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10439110-DS-38 | 10,439,110 | 25,161,623 | DS | 38 | 2146-03-28 00:00:00 | 2146-03-28 15:37:00 |
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 past medical history significant for A. fib,
COPD, hypertension, hyperlipidemia, rheumatoid arthritis, DVT on
apixaban, history of tracheobronchial malacia s/p TBP ___,
tracheostomy ___ s/p decannulation ___ now s/p cervical
tracheal resection and tracheoplasty on ___ presenting with
shortness of breath and palpitations with exertion. Patient
states that for the last day anytime she gets up and walks
around
she feels her heart race and has measured her blood pressure and
found to be 150/35. Patient went into the 140s when she is
picked
up by EMS. Patient does report shortness of breath as well. She
also reports new pain under the right breast over the last week
or so, not associated with eating. Patient denies any fevers,
chills, cough, congestion, chest pain, abdominal pain, nausea,
vomiting. Patient has experienced these symptoms in the past.
Denies any dysuria.
Patient was recently discharged from thoracic siurgery service,
admitted ___ for worsening dypnea and hypoxia. CTA ruled
out PE. Improved with nebs and mucinex. Her course was also
complicated by E coli UTI treated with 5 days of macrobid .
She was also recently admitted ___ for cervical tracheal
resection and reconstruction as well as cervical mediastinal
tracheoplasty, and has been admitted multiple times previously
with dyspnea.
In the ED...
- Initial vitals:99.0 60 140/67 18 100% 2L NC
- Exam
GA: Comfortable
HEENT: No scleral icterus, surgical site c/d/i
Cardiovascular: Normal S1, S2, regular rate and rhythm, no
murmurs/rubs/gallops, 2+ peripheral pulses bilaterally
Pulmonary: Clear to auscultation bilaterally
Abdominal: Soft, nontender, nondistended, no masses
Extremities: No lower leg edema
Integumentary: No rashes noted
- EKG: NSR, left bundle morphology, no TWI or ST changes
- Labs/studies notable for: WBC 14.7, Hb 9.1, Plt 449, trop
-x1,
Bicarb 21, AG 17, Cr 1.1, UA lg Leuk 20 WBC.
CXR: No evidence of pneumonia or pneumothorax. No significant
interval change compared to the prior radiograph.
Thoracic surgery: Patient w/ palpitations and DOE. CXR stable,
no
pneumonia. Return of leukocytosis 14K and ___ Cr 1.1 (from 0.8
at
d/c on ___. Suggest holding diuresis and IVFs, IV abx for UTI.
Agree with admission to at___ cardiology. Thoracic Surgery will
follow along.
- Patient was given: Atorvastatin 80, lorazapam 2mg, apixiban
5mg, albuterol neb , ipratropium neb, APAP 1000mg, CTX 1g
- Vitals on transfer:
On the floor patient reports history as above.
REVIEW OF SYSTEMS:
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope, or presyncope.
On further review of systems, denies any prior history of
stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. Denies exertional buttock or calf pain.
Denies recent fevers, chills or rigors. All of the other review
of systems were negative.
Past Medical History:
- Tracheo/cervical bronchomalacia s/p TBP ___, trach/PEG on
___, T-tube placement ___, ___ ___
- 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 PHYSICAL EXAM:
========================
VS: 98.4 PO 140 / 60 L Sitting 81 18 97 Ra
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD, previous tracheostomy site with sutures in
place
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: Reduced breath sounds LLL, otherwise CTAB, no wheezes,
rales, rhonchi, breathing comfortably without use of accessory
muscles
GI: Pain to plapation of RUQ, especially with inspiration.
otherwise abdomen soft, nondistended, nontender. no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
VS: 98.6, 153/77,80, 16, 90% Ra
GENERAL: Sitting in bed, AOx3, no distress
HEENT: AT/NC, anicteric sclera, MMM,
NECK: supple, no LAD, surgical scar midline, no appreciable JVD
CV: RRR, S1/S2, +3 MR murmur
PULM: Lungs relