indeterminate for left ventricular diastolic function. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened (?#). There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. An eccentric, posteriorly directed jet of Moderate to
severe (3+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Left ventricular systolic dysfunction with regional
variation c/w multivessel CAD. Possible moderate apical left
ventricular thrombus. Moderate to severe mitral regurgitation.
Normal right ventricular cavity size and systolic function.
___ EGD:
The esophagus was tortuous and there was mild sloughing of the
mucosa, but no esophagitis. No varices were seen.
Medium hiatal hernia
Mosaic appearance in the body compatible with portal
hypertensive gastropathy
Normal mucosa in the whole duodenum
Erosions in the fundus/hiatal hernia
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
___ year old female with PMH of cirrhosis of unclear etiology who
was transferred from ___ for hypotension,
bradycardia, and increased weakness.
# Hypotension: Initial BP at the outside hospital was 102/47,
which decreased to 86/52 and prompted transfer. She likely has
low BP at baseline due to cirrhosis, and was taking multiple
antihypertensives at home. She presented with a mild
leukocytosis of 11.1 and neutrophilic predominance (85.1%). Her
UA was positive for leukocytes, and was treated with a 3 day
course of ceftriaxone. Her hypotension was thought to be
primarily related to excess antihypertensives in the setting of
progressing cirrhosis rather than an infectious etiology. Her
home blood pressure medications were held with resulting
normalization in BP. She was discharged only on lisinopril to
treat CHF.
# Sinus bradycardia: Presented with sinus bradycardia in the
___. She had a normal TSH. Bradycardia was most likely secondary
to metoprolol, and resolved once metoprolol was held. She was
restarted on a lower dose of metoprolol to treat CHF, which was
reduced and then stopped again after she continued to miss doses
due to bradycardia.
# Cirrhosis: unknown etiology. Possibly due to NASH given
significant vascular disease, with worsening secondary to
hepatic congestion. She had a weakly positive SMA of 1:20 with a
negative ___ here, although it was reportedly positive at an
outside hospital. Her MELD was 22, and she had evidence of
reduced synthetic function given albumin of 2.0 and INR of 1.6
on admission. There was no evidence of portal vein thrombosis on
US. She was AAO X 3 and did not appear encephalopathic. She had
recently started a trial of prednisone on ___ for possible
autoimmune hepatitis without any significant improvement. She
was restarted on prednisone here, which was transitioned to a
slow taper due to lack of improvement in bilirubin. She went for
endoscopy which did not reveal any varices. She was diuresed
with lasix (increased from 20 to 40 daily), with resulting
significant improvement in peripheral edema. Pt was started on
LActulose and Rifaximine for HE.
# Systolic CHF/CAD: Underwent echo which showed a new onset of
reduced LVEF of 35% with moderate to severe mitral
regurgitation. Her most recent echo in ___ had shown an
EF of 50%. This reduction in EF was likely due to a relatively
recent (in past few months) silent infarct. Echo also revealed a
left ventricular mass concerning for a thrombus. On further
review it did not appear mobile and was thought to be chronic.
Cardiology was consulted and felt that she would not benefit
from anticoagulation for the thrombus. She was started on daily
20mg IV lasix, and was transitioned to 40mg PO. She was started
on lisinopril 2.5mg daily. She was also restarted on metoprolol,
which was stopped after she became bradycardic. She was
continued on home aspirin.
# Tachyarrhythmia/atrial fibrillation: had several episodes of
non-sustained wide complex tachycardia on telemetry. This was
felt to be likely atrial fibrillation with aberrancy considering
her history of paroxysmal afib and documented afib with LBBB
while admitted. There was some concern for VT given her history
of MI, although QRS complexes were identical in morphology to
her baseline afib. Electrolytes were aggressively repleted. She
did not require any rate control, and metoprolol was stopped due
to bradycardia. She has not been on any anticoagulation, and
cardiology did not recommend initiating it given her limited
life expectancy due to her liver disease.
# Anemia: Presented with a falling hemoglobin in the context of
rising coags and low fibrinogen as well as elevated indirect
bili. Low fibrinogen and haptoglobin are likely secondary to
liver faluire. Hematology was consulted and felt that she was
unlikely to be having active hemolysis given a negative urine
hemosiderin. They thought that she likely had low grade DIC due
to liver disease. She also appeared to have a component of
anemia of chronic disease given iron studies. Hemoglobin was
stable and she did not require any transfusions.
- will f/u hemoglobin electrophoresis
# Elevated creatinine: Presented with elevated creatinine to
1.8, likely cardiorenal in etiology. Creatinine decreased to 0.8
with diuresis.
Titrate bowel movements to ___ daily with lactulose. If more
than 4 daily, decrease dose from 30 ml to 15 ml BID.
****************TRANSITIONAL ISSUES****************:
1) She would like to be at home in her last days, please work
with hospice to arrange this.
2) She was started on lactulose and Rifaxmine for hepatic
encephalopathy. Please titrate the dose to have ___ BM daily. If
more than 4, decrease dose to 15 ml BID.
3)She is on a Prednisone taper:
Take 20 mg until the ___ mg until ___ then
10 mg until ___ then
5 mg until ___ mg until ___, then stop.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Cyanocobalamin 1000 mcg IM/SC MONTHLY
3. Losartan Potassium 100 mg PO BID
4. Potassium Chloride 10 mEq PO BID
5. Venlafaxine XR 75 mg PO DAILY
6. PredniSONE 40 mg PO DAILY
7. Chlorthalidone 50 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Aripiprazole 5 mg PO DAILY
11. Metoprolol Tartrate 25 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Venlafaxine XR 75 mg PO DAILY
RX *venlafaxine 75 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
3. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth DAILY Disp #*60
Tablet Refills:*2
4. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth DAILY Disp #*60 Tablet
Refills:*3
5. PredniSONE 20 mg PO DAILY Duration: 36 Days
Taper per discharge instructions.
Tapered dose - DOWN
RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Lactulose 30 mL PO BID
RX *lactulose 20 gram/30 mL 30 ml by mouth twice a day
Refills:*0
7. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg t tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*3
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Hypotension
Bradycardia
Crytptogenic cirrhosis
Systolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure taking care of you at ___. You were
transferred here after you were found to have low blood pressure
and a slow heart rate at another hospital. We think this is
because you were taking many blood pressure medications, and
some of them you no longer needed. Once we stopped these
medications your blood pressure and heart rate improved.
You also had a urinary tract infection that we treated with
three days of IV antibiotic.
You had an echocardiogram of your heart that showed that your
heart is not pumping as well as it should, something called
congestive heart failure. This is likely because you had a
missed heart attack. We started you on diuretics to remove extra
fluid as well as a medication called lisinopril to help your
heart pump as well as possible.
You were followed by the liver team. Your cirrhosis is advanced,
and unfortunatly there are no other medications or treatments to
cure this. You were seen by out palliative care team who helped
us to treat all of your symtpoms as best as we can. We want you
to keep up with your nutrition, eat things that bring you joy,
but try to limit salt intake as it will make your swelling
worse.
Followup Instructions:
___
|
10432130-DS-20 | 10,432,130 | 21,318,806 | DS | 20 | 2168-03-08 00:00:00 | 2168-03-18 15:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
___
Attending: ___.
Chief Complaint:
Right Lower abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is a ___ yo M with h/o HLD, hypothyroidism who p/w
acute onset RUQ/RLQ
abdominal pain x 1day with nausea/vomiting. He went to ___ Urgent Care where CT scan was equivocal for appendicitis.
However, due to abdominal tenderness and leukocytosis, he was
sent to ___ ED for further evaluation. He denies any fevers,
chills or diarrhea. His most recent travel was to ___ in
___. No recent changes in meal patterns
Past Medical History:
Mycosis fungoides
Depression
HLD
Hypothyroidism
Acute eosinophilic pneumonia
Social History:
___
Family History:
Noncontributory
Physical Exam:
Physical Exam on admission:
Vitals: 98.6, 78, 130/74, 18, 98%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended. Mildly tender to palpation in RUQ and
RLQ. No rebound tenderness or guarding.
DRE: Deferred
Ext: No ___ edema, ___ warm and well perfused
Physical Exam on discharge:
Vitals: 98.6, 78, 130/74, 18, 98%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended. Nontender.
RLQ. No rebound tenderness or guarding.
DRE: Deferred
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 07:30AM BLOOD WBC-11.0* RBC-5.36 Hgb-15.3 Hct-45.8
MCV-85 MCH-28.5 MCHC-33.4 RDW-12.9 RDWSD-39.7 Plt ___
___ 04:10PM BLOOD Neuts-84.9* Lymphs-7.9* Monos-6.2
Eos-0.2* Baso-0.5 Im ___ AbsNeut-12.95* AbsLymp-1.21
AbsMono-0.95* AbsEos-0.03* AbsBaso-0.07
___ 07:30AM BLOOD Glucose-102* UreaN-9 Creat-0.8 Na-139
K-3.7 Cl-101 HCO3-27 AnGap-15
___ 04:10PM BLOOD ALT-45* AST-23 AlkPhos-73 TotBili-0.4
___ 07:30AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.2
Brief Hospital Course:
Mr ___ is a ___ w/ acute onset of RUQ/RLQ abdominal pain,
nausea/vomiting & CT scan which was equivocal for acute
appendicitis. The patient was admitted for observation and
serial abdominal exam.
During observation, serial abdominal exam were negative the
patient had a feeding trail with no recurrent abdominal pain.
Leukocytes trended down from 15.3K to 11K.
He was afebrile and felt better no n/v.
The patient was discharged home to e further followed by his
PCP.
Medications on Admission:
ATORVASTATIN - 80 mg tablet. 1 tablet(s) by mouth QPM
BUPROPION HCL [WELLBUTRIN SR] - SR 100 mg tablet,once a day
FLUOXETINE [PROZAC] - 40 mg capsule. 1 once a day
LEVOTHYROXINE - 50 mcg tablet. 1 tablet(s) by mouth daily
Discharge Medications:
Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
ATORVASTATIN - 80 mg tablet. 1 tablet(s) by mouth QPM
BUPROPION HCL [WELLBUTRIN SR] - SR 100 mg tablet, once a day
FLUOXETINE [PROZAC] - 40 mg capsule. 1 once a day
LEVOTHYROXINE - 50 mcg tablet. 1 tablet(s) by mouth daily
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain unspecified
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 due to right lower and upper abdominal pain
with nausea/vomiting. You had a CT scan in an out side setting
which was equivocal for appendicitis.
However, due to abdominal tenderness and leukocytosis, you were
sent to ___ ED for further evaluation.
Review of the CT scan showed No acute intra-abdominal pathology
is identified. Candidate structure for the appendix appears
normal without evidence for appendicitis.
You were admitted for observation for a serial abdominal exams
which were negative.
You tolerated your diet as expected and now ready to be
discharge home with the following recommendations:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Followup Instructions:
___
|
10432130-DS-21 | 10,432,130 | 23,324,114 | DS | 21 | 2171-03-26 00:00:00 | 2171-03-26 17:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
___
Attending: ___
Chief Complaint:
right upper quadrant pain
Major Surgical or Invasive Procedure:
___ lap cholecystectomy, liver biopsy
___ ERCP
History of Present Illness:
Mr. ___ is a pleasant ___ year old man who presents to the
ED
for evaluation of right upper quadrant pain.
He reports right upper quadrant pain that has been present for
the past 2 weeks. It initially started suddenly while he was in
___ and then subsided somewhat but reports constant pain
since then. He does report on and off points where it gets worse
but he hasn't noticed any relationship to what he is eating. It
is associated with nausea and he denies fevers or chills. He has
recent travel to ___ and returned 1 weeks ago. He was
seen
and evaluated by his PCP and was noted to have LFT elevation but
normal total bilirubin. He performed a RUQ u/s with
cholelithiasis but no evidence of cholecystitis.
Hepatitis panel was sent with HBsAg: Neg ,HBs-Ab: Neg ,HAV-Ab:
Pos ,IgM-HAV: Neg ,HCV-Ab: Neg.
Of note hepatitis E has not been sent. He reports drinking ___
beers a night but denies alcohol use in the past 2 weeks. He is
currently on an antimalarial (but was held by his PCP, last dose
1 week ago). He had taken azithromycin from travel clinic when
he
had some diarrhea while traveling but stopped after 3 days when
diarrhea stopped.
In the ED today he was noted to be afebrile, tachycardic and
normotensive. His labs indicated a normal WBC at 7.7, Hct 47.9,
Plt 284, lactic acid 1.1, ALT ___, AST 304 (___), AP 734 (___), TB 2.3 ___, 0.7), DB 1.9, K 3.9, Cr
1, sugar 131. A RUQ ultrasound was performed which revealed
cholelithiasis, no evidence of acute cholecystitis, anterior
gallbladder lesion likely adherent sludge, CHD 3mm. Surgery is
consulted for further recommendations.
Past Medical History:
Mycosis fungoides
Depression
HLD
Hypothyroidism
Acute eosinophilic pneumonia
Social History:
___
Family History:
Noncontributory
Physical Exam:
Physical Exam: upon admission: ___
Vitals:
T 97.6 105 114/84 18 100% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Equal symmetric chest rise, no gross chest wall
deformities
ABD: Soft, nondistended, +RUQ tenderness, no rebound or
guarding,
no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Physical examination upon discharge: ___
GENERAL: NAD
CV: ns1, s2
LUNGS: clear
ABDOMEN: tender, soft, ecchymosis around umbilicus, port sites
clean and dry with steri-strips, no rebound, no guarding
EXT: no pedal edema bil., no calf tenderness bil
NEURO: alert and oriented x 3, speech clear, no tremors
Pertinent Results:
___ 06:55AM BLOOD WBC-11.3* RBC-5.09 Hgb-14.3 Hct-45.0
MCV-88 MCH-28.1 MCHC-31.8* RDW-13.0 RDWSD-42.6 Plt ___
___ 07:35AM BLOOD WBC-7.1 RBC-5.31 Hgb-14.9 Hct-46.6 MCV-88
MCH-28.1 MCHC-32.0 RDW-12.9 RDWSD-41.7 Plt ___
___ 05:15AM BLOOD WBC-7.7 RBC-5.45 Hgb-15.3 Hct-47.9 MCV-88
MCH-28.1 MCHC-31.9* RDW-12.8 RDWSD-41.2 Plt ___
___ 05:15AM BLOOD Neuts-70.8 Lymphs-15.4* Monos-8.3 Eos-4.3
Baso-0.8 Im ___ AbsNeut-5.49 AbsLymp-1.19* AbsMono-0.64
AbsEos-0.33 AbsBaso-0.06
___ 06:55AM BLOOD Plt ___
___ 07:28AM BLOOD ___
___ 06:55AM BLOOD Glucose-111* UreaN-11 Creat-0.8 Na-141
K-4.6 Cl-101 HCO3-25 AnGap-15
___ 07:35AM BLOOD Glucose-92 UreaN-14 Creat-0.9 Na-141
K-4.1 Cl-100 HCO3-25 AnGap-16
___ 06:55AM BLOOD ALT-329* AST-144* AlkPhos-428*
TotBili-0.7
___ 05:15AM BLOOD ALT-628* AST-304* AlkPhos-734*
TotBili-2.3* DirBili-1.9* IndBili-0.4
___ 06:55AM BLOOD Lipase-10
___ 06:55AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.0
___ 07:26AM BLOOD TSH-2.7
___: abdominal US:
Cholelithiasis without evidence for cholecystitis. Possible
additional 8 mm gallbladder polyp versus adherent sludge.
___: Liver/gallbladder US:
. Cholelithiasis without evidence of acute cholecystitis.
2. Previously seen anterior gallbladder wall lesion is not
visualized and
likely represented wall adherent sludge.
___: MRCP:
Cholelithiasis and choledocholithiasis without evidence of
cholecystitis or bile duct dilatation.
___: ERCP:
Sphincterotomy with removal of sludge and stone, small mucosal
disruption at distal esophagus.
___: barium swallow:
Normal esophogram.
Brief Hospital Course:
P: ___ year old male admitted to the hospital with RUQ pain
A: Imaging studies were done which showed gallstones. You also
underwent an ERCP which showed stones in the common bile duct
which were removed.
C: Statins and anti-depressants to resume at discharge
T Continue to monitor LFT's, start omeprazole on discharge.
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
___ year old male admitted to the hospital with right upper
quadrant pain. Upon admission, the patient was made NPO, given
intravenous fluids, and underwent imaging. His blood work
revealed elevated liver enzymes but normal bilirubin. He
underwent an ultrasound which showed cholelithiasis but no
evidence of cholecystitis. In addition to this, he underwent an
MRCP which showed cholelithiasis and choledocholithiasis. The
patient underwent an ERCP for extraction of stones from the CBD.
The Hepatology service was consulted for management of his
elevated liver enzymes.
The patient was taken to the operating room on HD #6 where he
underwent a laparoscopic cholecystectomy and liver biopsy.
Operative findings were notable for a congested vs. fatty liver
and chronically inflamed gallbladder with many small stones.
There was a 100cc blood loss. The patient was extubated after
the procedure and monitored in the recovery room.
The post-operative course was stable. The patient's pain was
controlled with intravenous analgesia. After return of bowel
function, he resumed a regular diet and transitioned to oral
analgesia. He was voiding without difficulty. The patient was
discharged home on POD # 2 with stable vital signs. Discharge
instructions were reviewed and questions answered. The patient
was instructed to follow-up in the Acute care clinic and with
the Hepatology service.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 100 mg PO QAM
2. Atorvastatin 80 mg PO QPM
3. Levothyroxine Sodium 50 mcg PO DAILY
4. FLUoxetine 40 mg PO DAILY
5. mefloquine 250 mg oral weekly
6. Azithromycin 500 mg PO DAILY x3d for travelers diarrhea
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
please take with food
3. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*14
Capsule Refills:*1
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
6. Atorvastatin 80 mg PO QPM
7. BuPROPion (Sustained Release) 100 mg PO QAM
8. FLUoxetine 40 mg PO DAILY
9. Levothyroxine Sodium 50 mcg PO DAILY
10. mefloquine 250 mg oral weekly
Discharge Disposition:
Home
Discharge Diagnosis:
cholelithiasis
choledocholithiasis
transaminitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for evaluation of abdominal
pain and were found to have gallstones. You underwent an ERCP
and then were taken to the operating room and had your
gallbladder removed laparoscopically. You tolerated the
procedure well and are now being discharged home to continue
your recovery with the following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10432862-DS-5 | 10,432,862 | 27,862,430 | DS | 5 | 2142-05-03 00:00:00 | 2142-05-03 15:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hydrohemothorax
Major Surgical or Invasive Procedure:
___
Bronchoscopy, thoracoscopy, thoracotomy, and decortication.
___
Left thoracotomy and evacuation of hemothorax
History of Present Illness:
___, otherwise healthy, presented to the ___ ED after being
transferred from ___ for loculated
hemothorax seen on CT/CXR. Two weeks ago at a volleyball game,
he had ___ to the left chest. He had no symptoms at the
time and felt sore the day after. Last ___, he began feeling
weak with increasing SOB and fatigue. He reports feeling very
thirsty and over the past week has stayed in bed with poor
appetite and ~10 lb weight loss in 2 weeks. He also reports a
cough, productive of yellow sputum, but no hemoptysis, no fevers
or chills. At ___, he was oxygenating at 92% RA. CT/CXR showed
loculated hydro/hemothorax, and he was transferred to ___ for
further care.
In the ED, he was at 100% on 2L NC, tachy to 100-105. CBC showed
WBC 26.9 with 87% bands, H/H 11.8/36.4. He was hemodynamically
stable.
Past Medical History:
NONE
Social History:
___
Family History:
Non-contributory
Physical Exam:
ON ADMISSION:
PHYSICAL EXAM:
Temp: 99.1 HR: 122 BP: 135/78 RR: 18 O2 Sat: 97% 2LNC
___
[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:
HEENT
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[x] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [x] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY
Decreased breath sounds on left compared to right. Dullness to
percussion throughout left side. Easy work of breathing, equal
chest rise.
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema
[x] Peripheral pulses nl [x] No abd/carotid bruit
[ ] Abnormal findings:
GI
[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia
[ ] Abnormal findings:
GU [x] Deferred
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO
[x] Strength intact/symmetric [x] Sensation intact/ symmetric
[x] Reflexes nl [x] No facial asymmetry [x] Cognition intact
[x] Cranial nerves intact [ ] Abnormal findings:
MS
[x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl
[x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl
[x] Nails nl [ ] Abnormal findings:
LYMPH NODES
[x] Cervical nl [x] Supraclavicular nl [x] Axillary nl
[x] Inguinal nl [ ] Abnormal findings:
SKIN
[x] No rashes/lesions/ulcers
[x] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC
[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect
[ ] Abnormal findings:
OTHER:
ON DISCHARGE:
VS: Temp 98.2, HR 91, BP 134/41, RR 18, SpO2 98% on room air
___: Pleasant gentleman in no acute distress, alert and
oriented
HEENT: Normocephalic, atraumatic, extraocular movements intact
CV: Regular rate and rhythm
Pulm: Lungs clear to auscultation bilaterally, non-labored
breathing
Wound: Left thoracotomy wound with staples in place, no erythema
or induration noted
Abd: Soft, non-tender to palpation, non-distended
Ext: Warm and well-perfused, peripheral pulses intact
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH ___ RDW Plt Ct
___ 15.2 3.05 9.3 28.5 93 30.4 32.5 16.4 379
___ 17.0 3.11 9.4 28.8 93 30.2 32.6 16.5 346
___ 16.6 3.03 9.2 27.9 92 30.2 32.9 16.0 342
___ 18.2 2.58 7.7 22.9 89 29.6 33.4 15.0 271
___ 24.0
___ 27.2 2.25 6.7 19.8 88 30.0 34.0 14.5 343
___ 30.2 2.43 7.3 21.2 87 30.0 34.3 14.4 341
___ 21.0
___ 21.5 2.48 7.3 21.1 85 29.5 34.6 14.6 273
___ 27.6 2.92 8.7 25.1 86 29.9 34.7 14.4 288
___ 31.9 3.04 9.1 26.8 88 30.0 33.9 14.2 269
___ 35.7 3.22 9.8 29.5 92 30.3 33.1 13.9 298
___ 39.7 2.22 6.7 20.9 94 30.0 31.9 13.1 406
___ 49.8 2.56 7.4 23.9 94 28.7 30.8 13.0 549
___ 51.1 3.27 9.5 30.4 93 29.2 31.4 13.0 623
___ 26.9 4.10 11.8 36.4 89 28.8 32.5 12.8 398
CHEMISTRY:
Glu BUN Creat Na K Cl HCO3 AnGap
___ 70 9 0.9 140 3.9 ___
___ 79 9 0.8 137 4.2 ___
___ ___ 138 3.8 100 28 14
___ 125 8 0.7 138 3.9 ___
___ 114 14 1.1 139 4.0 ___
___ 120 15 1.1 137 4.1 ___
___ 120 22 1.2 138 3.7 ___
___ ___ 4.4 ___
___ ___ 5.1 ___
___ ___ 5.9 ___
___ 133 22 1.4 136 5.5 ___
___ 139 21 1.2 136 5.3 ___
___ 144 20 1.0 136 5.0 ___
___ ___ 136 4.2 99 24 17
ALT AST LD(LDH) CK(CPK) AlkPhos TBili
DBili IndBili
___ 173 89 269 152
___ ___ 1.2
___ ___ 2.1
___ 433 414 79 2.3 2.0
0.3
___ 514 557 77 1.7
1.5 0.2
___ 37 55 293 89 1.4
___ 242
HEPATITIS
___ 02:33AM BLOOD HCV Ab-NEGATIVE
___ 02:33AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-BORDERLINE
___ 07:33AM BLOOD calTIBC-122* TRF-94*
VANCOMYCIN
___ 06:08AM BLOOD Vanco-20.2*
___ 07:33AM BLOOD Vanco-18.3
CT Chest ___
IMPRESSION:
1. Large multiloculated left hydropneumothorax with enhancement
of the pleura concerning for empyema.
2. Ground-glass opacification with ill-defined nodules in the
left upper lobe as well as centrilobular nodules in the right
middle and right lower lobe concerning for a small airways
infectious or inflammatory process such as aspiration.
3. Fatty liver.
RUQ US ___
IMPRESSION:
1. Unremarkable appearance of the liver and bile ducts. No
gallstones. No splenomegaly.
2. Small right pleural effusion incidentally noted.
Brief Hospital Course:
Mr. ___ is an otherwise healthy ___ who presented to the ED on
___ with an empyema. He was admitted to the thoracic
service at ___ and immediately
underwent bronchoscopy, thoracoscopy, thoracotomy, and
decortication with aspiration of foul-smelling infected
material. Specimens of the peel and pleural fluid were sent off
for microbiology and pathology. Towards the conclusion of the
decortication, the patient became hypotensive and
hemodynamically unstable requiring multiple vasopressors. Two
___ chest tubes were placed with good hemostasis. He
remained intubated at the end of the procedure and was
immediately taken to the ICU in critical but stable condition.
For other details of the procedure, please see Dr. ___
___ note.
While in the ICU, serial labs were drawn. It was noted that his
white count and creatinine were up-trending, hematocrit was
decreasing, and he was becoming increasingly acidotic with
coagulopathy developing. He was emergently taken back to the
operating room and underwent thoracotomy with evacuation of
retained hemothorax, and only generalized oozing was observed
with no evidence of active bleeding from the lung or an arterial
source. He received fresh frozen plasma and fluid resuscitation
which stopped the bleeding and coagulopathy. He was subsequently
transferred back to the ICU where he remained on triple
vasopressors. Over the next few days, he received a total of 5
units of packed red blood cells, and his hematocrit stabilized.
His white count initially rose, but steadily trended down. On
post-operative day 3 after the initial procedure, he was
extubated successfully without complications, and the anterior
chest tube was removed. Post-operative day 4, the remaining
chest tube was removed, and his foley was removed. He was
transferred out of the ICU to the thoracic surgery floor where
he remained through the rest of his hospitalization. It was
noted that he had elevated LFTs from baseline; however, RUQ US
showed no hepatic or gallbladder etiology. It was believe that
this was likely secondary to shocked liver and the liver
function enzymes steadily trended to normal over the subsequent
days. Infectious disease was consulted regarding management of
the poly-microbial content of the left chest, and they
ultimately recommended an extended course of IV antibiotics. A
___ line was placed on ___ and case management worked to set
up home IV infusion with ___. He will complete a 10 day course
of IV Vancomycin to end on ___, and a 4 week total course of
IV Zosyn (last day ___. He was also seen by physical therapy
who cleared him for home. At the time of discharge, Mr. ___ felt
well, and his wife felt comfortable taking care of him at home.
He was ambulating, voiding, eating regular diet, and pain was
controlled on PO pain medications. His incision looked clean and
dry with staples to be removed at his follow-up appointment. He
was schedule to follow-up with Dr. ___ and with the ___
infectious disease clinic for monitoring and management of his
outpatient IV antibiotics. He was deemed ready for discharge on
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H fever, pain
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every six (6) hours Disp #*30 Tablet Refills:*0
2. Piperacillin-Tazobactam 4.5 g IV Q8H
RX *piperacillin-tazobactam 4.5 gram 4.5 grams every eight (8)
hours Disp #*63 Vial Refills:*0
3. Vancomycin 1000 mg IV Q 12H
RX *vancomycin 1 gram 1 g IV every twelve (12) hours Disp #*6
Vial Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
5. Ibuprofen 400 mg PO Q8H
RX *ibuprofen 800 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
6. Senna 8.6 mg PO DAILY
RX *sennosides [senna] 8.6 mg 1 capsule by mouth at bedtime Disp
#*20 Capsule Refills:*0
7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally once a day Disp
#*5 Suppository Refills:*0
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left Empyema.
Postoperative left hemothorax.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital for lung surgery and you've
recovered well. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol ___ mg every 6 hours in between your narcotic.
If your doctor allows you may also take Ibuprofen to help
relieve the pain.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
___
|
10433022-DS-3 | 10,433,022 | 24,743,955 | DS | 3 | 2130-08-25 00:00:00 | 2130-08-26 22:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L-sided chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is an ___ ___ F with hx of borderline
HLD, peripheral neuropathy, osteoarthritis, and tachycardia,
presenting with subacute L-sided pleuritic chest pain which
acutely worsened 1 day ago. She was interviewed with her
daughter, ___, serving as ___. A professional translator
was declined by the patient.
The patient states that she has had constant, dull pain in her
L axillary region for the past month. It is pleuritic and
associated with dyspnea on exertion. Yesterday, around 10:00pm
the pain acutely worsened to ___. This morning, her daughter
convinced her to call an ambulance, since the pt was unable to
sleep and pain worsened. The pt also describes discomfort in her
left calf which she has had for many years and thinks is related
to her 6 pregnancies in the past. No recent long travel, no hx
of blood clots in the pt or her family, no hormone use, no
surgeries.
The pt also states she has had wheezing for the past 2 months,
which is very unusual for her. It comes and goes. Looking over
her PCP notes, it appears she was treated for a URI on ___
and was given a new prescription for albuterol. The wheezing
improves with albuterol use.
Prior to this recent illness, the pt had been very healthy and
independent. She had been started on metoprolol ER 25mg daily by
her PCP for tachycardia to low 100s in ___. Workup
including electrolytes, BUN, Cr, and TSH was unrevealing.
ED initial vitals 98.3 104 155/84 20 96% 2L NC. Labs were
remarkable for mildly low phos at 2.3 and a normal lactate. WBC
was elevated from the patient's baseline of 4.5-6.4, up to 9.9
with 77% PMNs. ALT/AST/AP/Lip/Tbili/alb all normal. CT abdomen
showed no evidence of nephrolithiasis, 4.8 cm nonenhancing
hypodense mass in the left adnexa, concerning for neoplasm,
bilateral atelectasis with small left pleural effusion,
scattered intramuscular calcifications likely due to
cysticercosis. CXR showed ? pneumonia and pt was given one dose
of levofloxacin 750mg IV at 1600. She was also given 2mg
morphine IV. Vitals on Transfer: 98.9 108 26 137/80 96% 2LNC
pain ___
On the floor, vs were: T 97.6 BP 147/77 P ___ R 32 O2 sat 97%
4L NC
The patient was complaining of pain in her L lower chest, which
was diminished since receiving morphine in the ED.
Review of sytems:
(+) Per HPI. Also, pt has chronic b/l knee pain.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies central chest pain, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias (except for her chronic knee pain) or myalgias. Ten
point review of systems is otherwise negative.
Past Medical History:
ARTHRITIS
HEARING LOSS
BORDERLINE HYPERCHOLESTEROLEMIA
L ___ CYST
OSTEOPENIA
PERIPHERAL NEUROPATHY
TACHYCARDIA
Social History:
The patient does not and has never smoked, drank or used drugs.
She lives alone in an apartment complex that is shared with
many other elderly people and mentally-ill young people. The
family is concerned about her safety. She is independent. She
does not drive, but does walk. She does not use any walkers. Her
diet mainly consists of vegetables, chicken with no skin, 1% low
fat milk, decaffeinated coffee (daily).
She has a great support network in her large family. She has
20+ grandchildren and 36 great grandchildren. She lost 2
daughters when they were young and lost 1 daughter to pancreatic
cancer. She still has 3 daughters who are alive.
In terms of her occupation, the patient has mainly been a
house___ for most of her life. Over ___ years ago in ___,
she worked at a ___. She also used to work as a
___ but never used pesticides. In addition, she cleaned
houses, but was not exposed to cleaning agents. She immigrated
to the ___ ___ years ago.
Family History:
- Daughter passed away from pancreatic cancer at ___
- Sister died at ___ and brother died at ___ from old age
Physical Exam:
ADMISSION EXAM:
Vitals: T:97.6 BP:147/77 P:107 R:18 O2:98%RA
General: Comfortable, no acute distress.
HEENT: PERRL. MMM.
Neck: Supple, No LAD, No JVD
Lungs: CTAB, no wheezes/rales/rhonchi
CV: RRR, S1 and S2 auscultated. II/VI systolic murmur loudest
at RUSB. No radiation to carotids.
Abdomen: Soft, nontender, no rebound or guarding, no HSM.
+bowel sounds
Ext: WWP, no ___ edema, no calf tenderness, negative ___
sign.
Skin: Warm and dry to touch
Neuro: A&Ox3, attention intact (correctly named months from ___
to ___ correctly but stopped because was getting tired). Light
touch and vibration sensation intact. CN2-12 grossly intact.
DISCHARGE EXAM:
Vitals: Afebrile, satting mid ___ on RA, does not desat with
ambulation, HR ___
General: Comfortable, NAD
Lungs: CTAB
Pertinent Results:
ADMISSION LABS
___ 09:20AM BLOOD WBC-9.9# RBC-4.23 Hgb-13.0 Hct-38.0
MCV-90 MCH-30.8 MCHC-34.4 RDW-13.9 Plt ___
___ 09:20AM BLOOD Neuts-77.7* Lymphs-16.9* Monos-4.2
Eos-0.6 Baso-0.5
___ 09:20AM BLOOD Glucose-135* UreaN-12 Creat-0.9 Na-134
K-4.2 Cl-98 HCO3-28 AnGap-12
___ 09:20AM BLOOD ALT-15 AST-24 AlkPhos-90 TotBili-0.9
___ 09:20AM BLOOD Lipase-16
___ 07:25PM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:20AM BLOOD Albumin-4.2 Calcium-8.9 Phos-2.3* Mg-2.0
___ 09:40AM BLOOD Lactate-1.3
___ 12:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 12:15PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 12:15PM URINE RBC-6* WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
DISCHARGE LABS
___ 08:45AM BLOOD WBC-5.5 RBC-3.83* Hgb-11.6* Hct-35.0*
MCV-91 MCH-30.2 MCHC-33.0 RDW-13.4 Plt ___
IMAGING
CXR (___): IMPRESSION: Increased left lung base opacity, may
represent a combination of a
small left pleural effusion and atelectasis. However, an
underlying
infectious process cannot be excluded.
CT abd/pelvis (___): 1. No evidence of nephrolithiasis.
2. 4.8 cm hypodense solid mass in the left adnexa, concerning
for neoplasm.
Further evaluation with MRI is recommended.
3. Diverticulosis without evidence of acute diverticulitis.
4. Cholelithiasis.
5. Bilateral atelectasis with small left pleural effusion.
6. Aneurysmal dilatation of the left common iliac artery
measuring up to 2.2
cm and aneurysmal dilatation of the abdominal aorta, measuring
up to 3 cm.
7. Scattered intramuscular calcifications likely likely due to
cysticercosis.
CTA (___):
1. Pulmonary embolism in several segmental arteries in the left
lower lobe.
2. Atelectasis in the left lower lobe with left pleural
effusion. Please note
that the extent of these changes is unusual for an acute PE and
unless the
patients symptoms are longer standing ___ days), other
etiologies such as
pneumonia or neoplasm cannot be excluded. Follow-up chest CT in
6 weeks to
ensure resolution is recommended.
MRI pelvis (___):
1. 4.2 cm left ovarian mass with signal characteristics and
enhancement
pattern most compatible with a fibroma. Trace neighboring
intrahepatic free fluid may represent mild Meig's syndrome.
2. Extensive sigmoid diverticulosis.
3. Trace fluid within the endometrial cavity is most likely
secondary to mild cervical stenosis in this age group. Correlate
with any recent history of vaginal discharge or bleeding.
4. 18 mm left common iliac artery aneurysm.
MICROBIOLOGY
Blood cultures pending
Brief Hospital Course:
Ms. ___ is a previously healthy ___ F with a history of
peripheral neuropathy, borderline hyperlipidemia,
osteoarthritis, hypertension, tachycardia who presented with
pleuritic chest pain, hypoxia, and tachycardia, found to have
pulmonary emboli.
ACTIVE DIAGNOSES:
# Pulmonary Emboli: The pt presented with pleuritic pain,
hypoxemia, and tachycardia. The ED had already done a CT abdomen
with contrast, so CTA could not be done until the following day
to avoid contrast nephropathy. The patient was empirically
treated with enoxaparin starting the night of ___. A CTA the
following day confirmed the diagnosis, showing multiple PEs in
the left lower lobe. The patient was started on warfarin on ___
and enoxaparin was continued for bridge. The patient was
discharged after her granddaughter received instructions on
injection technique. Her anti-coagulation will be handled by Dr.
___ office. INR should be checked daily until her PCP ___
appt.
The PE was unprovoked. She will need anticoagulation for 6
months. There was concern for ovarian mass (see below) being
malignant and causing hypercoagulable state, however mass
appears benign on MRI.
Pain was well controlled with standing Tylenol, lidocaine patch,
and low-dose oxycodone. The patient was discharged with a
prescription for low-dose oxycodone as well as a bowel regimen
while on narcotic.
# Ovarian Mass: CT abdomen/pelvis in ED showed concerning
ovarian mass and MRI was recommended for further work-up. The
MRI showed likely fibroma. The patient has outpatient follow-up
with GYN.
# Atelectasis and Pleural Effusion: There was an unusual amount
of atelectasis and effusion surrounding the PE in the LLL on
CTA. Radiology recommends a 6 week follow-up CT of the chest to
assess for resolution.
# Cysticercosis: Imaging finding of intramuscular calcifications
was consistent with a diagnosis of cysticercosis. The pt has
likely had this for many years and she does not have evidence of
neurocysticercosis. No need for treatment.
CHRONIC ISSUES:
#Osteoarthritis in knees: Stable. Continued on acetaminophen.
#Peripheral neuropathy in feet: Stable. Amitriptyline was held
given the patient's age. She was re-started on this medication
on discharge.
TRANSITIONAL ISSUES:
-Pt needs close anticoagulation follow-up. Goal INR ___.
Duration: 6 months
-Needs 6 week follow-up chest CT due to effusion/atelectasis
-Pt has GYN ___ for ovarian mass
-New meds: warfarin, enoxaparin (for bridge), oxycodone,
docusate, senna
-STOPPED meds: albuterol inhaler, metoprolol
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
2. Amitriptyline 25 mg PO HS
3. Acetaminophen 325-650 mg PO Q6H:PRN pain
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD DAILY knee pain
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Amitriptyline 25 mg PO HS
3. Lidocaine 5% Patch 1 PTCH TD DAILY knee pain
4. Enoxaparin Sodium 60 mg SC Q12H Start: ___, First Dose:
Next Routine Administration Time
RX *enoxaparin 60 mg/0.6 mL 60 mg SQ twice a day Disp #*4
Syringe Refills:*0
5. Warfarin 3 mg PO DAILY16
Take as instructed by ___, RN and/or Dr. ___
___ *warfarin 1 mg 3 tablet(s) by mouth once a day in the
afternoon Disp #*90 Tablet Refills:*0
6. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*15 Tablet Refills:*0
7. Docusate Sodium 100 mg PO BID:PRN constipation
If you are having loose stool, do not take this medication. Stop
taking when you stop oxycodone.
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*20 Capsule Refills:*1
8. Senna 2 TAB PO HS:PRN constipation
Do not take if you are having loose stool. Stop taking when you
stop oxycodone
RX *sennosides [senna] 8.6 mg 2 tab by mouth every night Disp
#*20 Capsule Refills:*1
9. Outpatient Lab Work
Patient has a diagnosis of Pulmonary Embolism. ICD-9 code 415.1.
She needs INR drawn daily from ___. Please fax result to
___, RN (fax ___ at ___
___.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Pulmonary embolism in several segmental arteries in the left
lower lobe
- Left lower lobe atelectasis and pleural effusion
- 4.8 cm hypodense mass on the left ovary: fibroma vs.
fibrothecoma
- Cysticercosis
Secondary:
-Osteoarthritis
-Peripheral neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you during your hospitalization at
___.
You were admitted because of pain in your left chest and you
were found to have a blood clot in your left lung. We treated
you with blood thinning medications called enoxaparin and
warfarin. You will need close follow-up with your primary care
doctor and his nurse, ___, to monitor the level of those
medicines in your body. You will need an injection of enoxaparin
on ___ and ___. You will also need daily blood work at Dr.
___ clinic through ___. Take the warfarin daily as
prescribed by Dr. ___.
A CT scan in the emergency department showed a mass on your left
ovary. An MRI was done to get a better look at it, and it is
thought to be a non-dangerous growth on your ovary. Sometimes,
those growths can secrete hormones which can be unhealthy over
long periods of time. We have scheduled an appointment for you
with a gynecologist to determine if any further treatment should
be done.
Finally, you will need a repeat CT scan of your lungs in 6
weeks. Dr. ___ will help you arrange that.
Followup Instructions:
___
|
10433146-DS-6 | 10,433,146 | 25,366,058 | DS | 6 | 2155-07-26 00:00:00 | 2155-07-24 17:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain, Nausea, Vomiting, fevers and chills.
Major Surgical or Invasive Procedure:
___- Laparoscopic Appendectomy
History of Present Illness:
Ms. ___ is a ___ year old female who had 24 hours of abdominal
pain, bilaterally lower quadrants associated with nausea and
vomiting, fevers and chills. She had a CT abdomen that
demonstrated an enlarged appendix containing an appedicolith
most compatable with appedicitis with probably microperforation.
Past Medical History:
Past Medical History:DM, HTN, HL, hypothyroid, HSV1,
diverticulitis, atrial tachycardia
Past Surgical History: thyroidectomy
Social History:
___
Family History:
non-contribtory, no history of crohns/UC
Physical Exam:
Admission Physical Exam
Vitals: 100.4 98.9 107/57 18 95 RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: unlabored
ABD: Soft, nondistended, bilateral lower quadrant/suprapubic
tenderness, R>L, + guarding, no rebound, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam
Vitals:
Gen: AAO, NAD
___: RRR, S1S2
Resp: CTABL, no distress
Abd: +BS, slight distention, tenderness at port incision sites.
Incision dressings C/D/I. No erythema noted around dressings.
Ext: No edema, warm
Pertinent Results:
___ 07:20PM NEUTS-90.9* LYMPHS-6.2* MONOS-2.3 EOS-0.1
BASOS-0.5
___ 07:20PM WBC-17.4*# RBC-4.93 HGB-15.2 HCT-44.8 MCV-91
MCH-30.9 MCHC-33.9 RDW-13.1
___ 07:20PM ALBUMIN-4.8 CALCIUM-9.3 PHOSPHATE-4.2
MAGNESIUM-1.8
___ 07:20PM LIPASE-27
___ 07:20PM ALT(SGPT)-28 AST(SGOT)-21 ALK PHOS-53 TOT
BILI-0.9
___ 07:31PM LACTATE-2.6*
___ 07:20PM GLUCOSE-160* UREA N-16 CREAT-0.7 SODIUM-136
POTASSIUM-3.7 CHLORIDE-96 TOTAL CO2-25 ANION GAP-19
CT ABD & PELVIS WITH CONTRAST Clip # ___
Reason: eval diverticulitis, appy
UNDERLYING MEDICAL CONDITION:
NO_PO contrast; History: ___ with prior diverticulitis with
lower abd pain RLQ>LLQ x 1 day
REASON FOR THIS EXAMINATION:
eval diverticulitis, appy
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: NRS WED ___ 10:08 ___
Enlarged tubular structure in the right lower quadrant measuring
up to 10 mm in widest diameter and containing appendicoliths,
most compatible with acute appendicitis. There is surrounding
stranding and inflammatory changes. No large amount of
extraluminal air drainable fluid collections identified.
Discussed with surgeon at time of discovery on ___ at
10:00 ___.
Brief Hospital Course:
Ms. ___ was admitted to the hospital with the above noted
history of present illness. She was taken urgently to the
operating room for a laparoscopic appendectomy. Acute gangrenous
appendicitis with phlegmon was found. She tolerated the
procedure well. Please see operative report for full details.
After a short and uneventful stay in the PACU, she was
transferred to the floor.
Discharged tolerating regular diet. Voided without issue.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. MetFORMIN XR (Glucophage XR) 1500 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Caltrate 600 + D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral daily
7. docosanol 10 % topical 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 #*60 Capsule Refills:*5
2. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen [Endocet] 5 mg-325 mg ___ tablet(s)
by mouth Q4-6 hours Disp #*15 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atenolol 25 mg PO DAILY
5. Caltrate 600 + D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral daily
6. docosanol 10 % topical PRN
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Lisinopril 10 mg PO DAILY
9. MetFORMIN XR (Glucophage XR) 1500 mg PO DAILY
10. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*4 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute gangrenous appendicitis with phlegmon.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions: Please
follow up in clinic at the appointment scheduled below (1:45 on
___. We also generally recommend that patients follow up
with their primary care provider after having surgery.
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 ___ weeks. (This is about the weight of a briefcase or a
bag of groceries.) This applies to lifting children, but they
may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple 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 could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
10433869-DS-16 | 10,433,869 | 26,142,530 | DS | 16 | 2129-10-18 00:00:00 | 2129-10-18 14:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
R acetabulum fx and R hip dislocation
Major Surgical or Invasive Procedure:
___ ORIF right acetabulum
History of Present Illness:
___ was the passenger in an intoxicated MVC vs pole last night
around 2am. Patient felt immediate pain in her right leg, but
denies having any other symptoms. Denies hitting her head or
LOC. She was taken to ___ where she was discovered
to have a right hip dislocation & acetabluar fracture. She
reports, refusing to let them attempt to reduce her hip and
opted to come to ___ definative ___. She denies any premorbid
hip pain. Does admit to having some numbness & tingling in her
right leg.
Past Medical History:
TBI in ___
Previous surgery on her left tibia after being hit by a car
Social History:
___
Family History:
NC
Physical Exam:
Right lower extremity:
Dressings: C/D/I
___ pulses, foot warm and well-perfused
Sensations intact
Pertinent Results:
___ 11:00AM BLOOD WBC-6.8 RBC-3.01* Hgb-8.6* Hct-27.7*
MCV-92 MCH-28.6 MCHC-31.1 RDW-12.8 Plt ___
___ 04:55AM BLOOD WBC-8.0 RBC-2.72* Hgb-8.1* Hct-24.5*
MCV-90 MCH-29.7 MCHC-33.0 RDW-12.3 Plt ___
___ 11:23PM BLOOD WBC-6.9 RBC-3.66* Hgb-10.9* Hct-34.2*
MCV-94 MCH-29.9 MCHC-32.0 RDW-12.8 Plt ___
___ 11:00AM BLOOD Glucose-122* UreaN-14 Creat-0.6 Na-137
K-3.8 Cl-101 HCO3-27 AnGap-13
___ 05:25AM BLOOD Glucose-121* UreaN-10 Creat-0.8 Na-132*
K-4.2 Cl-101 HCO3-26 AnGap-9
___ 11:00AM BLOOD CK(CPK)-557*
___ 11:00AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.1
___ 05:25AM BLOOD Calcium-7.7* Phos-2.4* Mg-1.8
___ 01:20PM BLOOD Calcium-8.3* Phos-3.2 Mg-2.0
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have rt acetabular dislocation and hip dislocation. patient
was admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for ORIF right
acetabulum, which the patient tolerated well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to a
facility was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is Touch down weight bearing in the
right lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*1
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*1
3. Enoxaparin Sodium 40 mg SC QPM Duration: 2 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC QPM Disp #*14 Syringe
Refills:*0
4. Ferrous Sulfate 325 mg PO DAILY
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth Q4H:PRN Disp #*90
Tablet Refills:*0
6. Multivitamins 1 CAP PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Right acetabulum fracture and Right hip dislocation
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
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- TDWB RLE. Posterior Precautions
Physical Therapy:
Activity: Activity: Activity as tolerated
Right lower extremity: Touchdown weight bearing
Encourage turn, cough and deep breathe q2h when
awake<br><br>Posterior hip precautions
Treatments Frequency:
Change primary dressing after 1 week. Then can change, dressing
if wound not bleeding/non draining.
Followup Instructions:
___
|
10434107-DS-13 | 10,434,107 | 27,207,587 | DS | 13 | 2165-12-24 00:00:00 | 2165-12-24 15:04:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old male with history of prior ICH
(aphasic at baseline), DMII, HTN, AFib (not on Coumadin),
presenting with mental status changes. Wife reports that the
patient has been less responsive to questions and has had
increased coughing over the past ___ days. No F/C, CP, or
abdominal pain.
___ the ED, initial VS: Temp not recorded, 80, 170/90, 16 and
95%. On exam, he had difficulty responding to questions and
following commands with poor air movement on lung exam and
irregularly irregular HR. Labs notable for WBC 11.1, Cr 1.3
(baseline), Na 130. CXR findings consistent with likely LLL PNA.
CT head was negative for any acute process. He was given a dose
of Levofloxacin 750mg IV and also given guaifenisin for cough.
Vitals on transfer: 98.5, 79, 154/85, 16 and 98% 2L.
On the floor, he is aphasic (difficulty thinking of words), but
understands well. He is coughing but does not complain of any
pain. The wife left for the evening, but did reconcile
medications with the nurse.
Past Medical History:
- L Temporal ICH ___ secondary to amyloid angiopathy, as
above
- h/o Pituitary tumor
- Systolic HF and Cardiomyopathy; last echo with EF 35-45%,
1+MR, ___ ___ ___
- Hypertension
- Diabetes mellitus, type II
- Chronic obstructive pulmonary disease
Social History:
___
Family History:
Mother with hx of CVA. Dad with CVA, EtOH, brother with heart
disease. No family history of early MI, arrhythmia,
cardiomyopathy, or sudden cardiac death.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
VS - Temp 96.4F, BP 140/90, HR 95, RR 20, 95% on RA, ___ 207
GENERAL - well-appearing male ___ no obvious respiratory
distress, otherwise comfortable, but difficult to converse with
given his aphasia.
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no appreciable JVD
LUNGS - crackles over the LLL, otherwise CTA, no r/rh/wh, no
accessory muscle use
HEART - irregularly irregular, no MRG, nl S1-S2
ABDOMEN - obese, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, follows commands well, but is disoriented (worse
from baseline); unable to write down responses or give one word
answeres, which per wife, is normally able to do. CNs II-XII
grossly intact, muscle strength ___ throughout, sensation
grossly intact throughout
PHYSICAL EXAMINATION ON DISCHARGE:
VS: Tc 97.6 BP 140/92 HR 81 RR 18 93-97% on RA
General: healthy appearing pleasant male ___ no acute distress.
Resp: cta bilaterally, no rales, crackles wheezes auscultated
Neuro: pt aphasic at baseline but following commands correctly,
demonstrating pleasant affect and showing great comprehension.
However, pt disoriented to place and time.
Pertinent Results:
LABS ON ADMISSION:
___ 10:05PM BLOOD WBC-11.1* RBC-5.11 Hgb-14.9 Hct-44.9
MCV-88 MCH-29.1 MCHC-33.1 RDW-13.9 Plt ___
___ 10:05PM BLOOD Neuts-82.0* Lymphs-9.8* Monos-5.3 Eos-1.8
Baso-1.1
___ 10:05PM BLOOD ___ PTT-30.7 ___
___ 10:05PM BLOOD Glucose-229* UreaN-23* Creat-1.3* Na-130*
K-5.0 Cl-94* HCO3-25 AnGap-16
___ 07:00AM BLOOD Glucose-178* UreaN-22* Creat-1.3* Na-126*
K-5.4* Cl-93* HCO3-19* AnGap-19
___ 10:05PM BLOOD Calcium-10.2 Phos-3.1 Mg-1.4*
___ 10:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:32PM URINE Blood-NEG Nitrite-NEG Protein-300
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 11:32PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
___ 10:38AM URINE Hours-RANDOM Creat-68 Na-65 K-42 Cl-65
___ 10:38AM URINE Osmolal-422
LABS ON DISCHARGE:
___ 08:00AM BLOOD Glucose-186* UreaN-32* Creat-1.7* Na-131*
K-4.2 Cl-95* HCO3-29 AnGap-11
MICRO:
- GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Preliminary): PENDING
- Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
IMAGING:
- ___ - CT HEAD - 1. No acute intracranial hemorrhage or
mass effect. Correlate clinically to decide on the need for
further workup. 2. Chronic atrophy and left temporal arachnoid
cyst. 3. Chronic sphenoid sinus disease.
- ___ - CXR - 1. Possible left lower lobe pneumonia. 2.
Moderate cardiomegaly and venous congestion.
Brief Hospital Course:
HOSPITAL COURSE: ___ year old male with history of ICH ___
amyloid angiopathy with resulting aphasia, ___ with EF 40% and
biventricular hypokinesis, atrial fibrillation off coumadin,
presenting with acute mental status changes, new onset cough,
leukocytosis and evidence of pneumonia on CXR, and hyponatremia.
Improved after 3 days of levofloxacin.
# Community acquired pneumonia: Likely secondary to infectious
process of pulmonary etiology, based on symptoms (new cough,
AMS), leukocytosis and CXR findings (LLL consolidation
consistent with PNA). Pt sputum gram stain showing Gram postive
rods, coccin and GNRs. Urinalysis was bland, legionella is
negative and GI/neuro sources seem unlikely. CURB-65 score of 3
for community-acquired pneumonia (confusion, elevated BUN, and
age>___), indicating a 14% 30-day mortality and appropriate for
inpatient management. We continued levofloxacin 750mg ___
days).
# Confusion w/ dementia: patient has likely vascular dementia at
baseline, w/ acute exacerbation d/t infection. Assessment
difficult d/t pt's known aphasia. We treat hyponatremia and
infection as detailed.
# HTN: Hypertensive upon reaching the floor. On 3-medication
regimen at home, supposedly taken prior to admission, per pt's
wife. SBPs have stabilized into the 150s after establishment of
home regimen and patient stabilization. We continued
amlodipine, hydralazine, and metoprolol per home dosing
# SIADH: Pt's Na was down to 126, lower from his baseline
(~138). His creatinine of 1.5 was up from his baseline of 1.3.
Na was likely not low enough to be the cause of his mental
status changes. Uosms suggest inappropriate secretion of Na
suggesting SIADH. We held off on any IVFs and Na was stable at
131 on ___.
# Cardiomyopathy with chronic sCHF: EF of 40% on last TTE ___ ___ with evidence of hypokinesis ___ both left and right
ventricles. No evidence of volume overload on exam or CXR and he
is not on any diuretics at home. We continued all home HF meds
as above
# Atrial fibrillation: Currently rate controlled, but not on
anticoagulation due to ICH ___ ___. Pt was ___ afib during the
stay and we continued metoprolol and monitored the pt on
telemetry
# Diabetes mellitus, type 2: Diet-controlled, with last A1c ___
___. We used ISS while ___ house and a diabetic/CC diet
was instituted.
# Pituitary tumor with hypogonadism: On depo-testosterone
q3weeks, not due until next week. We continued cabergoline
# Dyslipidemia: Last lipid panel done ___ ___, LDL of
78. We continued statin
# Seizure disorder: We continued home keppra
.
# FEN: hold IVFs for now / replete lytes prn / diabetic/CC diet
# PPX: heparin SQ, bowel regimen with colace/senna
# ACCESS: PIV
# CODE: confirmed fullcode
# CONTACT: ___ (wife) - ___
# DISPO: ___.
___, PGY-1
___
TRANSITIONAL ISSUES: Patient is being discharged to home with ___
services d/t diffiuclty ___ ambulation. Pt was also given 4 more
days of levofloxacin to complete his course.
Medications on Admission:
AMLODIPINE 5 mg daily
CABERGOLINE 0.25 mg weekly
HYDRALAZINE 50 mg TID
LEVETIRACETAM 750 mg BID
METOPROLOL TARTRATE 50 mg TID
SIMVASTATIN 20 mg daily
TESTOSTERONE ENANTHATE 200 mg/mL Oil - ___ cc IM q 3 weeks
ASPIRIN 81mg daily
Vitamin D 2600 units daily
Calcium 600mg BID
Discharge Medications:
1. cholecalciferol (vitamin D3) 400 unit Tablet, Chewable Oral
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. cabergoline 0.5 mg Tablet Sig: ___ Tablet PO weekly ().
4. hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
5. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO twice a
day.
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
10. Calcium 600 mg BID Oral
11. testosterone enanthate Intramuscular
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
- Community Acquired Pneumonia
- Syndrome of Inappropriate Antidiuretic Hormone
- Confusion with Dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr ___,
It was a pleasure taking care of you here at the ___. You came
___ with confusion and were found to have an infection ___ your
lungs. You were treated witha antibiotics and you responded well
to this treatment.
NEW MEDICATIONS:
-levofloxacin (antibiotic)
Followup Instructions:
___
|
10434107-DS-14 | 10,434,107 | 27,162,005 | DS | 14 | 2166-05-13 00:00:00 | 2166-05-13 15:51:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
increased difficulty speaking
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year-old man with DM2, HTN, afib (no
A/C
since L tpl hge ___ thought ___ AA), complex-partial seizures
(thought ___ old tpl hge; on LEV 750 bid), small parietal ___
stroke in ___, h/o pituitary adenoma, systolic HF (EF ~40% with
mild MR/AR in ___, and COPD. He has consistently-documented
word-finding difficulties and somewhat confused and
inappropriate
language at baseline.
He was BIBA to our ED for a change in his status this morning
which was initially unclear. ED resident (___) told me that
EMS told her that the patient's wife told them he became
"diaphoretic and more aphasic" this morning around 07:15am, and
that he had been more "normal" last night. The patient does not
give much history. His answers to most questions is ___
or
sometimes something else I asked him to say several questions
prior. He says "I feel good," and then "I felt lousy when I
came,
like a year ago." His wife was not present initially and not
answering their home phone. Later, after a CT ordered by the ED,
his wife (___) arrived. She said that, first, his walking has
been worse for about two weeks. He was able to walk in the house
without a cane until two weeks ago, but now he has difficulty
walking (lifting his legs) and requires his cane to go anywhere.
She believes that his "comprehension" is worse and his "voice is
weaker" and he is speaking less over roughly the same time
frame.
Denies any preceding illness or other symptoms. No change in
facial appearance or sound of his speech or arms/hands strength
or coordination. He was evaluated in the ED last week ___ (HCT
and labs no explanation, with the exception of slightly
increased
H&H on CBC), and in clinic by Dr. ___ Dr. ___ ___.
Dr. ___ MRI (scheduled for ___ open MRI, not
yet done), and possibly EEG if the MRI is unrevealing due to a
suspicion for seizure. He also recommended increasing aspirin
from 81 to 325 for the time being and following up in clinic
with
Dr. ___.
Last night and early this morning, he seemed no different that
he
has for the past couple weeks. He and his wife played cards at
the kitchen table. Then, around ___, he was "trying to tell me
something," and got up and walked to the counter. She thinks his
gait may have been a bit worse (slower) than recent, but not
remarkably so. Of primary concern to her was that he became "hot
and sweaty" and told her, "I can't breathe." He then went to his
bed and slept briefly, and seemed better when we awoke,
definitely by the time EMS arrived. FSBG was 200s. She had
called
___ because he was "sweating so much," but time, "it might have
been passing when I called ___ She says that a paramedic
suggested he may have had a seizure, and she is concerned he had
a new stroke. His one seizure that she can recall was years ago
and involving him "talking funny" -- she denies any h/o
generalized/convulsive seizure or LOC with a seizure.
Review of Systems: negative except as above; patient (who is
somewhat aphasic and therefore not reliable) explicitly denied
pain including chest and abdomen, headache. Also denied SOB,
feeling ill or recent illness. Denies painful or altered
urination.
Past Medical History:
- L Temporal ICH ___ secondary to amyloid angiopathy, as
above
- h/o Pituitary tumor
- Systolic HF and Cardiomyopathy; last echo with EF 35-45%,
1+MR, ___ in ___
- Hypertension
- Diabetes mellitus, type II
- Chronic obstructive pulmonary disease
Social History:
___
Family History:
Mother with hx of CVA. Dad with CVA, EtOH, brother with heart
disease. No family history of early MI, arrhythmia,
cardiomyopathy, or sudden cardiac death.
Physical Exam:
Vital signs: normal and stable in ED this morning
96.6F 72,irreg 138/80 16 98%RA
General: Awake and alert, lying in stretcher in pants and
hospital gown, waiting for CT, in NAD. Pleasant, smiles. Good
eye
contact. Confused speech.
HEENT: Normocephalic and atraumatic. No scleral icterus. Mucous
membranes are moist as best I can tell (does not open mouth or
stick out tongue. No lesions noted in oropharynx.
Neck: Supple. No bruits. No lymphadenopathy.
Pulmonary: Lungs CTA laterally/anteriorly. Non-labored.
Cardiac: IRregular, rhythm ___ no loud MGR appreciated in ED.
Abdomen: Obese, soft, non-tender, and non-distended.
Extremities: Cool x4, with slightly decreased capillary refill
(~10sec). No cyanosis or edema. 2+ radial and DP pulses
bilaterally.
Pertinent Results:
___ 06:02PM URINE HOURS-RANDOM
___ 06:02PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 05:53PM %HbA1c-7.0* eAG-154*
___ 11:45AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:45AM URINE RBC-2 WBC-5 BACTERIA-NONE YEAST-NONE
EPI-1 TRANS EPI-<1
___ 11:45AM URINE MUCOUS-RARE
___ 11:45AM URINE HYALINE-7*
___ 08:20AM GLUCOSE-221* UREA N-42* CREAT-1.7* SODIUM-138
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-26 ANION GAP-14
___ 08:20AM cTropnT-<0.01
___ 08:20AM ALT(SGPT)-12 AST(SGOT)-16 ALK PHOS-49 TOT
BILI-0.4
___ 08:20AM ALT(SGPT)-12 AST(SGOT)-16 ALK PHOS-49 TOT
BILI-0.4
___ 08:20AM ALBUMIN-3.8 CALCIUM-10.5* PHOSPHATE-2.6*
MAGNESIUM-1.7
___ 08:20AM WBC-9.0 RBC-5.74 HGB-16.6 HCT-52.9* MCV-92
MCH-28.9 MCHC-31.3 RDW-14.1
___ 08:20AM PLT COUNT-172
___ 08:20AM ___ PTT-27.5 ___
___ 08:20AM PLT COUNT-172
___ 08:20AM NEUTS-72.0* ___ MONOS-5.7 EOS-2.2
BASOS-0.8
MR head w/out contrast ___
INDINGS:
Preliminary ReportThere is no evidence of acute infarct or
hemorrhage. Again noted, there is
Preliminary Reportleft temporal encephalomalacia with chronic
blood products without significant
Preliminary Reportchange since prior exam. There is volume loss,
unchanged. Again seen there
Preliminary Reportis an arachnoid cyst in the anterior aspect of
the left middle cranial fossa,
Preliminary Reportjust anterior to the left temporal lobe. There
are bilateral subcortical and
Preliminary Reportperiventricular T2 FLAIR hyperintensities
likely representing microangiopathic
Preliminary Reportchronic ischemic changes. The major
intracranial flow voids are preserved.
Preliminary ReportThere is stable expansion of the sella turcica
and stable changes at the level
Preliminary Reportof the clivus. There are bilateral lens
replacements, otherwise the orbits are
Preliminary Reportunremarkable. The paranasal sinuses are clear.
Preliminary ReportIMPRESSION:
Preliminary Report1. No evidence of acute infarct or hemorrhage.
Preliminary Report2. Stable volume loss, left posterior temporal
encephalomalacia and
Preliminary Reportmicroangiopathic chronic ischemic changes.
CT head w/out contrast ___
IMPRESSION: No interval change from ___. No evidence of an
acute
intracranial process. MRI would be more sensitive for an acute
infarction, if
clinically warranted.
.
CXR ___
FINDINGS: Comparison is made to previous study from ___.
There is unchanged cardiomegaly. There is no focal
consolidation. There is
some atelectasis at the lung bases. There are no
pneumothoraces. There are
no signs for overt pulmonary edema.
Brief Hospital Course:
The patient was admitted after experiencing reported worsening
aphasia according to his wife. Per report, he has baseline
severe dementia with difficulty speaking. The patient was stable
during his hospital course, and CT/MRI of his head did not show
any new infarcts or hemorrhage. No underlying insystemic
infections were detected. These symptoms may be due to advancing
dementia or partial seizures. He was seen by ___ who recommended
that he go to a rehab facility. The patient is to follow up with
the neurologist in 4 weeks.
Medications on Admission:
1. aspirin 325mg daily
2. Keppra (LEVETIRACETAM) 750mg bid
3. SIMVASTATIN - 20mg daily
4. LISINOPRIL - 7.5mg daily
5. AMLODIPINE - 5mg daily
6. METOPROLOL TARTRATE - 50mg tid
7. CABERGOLINE - 0.25 weekly
8. TESTOSTERONE ENANTHATE - 200mg/mL Oil - ___ cc IM q3 weeks
9. CHLORPHENIRAMINE-HYDROCODONE - 10 mg-8 mg/5 mL Suspension,
Extended Rel 12 hr - 1 tsp(s) by mouth q 12h
10. METRONIDAZOLE [METROGEL] - 1 % Gel - apply daily as directed
11. CALCIUM CARBONATE - (Prescribed by Other Provider) - 600 mg
(1,500 mg) Tablet - 2 Tablet(s) by mouth daily
12. CHOLECALCIFEROL (VITAMIN D3) - (OTC) - 400 unit Capsule - 2
Capsule(s) by mouth daily
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. lisinopril 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. cabergoline 0.5 mg Tablet Sig: 0.5 Tablet PO weekly ___
evening) ().
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Three (3) Tablet, Chewable PO DAILY (Daily).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. testosterone enanthate 200 mg/mL Oil Sig: One (1) ___ cc
Intramuscular q3weeks.
10. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Seizure
SECONDARY DIAGNOSIS: Cervical spondylosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of worsening speech
problems. You were found to have features on your EEG suggesting
that you had a seizure. You did not have any signs of a stroke.
We have changed your medications as follows:
1. You should take LEVETIRACETAM 1000 MG twice daily to prevent
seizures.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek medical
attention. 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
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
10434107-DS-15 | 10,434,107 | 26,947,766 | DS | 15 | 2166-12-29 00:00:00 | 2166-12-29 12:22:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abnormal behavior
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an ___ gentleman with expressive aphasisa
secondary to a CVA who presents due to concern by wife for
"abnormal behavior." First noted around 5pm last night. Wife
not here to confirm history given by ED. Patient unable to
contribute to history.
Initially presented to an OSH but was transferred here as his
care providers are all affiliated with ___.
The following AM, patient's wife present and able to provide
history re: present illness. Per pt's wife, who is his primary
caregiver, pt has had several days of worsening weakness,
fatigue, and somnolence. Patient did not complain of any pain.
Patient's wife did not notice any fever, cough, nausea,
vomiting, diarrhea. Patient did not complain of dysuria, but
per his wife, his urinary frequency was increased. No urinary
incontinence noted. No seizure activity noted.
Past Medical History:
--L Temporal ICH ___ secondary to amyloid angiopathy
--Expressive aphasisa
--H/o Pituitary tumor
--Systolic HF and Cardiomyopathy; last echo with EF 40%, 1+MR,
___ in ___
--Hypertension
--Diabetes mellitus, type II, diet controlled
--Chronic obstructive pulmonary disease
--Atrial fibrillation
--CKD
Social History:
___
Family History:
Mother with history of CVA. Dad with CVA, EtOH, brother with
heart disease. No family history of early MI, arrhythmia,
cardiomyopathy, or sudden cardiac death.
Physical Exam:
ADMISSION EXAM:
VS: AVSS
GEN: nad, sleeping, easily arousable
CHEST: clear anteriorly
CV: rrr
ABD: nabs, soft, nt/nd
EXT: no c/c, 1+ edema b/l
NEURO: alert, follows simple commands, expressive aphasia
DISCHARGE EXAM:
Pertinent Results:
Bloodwork -
___ 12:45AM BLOOD WBC-18.8*# RBC-5.97 Hgb-17.9 Hct-56.3*
MCV-94 MCH-30.0 MCHC-31.8 RDW-14.6 Plt ___
___ 06:25AM BLOOD WBC-12.1* RBC-5.44 Hgb-15.9 Hct-49.7
MCV-91 MCH-29.3 MCHC-32.0 RDW-14.8 Plt ___
___ 04:30AM BLOOD WBC-10.9 RBC-5.64 Hgb-16.8 Hct-52.8*
MCV-94 MCH-29.8 MCHC-31.9 RDW-14.7 Plt ___
___ 07:20AM BLOOD WBC-10.0 RBC-5.12 Hgb-15.8 Hct-49.0
MCV-96 MCH-30.8 MCHC-32.2 RDW-14.5 Plt ___
___ 06:40AM BLOOD WBC-7.9 RBC-4.83 Hgb-14.5 Hct-45.7 MCV-95
MCH-30.0 MCHC-31.8 RDW-14.3 Plt ___
___ 12:45AM BLOOD Glucose-190* UreaN-43* Creat-1.8* Na-141
K-5.1 Cl-101 HCO3-26 AnGap-19
___ 06:25AM BLOOD Glucose-187* UreaN-36* Creat-1.5* Na-139
K-4.3 Cl-103 HCO3-28 AnGap-12
___ 04:30AM BLOOD Glucose-233* UreaN-34* Creat-1.9* Na-138
K-4.5 Cl-104 HCO3-25 AnGap-14
___ 07:20AM BLOOD Glucose-198* UreaN-34* Creat-1.7* Na-138
K-4.3 Cl-105 HCO3-27 AnGap-10
___ 06:40AM BLOOD Glucose-189* UreaN-35* Creat-1.5* Na-138
K-4.4 Cl-104 HCO3-25 AnGap-13
___ 04:30AM BLOOD ALT-12 AST-12 CK(CPK)-56 AlkPhos-56
TotBili-0.7
___ 12:45AM BLOOD Albumin-3.7 Calcium-10.3 Phos-3.0 Mg-1.7
___ 01:05PM BLOOD cTropnT-<0.01
.
Urinalysis -
___ 02:07AM URINE Color-Yellow Appear-Hazy Sp ___
___ 02:07AM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-70 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
___ 02:07AM URINE RBC-4* WBC-33* Bacteri-FEW Yeast-NONE
Epi-0
___ 02:07AM URINE CastHy-2*
___ 04:45AM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:45AM URINE Blood-LG Nitrite-NEG Protein-300
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 04:45AM URINE RBC->182* WBC-26* Bacteri-FEW Yeast-NONE
Epi-0
___ 04:45AM URINE CastHy-2*
.
Microbiology -
___ Blood Culture x 2 sets - no growth, final pending
___ Blood Culture x 1 set - no growth, final pending
___ Blood Culture x 2 sets - no growth, final pending
___ Urine Culture - no growth, FINAL
___ Respiratory Viral Screen and Culture - negative, FINAL
.
___ CXR PA/lat
FINDINGS:
Lung volumes are low. No definitive focal consolidation,
pleural effusion, or pneumothorax is seen. There is mild
pulmonary edema. Heart and mediastinal contours are stable with
cardiomegaly, and aortic and aortic valve calcification and
tortuosity.
IMPRESSION:
Low lung volumes with mild pulmonary edema.
.
___ CT HEAD
IMPRESSION:
Stable appearance of the brain. No acute hemorrhage. No CT
evidence for a large acute infarction. MR would be more
sensitive for an acute infarction, if indicated.
.
___ PCXR
FINDINGS: As compared to the previous radiograph, there is no
relevant change. Low lung volumes with moderate cardiomegaly
and signs of mild fluidoverload. Atelectasis at the right upper
lobe bases. No evidence of pneumonia. No pneumothorax. No
pleural effusions.
.
___ PCXR
Portable AP radiograph of the chest demonstrates unchanged heart
and mediastinal contours. Bibasal areas of consolidations are
slightly more pronounced than on the prior study. Substantial
enlargement of the main pulmonary artery is redemonstrated.
Overall, minimal change since the prior study has been noted
besides the mild increase in bibasal consolidations.
Minimal development of interstitial pulmonary edema can
potentially be suspected.
.
___ CT HEAD
IMPRESSION:
Stable appearance of the brain without CT evidence for acute
change. MRI is more sensitive for acute infarct.
.
___ KNEE X-RAY (bilateral)
IMPRESSION: Severe degenerative changes in the medial
compartment of the left knee associated with chondrocalcinosis.
Chondrocalcinosis can be seen with calcium pyrophosphate
deposition (pseudogout if symptomatic) and sometimes with a
disorder of calcium metabolism. No acute fractures.
.
DISCHARGE LABS:
Brief Hospital Course:
ASSESSEMENT & PLAN: ___ yo w/expressive aphasisa s/p CVA presents
with encephalopathy due to UTI, hospital course complicated by
likely HCAP/aspiration PNA and Afib with RVR.
.
# ACUTE TOXIC METABOLIC ENCEPHALOPATHY: Likely secondary to
UTI and subsequent HCAP/Aspiration PNA. Patient presented
initially with altered mental status, reports of increased
urinary frequency, leukocytosis and pyuria, overall picture felt
to be c/w UTI. He was started on IV CTX, but unfortunately the
ED did not send a urine culture prior to antibiotics. Initially
he improved significantly within 1 day, with near resolution of
his leukocytosis and near return to baseline for his mental
status. However, the next day, he then developed worsening
mental status, appeared to be more tachypneic and developed an
episode of Afib with RVR. He responded to IV lopressor, had a
negative head CT, and had his antibiotic regimen broadened to
Vanco/Cefepime to cover for HCAP/asp PNA given worsening
infiltrate on LLL. He also received Tamiflu as well. Over the
next ___ hours, he then continued to improve, with return of his
mental status to baseline. His flu culture then returned
negative and Tamiflu was stopped. He will be treated with a
course of antibiotics to cover for HCAP/asp PNA. All culture
data was negative .
# AFIB WITH RVR: Rate-controlled with BB. Not on Coumadin
given history of cerebral hemorrhage, only on ASA. Initially
remained in good rate-control, but he triggered for twice for
Afib with RVR to 150's, but all these episodes responded well to
IV lopressor. He was ruled out for ACS with 2 negative
troponins and stable EKG. He was monitored on telemetry for 24
hours with stable HR's. It was felt that his episodes of RVR
were reactive to underlying inflammation/infection, rather than
a primary cardiac event.
# HTN: Lasix initially held but then restarted.
# SEIZURE DISORDER: Continued on home med AED regimen of
Keppra
# HISTORY OF CVA WITH APHASIA: Continued Aspirin and
simvastatin.
#CKD: Baseline Cr 1.3 - 1.7, Cr during hospitalization within
this range. Is on ACE-I
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. cabergoline *NF* 0.25 Oral weekly
2. Chlorpheniramine-Hydrocodone 5 mL PO Q12H
3. Furosemide 20 mg PO DAILY
4. LeVETiracetam 750 mg PO BID
5. LeVETiracetam 250 mg PO EVERY OTHER DAY
6. Lisinopril 7.5 mg PO DAILY
7. Metoprolol Tartrate 50 mg PO TID
8. Simvastatin 20 mg PO DAILY
9. testosterone enanthate *NF* 200 mg/mL Injection q3weeks
10. Aspirin 81 mg PO DAILY
11. Calcium Carbonate 1250 mg PO DAILY
12. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. cabergoline *NF* 0.25 Oral QMON
3. Calcium Carbonate 1500 mg PO DAILY
4. LeVETiracetam 750 mg PO BID
5. LeVETiracetam 250 mg PO EVERY OTHER DAY
6. Vitamin D 800 UNIT PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Lisinopril 7.5 mg PO DAILY
9. Chlorpheniramine-Hydrocodone 5 mL PO Q12H
10. Metoprolol Tartrate 50 mg PO TID
11. Bisacodyl 10 mg PO/PR DAILY constipation
12. CefePIME 2 g IV Q12H
13. Heparin 5000 UNIT SC TID
14. Docusate Sodium 100 mg PO BID
15. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
16. Polyethylene Glycol 17 g PO DAILY
17. Vancomycin 1250 mg IV Q 24H
18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
19. Senna 1 TAB PO BID
20. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
21. testosterone enanthate *NF* 200 mg/mL Injection q3weeks
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Health Care Associated Pneumonia, Afib with
RVR
Secondary Diagnosis: atrial fibrillation, hx of CVA with
residual aphasia, seizure disorder, sCHF, DM2 (diet-controlled),
pituitary tumor
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 brought into the hospital with altered mental status.
This was most likely due to an underlying urinary tract
infection. You also likely developed a pnuemonia while you were
in the hospital. We will treat you with a course of IV
antibiotics, which will treat both the urinary tract infection
and the pneumonia. You had a few episodes of elevated HR,
likely due to underlying infection. Your HR responded with IV
doses of medication. You were evaluated by the physical
therapists, and they recommended ___ at rehab.
.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
.
Please take your medications as listed.
.
Please f/u with your doctors as listed.
.
Followup Instructions:
___
|
10434107-DS-16 | 10,434,107 | 22,097,626 | DS | 16 | 2167-01-12 00:00:00 | 2167-01-12 18:33:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Blood In Stool/Melena
Major Surgical or Invasive Procedure:
Upper endoscopy
History of Present Illness:
Mr. ___ is an ___ with PMH of stroke with expressive
aphasia, COPD, T2DM, HTN, ___, atrial fib, and CKD who
presented from rehab facility with melanotic stool and falling
hematocrit. Patient is aphasic at baseline from a previous
stroke. Per report, yesterday pt was noted be more lethargic
than normal. He then had some labs checked, which revealed a Hct
drop (from 43 to 28) and elevated of BUN (from 38 to 135). He
was also noted to have melena. He was referred to ___ for
further evaluation. On arrival to ___ he was hemodynamically
stable. His rectal exam revealed melena. He is nonverbal at
baseline. There was no hematemesis. Pt has been taking low dose
aspirin daily.
Of note patient was recently discharged from ___ on ___
with encephalopathy due to enterococcus UTI, with a hospital
course complicated by HCAP/aspiration PNA and Afib with RVR. He
was treated with vancomycin and cefepime for this and completed
his abx course at rehab.
In the ED, initial VS were: 96.6 74 104/62 22 96% 2L Nasal
Cannula. His maps were above 60. He had afib but no evidence of
ischemia on ECG. Pt received 1L IVF, unit 1 of PRBCs, IV
pantoprazole 40 mg bolus, and ceftriaxone 1g.
On arrival to the MICU, pt is awake alert, interactive and in no
acute distress. He is following commands. He reports he is is no
pain
REVIEW OF SYSTEMS:
(+) Per HPI +cough
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, or wheezing. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
nausea, vomiting, diarrhea, constipation, abdominal pain. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
L Temporal ICH ___ secondary to amyloid angiopathy
Expressive aphasisa
Small Left parietal ___ stroke in ___
Seizure Disorder-complex-partial seizures
Pituitary Macroadenoma
Systolic HF and Cardiomyopathy; last echo with EF 40%, 1+MR,
___ in ___
Hypertension
Diabetes mellitus, type II, diet controlled
Chronic obstructive pulmonary disease
Atrial fibrillation
CKD
AAA
Colonic Polyps- adenoma
Gastritis
Hearing loss
Hyperparathyroidism
Hypogonadism
Pseudogout
Sleep Apnea
Social History:
___
Family History:
Mother with history of CVA. Dad with CVA, EtOH, brother with
heart disease. Brother died of MI at age ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:97 BP:105/60 P:91 R: 18 O2:100%
General: Alert, aphasic, follows commands, in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: irregularly irregular, S1, S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: +foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: following commands, ___ strength upper/lower
extremities, grossly normal sensation
Discharge PE:
VS: T 97.6, P: 103, BP: 117/77, RR: 15, 98% on RA
General: Alert, aphasic, follows commands, in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: irregularly irregular, S1, S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: +foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: following commands, ___ strength upper/lower
extremities, grossly normal sensation
Pertinent Results:
___ 03:55PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 03:55PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 03:55PM URINE MUCOUS-RARE
___ 02:06PM K+-5.5*
___ 01:50PM GLUCOSE-162* UREA N-135* CREAT-1.7*
SODIUM-137 POTASSIUM-7.5* CHLORIDE-107 TOTAL CO2-23 ANION GAP-15
___ 01:50PM estGFR-Using this
___ 01:50PM WBC-12.7*# RBC-2.99*# HGB-9.2*# HCT-28.6*#
MCV-96 MCH-30.9 MCHC-32.3 RDW-15.5
___ 01:50PM NEUTS-65.7 ___ MONOS-5.9 EOS-1.7
BASOS-0.8
___ 01:50PM PLT COUNT-218
___ 01:50PM ___ PTT-27.6 ___
CBC Trend
___ 09:53AM BLOOD Hct-23.7*
___ 04:07AM BLOOD WBC-3.6* RBC-2.47* Hgb-7.5* Hct-23.8*
MCV-96 MCH-30.3 MCHC-31.6 RDW-17.1* Plt ___
___ 09:16PM BLOOD Hct-23.1*
___ 05:49PM BLOOD WBC-6.2 RBC-2.50* Hgb-7.8* Hct-23.4*
MCV-94 MCH-31.2 MCHC-33.3 RDW-17.0* Plt ___
___ 11:17AM BLOOD Hct-25.0*
___ 04:01AM BLOOD WBC-7.6 RBC-2.64* Hgb-7.8* Hct-24.6*
MCV-93 MCH-29.6 MCHC-31.7 RDW-16.2* Plt ___
___ 11:30PM BLOOD Hct-25.4*
___ 08:00PM BLOOD WBC-9.1 RBC-3.09* Hgb-9.5* Hct-29.4*
MCV-95 MCH-30.7 MCHC-32.3 RDW-16.1* Plt ___
___ 01:50PM BLOOD WBC-12.7*# RBC-2.99*# Hgb-9.2*#
Hct-28.6*# MCV-96 MCH-30.9 MCHC-32.3 RDW-15.5 Plt ___
Discharge labs:
___ 04:07AM BLOOD Glucose-140* UreaN-81* Creat-1.4* Na-148*
K-4.5 Cl-118* HCO3-25 AnGap-10
___ 04:07AM BLOOD Calcium-9.0 Phos-2.8 Mg-1.8
___ 09:53AM BLOOD Hct-23.7*
EGD ___
Impression: Diffuse erythema with congestion and multiple
erosions in the predominantly in the antrum, but seen throughout
the stomach compatible with gastritis
Erythema with erosions in the ___ and ___ portions of the
duodenum compatible with duodenitis
Clean based ulcer in the duodenal bulb
Otherwise normal EGD to third part of the duodenum
Recommendations: Given large size of duodenal ulcer would
continue IV PPI gtt for the next ___ hours then can reduce to
high dose PO PPI BID
Check H. pylori serology and stool antigen and treat if positive
Continue to trend hematocrit
Further plans per inpatient GI team
H. pylori negative ___
Brief Hospital Course:
Mr. ___ is an ___ with PMH of stroke with expressive
aphasia, COPD, T2DM, HTN, sCHF, atrial fib, and CKD who
presented from rehab facility with melanotic stool and falling
hematocrit concerning for upper GI bleed.
#) Upper GI Bleed: Pt presented with lethargy, melena and a 15
point HCt drop (5 point Hgb drop) which is consistent with an
upper GI bleed. Pt received 1 unit pRBC in the ED, and was
monitored regularly for hct stabilization. Pt was started on
pantoprazole bolus and drip. EGD was performed showing a clean
base ulcer in duodenum without evidence of active bleeding or
clot. H. pylori testing was negative. He was discharged on
pantoprazole 40 mg po BID. His HCT on discharge was 23.7 (stable
over 4 time points).
#) Atrial fib with RVR: On prior admission had Afib with RVR to
150's. Was then rate-controlled with beta-blocker. He is not on
Coumadin given history of cerebral hemorrhage but was on ASA.
His A. fib with RVR has been responsive to IV metoprolol.
Metoprolol PO was held initially while there was concern for
acute anemia, however, once pt was stabilized, regimen was
resumed.
#)HTN: Pt's outpt regimen of Lisinopril 7.5 mg PO DAILY was
initially held in setting of GI bleed. This should be restarted
at rehab if his blood pressures remain stable.
#)Hypernatremia: Na to 148, likely from poor po intake. He was
allowed to drink to thirst. Repeat lytes should be obtained
___.
#) Seizure Disorder: Pt with history of complex-partial
seizures. Pt with documented word-finding difficulties and
somewhat confused and inappropriate language at baseline. Pt was
continued on home Keppra (LeVETiracetam 750 mg PO BID,
LeVETiracetam 250 mg PO EVERY OTHER DAY)
#)History of Stroke: Pt with aphasia secondary to prior stroke.
In the setting of GI bleed, aspirin was initially held and
simvastatin was continued. Aspirin was restarted on discharge.
#) COPD: FVC 67% FEV1 88% FEV1/FVC ratio 132% from ___ showing
mild restrictive ventilatory defect. Mild desaturation with
exertion. Not on home inhalers.
#) sCHF: Pt with SCHF with an LVEF = 40 % on ___. Pt with
BNP in 3500 range.
#) Diabetes: Pt was placed on ISS while in the hospital.
#) CKD: Cr is 1.7 on admission. His baseline Cr is 1.3 - 1.7. On
discharge Cr was 1.4
#) h/o Pituitary tumor: Home meds were continued. cabergoline
0.25 Oral QMON
#) Hypogonadism: Continue testosterone enanthate *NF* 200 mg/mL
Injection q3weeks
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. cabergoline *NF* 0.25 Oral QMON
3. Calcium Carbonate 1500 mg PO DAILY
4. LeVETiracetam 750 mg PO BID
5. LeVETiracetam 250 mg PO EVERY OTHER DAY
6. Vitamin D 800 UNIT PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Lisinopril 7.5 mg PO DAILY
9. Chlorpheniramine-Hydrocodone 5 mL PO Q12H
10. Metoprolol Tartrate 50 mg PO TID
11. Bisacodyl 10 mg PO/PR DAILY constipation
12. Docusate Sodium 100 mg PO BID
13. Polyethylene Glycol 17 g PO DAILY
14. Senna 1 TAB PO BID
15. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
16. testosterone enanthate *NF* 200 mg/mL Injection q3weeks
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. cabergoline *NF* 0.25 Oral QMON
3. Calcium Carbonate 1500 mg PO DAILY
4. LeVETiracetam 750 mg PO BID
5. LeVETiracetam 250 mg PO EVERY OTHER DAY
6. Simvastatin 20 mg PO DAILY
7. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
8. Vitamin D 800 UNIT PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 1 TAB PO BID
11. testosterone enanthate *NF* 200 mg/mL Injection q3weeks
12. Bisacodyl 10 mg PO/PR DAILY constipation
13. Pantoprazole 40 mg PO Q12H
14. Metoprolol Tartrate 50 mg PO TID
15. Chlorpheniramine-Hydrocodone 5 mL PO Q12H
16. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute anemia
Duodenal ulcer with clean base
Discharge Condition:
Mental Status: Clear and coherent, but with expressive aphasia
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ intensive care unit from your
rehabilitation facility for decrease in your blood level and
conern for bleeding from your stomach. You were admitted and
given blood products. You also underwent a procedure to look for
ulcers in your stomach (called an endoscopy). The procedure
showed a nonbleeding ulcer in your small intestine. We gave you
medication to suppress stomach acid production to allow your
ulcer to heal. We also monitored you closely to ensure that your
blood levels remained stable.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10434107-DS-17 | 10,434,107 | 27,501,153 | DS | 17 | 2167-10-13 00:00:00 | 2167-10-14 20:23:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is ___ with history of left temporal
intraparenchymal hemorrhage in ___, afib not on coumadin,
complex partial seizures on keppra, DM, HTN, who is being
transferred from OSH ED with altered mental status. The
following history is taken from the ED report and the wife, as
the patient is unable to relay a history. As per report, the
patient was lethargic yesterday, and had difficulty getting out
of bed and chair. The patient's wife also thought that he was
confused, prompting her to bring him to OSH ED. While at OSH ED,
UA was notable for positive leuks/nitrites and he was given
Ceftriaxone. CT head was without any new abnormalities.
Of note, the patient was recently seen in our ED in ___ with
disorientation and worsening gait abnormalities. Neurology
evaluated the patient at this time who felt that he could be
postictal. Infectious work up at the time was negative. The
patient was discharged from the ED with no changes in keppra
dosing (though a level was sent), and instructed to follow up
with his neurologist.
In the ED intial vitals were: 97.3 80 140/76 20 99% RA.
Neurology evaluated the patient who felt that his exam was
unchanged from baseline (noted to have expressive aphasia,
dysarthria). Neuro had recommended treatment of UTI, checking
keppra level, stopping tramadol, as it can lower seizure
threshold, ABG, and potential Xray of L shoulder given history
of pseudogout. The patient was then admitted to medicine for
management of UTI/futher infectious workup and altered mental
status. Of note, while in the ED, the patient was intermittently
in afib with RVR and received IV metoprolol. Vitals upon
transfer: 101 134/94 24 98% RA.
On the floor, pt is lying in bed with no acute complaints. He is
pleasant and cooperative, following commands. Denies any pain,
but does not answer reliably to all questions.
Review of Systems:
(+) per HPI
(-) fevers/chills, shortness of breath, chest pain, abdominal
pain, nausea, vomiting, diarrhea, constipation, dysuria,
hematuria.
Past Medical History:
- L Temporal ICH ___ secondary to amyloid angiopathy
- small parietal stroke in ___
- complex partial seizures- manifest as episodes of
disorientation, worsened aphasia and gait troubles.
- h/o Pituitary tumor
- Systolic CHF and cardiomyopathy
- Hypertension
- Diabetes mellitus, type II, diet-controlled
- Chronic obstructive pulmonary disease
- afib not on coumadin since bleed
- CKD (cr 1.5-1.7)
- Hypogonadism
- Sleep apnea
- AAA
Social History:
___
Family History:
Father with stroke at ___ though lived ___ years beyond that
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- 97.4 129/82 98 22 99 RA, FSBS 161
General- Alert, not oriented, no acute distress
HEENT- Sclera anicteric, MM very dry, oropharynx clear
Neck- supple, no LAD
Lungs- Clear to auscultation bilaterally though extremely
limited exam as pt not fully cooperative with exam, no wheezes,
rales, ronchi
CV- irregularly irregular 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- foley draining dark yellow urine
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM
Vitals- 97.7 145/80 (137-145/70-89) 86 (69-84) 18 97 RA
General- Alert, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, no LAD
Lungs- Bibasilar rales
CV- irregularly irregular 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- foley removed
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS
___ 02:15AM BLOOD WBC-5.0 RBC-4.75 Hgb-12.4* Hct-40.4
MCV-85 MCH-26.1* MCHC-30.7* RDW-16.3* Plt ___
___ 02:15AM BLOOD Neuts-80.5* Lymphs-12.5* Monos-6.5
Eos-0.3 Baso-0.2
___ 02:15AM BLOOD Glucose-145* UreaN-38* Creat-1.9* Na-138
K-4.8 Cl-104 HCO3-25 AnGap-14
___ 07:30AM BLOOD Calcium-8.8 Phos-2.2* Mg-1.3*
DISCHARGE LABS
___ 08:10AM BLOOD WBC-5.2 RBC-4.66 Hgb-11.9* Hct-38.7*
MCV-83 MCH-25.6* MCHC-30.8* RDW-16.0* Plt ___
___ 08:10AM BLOOD Glucose-164* UreaN-33* Creat-1.5* Na-135
K-4.3 Cl-100 HCO3-26 AnGap-13
___ 08:10AM BLOOD Calcium-9.0 Phos-2.6* Mg-1.6
___ 04:45AM BLOOD LEVETIRACETAM (KEPPRA)-PND
MICRO
___ URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/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
___ Blood Culture, Routine (Pending):
___ Blood Culture, Routine (Pending):
IMAGING
___ EKG: Atrial fibrillation with a rapid ventricular
response and frequent ventricular ectopy. Delayed R wave
transition. Compared to the previous tracing of ___ there
is now frequent ventricular ectopy. The prior tracing showed
initial R wave in lead aVF and the axis is now more leftward. No
diagnostic interim change.
___ CHEST (PA & LAT): No evidence of acute cardiopulmonary
process.
___ CT Head (at ___: Stable moderate diffuse likely
age-related cerebral volume loss and likely microvascular
ischemic disease. Stable erosive changes and expansion at the
level of the sphenoid sinus and pituitary fossa, of uncertain
significance. ___ be more accurately evaluated with MRI. No
acute intracranial pathology.
Brief Hospital Course:
___ with history of left temporal intraparenchymal hemorrhage in
___, afib not on coumadin, complex partial seizures on keppra,
DM, HTN, who is being transferred from OSH ED with altered
mental status found to have UTI precipitaing his changes in
mental status.
# Altered mental status: Most likely secondary to UTI,
especially given improvement in mental status with treatment of
UTI with antibiotics. His Head CT at the OSH ED was unchanged.
There was initial concern that this could have represented a
seizure/post-ictal state. However, his mental status
significantly improved with treatment of UTI and he was back to
his baseline by discharge. His keppra level was 42.6 on ___,
though a more recent level was pending. No changes were made to
his keppra dosing.
# UTI: Pt noted to have pyuria on urinalysis along with positive
nitrite that creating concern for urinary tract infection, which
returned with pan-sensitive E.Coli from ___ and also from
urine culture at ___. His antibiotics (intially ceftriaxone)
was switched to oral ciprofloxacin, to complete treatment for a
complicated UTI with a 2-week course. His foley was removed
prior to discharge.
# Afib: He was in afib with RVR in the ED in the setting of not
taking his home metoprolol. He was given 5mg IV metoprolol with
normalization of his ventricular rates. He was continued on his
metoprolol while in house. He is not on coumadin due to hx of
parenchymal hemorrhage. He was continued on his aspirin.
# Thrombocytopenia: Has been intermittently thrombocytopenic in
the past. Was 137K on ___, now down to 122K. His coags were
normal on ___, causing less concern for DIC, though with
increased creatinine, considered TTP, but pt has baseline
underlying CKD and does not have anemia, so this is less likely.
4T score is sufficiently low, so likelihood of HIT is low. His
plt count was simply trended and can be worked up further as an
outpatient should his thrombocytopenia persist.
# Seizure disorder - Neurology consulted in the ED, who felt his
neuro exam was unchanged: has expressive aphasia, severely
dysarthric, follow commands, has bilateral asterixis.
Reassuringly his head CT at the OSH was unchanged. His ___
keppra level was 42.6, and he has a level from ___ pending.
His dosing was not changed and he was scheduled a follow-up
appointment with his neurologist.
# Acute on chronic kidney disease: Pre-renal in etiology, likely
due to current illness. His creatinine was initially 1.9 but
this improved back down to near baseline at 1.5 with IVF
hydration.
# Systolic CHF: Pt noted to have EF 40% on ECHO in ___. He was
continued on his lisionpril and metoprolol.
# Hx of pituitary tumor - He was continued on cabergoline.
# HTN - He was continued on his metoprolol, doxazosin, and
lisinopril.
# DM - Diet-controlled per his wife. ___ were checked
and he was put on a light insulin sliding scale while in house.
He was continued on his lisinopril.
# HL - He was continued on simvastatin.
# GERD - He was continued on pantoprazole.
TRANSITIONAL ISSUES
- Pt should continue to take cipro twice daily to complete a
14-day course
- Pt has a keppra level pending on discharge that should be
followed-up
- Pt has blood cultures from ___ that were pending upon
discharge that should be followed-up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. cabergoline 0.5 mg oral qweekly
2. Doxazosin 1 mg PO BID
3. LeVETiracetam 750 mg PO BID
4. LeVETiracetam 250 mg PO EVERY OTHER DAY
5. Lisinopril 5 mg PO DAILY
6. Metoprolol Tartrate 25 mg PO TID
7. Pantoprazole 40 mg PO Q12H
8. Simvastatin 20 mg PO DAILY
9. testosterone enanthate 200 mg/mL injection q3weeks
10. Aspirin 81 mg PO DAILY
11. Calcium Carbonate 1500 mg PO DAILY
12. Vitamin D 800 UNIT PO DAILY
13. Docusate Sodium 100 mg PO BID
14. iFerex ___ (polysaccharide iron complex) 150 mg iron oral
daily
15. Senna 1 TAB PO BID
16. Chlorpheniramine-Hydrocodone 5 mL PO Q12H:PRN cough
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 1500 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Doxazosin 1 mg PO BID
5. LeVETiracetam 750 mg PO BID
6. LeVETiracetam 250 mg PO EVERY OTHER DAY
7. Metoprolol Tartrate 25 mg PO TID
8. Pantoprazole 40 mg PO Q12H
9. Senna 1 TAB PO BID
10. Simvastatin 20 mg PO DAILY
11. Vitamin D 800 UNIT PO DAILY
12. cabergoline 0.5 mg oral qweekly
13. iFerex ___ (polysaccharide iron complex) 150 mg iron oral
daily
14. Lisinopril 5 mg PO DAILY
15. testosterone enanthate 200 mg/mL injection q3weeks
16. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice daily Disp
#*23 Tablet Refills:*0
17. Chlorpheniramine-Hydrocodone 5 mL PO Q12H:PRN cough
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Altered mental status
Urinary tract infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You were admitted due to altered mental status
(confusion) and you were found to have a urinary tract
infection. You were initially treated with IV antibiotics, but
once we received results of the specific bacteria growing in the
urine, we were able to change your antibiotic to a pill you can
take by mouth. Your confusion is improved and you soon felt
better. It was not felt that your confusion was secondary to
seizure, though it will be important that you follow up with
your neurologist as listed below.
Please continue taking this medication for a total of 14 days.
We wish you the best of luck!
Followup Instructions:
___
|
10434445-DS-14 | 10,434,445 | 28,127,014 | DS | 14 | 2139-10-08 00:00:00 | 2139-10-08 21:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p Vespa crash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y.o M s/p Vespa accident fall onto left side. Sustained
fractures of left scapula, left clavicle and left 1st rib
(ant+post)throguh 6 rib fractures and small apical
pneuomothorax.
Past Medical History:
Denies
PSH: nasal surgery
Family History:
Noncontributory
Physical Exam:
Upon presentation to ___
A&O in NAD
Breathing unlabored
pulses regular
LUE with hematoma over posterior shoulder
TTP over clavicle, AC joint, and glenoid
AIN/PIN/U fire
SILT
WWP distally
Pertinent Results:
___ 07:07PM GLUCOSE-125* LACTATE-2.7* NA+-140 K+-3.4
CL--106 TCO2-25
___ 07:00PM WBC-6.3 RBC-4.40* HGB-13.8* HCT-39.5* MCV-90
MCH-31.4 MCHC-35.0 RDW-14.4
___ 07:00PM PLT COUNT-223
___ 07:00PM ___ PTT-23.4* ___
___ 07:54AM BLOOD WBC-8.1 RBC-3.82* Hgb-12.0* Hct-35.8*
MCV-94 MCH-31.3 MCHC-33.4 RDW-14.5 Plt ___
___ 07:54AM BLOOD Plt ___
___ 07:54AM BLOOD Glucose-123* UreaN-13 Creat-0.9 Na-139
K-4.4 Cl-104 HCO3-28 AnGap-11
CT cervical spine
IMPRESSION:
1. No cervical spine fracture or malalignment.
2. Left first and second rib fractures. Minimally displaced left
distal
clavicular fracture.
3. Tiny left apical ptx.
CT chest/abdomen/pelvis
IMPRESSION:
1. Left ___ rib fractures with tiny left pneumothorax and
adjacent
subcutaneous air in the left chest wall.
2. Small left upper lobe pulmonary contusion. Bibasilar
atelectasis.
3. Comminuted left scapular fracture.
GLENO-HUMERAL SHOULDER xray
IMPRESSION:
1. Left distal clavicle fracture.
2. Comminuted left scapular fracture.
CT Left upper extremity
1. Minimally displaced fracture of the distal clavicle, with a
fracture line that appears to track inferiorly between the two
components of the
coracoclavicular ligaments, wth superior dispacement of the more
lateral
fragment but no extension of the fracture line into the
acromioclavicular
joint.
2. Fracture of the posterior aspect of the first and second ribs
as well as fracture of the cartilaginous portion of the first
rib.
3. Acute fractures of the lateral aspect of the third, fourth,
fifth and sixth ribs
4. Comminuted fracture of the ala of the scapula, with a
fracture line
tracking just inferiorly to the glenoid process but without
extending into its articular facet.
Brief Hospital Course:
He was admitted to the Acute Care Surgery team with left
clavicle and scapula fractures and fractures of his left ribs.
Orthopedics was consulted for the left clavicle and scapula
fractures. Initial discussions took place regarding possible
operative intervention for his scapula fracture. After further
review of his reconstructed films it was determined that surgery
was not indicated. He was placed in a sling and evaluated by
Occupational therapy and was cleared for discharge to home.
He was maintained in a hard cervical collar initially and
underwent MRI imaging to rule out ligamentous injury and no
acute injuries were identified. His collar was then removed
after physical exam findings were negative.
At time of discharge he was tolerating a regular diet,
ambulating independently and pain well controlled on oral
narcotics. He was given an incentive spirometer and instructed
on proper use.
He was discharged to home and will follow up in Orthopedics
clinic and in ___ clinic within the next couple of weeks.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every ___
Disp #*60 Tablet Refills:*0
3. Senna 1 TAB PO BID:PRN constipation
4. Acetaminophen 1000 mg PO Q6H
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Vespa crash
Injuries:
Left rib fractures ___
Left clavicle fracture
Left scapula fracture
Road rash left knee
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a Vespa crash where you
sustained rib fractures and a left clavicle and left scapula
fractures. Your injuires did not require any operations. You
were evaluated by the Orthopedic and Trauma doctors who have
recommended sling to be worn on your left arm when out of bed.
The sling can be removed for short periods throughout the day to
perform some of your daily acitivites. You should AVOID putting
full weight and or lifting any weights greater than 5 lbs on
your left arm for at least the next 4 weeks in order to allow
for proper healing.
* You rib sustained rib fractures which can cause severe pain
and subsequently cause you to take shallow breaths because of
the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
Followup Instructions:
___
|
10434527-DS-21 | 10,434,527 | 27,970,060 | DS | 21 | 2129-01-21 00:00:00 | 2129-01-21 20:04:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing Contrast Media / crab / latex
Attending: ___.
Chief Complaint:
1.5 weeks of n/v and diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ male with
CABGx5 (___) RCC s/p left nephrectomy (___) and left
adrenalectomy (___) presenting with 1.5 weeks of n/v and
diarrhea, found to have anion gap acidosis and acute kidney
injury.
He reports that he initially had ___ watery bowel movements per
day, but the day leading up to admission he had more than 20
watery, non-bloody stools. This has been accompanied by nausea,
and vomiting ___ times per day. Symptoms come with ___ seconds
of
abdominal cramping. He has had poor PO and 10lbs of weight loss
since his symptoms began. He saw his PCP and his labs were
notable for a creatinine of 1.3 to 1.7.
He denies any recent sick contacts or travel.
In the ED, initial vitals were: 97.4 | 93 | 112/70 | 16 | 97% RA
Labs were notable for:
13.0 > 14.4/43.4 < 272
85% PMNs
MCV 90
___ 13.2 PTT 24.9 INR 1.2
138 | 106 | 69 Ca 9.5 (corrected: 10.0)
---------------< 136 Mg 1.9
3.8 | 9 | 4.7 P 7.7
(baseline cr: 1.3)
AST 11 | ALT 13
AP 88 | Tbili 0.4
Alb 3.4
Lipase 73
Lactate 2.5 -> 1.4
Serum tox: neg
A CT A/P WITH Contrast showed
1. Mildly edematous, fluid-filled loops of small bowel could
suggest enteritis.
2. Short segment of thickening in the sigmoid colon could
represent a mild colitis.
3. Multiple pulmonary nodules measuring up to 6 mm in the right
lung base are suspicious for metastatic disease.
4. 2.4 x 2.1 cm right adrenal nodule is unchanged.
5. Prominent mesenteric nodes measuring up to 1.7 x 1.2 cm are
nonspecific, and possibly reactive.
6. Postsurgical changes related to left nephrectomy and partial
right nephrectomy are again noted. No evidence of local
recurrence.
Additionally, a chest x-ray showed no acute cardiopulmonary
process.
Renal was consulted and recommended 2L of isotonic saline (3
amps
of bicarb in 1L NS).
The patient was given:
- lorazepam 0.5mg IV
- dexamethasone 10mg IV
- 1L NS
- diphenhydramine 50mg IV
- pantoprazole 40mg IV
- 1L LR
- 150mEq sodium bicarb/D5W
- D5NS
Repeat labs showed:
133 | 99 | 65
--------------< 433
3.7 | 19 | 3.4
7.21 | 31 | 37 | 13 (@1330)
7.45 | 31 | 24 | 22 (@2140)
- Vitals prior to transfer: 82 | 136/82 | 16 | 100% RA
Past Medical History:
Coronary artery disease
Chronic Kidney Disease (baseline Cre 1.2-1.4)
Gastroesophageal Reflux Disease
Gout
Hypertension
Hypothyroidism
Metastatic Renal Cell Carcinoma
Surgical History:
Nephrectomy, left
Social History:
___
Family History:
Denies family history of premature cardiac disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
====================================
VS: 98.0 | 113/73 | 68 | 18 | 97%Ra
GENERAL: Cacehctic, appears fatigued but not acutely toxic.
HEENT: MMM, no conjunctival pallor, moist mucous membranes.
NECK: No concerning lymphadenopathy.
CV: RRR with quiet early systolic flow murmur heard best at
___.
PULM: CTAB without adventitious sounds.
ABD: Nontender and nondistended.
EXT: Warm, well-perfused; no edema.
SKIN: Tan in sun-exposed areas; no rash on face, arms, back,
abdomen, lower extremity.
NEURO: Face grossly symmetric, no dysarthria, moving limbs with
purpose against gravity.
DISCHARGE PHYSICAL EXAM
=====================================
___
Temp: 97.5 (Tm 98.3), BP: 134/75 (111-134/63-75), HR: 54
(51-56), RR: 18 (___), O2 sat: 97% (90-100), O2 delivery: ra
GENERAL: NAD
HEENT: MMM, no conjunctival pallor, moist mucous membranes.
NECK: No concerning lymphadenopathy.
CV: RRR with quiet early systolic flow murmur heard best at
LLSB.
PULM: CTAB
ABD: Nontender and nondistended.
EXT: Warm, well-perfused; no edema.
SKIN: Tan in sun-exposed areas; no rash on face, arms, back,
abdomen, lower extremity.
NEURO: AAOx3
Pertinent Results:
ADMISSION LABS
======================
___ 10:49AM BLOOD WBC-13.0* RBC-4.81 Hgb-14.4 Hct-43.4
MCV-90 MCH-29.9 MCHC-33.2 RDW-15.7* RDWSD-51.2* Plt ___
___ 10:49AM BLOOD Neuts-85.5* Lymphs-4.5* Monos-9.0
Eos-0.2* Baso-0.3 Im ___ AbsNeut-11.14* AbsLymp-0.59*
AbsMono-1.17* AbsEos-0.02* AbsBaso-0.04
___ 10:49AM BLOOD ___ PTT-24.9* ___
___ 10:49AM BLOOD Glucose-136* UreaN-69* Creat-4.7*# Na-138
K-3.8 Cl-106 HCO3-9* AnGap-22*
___ 12:56PM BLOOD Glucose-125* UreaN-66* Creat-4.1* Na-140
K-3.6 Cl-111* HCO3-9* AnGap-19*
___ 10:49AM BLOOD ALT-13 AST-11 AlkPhos-88 TotBili-0.4
___ 10:49AM BLOOD Lipase-73*
___ 10:49AM BLOOD Albumin-3.4* Calcium-9.5 Phos-7.7* Mg-1.9
___ 10:49AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 01:24PM BLOOD ___ pO2-37* pCO2-31* pH-7.21*
calTCO2-13* Base XS--15
___ 11:09AM BLOOD Lactate-2.5* K-4.5
___ 12:19PM BLOOD Lactate-1.4
___ 01:24PM BLOOD O2 Sat-58
PERTINENT LABS:
================================
___ 05:00AM BLOOD WBC-7.8 RBC-3.52* Hgb-10.4* Hct-30.1*
MCV-86 MCH-29.5 MCHC-34.6 RDW-14.6 RDWSD-45.8 Plt ___
___ 06:24AM BLOOD WBC-9.0 RBC-3.71* Hgb-11.0* Hct-31.8*
MCV-86 MCH-29.6 MCHC-34.6 RDW-14.7 RDWSD-46.0 Plt ___
___ 06:07AM BLOOD WBC-10.9* RBC-3.58* Hgb-10.6* Hct-31.6*
MCV-88 MCH-29.6 MCHC-33.5 RDW-15.0 RDWSD-48.6* Plt ___
___ 05:00AM BLOOD Glucose-200* UreaN-62* Creat-3.1* Na-135
K-3.0* Cl-103 HCO3-13* AnGap-19*
___ 06:24AM BLOOD Glucose-221* UreaN-58* Creat-2.3* Na-138
K-3.5 Cl-104 HCO3-20* AnGap-14
___ 06:07AM BLOOD Glucose-179* UreaN-57* Creat-1.7* Na-141
K-3.6 Cl-106 HCO3-22 AnGap-13
___ 05:00AM BLOOD ___ PTT-24.3* ___
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD Lipase-36
___ 05:29AM BLOOD ___ pO2-286* pCO2-25* pH-7.44
calTCO2-18* Base XS--4 Comment-GREEN TOP
___ 01:56PM BLOOD ___ pO2-93 pCO2-33* pH-7.32*
calTCO2-18* Base XS--8 Comment-GREEN TOP
___ 07:19AM BLOOD ___ pO2-66* pCO2-38 pH-7.37
calTCO2-23 Base XS--2 Comment-GREEN TOP
PERTINENT MICRO
============================
___ 7:07 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Pending):
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
___ 12:56 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
PERTINENT IMAGING
======================================
___BD & PELVIS WITH CO
IMPRESSION:
1. Nondilated, fluid-filled loops of small bowel could suggest
enteritis.
Fluid in the descending colon, with more formed stool in the
rectosigmoid
likely corresponds to reported diarrheal illness.
2. Redemonstration of multiple pulmonary nodules measuring up to
6 mm in the
visualized right lower lobe, compatible with metastatic disease.
3. 2.4 x 2.1 cm right adrenal nodule is unchanged compared to
MRI of the
abdomen from ___.
4. Prominent mesenteric nodes measuring up to 1.7 x 1.2 cm,
which may be
reactive.
5. Postsurgical changes related to left nephrectomy and partial
right
nephrectomy are again noted. No evidence of local recurrence.
___ Imaging CHEST (PA & LAT)
IMPRESSION:
In comparison with study of ___, the cardiomediastinal
silhouette is
stable and there is no evidence of acute pneumonia, vascular
congestion, or pleural effusion. The known multiple pulmonary
lesions were much better seen on the CT scan dated ___
DISCHARGE LABS:
___ 06:48AM BLOOD WBC-12.4* RBC-3.68* Hgb-10.8* Hct-32.8*
MCV-89 MCH-29.3 MCHC-32.9 RDW-15.1 RDWSD-49.2* Plt ___
___ 06:48AM BLOOD Plt ___
___ 06:48AM BLOOD Glucose-160* UreaN-53* Creat-1.7* Na-141
K-4.2 Cl-107 HCO3-24 AnGap-10
Brief Hospital Course:
TRANSITIONAL ISSUES
=========================
[ ] Please repeat Cr and lytes at next visit. Discharge Cr. is
1.7
[ ] Holding BP medications and Lasix given normotensive and
pre-renal ___. Please recheck BP, lytes, and consider restarting
medications at next visit.
[ ] Patient discharged on 60mg prednisone daily (1mg/kg). Please
continue to monitor BMs and consider prednisone taper as
outpatient.
[ ] Last TSH was low. Consider adjustment of levothyroxine.
BRIEF HPI:
=================================
ASSESSMENT & PLAN: ___ male with CABGx5 (___) RCC s/p
left nephrectomy (___) and left adrenalectomy (___) presenting
with 1.5 weeks of n/v and diarrhea, found to acute kidney injury
with an anion-gap and non-gap acidosis. ___ was pre-renal in
etiology and improved with fluids. Diarrhea was thought to be
secondary to immunotherapy induced enteritis. The patient was
started on 2mg/kg methylprednisolone IV and transitioned to
1mg/kg oral prednisone with improvement in BMs and complete
resolution of diarrhea. He was discharged on prednisone 60mg
daily. His Cr continued to improve. BP meds and Lasix were held
given ___ and normotensive off of meds. Ultimately he was
discharged home without services.
PROBLEM BASED SUMMARY:
======================
#Diarrhea - improved
#N/V
#Leukocytosis: Infectious colitis vs. nivolumab related
enteritis
;no obvious infectious exposures nor recent antibiotics. His
LFTs are wnl though his lipase is slightly elevated w/o
concomminant abdominal pain or CT finding for pancreatitis.
Notably, leukocytosis is mild; without left shift; and in the
setting of significant hemoconcentration by interpretation of
Hgb and Plts. ___ Leukocytosis and diarrhea improved. On ___,
leukocytosis is noted. Slight increase most likely secondary to
start of Methyl prednisone. Primary Oncologist was notified
about patient symptoms and states this has been going on since
last visit and declined a visit to the hospital a week prior to
presentation. Started MethylPREDNISolone Sodium Succ 125 mg IV
Q24H and tapered to Prednisone MR. ___: negative and Stool
studies (culture, giardia, cryptosporidium) thus far
unrevealing.
#Acute on Chronic Kidney Disease- downtrending
#Hyperphosphatemia: Baseline Cr 1.2-1.4; was 1.7 on ___ ta his
PCP's office, and 4.7 on arrival to the ___ ED. Most likely
pre-renal injury in the setting of his copious diarrhea, as well
as vomiting and poor PO x 2 weeks, with acute worsening of his
output in the 24h prior to admission and no cessation of his
ACEi, diuretic, and other antihypertensives. Of note, his Cr
improved to 3.4 with fluids in the ED, suggesting some component
of volume responsiveness, though I anticipate he likely has ATN.
He did get a contrast load in the ED and has baseline CKD and a
solitary kidney, so it is possible Cr may stagnate before
normalizing. Notably, he recently had proteinuria and refractory
HTN c/f nephrotic syndrome and attributed to Tivozanib, which
was
subsequently discontinued. Creatinine continue to improve on
___, Cr is 2.3. ___: Cr: 1.7. ___, Cr: 1.7.
#ANION GAP METABOLIC ACIDOSIS - Resolved
#NON-GAP METABOLIC ACIDOSIS: Admission labs pH 7.21, Co2 31 and
bicarb 13) c/w metabolic acidosis (AG 30) with
nearly-appropriate
respiratory compensation (Winter's formula: Co2 should be
___
delta-delta >2 suggesting a concomitant acidosis driving bicarb
further down. AG is likely from lactate (hypoperfusion) and
ketones from poor PO (though no UA to confirm); neg tox screen,
denies EtOH; A1c 5.6% a few months back. NGMA is most likely
from
bicarb wasting in the setting of profound diarrhea. Received
150mcq bicarbonate with IVF in the ED with good response. He
received additional IVF and bicarbonate per renal recs with
improvement in acidosis.
#Hyperglycemia
Most likely from the D5 fluids in the ED, as was only mildly
hyperglycemic on admission to the 120s-130s, though
his profoundly elevated glucose does suggest some baseline
insulin resistance - however, a1c was 5.6 only a few months ago,
so I think (with hyponatremia also that developed at 1745 labs)
it is more likely that his labs were drawn off of a line with
D5.
On ___, slight increase in glucose most likely secondary
steroid
initiation. Patient was on a sliding scale during admission.
Given that this is most likely secondary to steroid treatment
will hold off on further treatment.
#Hyponatremia- improved
___ does not appear that he got free water, so unsure if
this is hypo- or hyper-volemic. As above per #hyperglycemia,
thought to be lab artifact. Last Na 135.
#Severe Protein Calorie Malnutrition: The patient has evidence
on
exam of malnutrition and wasting. Their albumin was low at last
check. Attributable to underlying malignancy. Nutrition was
consulted.
STABLE/CHRONIC ISSUES
=====================
#CAD
#HTN
- held telmisartan iso ___, volume depletion. held metoprolol so
as not to blunt cardiac response to hypovolemia. hold
hydralazine, amlodipine, and furosemide in the setting of volume
depletion, ___. continue ASA 81mg in setting of recent 5 vessel
CABG (___) continue atorvastatin. Given patient is
normotensive will hold till next appointment with a physician.
# Gout:
allopurinol dosing adjusted per pharmacy given ___
# Hypothyroidism: Last TSH was 0.14 and has been low, so likely
needs a reduction in his home levothyroxine, but as I was unable
to confirm his dose with him I will continue what is in OMR for
now.
- continued home levothyroxine
# GERD
- ranitidine 150 daily
# Insomnia
# Anxiety:
home trazodone 50mg. home prn lorazepam.
# CODE STATUS: full presumed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. telmisartan 40 mg oral DAILY
3. Allopurinol ___ mg PO DAILY
4. Prochlorperazine ___ mg PO Q6H:PRN Nausea/Vomiting - Second
Line
5. LORazepam 1 mg PO Q8H:PRN anxiety
6. Metoprolol Tartrate 25 mg PO BID
7. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line
8. amLODIPine 2.5 mg PO DAILY
9. HydrALAZINE 50 mg PO TID
10. Ranitidine 150 mg PO DAILY
11. Atorvastatin 40 mg PO QPM
12. Furosemide 20 mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. TraZODone 25 mg PO QHS
15. Levothyroxine Sodium 125 mcg PO DAILY
Discharge Medications:
1. PredniSONE 60 mg PO DAILY
Continue until your next appointment
Tapered dose - DOWN
2. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
3. Allopurinol ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First
Line
7. Levothyroxine Sodium 125 mcg PO DAILY
8. LORazepam 1 mg PO Q8H:PRN anxiety
9. Prochlorperazine ___ mg PO Q6H:PRN Nausea/Vomiting - Second
Line
10. Ranitidine 150 mg PO DAILY
11. TraZODone 25 mg PO QHS
12. HELD- amLODIPine 2.5 mg PO DAILY This medication was held.
Do not restart amLODIPine until told by a physician
13. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until told by a physician
14. HELD- HydrALAZINE 50 mg PO TID This medication was held. Do
not restart HydrALAZINE until told by a physician
15. HELD- Metoprolol Tartrate 25 mg PO BID This medication was
held. Do not restart Metoprolol Tartrate until told by a
physician
16. HELD- telmisartan 40 mg oral DAILY This medication was
held. Do not restart telmisartan until told by a physician
___:
Home
Discharge Diagnosis:
#Diarrhea
#Leukocytosis
#Anion gap metabolic acidosis with non-anion gap metabolic
acidosis
#Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___ ,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for nausea and vomiting as well as one and
half weeks of diarrhea.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- In the hospital we noted that you were severely dehydrated
leading to kidney injury, and we gave you some fluids.
- We also suspected that your diarrhea was secondary to your
chemo treatment so we started you on some steroids to help with
the symptoms. We also did some blood work and imaging to exclude
any infectious causes for your symptoms.
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:
___
|
10434594-DS-10 | 10,434,594 | 28,268,301 | DS | 10 | 2124-09-25 00:00:00 | 2124-09-25 14:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Rising Creatinine
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with PMH of kidney stones,
asthma and allergic rhinitis who presents with 1 week of viral
symptoms now with worsening Cr. Patient states that about one
week ago had sore throat, muscle aches, fevers. This gradually
improved until ___ when she started vomiting. She has not
been able to keep anything down since then and has muscle
sorness from vomiting. She also notes that she was taking
spironolactone up until ___ when she began vomiting (this
was prescribed for acne). She still has pain across her lower
back, but rest of symptoms improving. Saw her primary MD who
noticed worsening ___, no recent increase in exercise or other
significant history/symptoms. No dysuria, frequency, no ___
pain. Is on menstrual period and flow is heavy, which is typical
for her. No sick contacts or recent travel. Denies bleeding from
gums, headaches, vision changes or hematuria. Husband also
thinks patient looks "puffy" since getting IVF.
Cr yesterday --> 1.66 --> 2.00 --> 3.00 today
In the ED, initial vitals: 104 105/54 16 100% RA
Labs/Studies notable for: plts 71, Cr 2.7
Patient was given: IVF, morphine and zofran
Currently, patient states she has low back pain and soreness,
muscle pain in abdomen from vomiting but denies any flank pain,
chest pain or SOB.
Past Medical History:
Asthma
Rhinitis, allergic
Pap smear abnormality of cervix with ASCUS favoring benign
Kidney stones
Social History:
___
Family History:
Breast cancer in mother, father has CAD, no h/o renal problems.
Physical Exam:
ADMISSION:
===========
Vitals: 98.9, 101/60, 101, 20, 100%RA
General: AAOx3, comfortable appearing, in NAD
HEENT: NCAT, EOMI. Sclera anicteric
Neck: supple, no JVP elevation
Lungs: CTAB, no w/r/r
CV: RRR, normal S1 and S2, no m/g/r
Abdomen: NABS, soft, nondistended, nontender. No HSM. No CVA
tenderness
GU: no foley
Ext: WWP. 2+ peripheral pulses. No edema.
Neuro: CNs II-XII intact. MAEE. Grossly normal strength and
sensation.
SKIN: no petechiae, purpura or signs of bleeding
DISCHARGE:
==========
Vitals: 98.5, 107/55, 61, 18, 98%RA
General: AAOx3, in NAD
HEENT: NCAT, MMM. Sclera anicteric
Neck: supple, no JVP elevation
Lungs: CTAB, no w/r/r
CV: RRR, normal S1 and S2, no m/g/r
Abdomen: NABS, soft, nondistended, nontender. No HSM. No CVA
tenderness
Ext: WWP. 2+ peripheral pulses. No edema.
Neuro: CNs II-XII intact. MAEE.
Pertinent Results:
ADMISSION:
==========
___ 03:25PM LACTATE-1.7
___ 03:08PM GLUCOSE-79 UREA N-38* CREAT-2.7* SODIUM-124*
POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-17* ANION GAP-13
___ 03:08PM estGFR-Using this
___ 03:08PM ALT(SGPT)-54* AST(SGOT)-62* LD(LDH)-372*
CK(CPK)-47 ALK PHOS-206* TOT BILI-0.5
___ 03:08PM HAPTOGLOB-166
___ 03:08PM OSMOLAL-271*
___ 03:08PM WBC-4.5 RBC-3.86* HGB-11.6* HCT-34.8* MCV-90
MCH-29.9 MCHC-33.2 RDW-14.3
___ 03:08PM NEUTS-83.3* LYMPHS-6.2* MONOS-7.7 EOS-2.5
BASOS-0.3
___ 03:08PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
___ 03:08PM PLT COUNT-71*
___ 03:08PM RET AUT-0.8*
___ 12:30PM URINE HOURS-RANDOM CREAT-78 SODIUM-30
POTASSIUM-25 CHLORIDE-LESS THAN TOT PROT-67 TOTAL CO2-LESS THAN
PROT/CREA-0.9 albumin-13.8 alb/CREA-176.9*
___ 12:30PM URINE UCG-NEGATIVE OSMOLAL-256
___ 12:30PM URINE GR HOLD-HOLD
___ 12:30PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 12:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 12:30PM URINE RBC-1 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-2
___ 12:30PM URINE MUCOUS-RARE
DISCHARGE:
==========
___ 06:45AM BLOOD WBC-2.4* RBC-3.41* Hgb-10.4* Hct-30.1*
MCV-88 MCH-30.7 MCHC-34.7 RDW-14.8 Plt ___
___ 06:45AM BLOOD Glucose-81 UreaN-25* Creat-1.4* Na-138
K-4.3 Cl-106 HCO3-21* AnGap-15
___ 06:45AM BLOOD ALT-366* AST-308* LD(LDH)-251*
AlkPhos-564* TotBili-0.4
___ 06:45AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.2
IMAGING:
========
___
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with rising LFTs, abdominal pain,
nauseaAlso with doppler, assess for inflammation, portal vein
thrombus
TECHNIQUE: Grey scale and color Doppler ultrasound images of
the abdomen were obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits.The
contour of the liver is smooth. There is no focal liver mass.
The main portal vein is patent with hepatopetal flow. There is
no ascites.
DOPPLER: Spectral Doppler waveform analysis demonstrates normal
phasicity and direction of flow within the hepatic veins, portal
veins, and hepatic artery.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD
measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening.
PANCREAS: Imaged portion of the pancreas appears within normal
limits, without masses or pancreatic ductal dilation, with
portions of the pancreatic tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 12.1 cm.
KIDNEYS: The right kidney measures 13.6 cm. The left kidney
measures 11.6 cm. Normal cortical echogenicity and
corticomedullary differentiation is seen bilaterally. There is
no evidence of masses, stones or hydronephrosis in the kidneys.
RETROPERITONEUM: Visualized portions of aorta and IVC are within
normal
limits.
IMPRESSION:
Normal abdominal ultrasound.
MICROBIOLOGY:
=============
___ 6:30 am Blood (EBV)
___ VIRUS VCA-IgG AB (Pending):
___ VIRUS EBNA IgG AB (Pending):
___ VIRUS VCA-IgM AB (Pending):
CMV IgG ANTIBODY (Final ___:
NEGATIVE FOR CMV IgG ANTIBODY BY EIA.
<4 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
Greatly elevated serum protein with IgG levels ___ mg/dl
may cause
interference with CMV IgM results.
Time Taken Not Noted Log-In Date/Time: ___ 6:56 pm
SEROLOGY/BLOOD
**FINAL REPORT ___
ASO Screen (Final ___:
< 200 IU/ml PERFORMED BY LATEX AGGLUTINATION.
Reference Range: < 200 IU/ml (Adults and children > ___
years old).
Brief Hospital Course:
Ms. ___ is a ___ female with PMH of kidney stones,
asthma and allergic rhinitis who presents with 1 week of viral
symptoms now with worsening Cr, anemia and thrombocytopenia.
# Transaminitis: LFTs mildly elevated on admission rising into
the hundreds. Hepatitis serologies, anti-smooth muscle
antibodies were ordered to rule out infectious and autoimmune
process. EBV and CMV also sent. CMV was negative and EBV is
pending. Synthetic function remained preserved. RUQ ultrasound
was within normal limits. On discharge, ALT 366, AST 308, LDH
251, AP 564, tbili 0.4. The values should be followed up after
discharge.
# ___: Baseline creatinine 0.65, rising to 3.0. Ddx includes
pre-renal etiologies such as dehydration vs. intrinsic causes
like TTP, nephritic or nephrotic syndromes. UA is positive for
blood though pt is menstruating. Rapid strep in office was
negative, but post-strep or other post-infectious GN is on the
differential. In setting of diuretic use pluse recent vomiting,
seems that dehydration and pre-renal is most likely. Creatinine
improved slowly to 2.0 on HD2. Nephrology was consulted and
recommended checking SPEP/UPEP, complement, hepatitis panel and
spinning the urine which showed granular casts, some muddy brown
casts and white blood cell casts, raising the possibility of
interstitial nephritis of uncertain etiology. Renal thought this
was most likely pre-renal and there was less concern for
nephritis. Creatinine was 1.4 on discharge.
# Thrombocytopenia: Ddx is broad including decreased production
(aplastic anemia, MDS, heme malignancies, myelofibrosis, viral
BM suppression), increased destruction (ITP, TTP, drug-induced,
DIC, sepsis, viral infections, liver failure) or sequestration.
Given what sounds like recent viral illness, likely c/w viral BM
suppression. No schistocytes on smear. This improved with time
and was 131 on discharge.
# Anemia: Baseline Hb per records around 12. MCV is 90 so
unlikely to be Fe deficiency. Differential for anemia includes
BM suppression as above, as well as DIC/TTP as a more concerning
cause. SPEP/UPEP was ordered to rule out a bone marrow process
and was pending at discharge.
# Hyponatremia: Likely hypovolemic hyponatremia in the setting
of recent illness.
This improved with IV fluids and was 138 on discharge.
# Metabolic acidosis: Originally non-gap related to NS
resuscitation. Then developed gap acidosis likely related to
decreased PO intake.
TRANSITIONAL ISSUES:
-will need transaminases and creatinine followed up after
discharge to ensure they are downtrending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Montelukast 10 mg PO DAILY
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Loratadine 10 mg PO DAILY:PRN nasal congestion
5. Multivitamins 1 TAB PO DAILY
6. Ranitidine 150 mg PO DAILY:PRN heartburn
7. Spironolactone 50 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Loratadine 10 mg PO DAILY:PRN nasal congestion
4. Montelukast 10 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Ranitidine 150 mg PO DAILY:PRN heartburn
7. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
acute kidney injury
transaminitis
Viral process of uncertain etiology
volume depletion
gastroenteritis
Secondary:
-acne
-asthma
-allergic rhinitis
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 during your
hospitalization. You were admitted with rising creatinine and
low platelets. This was likely due to a viral infection. Over
time, your platelets improved. Your creatinine got better with
fluids, though slowly, so nephrology was consulted. They
recommended sending various labs which were pending at
discharge. Your liver numbers were also going up, which can be
seen with viral infections as well. Several studies for
hepatitis and viruses were sent and your liver was ultrasounded.
The ultrasound was normal. Your liver numbers were stable and
it's important that you have them rechecked as an outpatient.
You were treated for nausea and vomiting with medications and
improved over time.
No changes were made to your medications.
Your ___ Care Team
Followup Instructions:
___
|
10434791-DS-3 | 10,434,791 | 24,742,827 | DS | 3 | 2148-02-27 00:00:00 | 2148-02-27 18:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___: L Chest tube placement, removed ___: R Chest tube placement, removed ___
History of Present Illness:
Mr. ___ is a ___ w/ Hx of Hx of Melanoma s/p resection in
___ with no adjuvent therapy (currently undergoing reg
screening at ___), Hx of Prostate Cancer s/p prostatectomy ___
years ago, Severe AS s/p valve repair, CAD and HTN who presents
for evaluation of dyspnea. Patient was discharged from ___
on ___ where he presented with similar symptoms and found to
have b/l pleural effusion. Imaging raised concern for malginant
effusion and 1.5L thoracentesis performed consistent with
exudate process. Cytology negative. CTA neg for PE and no
evidence of cardiac dysfunction on echo. Since discharge,
dyspnea has returned and he notes he feels even worse then when
he went to ___ earlier this month. Currently sleeping sitting
up in a chair and unable to perform basic ADLs without
difficulty. Denies CP, N/V/D,fevers, chills, or urinary
symptoms. Patient has remote smoking history, drinks ___ drinks
per day (last drink was yesterday, 1 drink but none other this
week) and denies illicit drug use.
In the ED, initial vital signs were: 98.2 95 123/72 20 95%
Labs were notable for proBNP 458 but otherwise wnl. CXR showed
bilateral pleural effusions L>R with likely loculation of R
effusion.
On Transfer Vitals were: 98.1 96 113/66 24 92% Nasal Cannula
Past Medical History:
Hyperlipidemia
Hypertension
Obesity
Hypoglycemia
Metabolic syndrome
Cardiac catheterization ___ with left circumflex ___ OM1
Aortic stenosis status post aVR ___
Status post CABG times ___
Malignant melanoma, stage II C. melanoma lesion removed from
patient's back in ___
Prostate carcinoma status post prostatectomy with subsequent
radiation therapy
Status post prostatectomy in ___
Lumbar spine surgery in ___
Was in teeth extraction
Surgery for reflux ___
Social History:
___
Family History:
Family history of colon cancer. Minimal insight into family
history.
Physical Exam:
ADMISSION:
Vitals: 97.9 113/65 P:97 RR22 97% 3L
General: Appears uncomfortable, sitting upright in bed
HEENT: NCAT, EOMI, ___, no oral lesions, MMM
Lymph: No appreciable cervical or axillary LNA
CV: RRR, no m/r/g, no JVD noted
Lungs:Markedly decreased breath sounds in lower half of lungs
b/l. No w/r/c.
Abdomen: Mildly distended but soft, nt, +BS no appreciable HSM
GU: No foley
Ext: No edema, clubbing, or cynanosis
Neuro: cn ___ intact, no focal deficits, ___ strength in all
extm
Skin: No rashes or skin breakdown
LABS: Reviewed in OMR, please see below.
DISCHARGE:
Vitals- Tm 100.6, Tc 97.3, HR 99 (90-100), BP 123/73
(95-128/53-79), RR ___ on my check, O2 sat 94-99% on
RA-3L
R chest tube with 10cc output yesterday, 75cc since midnight
FSBS ___ yesterday
General: Obese man sitting in chair nasal canula in place
breathing without accessory muscle use
HEENT: NCAT, EOMI, ___, no oral lesions, MMM
Lymph: No appreciable cervical or axillary LNA
CV: RRR, ___ systolic murmur heard best at RUSB, no JVD noted
Lungs:Markedly decreased breath sounds in lower half of lungs
b/l R>L, crackles in mid to lower R lung fields. No wheezes.
Abdomen: Mildly distended but soft, nt, +BS no appreciable HSM
GU: No foley
Ext: 2+ pitting edema to mid shin, no clubbing, or cynanosis
Skin: No rashes or skin breakdown
Labs: Reviewed, please see below.
Pertinent Results:
ADMISSION:
___ 04:49PM BLOOD WBC-8.0 RBC-5.25 Hgb-16.0 Hct-44.7 MCV-85
MCH-30.4 MCHC-35.7* RDW-13.7 Plt ___
___ 04:49PM BLOOD Neuts-74.0* Lymphs-14.7* Monos-8.1
Eos-2.6 Baso-0.6
___ 04:49PM BLOOD Plt ___
___ 04:30PM BLOOD Glucose-141* UreaN-14 Creat-1.0 Na-140
K-4.3 Cl-97 HCO3-31 AnGap-16
___ 04:30PM BLOOD proBNP-458*
___ 04:30PM BLOOD cTropnT-<0.01
___ 09:35AM BLOOD Albumin-3.1*
DISCHARGE:
___ 07:51AM BLOOD WBC-8.0 Hgb-14.8 Hct-42.2 Plt ___
___ 07:51AM BLOOD Plt ___
___ 05:00PM BLOOD Glucose-129* UreaN-16 Creat-1.1 Na-135
K-4.0 Cl-90* HCO3-30 AnGap-19
___ 05:00PM BLOOD Calcium-8.2* Phos-3.1 Mg-1.8
___ 04:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:30PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 04:30PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 04:30PM URINE Mucous-RARE
___ 4:39 pm PLEURAL FLUID PLRURAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 12:15 pm PLEURAL FLUID BNP.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
IMAGING:
___ CXR IMPRESSION:
Bilateral pleural effusions, left greater than right, with
probable loculation of the right effusion. Lower lung opacities
concerning for atelectasis versus pneumonia. Recommend followup
to resolution.
___ Cytology DIAGNOSIS:
PLEURAL FLUID, LEFT:
POSITIVE FOR MALIGNANT CELLS.
Consistent with metastatic malignant melanoma.
Abundant tumor cells are present on cell block preparation and
on immunostains are positive for S-100 protein, HMB-45, and
Melan-1, and are negative for prostatic acid phosphatase,
prostatic specific antigen, CK7, CK20, and TTF-1. Dr. ___.
___ and Ms. ___ were informed of the
preliminary diagnosis via e-mail on ___ and the final
diagnosis via e-mail on ___ by ___.
___ CT CHEST W/ CONTRAST IMPRESSION:
1. Extensive multifocal bilateral pleural based irregular soft
tissue masses,
the largest centered along the right medial pleura and
infiltrating the
anterior mediastinal pericardial soft tissue. No discernable
soft tissue
plane remains between the mass and portions of the right atrium,
right
ventricle and ascending aorta.
The appearance is highly suggestive of malignancy, potentially
malignant
mesothelioma. Consideration can be given to percutaneous biopsy
of one of the dominant masses either in the thorax or upper
abdomen if a tissue diagnosis is clinically necessary.
2. Nodularity within the upper abdomen is in incompletely
visualized and
evaluated. There is also a suspected hypoattenuating lesion
within segment II of the liver which is not well assessed on
this examination.
3. No pulmonary parenchymal lesion of concern.
___ CXR IMPRESSION:
Bibasal consolidations and bilateral pleural effusions appear to
be slightly worse since the prior study. The right chest tube
is noted, in unchanged position. Upper lungs are relatively
clear.
Brief Hospital Course:
___ w/ Hx of Hx of Melanoma s/p resection in ___ with no
adjuvent therapy, Hx of Prostate Cancer s/p prostatectomy ___
years ago, Severe AS s/p valve repair, CAD and HTN who presents
for evaluation of dyspnea. Patient discharged 5 days prior from
___ with similar symptoms, was found to have a
pleural effusion which underwent thoracentesis with negative
cytologies. He again was found to have bilateral pleural
effusions on this admission. Interventional pulmonology was
consulted and placed a left then right sided chest tube with
signficant drainage. Follow-up CT Chest showed signficant
pleural abnormalities bilaterally, suspicious for malignancy.
Cytology from his thoracentis of the L pleural fluid returned
with malignant cells consistent with metastatic melanoma on
pathological analysis. The case was dicussed with Dr.
___ physican coverage of his oncologist Dr. ___ at
___, who will be in touch to set up an appointment with the
patient within a week. The patient was weaned off oxygen with
ambulatory saturations of 91% on the day of discharge. The
patient will follow-up with interventional pulmonology on ___ for his pulmonary concerns.
#Pleural effusions c/w metastatic melanoma: Initial high concern
for malignant effusion given appearance on CT and pleural fluid
last week consistent with exudative effusion, now confirmed
malignant melanoma on cytology from repeat ___. From initial
work-up, cardiac function appeared stable and no evidence of
pulm edema on exam or CXR. Patient underwent left and then right
chest tube with copious exudative drainage which eventually
revealed above malignany cytology. Discussed with patient and
wife at bedside that cytology was malignant and plan for
follow-up with Dr. ___ as outpatient. Chest CT w contrast
showed malignant appearing effusions/surrounding soft tissue,
with extension into anterior mediastinum, with blurred
distinction between mass, aorta, R ventricle/R atrium. Patietn
weaned off O2 with ambulatory saturations stable at 91% on day
of discharge. Interventional pulmonology will follow-up with
symptoms and degree of reaccumulation patient in 2 weeks.
#CAD: No evidence of recent ischemia and recent echo shows EF of
60% without any focality. Single vessel disease on cath in ___.
Continued home metoprolol, aspirin, rosuvastatin
#HTN: Well-controlled throughout admission. Continued home
amlodipine and holding HCTZ.
#Anxiety: Continued with Ativan 0.5mg PRN for anxiety.
#DM II: Hold home metformin in favor of RISS. History of
hypoglycemia. Maintained on HISS with QACHS fingersticks and
hypoglycemic protocol
#EtOH abuse: Pt has prev had ___ drinks per night but has
greatly reduced over last month as symptoms developed. He had 1
glass of wine night prior to admission and no other etoh
recently. Given low concern for withdrawal with no evidence
during admission.
TRANSITIONAL ISSUES
-Discussed case with coverage for Dr. ___ office ___
contact patient to set up appointment this week
-Patient scheduled for CXR on ___ prior to appointment
with Dr. ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 500 mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Rosuvastatin Calcium 10 mg PO QPM
4. Aspirin 81 mg PO DAILY
5. Lorazepam 0.5 mg PO Q6H:PRN anxiety
6. TraZODone 25 mg PO QHS:PRN insomnia
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Lorazepam 0.5 mg PO Q6H:PRN anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth every six (6) hours Disp
#*15 Tablet Refills:*0
4. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
6. Rosuvastatin Calcium 10 mg PO QPM
RX *rosuvastatin [Crestor] 10 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
7. TraZODone 25 mg PO QHS:PRN insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
8. Hydrochlorothiazide 12.5 mg PO DAILY
RX *hydrochlorothiazide 12.5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
9. MetFORMIN (Glucophage) 500 mg PO DAILY
RX *metformin 500 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Recurrent Pleural Effusion, Metastatic cancer, melanoma
SECONDARY: Coronary artery disease, Aortic stenosis
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 treating you at ___
___. You were admitted with concern for your difficulty
breathing. You were found to have a recurrence of fluid building
up around your lungs. You underwent drainage of this fluid and
lab tests showed it was unfortunately a result of metastatic
spread of your melanoma. We've created a care plan to help
manage your disease. You will follow-up with the pulmonary
specialists in 2 weeks and the office of your known oncologist
Dr. ___ will be in touch to set up a follow-up appointment
within the week.
We wish you the best of health,
Your ___ team
Followup Instructions:
___
|
10435478-DS-2 | 10,435,478 | 26,937,234 | DS | 2 | 2112-05-17 00:00:00 | 2112-05-20 12:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine / morphine
Attending: ___.
Chief Complaint:
Leg Cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Male who presents from his PCP's office with leg
cellulitis. This history began 1 week prior to admission when
the patient locked himself out of the house, and attempted to
get into the house via a ladder through the window. As he was
worried about injuring his chest, he chose to go in legs first,
and the ladder slipped and he fell backwards. He struck his leg
against the window. He went to ___ the day after due to leg
swelling and was found with a large calf hematoma. Vascular
surgery there observed him out of concern for compartment
syndrom, which was ruled out via pressure monitoring.
The morning of presentation he awoke with increased erythema and
swelling, and pain. He notes it was very tender to palpation. He
went to his PCP's office who referred him to the ED here at
___.
In the ED his initial vitals were 98.9, 215/75, 65, 20, 100%. A
leg x-ray was performed, and he was noted with leg cellulitis,
so was started on ceftriaxone and vancomycin.
Past Medical History:
Type 2 Diabetes
CAD/CABG
Peripheral Vascular Disease s/p femoral stents
Cholecystectomy
Benign Hypertension
Social History:
___
Family History:
Pt does not know of dz in parents.
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain, + Leg swelling/pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM AT ADMISSION:
VSS: 98.3, 167/90, 73, 20, 97%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE, Left Leg: Markedly swollen left calf with
surrounding erythema, warm to touch and tender, Right Leg 3cm
ulcer
NEURO: CAOx3, Non-Focal
AT DISCHARGE:
Vitals: 98.1 148/68 65 18 99RA ___
General: Alert, oriented, no acute ditress, sitting in chair
with LLE elevated
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: LLE calf and anterior leg with much improved edema, warmth
and tenderness. Left foot also with edema slightly cooler but
good cap refill; some serous weeping from posterior abrasions;
active/passive flexion somewhat limited by edema. RLE with small
3cm eschar on anterior right leg.
Neuro: grossly normal
Pertinent Results:
LABS AT ADMISSION
___ 08:00AM BLOOD WBC-8.5 RBC-4.40* Hgb-12.7* Hct-39.6*
MCV-90 MCH-28.9 MCHC-32.1 RDW-13.9 RDWSD-45.1 Plt ___
___ 09:40PM BLOOD WBC-11.0* RBC-4.46* Hgb-12.9* Hct-38.3*
MCV-86 MCH-28.9 MCHC-33.7 RDW-13.9 RDWSD-43.5 Plt ___
___ 09:40PM BLOOD Neuts-66.0 Lymphs-15.0* Monos-12.5
Eos-4.8 Baso-0.8 Im ___ AbsNeut-7.23* AbsLymp-1.65
AbsMono-1.37* AbsEos-0.53 AbsBaso-0.09*
___ 08:00AM BLOOD ___ PTT-22.4* ___
___ 09:40PM BLOOD ___ PTT-27.7 ___
___ 08:00AM BLOOD Glucose-168* UreaN-21* Creat-1.5* Na-132*
K-4.5 Cl-100 HCO3-17* AnGap-20
___ 09:40PM BLOOD Glucose-157* UreaN-23* Creat-1.7* Na-136
K-4.5 Cl-99 HCO3-25 AnGap-17
LABS AT DISCHARGE
___ 07:40AM BLOOD WBC-7.8 RBC-4.05* Hgb-11.4* Hct-34.5*
MCV-85 MCH-28.1 MCHC-33.0 RDW-13.6 RDWSD-42.3 Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-168* UreaN-22* Creat-1.7* Na-137
K-4.4 Cl-101 HCO3-24 AnGap-16
___ 07:40AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.1
IMAGING:
Tib/Fib xray showed extensive SQ edema without evidence of gas.
Brief Hospital Course:
1. Leg Cellulitis
Cellulitis by appearance and history but extensive edema in left
foot concerning for possible venous obstruction; ___ negative
for DVT. Per patient, he has had left foot edema s/p vascular
procedure done in ___ however, foot edema appeared worse
than before. In ED, was initially started on
vancomycin/ceftriaxone. Vancomycin discontinued the following
day given low suspicion for MRSA. He was then transitioned to
Unasyn, with which he continued to improve. At discharge, he was
transitioned to PO augmentin for a total 10 day course to end
___.
___ also evaluated patient and recommended outpatient ___ and
walker with ambulation; patient was provided with prescriptions
for both at discharge.
2. Acute Renal Failure
- While aspirin is suboptimal for renal failure, given recent
stenting and severity of disease was continued
At presentation, creatinine was 1.7. ___ was
contacted for baseline creatinine which appears to be ~2.0.
Creatinine remained stable throughout stay; all medications were
renally dosed.
3. Leg Hematoma, Peripheral Vascular Disease
Patient obtained compartment pressures at OSH; WNL, per report.
Hematoma appeared to be resorbing throughout hospital stay. No
concerns for vascular compromise. Continued on home ASA,
clopidogrel, rosuvastatin.
4. Benign Hypertension - stable.
- Clonidine, Atenolol, Norvasc, Hydralazine continued
5. Type 2 Diabetes Uncontrolled with complications - stable
- Glargine, ISS
- Glimeperide held while inpatient
6. CAD/CABG - stable
- Aspirin, Atenolol, Rosuvastatin, Clopidogrel continued
===================
TRANSITIONAL ISSUES:
===================
-___ recommended outpatient ___ services and walker for ambulatory
support; please wean as tolerated
-hypertensive to SBP 190s in setting of uncontrolled pain; 160s
with pain control, despite continuation of home
antihypertensives; may require further titration
-total 10-day Augmentin course to end on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. CloniDINE 0.3 mg PO BID
3. Mirtazapine 30 mg PO QHS
4. Rosuvastatin Calcium 20 mg PO QPM
5. Atenolol 100 mg PO DAILY
6. glimepiride 1 mg oral DAILY
7. Pantoprazole 40 mg PO Q24H
8. Clopidogrel 75 mg PO DAILY
9. HydrALAzine 50 mg PO BID
10. Levothyroxine Sodium 75 mcg PO DAILY
11. Amlodipine 10 mg PO DAILY
12. Levemir 38 Units Bedtime
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. CloniDINE 0.3 mg PO BID
3. Clopidogrel 75 mg PO DAILY
4. Outpatient Physical Therapy
Patient requires further physical therapy for rehabilitation of
left leg function. Was treated for LLE cellulitis with edema
extending to thigh. Inpatient ___ eval recommending walker and
further outpatient therapy.
5. Walker
Patient recommended walker for limited left leg mobility in the
setting of cellulitis. Will need walker for at least one month
until cellulitis resolves and patient regains functional
mobility of leg.
6. Aspirin 81 mg PO DAILY
7. Atenolol 100 mg PO DAILY
8. HydrALAzine 50 mg PO BID
9. Levemir 38 Units Bedtime
10. Levothyroxine Sodium 75 mcg PO DAILY
11. Mirtazapine 30 mg PO QHS
12. Pantoprazole 40 mg PO Q24H
13. Rosuvastatin Calcium 20 mg PO QPM
14. Acetaminophen 650 mg PO TID
RX *acetaminophen 325 mg 2 tablet(s) by mouth three times a day
Disp #*100 Tablet Refills:*0
15. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
16. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
17. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth every 4 to 6 hours
Disp #*12 Tablet Refills:*0
18. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*30 Packet Refills:*0
19. glimepiride 1 mg ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
LLE cellulitis
Secondary:
HTN
elevated creatinine
peripheral vascular disease
Type 2 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 Mr. ___,
You were admitted to the ___ for cellulitis, or superficial
skin infection, of the left leg. You were assessed with x-ray
in the ED which did not show any evidence of deep tissue
infection or problems with the underlying bone; ultrasound of
your veins did not reveal any clots. You were provided with IV
antibiotics initially, after which you noticed improvement in
the swelling. At discharge, you were transitioned to oral
medications, called Augmentin, that you will continue taking for
the next ___ days.
While you were here, you were also seen by physical therapy
because of difficulty walking. The pain you feel in your left
leg and foot is likely due to the infection and should get
better with treatment. You can use Tylenol to help control the
pain. You should take the pain medication prescribed to you only
for severe pain.
Please follow up with your primary care doctor in the next ___
days for continued monitoring of your left leg infection.
It was a pleasure taking care of you,
Your ___ Medicine Team
Followup Instructions:
___
|
10435536-DS-18 | 10,435,536 | 22,083,139 | DS | 18 | 2196-06-26 00:00:00 | 2196-06-27 08:51:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
hyperglycemia, DKA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ IDDM w/ home inuslin pump and w/ one prior episode of DKA
presenting w/ URI symptoms, found to be hyperglycemic in urgent
care, and transferred to ___ for management of DKA. Patient
says he has had a cold x 3 weeks w/ a persistent cough. His
daughter has been sick with a URI and he is a ___ and
there have been sick children at school. On night prior to
admission, FSBG in 500s. Morning of admission- patient felt
acutely ill with nausea and dry heaving. He denies abdominal
pain, HA, chest pain, SOB, palpitations. He has not brought up
any vomit and has not had diarrhea. No fevers, chills. No
blurry vision. HE went to urgent care and received 8 units
Regular Insulin IV at 1pm as well as 4 mg IV Zofran for vomiting
and was given 1 L NS. He was transferred to ___ for
management of DKA with insulin gtt.
Of note, patient feels blood glucose well controlled at home.
He checks finger sticks 5x a day with FSBG ranging from 100-180.
In the ED
-VS: 100.5 120 125/56 16 98% RA.
-Labs notable for glucose 522, hyperkalemia 5.1, HCO3 12, and AG
38. WC elevated to 17.4 with 88.6% N. UA remarkable for
Glu:1000, Ket: 150, WBC <1. Flu-A and Flu-B rapid antigen tests
negative, PCRs pending. VBG: ___ (14.23); lactate
4.5--> pH 7.24, TCO2 12, Glu 345 (16:55).
-CXR negative for acute process. EKG w/ peaked T waves I, II,
V2-V4.
-Patient given: 2 L NS, started on insulin gtt.
On arrival to the FICU, VS T 99.1, HR 102, BP 137/68, RR 18, 99%
on RA. Patient is more comfortable and denies current abdominal
pain, fevers, chills, nausea.
Past Medical History:
IDDM
HYPERTENSION
OBESITY
HYPERLIPIDEMIA
Social History:
___
Family History:
(Per Dr. ___ note, confirmed with patient)positive for
prostate cancer and negative
for colon cancer or early CAD. Father has bladder cancer.
Physical Exam:
ADMISSION
VS T 99.1, HR 102, BP 137/68, RR 18, 99% on RA
GENERAL: NAD, lying in bed A&Ox3
HEENT: neck supple, no LAD
NECK: no JVD
LUNGS: CTA bl no wrr
CV: tachycardic, regular rhythm, nl S1 S2, and no MRG
ABD: soft NT ND +BS
DISCHARGE
AFVSS
GEN: NAD
HEENT: NC/AT
CV: RRR, no M/R/G
RESP: CTA B
ABD: N/NT/ND, BS present
NEURO: nonfocal
Pertinent Results:
Admission Labs:
___ 11:40AM BLOOD WBC-17.4*# RBC-4.50* Hgb-14.2 Hct-41.4
MCV-92 MCH-31.6 MCHC-34.3 RDW-12.2 RDWSD-40.8 Plt ___
___ 11:40AM BLOOD Neuts-88.6* Lymphs-4.9* Monos-5.5
Eos-0.1* Baso-0.3 Im ___ AbsNeut-15.40* AbsLymp-0.85*
AbsMono-0.96* AbsEos-0.02* AbsBaso-0.06
___ 11:40AM BLOOD Glucose-522* UreaN-25* Creat-1.5* Na-130*
K-6.1* Cl-86* HCO3-12* AnGap-38*
___ 02:10PM BLOOD Calcium-9.2 Phos-4.7* Mg-2.1
Discharge Labs:
___ 07:20AM BLOOD WBC-6.7 RBC-3.85* Hgb-12.0* Hct-35.4*
MCV-92 MCH-31.2 MCHC-33.9 RDW-13.1 RDWSD-43.3 Plt ___
___ 07:20AM BLOOD Glucose-165* UreaN-9 Creat-0.7 Na-139
K-3.9 Cl-105 HCO3-27 AnGap-11
___ 07:20AM BLOOD Calcium-9.2 Mg-2.0
___ 02:30PM URINE Color-Straw Appear-Clear Sp ___
___ 02:30PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 02:30PM URINE RBC-4* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 11:35AM OTHER BODY FLUID FLU A-RAPID ANTI FLU B-RAPID
ANTI
___ 11:35AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
BCx x 2 PENDING, NGTD
ECG - Sinus tachycardia. Non-specific ST-T wave abnormalities.
No previous tracing available for comparison.
CXR - No acute process.
Brief Hospital Course:
___ yo M hx IDDM p/w URI prodrome, hyperglycemia, ketonuria and
acidosis c/w DKA.
#DKA- IDDM, poorly controlled ___ HgA1C 10.2, ___ HgA1C
9.2, ___ HgA1C 10.5), 1 prior episode DKA, no clear source of
infectious etiology though URI sx speak to possible viral source
vs. poor compliance with diet/insulin regimen. Influenza A and
B antigen and PCR negative, UA not suggestive of infection, and
BCxs NGTD. +ketones and trace protein on UA on presentation w/
AG 32. Thought unlikely to be ___ ACS given nl EKG and lack of
chest pain. Pt started on insulin gtt with ___ w/ 40 mEq
KCl. Electrolyes closely monitored and repleted as necessary.
AG closed and patient transitioned to home insulin pump. Insulin
pump settings adjusted by ___ consult service (see d/c med
list below for details), and pt will follow-up with ___ at
discharge. Prior to d/c, pt instructed to monitor his FSBS at
home and increase basal rate if they remain consistently > 180.
At discharge, he was also given an Rx for Lantus to use in case
of pump failure (per ___ recommendations).
#LEUKOCYTOSIS- likely in setting of stress response in setting
of DKA>> viral URI.
- DKA treated as above
#HYPONATREMIA- pseudohyponatremia in the setting of
hyperglycemia. Corrected Na = 136
Na normalized with resolution of hyperglycemia
Transitional Issues
- Blood cultures x 2 pending with no growth to date, need to be
followed up
- Patient may need to be started on aspirin, higher dose statin
for primary prevention
- Patient with hematuria and proteinuria and will need a follow
up UA
- Patient needs yearly retinal exam
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Target glucose: 80-180
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Lisinopril 20 mg PO DAILY
3. Ketostix (acetone (urine) test) one miscellaneous QID
use if blood sugar >250
RX *acetone (urine) test [Ketostix] use to check for urine
ketones four times per day Disp #*100 Strip Refills:*3
4. BD Insulin Syringe (insulin syringe-needle U-100) 1 mL 26 x
___ miscellaneous QID:PRN
RX *insulin syringe-needle U-100 [BD Insulin Syringe] 28 gauge X
___ Inject into subcutaneous fat four times a day Disp #*100
Syringe Refills:*0
5. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Basal Rates:
Midnight - 0400: 1.2 Units/Hr
0400 - 0600: 1.45 Units/Hr
0600 - 2400: 1.3 Units/Hr
Meal Bolus Rates:
Breakfast = 1:12
Lunch = 1:12
Dinner = 1:12
High Bolus:
Correction Factor = 1:50
Correct To ___ mg/dL
MD acknowledges patient competent
MD has ordered ___ consult
MD has completed competency
6. Lantus (insulin glargine) 100 unit/mL subcutaneous as
directed
To be used as directed by ___ in the event of insulin pump
malfunction.
RX *insulin glargine [Lantus] 100 unit/mL as directed units SC
as directed Disp #*1 Vial Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Diabetic ketoacidosis, Upper Respiratory Tract
Infection
Secondary: Hypertension, Hyperlipidemia, Diabetes Mellitus 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted with diabetic ketoacidosis where you had very
high blood sugars. You were started on an insulin drip with
close monitoring of your blood sugar and electrolyte levels. You
were also given IV fluids. You were seen by ___ who made
recommendations regarding new insulin pump settings which you
should now follow. You should follow-up with your primary care
physician, have ___ dilated eye exam, and follow up with ___ in
___ weeks.
It was a pleasure caring for you.
-Your ___ Team
Followup Instructions:
___
|
10435823-DS-14 | 10,435,823 | 22,339,634 | DS | 14 | 2159-08-07 00:00:00 | 2159-08-07 11:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, pneumonia.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ man with alcohol/hepatitis C cirrhosis
and hepatocellular CA s/p ___ TACE ___ admitted for fever
and pneumonia. Since hospital discharge ___ for TACE, he
has had intermittent fevers up to ___ and LUQ abdominal pain,
although he did have a few days of feeling well. Yesterday, his
abdominal pain became too severe, so he presented to the ED.
CXR and CT torso in the ED showed a LLL infiltrate/effusion, but
no liver abscess. He was given pip/tazo, vancomycin, and
metronidazole in the ED and admitted.
.
ROS: He notes mild sweats and constipation since ___, but
denies chills, headache, dizziness, chest pain, dyspnea, cough,
back pain, diarrhea, hematochezia, hematuria, other urinary
symptoms, parasthesias, or rash. All other review of symptoms
are negative.
Past Medical History:
- Hepatocellular carcinoma, dx ___, s/p TACE ___,
complicated by fever.
- HCV cirrhosis, s/p interferon + ribavirin completed ___,
with VL ND ___.
- EtOH abuse.
- Hypothyroidism.
Social History:
___
Family History:
His mother died of rectal cancer at ___ years. She also had a
history of endometrial cancer. A maternal aunt has had breast
cancer. He has seven sisters and two brothers without health
concerns. He has no children.
Physical Exam:
Admission Physical Examination:
Vitals: T 97.5F, BP 110/70, HR 70, RR 18, O2 sat 96% RA,
Ins/Outs , wght 157.1 lbs, ht 74in.
Gen: A&O, NAD.
HEENT: Anicteric sclerae, PEARL, MMM, normal oropharynx, poor
dentition, no cervical LAD, no JVD, supple neck.
___: RRR, no MRG.
Resp: Decreased breath sounds at left base, otherwise CTA.
Back: Generalized mild back tenderness.
Ab: Soft, tender upper quadrants, ND, no HSM, no inguinal LAD.
Ext: No edema or calf tenderness.
Neuro: Strength ___ throughout, no focal deficits, no asterixis.
Skin: No rashes.
Psych: Calm and appropriate.
Pertinent Results:
ADMISSION LABS:
___ 06:30AM BLOOD WBC-6.8 RBC-3.62* Hgb-12.0* Hct-35.6*
MCV-98 MCH-33.0* MCHC-33.6 RDW-14.9 Plt ___
___ 06:30AM BLOOD Neuts-74.5* Lymphs-16.2* Monos-7.1
Eos-1.6 Baso-0.6
___ 06:30AM BLOOD ___ PTT-32.5 ___
___ 06:30AM BLOOD Glucose-132* UreaN-9 Creat-1.1 Na-132*
K-5.0 Cl-97 HCO3-29 AnGap-11
___ 06:39AM BLOOD Lactate-0.8
.
___ CXR: IMPRESSION: Moderate sized left pleural effusion
with probable left basilar atelectasis.
.
___ CT ABD: IMPRESSION:
1. Moderate-to-large left pleural effusion with a left lower
lobe opacity which may represent atelectasis, but infection is
not excluded. There is also lingular atelectasis. Mild
paraseptal emphysema.
2. Cirrhotic liver with numerous dysplastic nodules status post
chemoembolization of the left lobe of the liver.
3. Arterially enhancing 14 x 12 mm nodule within segment VI of
the liver with washout is noted. While a similar sized area of
washout was noted on prior CT and MR studies, the arterial
enhancement within this nodule is new and therefore concerning
for ___. Recommend MR for further characterization.
4. Mildly thickened esophagus, correlate clinically. This may
represent esophagitis.
.
DISCHARGE LABS:
___ 06:50AM BLOOD WBC-5.5 RBC-3.24* Hgb-10.7* Hct-31.9*
MCV-99* MCH-32.9* MCHC-33.4 RDW-14.9 Plt ___
___ 06:05AM BLOOD ___ PTT-38.7* ___
___ 06:50AM BLOOD Glucose-124* UreaN-9 Creat-0.9 Na-140
K-4.4 Cl-108 HCO3-27 AnGap-9
___ 06:50AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0
___ 06:50AM BLOOD ALT-35 AST-50* AlkPhos-194* TotBili-1.0
___ 06:05AM BLOOD T4-5.8 T3-102 Free T4-0.85*
___ 06:30AM BLOOD TSH-33*
Brief Hospital Course:
___ man with alcohol/hepatitis C cirrhosis and hepatocellular
CA s/p ___ TACE ___ admitted for fever and pneumonia. He
completed a 7d-course of ciprofloxacin prophylaxis ___ for
post-TACE fevers, but continued to have fevers to ___ at home.
He was given pip/tazo, vancomycin, and metronidazole in the ED.
.
# Fever/pneumonia: Given pip/tazo, vancomycin, and metronidazole
in the ED.
- Change ceftriaxone to cefpodoxime for hospital discharge.
- Continue azithromycin for community-acquired pneumonia.
- Plan to repeat CXR in ___ weeks and consider outpatient
thoracentesis.
- F/U blood cultures.
- Sputum culture if produced.
- Incentive spirometry.
- IV fluids while febrile.
.
# Hepatocellular carcinoma: s/p TACE ___. Increased LFTs
post-TACE improving.
- Anti-emetics as needed.
- Ranitidine 150 mg PO BID x30d post-TACE.
- Hydromorphone PO PRN.
.
# Thrombocytopenia and anemia: Chronic, mild. Due to liver
disease.
.
# Coagulopathy: Chronic, due to liver disease. Stable.
.
# Hypothyroidism: High TSH, low free T4. Increased
levothyroxine from 88 to 100mcg daily.
.
# Hepatitis C cirrhosis: LFTs stable post-TACE.
.
# Pain (abdomen): Amylase/lipase normal. Pain improved with
hydromorphone PO prn.
.
# FEN: Regular diet. Hyponatremia resolved with IV fluids.
.
# GI prophylaxis: Ranitidine for 30d post-TACE.
.
# DVT prophylaxis: Heparin SC.
.
# Lines: Peripheral.
.
# Precautions: None.
.
# CODE: FULL.
Medications on Admission:
CLOTRIMAZOLE 10 mg Troche dissolve PO 5x a day. Do not eat or
drink within 15 minutes after taking
HYDROMORPHONE ___ PO q3HR PRN pain
LEVOTHYROXINE 88 mcg Tab - 1.5 Tablet(s) PO daily
PROCHLORPERAZINE MALEATE 10mg PO q6HR PRN nausea
RANITIDINE HCL 150 mg PO BID
Discharge Medications:
1. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. azithromycin 250 mg PO Q24H for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
3. ranitidine HCl 150 mg PO BID for 4 weeks.
Disp:*56 Tablet(s)* Refills:*0*
4. docusate sodium 100 mg PO BID.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN
Constipation.
6. magnesium hydroxide 400 mg/5 mL 30 ML PO Q6H PRN
Constipation.
7. prochlorperazine maleate 5 mg Tablet Sig: ___ Tablets PO Q6H
PRN Nausea.
8. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H PRN Pain.
Disp:*30 Tablet(s)* Refills:*0*
9. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H PRN fever
or pain.
10. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Fever.
2. Abdominal pain.
3. Pneumonia.
4. Pleural effusion (fluid on lung).
5. Hepatocellular carcinoma (liver cancer).
6. Hypothyroidism (underactive thyroid).
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for fever and abdominal pain.
CT showed fluid on the left lung (pleural effusion). This could
be due to pneumonia, so you were treated with antibiotics and
will need to complete a course of this at home. In addition,
you will need a follow-up chest x-ray in several weeks to ensure
that the fluid in the lung resolves. Also, thyroid tests showed
that you have been markedly under treated and need to increase
the dose of your thyroid medication. Thyroid testing should be
repeated by your other physicians in several weeks.
.
MEDICATION CHANGES:
1. Cefpodoxime 2x a day x7 days.
2. Azithromycin 250mg daily x2 days.
3. Ranitidine (Zantac) 150mg 2x a day. PLEASE TAKE THIS FOR THE
NEXT ___ WEEKS.
4. Levothyroxine (Synthroid) increased from 88 to 100mcg daily.
Followup Instructions:
___
|
10436030-DS-22 | 10,436,030 | 23,621,452 | DS | 22 | 2159-05-31 00:00:00 | 2159-05-31 09:56:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Solu-Medrol / Nsaids
Attending: ___.
Chief Complaint:
bilateral upper extremity pain, paresthesias, and weakness
Major Surgical or Invasive Procedure:
FUSION CERVICAL ANTERIOR C5-C7 with Neuromonitoring on ___
with Dr. ___
___ of Present Illness:
___ w narcolepsy, CVID, neurologist at BI p/w BUE pain,
dystesthesias, and weakness s/p fall down 20+ stairs this
evening after missing a step. + HS, - LOC. States that she
could not initially move legs or arms, but this subsided.
Past Medical History:
Monoclonal IgA kappa
Hypogammaglobulinemia
hypertension
narcolepsy
knee surgery with synovectomy in ___
Social History:
___
Family History:
She does not have a family history of immune deficiency or
hematologic malignancy.
Physical Exam:
PE:
NAD, A&Ox4
nl resp effort
RRR
Sensory:
UE
C5 C6 C7 C8 T1
(lat arm) (thumb) (mid fing) (sm finger) (med arm)
R SILT SILT dys dys SILT
L SILT SILT dys dys SILT
___
L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R SILT SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT SILT
Motor:
UE Dlt(C5) Bic(C6) WE(C6) Tri(C7) WF(C7) FF(C8)FinAbd(T1)
R 5 5 4 5 5 4 5
L 5 4 4 5 5 4 5
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
___: Negative
Clonus: No beats
Pertinent Results:
___ 01:10AM BLOOD WBC-7.1 RBC-3.58* Hgb-11.5 Hct-34.4
MCV-96 MCH-32.1* MCHC-33.4 RDW-12.1 RDWSD-42.6 Plt ___
___ 09:16AM BLOOD WBC-6.5 RBC-4.00 Hgb-12.7 Hct-38.1 MCV-95
MCH-31.8 MCHC-33.3 RDW-11.9 RDWSD-41.6 Plt ___
___ 11:32PM BLOOD WBC-6.8 RBC-4.06 Hgb-13.0 Hct-39.7 MCV-98
MCH-32.0 MCHC-32.7 RDW-12.1 RDWSD-43.7 Plt ___
___ 09:16AM BLOOD Neuts-92.4* Lymphs-6.0* Monos-1.1*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-5.99 AbsLymp-0.39*
AbsMono-0.07* AbsEos-0.00* AbsBaso-0.01
___ 01:10AM BLOOD Plt ___
___ 09:16AM BLOOD Plt ___
___ 09:16AM BLOOD ___ PTT-29.8 ___
___ 11:32PM BLOOD ___ 01:10AM BLOOD Glucose-119* UreaN-9 Creat-0.5 Na-137
K-3.5 Cl-101 HCO3-24 AnGap-12
___ 09:16AM BLOOD Glucose-165* UreaN-10 Creat-0.6 Na-138
K-4.1 Cl-101 HCO3-24 AnGap-13
___ 11:32PM BLOOD Glucose-120* UreaN-14 Creat-0.8 Na-143
K-3.6 Cl-104 HCO3-24 AnGap-15
___ 11:32PM BLOOD LD(LDH)-256*
___ 11:32PM BLOOD Lipase-25
___ 01:10AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.8
___ 09:16AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.9
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure.Refer to the
dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as
tolerated.Foley was removed on POD#2. Physical therapy and
Occupational therapy were consulted for mobilization OOB to
ambulate and ADL's.
Hospital course was otherwise unremarkable.On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet.
Medications on Admission:
Medications - Prescription
ARMODAFINIL [NUVIGIL] - Nuvigil 250 mg tablet. 0.5 (One half)
tablet by mouth twice each day.
BUDESONIDE-FORMOTEROL [SYMBICORT] - Symbicort 160 mcg-4.5
mcg/actuation HFA aerosol inhaler. 2 puffs inhaled twice daily
CHLORTHALIDONE - chlorthalidone 25 mg tablet. 1 tablet(s) by
mouth once a day - (Dose adjustment - no new Rx)
CLOBETASOL - clobetasol 0.05 % topical ointment. apply at
bedtime
CODEINE-GUAIFENESIN [GUAIFENESIN AC] - Guaifenesin AC 10 mg-100
mg/5 mL oral liquid. ___ ml by mouth every eight (8) hours as
needed for cough Dispense 150cc bottle
FEXOFENADINE - fexofenadine 180 mg tablet. 1 tablet(s) by mouth
once prior to IVIG treatment
FEXOFENADINE - fexofenadine 60 mg tablet. 1 tablet(s) by mouth
twice as needed for allergic rhinitis
IMMUN GLOB G(IGG)-PRO-IGA ___ [___] - Hizentra 4 gram/20
mL
(20 %) subcutaneous solution. 10 grams every 10 days
LAMOTRIGINE - lamotrigine 150 mg tablet. 1 tablet(s) by mouth
once a day
LIDOCAINE-PRILOCAINE - lidocaine-prilocaine 2.5 %-2.5 % topical
cream. apply to area 1 hour before procedure one time as needed
for prn pain - (Not Taking as Prescribed: Discontinued)
LORAZEPAM - Dosage uncertain - (Prescribed by Other Provider:
0.5 mg 1x bedtime )
OSELTAMIVIR - oseltamivir 75 mg capsule. 1 capsule(s) by mouth
daily for ongoing flu prophylaxis.
Medications - OTC
ASPIRIN, BUFFERED - aspirin, buffered 325 mg tablet. one
Tablet(s) by mouth DAILY please take daily for one month to
prevent blood clots - (Not Taking as Prescribed)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
no more than 4G/24H
2. Bisacodyl 10 mg PO/PR DAILY
3. Docusate Sodium 100 mg PO BID
4. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: GI upset with oxycodone
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every
four (4) hours Disp #*40 Tablet Refills:*0
5. Pregabalin 100 mg PO BID
6. Chlorthalidone 25 mg PO DAILY
7. Clobetasol Propionate 0.05% Ointment 1 Appl TP QHS
8. LamoTRIgine 150 mg PO DAILY
9. LORazepam 0.5 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
C5-6, C6-7 disc herniation c/b cord impingement
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:
ACDF:
You have undergone the following operation:Anterior Cervical
Decompression and Fusion.
Immediately after the operation:
Activity:You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit in a car or chair for more than~45 minutes without
getting up and walking around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.
Swallowing:Difficulty swallowing is not
uncommon after this type of surgery.This should resolve over
time.Please take small bites and eat slowly.Removing the collar
while eating can be helpfulhowever,please limit your movement
of your neck if you remove your collar while eating.
Cervical Collar / Neck Brace:If you have been
given a soft collar for comfort, you may remove the collar to
take a shower or eat.Limit your motion of your neck while the
collar is off.You should wear the collar when walking,especially
in public.
Wound Care:Remove the dressing in 2 days.If the
incision is draining cover it with a new sterile dressing.If it
is dry then you can leave the incision open to the air.Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower.Do not soak the incision in a
bath or pool.If the incision starts draining at anytime after
surgery,do not get the incision wet.Call the office at that
time. f you have an incision on your hip please follow the same
instructions in terms of wound care.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions,so plan ahead.You can either have them
mailed to your home or pick them up at the clinic located on
___.We are not allowed to call in narcotic
(oxycontin,oxycodone,percocet) prescriptions to the pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
At the 2-week visit we will check your
incision,take baseline x rays and answer any questions.
We will then see you at 6 weeks from the day of
the operation.At that time we will most likely obtain
Flexion/Extension X-rays and often able to place you in a soft
collar which you will wean out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound,or have any questions.
Physical Therapy:
1)Weight bearing as tolerated.2)Gait,balance training.3)No
lifting >10 lbs.4)No significant bending/twisting.
C-collar at all times X 6 weeks. ___ remove for hygiene
Treatments Frequency:
Remove the dressing in 2 days.If the incision is draining cover
it with a new sterile dressing.If it is dry then you can leave
the incision open to the air.Once the incision is completely dry
(usually ___ days after the operation) you may take a shower.Do
not soak the incision in a bath or pool.If the incision starts
draining at anytime after surgery,do not get the incision
wet.Call the office at that time.
Followup Instructions:
___
|
10436040-DS-3 | 10,436,040 | 29,377,502 | DS | 3 | 2162-04-14 00:00:00 | 2162-04-14 14:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
shortness of Breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ M smoker, no PMH p/w several days of fever, cough, sore
throat, found to have bilateral pneumonia and hypoxia.
.
Patient had > 1 week cough and sore throat. Seen in PCPs office
___ prescribed robitussin. Seen again ___ prescribed
azithromycin, but his symptoms worsened. Presented today to
___ office, O2 sat was 91 on 2L with nebs, referred to ___ at
___. At ___, he was found to be hypoxic to the ___.
WBC 19. CXR showed RML PNA. There he was given solumedrol, nebs,
2l ns and levofloxacin. He was transferred to the ___ ___ due
to lack of bed availability.
On arrival to the ___ ___, VS were T 98, HR 98, BP 136/91, RR
20, SpO2 94% Non-Rebreather. On exam ?scleral icterus,
+pharyngitis
ronchi throughout bilaterally w/apical wheezing R>L. CXR from
___ showed bilateral pneumonia. He was given tamiflu, and
transferred to the ICU for hypoxia/pneumonia. On transfer VS
were 128/87 102 98 97/NRB.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
patient denies
Social History:
___
Family History:
Father Alive ___ - Type II; Glaucoma
Physical Exam:
Discharge:
VS: Afebrile 117/83 P97 R20 94%RA
GEN: well appearing, NAD.
RESP: Mild bibasilar rales. +dry cough. Good AE.
CV: RRR (sl tachy following coughing fit).
Pertinent Results:
IMAGING:
Echocardiogram ___: The left atrium is normal in size. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (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. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. The main pulmonary artery is
dilated. There is no pericardial effusion.
CXR ___: As compared to the previous radiograph, there is no
relevant
change. No evidence of pneumonia. No pulmonary edema. No pleural
effusions. Normal size of the cardiac silhouette.
CXR ___: As compared to the previous radiograph, there is no
relevant
change. A small retrocardiac atelectasis is slightly improved.
The
pre-existing right basal atelectasis is unchanged. Both areas of
atelectasis are documented on the CT examination from ___. In the interval, there is no evidence of newly
occurred parenchymal opacities that could reflect pneumonia. No
pleural effusions. Normal size of the cardiac silhouette. No
pulmonary edema.
Radiology Report
ABDOMEN U.S. (COMPLETE STUDY) Study Date of ___ IMPRESSION:
1. Heterogeneously increased echogenicity of the liver,
consistent with fatty infiltration. However, other forms of
liver disease including advanced liver disease or cirrhosis are
not excluded in this study.
2. No evidence of biliary obstruction. No focal liver lesions.
Microbiology:
___ 10:15 pm SEROLOGY/BLOOD
**FINAL REPORT ___
MONOSPOT (Final ___:
NEGATIVE by Latex Agglutination.
(Reference Range-Negative).
___ 1:13 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 2:42 am URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
___ 3:14 am Influenza A/B by ___
Source: Nasopharyngeal swab.
**FINAL REPORT ___
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Less than 60 columnar epithelial cells;.
Specimen inadequate for detecting respiratory viral
infection by DFA
testing.
Interpret all negative results from this specimen with
caution.
Negative results should not be used to discontinue
precautions.
Refer to respiratory viral culture results.
Recommend new sample be submitted for confirmation.
Reported to and read back by BERNIDETT LABAS ___ 1100.
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
___ 12:11 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
___ 2:16 pm SPUTUM Source: Induced.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii)..
___ 3:00 pm URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
___ 10:04 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
___ HIV-1 Viral Load/Ultrasensitive (Final ___:
HIV-1 RNA is not detected.
MYCOPLASMA PNEUMONIAE ANTIBODY IGM
Test Result Reference
Range/Units
M.PNEUMONIAE AB IGM, EIA 3552 H <770 U/mL
___ 02:42AM BLOOD WBC-13.5* RBC-4.87 Hgb-12.6* Hct-38.1*
MCV-78* MCH-25.9* MCHC-33.1 RDW-14.4 Plt ___
___ 05:05AM BLOOD WBC-20.4*# RBC-4.81 Hgb-12.4* Hct-37.9*
MCV-79* MCH-25.7* MCHC-32.6 RDW-14.6 Plt ___
___ 05:05AM BLOOD ___ PTT-29.1 ___
___ 05:50AM BLOOD ___ PTT-30.4 ___
___ 05:05AM BLOOD ___
___ 10:21AM BLOOD ___ 02:42AM BLOOD Glucose-135* UreaN-15 Creat-0.7 Na-138
K-4.9 Cl-106 HCO3-21* AnGap-16
___ 03:15PM BLOOD Glucose-126* UreaN-21* Creat-1.1 Na-132*
K-5.2* Cl-102 HCO3-17* AnGap-18
___ 06:45AM BLOOD Glucose-118* UreaN-22* Creat-0.8 Na-135
K-5.0 Cl-102 HCO3-23 AnGap-15
___ 10:15PM BLOOD ALT-72* AST-47* AlkPhos-116 TotBili-3.0*
DirBili-1.0* IndBili-2.0
___ 06:45AM BLOOD ALT-63* AST-31 AlkPhos-98 TotBili-1.2
___ 05:05AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.3
___ 06:45AM BLOOD Calcium-9.7 Phos-4.4# Mg-2.4
___ 02:42AM BLOOD Hapto-<5*
___ 05:05AM BLOOD D-Dimer-2860*
___ 05:05AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
___ 02:42AM BLOOD HIV Ab-NEGATIVE
___ 05:05AM BLOOD HCV Ab-NEGATIVE
___ 07:20AM BLOOD WBC-17.4* RBC-4.74 Hgb-12.4* Hct-38.1*
MCV-80* MCH-26.0* MCHC-32.4 RDW-15.8* Plt ___
___ 07:20AM BLOOD Glucose-127* UreaN-19 Creat-0.9 Na-136
K-5.3* Cl-103 HCO3-23 AnGap-15
___ 01:00PM BLOOD Na-137 K-5.0 Cl-103
___ 01:00PM BLOOD LD(LDH)-378*
______________
___ 05:05AM BLOOD calTIBC-259* Ferritn-1098* TRF-199*
Iron-220*
_______________
Pending:
___ 01:00PM BLOOD Hapto-PND
Brief Hospital Course:
___ yo M p/w cough, hypoxia b/l pneumonia
.
# Hypoxia/PNA: Patient had CTA in ___ that ruled
him out for PE, and showed multiple ground glass opacities,
though it had significant motion artifact. Ddx include typical
PNA, atypical PNA (mycoplasma, legionella, viral) vs OI,
especially PCP. Received levofloxacin and tamiflu in ___. Given
LFT abnormalities, concerning for legionella. Also, given
severity of hypoxia and b/l PNA concerned for OI such as PCP in
setting of immunosuppression/HIV, though patient endorses
minimal RF for HIV. Patient was continued on Levofloxacin and
Tamiflu, and was also started on high dose Bactrim for empiric
treatment of PCP. His urine legionella antigen, induced sputum
for PCP DFA and HIV antibody were negative. His Coombs and cold
agglutinins were positive. Patient was slowly weaned off
supplemental O2. Tamiflu was discontinued when respiratory
viral culture came back negative. Bactrim was also discontinued
as suspicion for PCP was lower after negative HIV antibody and
PCP DFA, and patient was having side effects from the
medication. Bactrim and tamiflu were discontinued upon negative
PCP/HIV and influenza test respectively. There was a strong
clinical suspicion for mycoplasma pneumonia, and his mycoplasma
IgM tested positive. He was continued on levofloxacin for
mycoplasma pneumonia for total 10 days.
# Indirect hyperbilirubinemia: Thought due to mild hemolysis
from mycoplasma. LDH was elevated and haptoglobin was low. Cold
agglutinins were positive, supporting this diagnosis.
Hyperbilirubinemia was monitored and improved.
# Transaminitis: Mild, initially thought to be related to
infection and trended without change. Iron studies showed
significantly elevated iron and ferritin, suggestive of iron
overload syndrome and possible transaminitis from it. RUQ
ultrasound was obtained to evaluate for the liver and showed
diffuse fatty changes. His iron studies should be repeated as
an outpatient, and he should be evaluated for possible
hemochromatosis.
# Sinus tachycardia: Patient with tachycardia to 110-120s on
admission, was concerning for PE but ruled out with CTA at
___. Given IVF with improvement in tachycardia,
however, patient still had exertional component to tachycardia.
This continued to improve throughout the hospitalization.
# L anterolateral thigh paresthesia: Likely lateral cutaneous
femoral nerve entrapment given his body habitus. No weakness,
pain or swelling in the area.
# Enlarged pulmonary artery on CT: incidental finding on CTA
done at ___. Echocardiogram was obtained to
evaluate for pulmonary hypertension and showed normal estimated
PA pressure, LV function and no right heart strain.
# Hyperkalemia:
Pt was noted to have periods of hyperkalemia during this
hospitalization. This may have been related to Bactrim vs
hemolysis vs other. His potassium was followed, and was 5 at
the time of discharge.
TRANSITIONS IN CARE:
[ ] Repeat iron study when not acutely ill to better evaluate
his iron load. Will need work up for hemachromatosis if still
elevated.
[ ] Pt on levofloxacin for presumed mycoplasma pneumonia,
treatment course 10 days (first day ___
Medications on Admission:
none
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
# Bilateral mycoplasma pneumonia, (confirmed)
# Hypoxemia
# Hemolytic anemia, cold agglutinin positive (d/t mycoplasma)
# Hyperbilirubinemia (d/t mycoplasma)
# Transaminitis (d/t mycoplasma)
# Possible hemochromatosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with shortness of breath, and were found to
have a severe pneumonia that required treatment in the ICU. You
were treated with antibiotics and steroids, and you improved.
It is important that you complete your course of antibiotics as
prescribed.
Followup Instructions:
___
|
10436108-DS-20 | 10,436,108 | 23,433,094 | DS | 20 | 2163-10-28 00:00:00 | 2163-10-28 13:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
T6 transpedicular decompression, T5-T7 posterior fusion:
1. T5-T6 laminectomy, biopsy intraspinal neoplasm,
extradural.
2. T6-T7 laminectomy, biopsy, intraspinal neoplasm,
extradural.
3. Costovertebral decompression, T6.
4. Posterior arthrodesis T5-T6, T6-T7.
5. Posterior instrumentation T5, T6, T7.
6. Allograft, morselized.
History of Present Illness:
Mr. ___ is a ___ man with lung cancer (mets to bone
and brain s/p whole brain radiation) who presents after a fall.
He was at work when he was walking up a ramp with a crutch under
his right arm. All of a sudden, he fell backwards and hit the
back of his head. No prodrome of lightheadedness, tunnel vision,
odd tastes or smells, de ___. Was conscious the entire time.
Hit the back of his head and was transported for head
laceration. His balance has been "off" the last ___ weeks. He
remembers that it occurred all of a sudden, and his symptoms of
an unsteady gait has not worsened since then. He is unable to
pinpoint the date or time when this happened. Son reports that
over the last 3 days, he has been "more wobbly" that previously.
At baseline, he walks with a crutch because of his left foot
drop ___ nivolumab and herniated disc that started after
___. Able to perform all ADLs independently. With
regard to his oncologic history, he is followed at ___
in ___ by ___. Lung cancer was diagnosed in ___ when he was getting worked up for a lump in his neck. No
surgery was done, but he did receive radiation and multiple
chemotherapies. There were also ?mets to his brain for which he
received whole brain radiation. Mets to bone (left hip) s/p
surgery. He does not remember which chemotherapies were started.
He is currently on nivolumab. This typically makes him feel more
tired and more unsteady. Nivolumab was started ___. He
developed a left foot drop ___ and colitis in ___ all thought to be side effects of nivolumab. This was
stopped by 3.5 months, and he recently restarted nivolumab ___ (monthly infusions).
Past Medical History:
PMH/PSH:
Stage IV Adenocarcinoma, non-small-cell lung cancer with mets to
brain, spine, and nodes. L foot drop, back surgery for disc
fusion, knee operation, colitis.
Social History:
___
Family History:
mother with breast cancer, no history of strokes
Physical Exam:
Admission Physical Exam:
PHYSICAL EXAMINATION
Vitals: T: 98.5F HR: 71 BP: 129/66 RR: 20 SaO2: 94% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR
Pulmonary: breathing comfortably on RA
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to self, ___, thinks
he is at ___. Has some trouble relating
history.
Speech is fluent with full sentences, intact repetition, and
intact verbal comprehension. Naming intact. No paraphasias. No
dysarthria. Normal prosody. No evidence of hemineglect. No
left-right confusion. Able to follow both midline and
appendicular commands.
- Cranial Nerves: ?very mild anisocoria R pupil>L pupil but
brisk
when reacting to light. VF full to number counting. EOMI, no
nystagmus. V1-V3 without deficits to light touch bilaterally. No
facial movement asymmetry. Hearing intact to finger rub
bilaterally. Palate elevation symmetric. SCM/Trapezius strength
___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 5 5 5 5- 3 5
R 5 5 5 5 5 5 5 5- 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 1+ 1+ 1+ 2+ 1
R 1+ 1+ 1+ 2+ 1
Plantar response flexor bilaterally
- Sensory: Decreased sensation to light touch in the left foot
(dorsally). Decreased sensation to pin in bilateral feet to
level
of ankle. Patchy decreased sensation to pin in bilateral arms,
seemed more in a radial distribution in the right arm than the
left, no spinal level. Decreased proprioception in L toe.
- Coordination: No dysmetria with finger to nose testing
bilaterally. No cerebellar rebound. No overshoot on mirror
testing. No axial ataxia.
- Gait: Needs help getting out of wide. Wide based, very
unsteady
even with crutch, which he holds under his right arm. Needs to
pick up left foot very high, no AFO. Positive Romberg.
Physical Exam on ___-
Vitals: T 97.4F BP 103/59 HR 116 RR 16 O2 sat 92% RA
Physical Exam:
Gen: lying with HOB flat, uncomfortable
HEENT: atraumatic
CV: tachycardic
Resp: breathing comfortably on RA
Ab: NTND
Neuro:
- Gen: awake, alert, follows simple commands, oriented to BI and
___
- Cranial Nerves - PERRL 3->2 brisk. EOMI, no nystagmus. V1-V3
without deficits to light touch bilaterally. No facial movement
asymmetry. No dysarthria. Palate elevation symmetric. Trapezius
strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ 5 4+ ___ 5- 3 5
R 5 ___ 5 4+ 5 4+ ___ 5
- Sensory - Deficits to pinprick in distal left foot, just below
joint of great toe unable to feel sharp. Temperature sensation
intact throughout. Proprioception impaired in left great toe,
intact in right great toe.
-DTRs: biceps/brachioradialis 2 bilaterally, patellae 1
bilaterally, no ankle jerks, toes downgoing
- Coordination - Dysmetria on left compared to right with FNF
testing
- Gait - deferred
Motor Exam ___ throughout, LLE TA ___ ___ throughout
SILT all distributions
Pertinent Results:
___ 02:15AM BLOOD WBC-12.2* RBC-3.01* Hgb-8.4* Hct-25.9*
MCV-86 MCH-27.9 MCHC-32.4 RDW-16.0* RDWSD-50.1* Plt ___
___ 01:27AM BLOOD WBC-12.2* RBC-3.10* Hgb-8.7* Hct-26.6*
MCV-86 MCH-28.1 MCHC-32.7 RDW-15.8* RDWSD-49.5* Plt ___
___ 05:30PM BLOOD WBC-15.0* RBC-3.25* Hgb-8.9* Hct-28.3*
MCV-87 MCH-27.4 MCHC-31.4* RDW-15.9* RDWSD-50.4* Plt ___
___ 01:08AM BLOOD Neuts-80* Bands-2 Lymphs-9* Monos-9 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-12.05* AbsLymp-1.32
AbsMono-1.32* AbsEos-0.00* AbsBaso-0.00*
___ 01:33PM BLOOD Neuts-81.0* Lymphs-9.7* Monos-7.2
Eos-0.6* Baso-0.3 Im ___ AbsNeut-11.70* AbsLymp-1.40
AbsMono-1.04* AbsEos-0.08 AbsBaso-0.04
___ 01:08AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 02:15AM BLOOD Plt ___
___ 01:27AM BLOOD Plt ___
___ 05:30PM BLOOD Plt ___
___ 02:15AM BLOOD Glucose-112* UreaN-8 Creat-0.6 Na-130*
K-3.3 Cl-98 HCO3-24 AnGap-11
___ 01:27AM BLOOD Glucose-96 UreaN-7 Creat-0.6 Na-135 K-3.6
Cl-102 HCO3-25 AnGap-12
___ 05:30PM BLOOD Glucose-94 UreaN-8 Creat-0.5 Na-131*
K-3.9 Cl-98 HCO3-23 AnGap-14
___ 05:30PM BLOOD ALT-10 AST-23 AlkPhos-43
___ 06:05AM BLOOD CK(CPK)-29*
___ 02:15AM BLOOD Calcium-7.5* Phos-3.8 Mg-1.6
___ 01:27AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.1
___ 05:30PM BLOOD Calcium-6.9* Phos-3.6 Mg-2.6
___ 05:30PM BLOOD TSH-2.2
___ 10:30AM BLOOD HIV Ab-Negative
___ 01:15AM BLOOD Lactate-1.3
___ 02:55AM BLOOD freeCa-1.07*
___ 06:05AM BLOOD PARANEOPLASTIC AUTOANTIBODY
EVALUATION-PND
___ 02:50PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 02:40PM CEREBROSPINAL FLUID (CSF) TNC-7* RBC-8*
Polys-24 ___ ___ 02:40PM CEREBROSPINAL FLUID (CSF) TNC-6* RBC-19*
Polys-37 ___ ___ 02:40PM CEREBROSPINAL FLUID (CSF) TotProt-86*
Glucose-55
___ 02:40PM CEREBROSPINAL FLUID (CSF) PARANEOPLASTIC
AUTOANTIBODY EVALUATION, CSF-PND
___ 07:03PM OTHER BODY FLUID IPT-DONE
___ 2:40 pm CSF;SPINAL FLUID Source: LP TUBE 3.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative ___ blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Test performed by Lateral Flow Assay.
Results should be evaluated in light of culture results
and clinical
presentation.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 05:15AM BLOOD WBC-4.1 RBC-2.83* Hgb-7.8* Hct-24.4*
MCV-86 MCH-27.6 MCHC-32.0 RDW-15.9* RDWSD-50.3* Plt ___
___ 07:30AM BLOOD WBC-6.8 RBC-3.13*# Hgb-8.7*# Hct-27.1*
MCV-87 MCH-27.8 MCHC-32.1 RDW-16.0* RDWSD-50.4* Plt ___
___ 11:30AM BLOOD Hct-25.1*#
___ 07:00AM BLOOD WBC-5.1 RBC-2.05*# Hgb-5.7*# Hct-18.0*#
MCV-88 MCH-27.8 MCHC-31.7* RDW-16.1* RDWSD-52.2* Plt ___
___ 02:49PM BLOOD WBC-8.6 RBC-3.12* Hgb-8.8* Hct-26.9*
MCV-86 MCH-28.2 MCHC-32.7 RDW-16.0* RDWSD-50.3* Plt ___
___ 02:15AM BLOOD WBC-12.2* RBC-3.01* Hgb-8.4* Hct-25.9*
MCV-86 MCH-27.9 MCHC-32.4 RDW-16.0* RDWSD-50.1* Plt ___
___ 02:40PM CEREBROSPINAL FLUID (CSF) TNC-7* RBC-8*
Polys-24 ___ ___ 02:40PM CEREBROSPINAL FLUID (CSF) TNC-6* RBC-19*
Polys-37 ___ ___ 02:40PM CEREBROSPINAL FLUID (CSF) TotProt-86*
Glucose-55
CXR ___:
IMPRESSION:
Compared to chest radiographs ___ through ___. Severe
atelectasis persists in the right lower lobe. Severe
atelectasis in the left lower lobe is new. Pleural effusions
are likely but not large. Heart size normal. No pneumothorax.
Right jugular central venous infusion catheter ends in the low
SVC.Thoracic spinal stabilization device noted, not evaluated
for position by this examination.
CTA Chest ___. No evidence of pulmonary embolism or aortic abnormality.
2. Findings compatible with marked aspiration on the right with
the right lower lobe bronchial tree nearly entirely opacified by
aerated debris. Diffuse bilateral bronchial wall thickening,
worse on the right.
Additional hypoenhancing pulmonary parenchyma is concerning for
pneumonia.
3. Moderate bilateral pleural effusions.
4. Mild pulmonary edema.
5. Postsurgical changes from recent laminectomy from T5-T7 with
bilateral
metallic screws at T5 and T7. The left T5 screw tip is outside
of the
vertebral body and runs along the lateral aspect of the bone
with its tip
terminating in the posterior mediastinum within 3 mm of the
aorta.
6. Diffuse sclerotic metastatic disease.
Echo ___-
The left atrium is normal in size. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). There is considerable beat-to-beat variability of
the left ventricular ejection fraction due to an irregular
rhythm/premature beats. Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. There is no aortic valve stenosis. No
aortic regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality.Preserved biventricular
systolic function with variability in ejection fraction related
to atrial fibrillation. Limited evaluation of valvular
structure/function related to poor acoustic windows.
___ 2:40 pm CSF;SPINAL FLUID Source: LP TUBE 3.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative ___ blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Test performed by Lateral Flow Assay.
Results should be evaluated in light of culture results
and clinical
presentation.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Brief Hospital Course:
Mr. ___ was initially admitted to the ___ neurology
floor after you fell at work. An MRI of his brain that showed
significant changes to the ___ matter in the brain. Neurology
team thinks these changes are likely caused by your whole-brain
radiation. He had lumbar puncture, and the spinal fluid had
___ blood cells and high protein, which are abnormal findings.
The medical team was concerned for meningitis, though nothing
grew. Cancer cells can cause a carcinomatous meningitis, but the
cytology results on the spinal fluid were also negative. He also
had some green sputum from his cough, and treated with a course
of azithromycin for a presumed bronchitis. A spinal MRI that
showed multiple spinal metastatic lesions: T6 and T12 metastatic
lesions and myelopathic symptoms. He was admitted to the
orthopedic spine team and taken to the operating room on ___
for T6 transpedicular decompression and T5-T7 posterior fusion.
In summary, ___ man with metastatic NSCLC with mets to the bone
s/p chemo (on nivolumab) and radiation (including WBRT) admitted
___ for fall in setting of subacute on chronic worsening of
gait. LP which was negative. MRI brain with diffuse subcortical
___ matter changes, likely consequent to prior whole brain
radiation. MRI spine with metastatic lesions compressing spinal
cord. Went to OR with spine after extensive convo with rad-onc,
med-onc, neuro-onc and patient.He is now s/p T6 transpedicular
decompression, T5-T7 posterior fusion.
Post op course was complicated by pain, acute blood loss anemia,
ileus followed by IBS symptoms of frequent stools and new onset
afib post op. Afib was managed with a low dose metoprolol for
rate control. He is currently in SR with HR in the ___ and a
stable blood pressure. Given his recent spinal surgery and
contraindication to systemic anticoagulation, Cardiology
recommended rate control. This was likely a catecholamine
response in the post-operative state. Pain was controlled with
oral and iv pain medications. labs were monitored closely for
electrolyte imbalances and post op anemia. He is currently
stable. Ileus has improved. Hosptial Course was otherwise
unremarkable. He is cleared for REHAB and should follow up with
his oncologist as an outpatient within 1 week for further care
and planning.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
2. Mirtazapine 15 mg PO QHS
3. difenoxin-atropine ___ mg oral QAM
4. Omeprazole 40 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Diazepam 5 mg PO BID:PRN pain
3. Heparin 5000 UNIT SC TID
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
5. Metoprolol Tartrate 12.5 mg PO Q6H
6. Diphenoxylate-Atropine 2 TAB PO Q8H:PRN loose stools
7. LORazepam 0.5 mg PO QHS:PRN insomnia
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*85 Tablet Refills:*0
9. difenoxin-atropine ___ mg oral QAM
10. Mirtazapine 15 mg PO QHS
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Aseptic meningitis. Ataxia of unknown origin.
1. Metastatic carcinoma, non-small cell lung cancer.
2. Metastatic spine disease.
3. T6 epidural lesion.
4. Thoracic myelopathy with lower extremity weakness.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You have undergone the following operation: Thoracic
Decompression With Fusion
Immediately after the operation:
Activity:You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit or stand more than~45 minutes without getting up and
walking around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
Diet: Eat a normal healthy diet.You may have
some constipation after surgery.You have been given medication
to help with this issue.
Brace:You have been given a brace. This brace
is to be worn when you are walking.You may take it off when
sitting in a chair or while lying in bed.
Wound Care:Remove the dressing in 2 days.If the
incision is draining cover it with a new sterile dressing.If it
is dry then you can leave the incision open to the air.Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower.Do not soak the incision in a
bath or pool.If the incision starts draining at anytime after
surgery, do not get the incision wet.Cover it with a sterile
dressing.Call the office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions,so please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on ___.We are not allowed to call in or fax narcotic
prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
At the 2-week visit we will check your
incision,take baseline X-rays and answer any questions.We may at
that time start physical therapy
We will then see you at 6 weeks from the day of
the operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
1)Weight bearing as tolerated.2)Gait,balance training.3)No
lifting >10 lbs.4)No significant bending/twisting. 5)TLSO when
OOB
Treatments Frequency:
Remove the dressing in 2 days.If the incision is draining cover
it with a new sterile dressing.If it is dry then you can leave
the incision open to the air.Once the incision is completely dry
(usually ___ days after the operation) you may take a shower.Do
not soak the incision in a bath or pool.If the incision starts
draining at anytime after surgery,do not get the incision
wet.Cover it with a sterile dressing and call the office.
Followup Instructions:
___
|
10436670-DS-14 | 10,436,670 | 24,346,987 | DS | 14 | 2148-11-18 00:00:00 | 2148-11-18 15:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Keflex / propranolol / sulfur dioxide
Attending: ___.
Chief Complaint:
LLE pain
Major Surgical or Invasive Procedure:
Left tibia intramedullary nail
History of Present Illness:
___ female with a h/o brain aneurysms, depression, anxiety who
presents after a slip and fall down stairs with a left tib/fib
fracture. Patient is not sure how she fell but thinks her left
foot was caught behind her body and twisted. She immediately
noted deformity. She did not hit her head or lose consciousness.
She was able to get herself up the stairs but was unable to bear
any weight on the left lower extremity. She went to ___
and was found to have a left tib/fib fracture. She was
transferred to ___ for further care.
Past Medical History:
Brain aneurysms s/p clipping
Depression
Anxiety
Social History:
Tobacco: 0.5ppd x ___ years- in process of quitting
Alcohol: 2 drinks per week
Illicit Drugs: Marijuana weekly
Occupation: ___
Physical Exam:
LLE:
dressing c/d/I
SILT S/S?SP/DP/T
Firing ___
+2 pulses distally
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left tibia and fibula fracture and was admitted to the
orthopedic surgery service. Upon being transferred from the ED
to the floor, the patient was noted to have an aphasia and was
urgently rushed to CT scan to rule out intracerebral hemorrhage
and dissection--results of which were negative. Neurology
recommended EEG monitoring due to her history of bleeding
cerebral aneurysms and she was noted to have abnormal activity
coming from the area of her previous bleed which correlated to
seizure-like activity for which she was subsequently started on
Keppra. The patient was taken to the operating room on ___
for left tibia intramedullary 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 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
touchdown weight bearing in the left lower extremity, and will
be discharged on Aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ (___) per 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 may be inaccurate and requires
futher investigation.
1. Mirtazapine 15 mg PO QHS
2. ALPRAZolam 0.5 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Calcium Carbonate 500 mg PO QID:PRN heart burn
3. Docusate Sodium 100 mg PO BID
4. LevETIRAcetam 1000 mg PO BID
5. Milk of Magnesia 30 ml PO BID:PRN Constipation
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
7. ALPRAZolam 0.5 mg PO BID
8. Mirtazapine 15 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left tibia and fibula fracture
Discharge Condition:
NVI, AAOx3, mentating appropriately
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- touch down weight bearing LLE
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Aspirin daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Physical Therapy:
touch down weight bearing LLE
Followup Instructions:
___
|
10436697-DS-18 | 10,436,697 | 26,196,627 | DS | 18 | 2123-11-22 00:00:00 | 2123-11-22 17:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old ___ speaking
woman with a history of HTN, DM, HLD, acinar cancer s/p
resection
and radiation, L Bell's palsy 8 months ago presenting with 1
week
of dizziness.
Pt reports that 1 week ago, she was standing and suddenly felt a
spinning sensation in her head lasting approximately 1 minute.
Since then, she has felt the same spinning sensation every time
she is standing or walking. These episodes last approximately
30
seconds to 1 minute. They resolve when she closes her eyes,
holds on to something and then sits down or lays down. She does
report possibly hearing a pulsating noise in both ears. She
also
reports fingertip tingling on her left hand. She does not have
any epsiodes while not standing. She denies feeling presyncopal
or the world spinning around her. She denies any hearing
change.
She denies headache, diplopia, dysphagia, dysarthria, numbness
or
weakness, or recent illness. She denies any nausea or vomiting.
Of note, in ___, the pt was evaluated and admitted to
the Stroke Service due to new onset left facial droop. Her CT,
MRI and Echo were normal. She was discharged with the diagnosis
of Bell's palsy due to postinfection, diabetic cranioneuropathy
or idiopathic. At that time, she had also reported some
dizziness
which was a sensation of lightheadedness precipitated by
walking.
She states this is a different dizziness than she feels now.
On neurologic review of systems, the patient denies headache, or
confusion. Denies difficulty with producing or comprehending
speech.
Denies loss of vision, diplopia, hearing difficulty, dysarthria,
or dysphagia. Denies muscle weakness. Denies loss of
sensation.
Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough. Denies nausea, vomiting,
diarrhea, constipation, or abdominal pain. Denies dysuria or
hematuria. Denies myalgias, arthralgias, or rash.
Past Medical History:
- DM
- HTN
- HLD
- acinar cell cancer s/p excision of the L submandibular gland
and XRT
- s/p hysterectomy
- anemia
- B12 deficiency
- subjective palpitations but event monitor did not record afib
Social History:
___
Family History:
no strokes or seizures
Physical Exam:
Admission Exam
Physical Examination:
VS T97.9, HR 87, BO 116/74, RR 19 and 99% on RA
General: NAD, sitting in bed comfortably eating dinner
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions,
nevus on right eye brow
Neck: Supple, no nuchal rigidity, no meningismus
Ears: ___ clear with no vesicles
Neurologic Examination:
- Mental Status -
Awake, alert, able to state her name and the month in ___. Repetition intact. Speech is fluent without dysarthria
per family. Follows complex commands.
- Cranial Nerves -
Equal and reactive pupils (4mm to 3mm). Visual fields were full
to finger counting. Smooth and full extraocular movements
without
diplopia. Nystagmus with both horizontal and rotatory components
on the left gaze. Left peripheral CN 7 palsy. Negative
___. No skew. Negative head impulse test. Symmetric
palate elevation. Tongue appears to deviate to the right. Left
tongue atrophy. Tongue with full movement.
- Motor -
Muscle bulk and tone were normal. No pronation, no drift. No
tremor or asterixis.
Delt Bic Tri ECR Fext Fflx IP Quad Ham TA Gas
L 5 5 ___ 5 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5
- Sensation -
Intact to light touch throughout, no extinction to DSS.
- DTRs -
Bic Tri ___ Quad Gastroc
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response flexor bilaterally.
- Cerebellar -
No dysmetria with finger to nose testing bilaterally. Good speed
and intact cadence with rapid alternating movements.
- Gait -
No ataxia. Negative Romberg. Able to tandem walk. Does report
some dizziness with standing and walking, but reports that
dizziness is not as bad as prior due to recently taking
Meclizine.
Pertinent Results:
___ 04:59PM BLOOD WBC-5.4 RBC-4.48 Hgb-13.3 Hct-38.0 MCV-85
MCH-29.7 MCHC-35.0 RDW-12.8 RDWSD-38.8 Plt ___
___ 04:59PM BLOOD Glucose-139* UreaN-16 Creat-0.7 Na-140
K-4.8 Cl-104 HCO3-23 AnGap-18
___ 07:30PM BLOOD Calcium-9.5 Phos-4.6* Mg-2.1
___ 06:20AM BLOOD %HbA1c-7.2* eAG-160*
___ 06:20AM BLOOD Triglyc-182* HDL-38 CHOL/HD-3.0
LDLcalc-39
CXR (PA & lateral) ___:
IMPRESSION:
Densities projecting over the bilateral upper lungs could relate
to the
bilateral anterior first ribs, new since the prior study from ___. Recommend shallow oblique radiographs or chest CT to
exclude pulmonary lesions.
Patchy left base retrocardiac opacity most likely relate to
atelectasis
although consolidation is not excluded in the appropriate
clinical setting.
RECOMMENDATION(S): Recommend shallow oblique radiographs or
chest CT to
exclude pulmonary lesions.
CT HEAD NONCONTRAST ___:
IMPRESSION:
No acute intracranial process.
CXR (obliques) ___:
IMPRESSION:
1. Atelectasis at the lung bases.
2. Equivocal parenchymal nodules within the upper lobes. These
likely
represents calcifications of the costochondral cartilage ;
however, CT scan is recommended for further evaluation.
MR ___ &W/O CONTRAST ___:
IMPRESSION:
1. Interval decreased contrast enhancement along the intra
canalicular portion of the left facial nerve with residual
asymmetric contrast enhancement along the labyrinthine portion
and geniculate ganglion of the left facial nerve.
2. Few nonspecific white matter signal abnormalities, likely
secondary to
chronic microvascular ischemic changes.
3. A 1 cm right scalp skin lesion. Correlate with physical
exam.
CT CHEST W/O CONTRAST ___:
IMPRESSION:
1. 1.7 cm right upper lobe and 1.4 cm left upper lobe lobulated
solid nodules correspond to the observed radiographic findings.
Based on their morphology and development compared to ___ CT neck study, they are concerning for the possibility of
synchronous primary lung cancers.
2. Right adrenal lesion, previously characterized as an adenoma
at MRI of the abdomen of ___.
RECOMMENDATION:
PET-CT for further evaluation of lung nodules.
Brief Hospital Course:
# Neurology:
Patient admitted for 1 week symptoms of dizziness/vertigo. On
initial examination she had end gaze nystagmus on left with
negative peripheral vertigo maneuvers. By day 2 her exam
normalized completely and she no more symptoms. Because of her
risk factors, MRI internal auditory canal was ordered and was
negative for acute infarct or mass. Etiology of her symptoms was
thought to be more likely peripheral vestibulopathy or less
likely orthostatic dizziness as her BPs were low this admission
even off her medications. Studies were sent to evaluate for
possible multicranial neuropathy ___ infiltrative/infectious
disease given her prior Bell's palsy, including ACE, RPR, ___,
___, which are pending.
# Pulmonary:
Patient had CXR which showed bilateral incidental pulmonary
nodules. She underwent CT chest for further evaluation which
showed lobulated nodules in the RUL (1.7cm) and LUL (1.4cm),
which were concerning for potential primary malignancy and
Radiology recommended PET-CT. Pulmonology was contacted and
recommended expedited workup. His PCP was contacted who will
order and follow up on PET-CT.
# Cardiology:
Patient's verapamil and lisinopril were held on admission due to
concern for ischemic infarct and possible need of permissive
hypertension. Her blood pressures remained low with SBP in
100-110s off her meds, so they were continued to be held
throughout admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. canagliflozin 300 mg oral DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. GlipiZIDE XL 20 mg PO DAILY
5. Lisinopril 30 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Omeprazole 20 mg PO BID
8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
9. Verapamil SR 120 mg PO Q24H
10. Zolpidem Tartrate 5 mg PO QHS
11. Atorvastatin 80 mg PO QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Zolpidem Tartrate 5 mg PO QHS
RX *zolpidem 5 mg 1 tablet(s) by mouth HS Disp #*30 Tablet
Refills:*0
4. Atorvastatin 80 mg PO QPM
5. canagliflozin 300 mg oral DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. GlipiZIDE XL 20 mg PO DAILY
8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
9. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Dizziness
Hypertension
Diabetes mellitus
Hyperlipidemia
Acinar cancer
Bell's balsy
Incidental bilateral pulmonary nodules
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for symptoms of vertigo and dizziness for
which we evaluated whether this could be from a stroke. We
performed an MRI which did not show any new stroke. We also sent
other lab tests to evaluate for the etiology of your symptoms,
which are still being processed and which your PCP can follow up
on. We think your symptoms may be due to a problem in your ear
canal, however you may also be having low blood pressure
contributing to your dizziness, so we stopped your blood
pressure medications temporarily.
We also incidental found 2 nodules in your lungs. We performed a
CT of your lung which showed that the nodules may be concerning
for a malignant process. You should see your PCP who will order
a PET-CT scan to determine whether the nodules could represent
cancer.
Please follow up with your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10436765-DS-13 | 10,436,765 | 26,424,995 | DS | 13 | 2136-12-13 00:00:00 | 2136-12-13 22:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ female with a past medical
history of malaria ___, otherwise healthy, who presents from
___ with cyclic high fevers, diarrhea, and
diffuse body aches after recently returning from ___.
Patient reports that she was in ___ for 3 weeks, working in
the
facility with children. While she was there she took malarial
prophylaxis with malarone. She returned on ___. The morning
of
___, she began to have some stomach discomfort. This was
quickly followed by chills during the afternoon, associated with
headache. She also had one episode of diarrhea. On ___, she
felt feverish, with worsening headache. Started to have several
bouts of liquidy diarrhea, nonbloody. She notes that this was
also associated with body aches. She does report a headache
that
started soon after her initial stomach upset. His headache is
severe, at times causing her to almost crying pain. She does
state that her neck is stiff when the headache is at its worse
as
well. She reports photophobia, no phonophobia. She reports the
headache has generally been much better today.
She does not know any sick contacts. She does note that 2 of
the
people that she stayed with in ___ needed to take
ciprofloxacin
for traveler's diarrhea, which she did not experience. She
drank
bottled water in a prepared food. Was in ___, which
she states was not very rural. Denies any potential sexual
exposures, or HIV exposure.
She initially presented to ___. She had a
fever to 103. Labs there were significant for a white count of
35. Parasite smear for malaria was sent, reportedly negative.
She received Vanco and Zosyn, and was transferred to ___
in order to be seen by an infectious disease specialist.
Of note, she is up-to-date on vaccines, including yellow fever.
She was taking prophylaxis for malaria and typhoid. She has had
malaria in the past ___ years ago) and says that she is
experiencing the same symptoms.
In the ED, initial vitals: T 98.6, HR 84, BP 90/60, RR 16, 98%
RA
Labs were significant for
- CBC: WBC 25.1 (92%n), Hgb 12.0, Plt 197
- Lytes:
141 / 106 / 7
------------- 116
5.3 \ 19 \ 0.9
- AST: 34 ALT: 12 AP: 57 Tbili: 0.9 Alb: 3.4 Lipase: 38
- Lactate 2.1
- Parst-S: NEGATIVE
- Urine UCG: Negative
- u/a negative
Imaging was significant for: no imaging
In the ED, pt received
___ 14:04 IVF LR 1000 mL
___ 14:54 PO Acetaminophen 650 mg
___ 17:08 IV Ketorolac 15 mg
___ 17:46 PO/NG LOPERamide 2 mg
___ 19:03 IVF LR Started 250 mL/hr
___ 20:23 PO Acetaminophen 650 mg
___ 20:23 IVF NS 1000 mL ordered
___ 20:59 IV Piperacillin-Tazobactam 4.5 g
Vitals prior to transfer: T 98.8, HR 54, BP 90/52, RR 19, 98% RA
Currently, patient states that generally she is feeling a little
bit better, with fever chills. She thinks that this may just be
from the cyclical nature of the fevers, but is not sure. Her
headache right now is fairly mild. She does note some neck
stiffness when she moves her chin to her chest.
ROS: Positive as noted above. Negative for: No changes in
vision
or hearing, no changes in balance. No cough, no shortness of
breath, no dyspnea on exertion. No chest pain or palpitations.
No
nausea or vomiting. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits.
Past Medical History:
- Malaria (___)
- labrum repair and hip flexor tendon lengthening ~ ___
Social History:
___
Family History:
Reports no significant family history.
Physical Exam:
ADMISSION EXAM
VITALS: T 98.3, HR 63, BP 103/66, RR 18, 98% RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. Neck
supple. Negative Brudzinski and Kernig signs
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, mildly tender to palpation
diffusely. Bowel sounds present. No HSM appreciated
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM
AVSS
pleasant, NAD, looks well
MMM
RRR no mrg, JVP 8cm
CTAB
s, mildly ttp diffusely, negative HSM, NABS
neg CVAT
wwp, neg edema
A&O grossly, MAEE, DOWB intact
no rashes
no joint swelling
Pertinent Results:
ADMISSION RESULTS
___ 01:23PM BLOOD WBC-25.1* RBC-3.91 Hgb-12.0 Hct-35.1
MCV-90 MCH-30.7 MCHC-34.2 RDW-13.4 RDWSD-43.8 Plt ___
___ 01:23PM BLOOD Neuts-91.7* Lymphs-3.2* Monos-3.7*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-23.01* AbsLymp-0.79*
AbsMono-0.92* AbsEos-0.00* AbsBaso-0.05
___ 07:30AM BLOOD ___ PTT-26.6 ___
___ 01:23PM BLOOD Glucose-116* UreaN-7 Creat-0.9 Na-141
K-5.3 Cl-106 HCO3-19* AnGap-16
___ 01:23PM BLOOD ALT-12 AST-34 AlkPhos-57 TotBili-0.9
___ 07:30AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.6
___ 01:23PM BLOOD Albumin-3.4*
___ 01:28PM BLOOD Lactate-2.1*
___ 01:23PM BLOOD Lipase-38
___ 03:31PM URINE Color-Straw Appear-Clear Sp ___
___ 03:31PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 03:31PM URINE UCG-NEGATIVE
CXR: nil acute
=========
PERTINENT INTERVAL RESULTS
___ parasite smear neg
___ parasite smear neg
___ pending x2
___ cx pending, giardia/cryptosporidium pending, no
vibrio, no yersinia, no E Coli 0157:H7
___ diff neg
___ ag neg
___ neg final
___ NGTD x2
=========
DISCHARGE RESULTS
___ 08:03AM BLOOD WBC-9.8 RBC-3.96 Hgb-11.6 Hct-35.2 MCV-89
MCH-29.3 MCHC-33.0 RDW-13.4 RDWSD-43.8 Plt ___
___ 08:03AM BLOOD Neuts-73.7* Lymphs-16.0* Monos-8.7
Eos-0.7* Baso-0.4 Im ___ AbsNeut-7.18* AbsLymp-1.56
AbsMono-0.85* AbsEos-0.07 AbsBaso-0.04
___ 08:03AM BLOOD Glucose-105* UreaN-6 Creat-0.8 Na-143
K-3.7 Cl-104 HCO3-24 AnGap-15
___ 08:03AM BLOOD Calcium-8.7 Mg-1.5*
Brief Hospital Course:
___ w previous episode of malaria (unknown type but presumably
falciparum) p/w fever, HA, diarrhea and malaise I/s/o returning
from ___. Initially treated broadly with vancomycin/zosyn but
discharged on azithro treatment for presumed typhoid versus
other traveler's diarrhea.
ACUTE/ACTIVE PROBLEMS:
# sepsis
# leukocytosis
# bandemia
# hypovolemia
# diarrhea
# headache
# photophobia
Ddx is broad, but given her return from ___ must consider
infection acquired abroad. Malaria ruled out with 3 smears (1 at
___, one at ___ and negative falciparum ag (also adequate
ppx/netting). ___ and OSH BCx NGTD. While had HA/mild neck
stiffness on initial symptoms, symptoms became overwhelmingly GI
with diarrhea and mild abdominal pain and nausea. Was treated
initially with vancomcyin/zosyn at OSH and then after seen by
ID, narrowed to azithro (1g on ___ and 500mg qd from ___
onwards for a 7d course). ID agreed that patient most likely had
traveler's diarrhea and agreed that LP was unnecessary, thinking
patient most likely had typhoid or paratyphoid. Azithro chosen
over fluoroquinolone given high level of typhoid FQ resistance
in ___. Received aggressive IVF, WBC and symptoms improved
with minimal to no diarrhea on day of discharge. Patient was
able to tolerate PO. Her hypomagnesemia was repleted prior to
discharge. Patient was advised to avoid large groups (such as
college) and immunocompromised until diarrhea fully resolved and
to wash hands carefully.
# OCP: continued home OCPs.
# depression/anxiety: cont home sertraline
# malaria ppx: was continued on home malaria ppx to complete 7d
after return home
>30 minutes spent on patient care and coordination on day of
discharge.
TRANSITIONAL ISSUES
- please recheck BMP, Mg, INR to ensure resolution of discharge
abnormalities which are suspected to resolve with resolution of
acute illness
- continue to monitor PO intake and diarrhea
- ensure patient completes abx course and malaria ppx regimen
- please follow up final microbiology at ___ and ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 100 mg PO DAILY
2. norgestimate-ethinyl estradiol 0.18/0.215/0.25 mg-35 mcg (28)
oral DAILY
3. Atovaquone-Proguanil (250mg-100mg) 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Azithromycin 500 mg PO/NG Q24H Duration: 7 Days
RX *azithromycin 500 mg 1 tablet(s) by mouth daily Disp #*6
Tablet Refills:*0
3. Atovaquone-Proguanil (250mg-100mg) 1 TAB PO DAILY
4. norgestimate-ethinyl estradiol 0.18/0.215/0.25 mg-35 mcg
(28) oral DAILY
5. Sertraline 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
fever
severe sepsis
lactic acidosis
diarrhea
presumed enteric fever
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.
You were admitted for fever and diarrhea with headache.
We are not completely sure what the cause of this is yet but we
think this is due to some sort of gastrointestinal infection,
possibly typhoid or paratyphoid, which you probably caught while
abroad.
This is being treated with antibiotics and should continue to
get better.
When you go home, please complete the antibiotic course and keep
up with fluid intake and advance your diet as tolerated. You can
take over the counter probiotics while on the antibiotics to
prevent adverse effects.
Fluids are most important, and don't push yourself too hard on
the food as it may take time for your stomach to get back to
normal, and be especially careful not to drink too much milk as
short term lactose intolerance can happen after an infection
like this.
Please wash your hands regularly and avoid large crowds
(including college) and anyone with an ___ medical
condition until your antibiotics are done and your diarrhea is
resolved.
Thank you for your service in global health, and good luck with
the course towards medical school!
Feel better soon.
Followup Instructions:
___
|
10437015-DS-16 | 10,437,015 | 27,185,402 | DS | 16 | 2168-05-17 00:00:00 | 2168-05-17 15:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
vaginal bleeding, pain
Major Surgical or Invasive Procedure:
s/p dilation and curettage
History of Present Illness:
___ year old G1P0 presents as a transfer from ___, where
she initially presented today with lower abdominal pain. Of
note, she had a termination of pregnancy at ___
___ 8 days ago, and had been doing well until about 1 day
prior to presentation. The night prior to presentation, she
started having a constant annoying pain. She was able to sleep
through this using motrin and a heating pad. This afternoon,
after her lunch break, she started having more constant pain
that was so severe she could no longer work. Nothing really
makes it better. She has also been feeling very lightheaded and
dizzy in the setting of the pain.
In addition, while she had virtually no bleeding following the
procedure, she started having spotting on ___, following
by passage of clots on ___ and day of presentation, going
through a pad an hour.
No nausea, vomiting, diarrhea, dysuria, fever or chills,
although she does not a low grade fever of 100.1 at home.
At the ___, she was started on IV clindamycin and given
IM ceftriaxone. An exam was notable for +CMT and uterine
tenderness, as well as heterogeneous material within the uterus
on ultrasound concerning for possible retained products,
although nothing was vascularized.
Past Medical History:
GYNHx:
- normal menses, not that crampy. every month
- denies STDs
- not currently sexually active
- No GYN concerns or prior procedures
- No history of pelvic pain
PMH: denies
PSH: denies
Social History:
___
Family History:
Non contributory
Physical Exam:
Exam on day of discharge:
Gen: NAD
CV: RRR
P: CTAB
Abd: soft, nontender, nondistended, no rebound or guarding
GU: pad with minimal spotting
Ext: WWP
Pertinent Results:
___ 02:53PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:53PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 02:53PM URINE RBC-66* WBC-4 BACTERIA-NONE YEAST-NONE
EPI-1
___ 02:53PM URINE RBC-66* WBC-4 BACTERIA-NONE YEAST-NONE
EPI-1
___ 10:35PM WBC-9.6 RBC-3.66* HGB-11.2 HCT-33.1* MCV-90
MCH-30.6 MCHC-33.8 RDW-12.4 RDWSD-41.0
___ 10:35PM WBC-9.6 RBC-3.66* HGB-11.2 HCT-33.1* MCV-90
MCH-30.6 MCHC-33.8 RDW-12.4 RDWSD-41.0
___ 10:35PM PLT COUNT-227
Brief Hospital Course:
Ms. ___ was admitted to the Gynecology service in the
setting of vaginal bleeding and pelvic pain, concerning for
endometritis and retained products of conception following a D&C
at ___ on ___.
She was admitted to the hospital and started on IV gentamicin
and clindamycin for presumed endometritis. A pelvic US
demonstrated findings concerning for retained products of
conception. The patient was counseled extensively regarding
management options and elected to proceed with a repeat dilation
and curettage to remove the retained products of conception.
She was taken to the OR on ___ for D&C. The procedure was
uncomplicated. Please see full procedure note for details. Post
operatively, she received PO oxycodone, Tylenol, and ibuprofen
for pain control with good effect. Her diet was advanced to a
regular diet, which she tolerated without nausea or vomiting.
She was voiding independently without issue. She was maintained
on IV antibiotics until ___, at which point she was
transitioned to PO doxycycline and flagyl. She was discharged
home on a 14 day course of this regimen.
On hospital day ___/POD1 she was discharged home in stable
condition with appropriate follow up care and instructions.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
4. Ibuprofen 600 mg PO Q6H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*42 Tablet Refills:*0
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
retained products of conception
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 Gynecology service with abdominal pain
and vaginal bleeding, concerning for an infection and retained
products of conception. You underwent an additional procedure to
evacuate the uterus, which was uncomplicated. You have recovered
well and it is safe for you to go home. You have been given
prescriptions for pain medication, please take these medications
as needed. You have also been given prescriptions for
antibiotics. Please DO NOT consume alcohol while taking these
antibiotics. Please take all of the antibiotic pills prescribed
for the full 14 day course.
Followup Instructions:
___
|
10437175-DS-14 | 10,437,175 | 24,918,337 | DS | 14 | 2183-02-23 00:00:00 | 2183-02-25 11:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Small bowel obstruction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year old man well known to ACS service
secondary to recurrent small bowel obstructions who presents
with approximately one day of nausea, vomiting of dark material,
and abdominal pain. Symptoms began suddenly. Last passed flatus
and stool around 3pm this afternoon. Last BM was reportedly
normal, but pt endorsed several episodes of nonbloody, non-tarry
diarrhea the day prior to presentation. Denies fevers, chills,
chest pain, BPR.
Pt reports that pain has resovled s/p placement of NGT in ED,
which was productive of only scant fluid.
Past Medical History:
Multiple SBOs (6 in last ___ years)
CVA ___ - residual R hemiparesis), afib,
Atrial fibrillation, HTN, CKD (baseline Cr 1.5)
IHSS (idiopathic hypertrophic subaortic stenosis),
MI
Anemia
___
Gastritisexlap/LOA/SBR? (___), neurosurgery for ___
Social History:
___
Family History:
Noncontributory
Physical Exam:
Physical Exam upon admission:
Vitals: 98.9 64 134/64 28 98% 2L NC
GEN: A&Ox, NAD
HEENT: No scleral icterus, mucus membranes moist; NGT in place,
productive of scant bilious appearing fluid
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, distended, nontender, no rebound or guarding, no
palpable masses, tympanitic, well healed midline laparotomy scar
DRE: deferred
Ext: No ___ edema, ___ warm and well perfused
Physical Exam upon discharge:
VS: 98.5, 64, 152/64, 18, 92/RA
GEN: AAOx4, ___ speaking only
HEENT: No scleral icterus, mucus membranes moist
CV: RRR. No MRG
PULM: Lungs CTAB No W/R/R
ABD: Soft/mild distention/nontender +BS
EXT: + pedal pulses. No CCE
Pertinent Results:
___ 05:55AM BLOOD WBC-12.2* RBC-3.62* Hgb-10.6* Hct-31.8*
MCV-88 MCH-29.4 MCHC-33.5 RDW-14.4 Plt ___
___ 03:45PM BLOOD WBC-11.9* RBC-3.88* Hgb-10.9* Hct-33.9*
MCV-87 MCH-28.1 MCHC-32.2 RDW-14.5 Plt ___
___ 06:50AM BLOOD WBC-12.0* RBC-3.78* Hgb-11.3* Hct-32.7*
MCV-86 MCH-29.8 MCHC-34.5 RDW-14.7 Plt ___
___ 10:40PM BLOOD WBC-12.0* RBC-3.77* Hgb-10.9* Hct-32.8*
MCV-87 MCH-29.1 MCHC-33.4 RDW-14.7 Plt ___
___ 10:40PM BLOOD Neuts-68.2 ___ Monos-7.0 Eos-0.5
Baso-0.4
___ 05:55AM BLOOD Glucose-89 UreaN-19 Creat-1.5* Na-141
K-3.8 Cl-107 HCO3-24 AnGap-14
___ 06:50AM BLOOD Glucose-122* UreaN-35* Creat-1.7* Na-141
K-4.1 Cl-104 HCO3-24 AnGap-17
___ 10:40PM BLOOD Glucose-142* UreaN-42* Creat-1.9* Na-139
K-4.2 Cl-104 HCO3-21* AnGap-18
___ 10:40PM BLOOD ALT-19 AST-19 AlkPhos-63 TotBili-0.3
___ 05:55AM BLOOD Calcium-8.2* Phos-2.5* Mg-2.0
___ 06:50AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.1
___ 10:40PM BLOOD Albumin-4.0
___ 10:48PM BLOOD Lactate-1.9
___ ABDOMEN (SUPINE & ERECT)
FINDINGS: Supine and upright views of the abdomen were
obtained. Multiple dilated loops of small bowel are seen with
air-fluid levels, highly worrisome for a small-bowel
obstruction. Loops of small bowel appear markedly dilated,
measuring up to at least 5 cm in diameter. No evidence of free
air is seen. A nasogastric tube is seen, sitting below the
level of the diaphragms, side port mostly in the gastric fundus.
A small amount of air seen is in the colon, without relative
paucity. Calcific structures are again seen in the pelvis,
stable when compared to ___ and seen to correspond with the
prostate calcifications on prior CT.
IMPRESSION: Findings consistent with small-bowel obstruction.
Brief Hospital Course:
This is an ___ year old man well known to ACS service secondary
to recurrent small bowel obstructions who presents with
approximately one day of nausea, vomiting of dark material, and
abdominal pain. CT Scan imaging revealed a small bowel
obstruction and the patient was admitted to the Acute Care
Service for conservative treatment due to the fact that he did
not want any surgical intervention. The patient was started kept
NPO, started on Intravenous fluids and he had a nasogastric tube
inserted to decompress his bowels. The nasogastric tube was
discontinued on the day of discharge at which time, the patient
was passed flatus and moved his bowels. He was tolerating a
regular diet upon discharge. Due to his INR being
supratherapeuticc, his warfarin dose was held during the
hospitalization. He will continue INR lab draws at ___
upon discharge. His next INR draw should be on ___.
Medications on Admission:
amiodarone 200'
finasteride 5'
hydrochlorothiazide 12.5'
levothyroxine 88' mcg
metoprolol succinate ER 100'
pravastatin 20'
coumadin 3'/5on ___
colace
senna
Vit D
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
hold for diarrhea
3. Levothyroxine Sodium 88 mcg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
hold for systolic blood pressure <110, hr <60
5. Pravastatin 20 mg PO DAILY
6. Senna 1 TAB PO BID:PRN constipation
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. Finasteride 5 mg PO DAILY
9. Aspirin EC 81 mg PO DAILY
Discharge Disposition:
Extended Care
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 ___ for a small bowel obstruction. You
didn't want to undergo surgery, so we treated the obstruction
coservatively with bowel rest, a nasogastric tube and
intravenous fluids. Upon discharge, the small bowel obstruction
opened up and you were able to return to your long term care
facility. Please call your doctor or nurse practitioner or
return to the Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10437475-DS-13 | 10,437,475 | 22,432,548 | DS | 13 | 2183-05-24 00:00:00 | 2183-05-24 13:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
clindamycin
Attending: ___.
Chief Complaint:
Vaginal pain and fevers
Major Surgical or Invasive Procedure:
Bartholin Gland Abscess s/p I&D on ___
History of Present Illness:
___ with history of Bartholin gland abscess s/p incision and
drainage and word catheter placement ___ who presented with
fevers and vaginal pain.
About 2 weeks prior to admission, the patient noted a pea-sized
lump near her labia. It got steadily larger and more painful, so
she presented to her Ob/Gyn on ___. She was noted to have
induration and tenderness of the right lab majora 8 x 6 cms with
palpable fluctuant mass. The patient underwent incision and
drainage of Bartholin gland abscess on ___, with procedural
notes stating that a large amount of purulent drainage was
obtained. Word catheter was inserted and secured with a suture.
She was also prescribed Bactrim, which she took.
On ___, she developed fever to 103 and presented to ___, where she reports that she was given an IV antibiotic
and then discharged on Bactrim. She continued to have fevers and
rigors throughout the weekend. She had worsening vaginal and
labial pain, and urination was painful
She presented again to her Ob/Gyn on ___, and in the office was
noted to be febrile to 103 and was referred to the ED for
further
management.
In the ED, vitals: 101.3 127 107/63 18 97% RA
Exam:
- Abd: Suprapubic tenderness. No rebound. No guarding.
- Perineal: Bartholin's drainage w/ catheter in place. No large
fluctuance. Very ttp. No spreading redness. No purulent
drainage.
Labs notable for: WBC 3.5 (79N, 4.3E), BUN/Cr ___ UA with 3
WBC, RBC 16, few bacteria, negative leuks, negative nitrites;
UCG
negative
Imaging notable for:
- EKG: Sinus tachycardia, NA/NI, no acute ischemic changes
- CT A/P:
1. Mild thickening of the urinary bladder wall. Correlation with
urinalysis is recommended.
2. Moderate fecal loading within the rectal vault.
- CXR: No acute cardiopulmonary process.
Consults: Ob/Gyn
- Per ED resident discussion with Ob/Gyn resident, they did not
think that the patient's sepsis was secondary to Bartholin gland
abscess; rather, think more likely to be urosepsis despite
negative urinalysis and therefore decline admission to their
service
Past Medical History:
- Anxiety/depression
- Obesity
- OSA
- Hypertension
- Exercise-induced asthma
- Thiamine deficiency
Social History:
___
Family History:
mother died of pancreatic cancer recently
Physical Exam:
DISCHARGE EXAM:
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, mildly tender to palpation in
mid and lower abdomen.
GU: wound from I&D healing well without fluctuance or discharge
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs.
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: Pleasant, appropriate affect
Pertinent Results:
Admission Data:
___ 12:23PM BLOOD WBC-3.5* RBC-3.75* Hgb-11.2 Hct-31.8*
MCV-85 MCH-29.9 MCHC-35.2 RDW-12.7 RDWSD-38.9 Plt ___
___ 12:23PM BLOOD Neuts-79.7* Lymphs-10.8* Monos-4.3*
Eos-4.3 Baso-0.0 Im ___ AbsNeut-2.81 AbsLymp-0.38*
AbsMono-0.15* AbsEos-0.15 AbsBaso-0.00*
___ 12:23PM BLOOD Plt ___
___ 12:23PM BLOOD Glucose-88 UreaN-7 Creat-1.3* Na-136
K-3.9 Cl-100 HCO3-24 AnGap-12
___ 12:23PM BLOOD ALT-14 AST-25 AlkPhos-68 TotBili-0.2
___ 12:23PM BLOOD Lipase-16
___ 04:50AM BLOOD CRP-61.9*
___ 04:50AM BLOOD HIV Ab-NEG
___ 04:50AM BLOOD Vanco-9.9*
___ 06:45AM BLOOD ANAPLASMA PHAGOCYTOPHILUM DNA,
QUALITATIVE-PND
Microbiology
URINE CULTURE (Final ___: NO GROWTH.
Imaging:
L spine plain films (___)
There is a transitional vertebra at the lumbosacral junction
with no evidence asymmetric appearance of the expanded
transverse process ease. Otherwise, the vertebra,
intervertebral disc spaces, and alignment are within normal
limits with no evidence of compression fracture.
Hip and SI joints are symmetric bilaterally.
CT A/P with contrast (___)
1. Mild thickening of the urinary bladder wall. Correlation with
urinalysis
is recommended.
2. Moderate fecal loading within the rectal vault.
discharge labs
___ 07:05AM BLOOD WBC-3.8* RBC-3.46* Hgb-10.5* Hct-30.1*
MCV-87 MCH-30.3 MCHC-34.9 RDW-12.5 RDWSD-39.1 Plt ___
___ 06:21AM BLOOD Neuts-39 Bands-0 ___ Monos-6 Eos-2
Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-1.33* AbsLymp-1.80
AbsMono-0.20 AbsEos-0.07 AbsBaso-0.00*
___ 06:21AM BLOOD Hypochr-NORMAL Anisocy-1+* Poiklo-1+*
Macrocy-1+* Microcy-NORMAL Polychr-1+* Ovalocy-1+*
Fragmen-OCCASIONAL
___ 07:05AM BLOOD Glucose-112* UreaN-6 Creat-0.8 Na-140
K-4.5 Cl-101 HCO3-27 AnGap-12
___ 11:10AM BLOOD ALT-274* AST-310* LD(LDH)-410*
AlkPhos-106* TotBili-0.6
___ 11:10AM BLOOD Albumin-4.1 Iron-69
___ 11:10AM BLOOD calTIBC-259* TRF-199*
Brief Hospital Course:
___ female with history of hypertension,
Bartholin gland cyst status post I&D and Word catheter
placement,
who presents with high fevers felt to be consistent with severe
viral illness. Course complicated by elevated LFTs.
#Sepsis
#Severe viral illness
#Bartholin's gland abscess
She presented with ___, high fevers, bandemia and severe pain.
OB/GYN was consulted in the emergency room and removed the
catheter. Her pain improved after catheter was removed. It was
unclear what was causing sepsis but concern for possible
contribution from Bartholin's gland abscess. Sepsis from
drainage of a Bartholin's gland abscess has been described only
a handful
times in case reports in the literature. MRSA, strep and GNRs
have all been implicated in these reports. Due to this she was
initially started on cefepime and vancomycin. She underwent a
CT scan which showed mild thickening of the bladder. CT and exam
argued against Fournier's gangrene. UCX was negative, ruling out
pyelo. CXR w/o consolidation. Blood cultures were sent and
negative. Anaplasma was done given leukopenia and remains
pending. Plain films and MRI of spine performed and were
unremarkable for osteo/discitis. Infectious disease was
consulted and ultimately felt that her sepsis was from severe
viral illness. HIV was checked and negative. A full workup
including EBV, CMV, respiratory viral panel, were sent and
pending. Infectious disease recommended stopping all
antibiotics. These were stopped the morning of ___. She was
monitored for 48 hours and remained afebrile.
[]Follow-up all viral studies
[]Follow-up with OB/GYN
#Transaminitis
Patient had elevated liver function tests while inpatient. This
is likely from known viral illness. Hepatitis serologies were
sent and remain pending. She had a CT scan of the abdomen which
was negative for any signs of obstruction or lesion. Her
synthetic function is preserved with a normal albumin of 4.1 INR
of 1.2 and a normal bilirubin. She will need her liver function
checked in 1 week from now. If LFTs not improving would refer
to hepatology.
[]Follow-up hepatitis serologies
[]recheck LFTs in one week
Greater than 30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin 500 mcg PO DAILY
2. Atenolol 25 mg PO DAILY
3. DULoxetine 60 mg PO DAILY
4. Vitamin D3 (cholecalciferol (vitamin D3)) 5,000 unit oral
DAILY
5. Thiamine 200 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. LORazepam 0.5 mg PO TID:PRN Anxiety
8. Cyclobenzaprine ___ mg PO HS:PRN Muscle spasm
Discharge Medications:
1. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*9 Tablet Refills:*0
2. Atenolol 25 mg PO DAILY
3. Cyanocobalamin 500 mcg PO DAILY
4. Cyclobenzaprine ___ mg PO HS:PRN Muscle spasm
5. DULoxetine 60 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. LORazepam 0.5 mg PO TID:PRN Anxiety
8. Thiamine 200 mg PO DAILY
9. Vitamin D3 (cholecalciferol (vitamin D3)) 5,000 unit oral
DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis due to severe viral illness
Transaminitis
Bartholin Gland Abscess s/p I&D
___ (resolved)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital due to fevers and vaginal
pain. You were started on broad antibiotics and your abscess was
drained successfully. It was determined that your fevers were
most likely due to **
You were admitted to the hospital due to fevers and vaginal
pain. You were started on broad antibiotics and your abscess was
drained successfully. You were seen by OB/GYN who felt that the
abscess was improving. Infectious disease specialists were
consulted and felt like your symptoms were likely from a severe
viral illness. This should get better with time. Your
antibiotics were stopped and you were monitored for 48 hours.
You had no further fevers.
Full workup of viral illnesses was sent including CMV, EBV, a
respiratory viral panel, hepatitis serologies. These tests are
still pending, if any return positive you will be called. You
were found to have elevated liver function tests and will need
these rechecked in 1 week. This is likely also from viral
illness.
You were having back pain while in the hospital. You underwent
an MRI which showed just some mild degenerative changes with no
signs of infection. You should follow-up with your primary care
doctor and be referred to physical therapy to help with your
pain.
It was a pleasure caring for you,
Your medical team
Followup Instructions:
___
|
10438089-DS-5 | 10,438,089 | 24,630,384 | DS | 5 | 2118-09-29 00:00:00 | 2118-09-29 15:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
allopurinol
Attending: ___
Chief Complaint:
Dyspnea, elevated troponin
Major Surgical or Invasive Procedure:
___ Right and left heart catheterization
History of Present Illness:
Mr ___ is a ___ year old gentleman with a history of CHF
(unknown pump function who presents with worsening edeme and
DOE.
Mr ___ has had episodes of swelling the past. He claims to
have gained 40 pounds in the last two months, although his
weight has fluctuated as his home diuretics have been altered.
He began having fluid accumulation, first in his left leg (as is
his usual pattern) then in his right leg. He now feels that he
is also accumulating fluid in his belly. His PCP had him on
varying doses of Lasix at home, but unfortunately aggressive
diuresis precipitated a gout flare.
Over the last 1.5 weeks, he has had progressive dyspnea with
exertion (although never symptomatically SOB at rest). He has,
however, been increasingly functionally limited. SOB with < 1
flight of stairs, even getting out of bed cases SOB. He has
never had chest pain, nausea or vomiting. He has chronic,
unchanged orthopnea, no PND. Had a TTE in the past, never had a
stress test, and never had a cardiac catheterization. Seen at
___ this AM and transferred over for management.
ED COURSE
- In the ED intial vitals were: 97.4 92 120/66 18 98% Nasal
Cannula
- Exam notable for crackles in base of lung with ___ > RLE and
chronic venous stasis.
- OSH studies notable for ___ negative for thrombosis. OSH
labs notable for cr 1.2, trop 0.10, bnp ___
- EKG not performed
- ___ labs: cr 1.4, trop 0.11, BNP 10870 INR 3.4, lactate 1.4
- Patient was given: heparin gtt
- Vitals on transfer: 88 117/63 20 95% Nasal Cannula
Upon arrival to the floor patient is lying in bed at 30
degrees, not SOB. Voices disappointment that he can't be with
his family, specifically his wife who was recently diagnosed
with cancer
Past Medical History:
DM Type 2
Left ankle fracture
Atrial fibrillation
Hypertension
Discectomy
Obstructive sleep apnea
Social History:
___
Family History:
Diabetes and HTN in father
Physical ___:
ADMISSION EXAM
==============
VS: 97.9 110/64 119 22 95/3L NC
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 10 cm (pt at 30 degrees)
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. irregular and borderline tachy, normal S1, S2 with I/VI
SEM pan precordially.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Rales in b/l bases ___
of way up.
ABDOMEN: Soft, NTND. No HSM or tenderness.
GU: Foley draining dark red-yellow urine
EXTREMITIES: B/L 2+ edema to thigh, left slightly greater than
right. Chronic venous stasis changes with b/l equal erythema and
minor superficial overlying ulcerations, healing.
SKIN: Stasis dermatitis, exam as above
PULSES: Distal pulses palpable and symmetric 1+ DP/2+ radial
DISCHARGE EXAM
==============
VS: Tm 98 110s-120s/60s-70s ___ RA
TELE: A-fib with irregular ventricular rate
WEIGHT: 99.5->102.3->99.2->95.8->93.2->94.6->95.6 -> 96.2 ->
96.7 -> 98.3 -> 97.8
I/O: ___ (net -1.3L) yesterday
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
NECK: Supple with JVP 13cm
CARDIAC: regular rate and rhythm, normal S1, S2 no murmurs,
rubs, or gallops
LUNGS: Intermittent rhonchi
EXTREMITIES: trace to 1+ edema up to lateral thighs, Chronic
venous stasis changes with b/l equal erythema and minor
superficial overlying ulcerations, healing.
PULSES: Distal pulses palpable and symmetric 1+ DP/2+ radial
Pertinent Results:
ADMISSION LABS
==============
___ 07:04PM BLOOD WBC-6.3 RBC-3.42* Hgb-11.3* Hct-35.8*
MCV-105* MCH-33.0* MCHC-31.6* RDW-17.3* RDWSD-64.0* Plt ___
___ 07:04PM BLOOD Neuts-66.0 Lymphs-12.3* Monos-14.9*
Eos-6.0 Baso-0.3 Im ___ AbsNeut-4.17 AbsLymp-0.78*
AbsMono-0.94* AbsEos-0.38 AbsBaso-0.02
___ 07:04PM BLOOD ___ PTT-150* ___
___ 07:04PM BLOOD Glucose-80 UreaN-26* Creat-1.4* Na-136
K-4.6 Cl-96 HCO3-28 AnGap-17
___ 07:04PM BLOOD ALT-15 AST-24 AlkPhos-181* TotBili-2.8*
___ 07:04PM BLOOD Lipase-11
___ 07:04PM BLOOD ___
___ 07:04PM BLOOD cTropnT-0.11*
___ 07:04PM BLOOD Albumin-3.4*
___ 07:08PM BLOOD D-Dimer-896*
___ 07:11PM BLOOD Lactate-1.4
PERTINENT LABS
==============
___ 05:15PM BLOOD DirBili-2.3*
___ 07:04PM BLOOD cTropnT-0.11*
___ 12:38AM BLOOD CK-MB-6 cTropnT-0.13*
___ 09:00AM BLOOD CK-MB-5 cTropnT-0.15*
___ 05:15PM BLOOD CK-MB-5 cTropnT-0.14*
___ 04:25AM BLOOD CK-MB-4 cTropnT-0.13*
___ 04:25AM BLOOD VitB12-1842*
___ 03:04AM BLOOD calTIBC-233* TRF-179*
___ 06:34AM BLOOD %HbA1c-6.3* eAG-134*
___ 05:15PM BLOOD Triglyc-72 HDL-28 CHOL/HD-5.5 LDLcalc-113
___ 05:55AM BLOOD TSH-6.3*
___ 05:15PM BLOOD T4-10.2
___ 05:15PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
___ 05:14AM BLOOD ___ * Titer-1:40
___ 03:04AM BLOOD PEP-ABNORMAL B IgG-1865* IgA-429* IgM-164
IFE-MONOCLONAL
___ 12:35PM BLOOD Digoxin-0.8*
DISCHARGE LABS
==============
___ 04:30AM BLOOD WBC-5.9 RBC-3.24* Hgb-10.6* Hct-32.5*
MCV-100* MCH-32.7* MCHC-32.6 RDW-15.8* RDWSD-58.4* Plt ___
___ 04:30AM BLOOD ___ PTT-72.7* ___
___ 04:30AM BLOOD Glucose-89 UreaN-71* Creat-1.6* Na-130*
K-4.5 Cl-88* HCO3-29 AnGap-18
___ 04:30AM BLOOD ALT-21 AST-34 LD(LDH)-177 AlkPhos-213*
TotBili-2.1*
___ 04:30AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.1
IMAGING
=======
___ doppler U/S ___
IMPRESSION:
Limited exam, with non visualized peroneal veins and inability
to demonstrate compressibility in the mid and distal femoral
veins due to patient body habitus. Within these limitations, no
evidence of deep venous thrombosis in the left lower extremity
veins.
CXR ___
IMPRESSION:
Compared to prior chest radiographs, ___.
Severe cardiomegaly has not changed over ___ years. Pulmonary
edema is mild. No focal pulmonary abnormality. No large pleural
effusion. Widening of the upper mediastinum is stable. It
could be due to fat deposition or a goiter. Mild narrowing of
the trachea just below the thoracic inlet is probably unchanged
as well.
TTE ___
IMPRESSION: Mild concentric left ventricular hypertrophy with
moderate cavity dilatation and moderate to severe global
hypokinesis. Markedly dilated right ventricle with mild global
hypokinesis. Mild mitral and aortic regurgitation. Moderate
tricuspid regurgitation. At least mild pulmonary artery systolic
hypertension.
Abdominal U/S ___
IMPRESSION:
1. No evidence of gallstones.
2. Normal appearance of the liver parenchyma with no focal
lesions identified. There is mild perihepatic ascites and a
right pleural effusion with an enlarged IVC and hepatic veins
and a highly pulsatile portal vein. This is likely consistent
with congestive hepatopathy based on the history of right-sided
heart failure.
TTE ___
IMPRESSION: Marked biatrial enlargement. Mild to moderate
symmetric left ventricular hypertrophy with mild to moderately
dilated cavity size and mild to moderately depressed global
systolic function. Markedly enlarged right ventricle with mild
to moderate global hypokinesis. Tricuspid leaflets fail to
coapt. Severe tricuspid regurgitation is present. There is at
least mild pulmonary hypertension. A very small pericardial
effusion is present. Increased biatrial filling pressures.
Findings could be consistent with infiltrative cardiomyopathy in
the right clinical context.
Compared with the prior study (images reviewed) of ___ the
tricuspid regurgitation is better characterized and is severe
(may have been underestimated on the prior). A very small
pericadial effusion is seen (also was present on prior). The
left ventricle is slightly smaller and global systolic function
improved.
MICRO
=====
UCx ___ final negative
Brief Hospital Course:
___ yo M w/ hx T2DM, afib, HTN, CHF who presented with 1.5 weeks
of progressive shortness of breath and DOE and pulmonary edema
on CXR consistent with CHF exacerbation.
ACUTE ISSUES
# Acute on chronic systolic CHF: Mr. ___ presented a 40 pound
weight gain and increasing ___ edema over the past two months,
with ___ weeks of dyspnea on exertion. His BNP was >10,000 on
admission, and he was grossly volume overloaded on exam. His
last TTE in ___ at ___ showed EF of 40-45% with global LV
dysfunction. He was noted to have a troponin elevation to 0.15,
however his CK-MB was negative so this was attributed to his
heart failure. The patient was diuresed to euvolemia with a
Lasix drip and transitioned to Torsemide 20. A R and L heart
cath was performed to evaluate etiology of CHF as patient has
unclear CHF history. RHC showed PCWP 16 and mPAP 27; LHC showed
___ LAD 50-60% stenosis, FFR neg so no stent was placed. He was
started on ASA 81 and atorvastatin 80 for medical management of
CAD. TTE performed showed LVEF 40%, severe TR, and marked
biatrial enlargement. Weight on discharge is 97.8 kg.
Patient was also found to have IgG kappa monoclonal gammopathy,
raising concern of possible infiltrative etiology to patient's
cardiomyopathy. Although TTE did not suggest infiltrative
cardiomyopathy, cardiac MRI was performed for further
evaluation, results pending at discharge.
# Atrial fibrillation with RVR: The patient has a history of
atrial fibrillation with prior episodes of RVR, and was on
amiodarone 100 mg daily as an outpatient prior to this being
discontinued due to an interaction with his febuxostat. During
his course, he was started on amiodarone and metoprolol, and due
to an episode of rates in the low 100s he was digoxin loaded and
put on digoxin 0.125 mg daily for maintenance. However, he then
experienced asymptomatic sinus pauses of ___, of unclear
etiology. Digoxin was discontinued due to questionable toxicity.
He stopped experiencing sinus pauses several days prior to
discharge.
Regarding his anticoagulation, he initially came in with a
supratherapeutic INR, and his warfarin was held. When his INR
reached 2, he was placed on a heparin drip and continued to have
his warfarin held due to plan for coronary angiogram. However
his INR later became subtherapeutic, and warfarin was restarted
along with heparin gtt to bridge. Current dose is 5mg (home dose
2.5 qd) in attempt to arrive at therapeutic levels. He will
continue to need heparin gtt at acute rehab for bridging. Goal
INR is ___.
#Hyponatremia: ___ hospital course was also complicated by
hyponatremia as low as 126. He became intermittently confused
but reoriented quickly, unclear if cause for confusion was
hyponatremia. Etiology of hyponatremia initially thought to be
due to autodiuresis, so diuresis was held for a few days. Day
prior to discharge he was started on Torsemide 20, and
hyponatremia improved to 130.
# NSVT:
The patient experienced several runs of NSVT during his course,
which may have been due to scar tissue from prior infarct versus
triggered from his severe systolic CHF. The patient was
asymptomatic, and may benefit from an ICD in the future if his
EF does not improve with maximal therapy. He was discharged with
a lifevest.
CHRONIC ISSUES
===============
# DM2: Not currently on medications, glucose well controlled
during his admission with a sliding scale as needed.
# Gout: Continued colchicine, febuxostat.
# Depression: Continued Cymbalta.
# GERD: On omeprazole.
# Iron deficiency: Continued ferrous sulfate.
# MRSA discitis: Continued home doxycycline.
# Asthma vs ?COPD: Continued home albuterol neb prn.
# OSA: Provided CPAP.
TRANSITIONAL ISSUES
===================
- New cardiac medications: ASA 81 qd, torsemide 20 qd,
atorvastatin 80 qd, metoprolol succinate 25 qd, amiodarone 100
mg
- Please follow-up on cardiac MRI done ___
- Please continue to follow daily chem10 to monitor Na, K/Mg,
and creatinine. Cr was 1.6 and Na 130 on discharge.
- Patient discharged on heparin gtt and warfarin as INR
subtherapeutic at 1.4. Please continue to monitor INR and PTT
regularly. Goal PTT 60-100 on heparin gtt. INR goal ___.
- Patient had ___, etiology thought to be cardiorenal. Please
continue to trend creatinine and evaluate etiology. Baseline
~1.2.
- Patient had elevated alk phos and tbili, attributed to
congestive hepatopathy. Please continue to trend LFTs.
- Please readdress need for amiodarone given possible
interaction with febuxostat
- Please monitor on telemetry, as patient had experienced
asymptomatic ___ sinus pauses during admission
- Please continue to evaluate etiology of hyponatremia and
monitor mental status
- Consider hematology/oncology referral for IgG monoclonal
gammopathy
- Patient to go home with life vest given depressed EF.
- Discharge weight: 97.8 kg. Please continue obtaining daily
weights and monitoring in/outs.
- Please consider discontinuation of omeprazole 20 mg if GERD
resolves.
- Code status: Full
- Contact: ___ ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H:PRN Pain / Fever
2. Warfarin 2 mg PO DAILY16
3. Colchicine 0.6 mg PO BID
4. Duloxetine 20 mg PO DAILY
5. Febuxostat 40 mg PO DAILY
6. Doxycycline Hyclate 100 mg PO Q12H
7. Ferrous Sulfate 325 mg PO DAILY
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
9. Furosemide 40 mg PO BID
10. Klor-Con M20 (potassium chloride) 20 mEq oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain / Fever
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Duloxetine 20 mg PO DAILY
4. Febuxostat 40 mg PO DAILY
5. Amiodarone 100 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Doxycycline Hyclate 100 mg PO Q12H
9. Warfarin 5 mg PO DAILY16
10. Colchicine 0.6 mg PO BID
11. Aspirin 81 mg PO DAILY
12. Atorvastatin 80 mg PO QPM
13. Metoprolol Succinate XL 25 mg PO DAILY
14. Klor-Con M20 (potassium chloride) 20 mEq oral DAILY
15. Torsemide 20 mg PO DAILY
16. Omeprazole 20 mg PO DAILY
17. Heparin IV Sliding Scale
No Initial Bolus
Initial Infusion Rate: 1500 units/hr
Start: Now
Target PTT: 60 - 100 seconds
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Acute-on-chronic systolic heart failure
Hyponatremia
Atrial fibrillation with rapid ventricular rate
Acute kidney injury
SECONDARY DIAGNOSES
===================
Atrial fibrillation
Diabetes type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after you experienced weight
gain, leg swelling, and shortness of breath on exertion. You
were found to be having a heart failure exacerbation, and were
treated with medications to help pull the fluid off of your
body. We started you on torsemide, a new medication to remove
fluid, which you should continue after discharge.
You were found to have coronary artery disease and were
therefore started on aspirin and atorvastatin. We added
metoprolol to control your heartrate as you had atrial
fibrillation with a fast heartrate.
You had an MRI done of your heart to see if you have any
deposits in your heart that may explain your heart failure. Your
cardiac MRI is pending; your cardiologist will inform you of the
results.
Please continue taking your medications as prescribed. You
should have a follow-up appointment with cardiology within one
week for ongoing management of your heart, see recommended
follow-up below.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
10438106-DS-4 | 10,438,106 | 22,746,395 | DS | 4 | 2172-11-22 00:00:00 | 2172-11-22 18:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
disulfiram
Attending: ___.
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
Transjugular liver biopsy ___
History of Present Illness:
___ year old woman with PMhx notable for bulemia and depression
who presented to the ___ after her LFTs were found to be
elevated in the ___ thought to be secondary to medication
(minocycline, disulfiram), transferred to ICU for NAC
initiation.
The patient reports that she has been nausous and vomiting for 2
weeks, ___ times per day prior to admission and was diagnosed
with gastroenteritis by her PCP. Reports that she has mild
intermittent LLQ pain. Denies fevers, chills, alcohol use,
tylenol ingestion, mushroom ingestion, new medications, or
herbal supplements. No recent travel or sick contacts. Last
alcohol was New Years, but she did take disulfiram x 3 weeks, 3
weeks ago. Her son recently went to ___ but is not sick. She
has been on minocycline and tretinoin cream for a long time. Per
patient, she and her sister were diagnosed with ___ dz as
children. An uncle had liver cancer. She is sexually active with
one male partner ___ years.
On arrival to the MICU, patient feels well and states that her
nausea has improved. Had no vomiting today.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, recent weight loss or gain. Denies
congestion, URI symptoms, sob, chest pain, abdominal pain, or
changes in bowel habits. Denies dysuria, frequency, arthralgias,
rashes.
Past Medical History:
Bulimia
Chronic constipation in the s/o h/o severe laxative abuse
Esophagitis
Depression
Anxiety
Social History:
___
Family History:
Mother has high cholesterol
Father hypertension, diabetes and depression
Paternal grandmother ___ dementia
Maternal grandfather dementia
Physical ___:
ADMISSION PHYSICAL EXAM
Vitals- T: 99 BP: 102/71 P: 87 R: 18 O2: 97% RA
HEENT: AT/NC, EOMI, PERRL, sclera icterus, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, A&Ox3, no asterixis
SKIN: warm and well perfused, jaundiced, no excoriations or
lesions, no rashes
DISCHARGE PHYSICAL EXAM
Vitals: 97.7 79 ___ 100%RA
GENERAL: NAD, icteric/jaundiced, awake in chair on computer and
walking around. A&O x3. No asterixis
HEENT: AT/NC, EOMI, PERRL, icteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, mildly tender to palpation in
epigastric area, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: tongue midline, palate rises symmetrically, EOMI, face
symmetric, moves all extremities. A&O x3. Gait normal.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
___ 12:16AM BLOOD WBC-8.0 RBC-4.85 Hgb-14.7 Hct-43.8 MCV-90
MCH-30.3 MCHC-33.5 RDW-14.0 Plt ___
___ 12:16AM BLOOD Neuts-66.6 ___ Monos-7.4 Eos-2.7
Baso-0.5
___ 12:16AM BLOOD ___ PTT-33.1 ___
___ 12:16AM BLOOD Glucose-92 UreaN-9 Creat-0.8 Na-134 K-3.8
Cl-94* HCO3-32 AnGap-12
___ 12:16AM BLOOD ALT-2719* AST-2145* AlkPhos-192*
TotBili-14.9* DirBili-11.6* IndBili-3.3
___ 10:35AM BLOOD Albumin-3.2* Calcium-8.4 Phos-2.9 Mg-1.9
Iron-148
PERTINENT LABS
___ 10:35AM BLOOD calTIBC-329 Ferritn-1217* TRF-253
___ 12:16AM BLOOD HCV Ab-NEGATIVE
___ 12:16AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:28PM BLOOD HIV Ab-NEGATIVE
___ 10:35AM BLOOD IgG-1405 IgA-136 IgM-110
___ 05:28PM BLOOD CEA-2.7 AFP-23.0*
___ 10:35AM BLOOD ___ Titer-1:320
___ 10:35AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 12:16AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HAV-NEGATIVE
___ 12:53PM BLOOD IgM HBc-NEGATIVE
___ 10:35AM BLOOD ANTI-LIVER-KIDNEY-MICROSOME ANTIBODY-
Negative
___ 05:28PM BLOOD CA ___: 19 (RR < 34)
___ 05:28PM BLOOD CERULOPLASMIN: 31
___ 05:28PM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 (IGG):
Negative
___ 05:28PM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 IGM:
Negative
___ 05:23AM BLOOD QUANTIFERON-TB GOLD: Negative
DISCHARGE LABS
___ 04:54AM BLOOD WBC-6.4 RBC-3.95* Hgb-12.2 Hct-34.6*
MCV-88 MCH-31.0 MCHC-35.3* RDW-16.2* Plt ___
___ 04:54AM BLOOD ___ PTT-102.2* ___
___ 04:54AM BLOOD Glucose-79 UreaN-7 Creat-1.0 Na-137 K-4.2
Cl-101 HCO3-29 AnGap-11
___ 04:54AM BLOOD ALT-395* AST-280* AlkPhos-97
TotBili-18.6*
___ 04:54AM BLOOD Calcium-8.5 Phos-4.7* Mg-2.3
MICRO
___ Blood (EBV) ___ VIRUS VCA-IgG AB-PENDING;
___ VIRUS EBNA IgG AB-PENDING; ___ VIRUS
VCA-IgM: Prior infection
___ Blood (CMV AB) CMV IgG ANTIBODY: Negative
___ SEROLOGY/BLOOD VARICELLA-ZOSTER IgG: Positive
___ BLOOD RUBELLA IgG: Positive
___ RAPID PLASMA REAGIN TEST: Non-reactive
___ HCV VIRAL LOAD: Negative
___ HBV Viral Load: Negative
___ Blood Culture: Negative
___ Blood Culture: Negative
___ CMV IgG ANTIBODY: Negative
___ MONOSPOT: Negative
IMAGING & PATHOLOGY
___ CXR
No previous images. The heart is normal in size and there is no
evidence of vascular congestion, pleural effusion, or acute
focal pneumonia.
___ CTA abdomen
Unremarkable CTA of the liver with no concerning focal liver
lesion and
incidental right replaced hepatic artery.
___ liver ultrasound
The gallbladder appears contracted, and therefore the
gallbladder wall is
minimally thickened. No evidence of acute cholecystitis. HIDA
scan could be performed for additional evaluation of chronic
cholecystitis, if clinically indicated.
___. Floridly active hepatitis with patchy, confluent hepatocyte
necrosis and abundant mixed inflammation consisting of prominent
neutrophils, admixed eosinophils, lymphocytes, and rare plasma
cells.
2. Mild canalicular cholestasis.
3. No histologic evidence of a toxic/metabolic pattern of
injury.
4. Trichrome and reticulin stains demonstrate no increase in
fibrosis.
5. Iron stain shows no stainable iron.
Note: Given the patient's known clinical history of a new
medication being introduced two weeks prior
to this acute illness and transaminitis, when taken together
with the histologic findings, support an
acute drug-induced liver injury as the cause of the active
hepatitis. In other clinical/serologic settings,
an acute autoimmune or viral hepatitis would be in the
histologic differential diagnosis.
___ PFT's
The FVC, FEV1, and FEV1/FVC ratio are normal. Flow-volume loop:
Normal contour with elevated peak flow. Lung Volumes: The TLC is
normal. The FRC, RV, and RV/TLC ratio are elevated. THe
diffusing capacity corrected for hemoglobin is normal.
IMPRESSION: The study results are within normal limits. RV is
likely overestimated and/or TLC underestimated due to a
suboptimal SVC maneuver.
___ Mammogram
No specific mammographic evidence of malignancy. BI-RADS: 1
Negative.
___ Panorex
No osteolytic foci suggesting abscess or osteomyelitis.
___ ECHO
Overall left ventricular systolic function is normal (LVEF>55%).
with normal free wall contractility. The estimated pulmonary
artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
Brief Hospital Course:
Ms. ___ is a ___ woman with a history of anxiety,
depression, and bulemia who presented with acute hepatitis, most
likely due to drug-induced liver injury from disulfiram. She
underwent pre-transplant evaluation but her labs stabilized and
she did not develop acute liver failure.
ACTIVE ISSUES
-------------------
# Acute Hepatitis: Most likely drug-induced liver injury from
disulfiram. Given elevated AST/ALT in the 2000s, differential
included acute viral hepatitis, ingestion/medication (tylenol,
mushroom), alcohol, ischemia, Budd-Chiari, autoimmune,
hemochromatosis, malignant infiltration, ___. Acetaminophen
and alcohol levels were negative, patient had no hypotension to
suggest ischemic process, ultrasound ruled out budd-chiari, CTA
ruled out liver malignancy. Serologies were unremarkable.
Transjugular liver biopsy was most consistent with drug-induced
liver injury and showed significant necrosis.
Patient had coagulopathy on arrival but did not have
encephalopathy to suggest fulminant liver failure. MELD was 22.
Did not meet transplant criteria per ___ criteria.
She was treated with NAC in the ICU and transferred to the floor
on ___. Given severity of lab abnormalities and degree of
necrosis on biopsy, patient underwent pre-transplant evaluation.
She did not develop confusion and labs stabilized, so she was
not listed for transplant.
Patient's disulfiram was stopped and listed as an allergy. Other
home medications, including psychiatric medications,
minocycline, and Linzess were held. Patient will discuss safety
of resuming these medication at her ___ appointment
with Dr. ___. She was counseled extensively on alarm
symptoms that should prompt her to seek emergency care.
# Bulemia: Patient has a long history of purging that remained
active up until hospitalization. She denied purging behavior in
house. She was followed by psychiatry and social work in-house.
Her weight was stable and she was not on ED Protocol. She
expressed interest in more intensive outpatient therapy and is
being voluntarily discharged to an inpatient ED treatment unit.
# Constipation: Patient has a long history of laxative abuse
resulting in severe constipation and dysmotility. Motility
studies have confirmed need for her very aggressive bowel
regimen. She required multiple agents and enemas to have bowel
movements every few days in house. Her bowel regimen is now
medically necessary and should be continued (titrated to 1 bowel
movement per day) in spite of concomitant eating disorder.
# Depression/Anxiety: Home medications were held due to acute
hepatitis. Please discuss safety of resuming these medications
at next hepatology visit.
TRANSITIONAL ISSUES
--------------------
- Patient needs labs 2x/week: CBC, Chem-10, AST, ALT, Tbili, ___,
PTT, INR. Please fax to ___ (f: ___, attn:
Dr. ___.
- Call ___ and present to ED STAT for any confusion or
change in mental status
- Psychiatric medications are currently on hold. Please discuss
safety of restarting them at appointment with Dr. ___ on
___.
- Continue treatment for bulemia, depression, anxiety as
outpatient
- PATIENT HAS SEVERE CONSTIPATION requiring significant bowel
reigmen. She has had motility testing and laxatives are
medically necessary for her in spite of her eating disorder.
Please titrate to 1 bowel movement per day.
- Emergency Contact: sister (___) ___
- Code status was full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluoxetine 40 mg PO DAILY
2. linaclotide 290 mcg oral DAILY
3. Minocycline 100 mg PO Q24H
4. Omeprazole 20 mg PO DAILY
5. Tretinoin 0.05% Cream 1 Appl TP QHS
6. MetronidAZOLE Topical 1 % Gel 1 Appl TP DAILY
7. BuPROPion (Sustained Release) 300 mg PO QAM
8. Vitamin D 50,000 UNIT PO DAILY
Discharge Medications:
1. Tretinoin 0.05% Cream 1 Appl TP QHS
2. MetronidAZOLE Topical 1 % Gel 1 Appl TP DAILY
3. Bisacodyl 30 mg PO/PR BID:PRN constipation
4. Docusate Sodium 400 mg PO BID per Dr. ___, this is
appropriate dosing for patient
5. Omeprazole 20 mg PO DAILY
6. Polyethylene Glycol 17 g PO QID
Hold for loose stools. Titrate to 1 bowel movement per day.
Reduce dose if > 1 BM/day
7. Senna 17.2 mg PO BID constipation
8. Ursodiol 300 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
- Drug-induced liver injury
- Acute hepatitis
SECONDARY DIAGNOSES
- Bulemia
- Alcohol use
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 admission to ___
___. As you know, you came in
because of a serious liver injury, which was most likely caused
by disulfiram.
We were initially worried that you might need a liver
transplant. Fortunately your liver function tests have
stabilized and we are hopeful that your liver will recover.
We are so glad you have decided to pursue inpatient treatment
for your bulemia. For now, your medications for depression and
anxiety are on hold. Please talk to Dr. ___ at your next
appointment about whether it is safe to restart these
medications.
If you develop ANY symptoms of confusion or disorientation,
headache, fluid build up in your abdomen, or disturbances in
your sleep/wake cycle, please call the ___
(___) and return to the ED right away.
Once again, it was a pleasure caring for you and we wish you the
best,
Sincerely,
Your Medical Team
Followup Instructions:
___
|
10438106-DS-5 | 10,438,106 | 25,758,425 | DS | 5 | 2176-10-03 00:00:00 | 2176-10-03 17:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
disulfiram
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS: Ms. ___ is a ___ yo woman with
history of bulimia, p-ANCA vasculitis and autoimmune hepatitis
who presents after being found not speaking and hypotensive.
Boyfriend found her at home unresponsive to him ___ bed but with
eyes open. Unknown LKTW. Found by EMS to have HR 130s, BP
___, given 500 cc fluids and brought here for further
evaluation, where she does not respond to questions but is
looking around the room at examiners. Not clearly following
commands. Reported to be drinking alcohol today.
On initial exam by ED providers, she had open eyes and
withdrawing and localizing to pain but was not reliably
following
commands. She was without obvious toxidrome. Pupils appeared
WNL,
no clonus or hyperreflexia. Neurology was consulted while ___ the
ED and felt there was less concern for seizure or serotonin
syndrome and CTA head and neck without evidence of leukocytosis.
___ the ED, initial vitals:
- Exam notable for:
VS: [] WNL [x] abnormal - tachycardia 120s
Constitutional: NAD, looking around room at examiners. Vomits
during interview.
Head/eyes: NCAT, PERRLA, EOMI.
ENT/neck: OP WNL
Chest/Resp: CTAB.
Cardiovascular: regular tachycardia, Normal S1/S2.
Abdomen: Soft, nondistended. Nontender.
Musc/Extr/Back: ___. No edema.
Skin: No rash. Warm and dry. No diaphoresis.
Neuro: Alert, unable to assess orientation. Localizes pain to
sternum with sternal rub. Withdraws to pain ___ 4 extremities. 2+
reflexes throughout. no clonus.
Psych: Normal mood. Normal mentation.
EKG: Sinus tachycardia 121. Normal PR and QRS. QTC prolonged at
491. Normal axis. T wave inversions ___ leads III, aVF, of
uncertain significance. Remainder of the tracing is
unremarkable.
- Labs notable for:
CBC: WBC 7.9 Hgb 11.3 Plt 418
Chemistry: Na 138 K3.4 BUN 10 Sr Cr 1.2
INR 1.0
LFTs: ALT 13, AST 22 AP34
Troponin <0.01
Lactate 4.4 -> 5.1 -> 2.3
UA: 24 epithelials, nitrites negative and trace leukocytes
Serum ETOH 119
Utox: Positive for amphetamines
- Imaging notable for:
CTA Head and Neck: The circle of ___ and its principal
branches are patent. The dural venous
sinuses are patent. The carotid and vertebral arteries are
patent. No
evidence of vasculitis.
- Pt given:
Zofran
Ceftriaxone
Thiamine 500mg
Compazine, Benadryl
Upon arrival to the floor, the patient reports she was last
feeling well at 3pm on ___. She notably had 4 vodka drinks and
experience some acute chest pain and then woke up ___ an
ambulance. She denies any new medications or drug use. Of note
she has been out of pregabalin for >7 days. She currently has a
headache which is similar to previous migraine patterns.
REVIEW OF SYSTEMS: Headache as above, no chest pain, dyspnea,
abdominal pain.
Past Medical History:
-bulimia
-p-ANCA vasculitis (MPO and PR3 negative), presented with
mononeuritis multiplex diagnosed by sural nerve bx ___,
lately
___ remission as of ___ Rheumatology note by Dr. ___.
-autoimmune hepatitis: confirmed by liver biopsy done ___ and
___, currently on azathiopurine therapy
-granuloma annulara
-mononeuritis multiplex
-esophagitis
-bronchitis
-constipation
-Livedoid rash BLEs
-depression
Social History:
___
Family History:
Relative Status Age Problem Onset Comments
Mother Living ___ HYPERLIPIDEMIA
Father ___ ___ ARTHRITIS died after flu
___ accident
HYPERTENSION
DIABETES TYPE II
PGM DIABETES TYPE II
ALZHEIMER'S DISEASE
Uncle ___ RENAL CANCER
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VITALS: ___ 0125 Temp: 97.7 PO BP: 145/105 HR: 115 RR: 17
O2
sat: 98% O2 delivery: Ra
General: Alert, oriented, no acute distress
HEENT: Pupils equal ___ size, reactive to light
CV: RRR, no murmurs
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended
GU: No foley
Ext: Warm, well perfused, 2+ pulses
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally. Has some
delayed response to following commands.
DISCHARGE PHYSICAL EXAM
========================
VITALS: 24 HR Data (last updated ___ @ 527)
Temp: 97.7 (Tm 97.7), BP: 145/105, HR: 115, RR: 17, O2 sat:
98%, O2 delivery: Ra
General: Alert, oriented, no acute distress
HEENT: Pupils equal ___ size, reactive to light
CV: RRR, no murmurs
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended
GU: No foley
Ext: Warm, well perfused, 2+ pulses
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally. Follows
commands without difficulty.
Pertinent Results:
ADMISSION LABS
=================
___ 05:28PM BLOOD WBC-7.9 RBC-3.44* Hgb-11.3 Hct-33.3*
MCV-97 MCH-32.8* MCHC-33.9 RDW-14.9 RDWSD-51.3* Plt ___
___ 05:28PM BLOOD Neuts-77.4* Lymphs-11.9* Monos-7.3
Eos-1.8 Baso-1.1* Im ___ AbsNeut-6.13* AbsLymp-0.94*
AbsMono-0.58 AbsEos-0.14 AbsBaso-0.09*
___ 05:28PM BLOOD Plt ___
___ 05:28PM BLOOD Glucose-147* UreaN-10 Creat-1.2* Na-138
K-3.4* Cl-104 HCO3-17* AnGap-17
___ 05:40PM BLOOD ALT-13 AST-22 AlkPhos-34* TotBili-0.4
___ 05:40PM BLOOD cTropnT-<0.01
___ 05:28PM BLOOD Calcium-8.5 Phos-2.0* Mg-1.7
___ 05:28PM BLOOD ASA-NEG ___ Acetmnp-NEG
Tricycl-NEG
___ 06:08PM BLOOD ___ pO2-42* pCO2-35 pH-7.40
calTCO2-22 Base XS--1
___ 05:44PM BLOOD Lactate-4.4*
PERTINENT LABS
=================
___ 10:55AM BLOOD WBC-4.3 RBC-3.06* Hgb-10.1* Hct-29.0*
MCV-95 MCH-33.0* MCHC-34.8 RDW-14.9 RDWSD-50.7* Plt ___
___ 10:55AM BLOOD Plt ___
___ 08:37AM BLOOD Glucose-84 UreaN-7 Creat-0.9 Na-144 K-4.5
Cl-108 HCO3-24 AnGap-12
___ 09:20PM BLOOD cTropnT-0.04*
___ 08:37AM BLOOD cTropnT-0.03*
___ 08:37AM BLOOD Calcium-8.1* Phos-3.3 Mg-2.8*
___ 05:28PM BLOOD ASA-NEG ___ Acetmnp-NEG
Tricycl-NEG
___ 09:24PM BLOOD pO2-43* pCO2-41 pH-7.36 calTCO2-24 Base
XS--1 Comment-GREEN TOP
___ 07:00PM BLOOD Lactate-5.1*
___ 09:24PM BLOOD Lactate-2.3*
IMAGING
==================
___
NONCONTRAST HEAD CT:
No acute intracranial abnormality.
CTA HEAD NECK:
The circle of ___ and its principal branches are patent. The
dural venous
sinuses are patent. The carotid and vertebral arteries are
patent. No
evidence of vasculitis.
Brief Hospital Course:
SUMMARY
===============
Ms. ___ is a ___ yo woman with history of bulimia, p-ANCA
vasculitis and autoimmune hepatitis who presents after being
found not speaking and hypotensive of unclear etiology.
ACUTE ISSUES
===============
# Toxic Metabolic Encephalopathy:
Patient initially was found minimally responsive by her
boyfriend at home. At that time, EMS was called and found that
she was minimally responsive to commands and hypotensive to
___. She was brought to ___ ED where a code stroke was
called and the patient was evaluated by neurology. She had a
NIHSS score of 14. Neurology thought it was unlikely that she
had a stroke and her symptoms likely reflected a toxidrome from
ingestion. She had a CTA head and neck that were unremarkable
and without signs consistent with vasculitis. Her symptoms
resolved shortly thereafter and she was back at baseline.
Initially, there was a discussion that perhaps this episode was
a seizure, but given return to baseline and indication for EEG
was NCSE which seemed unlikely it was decided to defer an EEG.
Per the patient, prior to presentation she had 4 vodka drinks ___
quick succession after seeing her son ___ the hospital. Unclear
exact etiology of altered mental status and associated
hypotension. Thought to be likely secondary to alcohol toxidrome
given quick resolution and high ethanol level on tox screen.
Also raises concern for other possible ingestions however no
clear toxidrome as patient without pupillary changes, no clonus.
Patient denies intentional ingestion therefore psychiatry was
not consulted. At discharge, an extended urine tox screen for
hallucinogens was pending. She notably takes an SSRI,
sumatriptan and Adderall but per Neurology evaluation low
suspicion for serotonin syndrome.
# Lactic Acidosis:
Lactate peaked at 5 without evidence of underlying infection or
hypoperfusion based on normal renal function. She had one
episode of hypotension prior to admission which could have
contributed. Her lactic acidosis had a quick resolution likely
secondary to fluid resuscitation.
# Atypical Chest Pain:
Reported episode of diffuse chest pain prior to unresponsive
episode. Troponin negative on admission. EKG with T wave
inversions ___ aVr and V1. She gives a minimal description of
chest pain so difficult to determine if consistent with cardiac
etiology. Patient had elevated troponin to 0.04 likely due to
hypotension when originally found by EMS. This down trended
prior to discharge. Patient was asymptomatic at discharge.
# Migraine Headache:
Has documented history of migraines and received migraine
cocktail ___ ED. Thought that trigger for migraine is likely ETOH
use. Resolved upon arrival to the medicine floor. She was given
acetminophen for pain control.
CHRONIC/STABLE PROBLEMS:
==========================
# ANCA Vasculitis: Follows with ___ Rheumatology Dr. ___ seen ___ ___ at which point she was noted to have
slightly worsened pulmonary symptoms but normal PFTs ___ ___.
- Continued Azathiopurine 100mg daily
- Continued Lyrica 75mg BID
# Autoimmune Hepatitis:
- Continued Azathiopurine 100mg daily
# Depression:
- Continued Cymbalta 30mg daily given return to baseline as well
as pregabalin 75mg BID
# ADHD:
- Held Adderall as an inpatient given altered mental status on
initial presentation. ___ restart on discharge given resolution
of symptoms.
Transitional Issues
=====================
[] Patient reports binge drinking prior to presentation. She was
previously ___ AA but hasn't been for several years. Recommend
encouragement for patient to attend AA meetings.
[] Patient reports that she lost her bottle of Lyrica
approximately 1 week prior to presentation. Patient not provided
with new prescription at discharge.
[] Adderall held on admission to the hospital given altered
mental status. This medication was restarted on discharge given
resolution of confusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amphetamine-Dextroamphetamine XR 40 mg PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
3. AzaTHIOprine 100 mg PO DAILY
4. DULoxetine 30 mg PO DAILY
5. Sumatriptan Succinate 25 mg PO DAILY PRN migraine
6. Pregabalin 75 mg PO BID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Amphetamine-Dextroamphetamine XR 40 mg PO DAILY
3. AzaTHIOprine 100 mg PO DAILY
4. DULoxetine 30 mg PO DAILY
5. Pregabalin 75 mg PO BID
6. Sumatriptan Succinate 25 mg PO DAILY PRN migraine
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
===================
Toxic Metabolic Encephalopathy
Lactic Acidosis
Atypical Chest Pain
SECONDARY DIAGNOSIS
======================
ANCA Vasculitis
Autoimmune Hepatitis
Depression
ADHD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You came to the hospital because you were not responding.
What did you receive ___ the hospital?
- You were given fluid to increase your blood pressure.
- You had a scan of your head that did not show a stroke.
- We think your symptoms were likely due to the alcohol you
drank earlier ___ the day.
What should you do once you leave the hospital?
- You should take your medicines as directed.
- You should follow up with your PCP.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10438253-DS-8 | 10,438,253 | 29,269,604 | DS | 8 | 2112-05-07 00:00:00 | 2112-05-12 18:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain, myocardial infarction
Major Surgical or Invasive Procedure:
___ - Coronary artery bypass grafting x3 with the left
internal mammary artery to left anterior descending artery and
reverse saphenous vein graft to the right acute marginal artery
and the obtuse marginal artery on intra-aortic balloon pump
History of Present Illness:
___ year old male with history of CVA without residual deficits,
hypertension, and hyperlipidemia who presents with multiple
episodes of chest tightness. Symptoms started yesterday evening
and woke the patient up from sleep twice. He described
substernal chest tightness without any radiation. The pain
lasted approximately 5 minutes each before resolving
spontaneously. He was able to sleep through the rest of the
night. Today while doing household chores he developed the same
substernal chest tightness. This was not associated with
lightheadedness, dizziness, nausea, or diaphoresis. The pain
felt better with rest. The pain lasted for approximately one
hour. He then had another episode of pain later that day while
sitting. The pain lasted 30 minutes prior to resolving. The pain
felt similar to reflux. He took 4 TUMS with some relief.
He describes similar symptoms over the past few weeks. All have
occurred with exertion and during times of stress, such as
watching the ___. He saw his PCP ___. An EKG was
reportedly normal and the patient was scheduled to have a stress
test on ___. He has a significant family history of coronary
artery disease. His mother died of an MI in her ___ and a
brother died of an MI at ___ years old.
In the ED initial vitals were: 98.7 89 123/82 17 100% RA.
- Labs: WBC 7.5, H/H 14.0/43.2, Cr 1.3 (baseline), troponin
<0.01 -> 0.08.
- EKG: Sinus rhythm, normal axis, delayed repolarization in
inferior leads, <1mm ST depression in V4.
- CXR: Small left pleural effusion.
- Patient was given ASA 324mg.
Vitals prior to transfer: 98.0 66 ___ 99% RA
Upon arrival to the floor, the patient denied any chest pain.
He expressed being very anxious.
Mr. ___ is a ___ year old man with a history of cerebrovascular
accidemtn, hyperlipidemia, and hypertension. He has noted chest
tightness with activity or stress. He was admitted for NSTEMI
and loaded with Plavix and started Heparin drip. He had a
pulseless ventricular fibrillation arrest. He was resuscitated
and taken emergently to the cath lab where he was found to have
left-main and multivessel coronary artery disease. Given the
severity of his disease, an intra-aortic balloon pump was
placed. Cardiac surgery was consulted and he was subsequently
taken urgently to the operating room for surgical
revascularization.
Past Medical History:
Cerebrovascular Accident, ___
Erectile Dysfunction
Gastroesophageal Reflux Disease
Hyperlipidemia
Hypertension
Insomnia
Irritable Bowel Syndrome
Patent Foramen Ovale
Social History:
___
Family History:
Mother: died at ___ years old from MI.
Father: died at ___ years old from brain tumor.
Brother: died at ___ years old from MI.
Physical Exam:
ADMISSION PHYSICAL EXAM: ___
========================
VS: 98.1 131/89 84 20 98RA 80.6kg
GENERAL: Anxious appearing but in no acute distress.
HEENT: Atraumatic. Moist mucous membranes. Oropharynx clear.
NECK: Supple, no JVD.
CARDIAC: RRR, normal S1, S2. No murmurs.
LUNGS: Clear to auscultation bilaterally. No wheezes, crackles,
or rhonchi.
ABDOMEN: +BS, soft, nondistended, nontender to palpation.
EXTREMITIES: Warm and well perfused. Pulses 2+. No peripheral
edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Constitutional: Comfortable in NAD
HEENT: Normocephalic, atraumatic
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender
GU/Flank: No costovertebral angle tenderness
Extr/Back: no edema
Skin: No rash, Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Pertinent Results:
___ Cardiac Catheterization
LM: 90%
LAD: 90%, ___ diagonal with mild disease
LCX: 90%, ___ OM is good target
RCA: no disease, acute marginal with 50% lesion and PDA normal
Transesophageal Echocardiogram ___
PREBYPASS
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is mildly dilated with
normal free wall contractility. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. There is
no aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
POSTBYPASS
There is preserved biventricular systolic function. The study is
otherwise unchanged from prebypass.
Brief Hospital Course:
___ year old male with history of CVA, hypertension,
hyperlipidemia, and family history of CAD who presents with
chest pain.
# NSTEMI: Patient describes at least 4 episodes of chest pain
that occurred both with exertion and at rest. EKG without any ST
changes though troponin up trending on admission (<0.01 ->
0.08). Peaked at 0.10 and was subsequently downtrending.
Posterior EKG performed without changes concerning for posterior
ACS. Patient was started on heparin gtt, ASA 81, atorvastatin
80mg, metoprolol 12.5mg XL daily, and plavix loaded with planned
cardiac catheterization on ___. Patient with multiple episodes
of chest pain overnight ___ to ___. EKG noted to have ST
depressions that reversed with resolution of chest pain with SL
nitroglycerin. On morning of ___ patient with ___ chest pain
and EKG showing deep ST depressions in anterior leads concerning
for posterior ACS. Patient subsequently entered ventricular
fibrillation and code blue was called. VF terminated after one
defibrillation. Patient sent for urgent cardiac catheterization.
Cardiac catheterization revealed severe left main, ostial
circumflex, and ostial LAD disease. IABP placed per C-surg
recommendations and patient transferred to CCU to await urgent
CT surgery.
On ___ he was taken urgently to the operating room where he
underwent coronary artery bypass grafting. Please see operative
note for full details. He tolerated the procedure well and was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
He weaned from sedation, awoke neurologically intact and was
extubated on POD 1. He was weaned from inotropic and vasopressor
support. Beta blocker, statin and aspirin were initiated. He
remained hemodynamically stable and was transferred to the
telemetry floor for further recovery. He had a brief run of afib
and was started on amiodarone and converted to sinus rhythm and
Coumadin therapy was not required. He was diuresed toward his
pre-op weight and had trace edema upon discharge and was sent to
rehab on Lasix x 1 week. He was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD #4, the sternal incision was
healing, and pain was controlled with oral analgesics. He was
discharged to ___ Rehab in ___ in good condition with
appropriate follow up instructions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Omeprazole 20 mg PO DAILY:PRN GERD
5. Aspirin 81 mg PO DAILY
6. Vitamin B Complex 1 CAP PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
dose decreased by ___ while you are on amiodarone
3. Omeprazole 20 mg PO DAILY:PRN GERD
4. Vitamin D 1000 UNIT PO DAILY
5. Acetaminophen 650 mg PO/PR Q4H:PRN pain or temperature >38.0
6. Amiodarone 400 mg PO BID Duration: 5 Days
then continue taper-400mg daily for 7 days then 200mg ongoing
7. Bisacodyl ___AILY:PRN constipation
8. Docusate Sodium 100 mg PO BID
9. Metoprolol Tartrate 12.5 mg PO TID
10. Simethicone 40-80 mg PO QID:PRN gas pain
11. Milk of Magnesia 30 mL PO DAILY
12. Furosemide 20 mg PO BID Duration: 7 Days
then stop
13. Potassium Chloride 20 mEq PO Q12H Duration: 7 Days
then stop
14. Lorazepam 0.25 mg PO Q8H:PRN anxiety
RX *lorazepam 0.5 mg 0.5 (One half) by mouth every 8 hours Disp
#*20 Tablet Refills:*0
15. Vitamin B Complex 1 CAP PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
- STEMI
- CVA without residual deficits; event monitor negative for
Afib, TEE showed PFO.
- Hypertension
- Hyperlipidemia
- GERD
- Irritable bowel syndrome
- Erectile dysfunction
- Insomnia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema 1+ lower extremities
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
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 provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10438363-DS-10 | 10,438,363 | 26,262,569 | DS | 10 | 2186-12-29 00:00:00 | 2186-12-29 14:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
droperidol
Attending: ___
Chief Complaint:
abdominal pain
Reason for MICU transfer: hypotension, lactic acidosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient has had ___ days of diffuse lower abdominal pain
associated with multiple episodes of nonbloody diarrhea daily.
She also has nausea but no vomiting. She has been suffering from
a viral like illness with myalgias and fever as well as headache
for the past several days. She denies dysuria, flank pain,
vaginal discharge, bleeding. Patient was taking immodium after
bowel movements.
She called EMS where she was found to be pale, cool, diaphoretic
complaining of flu like symptoms (diarrhea, dizziness,
headache). Vitals were HR ___, BP ___ RR 36 97% RA.
She was transferred to ___ ED.
On arrival to the ED, initial vitals were 98.4 108 105/67 18
100%. BP dropped to 82/57.
Labs were notable for WBC of 4.7 (6% bands) with repeat 3.1 (18%
bands), Lactate was 3.2 (that rose to a high of 3.8), Hgb
___. Given abdominal pain, she underwent CT of the abdomen
and pelvis that showed significant colitis most likely
infectious or inflammatory. ACS was consulted who felt this was
unlikely ischemic and recommended Medicine admission. The
patient refused CVL and foley placement and was felt competent
to make this decision. She was started on cipro/flagyl and
received a total of 6 L NS with lactate down to 3.4 on transfer
from the ED. She further received zofran, fentanyl 50mg IV,
famotidine Vitals on transfer were 98.5 126 ___ 26 98% RA.
On arrival to the FICU, she was afebrile, tachy to mid ___, BP
97/78, tachypneic to 26 but satting well on RA.
In the ICU she is moaning, complaining of a headache. She
complains of abdominal pain if specifically asked but can't
describe further. Can't say how much diarrhea she has. Denies
sick contacts except for husband who is liver transplant
patient. No new foods. Denied recent exposure to antibiotics.
Asking for something to drink and methadone.
Past Medical History:
obesity
+h Pylori
erosive gastritis
obesity
mood disorder
DM type 2, diet controlled per pt
htn
Lap band
Lap CCY ___
Umbilical hernia repair
Eye surgery for strabismus
ORIF tib/fib
Ovarian cyst removal
Social History:
___
Family History:
adopted, but birth mother had alcoholism and DM
Physical Exam:
ADMISSION EXAM
===============
T: 99.2 BP 126/67 HR 81 RR 27 SaO2 95% RA
General: Moaning, able to respond appropriately to questions
HEENT: Sclera anicteric, dry mucous membranes with dark red
juice crusting her lips, oropharynx clear
Neck: supple, no LAD
Lungs: Difficult to auscultate but generally clear to
auscultation bilaterally, no wheezes, rales, ronchi
CV: Distant but tachycardic, normal rhythm
Abdomen: obese, soft, diffusely tender (although somewhat
distractable), ___, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, no clubbing, cyanosis or edema
DISCHARGE EXAM
T 98.2, Tmax afebrile, BP 125/89, HR 75, RR 18, sat 95% on RA,
1600cc UOP
Gen: morbidly obese woman seated next to the bed in a chair,
ambulating without difficulty, with street clothes on, ready to
go home, alert, cooperative, NAD
HEENT: anicteric, MMM
Chest: equal chest rise, CTAB, no WOB or cough
Heart: RRR, trace pitting edema peripherally
Abd: NABS, soft, obese, ___, somewhat distended as before
Extr: WWP
Skin: no rashes noted
Neuro: speaking easily, no facial droop, eyes somewhat
disconjugate
Psych: normal affect
Pertinent Results:
ADMISSION LABS
==============
___ 12:55AM BLOOD ___
___ Plt ___
___ 12:55AM BLOOD ___
___
___ 12:55AM BLOOD Plt ___ Plt ___
___ 12:55AM BLOOD ___
___
___ 12:55AM BLOOD ___
___ 03:39AM BLOOD ___
___ 12:55AM BLOOD ___
___ 12:55AM BLOOD HCG-<5
___ 06:53AM BLOOD ___
___
___ 01:12AM BLOOD ___
INTERIM LABS
============
___ 07:00AM BLOOD ___
___
___ 03:18PM BLOOD ___
___ 12:13PM BLOOD ___
___ 08:30AM BLOOD ___
___ Plt ___
___ 08:30AM BLOOD ___
___
MICROBIOLOGY
============
___ 10:40 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___ ___ 230PM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference ___.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
MODERATE POLYMORPHONUCLEAR LEUKOCYTES.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING/STUDIES
===============
___ CT ABD PELVIS WITH CONTRAST:
IMPRESSION:
Diffuse thickening of portions of the sigmoid, the entire
ascending colon and portions of the transverse colon compatible
with colitis. The distribution makes inflammatory or infectious
etiology most likely.
Hepatic steatosis.
___ CXR PA/LATERAL:
Low lung volumes contributing to bibasal atelectasis and
vascular crowding. Consider repeat radiograph with full
inspiration to rule out pulmonary edema.
___ CT HEAD W/O CONTRAST:
No acute intracranial process. Mild prominence of the
intrasellar pituitary is of likely little clinical
significance.
NOTE ADDED AT ATTENDING REVIEW: There is a soft tissue mass
filling an
enlarged sella tursica. This suggests a pituitary tumor, most
likely an
adenoma. Recommend correlation with clinical findings and
consider an MR of the pituitary.
___ ABD SUPINE XR:
No evidence of obstruction. Colonic mucosal fold thickening
consistent with C. difficile colitis.
___: IMPRESSION:
1. Progressive C. difficile colitis with more proximal extension
and more
edema as compared to 6 days prior with new trace free fluid. No
free air.
2. Splenomegaly. 3. Slightly nodular contour of the liver
without other signs of cirrhosis. Attention on follow up is
recommended.
DISCHARGE LABS
==============
___ 07:30AM BLOOD ___
___ Plt ___
___ 07:25AM BLOOD ___
___
___ 07:25AM BLOOD ___
___ 01:00PM BLOOD HIV ___
___ 01:00PM BLOOD ___
___ HAV ___
___ 01:00PM BLOOD HCV ___ -- SAMPLE SHOWS
REPEATED LOW LEVEL REACTIVITY BY EIA
RIBA NO LONGER AVAILABLE FOR DEFINITIVE ASSESSMENT
A SECOND MANUFACTURER'S EIA WAS ALSO POSITIVE
SO PRESUMPTION IS THAT THIS IS A TRUE POSITIVE HCV ANTIBODY
RESULT
RECOMMENDED ___ FOR POSITIVE HCV ANTIBODY: HCV VIRAL LOAD
___ 08:30PM BLOOD Parst ___
___ 08:30PM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA AGENT) ___
___ 8:10 pm SEROLOGY/BLOOD
**FINAL REPORT ___
LYME SEROLOGY (Final ___:
NO ANTIBODY TO B. ___ DETECTED BY EIA.
Reference Range: No antibody detected.
Negative results do not rule out B. burg___ infection.
Patients
in early stages of infection or on antibiotic therapy may not
produce
detectable levels of antibody. Patients with clinical history
and/or
symptoms suggestive of lyme disease should be retested in ___
weeks.
Brief Hospital Course:
___ woman w/PMHx remote IVDU now on methadone,
hypertriglyceridemia, NIDDM, obesity s/p lap band, admitted with
septic shock from C. diff.
She was quite sick initially, meeting ___ SIRS criteria
(tachycardia, leukopenia/bandemia, tachypnea) on admission in
the setting of colitis. She was hypotensive to 82/57 and
admitted to the FICU. She received 6L NS in ED with lactate
subsequently normalized. CT abd/pelvis findings were most
consistent with inflammatory or infectious colitis. Was on
vanc/Zosyn but d/cd on ___. She was found to have stool
positive for C.diff and was started on IV flagyl and PO vanc.
She developed worsening leukocytosis up to 20.5 K and had
persistent abdominal pain and diarrhea. CT scan was repeated
and showed worsening colitis. ID and general surgery were
consulted. Vancomycin dose was increased from 125 mg to 500 mg
four times daily on ___. Her pain and leukocytosis then
improved.
On the day of discharge she was doing very well. Pain was much
improved, stools were starting to become more solid. She and I
discussed her plan of care and she was eager to go home. We
reviewed the importance of finishing her oral vancomycin -- she
had been calling pharmacies to ensure they'd have it available.
She felt comfortable with managing things going home. I
provided her a "last dose" letter for her ___ clinic. She
had no additional questions for me.
DETAILS BY PROBLEMS
Severe, complicated C. diff
- she was seen by Surgery and ID
- ID recommended 14d of C. diff treatment -- timed from when she
finally began to improve on ___, this would be 10 more days of
oral vancomycin as noted elsewhere
- she was counseled to ___ with her PCP regarding any
complications
Possible tick borne illness -- myalgias, headaches, fevers,
initial leukopenia and mild elevation in LFTs concering for
possible tick borne illness
- ID recommended checking Lyme titers, anaplasma titers and
parasite smear
- see results section -- Lyme negative, parasite smear negative,
Anaplasma pending
Pituitary lesion
- the patient had a noncon CT head for severe headaches and
sinus pain
- this scan showed a mass in the pituitary gland that radiology
suggest be followed up with MRI
- she refused having the MRI this admission due to abdominal
pain and diarrhea
- I spoke with her specifically about the importance of
___ for this with her primary care physician
- she is aware and understands -- she may require an anxiolytic
___ to be able to tolerate this
- her headaches resolved
Possible hypothyroidism
- h/o elevated TSH as outpt, but normal here, but with low T4
- suggest ___ as outpt when not likely to be confused
with sick euthyroid -- she's not overtly hypothyroid now
Nodular contour of the liver without other signs of cirrhosis on
CT A/P
- her Hep C testing returned presumptive positive -- this
requires ___ with viral load testing
Mild peripheral edema
- suspect mild volume overload in the ___ state related
to aggressive hydration -- she received one dose of furosemide
for this
GERD
- ranitidine
Bipolar d/o
- continue clonazepam, clonidine and lamotrigine
Chronic pain and h/o IVDU ___ ago
- continued home methadone 100 mg PO daily, last dose on ___ at
8:42am
- confirmed with ___ ___.
HTN
- continue clonidine
DM type 2, diet controlled with recent HgbA1C = 5.9 ___,
blood sugars under control
Active smoking
- received a nicotine patch here
- pt counseled on importance of cessation
OSA
- dx ___ per Atrius and unable to tolerate CPAP
Hypertriglyceridemia
- plan f/u w/PCP
___ on ___:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. ClonazePAM 1 mg PO DAILY
2. ClonazePAM 2 mg PO QHS
3. CloniDINE 0.2 mg PO BID
4. LaMOTrigine 150 mg PO DAILY
5. Methadone 100 mg PO DAILY
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Discharge Medications:
1. ClonazePAM 1 mg PO DAILY
2. ClonazePAM 2 mg PO QHS
3. CloniDINE 0.2 mg PO BID
4. LaMOTrigine 150 mg PO DAILY
5. Methadone 100 mg PO DAILY
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
7. Acetaminophen 1000 mg PO Q8H:PRN HA, pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth Q8H:PRN Disp #*60
Tablet Refills:*0
8. ___ Hydrox.-Simethicone ___ mL PO QID:PRN
heartburn
RX ___ 200 ___ mg/5 mL ___ mL
by mouth QID:PRN Refills:*0
9. Nystatin 500,000 UNIT PO Q8H
RX *nystatin 500,000 unit 1 UNIT by mouth every eight (8) hours
Disp #*21 Tablet Refills:*0
10. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
11. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours
Disp #*40 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Clostridium difficile colitis
Pituitary gland lesion
Presumptive Hepatitis C infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for fevers, abdominal pain and diarrhea. You
were admitted to the intensive care unit and were found to have
a severe clostridium difficile (C. Diff) infection of your
colon. This improved with antibiotics. You will need ___
with your primary care doctor to make sure this infection is
fully cured. CT scan of your head showed a lesion in your
pituitary gland, we recommend an MRI of your pituitary gland as
an outpatient.
Followup Instructions:
___
|
10438363-DS-9 | 10,438,363 | 22,763,874 | DS | 9 | 2186-02-24 00:00:00 | 2186-02-24 16:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
droperidol
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o female with HCV, obesity, h/o H pylori, erosive
gastritis, esophagitis, and recent lap cholecystectomy who
presents with RUQ and epigastric pain. Patient had a lap
cholecystectomy performed on ___ for symptomatic biliary colic.
Procedure was uncomplicated and patient was discharged home from
the procedure with minimal RUQ pain.
Pt reports an episode two days agao and then 2 epsiodes last
night that "felt like the pain before the surgery". Last night,
about a half hour after eating a learge meal she developed
severe pain in the RUQ, sharp in nature. She had "projectile
vomiting" and the pain improved. She was trying to relax with a
shower and the pain recurred. it was so severe that she called
911. By the time they arrived it was improved and she sent them
away. Then, it recurred, she called them again and presented
here. She reports that the pain radiates towards to epigastrum.
She has no sob, cp, cough, +some nausea, no diarrhea.
She has been taking about 3 ibuprofen once a day for the pain.
She stopped the oxycodone a few days after surgery.
ROS: 10 systems reviewed and are negative except where noted in
HPI above
Past Medical History:
obesity
+h Pylori
erosive gastritis
obesity
mood disorder
DM type 2, diet controlled per pt
htn
Social History:
___
Family History:
adopted, but birth mother had alcoholism and DM
Physical Exam:
afeb, vss
Cons: NAD, sitting up in bed
Eyes: EOMI, no scleral icterus
ENT: MMM
Neck: nl ROM, no goiter
Lymph: no cervical LAD
Cardiovasc: rrr, no murmur, no edema
Resp: CTA B
GI: +bs,soft, obese, healing surgical incisions
mild ruq ttp
MSK: no significant kyphosis
Skin: no rashes
Neuro: no facial droop
Psych: pleasant, but odd affect
Pertinent Results:
___ 11:40PM GLUCOSE-98 UREA N-14 CREAT-0.8 SODIUM-140
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-30 ANION GAP-16
___ 11:40PM ALT(SGPT)-34 AST(SGOT)-32 LD(LDH)-121
CK(CPK)-144 ALK PHOS-95 TOT BILI-0.2
___ 11:40PM LIPASE-84*
___ 11:51PM LACTATE-2.1*
___ 11:40PM cTropnT-<0.01
___ 11:40PM CK-MB-3
___ 11:40PM WBC-8.4 RBC-4.90 HGB-14.6 HCT-42.1 MCV-86
MCH-29.7 MCHC-34.6 RDW-13.3
___ 11:40PM NEUTS-57.6 ___ MONOS-4.3 EOS-5.8*
BASOS-1.5
___ 11:40PM PLT COUNT-256
U/S of abd ___
FINDINGS:
The liver is normal in echotexture with no concerning osseous
lesions or
evidence of biloma. The simple cyst in the left lobe measures 9
x 6 mm and
has no internal vascularity. The portal vein demonstrates
normal hepatopetal
flow. The gallbladder is surgically absent. There is no fluid
within the
gallbladder fossa. The proximal common bile duct measures 4 mm
and the
extrahepatic portion of the common bile duct measures 8 mm. The
the pancreas
is normal in echotexture without evidence of pancreatic duct
dilation. The
pancreatic tail is obscured by overlying bowel gas. The views
of the right
kidney are unremarkable. The visualized portions of the aorta
and IVC are
normal.
IMPRESSION:
The common bile duct measures 8 mm. No findings suggestive of
bilomas.
Brief Hospital Course:
___ female with hx of obesity, htn, mood disorder and recent
lap. cholecystectomy
here with episodes of RUQ pain.
No sign of infection, surgical complication. Pt throughtout the
day has been doing well and tolerated food without any problems.
Pt is not willing to stay for further evaluation. She reports
that she will return to medical care if she has recurrent pain
or vomiting. She reports that she will f/u with her PCP and GI
doc if this occurs as well.
Pt's PCP is out of the office, I spoke with RN at the office to
let her know of the situation and plan for d/c to home today.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO DAILY
2. ClonazePAM 2 mg PO QHS
3. LaMOTrigine 150 mg PO DAILY
4. Methadone 100 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. CloniDINE 0.2 mg PO BID
Discharge Medications:
1. ClonazePAM 1 mg PO DAILY
2. ClonazePAM 2 mg PO QHS
3. CloniDINE 0.2 mg PO BID
4. LaMOTrigine 150 mg PO DAILY
5. Methadone 100 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every 6
hours if needed for abdominal pain Disp #*10 Tablet Refills:*0
8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours as needed
for pain Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain of unclear reason
Discharge Condition:
alert, interactive, ambulatory
Discharge Instructions:
we are not sure why you had the pain and vomiting. there are
not signs of infections or complications of the surgery.
If you have any more pain we recommend an MRI of the biliary
tree.
Followup Instructions:
___
|
10438404-DS-10 | 10,438,404 | 23,334,108 | DS | 10 | 2122-11-25 00:00:00 | 2122-11-25 18:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R pupil dilation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ presents to ___ ED complaining of headache for 1 week,
worse today, located primarily on the right side. He also notes
his right pupil has been significantly larger than the left for
approximately 3 weeks, and he has blurred vision in the right
eye. He states he otherwise feels well and has no complaints.
He denies weakness, numbness, syncope, near-syncope, or other
neurological changes. He has recently been using IV heroin
though is reluctant to discuss this fact as his wife does not
know he uses heroin.
Past Medical History:
depression / anxiety
Social History:
___
Family History:
Non-contributory
Physical Exam:
Exam on Admission
98.8 68 128/86 18 100%RA
Gen alert, oriented, anxious, NAD
R pupil 5mm, fixed; L pupil 3-->2
EOMI
L eye lateral visual field diminished
R eye visual acuity decreased
RRR
Abd soft
Ext WWP
Strength / sensation equal and intact in UEs / ___
No pronator drift
Exam on Discharge
**** Was unable to examine as patient left against medical
advice
Pertinent Results:
___ CTA
Unremarkable non contrast head CT without evidence of infarct,
hemorrhage or mass effect.
The basilar tip is slightly patulous. The head CTA is otherwise
unremarkable without evidence of a significant stenosis,
aneurysm or other vascular abnormality.
___ Chest X-ray
The lung volumes are normal. Normal size of the cardiac
silhouette. Normal hilar and mediastinal structures. No
pulmonary edema. No pneumonia, no pleural effusions.
Brief Hospital Course:
___, Mr. ___ was admitted through the emergency
department to the SICU after presenting with a blown R pupil, a
complaint of headaches and a CT suspicious for a basilar tip
aneurysm.
___, the CTA of his head was read by neuroradiology, the
vascular neurosurgeon as negative for any intracranial processes
including an aneurysm. Opthomology was consulted for his
pupillary changes. They were able to constrict his pupils using
pilocardipine. They suggested follow up in the ___
clinic. While their final recommendations were pending, the
patient left the floor without notifying nursing staff or the
neurosurgery team. He recieved no discharge instructions or
medication scripts. He left without against medical advise.
Medications on Admission:
- clonopin 0.5mg PO TID
- abilify 10mg PO daily
- IC venlafaxine 150mg PO daily
Discharge Disposition:
Home
Discharge Diagnosis:
Left against medical advise
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Take your pain medicine as prescribed.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
GO TO THE EMERGENCY ROOM IMMEDIATELY IF YOU EXPERIENCE ANY OF
THE FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
10438404-DS-11 | 10,438,404 | 23,786,241 | DS | 11 | 2122-12-29 00:00:00 | 2122-12-31 16:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
+MSSA blood borne infection
Heroin withdrawal.
Adie's pupil.
Major Surgical or Invasive Procedure:
TEE.
Thoracic chest tube placement.
History of Present Illness:
___ with hx anxiety/depression, R Adie's pupil, active IV/
intranasal heroin use who presented with 3 days of SOB, chest
pain, and diarrhea.
Patient was in his usual state of health until 3 days ago, when
he awoke with a sudden squeezing chest pain and SOB. He reports
that the chest pain has been constant and radiates to his arms,
back, and lower legs. His SOB has increasingly worsen. He now
states that it is worse when lying down and improves when he
sits up or walks upright. Patient also endorses 3 days of
abdominal pain, nausea, and brown, watery diarrhea, requiring
multiple visits to the bathroom at night. Patient has been
unable to consume food or liquids as a result of the diarrhea.
One day prior to this admission, the patient reports that his
shortness of breath acutely worsened and since he "could not
catch his breath," he called EMS and was brought to ___ ED.
Patient reports that he started using IV heroin two months ago.
He only uses his own needles and utilizes 2.5 grams/day, but has
been trying to quit. His last usage was less than 24 hours
before his presentation to the ED. He states that his family
does not know about his drug use and he would like that
information withheld.
In the ED, initial vitals: 103.3 130 102/61 20 97%4L. D dimer
1009. CXR and Chest CT performed. UA, CBC, chem 10 were
collected. Patient recevied acetaminophen, morphine, IV
ceftriaxone and azithromycin, and ketorolac. Vitals prior to
transfer: 98.2 ___ 24 99%
Patient endorsed nausea, vomiting, fevers, chills, sweating,
restleness, lacrimation, nasal congestion, abdominal pain,
diarrhea, dyspnea.
Past Medical History:
Anxiety/Depression
Adie's Pupil (R side)
IV drug abuse (heroin)
Social History:
___
Family History:
Aunt has history of IVDU.
Physical Exam:
ADMISSION PHYSICAL:
Vitals- 98.3 ___ 20 99%RA
General- Diaphoretic, uncomfortable looking gentlemen with
nausea and abdominal pain. Multiple tattoos with diamond earing.
HEENT- Sclerae mildly icteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Shallow, frequent breaths. Bilateral breath sounds with
mild bibasilar crackles. No wheezes or rales.
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, ND, bowel sounds present, mild tenderness to deep
palpation with no rebound tenderness or guarding, no
organomegaly
GU- no foley
Ext- clammy, cool extremities with 2+ pulses, no clubbing,
cyanosis or edema
Neuro- R sided blown pupil dilated to 6 mm and non-responsive to
light. Remaining neurological function grossly normal.
DISCHARGE PHYSICAL:
VITALS- 97.6 130/81 58 20 98%RA
HEENT- Sclerae mildly icteric, MMM, oropharynx clear
Neck- Supple, JVP not elevated, no LAD
Lungs- CTAB. No wheezes or rales. Mild pain with deep
inspiration but no increased work of breathing.
CV- RRR, S1/S2 clear and of good quality, No murmurs, rubs, or
gallops.
Abdomen- Normoactive bowel sounds, soft, nontender,
nondistended, no rebound or guarding
GU- No foley
Ext- WWP, 2+ pulses, no clubbing, cyanosis or edema
Neuro- R sided pupil dilated to 7 mm and non-responsive to
light. Remaining neurological function grossly normal.
Pertinent Results:
ADMISSION LABS:
___ 03:50AM BLOOD WBC-8.6# RBC-4.43* Hgb-12.8* Hct-38.9*
MCV-88 MCH-28.9 MCHC-32.9 RDW-13.8 Plt ___
___ 03:50AM BLOOD Neuts-83* Bands-0 Lymphs-9* Monos-7 Eos-0
Baso-0 Atyps-1* ___ Myelos-0
___ 03:50AM BLOOD ___ PTT-31.9 ___
___ 03:50AM BLOOD Glucose-127* UreaN-18 Creat-1.4* Na-131*
K-3.4 Cl-94* HCO3-23 AnGap-17
___ 03:50AM BLOOD ALT-120* AST-130* AlkPhos-100
TotBili-3.1* DirBili-2.2* IndBili-0.9
___ 07:10AM BLOOD Calcium-8.3* Phos-1.7* Mg-1.9
___ 04:24AM BLOOD D-Dimer-1009*
___ 04:05PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 04:05PM BLOOD HIV Ab-NEGATIVE
___ 04:05PM BLOOD HCV Ab-NEGATIVE
DISCHARGE LABS:
___ 08:40AM BLOOD WBC-8.4 RBC-4.00* Hgb-11.4* Hct-36.7*
MCV-92 MCH-28.5 MCHC-31.1 RDW-15.2 Plt ___
___ 05:04AM BLOOD Glucose-92 UreaN-3* Creat-0.8 Na-139
K-3.6 Cl-107 HCO3-26 AnGap-10
___ 05:04AM BLOOD ALT-127* AST-88* AlkPhos-136* TotBili-1.2
___ 08:40AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.0
___ 04:05PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
CXR (___)
IMPRESSION: Opacity at the left lung base is of unclear
etiology.
Could represent atelectasis, peripheral lung infarction from an
pulmonary embolus. An acute infectious process such as a viral
etiology cannot be excluded.
CT (___)
IMPRESSION:
1. Although there is no evidence of a pulmonary embolus, and
evaluation of the subsegmental branches is limited due to
extensive motion artifact,
multiple wedge shaped peripheral consolidations with
predominantly grounds glass appearance in the lungs bilaterally,
as described in detail above, are suspicious for pulmonary
infarcts. Although less likely, this could also be secondary to
organizing pneumonia or multifocal pneumonia.
2. Nodules are seen measuring up to 0.8 cm, for which a
six-month followup is recommended for further evaluation.
RUQ U/S (___)
IMPRESSION:
1. Normal appearance of the liver and gallbladder. No biliary
dilatation.
2. Small hyperechoic lesion in segment VI of the liver likely
representing a hemangioma. 3. Small simple left renal cyst
incidentally noted.
LENIs (___)
IMPRESSION: No evidence of deep venous thrombosis in the either
leg.
MRI C, T, L ___
IMPRESSION: No evidence of spinal infection. Enlarging
bilateral pleural effusions. Renal abnormalities incompletely
characterized.
TTE (___)
The left atrium is elongated. 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. Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. No masses or vegetations are seen
on the mitral valve, but cannot be fully excluded due to
suboptimal image quality. An eccentric, posteriorly directed jet
of Mild (1+) mitral regurgitation is seen. Due to the eccentric
nature of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). No masses or vegetations are
seen on the tricuspid valve, but cannot be fully excluded due to
suboptimal image quality. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
IMPRESSION: No valve vegetations seen.
TEE (___)
Poor image qulality. No vegetations is seen. No aortic
regurgitation is seen. Mild (1+) mitral regurgitation is seen.
CXR (___)
IMPRESSION: Interval placement of right PICC in the lower SVC.
Brief Hospital Course:
___ with hx anxiety/depression, R Adie's pupil, active IV/
intranasal heroin use who was admitted for MSSA bacteremia c/b
septic pulmonary emboli.
# MSSA blood infection: Upon admission, multiple blood cultures
were positive for MSSA. Infectious disease was consulted and the
patient was started on IV nafcillin. Route likely from recent IV
drug abuse. Daily blood cultures were collected and revealed
NGTD since HD2 (___). On HD4, the patient underwent TTE, which
was negative for valve vegetations. On HD5, he underwent TEE,
which revealed no vegetations, though the image qualities were
suboptimal. ID recommended 4 week course of antibiotics from
___ forward (last day ___. Based on the need for a
4-week course of IV nafcillin, a PICC line was placed on HD5. He
was transferred to the ___ for further care.
# Pleuritic chest pain: In the ED, CXR and chest CT were
performed which were concerning for multi-focal pneumonia vs
pulmonary infarcts. Bilateral LENIs were negative for DVT. An
MRI (of the spine) performed on HD2 revealed increased bilateral
pleural effusions that were not present on the previous CT.
Interventional Pulmonology placed a R chest tube on HD3 and
extracted pleural fluid for staining, culture, and chemistry.
The fluid revealed no micoorganisms and an elevated LDH
consistent with an exudative process. Based on decreased ouput
(<100 cc/hr over 24 hours) and diminished effusions on CXR, the
chest tube was discontinued on HD6.
# Lower back pain and superior xiphoid pain: Given +MSSA blood
culture and acute worsening of back pain, patient underwent an
MRI of the C, T, and L spine on HD3 which was negative. Despite
endorsing ___ pain throughout his hospitalization, the patient
remained comfortable appearing with NAD. Ambulating and in less
pain upon discharge. Normal neuro exam (except for pupil, per
below).
# Transaminitis/Bilirubinemia: Patient's fever and elevated
liver enzymes were concerning for a viral illness, especially
given his recent IVDU history. HIV, HepB, and HepC were
negative. Based on concern for acute HepC, viral load remained
pending at time of discharge. RUQ u/s revealed no abnormalities.
LFTs stable and downtrending at discharge. HCV viral load is
pending at time of discharge.
# Heroin abuse: Patient's last usage was <48 hours prior to
admission. His tachycardia, nausea, sweating, abdominal
discomfort, and diaphoresis on admission were concerning for
withdrawal. He was started on a methadone taper, per ___
protocol. He also received medication for his withdrawal
symptoms. Daily EKGs performed to trend QTc, which did not
prolong. Substance abuse was consulted. He may be an excellent
candidate for suboxone abstinence program in the near future.
#Diarrhea: Patient's ongoing diarrheah was most likely ___ to
withdrawal. Legionella and C diff were negative.
# R sided dilated pupil: Patient was previously diagnosed with R
Adie's pupil based on "constriction to dilute pilocarpine"
during previous hospitalization on ___. Upon admisison, the
patient was evaluated and cleared by NSG. After conferring with
opthamology, recommended patient pursue outpatient follow-up for
refraction and potential pilocarpine.
# Anxiety: Continued outpatient abilify, venlafaxine, and
clonipine
Transitional Issues:
- Continue 4 weeks of IV antibiotic treatment for MSSA
septicemia
- Discontinuation of PICC following completion of Abx regiment
- Consider patient for outpatient suboxone abstinence program
- HIV/HepB/HepC in 3 months.
- Nodules are seen measuring up to 0.8 cm on Chest CT, for which
a six-month followup is recommended for further evaluation.
- Schedule appointment with opthamology for refractive glasses
and pilocarpine tratment for Adie's pupil.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO TID
2. Aripiprazole 10 mg PO DAILY
3. Venlafaxine 150 mg PO DAILY
Discharge Medications:
1. Aripiprazole 10 mg PO DAILY
2. ClonazePAM 0.5 mg PO TID
3. Venlafaxine 150 mg PO DAILY
4. Nafcillin 2 g IV Q4H
5. Naproxen 500 mg PO Q8H:PRN pain
6. Nicotine Patch 14 mg TD DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
MSSA blood stream infection
Exudative, culture-negative pleural effusion
Heroin withdrawal.
Adie's pupil.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to ___ for evaluation of your fever,
shortness of breath and abdominal pain.
Upon admission, you were found to be experiencing withdrawal
from heroin. For your withdrawal, you received tapered doses of
methadone and medications for your nausea, vomiting, abdominal
cramping, and diarrhea.
Based on blood cultures, you were also found to have a serious
bloodstream infection related to your IV drug abuse. You were
then started on IV antibiotics. Based on your difficulty
breathing, an x-ray and CT of your chest were performed which
revealed fluid around your lungs. A chest tube was then
temporarily placed to drain the fluid from around you lungs. Due
to your lower back pain, an MRI of your spine was performed
which did not reveal any infections. For long-term antibiotic
treatment of your blood infection, a catheter known as a PICC
line was placed in your arm.
Thank you for allowing ___ to participate in your care.
Followup Instructions:
___
|
10438489-DS-3 | 10,438,489 | 26,733,386 | DS | 3 | 2150-11-12 00:00:00 | 2150-11-12 12:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Epigastric pain x8 days
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
Mr ___ is a ___ with pancreatic divisum, remote alcoholic
pancreatitis, biliary duct stenosis s/p multiple ERCP with stent
placement most recently with stents removed ___ who presented
with epigastric pain x8 days.
He reports he had his first episode of pancreatitis
approximately ___ years ago, which was apparently attributed to
EtOH. He notes that his last ERCP was performed ___. Two
weeks after this ERCP, 7 days prior to this presentation, he
noted mild epigastric discomfort, which increased in intensity
after eating ___ of ___ sandwich. He describes the pain as
epigastric, radiating to the back when severe, without
associated N/V, F/C. The pain dissipated over the course of that
week. The evening prior to presentation, he ate clam chowder,
and developed marked increase in epigastric pain, reaching ___
at its peak, and not relieved with heating pad or a total of 7
tabs of ibuprofen in the 24 hours prior to presentation. The
pain prevented him from sleeping until 4 am on ___. When he
awoke, he reports that he phoned an ERCP MD (?Dr. ___, who
directed him to the ___.
Pt denies N/V, F/C, change in bowel movements, melena,
hematochezia, dysuria, hematuria, chest pain, shortness of
breath. He does endorse ___ year history of progressive ___
claudication, which prevents him from walking uphill and limits
his ability to walk any significant distance.
In the ___, labs were notable for WBC 20.6, ALT/AST
___, alk phos 94, Tbili 0.27, lipase 5. A CT abd/pelvis was
performed. Per review of ___ and vasc surg notes, apparently
revealed infrarenal aortic thrombus with >50% occlusion,
although report not yet available for review at time of this
admission. Pt was transferred to ___ for further eval of
epigastric pain and aortic thrombus.
In the ___ ___:
Triage VS 97.1 65 178/60 16 97% RA
Prior to transfer to floor: 97.4 60 184/71 16 98% RA
Labs notable for WBC 24.3, LFTs WNL, lipase 6
Review of ___ - per ___ notes, as above - pt
asymptomatic
Vasc surgery called - thrombus stable compared to CT ___, no
indication for intervention or further inpatient evaluation
RUQ u/s: stones, CBD dilitation, no acute cholecystitis
ERCP c/s - admit, likely MRCP
Received cipro/flagyl, lisinopril 20 mg and amlodipine 5 mg
(home BP meds)
Past Medical History:
PMH:
- Pancreatic divisum
- Recurrent mild pancreatitis
- Umbilical hernia
- Mild early COPD - PFTs from ___ at ___
- HTN
ERCP history:
___: 1 cm benign appearing stricture in distal CBD - 7 cm
by 10 fr plastic stent placed. Sphincterotomy performed.
___: Plastic stent removed, two new straight plastic
stents placed
___: Stents removed, three new straight plastic stents
placed. Previously noted CBD stricture "much improved."
___: Stents removed, "single smooth narrowing of benign
appearance that was 2 cm long seen at lower third of CBD,
significantly improved from previous ERCP." No new stents
placed.
PSH:
- S/p bilateral inguinal hernia repair (Gazmuri)
- Colonscopy (___)
Social History:
___
Family History:
No family history of pancreatic, gallbladder or liver cancer.
Brother with dementia
Father died age ___ from MI
Mother diagnosed with cervical cancer age ___
Sister with unknown medical history
Son with psoriasis
Physical Exam:
EXAM ON ADMISSION:
VITAL SIGNS: 97.9 53 171/70 18 97%RA
GENERAL: Alert, oriented, pleasant, lying in bed, NAD. Does not
seem anxious or depressed.
HEENT: Pupils are equal, round and reactive. EOMs are intact.
Oropharynx clear. Dentition intact.
NECK: Supple without lymphadenopathy.
CHEST: Lungs CTAB. Normal respiratory effort. No rales, wheezes
or rhonchi.
CARDIOVASCULAR: RRR, normal S1, S2. No murmurs, rubs, or
gallops.
ABDOMEN: Soft and nontender without guarding, rebound. Bowel
sounds are normoactive. Reports constant epigastric pain which
is unchanged with palpation.
EXTREMITIES: WWP, no clubbing, cyanosis or edema. 2+ DP on L, 1+
DP on R, 2+ femoral pulse on L, 1+ femoral pulse on R.
NEUROLOGICAL: Grossly intact.
SKIN: Warm and dry. No rashes or suspicious lesions.
EXAM ON DISCHARGE:
Vitals AF 97.5, BP 140s-160s/60s-70s, HR ___, RR ___,
>96%RA
GENERAL: Alert, oriented, pleasant, lying in bed, NAD. Does not
seem anxious or depressed.
HEENT: Pupils are equal, round and reactive. EOMs are intact.
Oropharynx clear. Dentition intact. No scleral icterus.
NECK: Supple without lymphadenopathy.
CHEST: Lungs CTAB. Normal respiratory effort. No rales, wheezes
or rhonchi. Slightly increased expiratory time.
CARDIOVASCULAR: RRR, normal S1, S2. No murmurs, rubs, or
gallops.
ABDOMEN: Soft and nontender without guarding, rebound. Bowel
sounds are normoactive. No longer with epigastric pain on
palpation.
EXTREMITIES: WWP, no clubbing, cyanosis or edema. 2+ DP on L, 1+
DP on R, 2+ femoral pulse on L, 1+ femoral pulse on R.
NEUROLOGICAL: Grossly intact. Steady gait.
SKIN: Warm and dry. No rashes or suspicious lesions.
Pertinent Results:
___ 11:35PM URINE BLOOD-SM NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 11:35PM URINE RBC-5* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 11:35PM URINE HYALINE-2*
___ 10:17PM ___ PTT-33.3 ___
___ 09:11PM LACTATE-1.4
___ 08:53PM GLUCOSE-137* UREA N-11 CREAT-0.9 SODIUM-135
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-23 ANION GAP-15
___ 08:53PM ALT(SGPT)-28 AST(SGOT)-20 ALK PHOS-93 TOT
BILI-0.4
___ 08:53PM LIPASE-6
___ 08:53PM cTropnT-<0.01
___ 08:53PM ALBUMIN-4.1 CALCIUM-9.4 PHOSPHATE-3.0
MAGNESIUM-1.9
___ 08:53PM WBC-24.3*# RBC-4.66 HGB-15.3 HCT-45.4 MCV-97
MCH-32.7* MCHC-33.6 RDW-13.5
___ 08:53PM NEUTS-81.1* LYMPHS-10.5* MONOS-6.9 EOS-1.1
BASOS-0.5
___ 08:53PM PLT COUNT-220
EKG from admission here:
Sinus bradycardia. Prominent precordial voltage. Consider left
ventricular hypertrophy with ST-T wave abnormalities in leads I,
aVL and V1-V2. Consider strain
RUQ US from admission here (obtained for futher delineation of
biliary tree to corroborate findings on CT at OSH):
Similar findings to CT from the same day with dilated CBD and
gallstones
without evidence of cholecystitis. No distal CBD stone
visualized on this
ultrasound.
Bladder US from ___ (obtained for incidental finding of bladder
thickening found on CT at OSH):
Unremarkable ultrasound of the bladder. Specifically, no mass
correlating to the irregular density along the bladder wall seen
on the recent CT from ___, reflecting contrast from
ureteral jets.
ERCP from ___:
- The CBD measured 9mm with mild tapering of the distal CBD.
- The previous distal CBD stricture appeared significant
improved from previous ERCPs.
- No filling defects were noted in the CBD and CHD.
- Opacification of the gallbladder was incomplete.
- The left and right hepatic ducts and all intrahepatic branches
were normal.
- The biliary tree was swept with an 8mm balloon starting at the
bifurcation with minimal resistance through the distal CBD. No
stones or sludge were seen.
- Otherwise normal ercp to third part of the duodenum
Brief Hospital Course:
Mr ___ is a ___ with mild COPD, HTN, recurrent pancreatitis,
cholelithiasis, and CBD stricture s/p stent placement/removal
who presented with recurrent epigastric pain and was found to
have a leukocytosis along with CBD dilitation on CT scan.
Besides the CBD dilatation, he additionally had two incidental
findings that prompted transfer for additional workup: aortic
thrombus and bladder thickening.
# Epigastric pain, CBD dilatation: He was kept NPO, given IVF,
and started on cipro/flagyl for empiric coverage of cholangitis.
His LFTs were not elevated on admission and remained normal.
ERCP team recommended proceeding directly to ERCP instead of
doing MRCP, and he underwent ERCP on ___ (findings above). No
obvious cause for his symptoms were found, though they
recommended continuing cipro for a course of ___ days and having
him seen by surgery for possible cholecystectomy, as his
symptoms could have been symptomatic cholelithiasis or perhaps a
passed stone.
# Infrarenal aortic thrombus: He was een by vascular surgery in
___. They reported that "thrombus appears to be longstanding
(seen on ___ CT scan) and stable at least for the past ___
years (appears very similar in appearance to ___ scans). He
reports this is his first time learning about the thrombus and
he doesn't want anything done about it as it does not bother
him. On questioning, he does report symptoms of claudication but
notes it does not interfere with his quality of life and that he
would not want an intervention. He smokes 1.5 PPD and has no
intention of quitting. He does have claudication though his
physical exam is indicative of good perfusion to his distal
extremities at this time. The thrombus shows no evidence of
acute worsening. His acute pain is unlikely to be caused by
this chronic thrombus. He could be optimized from a medical
perspective for his vascular issues including smoking cessation
and potentially adding a statin. Can discuss these issues
further with him if he chooses to followup with vascular
surgery." His lactate was negative on admission. He had adequate
pules while here, checked daily.
# Question of bladder thickening on CT: On further review of his
OSH CT scan, there was a question of bladder thickening. He had
5 RBCs in his urine on microscopy. Bladder ultrasound showed no
evidence of abnormality.
# Leukocytosis: Trended toward resolution with antibiotis. He
had no localizing signs or symptoms apart from his abdomen.
Blood cultures were negative at 48 hours before discharge. He
will complete a course of ciprofloxacin.
# HTN: Per OMR review, difficult to control HTN. He continued on
his home medications, including amlodipine 10 mg daily,
lisinopril 40 mg daily, metoprolol succinate 100 mg daily
# Tobacco Dependence: Declines nicotine TD, as has done on prior
admissions. I counselled him extensively, and he refused to
consider quitting.
TRANSITIONAL:
# Epigastric pain/cholelithiasis/possible cholangitis: Needs to
complete course of antibiotics, and to continue f/u with GI and
should be encouaraged to see a surgeon for cholecystectomy.
# Aortic thrombus: Can be referred to local vascular surgeon for
continued followup. Could start statin for secondary prevention
of atherosclerosis.
# Smoking: Needs continued education and counseling regarding
quitting.
# CODE: FULL (confirmed with pt - would not want prolonged
intensive measures)
BILLING:
>30 minutes spent coordinating and arranging discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown
6. Vitamin D Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Fish Oil (Omega 3) 1000 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Amlodipine 10 mg PO DAILY
7. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice
daily Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Bile duct dilatation
Cholelithiasis without evidence of choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain. You had an elevated white
blood cell count and your bile duct was enlarged. You went for
ERCP, and they did not find any cause for your enlarged bile
duct or abdominal pain. Overall, the most likely cause of your
pain was a bile duct infection which may have occurred because
of a stone that passed. You should follow up with your GI doctor
and your PCP to make sure you continue to improve, and
potentially a surgeon to have your gallbladder removed.
Followup Instructions:
___
|
10438560-DS-2 | 10,438,560 | 29,761,182 | DS | 2 | 2158-10-11 00:00:00 | 2158-10-11 19:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Reason for Consult: Headache
___ Stroke Scale - Total [1]
1a. Level of Consciousness -
1b. LOC Questions -
1c. LOC Commands -
2. Best Gaze -
3. Visual Fields -
4. Facial Palsy - 1 (left--wrong side)
5a. Motor arm, left -
5b. Motor arm, right -
6a. Motor leg, left -
6b. Motor leg, right -
7. Limb Ataxia -
8. Sensory -
9. Language -
10. Dysarthria -
11. Extinction and Neglect -
mRS: 0. ABC/2=2.5 mL (cm3). GCS 3. ICH score 1.
HPI: ___ is a ___ female with a PMHx of anxiety
who
presents with 3 days of holocephalic headache and R>L pupils.
She was in her USOH until 3 days ago at which time she had
gradual onset of holocephalic headache. It was sometimes sharp
and sometimes dull, ___ in severity at the time of interview.
Worse with sudden movements but no positional component, did not
wake her from sleep. She also noticed a feeling of alternating
warmth/coolness on her right face (behind her eye, behind her
cheek, behind her right ear, per patient). She took Tylenol,
alprazolam. She also took her home magnesium and melatonin. No
NSAIDs. No recent falls.
This morning, she awoke at 7:30am and noticed that her right
pupil was larger than her left one. She also had blurry vision
with right eye open or both eyes open. She did not notice if it
was worse far away/up close, and it involved her whole field of
vision. She went to see her PCP, who referred her to an
ophthalmologist. The ophthalmologist did not note any ocular
abnormalities (dilated exam not performed).
Her PCP referred her to ___, where she was noted
to have R>L pupil; she was otherwise thought to be
neurologically
intact. A head CT revealed an area of hyperdensity (1.2x2.1x2.2)
involving the anterior aspect of the right pons, and she was
transferred to ___. Per ___ ED, she was noted to anisocoria
and absent consensual response in right pupil when shining light
in left pupil. She was evaluated by neurosurgery who did not
recommend neurosurgical intervention.
On neuro ROS, the pt denies loss of vision,=diplopia,
dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus, and hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness, and parasthesiae. No
bowel or bladder incontinence or retention. Denies difficulty
with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation,
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Anxiety
Social History:
___
Family History:
Father with asthma. PGF with death at ___ of unknown etiology.
MGF
with kidney and prostate cancer. No strokes, brain masses, or
bleeds.
Physical Exam:
ADMISSION Physical Exam:
Vitals: T: 97.5 P: 96 R: 18 BP: 147/96 SaO2: 99RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: No WOB
Cardiac: WWP
Abdomen: ND
Extremities: No C/C/E bilaterally
Neurologic:
Please see top of note for NIHSS.
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes ___ with categ
prompts). There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: R pupil 5.5-->5 and subtly sluggish. L pupil
3-->2. Both direct and consensual response with light in either
pupil. Acuity ___ -1 on right, ___ left. Absent convergence
and accommodation in right eye. No ptosis. Gaze conjugate. EOMI
without nystagmus. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: Mild L NLFF but normal activation (wrong side)
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 and tone. No pronation, no drift. No
orbiting
with arm roll. No adventitious movements, such as tremor, noted.
No asterixis noted.
[___]
[C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, cold sensation. Made ___
errors with LLE proprioceptive testing. No extinction to DSS.
-DTRs: ___ down but this may be due to patient failure to
relax. No clonus. Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Mild sway
with
Romberg but no step.
============================================
DISCHARGE PHYSICAL EXAM
Vitals:
Tmax: 37.1 °C (98.7 °F)
Tcurrent: 37.1 °C (98.7 °F)
HR: 65 (65 - 79) bpm
BP: 129/96(105) {124/86(100) - 131/96(105)} mmHg
RR: 14 (14 - 19) insp/min
SpO2: 97%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema.
Neurologic:
-Mental Status: Alert, oriented x 3. Attentive, able to name ___
backward without difficulty. Language is fluent with intact
repetition and comprehension. There were no paraphasic errors.
Naming intact to high and low frequency objects. Able to follow
both midline and appendicular commands. Delayed recall ___ at 5
minutes.
-Cranial Nerves: Anisocoria - R pupil 5->4 and sluggish, L pupil
3->2 and brisk. Both pupils react equally to light in either
eye. No RAPD. ___ ___ OS, ___ OD. Normal convergence and
accomodation ___. VFF to confrontation. EOMI without nystagmus.
Facial sensation intact to light touch. Face symmetric at rest
and with activation. Hearing intact to conversation. Palate
elevates symmetrically. ___ strength in trapezii bilaterally.
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 Gastroc
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
-Sensory: Proprioception intact BUE. Intact to LT throughout.
-Coordination: No dysmetria on FNF bilaterally.
Pertinent Results:
___ 06:30PM BLOOD WBC-6.3 RBC-4.42 Hgb-11.7 Hct-36.5 MCV-83
MCH-26.5 MCHC-32.1 RDW-12.7 RDWSD-38.8 Plt ___
___ 06:35AM BLOOD WBC-5.7 RBC-4.51 Hgb-12.0 Hct-37.8 MCV-84
MCH-26.6 MCHC-31.7* RDW-13.1 RDWSD-39.8 Plt ___
___ 06:30PM BLOOD ___ PTT-30.0 ___
___ 06:35AM BLOOD ___ PTT-29.3 ___
___ 06:35AM BLOOD GGT-15
___ 06:35AM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:35AM BLOOD TotProt-7.3 Albumin-4.6 Globuln-2.7
Cholest-173
___ 06:35AM BLOOD %HbA1c-5.1 eAG-100
___ 06:35AM BLOOD Triglyc-75 HDL-89 CHOL/HD-1.9 LDLcalc-69
___ 06:35AM BLOOD TSH-3.8
___ 06:35AM BLOOD CRP-0.7
___ 06:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:40PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 08:40PM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-1
___ 08:40PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
Imaging:
CTA head/neck ___: 1. Acute intraparenchymal hematoma at
right cerebral peduncle is stable compared to 8 hr ago.
2. Major intracranial and cervical arteries are patent without
evidence of vascular malformation or aneurysm.
MRI brain w/wo ___: Small focus of acute hemorrhage in the
right side of the pons with surrounding edema and mild
surrounding enhancement. In presence of a chronic hemorrhage in
the left periventricular region and presence of a developmental
venous
anomaly in the left cerebellum, the pontine hemorrhage is likely
due to a cavernous malformation. However, follow-up until
resolution of hemorrhage is recommended for better assessment.
Brief Hospital Course:
Ms. ___ was admitted after presenting with anisicoria and
blurry vision in right eye only and hyperdensity on CT head.
Hyperdensity was initially thought concerning for acute
hemorrhage and she was transferred to ___. MRI was obtained,
which raised the possibility of a cavernous hemangioma
underlying the hemorrhage. Given new anisicoria, we expect that
her presentation is due to very small amount of new hemorrhage
from this cavernous hemangioma. She was also found to have a
small second cavernous hemangioma in the left corona radiata
(near basal ganglia).
She remained clinically stable and was discharged. She should
avoid anticoagulation, NSAIDs and other medications that thin
the blood, but otherwise can continue normal health management
and normal activities. She will have follow up with stroke
neurology.
She was evaluated by ___, who noted no deficits.
24 hour events prior to discharge:
- No overnight events. feeling well this am.
**Transitional issues:
- repeat MRI brain in ___ weeks
- follow up with stroke neurology after MRI, in ___ weeks
====================================================
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. ALPRAZolam 0.5 mg PO TID:PRN Anxiety
2. Omeprazole 20 mg PO BID
3. melatonin 6 Mg oral QPM
4. Magnesium Oxide 500 mg PO ONCE
Discharge Medications:
1. ALPRAZolam 0.5 mg PO TID:PRN Anxiety
2. Magnesium Oxide 500 mg PO ONCE
3. melatonin 6 Mg oral QPM
4. Omeprazole 20 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Brainstem hemorrhage
Cavernous hemangioma, brainstem (midbrain and pons) and left
corona radiata near basal ganglia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted with symptoms of right eye blurry vision and
right eye dilated pupil. These symptoms were due to a small
leakage of blood (hemorrhage) in your brainstem. You had this
hemorrhage due to a cavernous hemangioma, a small abnormal
collection of capillary blood vessels, in your brainstem. You
also have an incidental cavernous hemangioma in the left side of
your brain, adjacent to an area called the basal ganglia. We are
unable to determine why this vascular anomaly bled at this time,
and do not have clear evidence that any behavior modification or
health modifications will change your risk of having another
bleed. However, we recommend that you do not take any blood
thinner medication (anticoagulation) and restrict your use of
NSAIDs (aspirin, ibuprofen, motrin, aleve, naproxen) as these
medications thin the blood and could lead to increased risk of
bleeding. You should not perform strenuous activities for 1
month, but can continue to perform normal daily activities
during this time. Overall, there are no activity restrictions
for the future and we encourage you to live your normal life.
We do not know if you will have another bleed; if you do, we
will refer you to a neurosurgeon to consider removal of the
cavernous hemangioma.
You will have a follow up MRI brain in ___ weeks and follow up
with a stroke neurologist at ___.
It was a pleasure taking care of you during your stay.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10438851-DS-6 | 10,438,851 | 20,568,704 | DS | 6 | 2176-10-28 00:00:00 | 2176-10-28 15:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tolmetin / bupivacaine
Attending: ___
Chief Complaint:
groin pain
Major Surgical or Invasive Procedure:
___: cystoscopy and right ureteral stent placement
History of Present Illness:
___ year old female with PMH of legal blindness, nephrolithiasis
in ___, CKD III, HTN and distant history of breast cancer s/p
lumpectomy, lymph node dissection and radiation presenting with
1 day of sudden onset of right groin pain radiating to right
flank. She reports at 1 AM on ___ morning she had sudden
onset of constant right groin pain radiating to right flank,
associated with chills, nausea and vomiting. She denies dysuria
or blood in urine. The pain was constant and worse with
movement. She presented to the ED, found to have fever up to
104.8, tachycardic up to 115, leukocytosis to 14.6, lactate 3,
U/A showing hematuria and pyuria, CT scan showed right distal
ureter obstructing stone. She was given ceftriaxone, vancomycin
and Zosyn. Urology was consulted and she went to the OR for
placement of a right ureteral stent with purulent appearing
urine. In the PACU she had transient hypotension, given 100 mcg
of phenylephrine.
Currently she reports that her groin and flank pain has
resolved. She is reporting left hand numbness and pain, she
says this occurs frequently at home but usually goes away
quickly on its own and is not as severe. She denies weakness in
the hand. She denies CP, SOB, cough, diarrhea, leg swelling.
ROS: as above, ten point ROS otherwise negative.
Past Medical History:
-Blindness (L eye, congenital, R eye Toxo complications)
-Hx of breast CA (Dx ___. L breast Infiltrating lobular.
Treated with lumpectomy, axillary sampling and XRT)
-Osteoarthritis
-Nephrolithiasis in ___
-Depression
-Osteopenia
-Obesity
-Current smoker
-Diverticulosis (Severe, seen on ___ in ___
-HTN
-CKD 3
-Spinal stenosis
-Insomnia
-Sciatica
-Carpal tunnel surgery on right
-Shingles
Social History:
___
Family History:
Kidney stones in siblings and niece. ___ cancer in father and
brother. Sister with breast cancer.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.3 90 / 59 97 22 96 2L NC
Gen: Obese women in NAD, resting in bed, occasionally grimacing
and grabbing left hand
HEENT: EOMI, dry mucus membranes, OP clear
CV: tachycardic, regular, nl s1s2 no m/r/g
Resp: crackles bilaterally up to mid lung fields
Abd: Soft, NT, ND +BS
Flank: mild right sided CVA tenderness
GU: foley in place draining dark yellow urine
Ext: trace b/l pitting edema. Left hand warm with 2+ pulses,
full range of motion of fingers and wrist, normal strength,
slightly decreased sensation to light touch.
Neuro: CN II-XII intact, ___ strength throughout
Skin: warm, dry no rashes
DISCHARGE EXAM:
Vitals: 98.2PO 135 / 77R Lying 77 17 95 Ra
Gen: NAD
HEENT: EOMI, dry mucus membranes, OP clear; Eyes: legally blind,
can see shadows
CV: NS1/S2, RRR, ___ systolic murmur
Resp: CTAB
Abd: Soft, mild TTP RLQ, NABS, ND
Ext: trace bilateral edema, +2 DP pulses
Right hip: TTP over right trochanteric bursa
Neuro: CN II-XII intact, ___ strength throughout, AXOX3
MSK: ___ strength in ___
Skin: warm, dry no rashes
Pertinent Results:
ADMISSION LABS:
___ 08:29AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
___ 08:29AM URINE RBC->182* WBC-26* BACTERIA-MANY
YEAST-NONE EPI-0
___ 05:57AM LACTATE-3.0*
___ 05:12AM GLUCOSE-156* UREA N-18 CREAT-1.1 SODIUM-136
POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-22 ANION GAP-21*
___ 05:12AM ALT(SGPT)-17 AST(SGOT)-28 ALK PHOS-85 TOT
BILI-0.4
___ 05:12AM LIPASE-40
___ 05:12AM ALBUMIN-4.4 CALCIUM-9.7 PHOSPHATE-3.7
MAGNESIUM-1.5*
___ 05:12AM WBC-14.6*# RBC-4.29 HGB-13.4 HCT-38.2 MCV-89
MCH-31.2 MCHC-35.1 RDW-13.0 RDWSD-42.3
___ 05:12AM NEUTS-82.3* LYMPHS-10.3* MONOS-6.5 EOS-0.2*
BASOS-0.3 IM ___ AbsNeut-11.99*# AbsLymp-1.51 AbsMono-0.95*
AbsEos-0.03* AbsBaso-0.05
CT A/P ___:
IMPRESSION:
1. There is a 4 mm obstructive radiopaque stone in the distal
right ureter
with associated mild right hydroureteronephrosis and fat
stranding seen
surrounding the right kidney.
2. Hypodensities in the uterus is abnormal in a postmenopausal
patient.
Further follow up is recommended with nonemergent pelvic
ultrasound.
RECOMMENDATION(S): Further follow up is recommended with
nonemergent pelvic ultrasound.
CXR ___:
IMPRESSION:
1. Low lung volumes and increased airspace opacity at the left
lung base,
which may reflect atelectasis although superimposed infection
cannot be
excluded.
2. Large right perihilar consolidation and fullness is new from
___. Differential diagnosis includes consolidation, right
hilar adenopathy, or a right hilar mass. Follow up to
resolution is recommended and a CT scan is recommended if
opacity persists.
Bilateral ___ ultrasound: ___
No evidence of DVT in the right or left lower extremity veins.
Chest X-ray ___
In comparison with study of ___, there has been substantial
clearing of the bilateral pulmonary opacifications,
predominantly reflecting decrease in pulmonary vascular
congestion. Indeed, there is no evidence of elevated pulmonary
venous pressure at this time.
Small residual areas of opacification at the left base and in
the region of the right cardiophrenic angle could represent
residuals of clearing
consolidations.
CT chest w/contrast ___:
1. Top normal right hilar lymph nodes, most likely reactive in
etiology. If specific concern for malignancy or
lymphoproliferative disorder, a follow-up CT could be
considered.
2. Multiple bilateral millimetric pulmonary nodules and a small
area of
ground-glass opacity in the left upper lobe. Given a smoking
history and
background of mild centrilobular emphysema, follow up CT
examination in 12
months could be considered per ___
recommendations on
incidentally discovered nodules.
3. Severe LAD coronary artery atherosclerosis.
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-14.6* RBC-4.10 Hgb-12.3 Hct-36.9
MCV-90 MCH-30.0 MCHC-33.3 RDW-13.4 RDWSD-44.3 Plt ___
___ 07:23AM BLOOD WBC-16.4* RBC-4.10 Hgb-12.3 Hct-36.4
MCV-89 MCH-30.0 MCHC-33.8 RDW-13.4 RDWSD-43.4 Plt ___
___ 07:23AM BLOOD Neuts-48 Bands-4 ___ Monos-10 Eos-1
Baso-0 Atyps-1* Metas-4* Myelos-6* AbsNeut-8.53* AbsLymp-4.43*
AbsMono-1.64* AbsEos-0.16 AbsBaso-0.00*
___ 07:10AM BLOOD Neuts-71 Bands-1 Lymphs-8* Monos-10 Eos-4
Baso-0 ___ Metas-4* Myelos-2* AbsNeut-11.02* AbsLymp-1.22
AbsMono-1.53* AbsEos-0.61* AbsBaso-0.00*
___ 07:23AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-1+
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD ___ PTT-24.5* ___
___ 07:00AM BLOOD Glucose-96 UreaN-12 Creat-0.8 Na-140
K-4.0 Cl-103 HCO3-23 AnGap-18
___ 07:00AM BLOOD ALT-14 AST-18 AlkPhos-114* TotBili-0.3
___ 08:10AM BLOOD ALT-9 AST-11 AlkPhos-101 TotBili-0.4
___ 07:00AM BLOOD Calcium-9.2 Phos-4.2 Mg-1.6
___ 07:10AM BLOOD ___ 07:10AM BLOOD TSH-8.2*
___ 06:40AM BLOOD Free T4-1.0
___ 07:10AM BLOOD 25VitD-39
___ 05:30PM BLOOD Lactate-3.1*
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
464-7058L
___.
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
**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
___ 5:29 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed 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
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ ___ 00:00
AM ___.
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
Brief Hospital Course:
___ year old female with PMH of legal blindness, nephrolithiasis
in ___, CKD III, HTN and distant history of breast cancer s/p
lumpectomy, lymph node dissection and radiation presenting with
1 day of sudden onset of right groin pain radiating to right
flank found to have obstructing ureteral stone and E. coli
bacteremia. She is s/p cystoscopy and stent placement and will
need outpatient follow-up with urology, treated with 14-day
course of antibiotics for E.coli UTI/bacteremia.
#Obstructing nephrolithiasis
#Septic shock
Pt presented with severe sepsis with fever, tachycardia,
leukocytosis and hypotension which resolved with fluids and 1
bolus of neosynephrine. S/p cystoscopy and stent placement on
___ with grossly infected appearing urine past the stone. No
known prior history of resistant organisms but given her severe
sepsis was covered broadly with Vanc/cefepime pending cultures.
Blood and urine cultures from ___ returned with pan-sensitive
Ecoli. She was subsequently narrowed to IV Ceftriaxone, and
will complete 2 week course of abx with oral Cipro on discharge.
She will need outpatient definitive stone procedure and stent
removal, they will set up appointment as outpatient.
#Hypoxia
#Likely acute heart failure exacerbation
Pt required ___ NC O2 to maintain sat's in the ______s. Exam
initially c/f volume overload iso aggressive volume repletion
for septic shock. She auto-diuresed and did not require any
doses of Lasix.
#Large right perihilar consolidation
Initial CXR showing very concerning large right perihilar
consolidation vs. mass, given her extensive smoking history and
lack of pulmonary infectious symptoms, follow-up CXR and CT
which showed improvement but still persistent perihilar LAD,
likely reactive. However, given persistent LAD with multiple
bilateral millimetric pulmonary nodules and a small area of
ground-glass opacity in the left upper lobe, in active smoker,
would repeat CT scan in 12 months for f/u.
#Hypertension
Attempted to increase dose of amlodipine while pt hospitalized
given her elevated BP's likely iso volume overload. However,
pt's BP's decreased after approaching euvolemia and she will be
discharged on home 2.5 mg amlodipine given her history of
orthostatic hypotension at home.
#Leg pain: Checked Doppler ___ ultrasound, negative for DVT.
Patient with likely right trochanteric bursitis, discussed
outpatient physical therapy
#Insomnia: Continued trazodone
# ___ consult: patient has stairs at home, outpatient ___ at home.
Medical bed ordered for home, but per Medicare, pt does not meet
criteria and would have to pay 200/month out of pocket. Pt
declined.
Transitional issues:
-- CXR on admission showing severe ___ fullness. CT
thorax showed improvement but still persistent perihilar LAD,
likely reactive. However, given persistent LAD with multiple
bilateral millimetric pulmonary nodules and a small area of
ground-glass opacity in the left upper lobe, in active smoker,
would repeat CT scan in 12 months for f/u.
-- CT thorax also showed severe LAD atherosclerosis. Pt needs
to be started on ASA, statin, BB for presumed CAD. Can also
consider stress testing vs. TTE for further evaluation.
-- Check lipid panel as outpatient
-- Repeat TFTs in 6 weeks to reevaluate elevated TSH/Free T4.
-- Recommend pelvic ultrasound to f/u hypodensities noted on CT
abdomen/pelvis
-- Outpatient follow-up with urology for stent pull/definitive
management of nephrolithaisis
-- Outpatient routine colonoscopy per PCP recommendations
___ status: DNR/DNI (confirmed with patient)
HCP: ___ Sr (husband) ___, ___
(son) ___
___: greater than 30 minutes spent on discharge counseling
and coordination of care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lidocaine 5% Patch 2 PTCH TD QAM
2. Sertraline 25 mg PO DAILY
3. TraZODone 100 mg PO QHS
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
5. diclofenac sodium 1 % topical TID:PRN
6. amLODIPine 2.5 mg PO DAILY
7. Ranitidine 150 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*14 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. amLODIPine 2.5 mg PO DAILY
4. diclofenac sodium 1 application topical TID:PRN pain
5. Lidocaine 5% Patch 2 PTCH TD QAM
6. Ranitidine 150 mg PO DAILY
7. Sertraline 25 mg PO DAILY
8. TraZODone 100 mg PO QHS
9.Medical bed
Medical bed
Duration of need:indefinite
Diagnosis:Increased fall risk: V15.88
Discharge Disposition:
Home
Discharge Diagnosis:
Severe sepsis due to obstructing nephrolithiasis
Discharge Condition:
stable
Discharge Instructions:
Dear Ms. ___,
You were admitted with pain in your groin and fevers and were
found to have an infected kidney stone. You were seen by the
urologists and a stent was placed in your ureter and your
infection improved. You will continue antibiotics after
discharge to complete a 2 week course.
Please return if you have worsening fevers, chills,
nausea/vomiting, abdominal pain, or if you have any other
concerns.
It was a pleasure caring for you at ___ ___
___.
Followup Instructions:
___
|
10438899-DS-5 | 10,438,899 | 23,438,499 | DS | 5 | 2127-12-30 00:00:00 | 2127-12-30 20:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Lisinopril / Piroxicam
Attending: ___
Chief Complaint:
Headache/small ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o woman with PMH notable for HTN, HLP, OSA on CPAP, COPD,
and recently diagnosed DVT/PE, presenting as transfer from ___ due to concern for ___.
Per patient, she was last in her normal state of health about 2
weeks prior to presentation. At that point, she was in ___ visiting her daughter. There she began to develop left
lower extremity swelling and pain in addition to shortness of
breath, prompting visit to urgent care. At urgent care, her
workup was notable for lower extremity noninvasives showing
large
left lower extremity DVT. She was referred to the emergency
department, where she was also diagnosed with pulmonary
embolism.
Details are unavailable and the patient unfortunately does not
recall specifics regarding the nature of her PE or DVT. She was
started on rivaroxaban and patient was briefly on oxygen even
after discharge on ___ and during her plane flight home on
___. Per patient, she denied any chest discomfort or
chest pain prior
to diagnosis of her PE. She states that following initiation of
anticoagulation, her symptoms of difficulty breathing actually
began to improve. Her leg continues to be swollen.
Since arrival back home, she has felt increasingly confused and
not like her self, generally unwell. While her respiratory
symptoms have improved, she has developed increasing headache,
persistent enough to warrant presentation to ___ for
further workup.
At the ___, the patient was worked up for possible
causes of headache with noncontrast head CT. Head CT was normal
however CTA showed possible hyperdensity along sulcus concerning
for subarachnoid hemorrhage. After back-and-forth discussion
between neuroradiology and radiology, the patient was
transferred
to ___ for further care given possible need for neurosurgery
and neurologic evaluation.
While at the outside hospital, Ms. ___, unfortunately,
developed an episode of chest discomfort. She describes it as a
substernal heaviness, nonradiating, not associated with any
other
symptoms including palpitations, lightheadedness, nausea,
vomiting, abdominal discomfort, arm or jaw discomfort. She had
the symptoms for several minutes, worked up with ECG and she was
given possible dosage of sublingual nitroglycerin in addition to
morphine which immediately took her pain away. She has never
had
this pain before. She states that the pain came on shortly
after
she walked to the bathroom and back to her stretcher. At
baseline she is ambulatory independently, able to climb stairs
and do housework without any assistance. She denies ever having
any limitations in her exercise due to shortness of breath or
chest discomfort.
On arrival to ___, neurosurgery and neurology were both
consulted. They agreed aspirin would be okay to administer
despite the concern for subarachnoid hemorrhage. As such Ms.
___ did receive aspirin 162 mg x1. She has remained
pain-free since being at
___. Cardiology was consulted in the setting of this new
onset
pain as well as elevated troponin.
Otherwise, the patient has been taking her rivaroxaban without
issues. She has not missed a dose until today, when she has not
received anticoagulation due to recommendations of neurosurgery
and neurology. Of note, she does not think
there are many people in her family who have developed blood
clots apart from her daughter, who did have an extensive left
lower extremity blood clot in the setting of foot surgery.
- Labs notable for:
Creatinine of 1.2
troponin of 0.75
AST of 45 alk phos of 130 4T bili of 0.5
White blood cell count of 11.8 INR 2.1
Haptoglobin of 240
Fibrinogen of 134
ProBNP of 1898
- Imaging was notable for:
CT head:
1. Unenhanced head CT again demonstrates hyperdense material in
a
right
parietal sulcus (02:22). Volume is similar. There is no mass
effect or
midline shift.
2. CTV demonstrates patent dural venous sinuses, with arachnoid
granulations
demonstrated in the right and left transverse sinuses (3:73,
3:68
respectively).
RUQUS
Patent portal and hepatic veins.
LENIs
1. Occlusive thrombus in the left great saphenous vein extending
to the
saphenofemoral junction, with nonocclusive thrombus in the left
common femoral
and superficial femoral vein.
2. Bilateral superficial thrombophlebitis in superficial calf
veins.
3. No deep vein thrombosis in the right lower extremity.
- Patient was given:
Morphine 4 mg
Aspirin 162 mg
Acetaminophen 650 mg
Heparin drip
Vitamin K 5 mg
nicardipine drip
Upon arrival to the ICU, patient reports no chest or abdominal
pain, notes mild leg swelling, no dyspnea and has significant
word finding difficulty.Review of systems was negative except as
detailed above.
Past Medical History:
-s/p back surgery in ___
-s/p b/l tubal ligation ___
-s/p bladder surgery ___
-s/p cholecystectomy and appendectomy ___
-GERD
-Hypertension
-Lichen sclerosis
-Obesity
-Osteoarthritis
-s/p axillary sweat gland removal in ___
-Sciatica
-Obstructive sleep apnea on CPAP
-COPD
-Throat surgery ___ and ___
-Thyroid nodule ___ (normal per prior report at ___)
-Shoulder pain
-Chronic hip/knee pain
Social History:
___
Family History:
Father with DM, MGM with CAD, DM, and stroke, PGM with DM
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
Vitals: T: 98.1 HR: 80 BP: 180/90 RR: 18 SaO2: 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple.
Pulmonary: Normal work of breathing.
Cardiac: warm, well-perfused.
Abdomen: Soft, obese distention
Extremities: 1+ edema b/l ___
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to self, hospital, date. Able to
relate history very slowly. Very slow to process and produce
answers to questions. Inattentive, very slow to ___
backwards,
could not get past ___ when starting on ___. Language is
fluent with intact repetition and comprehension. Normal prosody.
There were no paraphasic errors. Able to name both high and low
frequency objects. Able to read without difficulty. No
dysarthria. Able to follow both midline and appendicular
commands. There was no evidence of apraxia.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. L inferior quadrantanopia. Visual acuity ___ OD,
___ OS. Unable to fully visualize optic disc on fundoscopic
exam.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk and tone throughout. Right pronation and
drift. No adventitious movements, such as tremor or asterixis
noted.
[___]
L 5 5 5 5 5 5 5 5 5 5 5
R 4 5 5- 4+ 4+ 5 5 5 5 5 5
Unable to assess IP due to back pain.
-Sensory: No deficits to light touch, temperature, vibration
throughout. No extinction to DSS.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 3 2 3 0 0
R 3 2 3 0 0
Plantar response was withdrawal bilaterally.
-Coordination: Dysmetria on R FNF. Clumsy rapid finger tapping
on
R hand.
-Gait: Unable to assess
==============================================
DISCHARGE PHYSICAL EXAM
General: obese woman sitting comfortably in bed, NAD
HEENT: NC/AT,
Pulmonary: no increased WOB
Cardiac: warm, well-perfused
Abdomen: soft, obese distention
Extremities: wwp, no C/C/E bilaterally
Skin: no rashes or lesions noted.
MSK: Improved ROM of neck in left and right directions. Full ROM
to flexion and extension.
Neurologic:
-MS - awake, alert, oriented to self, ___, date. Able to
relate
history with difficulty. Language is fluent. No paraphasic
errors. No dysarthria. Follows midline
and appendicular commands.
-CN: PERRL 3.5-2.5mm. VFF to confrontation with finger wiggling.
EOMI, ___ beats b/l nystagmus on lateral endgaze that
extinguish.
Intact to light touch in V1, V2, V3. No facial asymmetry.
Symmetric palate elevation. Tongue midline with good excursions.
___ trapezius b/l.
-Motor - R pronation without downward drift, much improved from
initial presentation. Orbiting.
[Delt] [Bic] [Tri] [ECR] [FEx] [IP] [Quad] [Ham] [TA] [Gas]
L 5 5 5 5 5 5- 5 5 5 5
R 4+ 5 5- 5- 5 5- 5 5 5 5
-Sensory - intact to light touch throughout
-Reflexes - 2+ bilateral biceps. ___ patellar reflexes (chronic
-Coordination - RUE Dysmetria in proportion to her RUE weakness.
-Gait - ambulates with walker, no ataxia
Pertinent Results:
Admission Labs
==============
___ 06:55AM BLOOD WBC-11.8* RBC-4.71 Hgb-14.2 Hct-43.2
MCV-92 MCH-30.1 MCHC-32.9 RDW-13.2 RDWSD-43.8 Plt ___
___ 06:55AM BLOOD Neuts-72.6* Lymphs-13.7* Monos-9.5
Eos-3.0 Baso-0.8 Im ___ AbsNeut-8.59* AbsLymp-1.62
AbsMono-1.12* AbsEos-0.36 AbsBaso-0.09*
___ 06:55AM BLOOD ___ PTT-34.1 ___
___ 06:55AM BLOOD ___
___ 06:55AM BLOOD Glucose-122* UreaN-16 Creat-1.2* Na-144
K-3.6 Cl-103 HCO3-27 AnGap-14
___ 06:55AM BLOOD ALT-26 AST-45* CK(CPK)-158 AlkPhos-134*
TotBili-0.5
___ 06:55AM BLOOD CK-MB-14* MB Indx-8.9*
___ 06:55AM BLOOD Albumin-4.2
___ 08:22PM BLOOD Calcium-9.4 Phos-3.5 Mg-1.8
___ 10:20AM BLOOD Hapto-240*
___ 06:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
Important Imaging
==================
CTA head ___
1. Unenhanced head CT again demonstrates hyperdense material in
a right
parietal sulcus (02:22). Volume is similar. There is no mass
effect or
midline shift.
2. CTV demonstrates patent dural venous sinuses, with arachnoid
granulations
demonstrated in the right and left transverse sinuses (3:73,
3:68
respectively).
RUQUS ___
Patent portal and hepatic veins.
LENIs ___
1. Occlusive thrombus in the left great saphenous vein extending
to the
saphenofemoral junction, with nonocclusive thrombus in the left
common femoral
and superficial femoral vein.
2. Bilateral superficial thrombophlebitis in superficial calf
veins.
3. No deep vein thrombosis in the right lower extremity.
MRI brain ___
1. Study is moderately degraded by motion.
2. Multiple acute to subacute infarcts are seen the bilateral
infratentorial
and supratentorial brain, some which demonstrate enhancement,
with no definite
evidence of hemorrhagic transformation. Given the distribution
these raise
the possibility of thromboembolic events. Please note septic
emboli are not
excluded on the basis of this examination.
3. Findings compatible with subarachnoid blood products as
described.
4. Paranasal sinus disease , as described.
5. Findings suggestive of nonocclusive atherosclerotic changes
of circle of
___ as described. Please note that vasospasm is not excluded
on the basis
of this motion degraded examination.
6. Question occlusion of distal left V4 segment versus artifact
as described.
7. Otherwise grossly patent circle of ___ without definite
evidence of
stenosis, occlusion or aneurysm.
Trans-esophageal Echocardiogram ___: CONCLUSION:
There is no spontaneous echo contrast or thrombus in the body of
the left atrium/left atrial appendage. The left atrial appendage
ejection velocity is normal. No spontaneous echo contrast or
thrombus is seen in the body of the right atrium/right atrial
appendage. The right atrial appendage ejection velocity is
normal. There is an intermittent left-to-right color flow
Doppler signal in the area of the foramen ovale on 2D/color
doppler c/w with a stretched PFO/tiny ASD (e.g. clip 28 and 38).
However with injection of agitated saline, right to left
shunting was not seen at rest nor with simulated valsava with
application and release of abdominal pressure while under MAC
sedation (images not saved). Overall left ventricular systolic
function is low normal. The right ventricle has low normal free
wall motion. There are simple atheroma in the aortic arch with
simple atheroma in the descending aorta to 32 cm from the
incisors. The aortic valve leaflets (3) are mildly thickened. No
masses or vegetations are seen on the aortic valve. No abscess
is seen. There is trace aortic regurgitation. The mitral valve
leaflets are mildly thickened with no mitral valve prolapse. No
masses or vegetations are seen on the mitral valve. No abscess
is seen. There is mild [1+] mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. No mass/vegetation
are seen on the tricuspid valve. No abscess is seen. There is
physiologic tricuspid regurgitation. IMPRESSION: Stretched
PFO/tiny ASD with left to right flow by 2D color doppler but no
evidence of right to left shunting with injection of agitated
intravenous saline at rest or with maneuver while under
sedation. Mild mitral regurgitation. Simple atheroma in the
descending thoracic aorta and aortic arch.
CT abd/pelvis with contrast ___: IMPRESSION:
1. Splenic infarcts suggesting embolic phenomenon.
2. Areas of mild-to-moderate cortical thinning in each kidney
suggesting
prior infectious or vascular insults; regarding some of the very
small
peripheral perfusion defects, however, more recent ischemic
insult is not
excluded.
3. Postmenopausal left ovarian cyst, incompletely assessed.
Followup pelvic ultrasound is recommended when clinically
appropriate.
CT Chest wo contrast ___: IMPRESSION:
New mild but abnormal mediastinal lymphadenopathy of uncertain
etiology and significance.
Pelvic US ___:
IMPRESSION:
The left ovary is not visualized. Otherwise, unremarkable
pelvic ultrasound.
Brief Hospital Course:
============
MICU Course
============
Ms. ___ is a ___ yo female with PMH of HTN, HLP, OSA on CPAP,
COPD and recent diagnosis of DVT/PE, who presented to ___
for confusion, had a CT concerning for ___ and was subsequently
transferred for ___, ___ evaluation and further management.
==============
ACTIVE ISSUES:
==============
#SAH in right frontal lobe
Patient with normal functional baseline status who presented
with altered mental status. Her exam is notable for R drift,
RUE weakness in upper motor neuron pattern, R dysmetria, and
significant word finding difficulties.MRI revealed multiple,
bilateral infratentorial and supratentorial enhancement with
concern for thromboembolic disease, a SAH, paranasal sinus
disease and atherosclerotic changes of circle of ___. There
was also a question of distal left V4 segment occlusion vs
artifact. Repeat imaging was stable and no new focal findings of
intraparenchymal ischemia were observed. The the patient was
placed on a heparin gtt with target PTT of 60-80. Repeat imaging
as above. TTE showed small PFO without evidence of shunting.
#HTN
The patient is on amlodipine and losartan at home. She
presented with elevated blood pressure into the 180s systolic.
This was in the setting of new subarachnoid hemorrhage. It is
unclear if the patient was taking her home antihypertensives
prior to admission.
#NSTEMI
#Elevated BNP
The patient has no known history of coronary artery disease but
is a previous smoker. The patient developed substernal chest
pressure without radiation that was associated with exertion the
outside hospital. Her chest pain resolved with nitroglycerin
and morphine. The patient has an elevated troponin that has
been
rising since admission. Troponin peaked at 0.86 on ___ and
has been downtrending until ___ when it rose to 0.79. BNP
elevation in this setting may be secondary to HTN. The patient
continues to be asymptomatic from a cardio-respiratory
standpoint. She was continued on ASA and heparin gtt throughout
her stay. High dose atorvastatin and metoprolol were initiated.
At this junction, a TTE with bubble study is pending to evaluate
for PFO.
#Left leg DVT
#PE
#Coagulopathy
Patient appeared to develop unprovoked VTE with subsequent
findings of pulmonary emboli and left lower extremity DVT. It
is unclear if the patient has ever had a hypercoagulable workup
but family history is unrevealing. Hypercoaguable workup is
largely pending at this junction. The patient initially
required supplemental O2 via NRB, but has been weaned to 2LNC
and now has an oxygen saturation of 98% and no labored
breathing. For the presumed thromboembolic disease as well as
NSTEMI, the patient was placed on a heparin gtt as above to a
target PTT of 60-80. She was then transitioned to therapeutic
Lovenox on ___ which she tolerated well. Much of her
hypercoguability work-up was pending at discharge. One of her
anti-cardiolipin antibodies was indeterminate and will be
repeated outpatient. Given her multiple clots she had a CT torso
performed on ___ which showed mediastinal LAD, splenic infarcts,
chronic renal infarcts, and a left ovarian cyst. A follow up
ultrasound of the ovarian cyst was most consistent with
post-menopausal benign cyst and no further imaging was
recommended. Interventional pulmonary was consulted for biopsy
of the lymph nodes but recommended monitoring as these could
just be reactive. She will be scheduled for outpatient CT chest
on ___ and reconsider biopsy in the future.
#COPD
The patient has a history of COPD, and despite initial higher O2
requirepments, the patient was successfully weaned to 2LNC with
saturations of 98%. The patient also received home tiotropium,
budesonide and albuterol inhalers.
#Elevated Transaminases
No evidence of portal or hepatic thrombus on RUQ U/S. LFTs were
downtrending as of ___ and the patient is pain free. This may
represent hepatic congestion in the setting of significant
hypertension vs pre-existing liver disease. Given the negative
RUQ US, it is unlikely that the patient had a hepatic thrombus.
___
Towards the end of her hospitalization she had an ___, with peak
Cr 1.6 (baseline 1.1-1.2). She received some small boluses and
encouraged to drink fluids and her Cr downtrended. Cr 1.2 at
discharge.
#Neck pain
She had neck stiffness and pain, radiating to her occipital area
and producing headache. She had acute worsening on ___ so a
NCHCT was performed which was stable. She was started on
Tizanidine and heat packs given this is most likely
musculoskeletal and her neck pain/stiffness was much improved on
discharge.
=====================
TRANSITIONAL ISSUES:
=====================
[ ] Chest CT later this month, IP and Hem/Onc will discuss
possible biopsy if
[ ] Repeat anti-cardiolipin antibodies
[ ] BP management: Losartan held I/s/o ___ and pt's BPs only
occasionally elevated. Rehab and PCP to titrate
antihypertensives with goal BP ___
==========================================
AHA/ASA Core Measures for Ischemic Stroke
==========================================
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? () Yes (LDL = 102) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
Medications on Admission:
HOME MEDICATIONS: Confirmed with patient
Furosemide 20 mg daily
Losartan 100 mg daily
Amlodipine 5 mg daily
Omeprazole 40 mg BID
Gabapentin 300 mg TID
Clobetasol 0.05% ointment 2x/week
Spiriva 2.5 mg 2 puffs daily
Symbicort 160/45 2 puffs BID
Proair HFA 90 8.5 inhaler 2 puffs Q4 prn
Claritin reditabs 10 mg daily
Calcium 600 + D BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Ichemic infarctions due to embolus
Secondary diagnoses:
NSTEMI
Hypercoagulable state
small convexal subarachnoid hemorrhage
Splenic infarcts
Renal infarcts
Deep vein thrombosis, Left leg
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of headache, vision
problems resulting from an ACUTE ISCHEMIC STROKE, a condition
where a blood vessel providing oxygen and nutrients to the brain
is blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- hypertension
- obesity
- PFO (patent foramen ovale) - a small hole in the heart
We suspect that your blood may be hypercoagulable or more likely
to form blood clots.
We are changing your medications as follows:
-discontinuing xarelto (rivaroxaban) and starting lovenox
(enoxaparin sodium)
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10439110-DS-12 | 10,439,110 | 20,896,205 | DS | 12 | 2144-08-24 00:00:00 | 2144-08-24 20:38:00 |
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:
___ year old female with a past history of COPD/asthma, moderate
OSA on nightly CPAP, with ___ diagnosis of severe diffuse TBM
with stenting ___ and stent removal ___, who presents with
difficulty breathing.
Her recent history is notable for an ___ admission for
dyspnea which was attributed to her recent diagnosis of
tracheobronchomalacia, for which she was stented on ___ after
stabilization with CPAP, nebulizers and inhalers. She clinically
improved and was able to be discharged. Per IP note, on follow
up ___ her dyspnea had improved but she had productive cough
and "throat/chest burning." She had an uneventful, planned stent
removal on ___. More broadly, per IP note, she has had ongoing
dyspnea on exertion and recurrent infections for several years,
requiring prior intubation for respiratory distress.
Also during the admission she was treated with ciprofloxacin and
flagyl for diverticulitis for a 7 day course that completed on
___. notably, she had a hospitalization at ___
___ for the same, treated with 10d PO levaquin and
flagyl.
In the ED, initial vitals: 97.7 | 74 | 155/71 | 16 | 100%RA
#LABS notable for:
- WBC 10.6 | H/H 12.2/37.0 [MCV 83] | Platelets 333
- Na 132 | K 7.3 [hemolyzed] | Cl 96 | Bicarb 21 | BUN 12 | Cr
0.8
- Repeat K 3.7
- pH 7.41 | pCO2 39 | pO2 48 | HCO3 26
- Lactate 1.9
- Trop T <0.01
#IMAGING included
-CXR: Right medial opacity/confluence over heart
border/costosternal angle
-CT ABDOMEN AND PELVIS:
1. Minimal fat stranding surrounding a few descending colonic
diverticula, improved compared to ___, likely
representing the sequela of prior diverticulitis.
2. Otherwise, no acute abnormalities within the abdomen or
pelvis.
3. 5 mm solid nodule within the right lower lobe with 2
adjacent foci of ground-glass opacification. Follow-up CT is
recommended.
4. Prominent portacaval lymph node measuring up to 1.1 cm in
short axis, nonspecific.
#PATIENT was given: ___ 17:55 IV Morphine Sulfate 4 mg
#CONSULTS included interventional pulmonology, who agreed with
admission and agreed to follow.
#Vitals on Transfer: 97.9 70 130/79 20 99% RA
Her respiratory status improved during her ED course, she was
weaned from BIPAP to room air and admitted to the medicine
service. On arrival to the floor the patient states that she
feels more comfortable than when she first arrived to the ED.
Her symptoms began suddenly today with a nonproductive cough and
shortness of breath at rest. She denies fevers and chills. This
episode feels similar to the episode when she was admitted to
___ in ___.
Past Medical History:
#RESPIRATORY
COPD/Asthma, active e-cigarette smoker
Tracheobronchomalacia s/p stenting ___
#GASTROINTESTINAL
Chronic smouldering diverticulitis
GERD
#MSK
Rheuamtoid arthritis
Fibromyalgia
Patellofemoral arthralgia of both knees
#CARDIAC
Hypertension
#ENDOCRINE
Type 2 diabetes mellitus, uncontrolled
Osteopenia
#HEME
Iron deficiency anemia
#NEURO/PSYCH
Insomnia
Restless leg syndrome
Anxiety
Polysubstance abuse Clonazepam, Vicodin, Percocet - s/p
inpatient detox in ___
Depression, h/o hospitalization
PSTD
#RENAL
Microhematuria
#DERM
Recurrent oral ulcers
Bullous disorder
Social History:
___
FAMILY HISTORY:
Mother - ___ - Type II; Hypertension
Son - ___ at age ___
Family History:
Mother recently passed of lung cancer, DM and HLD
Physical Exam:
ADMISSION PHYSICAL EXAM
=================
VITALS: 97.9 119/58 67 18 95 RA
GENERAL: Well appearing woman in no acute distress, breathing
comfortably on room air
HEENT: PERRL, EOMI, MMM oropharynx clear, no stridor
NECK: Supple without lymphadenopathy
CARDIAC: Regular rate and rhythm no murmurs rubs or gallops
LUNG: Diffuse expiratory wheezes throughout. Good air movement
on inspiration, no egophony
ABDOMEN: Soft, nontender, nondistended
EXTREMITIES: warm well perfused without clubbing cyanosis or
edema
PULSES: 2+ in radial and DP
NEURO: A+Ox3, moves all extremities.
DISCHARGE PHYSICAL EXAM
=================
Vitals: 97.8 127/76 77 18 94%RA
GENERAL: Well appearing woman in no acute distress, breathing
comfortably on room air
HEENT: PERRL, EOMI, MMM oropharynx clear, no stridor
NECK: Supple without lymphadenopathy
CARDIAC: Regular rate and rhythm no murmurs rubs or gallops
LUNG: Diffuse expiratory wheezes/rhonchi throughout. Good air
movement on inspiration, no egophony
ABDOMEN: Soft, nontender, nondistended
EXTREMITIES: warm well perfused without clubbing cyanosis or
edema
PULSES: 2+ in radial and DP
NEURO: A+Ox3, moves all extremities.
Pertinent Results:
ADMISSION LABS
==========
___ 11:48AM BLOOD WBC-10.6* RBC-4.48 Hgb-12.2 Hct-37.0
MCV-83 MCH-27.2 MCHC-33.0 RDW-14.0 RDWSD-41.2 Plt ___
___ 11:48AM BLOOD ___ PTT-28.2 ___
___ 11:48AM BLOOD Glucose-131* UreaN-12 Creat-0.8 Na-132*
K-7.3* Cl-96 HCO3-21* AnGap-22*
___ 11:48AM BLOOD cTropnT-<0.01
___ 11:58AM BLOOD ___ pO2-48* pCO2-39 pH-7.41
calTCO2-26 Base XS-0
___ 11:58AM BLOOD Lactate-1.9 K-3.7
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
DISCHARGE LABS
==========
___ 07:40AM BLOOD WBC-7.4 RBC-4.44 Hgb-11.7 Hct-37.7 MCV-85
MCH-26.4 MCHC-31.0* RDW-13.9 RDWSD-43.1 Plt ___
___ 07:40AM BLOOD Glucose-248* UreaN-15 Creat-1.0 Na-134
K-4.1 Cl-95* HCO3-20* AnGap-23*
___ 07:40AM BLOOD Calcium-9.2 Phos-4.5 Mg-2.1
IMAGING/STUDIES
===========
___ CXR
No acute pulmonary process identified. No pneumothorax
detected.
If there is ongoing concern for subtle lower lobe pneumonia,
then a lateral
chest radiograph may help for further assessment
___ CT ABDOMEN PELVIS
1. Minimal fat stranding surrounding a few descending colonic
diverticula,
improved compared to ___, likely representing the
sequela of
prior diverticulitis.
2. Otherwise, no acute abnormalities within the abdomen or
pelvis.
3. 5 mm solid nodule within the right lower lobe with 2 adjacent
foci of
ground-glass opacification. Follow-up CT is recommended.
4. Prominent portacaval lymph node measuring up to 1.1 cm in
short axis,
nonspecific.
RECOMMENDATION(S): The ___ guidelines for
pulmonary nodule
guidelines suggest for pulmonary nodules greater than 4 mm or
less than 6mm,
12 month follow-up in low-risk patients, and ___ month
follow-up in high risk
patients.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a past medical history
of tracheobronchomalacia, COPD/asthma, moderate OSA on nightly
CPAP, with ___ diagnosis of severe diffuse TBM with stenting
___ and stent removal ___, who presents with worsening
dyspnea.
#Dyspnea
#COPD Exacerbation
#Tracheobronchomalacia:
In the emergency department she was placed on BIPAP with
improvement in her symptoms. She was weaned from BIPAP to room
air and was stable on transfer to the floor. CXR was clear with
no infiltrate or volume overload. Influenza swab was negative.
Legionella urine antigen was negative. Blood cultures were drawn
and were pending at the time of discharge. She did not produce
adequate sputum for culture. She was started on solumedrol,
azithromycin, and standing duo nebulizers for COPD exacerbation.
She wore home CPAP overnight and tolerated it well. She
continued on home flutter valve and mucinex. Her respiratory
status remained stable without supplemental oxygen. She was
transitioned to home Spiriva and advair was added to her COPD
regimen. She was discharge with a prednisone taper of 40mg x 5
days with a taper by 10mg Q2 days. She will continue
azithromycin to complete a 5 day course.
#History of Diverticulitis: A CT scan was performed in the
emergency department that showed no signs of active
diverticulitis.
#Pain control: She was placed on standing tylenol and prn
tramadol for pain control. At the time of discharge she demanded
a prescription for opiate medications for control of chronic
pain. Her PMP was checked and showed that she had opiates
prescribed by multiple providers. There was a discussion that we
would not prescribe her opiates from the inpatient setting. She
was offered a trial of non-opiate medications and to stay in the
hospital but she declined and was discharged. She was counseled
to follow up with her PCP for discussion of pain control.
===========================
TRANSITIONAL ISSUES
**NEW MEDICATIONS
- Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
- Azithromycin 500mg daily (completes ___
- Prednisone daily: Taper
-40mg x 5 days (___)
-30mg x 2 days (___)
-20mg x 2 days (___)
-10mg x 2 days (___)
- Follow up CT scan for lung nodule as scheduled ___
- GI motility follow up as scheduled ___ at
8:30 AM
- Optimize pain regimen for low back pain/rheumatoid arthritis
# CONTACT: ___, boyfriend, phone: ___
# Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. BusPIRone 30 mg PO DAILY
5. Cyclobenzaprine 5 mg PO DAILY:PRN spasm
6. FLUoxetine 40 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheezing
10. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB, wheezing
11. ARIPiprazole 5 mg PO DAILY
12. MetFORMIN XR (Glucophage XR) 750 mg PO DAILY
13. Tiotropium Bromide 1 CAP IH DAILY
14. GuaiFENesin ER 1200 mg PO Q12H
Discharge Medications:
1. Azithromycin 500 mg PO Q24H
RX *azithromycin 500 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/dose 1
puff BID daily Disp #*1 Disk Refills:*0
3. PredniSONE 40 mg PO DAILY Duration: 5 Doses
Please take from ___
This is dose # 1 of 4 tapered doses
Tapered dose - DOWN
RX *prednisone 10 mg 1 tablet(s) by mouth as directed Disp #*32
Tablet Refills:*0
4. PredniSONE 30 mg PO DAILY Duration: 2 Doses
Please take ___
This is dose # 2 of 4 tapered doses
Tapered dose - DOWN
5. PredniSONE 20 mg PO DAILY Duration: 2 Doses
Please take ___
This is dose # 3 of 4 tapered doses
Tapered dose - DOWN
6. PredniSONE 10 mg PO DAILY Duration: 2 Doses
Please take ___
This is dose # 4 of 4 tapered doses
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheezing
8. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB, wheezing
9. amLODIPine 10 mg PO DAILY
10. ARIPiprazole 5 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Atorvastatin 80 mg PO QPM
13. BusPIRone 30 mg PO DAILY
14. Cyclobenzaprine 5 mg PO DAILY:PRN spasm
15. FLUoxetine 40 mg PO DAILY
16. GuaiFENesin ER 1200 mg PO Q12H
17. MetFORMIN XR (Glucophage XR) 750 mg PO DAILY
18. Metoprolol Succinate XL 100 mg PO DAILY
19. Omeprazole 20 mg PO DAILY
20. Tiotropium Bromide 1 CAP ___ DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
COPD exacerbation
Secondary:
Tracheobronchomalacia
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the ___
with shortness of breath. You were given BiPAP while you were in
the emergency department and your symptoms improved. You were
given steroids, antibiotics, and nebulizers to help with your
breathing.
When you leave the hospital, you should take the prednisone
doses as prescribed to help with the inflammation in the lungs.
You will also keep taking antibiotics for the next 4 days. You
will also take a new inhaler to help treat your COPD.
If you feel short of breath at home, you should try your CPAP
machine at home to see if it improves your symptoms. If you
still have shortness of breath, you should call your doctor or
return to the emergency department.
You should continue the mucinex twice daily and the flutter
valve twice daily.
It was a pleasure taking care of you. We wish you the best in
your health.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10439110-DS-13 | 10,439,110 | 24,938,797 | DS | 13 | 2144-09-22 00:00:00 | 2144-09-25 13:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ h/o COPD/asthma, moderate OSA on nightly CPAP, with
severe TBM (dx'd ___, stenting ___, stent removal
___, with recent admission for dyspnea for which she had
BiPAP and prednisone and nebs, re-presenting with acute onset of
coughing and dyspnea 1 hour prior to arrival.
She explains that in the past several days she has felt "totally
fine," and that today while at rest at home she began coughing
uncontrollably "until I was blue in the face" and felt that she
couldn't catch her breath. She explains that she told her
boyfriend she needed to come to the ED mainly because she was
scared she would not be capable of breathing on her own. She
cannot recall any provoking factors and she reports nothing made
her Sx better. She cannot recall when her Sx improved. Ms.
___ explains that she has had an intermittent sore throat
for the past month and one week of rhinorrhea. A CXR in the ED
was not c/f PNA. Denies fever, chills, N/V, diarrhea, recent
travel, sick contacts, chest pain, vision changes, dysuria,
hematuria.
In the ED, she received ipratroprium neb x1 and albuterol neb x1
as well as 500mg IV azithromycin. She also received 5mg
oxycodone x1 and oxycodone-acetaminophen 5mg-325mg x2. Currently
she denies pain.
Past Medical History:
#RESPIRATORY
COPD/Asthma, active e-cigarette smoker
Tracheobronchomalacia s/p stenting ___
#GASTROINTESTINAL
Chronic smouldering diverticulitis
GERD
#MSK
Rheuamtoid arthritis
Fibromyalgia
Patellofemoral arthralgia of both knees
#CARDIAC
Hypertension
#ENDOCRINE
Type 2 diabetes mellitus, uncontrolled
Osteopenia
#HEME
Iron deficiency anemia
#NEURO/PSYCH
Insomnia
Restless leg syndrome
Anxiety
Polysubstance abuse Clonazepam, Vicodin, Percocet - s/p
inpatient detox in ___
Depression, h/o hospitalization
PSTD
#RENAL
Microhematuria
#DERM
Recurrent oral ulcers
Bullous disorder
Social History:
Social History:
UPBRINGING: Originally from ___.
LIVING: Lives in apartment with boyfriend
EMPLOYMENT: ___
RELATIONSHIPS: Divorced, has long-term ___ year) boyfriend
CHILDREN: She had two children, one lives in ___ and another son
passed away ___ at the age of ___ from heroin overdose.
TOBACCO: Former 1ppd smoker with ___ year history; in "past few
years" switched to e-cigarettes and smokes 1 tank/day (roughly 1
PPD)
ALCOHOL: Denies current alcohol or recreational drug use.
OTHER SUSBTANCES: She denies current polysubstance abuse,
explains that she is "too scared" of what would happen. She
previous attempted suicide by Xanax overdose in ___ citing
son's death as reason. Is not actively suicidal.
Family History:
Family History:
Mother - ___ ___ - ___ - Type II; Hypertension
Son - ___ at age ___ - heroin overdose
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 97.5, 155/79, 78,22, 94% RA
GENERAL: AOx3, NAD. Very somnolent, alert to voice and nudge.
HEENT: Normocephalic, atraumatic. PERRLA, pupils 3mm. No
conjunctival pallor or injection, sclera anicteric and without
injection. Moist mucous membranes, good dentition. Oropharynx
is clear.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy.
CARDIAC: Distant heart sounds, RRR, no MGR. No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
Resonant to percussion.
BACK: Skin. no spinous process tenderness. no CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation in all four quadrants. Tympanic to percussion.
No organomegaly.
EXTREMITIES: Warm/well-perfused.No clubbing, cyanosis, or edema,
no sign of atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: CN2-12 intact. ___ strength througout.
DISCHARGE PHYSICAL EXAM
Vitals: T 98.8 BP 119/67 HR 72 RR 18 O2sat 98% RA
General: Alert, comfortable, engaged, sitting upright. NAD.
HEENT: PERRLA, EOMI, no thyromegaly, no lymphadenopathy, no
carotid bruit.
Lungs: Fine bibasilar crackles b/l, notably I:E 1:1. Mild
wheezes auscultated in upper lung fields b/l. Auscultation of
expiratory breath sounds limited by extremely noisy upper resp
tract transmissions.
CV: Faint heart sounds, RRR, no MGR, nl S1, prominent S2.
Abdomen: Round, soft, nondistended, nontender to deep palpation.
Normoactive bowel sounds.
Ext: Warm, pink, radial and DP pulses 2+ bilaterally.
Neuro: AOx3, CNII-XII intact, strength ___ throughout. Intact
and equal sensation, proprioception in distal extremities.
Pertinent Results:
ADMISSION LABS:
=====================
___ 06:07AM BLOOD Glucose-136* UreaN-15 Creat-0.8 Na-138
K-4.6 Cl-100 HCO3-23 AnGap-20
___ 06:15AM BLOOD Glucose-125* UreaN-22* Creat-1.5* Na-137
K-4.2 Cl-97 HCO3-21* AnGap-23*
___ 08:20AM BLOOD Glucose-111* UreaN-10 Creat-0.7 Na-139
K-4.1 Cl-100 HCO3-21* AnGap-22*
___ 06:15AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:15AM BLOOD Calcium-8.6 Phos-7.0* Mg-2.1
___ 08:20AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.0
___ 06:15AM BLOOD RheuFac-<10 CRP-29.9*
___ 06:15AM BLOOD ___
___ 09:17PM BLOOD ___ pO2-185* pCO2-50* pH-7.30*
calTCO2-26 Base XS--1 Comment-GREEN TOP
___ 08:44AM BLOOD ___ pO2-142* pCO2-44 pH-7.37
calTCO2-26 Base XS-0 Comment-GREEN TOP
___ 06:15AM BLOOD SED RATE-Test
___ 06:15AM BLOOD CYCLIC CITRULLINATED PEPTIDE (CCP)
ANTIBODY, IGG-PND
URINE STUDIES:
=====================
___ 05:53PM URINE Hours-RANDOM Creat-118 Na-149
___ 05:53PM URINE Color-Straw Appear-Clear Sp ___
___ 05:53PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:53PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 05:53PM URINE
___ 06:00AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
IMAGING:
===============
CXR ___
FINDINGS:
The lungs are well expanded and clear. No focal consolidations.
No pulmonary edema. Stable appearance of the cardiomediastinal
silhouette. No pleural effusion. No pneumothorax.
IMPRESSION:
No evidence of pneumonia.
DISCHARGE LABS:
==================
___ 08:20AM BLOOD WBC-8.3 RBC-3.95 Hgb-10.5* Hct-33.3*
MCV-84 MCH-26.6 MCHC-31.5* RDW-14.2 RDWSD-43.8 Plt ___
___ 08:20AM BLOOD Glucose-111* UreaN-10 Creat-0.7 Na-139
K-4.1 Cl-100 HCO3-21* AnGap-22*
___ 08:20AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.0
___ 06:15AM BLOOD ___
___ 06:15AM BLOOD RheuFac-<10 CRP-29.9*
___ 08:44AM BLOOD ___ pO2-142* pCO2-44 pH-7.37
calTCO2-26 Base XS-0 Comment-GREEN TOP
SED RATE
Test Result Reference
Range/Units
SED RATE BY MODIFIED 11 < OR = 30 mm/h
___
CYCLIC CITRULLINATED PEPTIDE (CCP) ANTIBODY, IGG
Test Result Reference
Range/Units
CYCLIC CITRULLINATED PEPTIDE <16 UNITS
(CCP) AB (IGG)
Reference Range
Negative: <20
Weak Positive: ___
Moderate Positive: 40-59
Strong Positive: >59
Brief Hospital Course:
Ms. ___ was admitted to ___ 2 from the ED with a CC of
acute cough and dyspnea 1 hr prior to arrival. She remained HDS
and SORA in the ED and on the floor and did not require
supplemental O2 during her stay.
#COPD exacerbation
Given her PMHx significant for COPD/asthma and severe
tracheobroncheomalacia which together make her high-risk for
complicated COPD exacerbations, in the ED she was placed on IV
azithromycin 500mg with plan 4 day course of PO azith 250mg
thereafter. She was given IV ipratroprium and albuterol nebs as
well as 40mg prednisone per standard COPD exacerbation regimen.
A CXR was not c/f PNA and ECG done on the floor in the evening
on ___ was negative for acute ischemia or heart strain, though
notable for a prolonged ___ of 467. A repeat ECG the following
day revealed a ___ of 507. Ms. ___ is on ___ prolonging
drugs. On the floor, Ms. ___ appeared well, remained
afebrile, did not require supplemental O2 at any time, and was
not in respiratory distress throughout her stay. She explained
that her current Sx were significantly milder than her usual
COPD exacerbations and given her reassuring physical exam, labs,
and vital signs, as well as her prolonged ___, azithromycin and
prednisone were d/c'd in the morning of ___ with IP in agreement
with this plan. She continued to improve after this regimen was
canceled.
#Somnolence
On admission exam Ms. ___ was very somnolent, notably
falling asleep mid-sentence, and was arousable to loud voice and
nudge. Her status was concerning for obtundation possibly
secondary to hypercapnia given her several risk factors that
predispose her to hypoventilation, namely COPD/asthma/TBM. In
the ED, Ms. ___ received a total of 15mg oxycodone over 11
hrs for back pain. Opioids likely contributed to her somnolence,
though independently were another possible source of
hypercapnia. On the floor an initial VBG was notable for
respiratory acidosis compared to a baseline ABG with normal
pH/pCO2/pO2 from ___. All narcotics were subsequently held and
Tylenol was ordered as pain control. A repeat VBG the following
day ___ reflected resolution of her respiratory acidosis, and
on exam she was notably more alert and awake.
___
Ms. ___ was incidentally found to have ___ the morning
after her arrival to the floor - ___ ED labs showed BUN/Cr of
___ and ___ AM labs revealed BUN/Cr of ___. All NSAIDs
were subsequently held to prevent decreased renal perfusion
i/s/o ___. With resolution of her COPD exacerbation the same
day, her new ___ was the primary reason for observed an
additional night. It was felt that in the absence of other RFs
and urinary Sx such as gross hematuria/frequency/urgency that
her ___ was most likely secondary to prerenal azotemia - Ms.
___ reported decreased PO intake in the days before
admission, explaining she had only had two 20oz diet cokes per
day with regular meals. Her chemistry on admission and from ___
AM labs reflected a mild metabolic acidosis that was likely
related to her ___. BUN/Cr, bicarb and phosphate normalized to
her baseline per ___ AM labs after a 1L bolus of NS given
confirming likely prerenal azotemia over 1 hr and she was felt
to be safe for discharge thereafter.
#Pain
Ms. ___ intermittently complained of low back and knee pain
in the ED and on the floor respectively, but due to her
potential for respiratory compromise all narcotic pain meds were
held and her pain was managed with Tylenol. She has a history of
rheumatoid arthritis for which she has not taken medication for
several years but occasionally receives intraarticular steroid
injections. It was felt that she may benefit from regular visits
with her rheumatologist to address potential rheum etiologies of
her pain, and a f/u appointment with Dr. ___ at
___ was made for her.
TRANSITIONAL ISSUES:
- patient should follow up with rheumatology for joint pain
- patient instructed to return the morning of ___ for her
scheduled tracheobronchoplasty
- case management working on reinstating insurance as it has
lapsed.
# CODE: full code
# Contact: ___, boyfriend, Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO TID
2. BusPIRone 30 mg PO DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. Cyclobenzaprine 5 mg PO DAILY
5. MetFORMIN XR (Glucophage XR) 750 mg PO DAILY
6. Metoprolol Succinate XL 150 mg PO DAILY
7. ARIPiprazole 5 mg PO DAILY
8. FLUoxetine 20 mg PO DAILY
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. amLODIPine 10 mg PO DAILY
11. Atorvastatin 80 mg PO QPM
12. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. BusPIRone 15 mg PO BID
2. amLODIPine 10 mg PO DAILY
3. ARIPiprazole 5 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. ClonazePAM 0.5 mg PO TID
6. Cyclobenzaprine 5 mg PO DAILY
7. FLUoxetine 20 mg PO DAILY
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. MetFORMIN XR (Glucophage XR) 750 mg PO DAILY
10. Metoprolol Succinate XL 150 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- COPD exacerbation
SECONDARY DIAGNOSIS:
- acute renal injury
- tracheobronchialmalacia
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
shortness of breath.
WHAT WAS DONE WHILE YOU WERE HERE:
- You were treated briefly with steroids and antibiotics for
possible COPD flair. You were also treated with nebulized
albuterol to help with your breathing.
- You got IV fluids for dehydration and your kidney function got
better.
WHAT YOU NEED TO DO ONCE YOU LEAVE:
- resume your home medications except for the ones that the
surgeons told you to stop prior to your procedure
- come to ___ Building ___ floor at 8am to
check-in for your procedure on ___
It was a pleasure taking care of you. We wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10439110-DS-15 | 10,439,110 | 24,517,160 | DS | 15 | 2144-12-02 00:00:00 | 2144-12-02 22:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headaches, weakness, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old woman with a history of anxiety and
severe diffuse TBM s/p tracheobronchoplasty with mesh and recent
prolonged hospital course ___ - ___, who presented with
dyspnea, headache, and intermittent lower extremity weakness.
Notably, she was most recently hospitalized in ___
initially for tracheobronchoplasty with mesh following a
successful stent trial in ___. Her post-op course was
complicated by inability to wean from the ventilator ___ ARDS,
agitation and panic attacks that resolved with Seroquel and
higher doses of her home psychiatric medications, as well as
non-infectious organizing pneumonia, for which she was placed on
prednisone with a long taper. She also required PEG and
tracheostomy tube placement given the prolonged intubation and
was weaned off the ventilator on ___ (intubated ___.
During that hospitalization, she also developed prolonged
leukocytosis and fevers as high as 103 and was treated with
vancomycin/zosyn, though no infectious source was identified and
all cultures were negative.
During the week prior to admission, she noted that she felt
tired with a sore throat and decreased appetite, and endorsed
decreased PO intake and decreased urine output during this time.
She noted 10 lbs unintentional weight loss since her discharge
on ___.
Two days prior to admission, she experienced moderate-to-severe
headaches and increased anxiety along with shaking, and had been
unable to sleep more than 2 hours per night since then. She also
had one episode of urinary incontinence in bed, though has had
urinary incontinence approximately once per month for about ___
years. She denied any hesitancy, frequency, dysuria, or
hematuria.
She had also experienced intermittent lower extremity weakness
with one fall, landing on her elbow; she denied head strike,
loss of consciousness, dizziness, or visual changes. She
endorsed some nausea since yesterday but denied fevers, chills,
rhinorrhea, orthopnea, melena, or hematochezia.
Notably, she only took 20 mg prednisone rather than her
prescribed 40 mg on ___ and ___ as she felt the prednisone was
exacerbating her fatigue and headaches. She did not take any
medications on the day of admission.
Past Medical History:
COPD
Tracheobronchomalacia s/p stent placement ___ removal ___
and
tracheobronchoplasty ___
RUE DVT ___ on warfarin until ___
Chronic smouldering diverticulitis
GERD
Rheumatoid arthritis
Fibromyalgia
Patellofemoral arthralgia of both knees
Hypertension
Carotid stenosis
T2DM, uncontrolled
Osteopenia
Iron deficiency anemia
Insomnia
Restless leg syndrome
Anxiety
Polysubstance abuse (Clonazepam, Vicodin, Percocet) s/p
inpatient
detox in ___
Depression, h/o hospitalization
PSTD
Microhematuria
Recurrent oral ulcers
Bullous disorder
H/o C-section
PEG ___ s/p removal ___
___ tube ___
Social History:
___
Family History:
Mother - COPD, CHF, DM2, HTN: deceased ___
Father - CHF
Son - ___ ___ at age ___ from heroin overdose
Physical Exam:
===============
ADMISSION EXAM
===============
VITALS: 98.3 143/72 107 20 95RA
GENERAL: Alert, oriented x4, in no acute distress
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, JVP flat
CARDIAC: Tachycardic, RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Diffuse wheezes, breathing comfortably without use of
accessory muscles, no rales or rhonchi.
ABDOMEN: soft, nontender, nondistended, +BS, no
rebound/guarding, no organomegaly though exam limited by body
habitus
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
===============
DISCHARGE EXAM
===============
VITALS: 98.6 139/66 81 18 98RA
GENERAL: Alert, oriented x4, in no acute distress
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, JVP flat
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Breathing comfortably without use of accessory muscles,
very mild end-expiratory wheezes, no rales or rhonchi.
ABDOMEN: soft, nontender, nondistended, +BS, no
rebound/guarding, no organomegaly appreciated
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
==============
ADMISSION LABS
==============
___ 06:45AM BLOOD WBC-21.9*# RBC-4.82# Hgb-13.6# Hct-41.1#
MCV-85 MCH-28.2 MCHC-33.1 RDW-15.5 RDWSD-48.4* Plt ___
___ 06:45AM BLOOD Neuts-66 Bands-0 ___ Monos-3* Eos-0
Baso-0 ___ Myelos-0 AbsNeut-14.45* AbsLymp-6.79*
AbsMono-0.66 AbsEos-0.00* AbsBaso-0.00*
___ 06:45AM BLOOD ___ PTT-36.6* ___
___ 06:45AM BLOOD Glucose-222* UreaN-11 Creat-0.8 Na-137
K-5.1 Cl-100 HCO3-15* AnGap-27*
___ 06:45AM BLOOD cTropnT-<0.01
___ 03:28PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:45AM BLOOD Calcium-9.4 Phos-4.1 Mg-1.5*
___ 03:28PM BLOOD TSH-2.2
___ 03:28PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-11
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:06AM BLOOD ___ pO2-53* pCO2-25* pH-7.47*
calTCO2-19* Base XS--2
___ 07:06AM BLOOD Lactate-4.7*
___ 10:40AM BLOOD Lactate-1.1
====================
HOSPITAL COURSE LABS
====================
___ 03:28PM BLOOD WBC-12.7* RBC-4.26 Hgb-11.6 Hct-36.8
MCV-86 MCH-27.2 MCHC-31.5* RDW-15.5 RDWSD-49.3* Plt ___
___ 07:35AM BLOOD WBC-8.7 RBC-3.93 Hgb-10.8* Hct-34.3
MCV-87 MCH-27.5 MCHC-31.5* RDW-15.3 RDWSD-49.4* Plt ___
___ 07:15AM BLOOD WBC-10.8* RBC-3.62* Hgb-10.0* Hct-31.7*
MCV-88 MCH-27.6 MCHC-31.5* RDW-15.1 RDWSD-48.9* Plt ___
___ 06:08AM BLOOD WBC-11.0* RBC-3.60* Hgb-9.7* Hct-31.4*
MCV-87 MCH-26.9 MCHC-30.9* RDW-14.9 RDWSD-47.8* Plt ___
___ 07:46AM BLOOD WBC-12.6* RBC-3.87* Hgb-10.6* Hct-33.4*
MCV-86 MCH-27.4 MCHC-31.7* RDW-14.8 RDWSD-46.7* Plt ___
___ 07:10AM BLOOD WBC-14.5* RBC-4.17 Hgb-11.7 Hct-36.8
MCV-88 MCH-28.1 MCHC-31.8* RDW-15.8* RDWSD-50.6* Plt ___
___ 03:28PM BLOOD ___ PTT-40.1* ___
___ 09:20AM BLOOD ___
___ 07:15AM BLOOD ___
___ 06:08AM BLOOD ___
___ 07:46AM BLOOD ___
___ 07:10AM BLOOD ___
==================
IMAGING AND STUDIES
==================
___ CXR: No acute cardiopulmonary process.
___ CT Head: No acute intracranial process.
___ CTA Chest:
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Substantial interval improvement of multifocal opacities
within both lungs that have nearly resolved compatible with
resolved multifocal pneumonia. No new focal opacity identified.
___ Urine Culture - < 10,000 CFU/mL
___ Blood cultures x 2 - no growth at time of discharge
Brief Hospital Course:
This is a ___ year old female with past medical history of
anxiety, diabetes type 2, severe tracheobronchomalacia with
recent admission on thoracic surgery service ___ for
R thoracotomy and tracheobronchoplasty with mesh, with
prolonged course notable for initial inability to wean form
ventilator requiring percutaneous tracheostomy tube placement,
subsequently found to have an organizing pneumonia requiring
steroid initiation, subsequently weaned from ventilator and was
able to tolerate capping of trach tube, course complicated by
RUE DVT requiring initiation of anticoagulation, readmitted ___
with new atrial tachycardia and dyspnea in setting of
self-discontinuation of her steroids, slowly improving on
steroids and rate control over course of 1 week, able to be
discharged home with services and close follow-up
# Atrial Tachycardia with L Bundle Branch Block - Patient
presented with dyspnea and was found to have new atrial
tachycardia, with HR 110s, with wide QRS consistent with a new
left bundle branch block. Patient was seen by Atrius Cardiology
who felt that felt that respiratory disease (see below) was
cause, with a rate related left bundle branch block. Patient
was started on diltiazem ___ with HR subsequently
controlled to ___. Left bundle branch block resolved with
improved heart rate. Patient discharged on 180mg long-acting
diltiazem daily
# Organizing Pneumonia
# Dyspnea
# Chronic Respiratory Failure with Hypoxia
# Chronic COPD
Patient with severe tracheobronchomalacia, with recent complex
admission on thoracic surgery service (see prior discharge
summary for full details) relating to respiratory failure
requiring prolonged ventilation and subsequent tracheostomy
placement, subsequently diagnosed with an organizing pnuemonia
and started on a steroid taper. Patient presented with dyspnea,
but with O2 sats in the mid-high ___ on RA. History notable for
patient self-discontinuing her prednisone as an
outpatient due to anxiety. Workup notable for wheezing on exam
without focal infectious process or pulmomary embolism
identified on CT-PE. Given concern regarding organizing
pneumonia as cause, patient was restarted on steroid dosing
with resolution of symptoms over subsequent 1 week. Per ___
Pulmonary, she was discharged on prednisone course and Bactrim
prophylaxis, as well as fluticasone and tiotropium. Scheduled
for outpatient pulmonology follow-up.
# Anxiety - Patient reported anxiety that she attributed to
prednisone. Increased Seroquel dosing with good response.
#Headache: Course notable for intermittent headaches consistent
with her chronic headaches for which she takes Tylenol and
occasional prn opiate at home. These resolved with IV fluids
and were felt to relate to dehydration.
# Chronic RUE DVT of axillary vein - Diagnosed ___ during
prior admission, and was on planned 3 month course of coumadin.
Coumadin was held initially as INR was supratherapeutic on
presentation. Coumadin restarted on ___ with lovenox
bridging given sub-therapeutic INR and DVT within 3 months. INR
at discharge 1.7.
# Diabetes type 2 - Per ___ recommendations
from last admission, metformin was held for one month at
previous discharge ___ out of concern for lactic acidosis in
the setting of acute illness; continued to hold this
admission--can consider restarting at follow-up; continued
glimepiride 1mg
# Hypertension - Continued clonidine
===================
TRANSITIONAL ISSUES
===================
- Follow-up with ___ cardiology to consider additional workup
and management of atrial tachycardia
- Recheck INR on ___, titration of warfarin by PCP. Was
discharged on 2.5mg daily (previously 3mg 5x/week, 1.5mg
2x/week)
- Discharged on ___ with injection education to be
discontinued when INR at goal of ___
- Continue prednisone at 30 mg WITHOUT taper and follow-up with
___ pulmonology (Dr. ___ to discuss further management
- increased Seroquel dose to 100mg QAM and 50mg QHS to help
address anxiety related to steroids. QTc 460ms
- Continue warfarin AT LEAST UNTIL ___ for ___VT treatment; defer decision to lengthen course to primary care
/ cardiology
- Would consider referrals to urology for episodes of urinary
incontinence (occurring approx. once / month over last couple
years, most recently two days prior to this admission) as well
as to Dr. ___ rheumatologist) for ongoing
management of rheumatoid arthritis
- Ipratropium nebulizer stopped this admission given concern for
contribution to tachycardia in setting of coadministration with
tiotropium
- Patient reported intermittent noncompliance with clonidine;
counseled her on importance on taking as prescribed; would
consider continued counseling regarding this
- Patient had persistently elevated WBC (___), attributed to
steroids; if does not resolve, could consider additional workup
#COMMUNICATION: ___ (sister) ___ (health
care proxy, nurse)
#CODE: Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
3. CloNIDine 0.2 mg PO Q6H
4. Docusate Sodium 100 mg PO BID
5. glimepiride 1 mg oral QAM
6. Ipratropium Bromide Neb 1 NEB IH Q6H
7. Morphine Sulfate ___ 15 mg PO Q6H:PRN Pain - Mild
8. PredniSONE 30 mg PO DAILY
This is dose # 1 of 3 tapered doses
9. PredniSONE 20 mg PO DAILY
Start: After 30 mg DAILY tapered dose
This is dose # 2 of 3 tapered doses
10. PredniSONE 10 mg PO DAILY
Start: After 20 mg DAILY tapered dose
This is dose # 3 of 3 tapered doses
11. QUEtiapine Fumarate 50 mg PO BID
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis on
prednisone
13. Vitamin D 400 UNIT PO DAILY
14. Warfarin 3 mg PO 5X/WEEK (___)
15. Warfarin 1.5 mg PO 2X/WEEK (___)
16. amLODIPine 10 mg PO DAILY
17. Atorvastatin 80 mg PO QPM
18. BusPIRone 15 mg PO BID
19. ClonazePAM 0.5 mg PO TID
20. FLUoxetine 20 mg PO DAILY
21. Fluticasone Propionate 110mcg 2 PUFF IH BID
22. Omeprazole 20 mg PO DAILY
23. Tiotropium Bromide 1 CAP ___ DAILY
Discharge Medications:
1. Calcium Carbonate 500 mg PO DAILY
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
2. Diltiazem Extended-Release 180 mg PO DAILY
RX *diltiazem HCl 180 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
3. Enoxaparin Sodium 80 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 80 mg/0.8 mL 80 mg SC twice daily Disp #*20
Syringe Refills:*0
4. PredniSONE 30 mg PO DAILY
RX *prednisone 10 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
5. QUEtiapine Fumarate 100 mg PO QAM
RX *quetiapine 100 mg 1 tablet(s) by mouth every morning Disp
#*30 Tablet Refills:*0
6. QUEtiapine Fumarate 50 mg PO QHS
7. Warfarin 2.5 mg PO DAILY
RX *warfarin 2.5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Acetaminophen 650 mg PO Q6H
9. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
10. amLODIPine 10 mg PO DAILY
11. Atorvastatin 80 mg PO QPM
12. BusPIRone 15 mg PO BID
13. ClonazePAM 0.5 mg PO TID
14. CloNIDine 0.2 mg PO Q6H
15. Docusate Sodium 100 mg PO BID
16. FLUoxetine 20 mg PO DAILY
17. Fluticasone Propionate 110mcg 2 PUFF IH BID
18. glimepiride 1 mg oral QAM
19. Morphine Sulfate ___ 15 mg PO Q6H:PRN Pain - Mild
20. Omeprazole 20 mg PO DAILY
21. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis on
prednisone
22. Tiotropium Bromide 1 CAP IH DAILY
23. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Atrial Tachycardia
# Organizing pneumonia
# Chronic Hypoxic Respiratory Failure
# Chronic RUE DVT of axillary vein
# Severe tracheobronchomalacia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with headaches, weakness, and
difficulty with breathing. You were found to have a rapid heart
beat and were given some medication to help slow it down. This
made you feel better.
Your breathing was stable on your inhalers. Your headache was
also well-controlled on Tylenol.
Cardiology saw you for the fast heart rate and recommended a new
medication called diltiazem. You will have follow-up with
cardiology after you leave (see appointments).
Physical therapy worked with you while here and felt you were
strong enough to go home.
You will have follow-up with the lung doctors, the heart
doctors, and your PCP when you leave.
You were continued on prednisone (30mg) while here. It is very
important that you continue to take this medication. Stopping it
suddenly can be very dangerous.
You were also discharged on two blood thinners and will have
your blood checked to make sure they are working. Your PCP ___
tell you when to stop the injections and how much Coumadin
(warfarin) to take. Please continue to take these medicines
until you are told to stop.
It is very important that you attend your follow-up appointments
and continue to take your medicines in order to keep getting
better!
We wish you all the best!
Your ___ medical team
Followup Instructions:
___
|
10439110-DS-16 | 10,439,110 | 23,781,724 | DS | 16 | 2144-12-27 00:00:00 | 2144-12-27 21:28:00 |
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:
___ year old woman with asthma/COPD not on home oxygen, OSA on
nocturnal CPAP, HTN, DMT2 and severe tracheobronchomalacia who
is s/p tracheobronchoplasty on ___ with a prolonged recovery
remaining in the hospital until ___ who presents with 1 day of
shortness of breath.
She had bronchoscopy on ___ with IP with Balloon dilation of
the BI; cleaning of the ___ cannula, which was
successful. She went home and was feeling well. this AM she woke
up with shortness of breath, tried nebs at home but were not
effective and came to the emergency room. She denies fevers,
chills, chest pain, leg swelling. She had mild nausea during the
shortness of breath but it resolved and her appetite has since
returned. No diarrhea. She had been treated for a UE DVT with
warfarin but just discontinued it prior to the bronch (and has
completed a 3 month course without plans to restart). She also
was being weaned from a steroid taper for organizing pneumonia
and had recently decreased her prednisone from 30mg daily to
20mg daily.
Of note, pt had a prolonged hospital course from ___.
She was admitted initially for tracheobronchoplasty with long
course c/b ARDS, respiratory failure requiring trach and PEG,
and organizing pneumonia treated with steroids with clinical and
radiologic improvement. Her trach was downsized on ___ to
Prtoex #6 and then capped on ___, and then transitioned to
___ cannula on ___.
On ___ she was readmitted for new tachycardia though to be
atrial tachycardia and dyspnea in setting of self
discontinuation of steroids.
In ED initial VS: 97.7 118 (up to 130's) 131/57 28 100%
nebulizer
IP following, likely reactive airway disease s/p bronchoscopy
Atrius cards also consulted.
1L IVF given upon arrival.
Labs notable for:
- WBC 41.5, Hgb 12.2, Plt 326, INR 1.0, Cr 0.8, Na 137, K 4.8,
Cl 98, Bicarb 18, AG 21, proBNP 708, VBG 7.34/39. Lactate 3.9 ->
6.4. UA negative.
-negative flu swab
-urine culture: pending
-blood culture: pending
Patient was given:
___ 08:43 IV MethylPREDNISolone Sodium Succ 125 mg
___
___ 08:43 IVF NS ___ Started
___ 08:43 IV Diltiazem 0 mg ___
___ 08:45 IH Albuterol 0.083% Neb Soln 1 NEB
___
___ 08:45 IH Ipratropium Bromide Neb 1 NEB ___
___ 08:49 IH Albuterol 0.083% Neb Soln 1 NEB
___
___ 08:49 IH Ipratropium Bromide Neb 1 NEB ___
___ 10:30 IV Vancomycin ___ Started
___ 10:30 PO/NG ClonazePAM .5 mg ___
___ 11:24 IV Piperacillin-Tazobactam ___
Started
___ 11:24 IV Diltiazem 10 mg ___
___ 11:25 IH Albuterol 0.083% Neb Soln 1 Neb ___
___ 11:25 IH Ipratropium Bromide Neb 1 Neb ___
___ 11:39 IV Vancomycin 1 mg ___ Stopped (1h
___
___ 11:40 IV Piperacillin-Tazobactam 4.5 g ___
Stopped (___)
___ 11:41 IVF NS 1 mL ___ Stopped (2h ___
___ 15:32 PO Ibuprofen 600 mg ___
Imaging notable for: CXR with interval worsening of pulmonary
edema.
Consults: ___ cardiology
On arrival to the MICU, patient reported that her symptoms had
improved significantly with nebulizers but breathing still not
at baseline. Complaining o headache and tremors she feels are
related to prednisone. Denies other symptoms.
Past Medical History:
Tracheobronchomalacia s/p TBP ___
HTN
Hypercholesterolemia
COPD/asthma
Moderate obstructive sleep apnea (AHI 29)
DMT2
GERD
RUE DVT ___
Rheumatoid arthritis
Restless leg syndrome
Depression
Polysubstance abuse - Clonazepam, Vicodin, Percocet - s/p
inpatient detox
Social History:
___
Family History:
Mother - COPD, CHF, DM2, HTN: deceased ___
Father - CHF
Son - ___ ___ at age ___ from heroin overdose
Physical Exam:
Admission exam:
VITALS: afebrile, 107 156/49 24 95%
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: breathing comfortably, inspiratory and expiratory
wheezes. trach in place
CV: tachycardic, 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 abnormalities
NEURO: AAOx3, moves all extremities and face grossly symmetric
ACCESS: PIVs
DIscharge Exam
Vital Signs per POE
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Strong inspiratory effort, no wheezes or crackles
appreaciated, trach in place
Cardiac; RRR
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 abnormalities
NEURO: AAOx3, moves all extremities and face grossly symmetric
Pertinent Results:
Admission labs:
___ 08:30AM BLOOD WBC-41.5*# RBC-4.33 Hgb-12.2 Hct-38.5
MCV-89 MCH-28.2 MCHC-31.7* RDW-15.8* RDWSD-51.0* Plt ___
___ 08:30AM BLOOD Neuts-82* Bands-1 Lymphs-15* Monos-2*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-34.45*
AbsLymp-6.23* AbsMono-0.83* AbsEos-0.00* AbsBaso-0.00*
___ 08:30AM BLOOD ___ PTT-23.2* ___
___ 08:30AM BLOOD Glucose-297* UreaN-11 Creat-0.9 Na-127*
K-4.0 Cl-90* HCO3-15* AnGap-26*
___ 11:38PM BLOOD ALT-32 AST-16 LD(LDH)-296* AlkPhos-74
TotBili-0.4
___ 08:30AM BLOOD proBNP-708*
___ 03:45PM BLOOD CK-MB-3 cTropnT-<0.01
___ 11:38PM BLOOD Calcium-9.4 Phos-4.6* Mg-1.9
___ 08:44AM BLOOD ___ pO2-61* pCO2-39 pH-7.34*
calTCO2-22 Base XS--4
___ 08:44AM BLOOD Lactate-3.9*
___ 03:45PM BLOOD Lactate-6.4* K-4.7
___ 11:54PM BLOOD Lactate-0.7
___ 08:44AM BLOOD O2 Sat-87
___ 02:00PM URINE Color-Straw Appear-Clear Sp ___
___ 02:00PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 02:00PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 12:40PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
Discharge labs:
___ 07:14AM BLOOD WBC-18.3* RBC-3.89* Hgb-10.9* Hct-33.7*
MCV-87 MCH-28.0 MCHC-32.3 RDW-15.3 RDWSD-48.5* Plt ___
___ 07:14AM BLOOD Plt ___
___ 07:14AM BLOOD Glucose-146* UreaN-20 Creat-0.7 Na-134
K-4.0 Cl-91* HCO3-29 AnGap-18
___ 07:14AM BLOOD Calcium-9.5 Phos-4.4 Mg-2.0
Imaging:
CXR ___
Tracheostomy tube is unchanged. There is unchanged
cardiomegaly. There is
slight elevation of the right hemidiaphragm with atelectasis at
the right lung base. There is improvement of the prominent
interstitial markings since the prior study. No definite
consolidation or pneumothoraces are seen.
Brief Hospital Course:
___ year old woman with a PMH of asthma/COPD (not on home
oxygen), OSA on nocturnal CPAP, HTN, DMT2 and severe
tracheobronchomalacia who is s/p tracheobronchoplasty on ___
with a prolonged recovery remaining in the hospital until ___
who presented with 1 day of shortness of breath after outpatient
balloon dilation of trachea on ___ treated for presumed COPD
exacerbation in the setting of recent IP procedure and
tachycardia.
ACTIVE ISSUES
============
# Dyspnea/Acute Respiratory Distress:
# COPD
# TBM
She was initially admitted to the ICU given respiratory distress
and concurrent tachycardia requiring IV rate control as below.
Overall, her worsening dyspnea was thought to be likely reactive
in the setting of recent IP balloon dilation of trach along with
concurrent COPD exacerbation. She was treated initially with IV
methypred and then PO prednisone taper. By the time of discharge
she was tapered to 30mg PO Prednisone daily to be continued
until outpatient follow up. She was given a 5 day treatment
course of azithromycin. Home inhalers were continued and
respiratory status improved. While on the floor, she was weaned
from O2 and was not SOB with ambulation.
# Atrial Tachycardia with L Bundle Branch Block: EKG this
admission consistent with prior documented atrial tachycardia
with rate-related LBBB. While in the ED, she required IV dilt
for rate control, necessitating ICU admission. Her rates
stabilized and she was transitioned back to her home dose of
Diltiazem ER with rates in 80-90s at rest and with ambulation
the remainder of the admission.
# Lactate Elevation: The patient had initial lactate elevation
likely due to albuterol administration. This quickly normalized
with cessation of this medication.
CHRONIC ISSUES
==============
# HTN: Continued home clonidine 0.2 q6H
# DM: Held home glimepiride. Managed on an insulin sliding scale
during admission. Advised patient to follow up with PCP for
diabetes monitoring in setting of increased steroid regimen.
# Depression/anxiety: Continued home clonazepam 0.5 TID,
buspirone 30mg daily, and fluoxetine 60mg PO daily.
# Hyperlipidemia: She was continued on home atorvastatin 80mg
TRANSITIONAL ISSUES
===================
Pulmonology Follow up, with repeat PFTs scheduled on ___
- Prednisone taper: 40mg ___, then 30mg daily starting
___ with taper to be determined in pulmonology follow uo
- Azithromycin: To complete 5 day treatment course on ___
Intervention Pulmonology Follow Up
- ___ Trach stoma downsized to ___.
- Follow up with Dr. ___ as scheduled on ___
PCP ___ up
- Recommend close monitoring of blood glucose in the outpatient
setting given increased steroids. Patient required insulin for
control while hospitalized.
# Communication: ___ (sister) ___ (health
care proxy, nurse)
#CODE: Full code
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
2. Atorvastatin 80 mg PO QPM
3. BusPIRone 15 mg PO BID
4. ClonazePAM 0.5 mg PO TID
5. CloNIDine 0.2 mg PO Q6H
6. FLUoxetine 20 mg PO DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Omeprazole 40 mg PO DAILY
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis on
prednisone
10. Tiotropium Bromide 1 CAP IH DAILY
11. Diltiazem Extended-Release 240 mg PO DAILY
12. glimepiride 1 mg oral QAM
13. PredniSONE 30 mg PO DAILY
14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
Discharge Medications:
1. Azithromycin 250 mg PO Q24H Duration: 1 Dose
Continue taking until ___
RX *azithromycin 250 mg 1 tablet(s) by mouth once Disp #*1
Tablet Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Severe pain or
headache
RX *oxycodone 5 mg 1 capsule(s) by mouth daily Disp #*3 Capsule
Refills:*0
3. PredniSONE 30 mg PO DAILY
RX *prednisone 10 mg 3 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
5. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
6. Atorvastatin 80 mg PO QPM
7. BusPIRone 15 mg PO BID
8. ClonazePAM 0.5 mg PO TID
9. CloNIDine 0.2 mg PO Q6H
10. Diltiazem Extended-Release 240 mg PO DAILY
11. FLUoxetine 20 mg PO DAILY
12. Fluticasone Propionate 110mcg 2 PUFF IH BID
13. glimepiride 1 mg oral QAM
14. Omeprazole 40 mg PO DAILY
15. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis on
prednisone
16. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Reactive airway exacerbation
COPD Exacerbation
Secondary Diagnosis
Tracheobronchomalacia
Atrial Tachycardia
Hypertension
Diabetes
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of ___ during your
hospitalization. Briefly, ___ were hospitalized with shortness
of breath and fast heart rates after your procedure with the
lung doctors. ___ were in the ICU for monitoring but improved.
___ were started on a higher dose of prednisone and should
follow up with your lung doctors on ___ when ___
leave the hospital to discuss the course of this medication. ___
were also started on an antibiotic to treat a possible infection
which ___ will continue for several more days. Your heart rate
was controlled with your medication and ___ were able to
ambulate without worsening in your breathing or heart.
We wish ___ the best,
Your ___ Treatment Team
Followup Instructions:
___
|
10439110-DS-19 | 10,439,110 | 26,698,258 | DS | 19 | 2145-02-09 00:00:00 | 2145-02-09 20:51:00 |
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, cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old woman with asthma/COPD not on
home oxygen, OSA on nocturnal CPAP, HTN, DMT2 and severe
tracheobronchomalacia who is s/p tracheobronchoplasty
on ___ complicated by persistent severe hypoxemic
respiratory
failure s/p trach/PEG on ___ and now with ___ who
presents
with dyspnea and wheezing.
She reports that for the past few, approximately three, days she
has been getting short of breath with activity such as getting
up and going to bathroom. Also having increased cough and maybe
more secretions. No change in color of secretions. Denies any
other symptoms, specifically fever, chills, sick contacts,
recent travel. Her boyfriend has not had any sick contacts. She
has had no change in PO intake recently. Came to the ED for
these symptoms.
In the ED, initial VS were
VS: T 96.0
HR 64
BP 120/48
R 22
O2 96% RA.
Exam notable for diffuse wheezing
Labs showed: WBC 15.7, Cr 1.8 (baseline 0.7)
Imaging showed: new patchy right basilar opacities
Received:albuterol and ipratropium nebs, azithromycin 500mg,
methylprednisolone 125mg, ___, home medications
(aspirin, omeprazole, buspirone, clonazepam, clonidine,
fluticasone, diltiazepam)
Interventional Pulmonary was consulted and felt the ___ was
___ without erythema or secretions. They recommended
no interventions, but admission for asthma treatment with nebs
and steroids, course of antibiotics to treat possible pneumonia
and continued management of ___.
On arrival to the floor, patient reports the history above.
REVIEW OF SYSTEMS: denies fever, abdominal pain, dysuria, chest
pain, change in urination.
Past Medical History:
Tracheobronchomalacia s/p TBP ___
Organizing pneumonia on prednisone taper
HTN
Hypercholesterolemia
COPD/asthma
Moderate obstructive sleep apnea (AHI 29)
DMT2
GERD
RUE DVT ___, off coumadin
Rheumatoid arthritis
Restless leg syndrome
Depression
Polysubstance abuse - Clonazepam, Vicodin, Percocet - s/p
inpatient detox
Social History:
___
Family History:
Mother: Lung cancer, CHF
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
VS: 97.4 PO 108/52 58 22 92 Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: no JVD. T tube in place with no surrounding erythema, no
secretions presently
HEART: distant heart sounds, RRR, S1/S2, no murmurs, gallops, or
rubs
LUNGS: diffuse inspiratory and expiratory wheezing. few crackles
at R base
ABDOMEN: obese, nondistended, +BS, nontender in all quadrants,
no rebound/guarding
EXTREMITIES: trace ___ edema, moving all 4 extremities with
purpose
PULSES: 2+ DP pulses bilaterally
NEURO: grossly intact, A&Ox3
SKIN: no significant rash
DISCHARGE PHYSICAL EXAM
======================
VS: 97.8 PO 172 / 73 93 18 94 Ra
GENERAL: resting comfortably, NAE.
HEENT: AT/NC, anicteric sclera, pink conjunctiva
NECK: T tube in place with no surrounding erythema, no
secretions presently
HEART: distant heart sounds, RRR, no murmurs
LUNGS: no accessory muscle use, diffuse coarse breath sounds
ABDOMEN: obese, soft, NDNT
EXTREMITIES: warm, no edema.
NEURO: A&Ox3
Pertinent Results:
ADMISSION LAB RESULTS
====================
___ 07:50AM BLOOD ___
___ Plt ___
___ 07:17AM BLOOD ___
___ Plt ___
___ 07:50AM BLOOD ___
___ Im ___
___
___ 06:40AM BLOOD ___
___
___ 07:50AM BLOOD ___
___
___ 07:17AM BLOOD ___
___
___ 07:17AM BLOOD ___
___ 06:47AM BLOOD ___
DISCHARGE LAB RESULTS
====================
___ 06:50AM BLOOD ___
___ Plt ___
___ 06:50AM BLOOD ___
___
STUDIES AND IMAGING
=================
-CXR ___
IMPRESSION:
1. Cardiomegaly and widening of the mediastinum, which may in
part be due to
low lung volumes. Repeat imaging with increased inspiratory
effort is
recommended, to ensure that this finding is technical.
2. New patchy right basilar opacities, findings could represent
atelectasis or
developing infection, possibly secondary to aspiration.
___ ECHOCARDIOGRAM:
The left atrium is elongated. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. The right ventricular free
wall is hypertrophied. Right ventricular chamber size is normal
with normal free wall contractility. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion. There is
an anterior space which most likely represents a prominent fat
pad.
IMPRESSION: Normal global biventricular systolic function. Mild
aortic regurgitation. Moderate mitral regurgitation.
MICROBIOLOGY
============
___ 6:03 pm SPUTUM: No growth
Brief Hospital Course:
___ year old woman with asthma/COPD not on home oxygen and severe
tracheobronchomalacia who is s/p tracheobronchoplasty on ___
complicated by persistent severe hypoxemic respiratory failure
s/p trach/PEG on ___ recently exchanged for ___, who
presented with roughly three days of dyspnea on exertion and
increased cough. She was treated for a COPD exacerbation with
improvement in symptoms. Ambulatory O2 saturation was 95% on day
of discharge.
#Asthma/COPD Exacerbation:
Unclear precipitant, thought more likely viral than bacterial if
infectious. She received 125 mg IV methylpred in the ED and was
started on PO pred 40 daily for total ___nd
azithromycin (___). Treated with standing DuoNebs, flutter
valve, home fluticasone on floor. IP was consulted in the ED and
felt there were no acute problems with her T tube; it was
managed with albuterol and Mucomyst nebs as well as saline
rinse/suction.
#Atrial tachycardia with ___ LBBB
Patient reported a single episode of ___ chest/jaw pain
with exertion, relieved by rest, consistent with angina. ECG
showed sinus vs. atrial tachycardia with ___ LBBB,
previously documented in Atrius system. LBBB appears
___ -- not present on prior ECGs this admission with
lower HRs. No evidence for ACS, trops negative. This was likely
in the setting of holding home metoprolol and home diltiazem.
Patient remained in normal sinus rhythm when her home rate
control medications were ___.
___: (from baseline Cr of ~0.7). Felt to be prerenal as
improved from 1.8 to 1.2 with 1L IVFs. PO fluids were
encouraged.
#DM: A1C (checked because has been on steroids for months) was
8.3%. Difficult to control with increased steroid dose. Started
on glargine 15 units QHS on ___ in addition to Humalog sliding
scale in house. She was discharged on her home glimepiride.
#HTN: Home meds were initially held due to concern for
infection. The patient remained normotensive during admission,
and hypertensive on day of discharge. Her home meds were resumed
upon discharge.
#Depression:
#Anxiety: continued home buspirone, fluoxetine, quetiapine,
clonazepam
#GERD: continued home omeprazole
TRANSITIONAL ISSUES
====================
#Prednisone taper schedule:
___: 40mg daily
___ - ___: 30mg daily
___ - ___: 20mg daily
___: 10mg daily
___: return to prednisone 2.5mg daily until directed PCP
- ___ azithromycin for total 5 day course (___)
- Please continue to monitor blood pressure. Her home
chlorthalidone and clonidine were resumed on day of discharge as
patient became hypertensive in the hospital.
#CODE: full (confirmed)
#CONTACT: HCP ___ sister ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. BusPIRone 15 mg PO BID
5. Chlorthalidone 25 mg PO DAILY
6. CloNIDine 0.2 mg PO Q6H
7. Diltiazem ___ 300 mg PO DAILY
8. FLUoxetine 60 mg PO DAILY
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Omeprazole 40 mg PO DAILY
12. PredniSONE 2.5 mg PO DAILY
13. QUEtiapine Fumarate 100 mg PO QHS
14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis on
prednisone
15. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
16. ClonazePAM 0.5 mg PO TID
17. glimepiride 2 mg oral QAM
18. Tiotropium Bromide 1 CAP IH DAILY
19. GuaiFENesin ER 1200 mg PO Q12H
20. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB
21. Codeine Sulfate ___ mg PO Q6H:PRN cough
Discharge Medications:
1. Azithromycin 250 mg PO Q24H Duration: 3 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
2. ___ mL PO Q6H:PRN cough
RX ___ [Adult Cough Formula DM Max]
200 ___ mg/5 mL 5 mL by mouth Every six hours Refills:*0
3. PredniSONE 10 mg PO DAILY
Please follow prednisone taper schedule.
Tapered dose - DOWN
RX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*40 Tablet
Refills:*0
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
5. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. BusPIRone 15 mg PO BID
10. Chlorthalidone 25 mg PO DAILY
11. ClonazePAM 0.5 mg PO TID
12. CloNIDine 0.2 mg PO Q6H
13. Codeine Sulfate ___ mg PO Q6H:PRN cough
14. Diltiazem ___ 300 mg PO DAILY
15. FLUoxetine 60 mg PO DAILY
16. Fluticasone Propionate 110mcg 2 PUFF IH BID
17. glimepiride 2 mg oral QAM
18. GuaiFENesin ER 1200 mg PO Q12H
19. Metoprolol Succinate XL 25 mg PO DAILY
20. Omeprazole 40 mg PO DAILY
21. QUEtiapine Fumarate 100 mg PO QHS
22. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis on
prednisone
23. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: COPD Exacerbation
Secondary: Acute Kidney Injury, 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:
Dear Ms. ___,
You were seen at ___ for cough and shortness of breath.
What did we do for you?
========================
- We treated you for a COPD/asthma exacerbation with steroids
and antibiotics.
- You had a decrease in kidney function that improved with IV
fluids.
- Your blood sugar was difficult to control on steroids.
What do you need to do?
=======================
-Follow up with your primary doctor ___ information
below)
-Follow up with the Interventional Pulmonology doctors for
___ of your T tube. Please call ___ to schedule
an appointment.
-Take your azithromycin antibiotics through ___
-Please complete a Prednisone taper:
___: 40mg daily
___ - ___: 30mg daily
___ - ___: 20mg daily
___: 10mg daily
___: return to prednisone 2.5mg daily until directed by your
primary care doctor
- While you are taking the higher doses of prednisone, continue
to check your blood sugars often. If your blood sugars remain
above 300, please call your primary care doctor.
-Be sure you are keeping up with fluids and staying hydrated at
home.
We wish you the very best!
Your ___ Care Team
Followup Instructions:
___
|
10439110-DS-20 | 10,439,110 | 22,835,521 | DS | 20 | 2145-03-10 00:00:00 | 2145-03-11 21:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Bronchoscopy (___) - showed granulation tissue and thin
secretions
History of Present Illness:
Ms. ___ is a ___ yo F with HTN, DMT2, asthma/COPD not on home
oxygen, OSA previously on CPAP, and severe TBM s/p TBP on
___ complicated by persistent severe hypoxemic respiratory
failure s/p trach/PEG on ___, now s/p T-tube for cervical
tracheal malacia who presented to the ___ today with worsening
dyspnea and mucus plugging for the last 3 days.
At her IP appointment this AM, she was noted to be dyspneic with
RR ___ the ___, and there was concern for mucous plugging.
Patient ran out of her Mucomyst today, but feels like these
symptoms have been steadily getting worse for last three days.
She denies any fevers, chills or change ___ her suction
secretions. She denies any sore throat, cough, increased sputum
production, chest pain, abdominal pain, changes ___ bowel or
bladder habits.
Of note, she was recently hospitalized from ___ for COPD
exacerbation for which she received steroids and azithromycin.
Previous steroid taper per discharge summary:
#Prednisone taper schedule:
___: 40mg daily
___ - ___: 30mg daily
___ - ___: 20mg daily
___: 10mg daily
___: return to prednisone 2.5mg daily until directed PCP
___ the ___, initial vitals: 98.6 | 124 | 133/65 | 38 | 94%
- Exam notable for: tachypnea
- Labs notable for K of 2.6 and WBC of 19.4
- Imaging notable for a CXR with low lung volumes. Bibasilar
subsegmental atelectasis with trace right pleural effusion. No
definite focal consolidation to suggest pneumonia.
- IP was consulted and were able to pass suction catheter down
the distal limb and to the carina without difficulty and then up
the proximal limb without difficulty. Small amount of mucus
aspirated. They recommended unasyn to cover for tracheitis, and
admission to medicine.
- ___ ___, patient was given 40mEq K @ 250ml/hr and Unasyn 3g.
Patient also received Ondansetron 4mg IV, lorazepam 0.5mg,
oxycodone 5mg, and Ibuprofin 800mg PO
- Vitals prior to transfer: 98.6 | 118 | 151/71 | 16 | 98% RA
On the floor, Patient endorses DOE for last three days,
associated with a racing heart. She says this feels different
than her COPD exacerbation last month ___ that her SOB is worse,
and she has had some significant mucus plugging of her T-tub
which is frightening for her.
Past Medical History:
Tracheo/cervical bronchomalacia s/p TBP ___, trach/PEG on
___, and T-tube placement.
HTN
Hypercholesterolemia
COPD/asthma
Moderate obstructive sleep apnea (AHI 29)
T2DM
GERD
RUE DVT ___
Rheumatoid arthritis
Restless leg syndrome
Depression
Polysubstance abuse - Clonazepam, Vicodin, Percocet - s/p
inpatient detox
Social History:
___
Family History:
Mother: Lung cancer, CHF
Physical Exam:
Admission Exam:
=====================
Vital Signs: 98.6 | 144/77 | 113 | 24 | 97 2L
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, but difficult to appreciate. No
Lymphadenopathy
CV: increased rate, normal rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Expiratory wheezes diffusely, louded ___ RUL. Crackles at
left lower base
Abdomen: Soft, non-distended. Some tenderness to deep palpation
___ LUQ. Bowel sounds present, no organomegaly, no rebound or
guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
Discharge Exam:
=====================
Vitals: 98.1F BP 124/63 HR 80 RR 20 96% on RA
General: NAD. Sitting ___ bed.
HEENT: Round face. NC/AT. MMM.
Neck: T-tube ___ place.
Lungs: Normal respiratory effort. Diffuse scattered rhonchi over
bilateral lung fields.
CV: RRR with normal S1 + S2. Mildly distant heart sounds. No
murmurs, rubs, or gallops.
Abdomen: Soft, non-tender, non-distended, normoactive BS.
Ext: No ___ edema or erythema. SCDs ___ place.
Neuro: A&Ox3. Moves all extremities.
Psych: Normal Mood and affect.
Pertinent Results:
Admission Labs:
================================
___ 12:00PM BLOOD WBC-19.4*# RBC-4.26 Hgb-11.0* Hct-35.2
MCV-83 MCH-25.8* MCHC-31.3* RDW-15.4 RDWSD-45.9 Plt ___
___ 12:00PM BLOOD Neuts-77.8* Lymphs-11.5* Monos-9.0
Eos-0.8* Baso-0.3 Im ___ AbsNeut-15.10*# AbsLymp-2.24
AbsMono-1.75* AbsEos-0.16 AbsBaso-0.06
___ 12:00PM BLOOD Plt ___
___ 12:00PM BLOOD Glucose-232* UreaN-8 Creat-0.9 Na-138
K-2.6* Cl-96 HCO3-23 AnGap-22*
___ 07:02AM BLOOD ALT-42* AST-39 LD(LDH)-291* AlkPhos-106*
TotBili-0.6
___ 07:02AM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 11:21PM BLOOD Calcium-8.0* Phos-3.7 Mg-1.4*
___ 12:00PM BLOOD GreenHd-HOLD
___ 12:00PM BLOOD
___ 12:27PM BLOOD ___ pO2-29* pCO2-46* pH-7.38
calTCO2-28 Base XS-0 Intubat-NOT INTUBA
___ 06:19PM BLOOD K-2.9*
Discharge Labs:
================================
___ 06:19AM BLOOD WBC-12.8* RBC-3.63* Hgb-9.3* Hct-30.3*
MCV-84 MCH-25.6* MCHC-30.7* RDW-15.7* RDWSD-47.6* Plt ___
___ 06:19AM BLOOD Glucose-148* UreaN-19 Creat-0.9 Na-138
K-3.4 Cl-93* HCO3-28 AnGap-20
___ 06:19AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.8
Micro:
================================
___ 9:06 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
___: Legionella urine Antigen- Negative
___: Urine culture: negative
Blood Cultures pending
___ 9:55 am BRONCHIAL WASHINGS
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
RESPIRATORY CULTURE (Final ___:
>100,000 CFU/mL Commensal Respiratory Flora.
FUNGAL CULTURE (Preliminary):
YEAST. OF TWO COLONIAL MORPHOLOGIES.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). RARE GROWTH.
Imaging:
========================
CXR ___ Impression:
Low lung volumes.Bibasilar subsegmental atelectasis with trace
right pleural effusion. No definite focal consolidation to
suggest pneumonia.
Brief Hospital Course:
Ms. ___ is a ___ y/o woman with PMH notable for HTN, T2DM,
asthma/COPD not on home O2, OSA previously on CPAP, and severe
TBM s/p TBP on ___ c/b persistent severe hypoxemic
respiratory failure requiring trach/peg on ___, now
converted to T-tube, admitted for worsening dyspnea and mucus
plugging for the past 3 days. She was initially admitted to
medicine for what was felt to be tracheitis, for which she was
started on unasyn. Otherwise, she received IV Zofran, lorazepam,
oxycodone, and ibuprofen for pain control. On the night of
admission, the patient developed worsening respiratory distress
with increasing WOB per floor RN, but was maintaining saturation
and stable VBGs. She was then transferred to the ICU for further
care due to concern for tiring out and worsening distress. IP
___ patient and noted a small subglottic lesion, likely
granulation tissue, but no significant mucous plugs that may be
causing her symptoms. Sputum cx grew GPC ___ pairs. She was
started on azithromycin. SHe was also treated with Lasix and
methylprednisolone and her respiratory status improved, so she
was then transferred to the floor on ___.
Floor Course:
#Shortness of breath/Increased work of breathing:
Patient presented with increased work of breathing. She was
diagnosed with possible tracheitis and started on unasyn. On day
1, she developed worsening SOB (though satting well on 2L) so
was transferred to ICU for a night due to concern for tiring out
from persistent tachypnea. Bronchoscopy (___) was unremarkable
though sputum grew GPC and she was febrile so vancomycin and
azithromycin were added. Both were discontinued one day later
after final speciation showed respiratory flora. She was also
treated with methylprednisolone 60 mg x 2 doses and lasix 40 mg
IV x 1 due to elevated BNP ___. It appeared that these
significantly improved her breathing. She was weaned to room air
and switched to Augmentin with plan to complete a 7 day course
for tracheitis on ___. Ultimately, it was believed that her
SOB was due to both tracheitis and perhaps mild fluid overload.
#Hyperglycemia: Following the administration of steroids, the
patient became hyperglycemic to the 400s, requiring increasing
dosing of NPH and SSI. Patient refused metformin due to a
previous history of elevated LFTs while on metformin.
Ultimately, she was still poorly controlled with NPH 20 units
BID although with significant intake of sugary beverages. She
was switched back to her home glimepiride 2 mg daily upon
discharge and advised to avoid sugar intake.
#Subglottic Granulation Tissue: Granulation tissue initially
noted on bronchoscopy. ENT was consulted and recommended
outpatient follow-up with Dr. ___ for further
management.
TRANSITIONAL ISSUES:
[ ] Consider referral to outpatient pulmonary rehab
[ ] Patient should complete course of Augmentin ending on ___
[ ] Recommend monitoring of blood glucose and further medical
management, consider increasing glimepiride to 2 mg BID
[ ] Follow-up on subglottic granulation tissue/ENT
recommendation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. BusPIRone 30 mg PO BID
7. FLUoxetine 80 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. glimepiride 2 mg oral QAM
10. Tiotropium Bromide 1 CAP IH DAILY
11. Diltiazem Extended-Release 360 mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Chlorthalidone 12.5 mg PO DAILY
14. CloNIDine 0.2 mg PO Q6H
15. LORazepam 1 mg PO Q8H:PRN Anxiety
16. ARIPiprazole 5 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*9 Tablet Refills:*0
2. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*15 Capsule Refills:*0
3. GuaiFENesin 10 mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL 10 ml by mouth every six (6) hours
Refills:*0
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
5. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
7. ARIPiprazole 5 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. BusPIRone 30 mg PO BID
11. Chlorthalidone 12.5 mg PO DAILY
12. CloNIDine 0.2 mg PO Q6H
13. Diltiazem Extended-Release 360 mg PO DAILY
14. FLUoxetine 80 mg PO DAILY
15. glimepiride 2 mg oral QAM
16. LORazepam 1 mg PO Q8H:PRN Anxiety
17. Metoprolol Succinate XL 25 mg PO DAILY
18. Omeprazole 40 mg PO DAILY
19. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
#Tracheitis
#Shortness of breath
Secondary:
#Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Why you were admitted to the hospital:
- You came to the hospital with shortness of breath and rapid
breathing.
What we did why you were here:
- Due to your shortness of breath, you spent a brief time ___ the
medical ICU before returning to the floor.
- You were treated with antibiotics and steroids for possible
tracheitis.
- You were also given a diuretic (Lasix) to remove fluid and
help your breathing.
- We managed your diabetes with insulin because the steroids
made your blood sugars significantly elevated.
What you need to do once you return home:
- Please take Augmentin (an antibiotic) until ___.
- Please follow-up at your scheduled appointments, especially
with your primary care doctor to discuss further management of
your diabetes. You should check your blood sugar each morning
and call your PCP if it is consistently greater than 250.
It was a pleasure taking care of you during this
hospitalization.
Sincerely,
___ Team
Followup Instructions:
___
|
10439110-DS-21 | 10,439,110 | 20,771,005 | DS | 21 | 2145-03-26 00:00:00 | 2145-03-27 11:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea on exertion, c/f unresolved tracheitis
Major Surgical or Invasive Procedure:
Bronchoscopy on ___.
History of Present Illness:
Ms. ___ is a ___ year old woman with HTN, T2DM, asthma/COPD
not on home oxygen, OSA previously on CPAP, and severe TBM s/p
TBP on ___ complicated by persistent severe hypoxemic
respiratory failure s/p trach/PEG on ___, now s/p T-tube for
cervical tracheal malacia, s/p recent admission for
GNR trachitis presenting with worsening dyspnea on exertion and
brown secretions.
She was hospitalized in late ___ for increased WOB and started
on unsayn for tracheitis. She was switched to augmentin, with
plans to complete a 7-day course on ___. However, on ___,
culture data revealed that her infection was resistant to
augmentin so she was switched to a 7-day course of cefpodoxime.
She reports taking her last pill the night prior to admission
(___).
During the interval between her discharge and this admission,
she had ___ days of brown sputum production, seen while
suctioning her trach or coughing. She denies fevers/chills, no
dyspnea at rest. Her cough is otherwise at baseline except for
the change in color. No bright red in sputum.
In the ED, initial VS were .97.9 | 64 | 138/76 | 16 | 100%RA
Past Medical History:
Tracheo/cervical bronchomalacia s/p TBP ___, trach/PEG on
___, and T-tube placement.
HTN
Hypercholesterolemia
COPD/asthma
Moderate obstructive sleep apnea (AHI 29)
T2DM
GERD
RUE DVT ___
Rheumatoid arthritis
Restless leg syndrome
Depression
Polysubstance abuse - Clonazepam, Vicodin, Percocet - s/p
inpatient detox
Social History:
___
Family History:
Mother: Lung cancer, CHF
Physical Exam:
ADMISSION:
============
VS: 98.0 | 131/68 | 75 | 18 | 100%2L
GENERAL: NAD
HEENT: PERRL, MMM
NECK: full ROM, no LAD, JVD difficult to assess d/t habitus
HEART: soft d/t habitus but RRR, S1/S2, no murmurs appreciated
LUNGS: Transmitted upper-airway wheeze from trach, heard in all
lung fields. Otherwise overall clear without rales, rhonchi.
Breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing. Trace b/l edema mid-calf.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, face
grossly
symmetric
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE:
==============
Vitals: 98.5PO 155/79 L Lying ___ Ra
GENERAL: NAD
HEENT: PERRL, MMM
NECK: full ROM, no LAD, JVD difficult to assess d/t habitus
HEART: soft sounds d/t habitus but RRR, S1/S2, no murmurs
appreciated
LUNGS: Transmitted upper-airway wheeze from trach, heard in all
lung fields. Otherwise overall clear without rales, rhonchi.
Breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing. No edema.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox4, moving all 4 extremities with purpose, face
grossly
symmetric
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
====================
___ 03:27PM BLOOD WBC-14.3* RBC-3.89* Hgb-10.0* Hct-32.5*
MCV-84 MCH-25.7* MCHC-30.8* RDW-16.4* RDWSD-49.2* Plt ___
___ 03:27PM BLOOD Plt ___
___ 03:27PM BLOOD Glucose-129* UreaN-7 Creat-0.8 Na-137
K-4.2 Cl-100 HCO3-19* AnGap-22*
DISCHARGE LABS:
====================
___ 06:45AM BLOOD WBC-9.6 RBC-3.25* Hgb-8.4* Hct-27.1*
MCV-83 MCH-25.8* MCHC-31.0* RDW-16.1* RDWSD-49.1* Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-210* UreaN-9 Creat-0.8 Na-142
K-3.9 Cl-100 HCO3-25 AnGap-17*
___ 06:45AM BLOOD Calcium-8.6 Phos-4.7* Mg-1.6
IMAGING:
====================
CHEST (PA & LAT) ___
Tracheostomy tube tip is in unchanged position. Cardiac
silhouette size is moderately enlarged. Mediastinal and hilar
contours are unremarkable. The pulmonary vasculature is not
engorged. Blunting of the right costophrenic angles is
suggestive of a small right pleural effusion. Streaky
atelectasis is seen in the lung bases. No pneumothorax is
present. No acute osseous abnormality is visualized.
CT CHEST W/O CONTRAST ___
1. No focal consolidation or other acute pulmonary finding to
explain the
patient's shortness of breath and sputum production.
2. Tracheostomy in place terminating in the mid trachea.
3. Hypodense cardiac blood pool suggestive of anemia.
MICROBIOLOGY:
====================
ENDOTRACHEAL SPUTUM ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
ESCHERICHIA COLI. MODERATE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
CEFPODOXIME REQUESTED BY ___ ___.
Cefpodoxime = SUSCEPTIBLE : test result performed by
___.
GRAM NEGATIVE ROD #2. SPARSE GROWTH.
CONSISTENT WITH ISOLATE #3 STENOTROPHOMONAS
MALTOPHILIA.
NO FURTHER WORKUP WILL BE PERFORMED.
STENOTROPHOMONAS MALTOPHILIA. MODERATE GROWTH.
CEFTAZIDIME Levofloxacin AND CIPROFLOXACIN TESTING
REQUESTED BY ___
___ (___).
MINOCYCLINE = SUSCEPTIBLE , test result performed by
___.
TIMENTIN = 32 MCG/ML= INTERMEDIATE , test result
performed by
Microscan.
CEFTAZIDIME = test result performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| STENOTROPHOMONAS
MALTOPHILIA
| |
AMIKACIN-------------- 16 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S 16 I
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- 2 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R <=1 S
BLOOD CULTURE ___
NO GROWTH.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with past medical history
notable for hypertension, T2DM, asthma/COPD not on home O2, OSA
previously on CPAP, and severe tracheobronchial malasia s/p
tracheobronchial plasty on ___ complicated by persistent
severe hypoxemic respiratory failure requiring trach/peg on
___, now converted to T-tube, s/p recent admission for
tracheitis, admitted for shortness of breath with exertion. Her
presentation was initially felt to be consistent with unresolved
tracheitis. Afebrile with unremarkable vitals. Physical exam
remarkable thick brown sputum produced with saline + suction
washes of her trach(normally her sputum is clear). Labs on
admission were notable for an elevated WBC 14.3. Sputum sample
was remarkable for E COLI and STENOTROPHOMONAS MALTOPHILIA.
Treatment was initiated with a 7-day course of ceftazidime 2 g
IV Q12H(ending ___. The patient was followed by Interventional
Pulmonology and Infectious Disease. She underwent a bronchoscopy
on ___, which revealed yellow secretions throughout her
T-tube, which were removed. After this procedure, the patient
noted improved breathing and reduced shortness of breath. She
was discharged on a ___-day course of Bactrim. Unclear if patient
had an acute infection verses poor home trach hygiene and
chronic colonizer. Ambulatory saturation at 95% on discharge.
#Tracheitis
Admitted for shortness of breath with exertion. Her presentation
was initially felt to be consistent with unresolved tracheitis.
Afebrile with unremarkable vitals. Physical exam remarkable
thick brown sputum produced with saline + suction washes of her
trach(normally her sputum is clear). Labs on admission were
notable for an elevated WBC 14.3. Sputum sample was remarkable
for E COLI and STENOTROPHOMONAS MALTOPHILIA. Treatment was
initiated with a 7-day course of ceftazidime 2 g IV Q12H(ending
___. The patient was followed by Interventional Pulmonology
and Infectious Disease. She underwent a bronchoscopy on
___, which revealed yellow secretions throughout her
T-tube, which were removed. After this procedure, the patient
noted improved breathing and reduced shortness of breath. She
was discharged on a 7-day course of Bactrim. Unclear if patient
had an acute infection verses poor home trach hygiene and
chronic colonizer. Ambulatory saturation at 95% on discharge.
- Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB
- Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 7 Days end
date ___
- Benzonatate 100 mg PO TID:PRN cough
- GuaiFENesin 10 mL PO Q6H:PRN cough
#Asthma/COPD:
- Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
- Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
- Tiotropium Bromide 1 CAP IH DAILY
#Rheumatoid Arthritis:
She occasionally had pains from her rheumatoid arthritis,
treated at various times with Acetaminophen 1000mg Q8H,
Oxycodone 2.5-5mg, Tramadol 50mg, Ibuprofen 400-800mg. Patient
should follow up with outpatient rheumatology.
#Hypertension:
- Chlorthalidone 12.5 mg PO DAILY
#Sinus Tachycardia:
- Diltiazem Extended-Release 360 mg PO DAILY
- Metoprolol Succinate XL 25 mg PO DAILY
#Type 2 Diabetes Mellitus:
- glimepiride 2 mg oral QAM
#Anxiety, PTSD: Checked PMP
- ARIPiprazole 5 mg PO QHS
- BusPIRone 30 mg PO BID
- CloNIDine 0.2 mg PO Q6H
- FLUoxetine 60 mg PO DAILY
- LORazepam 1 mg PO Q8H:PRN Anxiety
- Mirtazapine 30 mg PO QHS
- ClonazePAM 0.5 mg PO TID
#Muscle spasm:
- Cyclobenzaprine 5 mg PO HS:PRN spasm
#Coronary artery disease
Patient continued on atoravastatin and aspirin.
#GERD:
- Omeprazole 40 mg PO DAILY
Transitional issues:
=====================
1. Patient should maintain regular schedule of cleaning her
trach with saline + suction. She was counseled extensively on
this to prevent readmission.
2. She should see pulmonology as an outpatient.
3. Her anemia should be worked-up: iron studies during admission
were unremarkable. Consider colonoscopy if she has not already
gotten one. Discharge Hgb 8.4.
4. Monitor QTc, given patient's psychiatric medications.
Discharge QTc 529
5. Her chlorthalidone 25 mg PO daily was changed to 12.5mg
daily, remained normotensive while in patient on this regimen.
6. Patient complaining of pain from arthritis during admission.
She should follow-up with her rheumatologist at ___
___.
7. Follow up with infectious disease.
8. Discharged on 7 days of Bactrim end date ___.
9. Pulmonary Hygiene for Discharge Planning
T-Tube Instructions
1. Mucinex ___ by mouth twice a day (take one tablet at
8am, one tablet at 8 pm)
2. Please use albuterol nebulizer (2.5 mg) nebulizer twice a
day before you use Mucomyst. Please give yourself treatment at
7am and 7pm.
3. Mucomyst (N-acetylcysteine) 10% solution - you can use
this undiluted. Use 6 to 10 mL of 10% solution until nebulized
given 2 times/day. Please give yourself treatment at 7:30am and
7:30pm (ideally, ___ minutes after you use albuterol
nebulizer).
4. Right after nebulizer treatment with Mucomyst, please use
___ of Saline into t-tube, then suction 3 inches above and 3
inches below.
5. Please clean the external opening of the t-tube with an
extra LONG Q-tip 50% saline and 50% hydrogen peroxide daily to
keep insertion site clean.
6. Sodium bicarbonate instillation treatment for t-tubes:
***At lunch time and at bedtime
Supplies needed:
1. A 10 ml syringe
2. 4.2% Bicarb solution
3. Suction machine and catheters
4. Normal saline
5. Tissues
To instill the bicarb:
1. Wash and dry your hands
2. Draw up 5 ml of the bicarb
3. Uncap the T-tube
4. Slowly instill the bicarb into the T-tube in small
amounts (be prepared to cover the end of the T-tube with a
tissue
to prevent you from coughing the bicarb out of the T-tube)
5. After the bicarb is instilled, recap the T-tube
6. Wait 15 minutes then uncap the T-tube
7. Slowly place a total of 5 ml saline drops into the
T-tube and suction the T-tube up and down as described earlier
(instilling small amounts of saline into the T-tube before each
suction pass helps rinse the T-tube of the mucus and bicarb)
8. After suctioning is complete, recap the T-tube
This is essential for proper care of your T-tube.
Please call our office at ___ with any questions or
concerns.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. BusPIRone 30 mg PO BID
6. CloNIDine 0.2 mg PO Q6H
7. Diltiazem Extended-Release 360 mg PO DAILY
8. FLUoxetine 60 mg PO DAILY
9. glimepiride 2 mg oral QAM
10. LORazepam 1 mg PO Q8H:PRN Anxiety
11. Omeprazole 40 mg PO DAILY
12. Benzonatate 100 mg PO TID:PRN cough
13. GuaiFENesin 10 mL PO Q6H:PRN cough
14. Tiotropium Bromide 1 CAP IH DAILY
15. Chlorthalidone 25 mg PO DAILY
16. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
17. Mirtazapine 30 mg PO QHS
18. ClonazePAM 0.5 mg PO TID
19. Cyclobenzaprine 5 mg PO HS:PRN spasm
20. ARIPiprazole 5 mg PO QHS
21. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 7 Days
end date ___. Chlorthalidone 12.5 mg PO DAILY
4. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
6. ARIPiprazole 5 mg PO QHS
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Benzonatate 100 mg PO TID:PRN cough
10. BusPIRone 30 mg PO BID
11. ClonazePAM 0.5 mg PO TID
RX *clonazepam 0.5 mg 0.5 (One half) tablet(s) by mouth three
times a day (TID) Disp #*21 Tablet Refills:*0
12. CloNIDine 0.2 mg PO Q6H
13. Cyclobenzaprine 5 mg PO HS:PRN spasm
14. Diltiazem Extended-Release 360 mg PO DAILY
15. FLUoxetine 60 mg PO DAILY
16. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
17. glimepiride 2 mg oral QAM
18. GuaiFENesin 10 mL PO Q6H:PRN cough
19. LORazepam 1 mg PO Q8H:PRN Anxiety
RX *lorazepam 1 mg 1 by mouth every 8 hours as needed for
anxiety Disp #*21 Tablet Refills:*0
20. Metoprolol Succinate XL 25 mg PO DAILY
21. Mirtazapine 30 mg PO QHS
22. Omeprazole 40 mg PO DAILY
23. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
====================
TRACHEITIS
TRACHEAL CONGESTION
SECONDARY DIAGNOSIS:
====================
Anxiety
Type II Diabetes Mellitus
Asthma/COPD
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you here at ___.
What happened while you were at the hospital?
- You were admitted for shortness of breath while performing
everyday tasks, such as walking and doing chores.
- You were found to have an unresolved infection of the upper
airway, called tracheitis. This is the same reason you were
admitted in late ___.
- Sputum samples were tested, and you were started on a 7-day
course of intravenous antibiotics to treat this infection. You
finished this medicine before leaving the hospital.
- Your congested T-tube was also likely contributing to your
symptoms. You underwent a bronchoscopy, and mucus blocking the
tube was removed.
- You finished your course of intravenous antibiotics, and had
improved breathing.
- You were started on another medication before discharge to
treat any residual infection you may have in your tube.
- On discharge, you feel back to your baseline breathing and
well.
What to do on discharge?
- Please complete a 7-day course of Bactrim ending ___.
- You will be discharged to a rehabilitation center to help you
get stronger.
- Please clean your T-tube with saline and suction on a regular
daily basis to prevent mucus build-up.
- Please follow-up with your primary doctor.
- Please follow-up with pulmonology as an outpatient.
- Below is your pulmonary regimen:
Pulmonary Hygiene for Discharge Planning
T-Tube Instructions
1. Mucinex ___ by mouth twice a day (take one tablet at
8am, one tablet at 8 pm)
2. Please use albuterol nebulizer (2.5 mg) nebulizer twice
a
day before you use Mucomyst. Please give yourself treatment at
7am and 7pm.
3. Mucomyst (N-acetylcysteine) 10% solution - you can use
this undiluted. Use 6 to 10 mL of 10% solution until nebulized
given 2 times/day. Please give yourself treatment at 7:30am and
7:30pm (ideally, ___ minutes after you use albuterol
nebulizer).
4. Right after nebulizer treatment with Mucomyst, please
use
___ of Saline into t-tube, then suction 3 inches above and 3
inches below.
5. Please clean the external opening of the t-tube with an
extra LONG Q-tip 50% saline and 50% hydrogen peroxide daily to
keep insertion site clean.
6. Sodium bicarbonate instillation treatment for t-tubes:
***At lunch time and at bedtime
Supplies needed:
1. A 10 ml syringe
2. 4.2% Bicarb solution
3. Suction machine and catheters
4. Normal saline
5. Tissues
To instill the bicarb:
1. Wash and dry your hands
2. Draw up 5 ml of the bicarb
3. Uncap the T-tube
4. Slowly instill the bicarb into the T-tube in
small
amounts (be prepared to cover the end of the T-tube with a
tissue
to prevent you from coughing the bicarb out of the T-tube)
5. After the bicarb is instilled, recap the T-tube
6. Wait 15 minutes then uncap the T-tube
7. Slowly place a total of 5 ml saline drops into
the
T-tube and suction the T-tube up and down as described earlier
(instilling small amounts of saline into the T-tube before each
suction pass helps rinse the T-tube of the mucus and bicarb)
8. After suctioning is complete, recap the T-tube
This is essential for proper care of your T-tube.
Please call our office at ___ with any questions or
concerns.
We are happy to see you feeling better and wishing you all the
best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10439110-DS-23 | 10,439,110 | 20,294,421 | DS | 23 | 2145-04-17 00:00:00 | 2145-04-17 09:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
regurgitating food
Major Surgical or Invasive Procedure:
EGD ___: ___ esophagus, angle at gastroesophageal
junction
History of Present Illness:
Ms. ___ is a ___ female with a past medical history
of tracheobronchomalacia s/p tracheobronoplasty in ___ of
this year, s/p trach and then trach exchange in ___, with a
recent admission (discharged on ___ for flash pulmonary
edema and a heart failure exacerbation, who is admitted with
regurgitation of her food, and feeling weak in the setting of
poor PO intake. The patient reports that she has had
intermittenet regurgitation for months -- she will completely
swallow a bite of food. After about five minutes, she will
develop severe epigastric pain that radiates throughout her
abdomen, and then the food will regurgitate. She denies gagging
and vomiting. She states that the food appears whole, and that
there is no bilious material. She is intermittently able to
drink liquids, but those have also regurgitated in the past.
There are no foods that make it worse. She had several episodes
of this while in the hospital. After discharging, she felt very
hungry and ate a hamburger, which regurgitated. Since then, she
was not able to keep any food down. Since leaving the hospital
she denies any shortness of breath, fevers, chills, diarrhea.
She has diabetes and takes glimepiride at home. Her last A1C was
8.3 on ___. She has never had an endoscopy, and reports that
her pulmonologist Dr. ___ ordered a "transit study", but
she had to cancel it. She did have esophageal manometry done in
___ that was normal.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Tracheo/cervical bronchomalacia s/p TBP ___, trach/PEG on
___, and T-tube placement.
HTN
Hypercholesterolemia
COPD/asthma
Moderate obstructive sleep apnea (AHI 29)
T2DM
GERD
___ DVT ___
Rheumatoid arthritis
Restless leg syndrome
Depression
Polysubstance abuse - Clonazepam, Vicodin, Percocet - s/p
inpatient detox
Social History:
___
Family History:
Mother: Lung cancer, CHF
Physical Exam:
ADMISSION EXAM
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Trach in place in the neck and capped. No discharge. No
cervical LAD.
CV: Heart regular, II/VI murmur at RUSB, no S3, no S4. Was not
able to assess JVP. No peripheral edema
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, EOMI.
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM
98.6 144 / 82 89 16 93 Ra
-General: sitting up in bed, NAD
-HEENT: Anicteric, eyes conjugate, MMM, no JVD. trach capped
-Cardiovascular: RRR, no murmur
-Pulmonary: clear b/l, no wheeze, somewhat coarse
-Gastroinestinal: Soft, non-tender, non-distended, bowel sounds
present
-MSK: No edema
-Skin: No rashes or ulcerations evident
-Neurological: no focal neurological deficits, AAOx3
-Psychiatric: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS
___ 05:30PM BLOOD WBC-12.0* RBC-4.24 Hgb-10.7* Hct-33.2*
MCV-78* MCH-25.2* MCHC-32.2 RDW-15.4 RDWSD-43.0 Plt ___
___ 05:30PM BLOOD Glucose-125* UreaN-37* Creat-1.4* Na-135
K-3.7 Cl-81* HCO3-35* AnGap-19*
___ 05:30PM BLOOD ALT-18 AST-45* AlkPhos-113* TotBili-0.2
___ 05:30PM BLOOD proBNP-652*
DISCHARGE LABS
___ 07:00AM BLOOD WBC-7.5 RBC-3.56* Hgb-8.8* Hct-28.7*
MCV-81* MCH-24.7* MCHC-30.7* RDW-15.8* RDWSD-46.5* Plt ___
___ 07:00AM BLOOD Glucose-151* UreaN-12 Creat-0.9 Na-141
K-3.4 Cl-95* HCO3-29 AnGap-17*
___ 05:30PM BLOOD ALT-18 AST-45* AlkPhos-113* TotBili-0.2
IMAGING/STUDIES
-EGD ___: Abnormal mucosa in the esophagus (biopsy).
Erythema in the antrum. Normal mucosa in the duodenal bulb,
first part of the duodenum and second part of the duodenum. No
esophageal web, stricture, or diverticulum was seen. Otherwise
normal EGD to third part of the duodenum
-CT chest: 1. There is no mass effect on the esophagus or
paraesophageal mass identified.
2. No acute findings within the thorax to explain patient's
symptoms.
Barium Swallow
The esophagus was not dilated. There was no stricture within
the esophagus. There was no esophageal mass. The esophageal
mucosa appear normal.
Mild tertiary contractions were noted. The lower esophageal
sphincter opened and closed normally.
A 13 mm barium tablet was administered, which passed into the
stomach without holdup.
There was significant gastroesophageal reflux. There was no
hiatal hernia.
No overt abnormality in the stomach or duodenum on limited
evaluation.
IMPRESSION:
1. Significant gastroesophageal reflux.
2. Mild tertiary contractions.
3. No Zenker's diverticulum.
Brief Hospital Course:
___ h/o tracheobronchomalacia s/p trach w/ recent admission
(discharged on ___ for flash pulmonary edema and a heart
failure exacerbation who presents w/ regurgitation found to have
___ and electrolyte abnormalities.
1. Regurgitation
-CT neck without apparent abnormality. It appears that
gastroparesis was considered in the past w/ HbA1C of 8.3%
___ but patient canceled 'transit study' as per Dr. ___
___. GI was consulted who recommended barium swallow, which
was negative. In setting of tracheobronchomalacia EGD was high
risk procedure requiring coordination between GI and IP; EGD
___ showed ___ Esophagus and she was changed from home
omeprazole 40mg daily to pantoprazole 40mg PO BID. She will
need to follow up with ___ clinic. Patient should
continue on soft diet and advance as tolerated. It is possible
that her high dose CCB is contributing to her reflux disease.
If she remains unable to advance her diet despite tx of GERD
with high dose PPI, would obtain gastric emptying study as an
outpatient.
2. ___ and electrolyte abnormalities (hypokalemia,
hypochloremia)
-Baseline creatinine 1 that was 1.5 on admission, which is
likely pre renal in setting of poor PO intake vs intrinsic in
setting of NSAIDs. Patient initially declined IV fluids due to
h/o pulmonary edema in the past, so torsemide ws held and
creatinine monitored. Creatinine returned to baseline and
toresemide resumed. Potassium was repleted. K was 3.4 on day
of discharge. Would recheck at PCP ___. Patient encouraged to
take multivitamin.
3. Acute on chronic pain h/o rheumatoid arthritis
-Patient notes worsening arthritic pain coming off prednisone in
___. She is not taking any immuodomodulators in setting of
tracheobronchomalacia and has just been using NSAIDs for pain
control. Patient needs to follow up with rheumatology to figure
out treatment plan. While inpatient continue with
acetaminophen, tramadol, and PRN oxycodone. Advise against long
term opioid abuse given h/o polysubstance abuse.
Chronic Medical Problems
1. Trachobronchomalacia s/p trach, Asthma, COPD, OSA: continue
albuterol, tiotropium, guaifenesin, benzonatate,
Fluticasone/salmeterol, N-acetylcysteine news. IP is involved.
2. Mitral regurgitation, HTN, chronic diastolic heart failure,
CAD, atrial tachycardia: euvolemic w/ BNP lower than previous
admission. Torsemide initially held due to ___ and resumed once
resolved. Continue clonidine, diltiazem, metoprolol, aspirin,
atorvastatin.
3. DM: HbA1C 8.3% ___. Hold home glimepiride. SSI.
4. Anxiety, depression, PTSD, fibromyalgia: continue
mirtazapine, lorazepam, fluoxetine, cyclobenzaprine, buspirone,
and aripiprazole.
5. GERD: continue omeprazole
6. Chronic leukocytosis: likely in setting of chronic tracheitis
7. Chronic microcytic anemia: likely anemia of chronic disease.
Iron 35 ___.
TRANSITIONAL ISSUES (from discharge summary ___
=================
[ ] ___ with cardiology for new diagnosis of HFrEF as well as
worsening MR. ___ discontinuing diltazem and starting BB.
___ need a cardiac stress test.
[ ] Consider w/u for MVR/mitraclip given severe mitral regurg on
ECHO.
[ ] ___ with IP as scheduled
[ ] Outpatient sleep study to evaluate for OSA.
[ ] ___ with PCP ___: anemia (consider colonoscopy, small bowel
study).
[ ] Patient complaining of pain from arthritis during admission.
She should follow-up with her rheumatologist at ___
___.
>30 minutes spent on discharge planning
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
4. ARIPiprazole 5 mg PO QHS
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Benzonatate 100 mg PO TID:PRN cough
8. BusPIRone 30 mg PO BID
9. CloNIDine 0.2 mg PO Q6H
10. Cyclobenzaprine 5 mg PO HS:PRN spasm
11. Diltiazem Extended-Release 360 mg PO DAILY
12. Tiotropium Bromide 1 CAP IH DAILY
13. glimepiride 2 mg oral QAM
14. FLUoxetine 60 mg PO DAILY
15. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
16. GuaiFENesin 10 mL PO Q6H:PRN cough
17. LORazepam 1 mg PO Q8H:PRN Anxiety
18. Metoprolol Succinate XL 25 mg PO DAILY
19. Mirtazapine 30 mg PO QHS
20. Omeprazole 40 mg PO DAILY
21. Torsemide 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Regurgitation, ___ Esophagus, GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted with regurgitation. The gastroenterology and
interventional pulmonology teams were involved in your care and
performed and endoscopy on ___ that showed ___
Esophagus, which we can see in the setting of acid reflux. You
were put on a high dose of acid suppressant with plans to follow
up outpatient with the GI/motility team. You can continue soft
diet for now, and after having been on the acid medicine for a
few days can try more solid foods.
When you followup with your PCP, please do the following:
1. Discuss your anemia
2. Get your potassium rechecked
3. Discuss your GI followup should occur (at ___ or
___, and get referral if needed)
4. Get refills on your protonix
5. Get a ___ with your rheumatologist
6. Get a follow up with a cardiologist to discuss your heart
failure and issue with your mitral valve
Followup Instructions:
___
|
10439110-DS-26 | 10,439,110 | 27,900,840 | DS | 26 | 2145-06-18 00:00:00 | 2145-06-19 18:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain, Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with PMHx of tracheobronchial malacia s/p
tracheobronchoplasty in ___, trach ___, and T tube
placement ___ who presented to the ED with new onset right
sided chest pain and dyspnea.
Of note, the patient was recently admitted ___ with LLL PNA
and from ___ with vertigo. The patient reported feeling
well after discharge developed a subacute onset right sided
chest
pain that was pleuritic in nature with associated dyspnea. She
reported that the chest pain was a sharp/ stabbing pain below
her
right breast. She also endorsed dyspnea on exertion and a
sensation of not being able to catch her breath. She tried using
nebs, but with no relief in her symptoms. She endorses a mild
cough with scant brown sputum which is at her baseline. She
denies fevers or chills. She states that her pain and shortness
of breath acutely worsened today her symptoms worsened prompting
her to come to the ED for further evaluation.
In the ED, initial her vitals were significant for mild
tachycardia but otherwise she was afebrile and her other vitals
were within normal limits.
- Her ECG showed a known LBBB and no peaked T-waves.
- Labs w/ new leukocytosis to 16.8, trop <0.01, and an elevated
D-Dimer of 1676, and a pro-BNP of 582 (ranged ___ in past).
- Imaging notable for: a CXR showing Right base atelectasis/
scarring without definite focal consolidation. No evidence of
pneumothorax. A CTA showed no acute aortic pathology or PE.
- IP was consulted who recommended: pursuing a CTA, treating
with
Augmentin x7 days for Tracheitis
Past Medical History:
- Tracheo/cervical bronchomalacia s/p TBP ___, trach/PEG on
___, and T-tube placement.
- HFrEF
- A.Fib
- COPD/asthma
- Moderate obstructive sleep apnea (AHI 29)
- HTN
- Hypercholesterolemia
- T2DM
- GERD, ___ esophagus
- Diverticulitis
- RUE DVT ___ on apixaban
- Rheumatoid arthritis
- Restless leg syndrome
- Depression
- Polysubstance abuse- Clonazepam, Vicodin, Percocet- s/p
inpatient detox
Social History:
___
Family History:
Mother: Lung cancer, CHF
Father: CHF
Aunt: ___ CA
Physical Exam:
Admission Exam:
VITALS: T: 100.2, BP: 114 / 55, HR: 99, RR: 18, O2: 97 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, EOMI, PERRL, neck supple, trach
in
place, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2. ___ systolic
murmur.
No rubs, gallops
Lungs: Clear to auscultation bilaterally. Mild wheezes
diffusely.
No rales, rhonchi.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: 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, 2+ reflexes bilaterally.
Discharge Exam:
VITALS: 98.0 PO 123 / 75 L Sitting 84 19 96 Ra
GENERAL: Obese female, lying in bed comfortably, AOx3
HEENT: PERRLA, EOMI, MMM
CV: Irregularly irregular, no r/m/g, no JVD
RESP: coarse rhonchi and upper airway sounds, no crackles
Chest: Right sided pain with palpation on the lower ribs that's
improved. no bruising or evidence of trauma
GI: +BS, NTND
GU: no foley
MSK: no ___ edema, warm and well perfused
NEURO: AOx3, moves all 4 extremities equally
Pertinent Results:
Admission labs:
___ 02:18PM BLOOD WBC-16.1*# RBC-3.90 Hgb-9.4* Hct-32.1*
MCV-82 MCH-24.1* MCHC-29.3* RDW-16.8* RDWSD-50.6* Plt ___
___ 02:18PM BLOOD Neuts-73.4* Lymphs-15.5* Monos-7.4
Eos-3.0 Baso-0.2 Im ___ AbsNeut-11.81* AbsLymp-2.50
AbsMono-1.19* AbsEos-0.48 AbsBaso-0.04
___ 02:18PM BLOOD ___ PTT-24.0* ___
___ 02:18PM BLOOD Glucose-168* UreaN-14 Creat-0.7 Na-140
K-10.0* Cl-103 HCO3-21* AnGap-16
___ 02:18PM BLOOD proBNP-582*
___ 06:30AM BLOOD Calcium-8.7 Phos-5.0* Mg-1.6
___ 02:10PM BLOOD D-Dimer-1676*
___ 03:47PM BLOOD K-5.8*
Discharge labs:
___ 06:20AM BLOOD WBC-8.3 RBC-3.31* Hgb-7.9* Hct-26.8*
MCV-81* MCH-23.9* MCHC-29.5* RDW-16.9* RDWSD-50.4* Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD Glucose-181* UreaN-13 Creat-0.8 Na-140
K-4.5 Cl-101 HCO3-23 AnGap-16
___ 08:43PM BLOOD cTropnT-<0.01
___ 06:20AM BLOOD Calcium-8.5 Phos-5.3* Mg-2.2
___ 08:45PM BLOOD K-4.0
Imaging:
___ CXR:
Right base atelectasis/scarring without definite focal
consolidation. No
evidence of pneumothorax.
___ CTA chest
Within limitations of suboptimal bolus timing, no evidence of
pulmonary
embolism or aortic abnormality.
Brief Hospital Course:
___ with PMHx significant for TBM s/p tracheobronchoplasty in
___, trach ___, and T tube placement ___ who
presented with new onset of right sided chest pain and
progressive dyspnea, found to have likely tracheitis and mucous
plugging by IP. Shortness of breath improved with removal of
large mucous plug. Treated with 7 days of Augmentin. Chest pain
not consistent with cardiac cause with negative nuclear study in
___ and negative trops here. Pain consistent with
costrochondritis and treated with naproxen with improvement.
Active Issues:
=====================
# Mucous Plugging
# Tracheitis
# Dyspnea
Clinical exam and imaging not concerning for pneumonia or PE
though CTA has suboptimal bolus timing. However, given
reproducibility of pleuritic chest pain with palpation, lack of
tachycardia, or EKG changes consistent with PE unlikely to
represent PE. Not clinically volume overloaded with normal JVP,
no crakcles and no ___ with ~baseline pro-bnp making acute on
chronic HFrEF unlikely. Given improvement in symptoms with
suction and removal of mucous plug as well as leukocytosis in
the setting of brown mucous, dyspnea most consistent with mucous
plugging and tracheitis. Treated with 7 days of augmentin
(___) w/ plan for close follow up for elective
bronchoscopy if needed on ___.
# Chest Pain- Negative troponin x2 with chest pain reproducible
on exam with palpation. Unlikely to represent PE as above given
negative CTA, no tachycardia, and no EKG changes concerning for
PE. Negative nuclear stress test on last admission ___. Chest
pain most likely represents costochondritis and improved on
Naproxen.
CHRONIC/RESOLVED ISSUES:
===============================
# HFrEF
Last echo in ___ with Grade II LV diastolic dysfunction with
elevated LVEDP, mild to moderate MR, and LVEF of 49%. Pro-BNP of
582 is close to baseline witout JVD, orthopnea, PND, pulmonary
edema, ___ edema. Continued home Torsemide 20 mg PO every
other day.
# A.Fib
Rate controlled on diltiazem and metoprolol. Continued on home
Diltiazem Extended-Release 360 mg PO Daily, Metoprolol Succinate
XL 25 mg PO Daily, and Apixiban 5 mg BID
# RUE DVT ___ on Apixiban- Continued on Apixiban and ASA.
# COPD/asthma - Continued on home albuterol, benzonatate,
mucomyst and fluticasone.
# HTN- Continued home clonidine, metop, and diltiazem.
# T2DM- Held home glimepride and on SS as inpatient. Resumed
home meds on discharge.
# GERD, ___ esophagus- Continued on home Pantoprazole
# Depression/ Anxiety-Continued on home Fluoxetine, Buspirone,
and clonazepam
# Restless leg syndrome-Continue Cyclobenzaprine
# Chronic Pain- Continued PRN Tramadol, acetaminophen
# Hypercholesterolemia-Continue Atorvastatin
TRANSITIONAL ISSUES:
- New Meds: Augmentin 875 mg PO/NG Q12H x7 days (___)
- Stopped/Held Meds: none
- Changed Meds: none
- Post-Discharge Follow-up Labs Needed: Cbc
- Incidental Findings: None
- Discharge weight: 176.5 lb
() Continue Augmentin until ___
() Follow up with IP as above
() recheck H/H in 1 week though hgb around baseline
() Follow up blood culture results pending at discharge
# Code status: Full Code (Verified)
# Health care proxy/emergency contact:
- ___ (Sister), Phone number: ___
- ___, Phone number: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
4. Apixaban ___ mg PO BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO EVERY OTHER DAY
7. Benzonatate 100 mg PO TID:PRN cough
8. BusPIRone 30 mg PO DAILY
9. ClonazePAM 0.5 mg PO TID:PRN anxiety
10. CloNIDine 0.2 mg PO TID
11. Cyclobenzaprine 5 mg PO HS:PRN spasm
12. Diltiazem Extended-Release 360 mg PO DAILY
13. FLUoxetine 60 mg PO DAILY
14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
15. Metoprolol Succinate XL 25 mg PO DAILY
16. Pantoprazole 40 mg PO Q24H
17. Torsemide 20 mg PO EVERY OTHER DAY
18. TraMADol 50 mg PO DAILY:PRN Pain - Moderate
19. glimepiride 2 mg oral QAM
20. Potassium Chloride 20 mEq PO EVERY OTHER DAY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO/NG Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*10 Tablet Refills:*0
2. Naproxen 500 mg PO Q12H costochondritis
3. Apixaban 5 mg PO BID
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
5. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO EVERY OTHER DAY
9. Benzonatate 100 mg PO TID:PRN cough
10. BusPIRone 30 mg PO DAILY
11. ClonazePAM 0.5 mg PO TID:PRN anxiety
12. CloNIDine 0.2 mg PO TID
13. Cyclobenzaprine 5 mg PO HS:PRN spasm
14. Diltiazem Extended-Release 360 mg PO DAILY
15. FLUoxetine 60 mg PO DAILY
16. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
17. glimepiride 2 mg oral QAM
18. Metoprolol Succinate XL 25 mg PO DAILY
19. Pantoprazole 40 mg PO Q24H
20. Potassium Chloride 20 mEq PO EVERY OTHER DAY
21. Torsemide 20 mg PO EVERY OTHER DAY
22. TraMADol 50 mg PO DAILY:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Tracheitis
Costochondritis
Secondary diagnosis:
Atrial fibrillation
Heart failure with reduced ejection fraction
Asthma
Hypertension
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
-You were feeling short of breath and having some chest pain
WHAT HAPPENED IN THE HOSPITAL?
-You were evaluated by IP and found to have a large brown mucous
plug that was removed and helped your shortness of breath
-You were thought to have a infection in the trachea/T-tube and
started on Augmentin antibiotic
-Your chest pain was thought to be due to musculoskeletal causes
and improved with NSAIDs
WHAT SHOULD YOU DO AT HOME?
- Continue to take your antibiotic until ___
- Follow up with Interventional Pulmonology on ___
- Continue to take Naproxen 500mg twice daily until your Right
sides chest pain resolves but Please stop this medication if you
notice any blood in your stool or start having abdominal pain
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
10439110-DS-27 | 10,439,110 | 22,732,326 | DS | 27 | 2145-07-02 00:00:00 | 2145-07-06 19:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
___ Flex Bronchoscopy
History of Present Illness:
Ms. ___ is a ___ year old woman with a past medical history
of tracheobronchial malacia s/p tracheo-bronchoplasty ___ ___,
trach ___, and T tube placement ___, also with HFrEF
(EF 49%), COPD, atrial fibrillation, RUE DVT on apixiban,
anxiety and a history of polysubstance abuse who presents for
evaluation of shortness of breath that began this afternoon.
She reports that shortness of breath developed gradually over
the course of the day. She felt that she had increased
secretions that she was unable to clear. She tried albuterol
nebs, mucomyst, saline flushes and oxygen at home. She denies
fevers, chills or change ___ color of her sputum, which she
reports is usually a brown or tan color. She called EMS and was
brought ___ to the
hospital for further evaluation. She takes Torsemide 20mg every
other daily and her weight has been stable. She specifically
denies fever, chills, chest pain or abdominal pain, N/V/D. She
denies ___ edema. Her primary complaint is the sensation that she
has secretions that cannot be cleared.
___ the ED, initial vital signs were: HR 109 BP 150/64 RR ___
100% on Trach Mask.
Labs were notable for: WBC 22.1, HB 10.6, HCT 34.4, PLT 515, NA
141, K 4.2, Cl 92, HC03 22, BUN 16, Cr. 0.9. Lactate was 4.9
though repeat was 3.6. Trop <0.01, BNP 777.
Studies performed included a CXR ___ that showed no evidence
of pneumonia.
Patient was given:
___ 18:14 IV LORazepam 1 mg
___ 18:29 IH Albuterol 0.083% Neb Soln 1 NEB
___ 18:29 IH Ipratropium Bromide Neb 1 NEB
___ 18:30 IH Albuterol 0.083% Neb Soln 1 NEB
___ 18:30 IH Ipratropium Bromide Neb 1 NEB
___ 18:56 IV Levofloxacin
___ 20:13 IV MethylPREDNISolone Sodium Succ 125 mg
___ 20:13 PO Acetaminophen 650 mg
___ 20:18 IV Levofloxacin 750 mg Stopped (1h ___
___ 21:22 IV LORazepam 1 mg
Upon arrival to the floor, the patient reports the history
above.
Review of Systems: 10-point review of systems negative except as
reviewed ___ HPI.
Past Medical History:
- Tracheo/cervical bronchomalacia s/p TBP ___, trach/PEG on
___, and T-tube placement.
- HFrEF
- A.Fib
- COPD/asthma
- Moderate obstructive sleep apnea (AHI ___)
- HTN
- Hypercholesterolemia
- T2DM
- GERD, ___ esophagus
- Diverticulitis
- RUE DVT ___ on apixaban
- Rheumatoid arthritis
- Restless leg syndrome
- Depression
- Polysubstance abuse- Clonazepam, Vicodin, Percocet- s/p
inpatient detox
Social History:
___
Family History:
Mother: Lung cancer, CHF
Father: CHF
Aunt: ___ CA
Physical Exam:
==============================
EXAM ON ADMISSION
==============================
VS: 98.7 PO 128 / 68L Sitting 90 20 97Venti
GENERAL: well-appearing woman ___ NAD, sitting up ___ bed
HEENT: AT/NC, EOMI, anicteric sclera
NECK: non-tender supple neck
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: coarse breath sounds ___ all lung fields, no crackles
ABDOMEN: non-distended, +BS, nontender ___ all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no edema, moving all 4 extremities with purpose
NEURO: CN II-XII intact, strength ___ the ___ intact and
symmetric
SKIN: warm and well perfused, no rashes
==============================
EXAM ON DISCHARGE
==============================
VS: 98.0, HR 54, BP 113/69, RR 20, 98% on 36% TM
GENERAL: sitting up ___ bed, NAD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: coarse breath sounds ___ all lung fields, no crackles
EXTREMITIES: no edema
Pertinent Results:
===========================
LABS ON ADMISSION
===========================
___ 06:00PM BLOOD WBC-22.1* RBC-4.43 Hgb-10.6* Hct-34.3
MCV-77* MCH-23.9* MCHC-30.9* RDW-16.8* RDWSD-47.2* Plt ___
___ 06:00PM BLOOD Neuts-64.5 ___ Monos-6.5 Eos-0.4*
Baso-0.5 Im ___ AbsNeut-14.22* AbsLymp-6.05* AbsMono-1.44*
AbsEos-0.09 AbsBaso-0.11*
___ 06:00PM BLOOD Glucose-140* UreaN-16 Creat-0.9 Na-141
K-4.2 Cl-96 HCO3-22 AnGap-23*
___ 09:00AM BLOOD Calcium-9.7 Phos-3.5 Mg-1.8
___ 06:00PM BLOOD proBNP-777*
___ 06:00PM BLOOD cTropnT-<0.01
___ 06:10PM BLOOD ___ pO2-33* pCO2-35 pH-7.44
calTCO2-25 Base XS--1
___ 06:10PM BLOOD Lactate-4.9*
===========================
PERTINENT INTERVAL LABS
===========================
___ 06:10PM BLOOD Lactate-4.9*
___ 08:52PM BLOOD Lactate-3.6*
___ 09:18AM BLOOD Lactate-5.3*
___ 01:03PM BLOOD Lactate-3.2*
===========================
LABS ON DISCHARGE
===========================
___ 06:15AM BLOOD WBC-10.0 RBC-3.37* Hgb-7.8* Hct-27.3*
MCV-81* MCH-23.1* MCHC-28.6* RDW-17.1* RDWSD-50.2* Plt ___
___ 06:15AM BLOOD Glucose-200* UreaN-20 Creat-0.8 Na-139
K-4.0 Cl-98 HCO3-20* AnGap-21*
___ 06:15AM BLOOD Calcium-8.4 Phos-4.4 Mg-2.0
===========================
MICROBIOLOGY
===========================
- ___ Blood cultures x2 - NGTD
- ___ Urine culture -
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH
SKIN
AND/OR GENITAL CONTAMINATION.
ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL. PREDOMINATING
ORGANISM INTERPRET RESULTS WITH CAUTION.
- ___ 1:50 pm BRONCHOALVEOLAR LAVAGE BAL-TRACHEA.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final ___:
>100,000 CFU/mL Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). ~7000 CFU/mL.
SENSITIVITIES PERFORMED ON REQUEST..
Isolates are considered potential pathogens ___ amounts
>=10,000
cfu/ml.
===========================
IMAGING/STUDIES
===========================
- ___ CXR : No evidence of pneumonia.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a complex past medical
history of tracheobronchial malacia s/p tracheobronchoplasty ___
___, trach ___, and T-tube placement ___, also with
HFrEF (EF 49%), COPD, atrial fibrillation, RUE DVT on apixiban,
anxiety and a history of polysubstance abuse who presents for
evaluation of shortness of breath with associated leukocytosis
and elevated lactate.
===================================
ACUTE MEDICAL ISSUES ADDRESSED
===================================
# Dyspnea - Patient presenting with feelings of dyspnea and with
thicker than normal mucous secreations ___ her t-tube. She
otherwise had no clinical signs of pneumonia or heart failure,
and a chest x-ray was clear. She was seen by the interventional
pulmonology service, and underwent a flex bronchoscopy on
___ with aspiration of secretions and a BAL. She tolerated
this well, and afterwards was able to be discharged home.
# Leukocytosis and elevated lactate - Patient initially
presenting with leukocytosis of 22 and elevated lactate ranging
from 3.2 to 5.3. Though initially concerning for infection and
sepsis, patient was otherwise clinically stable with no signs of
infection and no hypotension during the admission. A review of
her chart suggests that previous elevations ___ lactate were also
not associated with sepsis or
hypotensive episodes, and were felt to be secondary to
medications. Though her urine culture did show enterococcus, was
___ the setting of mixed bacterial flora and patient denied
symptoms of UTI, and therefore decision was made not to treat.
Other potential source of elevated lactate could be GI, but
benign abdominal exam and lack of symptoms made this unlikely.
It was felt that the elevated lactate was more likely ___
frequent albuterol use than poor perfusion. Her white count also
resolved rapidly without treatment with antibiotics, felt to be
more consistent with stress leukocytosis than an active
infection. WBC 10 at time of discharge.
===================================
CHRONIC MEDICAL ISSUES ADDRESSED
===================================
#HFrEF
# Chronic systolic heart failure:
Most recent prior echo ___ with Grade II LV diastolic
dysfunction, mild to moderate MR, and LVEF of 49%. As above, no
evidence of exacerbation during this hospitalization, with BNP
700s, no extremity edema, and no increased pulmonary edema on
chest x-ray. Continued home torsemide 20 mg PO every other day
and metoprolol, aspirin, atorvastatin.
#AFIB: Rate-controlled on diltiazem and metoprolol, which were
continued during this admission with no tachycardic episodes.
Apixaban held on ___ for bronch, restarted following
procedure.
#RUE DVT: As above, apixaban held on ___ for bronch, restarted
following procedure
#COPD: Continued on home albuterol, benzonatate, mucomyst and
fluticasone
#HTN: Continued home clonidine, metop, and diltiazem
#T2DM: Held home glimepride, HISS as inpatient
#GERD: Continued home pantoprazole
#DEPRESSION: Continued home Fluoxetine, Buspirone, Klonopin PRN,
with home Ativan for breakthrough anxiety
#RLS: Continued home Flexeril
#Chronic Pain: Continued Tramadol PRN
#HL: Continued home Atorvastatin
===================================
TRANSITIONAL ISSUES
===================================
[] Patient noted to have anemia, which has been her baseline.
Should have CBC ___ 1 week to monitor. Hgb on discharge 7.8.
[] Final blood cultures, urine cultures, and BAL cultures were
pending at time of discharge. These will be followed by
inpatient team and by PCP.
[] Patient was discharged on her home medications with no
changes
[] Patient was evaluated for home O2 while ___ hospital, but did
not meet insurance requirements.
[] Has follow up palliative care appointment to discuss symptom
management for dyspnea and anxiety.
#CODE: FULL (presumed)
#CONTACT: HCP sister ___ ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Apixaban 5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. BusPIRone 30 mg PO DAILY
5. ClonazePAM 0.5 mg PO TID:PRN anxiety, insomnia
6. CloNIDine 0.2 mg PO TID
7. Cyclobenzaprine 5 mg PO HS:PRN spasm
8. Diltiazem Extended-Release 360 mg PO DAILY
9. FLUoxetine 60 mg PO DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. glimepiride 2 mg oral DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. TraMADol 50 mg PO DAILY:PRN Pain - Moderate
15. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
16. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB
17. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
18. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze
19. Benzonatate 100 mg PO TID:PRN cough
20. Torsemide 20 mg PO EVERY OTHER DAY
21. LORazepam 1 mg PO Q8H:PRN breakthrough anxiety
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze
4. Apixaban 5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Benzonatate 100 mg PO TID:PRN cough
8. BusPIRone 30 mg PO DAILY
9. ClonazePAM 0.5 mg PO TID:PRN anxiety, insomnia
10. CloNIDine 0.2 mg PO TID
11. Cyclobenzaprine 5 mg PO HS:PRN spasm
12. Diltiazem Extended-Release 360 mg PO DAILY
13. FLUoxetine 60 mg PO DAILY
14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
15. glimepiride 2 mg oral DAILY
16. LORazepam 1 mg PO Q8H:PRN breakthrough anxiety
17. Metoprolol Succinate XL 25 mg PO DAILY
18. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
19. Pantoprazole 40 mg PO Q24H
20. Torsemide 20 mg PO EVERY OTHER DAY
21. TraMADol 50 mg PO DAILY:PRN Pain - Moderate
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
# dyspnea secondary to tracheobronchomalacia
SECONDARY DIANGOSES:
# chronic systolic heart failure
# atrial fibrillation
# DVT
# COPD
# Diabetes mellitus
# Hypertension
# Depression
# Restless leg syndrome
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 be a part of your care team at ___
___. You were admitted because you were
feeling short of breath. We did not find any signs that you had
a pneumonia or this was because of your heart failure. The
interventional pulmonology team saw you, and recommended that
you have a bronchoscopy while you are here. You had this done,
and some secretions were suctioned. You were feeling better, and
so were able to be discharged home with your normal medications.
Because you have a history of heart failure, it is important
that you weigh yourself every day, and call your primary care
doctor if your weight increases by 3 pounds or more.
Again, it was a pleasure participating ___ your care. We wish you
the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10439110-DS-29 | 10,439,110 | 26,144,054 | DS | 29 | 2145-08-19 00:00:00 | 2145-08-19 19:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with PMH of tracheobronchial malacia s/p
trachea-bonchoplasty (___), trach on ___, and a T tube
placed ___, as well as CHF with EF of 49%, COPD, Afib, RUE
DVT on ___ presents with worsening shortness of breath and
complaints of bright red blood per rectum.
Of note, Ms. ___ was recently admitted to ___ from
___ - ___ for dyspnea. Her dyspnea was felt to be
due to acute on chronic diastolic heart failure and she was
treated with IV Lasix. She was also treated for CAP with
cefepime/azithromycin for a single day and was then transitioned
to levofloxacin for 3 day treatment course. She was discharged
on torsemide 20mg daily. She was continued on ___ for
history of RUE DVT.
In the ED, initial VS were: 97.1 66 110/51 16 99% RA
Exam notable for:
CTAB
Irregular rhythm, regular rate
No abdominal tenderness
Heme negative, no BRBPR
EKG:
non-specific changes in V1-V2.
Labs showed:
8.9
9.8 >---< 359
28.8
139|96|15
---------< 117
3.9|27|0.8
ALT 17 AST 26 AP 129 bili 0.4 alb 4.1
BNP 1065
TropT < 0.01
Imaging showed:
CXR - No acute cardiopulmonary process.
Consults:
Atrius cardiology was consulted who recommended admission to
medicine.
Patient received:
+ Pregabalin 75mg
+ Lorazepam 1mg PO
+ Lasix 40mg IV
+ Metoclopramide 10mg IV
+ Dephenhydramine 25mg IV
+ Aspirin 243mg PO
+ Pregabalin 75mg PO
+ Lorazepam 1mg PO
Transfer VS were: 98.9 65 103/45 16 98% RA
On arrival to the floor, patient reports that she feels well.
Has had no further bleeding events or bowel movements. Denies
dizziness or lightheadedness.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
- Tracheo/cervical bronchomalacia s/p TBP ___, trach/PEG on
___, and T-tube placement ___.
- HFpEF + mild HFrEF (EF 49%)
- atrial fibrillation
- atrial tachycardia with rate-dependent LBBB
- COPD/asthma
- Moderate OSA(AHI 29)
- HTN
- Hypercholesterolemia
- T2DM
- GERD, ___ esophagus
- Diverticulitis
- RUE DVT ___ on apixiban
- Rheumatoid arthritis
- Restless leg syndrome
- Depression
- Polysubstance abuse
Social History:
___
Family History:
Mother: Lung cancer, CHF
Father: CHF
Aunt: ___ CA
Physical Exam:
==========================
EXAM ON ADMISSION
==========================
VS: 97.8 111 / 66 66 17 96 Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, 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: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
==========================
EXAM ON DISCHARGE
==========================
VS: T 98.0, HR 84, BP 143/78, 18, 95% Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: some course sounds at bases, good air movement
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
Rectal: external hemorrhoids noted, guaiac negative
EXTREMITIES: no cyanosis, clubbing, or edema
Pertinent Results:
==============================
LABS ON ADMISSION
==============================
___ 12:30PM BLOOD WBC-9.8 RBC-3.82* Hgb-8.9* Hct-28.8*
MCV-75* MCH-23.3* MCHC-30.9* RDW-16.5* RDWSD-44.5 Plt ___
___ 12:30PM BLOOD Neuts-57.6 ___ Monos-8.1 Eos-1.9
Baso-0.6 Im ___ AbsNeut-5.66# AbsLymp-3.07 AbsMono-0.80
AbsEos-0.19 AbsBaso-0.06
___ 12:50PM BLOOD ___ PTT-34.5 ___
___ 12:30PM BLOOD Glucose-117* UreaN-15 Creat-0.8 Na-139
K-3.9 Cl-96 HCO3-27 AnGap-16
___ 12:30PM BLOOD ALT-17 AST-26 CK(CPK)-89 AlkPhos-129*
TotBili-0.4
___ 12:30PM BLOOD CK-MB-2 proBNP-1065*
___ 12:30PM BLOOD cTropnT-<0.01
___ 05:30PM BLOOD cTropnT-<0.01
==============================
LABS ON DISCHARGE
==============================
___ 10:25AM BLOOD Albumin-3.9 Calcium-9.1 Phos-4.0 Mg-1.7
___ 10:25AM BLOOD WBC-8.7 RBC-3.61* Hgb-8.1* Hct-26.8*
MCV-74* MCH-22.4* MCHC-30.2* RDW-16.3* RDWSD-43.9 Plt ___
___ 10:25AM BLOOD ___ PTT-33.2 ___
___ 10:25AM BLOOD Glucose-185* UreaN-14 Creat-0.9 Na-140
K-3.7 Cl-94* HCO3-29 AnGap-17
___ 10:25AM BLOOD ALT-16 AST-20 LD(___)-188 AlkPhos-124*
TotBili-0.4
___ 10:25AM BLOOD Albumin-3.9 Calcium-9.1 Phos-4.0 Mg-1.7
==============================
MICROBIOLOGY
==============================
___ Urine culture - GNRs ___
==============================
IMAGING
==============================
___ Chest Pa and Lat:
Midline tracheostomy is re-demonstrated.No focal consolidation
is seen. There is no large pleural effusion or pneumothorax.
Persistent chronic blunting of the right costophrenic angle is
re-demonstrated. The cardiac and mediastinal silhouettes are
stable.
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
___ female with PMH of tracheobronchial malacia s/p
trachea-bonchoplasty (___), trach on ___, and a T tube
placed ___, as well as CHF with EF of 49%, COPD, Afib, RUE
DVT on apixaban presents with worsening shortness of breath and
complaints of bright red blood per rectum.
============================
ACUTE ISSEUS ADDRESSED
============================
# Bright red blood per rectum
# Anemia:
Patient initially presenting with complaints of bright red blood
per rectum and hemoglobin 8.9 from 9.4 at last hospitalization.
She was started on an IV PPI and her apixaban was held. However,
stool guaiac was negative, and patient was found to have
hemorrhoids on exam. Hgb stayed stable at 8.4. It was felt that
this was unlikely to be an active GI bleed. Her home medications
were resumed.
# Dyspnea: Patient with normal CXR and BNP elevated to 1000. She
received IV Lasix 40mg in the ED with improvement of symptoms.
She felt back to her baseline the following day, and was able to
be discharged on her home medications.
============================
CHRONIC ISSEUS ADDRESSED
============================
# h/o RUE DVT: Diagnosed on ___ in the right axillary
vein. Has been anticoagulated since then. Her apixaban was held
on admission given concern for GI bleed, but given that her
hemoglobin remained stable with no evidence of active bleed, was
able to be restarted.
# COPD/Tracheobronchial Malacia: Known COPD and tracheobronchial
malacia. Patient felt that her breathing was at baseline.
Continued home Albuterol, Benzonatate, Mucomyst, Fluticasone and
T Tube maintenance. Dr. ___ notified via ___ fellow by
phone of patient's admission.
# Afib:
# Rate-dependent LBBB: Currently with well controlled heart
rates. Was continued on home metoprolol and dilt, and
anticoagulation was restarted as above.
# CAD: Continued aspirin and atovastatin
# Rheumatoid Arthritis Currently follows with a rheumatologist.
Has taken
multiple RA meds at various points in the past, including MTX,
plaquenil, Enbril, and Humira. Not currently on a DMARD or
biologic. Continued home medications.
# Fibromyalgia: Continued pregabalin 75mg PO TID.
# T2DM: Held home glimepiride and start ISS while in house.
Discharged on home medications.
# GERD: Patient with recent NSAID use in the setting of RA. Last
EGD demonstrated antral erythema. Initially given IV PPI given
concern for GI bleed, but was discharged on home pantoprazole.
# DEPRESSION: Continued home Fluoxetine, Buspirone, and PRN
Ativan
# RLS: Continued home Flexeril
============================
TRANSITIONAL ISSUES
============================
[] Patient was discharged on her home medications.
[] should have CBC recheck on ___ at time of next
appointment
[] Found to have QTc of 576. Would avoid any QTc prolonging
medications. Patient aware of prolonged QTc as well. Would
continue to closely monitor.
[] please ensure all health maintenance including colonoscopy
are completed given iron deficiency anemia
[] consider sleep apnea workup as cause of pulmonary issues
[] urine with GNRs following discharge. Inpatient team will f/u
results and contact patient to be sure not having symptoms
HCP: ___ (sister)
Phone number: ___
- Code: Full, Confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze
4. Apixaban 5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Benzonatate 100 mg PO TID:PRN cough
8. BusPIRone 30 mg PO DAILY
9. CloNIDine 0.2 mg PO TID
10. FLUoxetine 60 mg PO DAILY
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. Metoprolol Succinate XL 37.5 mg PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. Pregabalin 75 mg PO TID
15. Torsemide 20 mg PO DAILY
16. TraMADol 50 mg PO DAILY:PRN Pain - Moderate
17. Diltiazem Extended-Release 360 mg PO DAILY
18. glimepiride 2 mg oral DAILY
19. LORazepam 1 mg PO Q8H:PRN breakthrough anxiety
20. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
21. Cyclobenzaprine 5 mg PO HS:PRN spasm
22. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze
4. Apixaban 5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Benzonatate 100 mg PO TID:PRN cough
8. BusPIRone 30 mg PO DAILY
9. CloNIDine 0.2 mg PO TID
10. Cyclobenzaprine 5 mg PO HS:PRN spasm
11. Diltiazem Extended-Release 360 mg PO DAILY
12. Ferrous Sulfate 325 mg PO DAILY
13. FLUoxetine 60 mg PO DAILY
14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
15. glimepiride 2 mg oral DAILY
16. LORazepam 1 mg PO Q8H:PRN breakthrough anxiety
17. Metoprolol Succinate XL 37.5 mg PO DAILY
18. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
19. Pantoprazole 40 mg PO Q24H
20. Pregabalin 75 mg PO TID
21. Torsemide 20 mg PO DAILY
22. TraMADol 50 mg PO DAILY:PRN Pain - Moderate
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
# Dypsnea - likely secondary to acute on chronic diastolic heart
failure
# Rectal bleeding, likely ___ hemorrhoids
Secondary Diagnosis
# h/o RUE DVT
# COPD/Tracheobronchial Malacia
# Afib
# Rate-dependent LBBB
# Coronary artery disease
# Fibromyalgia
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 be a part of your care team at ___
___. You were admitted because you had some
more difficulty breathing and weight gain. You also had noticed
some rectal bleeding. You were feeling better after getting some
Lasix through the IV. We think that the bleeding is from
hemorrhoids, and your blood counts were fine.
You can take all of your normal medications when you go home.
Please see below for your discharge appointments.
Again, it was very nice to meet you, and we wish you the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10439110-DS-30 | 10,439,110 | 21,656,566 | DS | 30 | 2145-09-27 00:00:00 | 2145-09-27 20:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
FROM ADMISSION NOTE
___ yo female with PMH of
tracheobronchial malacia s/p trachea-bonchoplasty (___), trach
on ___, and a T tube placed ___, HFpEF, COPD, Afib,
RUE
DVT on ___, who presents with worsening shortness of
breath.
Per the ED, patient presented to the emergency department with a
2 day history of fever and shortness of breath associated with
chills, headache, and congestion. She denied dysuria, abdominal
pain, N/V/D. She denied sick contacts or new medication changes.
She tried nebulizers at home, but eventually came ___ because she
was unable to breathe.
___ ED initial VS: T 102.2F HR 110 BP 135/63 RR 24 O2Sat 94% 2L
Exam: tachycardia, clear lungs
Labs significant for: WBC 26.3, Hgb 9.5 (baseline Hgb ___, trop
x 1 negative, lactate 3.2, VBG 7.39/43, flu negative
Patient was given: 1.25 L NS, acetaminophen 1 gram,
ipratropium/albuterol nebs, vancomycin, cefepime, azithromycin,
home meds: omeprazole, fluoxetine, buspirone, clonidine,
apixaban, insulin, lyrica, lorazepam
Imaging notable for: CXR: Right lower lobe peribronchial
opacification probably atelectasis but could represent pneumonia
___ appropriate clinical setting. The pulmonary vasculature is
unremarkable.
On arrival to the MICU patient improved on antibiotics. Has
remained afebrile but still on 2L NC. Continued on home
torsemide
as making good UOP. Antibiotics narrowed with clinical
improvement to CTX/azithro and continued on COPD medications.
When seen on the floor, patient stable with no complaints of
SOB,
CP, palpitations, fevers, chills, nausea, vomiting, abdominal
pain. Productive cough and wheezing still present but improved
with nebs. Still having chronic bilateral pain of her UEs from
RA.
Past Medical History:
FROM ADMISSION NOTE
- Tracheo/cervical bronchomalacia s/p TBP ___, trach/PEG on
___, and T-tube placement ___.
- HFpEF + mild HFrEF (EF 49%)
- atrial fibrillation
- atrial tachycardia with rate-dependent LBBB
- COPD/asthma
- Moderate OSA(AHI 29)
- HTN
- Hypercholesterolemia
- T2DM
- GERD, ___ esophagus
- Diverticulitis
- RUE DVT ___ on apixiban
- Rheumatoid arthritis
- Restless leg syndrome
- Depression
- Polysubstance abuse
Social History:
___
Family History:
FROM ADMISSION NOTE
Mother: Lung cancer, CHF
Father: CHF
Aunt: ___ CA
Physical Exam:
ADMISSION PHYSICAL EXAM
=====================
VITALS: reviewed ___ ___
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Coarse breath sounds 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 obvious rashes
NEURO: moving extremities with purpose
DISCHARGE PHYSICAL EXAM
=====================
___ ___ Temp: 97.7 PO BP: 128/73 HR: 64 RR: 20 O2 sat:
100%
O2 delivery: 3l FSBG: 174
GENERAL: NAD
HEENT: anicteric sclerae
NECK: supple, T-tube ___ place
CV: RRR, S1/S2, no m/r/g
PULM: unlabored, good air movement, rare bibasilar crackle
EXT: WWP, without edema
NEURO: non-focal
Pertinent Results:
ADMISSION LABS
=============
___ 04:22AM BLOOD WBC-26.3*# RBC-4.08 Hgb-9.5* Hct-31.6*
MCV-78* MCH-23.3* MCHC-30.1* RDW-17.3* RDWSD-49.1* Plt ___
___ 04:22AM BLOOD Neuts-89.6* Lymphs-5.0* Monos-4.1*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-23.55*# AbsLymp-1.32
AbsMono-1.07* AbsEos-0.02* AbsBaso-0.06
___ 04:22AM BLOOD Glucose-299* UreaN-23* Creat-0.9 Na-135
K-5.0 Cl-95* HCO3-21* AnGap-19*
___ 08:20PM BLOOD ALT-16 AST-15 LD(LDH)-213 AlkPhos-108*
TotBili-0.2
___ 04:22AM BLOOD cTropnT-<0.01
___ 08:45PM BLOOD proBNP-1530*
___ 08:45PM BLOOD Calcium-8.5 Phos-3.3 Mg-2.1
___ 04:42AM BLOOD ___ pO2-52* pCO2-43 pH-7.39
calTCO2-27 Base XS-0
___ 07:15PM BLOOD ___ pO2-57* pCO2-37 pH-7.35
calTCO2-21 Base XS--4
___ 09:00PM BLOOD ___ pO2-46* pCO2-48* pH-7.36
calTCO2-28 Base XS-0
___ 11:57PM BLOOD ___ pO2-41* pCO2-48* pH-7.35
calTCO2-28 Base XS-0
___ 04:28AM BLOOD Lactate-3.2*
___ 08:02AM BLOOD Lactate-2.1*
___ 07:15PM BLOOD Lactate-1.1
DISCHARGE LABS
=============
___ 05:45AM BLOOD WBC-23.4* RBC-3.76* Hgb-8.4* Hct-27.9*
MCV-74* MCH-22.3* MCHC-30.1* RDW-18.1* RDWSD-48.0* Plt ___
___ 06:21AM BLOOD Glucose-128* UreaN-29* Creat-1.0 Na-137
K-4.7 Cl-100 HCO3-21* AnGap-16
___ 05:45AM BLOOD Glucose-154* UreaN-35* Creat-1.4* Na-135
K-4.3 Cl-95* HCO3-21* AnGap-19*
___ 05:45AM BLOOD Calcium-8.6 Phos-5.7* Mg-2.2
IMAGING
=======
CXR (___)
IMPRESSION:
Right basal atelectasis and pleural scarring.
CXR (___)
IMPRESSION:
There are low lung volumes. The tracheostomy tube is unchanged
imposition.
There are progressive pulmonary opacities, more severe on the
right.
Pulmonary edema and/or pneumonia should be considered ___ the
appropriate
clinical setting. The cardiomediastinal silhouette is
unchanged. The aorta
is tortuous. There is chronic mild elevation of the right
hemidiaphragm.
TTE (___)
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. Normal left ventricular wall
thickness, cavity size, and regional/global systolic function
(biplane LVEF = 68 %). [Intrinsic left ventricular systolic
function is likely more depressed given the severity of mitral
regurgitation.] The estimated cardiac index is normal
(>=2.5L/min/m2). The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. Mild to moderate (___) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The mitral valve shows characteristic rheumatic
deformity with immobility of the posterior leaflet. There is no
mitral stenosis. There is no mitral valve prolapse. Moderate to
severe (3+) mitral regurgitation is seen. There is mild-moderate
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Moderate to
severe mitral regurgitation with leaflet thickening.
Mild-moderate pulmonary artery systolic hypertension.
Mild-moderate aortic regurgitation.
Compared with the prior study (images reviewed) of ___,
the estimated PA systolic pressure is now greater. The severity
of mitral regurgitation is likely similar.
CXR (___)
IMPRESSION:
Compared to chest radiographs ___ through ___.
Generalized pulmonary abnormality which developed between
___ and
___ has improved. Because moderate cardiomegaly and
pulmonary venous
distension both increased concurrently, the lung findings are
most likely due
to either pulmonary edema with acute mitral regurgitation or
aspiration and
concurrent cardiac decompensation. Right upper lobe is still
substantially
consolidated and the heart is still quite large. Pleural
effusions are small.
No pneumothorax. Tracheal T tube ___ place.
CXR (___)
IMPRESSION:
Heart size is enlarged, unchanged. Mediastinum is stable.
Right upper lung
consolidation has progressed concerning for progression of right
upper lung
infectious process. Minimal basal atelectasis is unchanged. No
appreciable
pleural effusion is noted. No pulmonary edema is present.
CXR (___)
IMPRESSION:
Compared to chest radiographs ___ through ___.
Moderately severe pulmonary edema developed on ___,
improved on ___, and has subsequently is worsened. Moderate to severe
cardiomegaly is
stable over the past several days, but increased since ___. Small
pleural effusions are likely. No pneumothorax. Tracheal T tube
___ place.
VIDEO OROPHARYNGEAL SWALLOW (___)
IMPRESSION:
Normal oropharyngeal swallowing videofluoroscopy.
MICROBIOLOGY
============
___ 5:08 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
THIS IS A CORRECTED REPORT AT 15:28 ___ Reported to and
read back
by ___ AT 15:23 ___.
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
PREVIOUSLY REPORTED AS ON ___ NO GRAM NEGATIVE ROD
SEEN.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
STENOTROPHOMONAS MALTOPHILIA. MODERATE GROWTH.
test result performed by Microscan.
GRAM NEGATIVE ROD #2. RARE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STENOTROPHOMONAS MALTOPHILIA
|
TRIMETHOPRIM/SULFA---- <=2 S
Brief Hospital Course:
___ female with history of tracheobronchomalacia s/p
tracheobonchoplasty, tracheostomy (___), and T-tube placement
(___), chronic diastolic heart failure, COPD, atrial
fibrillation, type II diabetes admitted for hypercarbic
respiratory failure ___ the context of pneumonia and mixed COPD
and heart failure exacerbations, initially requiring BiPAP,
though promptly weaned to room air. She then decompensated,
necessitating return to the MICU for respiratory distress. CAP
coverage then broadened and ultimately narrowed for
Stenotrophomonas pneumonia. Transferred to floor once again,
where respiratory and volume status were optimized.
#) Pneumonia: fever, leukocytosis, equivocal right lower lobe
consolidation, concerning for community-acquired pneumonia.
Ceftriaxone/azithromycin broadened to cefepime for completion of
7-day course ___ the context of respiratory decompensation.
Sputum culture later grew Stenotrophomonas sp. Bactrim DS two
tabs TID added on ___ for directed 7-day course (end date =
___ ___ that regard. Persistence of leukocytosis likely
confounded by tandem corticosteroids for COPD component.
#) Acute on chronic diastolic heart failure: LVEF = 68%.
Initially presumed to be euvolemic. Home beta blockade and
torsemide continued ___ that regard. Patient later decompensated
___ the context of hypertension, suggesting flash pulmonary
edema. Returned to the MICU, where she was aggressively
diuresed; euvolemic thereafter. Captopril initiated for
moderate-severe MR, but ultimately held for acute kidney injury.
Home Toprol XL 37.5 mg and torsemide 20 mg resumed prior to
discharge. Weight at discharge = 78.5 kg.
#) COPD exacerbation: likely provoked by pulmonary edema ___ the
context of tandem heart failure exacerbation. Completed 5-day
course of prednisone. Inhaled bronchodilators continued for
symptomatic care. Weaned to room air by discharge.
#) Tracheobronchomalacia: status-post trachebronchoplasty and
T-tube placement. Aggressive pulmonary toilet by way of inhaled
mucolytics and suctioning continued.
#) Acute kidney injury: secondary to volume contraction.
Creatinine then climbed to 1.4 from baseline 0.9-1.1 possibly
spurious due to Bactrim. Suggest repeating BMP ___ three days
(after completion of Bactrim), and if creatinine is worsening,
would require dose adjustment of renally cleared medications
(i.e., apixaban, fluoxteine, pregabalin).
#) Type II diabetes: labile. Home glimepiride held. Required
Lantus 10U QHS, standing Humalog 2U AC, and HISS for euglycemia.
CHRONIC/STABLE ISSUES:
#) Atrial fibrillation: home Toprol XL, diltiazem, and apixaban
continued.
#) h/o RUE DVT: home apixaban continued, as above.
#) Chronic pain syndrome: home pregabalin 75 mg TID continued.
#) Mixed mood-anxiety disorder: home buspirone, fluoxetine,
clonidine, and Ativan continued.
TRANSITIONAL ISSUES:
[ ]Facilitate follow-up with cardiology
[ ]Ensure completion of 7-day course of Bactrim DS 2 tabs TID
(end date = ___
[ ]Check BMP on ___ (lab prescription provided); at discharge,
creatinine = 1.4
[ ]When creatinine normalizes, consider addition of ACE
inhibitor for afterload reduction ___ the context of
moderate-severe mitral regurgitation and heart failure
[ ]Insulin requirements, as above, for hyperglycemia; repeat A1C
and titrate oral hypoglycemic +/- insulin as needed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze
4. Apixaban 5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Benzonatate 100 mg PO TID:PRN cough
8. BusPIRone 30 mg PO DAILY
9. Cyclobenzaprine 5 mg PO HS:PRN spasm
10. FLUoxetine 60 mg PO DAILY
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. LORazepam 1 mg PO Q8H:PRN breakthrough anxiety
13. Pantoprazole 40 mg PO Q24H
14. Pregabalin 75 mg PO TID
15. TraMADol 50 mg PO DAILY:PRN Pain - Moderate
16. Torsemide 20 mg PO DAILY
17. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
18. Metoprolol Succinate XL 37.5 mg PO DAILY
19. glimepiride 2 mg oral DAILY
20. Ferrous Sulfate 325 mg PO DAILY
21. Diltiazem Extended-Release 360 mg PO DAILY
22. CloNIDine 0.2 mg PO TID
23. Potassium Chloride 20 mEq PO EVERY OTHER DAY
Discharge Medications:
1. GuaiFENesin ER 1200 mg PO Q12H
RX *guaifenesin 1,200 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*30 Tablet Refills:*0
2. Sulfameth/Trimethoprim DS 2 TAB PO TID Duration: 7 Doses
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth three times a day Disp #*14 Tablet Refills:*0
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
4. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze
6. Apixaban 5 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Benzonatate 100 mg PO TID:PRN cough
10. BusPIRone 30 mg PO DAILY
11. CloNIDine 0.2 mg PO TID
12. Cyclobenzaprine 5 mg PO HS:PRN spasm
13. Diltiazem Extended-Release 360 mg PO DAILY
14. Ferrous Sulfate 325 mg PO DAILY
15. FLUoxetine 60 mg PO DAILY
16. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
17. glimepiride 2 mg oral DAILY
18. LORazepam 1 mg PO Q8H:PRN breakthrough anxiety
19. Metoprolol Succinate XL 37.5 mg PO DAILY
20. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
21. Pantoprazole 40 mg PO Q24H
22. Potassium Chloride 20 mEq PO EVERY OTHER DAY
23. Pregabalin 75 mg PO TID
24. Torsemide 20 mg PO DAILY
25. TraMADol 50 mg PO DAILY:PRN Pain - Moderate
26.Outpatient Lab Work
ICD 10: N17.9 Acute Kidney Injury
Please obtain chem ___
Fax results to: Dr. ___: ___
and Dr. ___ ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
-Pneumonia
-Acute on chronic diastolic heart failure
-Acute COPD exacerbation
Secondary:
-Tracheobronchomalacia
-Acute kidney injury
-Atrial fibrillation
-Type II diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
-You had a fever and difficulty breathing. You required BiPAP ___
the emergency department to support your breathing.
WHAT HAPPENED WHILE I WAS ___ THE HOSPITAL?
-You received antibiotics for pneumonia.
-You received Lasix (water pill) through your IV to dry out your
lungs.
-You received steroids too for your COPD.
WHAT SHOULD I DO WHEN I GO HOME?
-Please follow-up with your primary doctor and cardiologist ___
the next one to two weeks. Please see below.
-We need to check your kidney function sooner. Have your blood
drawn at your primary doctor's office ___ three days (___). Please see below.
-Continue your antibiotic (Bactrim) until ___.
-Weigh yourself daily, and call your doctors if your ___ goes
up by three pounds.
-Take all of your medications as prescribed.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10439110-DS-32 | 10,439,110 | 22,813,091 | DS | 32 | 2145-11-24 00:00:00 | 2145-11-24 13:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ h/o TBM and multiple other
serious comorbidities s/p tracheobronchoplasty ___,
tracheostomy ___, recent T-tube exchange to ___ by
IP ___ p/w cellulitis around stoma. She was seen yesterday in
the ED for the same issue, as well as some plugging of her
___ tube with secretions. Has been having increased
postnasal drip for the past 1 week, but no other URI symptoms.
Has a chronic cough. She was deep suctioned and started on
Augmentin for the cellulitis, Percocet for the pain. Today she
returns for continued pain, inability to tolerate the Percocet
(nausea), concerns regarding an exposed stitch, and anxiety
surrounding the management of the ___ tube.
Past Medical History:
FROM ADMISSION NOTE
- Tracheo/cervical bronchomalacia s/p TBP ___, trach/PEG on
___, T-tube placement ___, ___ Cannula ___
- HFpEF + mild HFrEF (EF 49%)
- atrial fibrillation
- atrial tachycardia with rate-dependent LBBB
- COPD/asthma
- Moderate OSA(AHI ___)
- HTN
- Hypercholesterolemia
- T2DM
- GERD, ___ esophagus
- Diverticulitis
- RUE DVT ___ on apixiban
- Rheumatoid arthritis
- Restless leg syndrome
- Depression
- Polysubstance abuse
- Anxiety
Social History:
___
Family History:
Mother: Lung cancer, CHF
Father: CHF
Aunt: ___ CA
Physical Exam:
___.5 86 SR 134/85 16 94% RA
GENERAL
[ ] WN/WD frail [x] NAD [x] AAO [ ] abnormal findings:
HEENT
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[x] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [x] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[x] Abnormal findings: tracheostomy with minimal erythema,
blanching, and area of ulceration beneath plastic. exposed
stitch. tender to palpation around trachea, supraclavicular area
RESPIRATORY
[ ] CTA/P -expiratory and inspiratory rales/rhonchi and
scattered wheezes [ ] Excursion normal -poor excursion [x]
No fremitus
[x] No egophony [x] No spine/CVAT
[ ] Abnormal findings:
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [ ] No edema
-trace edema bilaterally
[x] Peripheral pulses nl [ ] No abd/carotid bruit
[ ] Abnormal findings:
GI
[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia
[ ] Abnormal findings:
GU [x] Deferred
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO
[x] Strength intact/symmetric [x] Sensation intact/ symmetric
[x] Reflexes nl [x] No facial asymmetry [x] Cognition intact
[x] Cranial nerves intact [ ] Abnormal findings:
MS
[x] No clubbing [x] No cyanosis [ ] No edema [x] Gait nl
[x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl
[x] Nails nl [x] Abnormal findings: left wrist edema, palpable
nodule
LYMPH NODES
[x] Cervical nl [x] Supraclavicular nl [ ] Axillary nl
[ ] Inguinal nl [ ] Abnormal findings:
SKIN
[ ] No rashes/lesions/ulcers -as per HEENT, ulcerated area
beneath tracheostomy
[x] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC
[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
___ 09:50AM WBC-18.3* RBC-4.02 HGB-8.7* HCT-28.8* MCV-72*
MCH-21.6* MCHC-30.2* RDW-17.3* RDWSD-44.7
___ 09:50AM NEUTS-69.2 ___ MONOS-7.0 EOS-3.7
BASOS-0.3 IM ___ AbsNeut-12.68* AbsLymp-3.50 AbsMono-1.29*
AbsEos-0.67* AbsBaso-0.06
___ 09:50AM PLT COUNT-386
___ 09:50AM GLUCOSE-149* UREA N-8 CREAT-0.8 SODIUM-138
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-22 ANION GAP-17
___ CT trachea:
1. There is severe dynamic collapse on expiratory phase from the
midtrachea to approximately 4 cm below tip of the tube, the most
severe an 87% decrease in area.
2. Moderate air-trapping similar to prior.
___ RUE duplex scan :
No evidence of deep vein thrombosis in the right upper
extremity.
Brief Hospital Course:
Ms. ___ was evaluated by the Thoracic Surgery service and
Interventional Surgery service in the Emergency Room and
admitted to the hospital for pulmonary toilet, treatment of her
trach stoma cellulitis and possible future surgical planning.
Augmentin was resumed, she remained afebrile and her stoma site
was improving. She was placed on mucolytics via nebulizers as
well as oral Mucinex to help with her congestion.
An upper extremity duplex scan was done to assess an old right
upper extremity DVT. It was negative but she remains on apixaban
for her PAF. A dynamic airway CT was also done to assess her
tracheobronchomalacia and she has severe malacia from mid
trachea to 4 cm below the ___ tube. It is unclear at
this time if she'd be a surgical candidate and will have a
repeat scan in a few weeks followed by a discussion with IP and
Thoracic Surgery.
Her stoma site is improving on Augmentin and she should complete
her 10 day course on ___. She will remain on Albuteral and
Mucomyst at home to help ease some of her congestion along with
the use of her flutter valve.
She was discharged home on ___ and will follow up in the
Clinic in 2 weeks with Dr. ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetylcysteine Inhaled - For interventional pulmonary use
only ___ mL NEB BID
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
4. Apixaban 5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Benzonatate 100 mg PO TID:PRN cough
8. BusPIRone 30 mg PO DAILY
9. Cyclobenzaprine 5 mg PO HS:PRN muscle spasm
10. Diltiazem Extended-Release 360 mg PO DAILY
11. FLUoxetine 80 mg PO DAILY
12. Fluticasone Propionate 110mcg 2 PUFF IH BID
13. LORazepam 1 mg PO TID anxiety
14. Naproxen 500 mg PO Q12H:PRN Pain - Mild
15. Pantoprazole 40 mg PO Q12H
16. Pregabalin 75 mg PO TID restless leg syndrome
17. roflumilast 500 mcg oral daily
18. Tiotropium Bromide 1 CAP IH DAILY
19. Torsemide 20 mg PO DAILY
20. Lidocaine 5% Patch 1 PTCH TD QAM
21. glimepiride 2 mg oral DAILY
22. guaiFENesin (pseudoephedrine-codeine-GG) 100 mg/5 mL oral
BID
23. Potassium Chloride 20 mEq PO EVERY OTHER DAY
24. Acetaminophen 1000 mg PO Q6H
25. Lisinopril 5 mg PO DAILY
26. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
27. Metoprolol Succinate XL 50 mg PO DAILY
28. Guaifenesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough
29. Daliresp (roflumilast) 500 mcg oral DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days
use through ___
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*15 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*2
3. Milk of Magnesia 30 mL PO Q12H:PRN constipation
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ to 1 tablet(s) by mouth every four (4)
hours Disp #*20 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*14 Packet Refills:*2
6. Acetaminophen 1000 mg PO Q6H
7. Acetylcysteine Inhaled - For interventional pulmonary use
only ___ mL NEB BID
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
10. Apixaban 5 mg PO BID
11. Aspirin 81 mg PO DAILY
12. Atorvastatin 40 mg PO QPM
13. Benzonatate 100 mg PO TID:PRN cough
14. BusPIRone 30 mg PO DAILY
15. Cyclobenzaprine 5 mg PO HS:PRN muscle spasm
16. Daliresp (roflumilast) 500 mcg oral DAILY
17. Diltiazem Extended-Release 360 mg PO DAILY
18. FLUoxetine 80 mg PO DAILY
19. Fluticasone Propionate 110mcg 2 PUFF IH BID
20. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
21. glimepiride 2 mg oral DAILY
22. guaiFENesin (pseudoephedrine-codeine-GG) 100 mg/5 mL oral
BID
23. Lisinopril 5 mg PO DAILY
24. LORazepam 1 mg PO TID anxiety
25. Metoprolol Succinate XL 50 mg PO DAILY
26. Naproxen 500 mg PO Q12H:PRN Pain - Mild
27. Pantoprazole 40 mg PO Q12H
28. Potassium Chloride 20 mEq PO EVERY OTHER DAY
Hold for K >
29. Pregabalin 75 mg PO TID restless leg syndrome
30. roflumilast 500 mcg oral daily
31. Tiotropium Bromide 1 CAP IH DAILY
32. Torsemide 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis trach stoma
Tracheobronchomalacia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital with difficulty breathing
and a cellulitis around your ___ cannula.
* You will have another CT of the trachea on ___ and more
discussions will take place regarding the findings and further
plans at your next appointment with Dr. ___ on that day.
* You need to continue the Augmentin through ___, use your
flutter valve and continue the nebulizers on a scheduled basis
to help relieve your congestion.
* Continue to care for your Monrgomery T tube and clean the
inner cannula daily to maintain patency.
* Continue your nebulizers as ordered.
* Resume the Apixaban.
* Call Dr. ___ at ___ if you have any
increased shortness of breath, increased secretions or increased
redness around T tube.
* Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10439110-DS-34 | 10,439,110 | 20,307,305 | DS | 34 | 2146-01-22 00:00:00 | 2146-01-22 18:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
altered mental status, shortness of breath, headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o F with PMhx of TBM with frequent admissions, OSA, HFpEF,
COPD, RUE DVT, Afib (apixaban), T2DM, HTN, anxiety and hx of
polysubstance abuse who was seen in the ED on ___ for rib pain
and returns by ambulance on ___ with AMS, SOB, diffuse pain and
HA. Pt was lethargic in the ED and underwent head CT without
acute process. Additional history was obtained from her fiancé
that she has been more depressed and he is concerned that she is
taking many more Ativan than prescribed. He counted her pills
and since getting Ativan filled on ___, she has taken 40 more
pills than prescribed.
Pt was reporting intermittent SOB, rib pain, cough, HA and 2
weeks of malaise. Work up in the ED notable for WBC of 10,
stable anemia, normal renal function, lactate 1.8, VBG with pH
7.33/50, UA suggestive of UTI and Urine Tox positive for
oxycodone. CXR notable for increase pulm vascular congestion and
pt was treated with Albuterol, Ceftriaxone, IVF and Tylenol.
She was noted to have mild tachycardia that improved after she
resumed home dose of Diltiazem. Around 1800, pt was given IV
Benadryl, Compazine and more Tylenol prior to transfer for
ongoing HA. Psych could not place patient under ___
while she was still intoxicated but pt remains on suicide
precautions with 1:1 sitter.
On arrival to the floor, pt was sleeping but awakes briefly to
voice. She answers short questions appropriately but goes back
to sleep quickly. She endorses feeling like she has a cold with
congestion, cough with sputum and rib pain. Report intermittent
HAs over the last 2 weeks and last had a subjective fever more
than 1 week ago. When asked about suicidal ideation, pt
responds briefly that she was not trying to harm herself and
quickly falls asleep again. She is unable to provide full ROS
due to falling asleep. I returned to evaluate again at 1:30am
and pt reports that symptoms including HA feel better after
toradol. Currently, she is denying any chest pain, rash, neck
pain, abd
pain and is unable to localize her chronic pain from
fibromyalgia but reports that it gets better with lyrica.
ROS: limited by patient's mental status
Past Medical History:
FROM ADMISSION NOTE
- Tracheo/cervical bronchomalacia s/p TBP ___, trach/PEG on
___, T-tube placement ___, ___ Cannula ___
- HFpEF + mild HFrEF (EF 49%)
- atrial fibrillation
- atrial tachycardia with rate-dependent LBBB
- COPD/asthma
- Moderate OSA(AHI ___)
- HTN
- Hypercholesterolemia
- T2DM
- GERD, ___ esophagus
- Diverticulitis
- RUE DVT ___ on apixiban
- Rheumatoid arthritis
- Restless leg syndrome
- Depression
- Polysubstance abuse
- Anxiety
Social History:
___
Family History:
Mother: Lung cancer, CHF
Father: CHF
Aunt: ___ CA
Physical Exam:
Admission exam
___ Temp: 97.9 PO BP: 117/70 R Lying HR: 95 RR: 20 O2
sat: 95% O2 delivery: RA
GEN Caucasian female in NAD, sleepy but awakes briefly to voice
and answers questions appropriately
HEENT: MM DRY, pupils > 3mm bilaterally
CV: RRR
RESP: CTA with scatter expiratory wheezes
ABD: soft, NT, ND, NABS
GU: no foley
EXTR: warm, no edema
NEURO: moving all four extremities, sleepy but responds to voice
before falling back asleep
Discharge exam
98.4 147/76 80 18 97 Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Asleep and easily arousable to voice. Oriented x3, able
to recount recent history and reason for admission. face
symmetric, gaze
conjugate with EOMI, speech fluent, moves all limbs, sensation
to
light touch grossly intact throughout
PSYCH: guarded flat affect
Pertinent Results:
Admission labs
___ 09:45AM BLOOD WBC-10.5* RBC-3.71* Hgb-8.3* Hct-28.3*
MCV-76* MCH-22.4* MCHC-29.3* RDW-20.1* RDWSD-55.9* Plt ___
___ 09:45AM BLOOD Glucose-95 UreaN-17 Creat-1.0 Na-144
K-3.7 Cl-106 HCO3-23 AnGap-15
___ 09:45AM BLOOD Albumin-3.9 Calcium-8.8 Phos-5.6* Mg-1.9
___ 09:45AM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
Discharge labs
___ 07:04AM BLOOD WBC-8.6 RBC-3.65* Hgb-8.2* Hct-27.2*
MCV-75* MCH-22.5* MCHC-30.1* RDW-20.2* RDWSD-55.2* Plt ___
___ 07:04AM BLOOD Glucose-132* UreaN-9 Creat-0.6 Na-145
K-3.8 Cl-106 HCO3-22 AnGap-17
___ 07:04AM BLOOD Calcium-8.8 Phos-3.7 Mg-1.8
CXR ___
FINDINGS:
Heart size remains moderately enlarged. Mediastinal and hilar
contours are unchanged. Mild pulmonary vascular congestion is
demonstrated without frank pulmonary edema. Linear opacities in
the right lung base are similar as is chronic blunting of the
right costophrenic angle which likely reflects chronic pleural
thickening. There is mild elevation of the right hemidiaphragm
as seen previously. No new focal consolidation, pleural
effusion, or pneumothorax is detected. No acute osseous
abnormality is present.
IMPRESSION:
Mild pulmonary vascular congestion. No radiographic evidence
for pneumonia.
___ ___
IMPRESSION:
No acute intracranial abnormality.
Brief Hospital Course:
___ y/o F with PMHx of TBM (s/p tracheobronchoplasty ___,
recent trach removal and T-tube exchange to ___ ___,
OSA, HFpEF, COPD, RUE DVT, Afib (apixaban), T2DM, HTN,
diverticulitis, anxiety who presents with lethargy, myalgias and
c/f benzodiazepine overdose. Pt was seen by psychiatry during
hospitalization. Mental status at baseline by time of discharge.
#Altered mental status
#Concern for Benzodiazepine overdose: VBG reassuring without
severe hypercarbic resp acidosis and pt mentating better on
arrival to the floor. Patient denies active SI. Collateral from
fiancé obtained - he was giving her 3 pills of Ativan three
times
as a day as she requested, no intention of harming her and
patient states this was due to increasing anxiety. Presentationw
as felt to not be due to intentional overdose but was concerning
for benzo/medication misuse. She was seen by psych during her
admission. She was slightly delirious secondary to benzo overuse
however mental status improved prior to discharge.
#Possible viral syndrome: Pt presented with rib pain, cough and
congestion on ___ and was discharged home. Per EMS runsheet, pt
was reporting worsened SOB which prompted EMS call on ___
though fiancé reports concern for benzo overdose as reason for
call. Pt reported symptomatic improvement with NSAIDS and IVF.
Given lack of fevers, leukocytosis, neck pain and overall
improving sedation/AMS, there was low concern for meningitis. Pt
was treated empirically for possible PNA and UTI with
Ceftriaxone initially however without localizing symptoms
therefore further abx held
#anxiety/depression: as above, concern for Ativan misuse in
setting of anxiety. Seen by psych and SW during admission.
Declined request to speak with her outpatient provider. Home
fluoxetine was continued, no benzos prescribed during admission.
Close follow up outpatient psychiatrist was recommended with
judicious use of benzos going forward. Outpatient resources were
also provided.
#Chronic HFpEF: continued torsemide
#p-AFib along with a rate-dependent LBBB: continued home
apixaban 5 mg PO BID, metoprolol 50mg daily, diltiazem ER 360 mg
PO daily
#COPD: no evidence of exacerbation during admission. HOme
roflumilast hled (non-formulary), home fluticasone was
continued.
#T2DM: held home glimepiride and covered with insulin sliding
scale prn
#h/o UE DVT: continued home apixaban
#PAD: continued ASA, statin
TRANSITIONAL ISSUES:
[]close psych follow up
[]taper benzo use
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Torsemide 20 mg PO DAILY
2. Pregabalin 75 mg PO TID restless leg syndrome
3. Pantoprazole 40 mg PO Q12H
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. FLUoxetine 80 mg PO DAILY
7. Diltiazem Extended-Release 360 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Aspirin 81 mg PO DAILY
10. Apixaban 5 mg PO BID
11. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
12. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
13. Acetylcysteine Inhaled - For interventional pulmonary use
only ___ mL NEB Q4H:PRN SOB
14. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
15. Cyclobenzaprine 5 mg PO HS:PRN muscle spasm
16. Daliresp (roflumilast) 500 mcg oral DAILY
17. glimepiride 2 mg oral DAILY
18. LORazepam 2 mg PO TID anxiety
19. Naproxen 500 mg PO Q12H:PRN Pain - Mild
20. Potassium Chloride 20 mEq PO EVERY OTHER DAY
Discharge Medications:
1. LORazepam 2 mg PO Q8H:PRN anxiety
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. Acetylcysteine Inhaled - For interventional pulmonary use
only ___ mL NEB Q4H:PRN SOB
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
6. Apixaban 5 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Cyclobenzaprine 5 mg PO HS:PRN muscle spasm
10. Daliresp (roflumilast) 500 mcg oral DAILY
11. Diltiazem Extended-Release 360 mg PO DAILY
12. FLUoxetine 80 mg PO DAILY
13. Fluticasone Propionate 110mcg 2 PUFF IH BID
14. glimepiride 2 mg oral DAILY
15. Metoprolol Succinate XL 50 mg PO DAILY
16. Naproxen 500 mg PO Q12H:PRN Pain - Mild
17. Pantoprazole 40 mg PO Q12H
18. Potassium Chloride 20 mEq PO EVERY OTHER DAY
19. Pregabalin 75 mg PO TID restless leg syndrome
20. Torsemide 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Altered mental status due to benzodiazepine misuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for increased somnolence and lethargy likely
due to improper medication use. No infections were found.
Overall, we think your symptoms are most likely due to
inappropriate use of Lorazepam, or Ativan. Please follow up
closely with your psychiatrist to discuss alternative ways to
treat your anxiety. Please DO NOT take any more Ativan than
prescribed. Please do not drink alcohol or drive while taking
this medication.
Thank you for allowing us to participate in your care
Your ___ team
Followup Instructions:
___
|
10439110-DS-35 | 10,439,110 | 24,625,943 | DS | 35 | 2146-02-18 00:00:00 | 2146-02-20 07:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o F with PMhx of TBM s/p tracheostomy, with recent
(___)
decannulation, OSA, HFpEF, COPD, RUE DVT, pAfib (on ___,
anxiety and hx of polysubstance abuse presenting with 2 days of
worsening dyspnea and wheezing.
She was last seen in ___ clinic on ___ where her breathing was
felt to be stable since her decannulation, and PFTs were noted
to
be stable as well. Plan at that point was for 3 month f/u for CT
trachea and repeat spirometry.
Since her decannulation, she has had 5 ED visits for various
complaints (pain, vomiting, concern for benzo overdose),
resulting in 3 inpatient admissions. Only one (on ___ was for
dyspnea, which had actually resolved by the time she made it to
the floor and she was discharged on the same day.
She called ___ clinic today to report progressive DOE and
wheezing
over the past two days. Restarting her Advair and Spiriva as
well
as albuterol did not improve her symptoms. She began developing
difficulty speaking this evening, so it was recommended she come
to the ED due to concern for tracheal stenosis.
She denies fever/chills, productive cough, orthopnea, ___ edema.
She says it feels like she is "breathing through a straw." She
says the nebulizers she was given in the ED were not helpful.
In the ED, initial VS were:
98.9
104
135/49
20
97% RA
No exam documented.
ECG: Sinus tachycardia at 102. Normal axis. QTc 506, QRS
155--IVCD. Overall, unchanged from prior.
Labs showed: WBC 12, K 3.1 with otherwise normal chem10, BNP
562,
trop negative. VBG on arrival to floor with pCO2 40, pH 7.45.
Imaging showed:
CXR: Low lung volumes with probable mild pulmonary vascular
congestion and bibasilar atelectasis.
Case discussed with IP fellow:
concern for tracheal stenosis I/s/o recent decannulation.
Recommendations were:
- ct trachea in AM
- hold apixiban
- NPO after midnight
Patient received:
___ 19:59 IH Albuterol 0.083% Neb Soln 1 NEB ___
___ 19:59 IH Ipratropium Bromide Neb 1 NEB ___
___ 21:52 IH Albuterol 0.083% Neb Soln 1 NEB
___
___ 22:49 IH Albuterol 0.083% Neb Soln 1 NEB
___
IV Azithromycin 500 mg
Transfer VS were:
109
127/61
24
98% 2L NC
On arrival to the floor, patient reports ongoing dyspnea,
although feels this is stable from arrival. She endorses ankle
and back pain, and is requesting pain medication.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
- Tracheo/cervical bronchomalacia s/p TBP ___, trach/PEG on
___, T-tube placement ___, ___ Cannula ___
- HFpEF + mild HFrEF (EF 49%)
- atrial fibrillation
- atrial tachycardia with rate-dependent LBBB
- COPD/asthma
- Moderate OSA(AHI ___)
- HTN
- Hypercholesterolemia
- T2DM
- GERD, ___ esophagus
- Diverticulitis
- RUE DVT ___ on ___
- Rheumatoid arthritis
- Restless leg syndrome
- Depression
- Polysubstance abuse
- Anxiety
Social History:
___
Family History:
Mother: Lung cancer, CHF
Father: CHF
Aunt: ___ CA
Physical Exam:
ADMISSION
VS: reviewed in eflowsheets
GENERAL: Appears in moderate respiratory distress, unable to
speak in complete sentences.
HEENT: EOMI, PERRL, anicteric sclera, MMM
NECK: supple, no LAD, no JVD. Site of tracheostomy is
well-healed. There is expiratory wheeze heard over the anterior
neck, without inspiratory stridor.
HEART: RRR, no murmurs, gallops, or rubs
LUNGS: CTAB with transmitted expiratory wheeze from upper airway
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE
VS: ___ 0735 Temp: 97.9 PO BP: 113/73 HR: 77 RR: 16 O2 sat:
97% O2 delivery: Ra FSBG: 163
GENERAL: NAD, awake, alert
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD, no JVD
HEART: irreg irreg, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, intermittent transmitted upper airway sounds
without
focality. No increased WOB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
================
___ 07:18PM BLOOD WBC-12.0* RBC-3.95 Hgb-9.1* Hct-29.6*
MCV-75* MCH-23.0* MCHC-30.7* RDW-19.9* RDWSD-53.9* Plt ___
___ 07:18PM BLOOD Neuts-63.1 ___ Monos-7.5 Eos-1.8
Baso-0.6 Im ___ AbsNeut-7.55* AbsLymp-3.19 AbsMono-0.90*
AbsEos-0.21 AbsBaso-0.07
___ 07:18PM BLOOD ___ PTT-31.7 ___
___ 07:18PM BLOOD Glucose-255* UreaN-9 Creat-0.8 Na-140
K-3.1* Cl-100 HCO3-24 AnGap-16
___ 02:31AM BLOOD Calcium-8.7 Phos-4.4 Mg-1.9
___ 07:18PM BLOOD cTropnT-<0.01 proBNP-562*
___ 02:38AM BLOOD ___ pO2-252* pCO2-40 pH-7.45
calTCO2-29 Base XS-4 Comment-GREEN TOP
___ 10:30PM URINE Color-Straw Appear-Clear Sp ___
___ 10:30PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD*
___ 10:30PM URINE RBC-0 WBC-8* Bacteri-FEW* Yeast-NONE
Epi-1 TransE-<1
OTHER PERTINENT/DISCHARGE LABS
=================================
___ 05:31AM BLOOD WBC-10.8* RBC-3.68* Hgb-8.6* Hct-27.9*
MCV-76* MCH-23.4* MCHC-30.8* RDW-19.9* RDWSD-54.5* Plt ___
___ 02:31AM BLOOD ___
___ 10:45AM BLOOD Glucose-140* UreaN-9 Creat-0.9 Na-141
K-4.5 Cl-100 HCO3-26 AnGap-15
___ 05:38AM BLOOD ___ pO2-195* pCO2-47* pH-7.41
calTCO2-31* Base XS-4
MICROBIOLOGY
___ 10:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
REPORTS
=========
CHEST (PA & LAT)Study Date of ___ 9:34 ___
Low lung volumes with probable mild pulmonary vascular
congestion and
bibasilar atelectasis.
CT TRACHEA W/O CONTRASTStudy Date of ___ 10:52 AM
Status post removal of the tracheostomy tube in the interim.
Significant
collapse of the proximal trachea at the level of the aortic arch
for a
distance of 1.5 cm with the narrowest airway diameter measures
approximately 1.9 mm. The distal trachea and the mainstem
bronchi are unremarkable.
Bibasilar atelectasis.
Evaluation of lung parenchyma is somewhat limited due to
respiratory motion
Brief Hospital Course:
___ year old woman with PMhx of TBM s/p tracheostomy, with recent
(___) decannulation, HFpEF, COPD, admitted due to concern
for tracheal stenosis. Evaluated by IP and Thoracic Surgery,
felt to have proximal stenosis better addressed by surgery.
Planned readmission ___.
Acute issues:
#Dyspnea
#TBM s/o tracheostomy with decannulation, c/f tracheal stenosis:
CT with evidence of proximal tracheal stenosis. Plan for
thoracic surgery on ___
-appreciate thoracic surgery recs. Resumed ___ need
to hold 72 hours prior to OR.
-Started mucinex ___ BID, Advair 500/50, and Spiriva per IP
-Patient intermittently somnolent with loose Xanax found in bed.
Concern she was taking these for anxiety with resultant
somnolence.
-normal ambulatory O2 sat on day of discharge (92-96% on RA).
#Benzodiazepine misuse
-patient amenable to having her belonging stored, though she had
one more day of morning somnolence lasting several hours. Pt
denied taking her own supply of benzos while inpatient, though
her fiance confided in the medical team that she was misusing
her medication while inpatient.
-will need ongoing counseling as an outpatient
CHRONIC ISSUES:
===============
#AFib
-fractionated home metop 50, dilt 360 while inpatient. Resumed
home regimen upon discharge.
-resumed ___ as above
#COPD
-start Advair 500/50 and Spiriva per IP. Albuterol nebs prn
-Respiratory consulted for inhaler teaching
#DM2
-held home glimepiride, HISS while here
-continued home atorvastatin 80mg, ASA 81mg
#Anxiety/Depression
-continued home fluoxetine
-held Ativan pending mental status
#HFpEF
-continued home torsemide 20mg PO daily
#GERD
-continue home pantoprazole BID
#Restless leg syndrome
-held home lyrica given somnolence, though felt unlikely to be
driving factor and resumed on discharge
TRANSITIONAL ISSUES:
-Concern that patient may be mis-using benzodiazepine during
times of anxiety with resultant sleepiness.
-Plan for cervical tracheal resection and reconstruction,
cervical tracheoplasty ___
-Patient to stop taking ___ on ___, 72 hours prior to
planned surgery on ___
-Full code
-Name of ___ care proxy: ___
Relationship: Sister
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
4. ___ 5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Diltiazem Extended-Release 360 mg PO DAILY
8. FLUoxetine 80 mg PO DAILY
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Pantoprazole 40 mg PO Q12H
12. Torsemide 20 mg PO DAILY
13. Acetylcysteine Inhaled - For interventional pulmonary use
only ___ mL NEB Q4H:PRN SOB
14. Cyclobenzaprine 5 mg PO HS:PRN muscle spasm
15. Daliresp (roflumilast) 500 mcg oral DAILY
16. glimepiride 2 mg oral DAILY
17. LORazepam 2 mg PO Q8H:PRN anxiety
18. Naproxen 500 mg PO Q12H:PRN Pain - Mild
19. Potassium Chloride 20 mEq PO EVERY OTHER DAY
20. Pregabalin 75 mg PO TID restless leg syndrome
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/dose 1
puff IH twice a day Disp #*30 Disk Refills:*0
2. GuaiFENesin ER 1200 mg PO Q12H
RX *guaifenesin 1,200 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
3. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 puff
IH daily Disp #*30 Capsule Refills:*0
4. ___ 5 mg PO BID
STOP taking this medication on ___, 3 days before your
surgery.
5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
6. Acetylcysteine Inhaled - For interventional pulmonary use
only ___ mL NEB Q4H:PRN SOB
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 80 mg PO QPM
11. Cyclobenzaprine 5 mg PO HS:PRN muscle spasm
12. Daliresp (roflumilast) 500 mcg oral DAILY
13. Diltiazem Extended-Release 360 mg PO DAILY
14. FLUoxetine 80 mg PO DAILY
15. glimepiride 2 mg oral DAILY
16. LORazepam 2 mg PO Q8H:PRN anxiety
17. Metoprolol Succinate XL 50 mg PO DAILY
18. Naproxen 500 mg PO Q12H:PRN Pain - Mild
19. Pantoprazole 40 mg PO Q12H
20. Potassium Chloride 20 mEq PO EVERY OTHER DAY
21. Pregabalin 75 mg PO TID restless leg syndrome
22. Torsemide 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Proximal tracheal stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to ___ because you were feeling short of breath. You
were found to have an area of collapse in your trachea that will
be addressed with surgery on ___. Please
see more details listed below about what happened while you were
in the hospital and your instructions for what to do after
leaving the hospital.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
- You were evaluated by the Interventional Pulmonology team and
Thoracic Surgery team and they recommended that you have surgery
to correct the area of collapse in your trachea.
- You were started a new breathing medications to help in the
meantime.
- You improved considerably and were ready to leave the hospital
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please follow up with your primary care doctor and other
health care providers (see below)
- Please take all of your medications as prescribed (see below).
- Seek medical attention if you have worsening shortness of
breath or other symptoms of concern.
-Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10439110-DS-37 | 10,439,110 | 24,853,045 | DS | 37 | 2146-03-09 00:00:00 | 2146-03-09 14:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypoxia and shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ w Afib on apixiban and TBM s/p TBP ___,
tracheostomy ___ s/p decannulation ___ now s/p cervical
tracheal resection and tracheoplasty on ___ who presented to
the ED with hypoxia. She was at home on her home O2 monitor when
she desat in the ___. This prompted her to present to the
emergency department. At that time she reported dyspnea as well.
She denied any chest pain, cough, fever, or leg swelling.
Past Medical History:
- Tracheo/cervical bronchomalacia s/p TBP ___, trach/PEG on
___, T-tube placement ___, ___ Cannula ___
- HFpEF + mild HFrEF (EF 49%)
- atrial fibrillation
- atrial tachycardia with rate-dependent LBBB
- COPD/asthma
- Moderate OSA(AHI 29)
- HTN
- Hypercholesterolemia
- T2DM
- GERD, ___ esophagus
- Diverticulitis
- RUE DVT ___ on apixiban
- Rheumatoid arthritis
- Restless leg syndrome
- Depression
- Polysubstance abuse
- Anxiety
Social History:
___
Family History:
Mother: Lung cancer, CHF
Father: CHF
Aunt: ___ CA
Physical Exam:
Temp: 98.2 HR: 85 BP: 111/37 Resp: 20 O(2)Sat: 95 Normal
Constitutional: Constitutional: comfortable
Head
/ Eyes: NC/AT
Neck: Supple, incision site clean, dry, intact
ENT: OP WNL
Resp: Very faint and expiratory wheezes bilaterally, no
focality
Cards: RRR. s1,s2. no MRG.
Abd: S/NT/ND
Flank: no CVAT
Skin: no rash
Ext: No c/c/e, equal extremity pulses
Neuro: speech fluent, moving all extremities with no gross
focal lateralizing neurologic deficit
Psych: Anxious, tearful
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW
RDWSD Plt Ct
___ 05:47 11.7* 3.33* 7.7* 25.1* 75* 23.1* 30.7* 18.6*
50.9* 454*
___ 06:20 13.5* 3.49* 8.0* 26.2* 75* 22.9* 30.5* 18.6*
50.8* 476*
___ 17:33 9.8 3.29* 7.6* 25.0* 76* 23.1* 30.4* 18.4*
51.4* 494*
___ 06:50 13.5* 3.48* 8.2* 27.1* 78* 23.6* 30.3* 18.7*
53.0* 521*
___ 13:06 12.9* 3.38* 7.9* 26.1* 77* 23.4* 30.3* 19.1*
53.8* 506*
___ 16:25 14.2* 3.41* 7.8* 26.0* 76* 22.9* 30.0* 19.7*
54.1* 404
Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 05:47 ___ 1422 4.23 ___
___ 06:20 ___ 1402 ___ 182
___ 17:33 ___ 1412 ___ 172
___ 06:50 ___ 1392 4.13 94* 28 172
___ 13:06 ___ 1412 4.23 95* 25 21*2
___ 16:25 ___ 1392 ___ 172
___ 5:54 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- 16 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
___ CTA Chest :
1. No evidence of pulmonary embolism or aortic abnormality.
2. Nonspecific ground-glass opacifications involving the right
upper and lower lobes, and some parts of the left upper lobe
appear more conspicuous compared to prior exam and can be seen
in the setting of infection.
3. Prominent mediastinal lymph nodes are unchanged compared to
prior exam.
___ CXR :
1. Expected postoperative left pleural effusion with bibasilar
atelectasis, similar in comparison to the prior.
2. Elevation of the left hemidiaphragm which raises the
possibility of phrenic nerve pathology.
Brief Hospital Course:
Given her recent surgery and hospitalization, Ms. ___ was
admitted to Thoracic Surgery for work up of her hypoxia. A CT
angio of her chest was performed to r/o a pulmonary embolism and
was negative for this finding. She was placed on oxygen as well
as given pulmonary toilet and scheduled inhalers. She was on HOD
2 she was found to have ___ with a rise in her Cr from 1.0 to
1.3. Her diuretics were held at this time and a urinalysis was
sent. UA revealed WBCs, bacteria, and +nitrates sp we placed her
on a 5d course of a Bactrim to treat her UTI. A urine culture
was also sent at this time which showed > 100K Ecoli, resistant
to Bactrim. She was placed on a 5 day course of Macrobid on
___. With increased PO intake and holding diuresis, her
___ resolved. Her oxygen requirement was slowly weaned until she
was tolerating room air with ambulatory saturations of 91-96%.
She seemed to improve with more nebulizer treatments and
Mucinex. Her home medications were resumed. At time of discharge
she was tolerating PO, ambulating independently, urinating
normally and having regular bowel movements. She will follow up
with Dr. ___ on ___ to ensure she continues to progress
well and she have her post op visit with Dr. ___ later
in ___. She refused all ___ services.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
3. Diltiazem Extended-Release 240 mg PO DAILY
4. FLUoxetine 60 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. LORazepam 2 mg PO Q8H:PRN anxiety
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Pregabalin 75 mg PO TID restless leg syndrome
10. Psyllium Powder 1 PKT PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. Torsemide 20 mg PO DAILY
13. Docusate Sodium 100 mg PO BID
14. OxyCODONE (Immediate Release) 5 - 10 mg PO Q4H:PRN Pain -
Moderate
15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Reason for PRN duplicate override: Alternating agents for
similar severity
16. Senna 8.6 mg PO BID:PRN Constipation - First Line
17. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
18. Align (Bifidobacterium infantis) 1 cap oral DAILY
19. Apixaban 5 mg PO BID
20. Aspirin 81 mg PO DAILY
21. Atorvastatin 80 mg PO QPM
22. Cyclobenzaprine ___ mg PO HS:PRN muscle spasm
23. Daliresp (roflumilast) 500 mcg oral DAILY
24. Ferrous Sulfate 160 mg PO 3X/WEEK (___)
25. glimepiride 2 mg oral DAILY
26. Ondansetron 4 mg PO PRN nausea
27. Potassium Chloride 20 mEq PO EVERY OTHER DAY
28. Vitamin D ___ UNIT PO EVERY 2 WEEKS (___)
29. Acetylcysteine Inhaled - For interventional pulmonary use
only ___ mL NEB Q4H:PRN SOB
30. Sulfameth/Trimethoprim DS 1 TAB PO BID
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
3. Diltiazem Extended-Release 240 mg PO DAILY
4. FLUoxetine 60 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. LORazepam 2 mg PO Q8H:PRN anxiety
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Pregabalin 75 mg PO TID restless leg syndrome
10. Psyllium Powder 1 PKT PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. Torsemide 20 mg PO DAILY
13. Docusate Sodium 100 mg PO BID
14. OxyCODONE (Immediate Release) 5 - 10 mg PO Q4H:PRN Pain -
Moderate
15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Reason for PRN duplicate override: Alternating agents for
similar severity
16. Senna 8.6 mg PO BID:PRN Constipation - First Line
17. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
18. Align (Bifidobacterium infantis) 1 cap oral DAILY
19. Apixaban 5 mg PO BID
20. Aspirin 81 mg PO DAILY
21. Atorvastatin 80 mg PO QPM
22. Cyclobenzaprine ___ mg PO HS:PRN muscle spasm
23. Daliresp (roflumilast) 500 mcg oral DAILY
24. Ferrous Sulfate 160 mg PO 3X/WEEK (___)
25. glimepiride 2 mg oral DAILY
26. Ondansetron 4 mg PO PRN nausea
27. Potassium Chloride 20 mEq PO EVERY OTHER DAY
28. Vitamin D ___ UNIT PO EVERY 2 WEEKS (___)
29. Acetylcysteine Inhaled - For interventional pulmonary use
only ___ mL NEB Q4H:PRN SOB
30. Sulfameth/Trimethoprim DS 1 TAB PO BID
Discharge Medications:
1. GuaiFENesin ER 1200 mg PO Q12H
RX *guaifenesin 1,200 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
2. Ipratropium Bromide Neb 1 Neb IH Q6H:PRN wheeze/SOB
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 neb inh every six
(6) hours Disp #*30 Vial Refills:*2
3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
twice a day Disp #*8 Capsule Refills:*0
4. Sodium Chloride 3% Inhalation Soln 15 mL NEB Q6H
RX *sodium chloride 3 % ` neb INH every six (6) hours Disp #*30
Vial Refills:*2
5. Acetaminophen 1000 mg PO Q8H
6. Apixaban 5 mg PO BID
7. Acetylcysteine Inhaled - For interventional pulmonary use
only ___ mL NEB Q4H:PRN SOB
8. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
10. Align (Bifidobacterium infantis) 1 cap oral DAILY
11. Aspirin 81 mg PO DAILY
12. Atorvastatin 80 mg PO QPM
13. Cyclobenzaprine ___ mg PO HS:PRN muscle spasm
14. Daliresp (roflumilast) 500 mcg oral DAILY
15. Diltiazem Extended-Release 240 mg PO DAILY
16. Docusate Sodium 100 mg PO BID
17. Ferrous Sulfate 160 mg PO 3X/WEEK (___)
18. FLUoxetine 60 mg PO DAILY
19. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
20. glimepiride 2 mg oral DAILY
21. LORazepam 2 mg PO Q8H:PRN anxiety
22. Metoprolol Succinate XL 25 mg PO DAILY
23. OxyCODONE (Immediate Release) 5 - 10 mg PO Q4H:PRN Pain -
Moderate
24. Pantoprazole 40 mg PO Q24H
25. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Reason for PRN duplicate override: Alternating agents for
similar severity
26. Potassium Chloride 20 mEq PO EVERY OTHER DAY
27. Pregabalin 75 mg PO TID restless leg syndrome
28. Psyllium Powder 1 PKT PO DAILY
29. Senna 8.6 mg PO BID:PRN Constipation - First Line
30. Tiotropium Bromide 1 CAP IH DAILY
31. Torsemide 20 mg PO DAILY
32. Vitamin D ___ UNIT PO EVERY 2 WEEKS (___)
Discharge Disposition:
Home
Discharge Diagnosis:
1. Hypoxia
2. Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital with increased shortness of
breath following surgery on your airway. A chest CT was done
which was negative. Your breathing improved with more frequent
nebulizer treatments and currently you are doing well off of
oxygen with room air saturations of 94%.
* Continue to use your incentive spirometer every hour and also
use your nebulizers as ordered.
* Check your neck incision daily and call Dr. ___ at
___ with any concerns.
* Stay well hydrated and eat well to help heal your incisions.
* Increase your activity daily to improve your stamina and
mobility.
* An appointment has been made with Dr. ___ next ___ so
that he can assess your progress.
* You also have a UTI and will need to complete a course of
antibiotics.
Followup Instructions:
___
|
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.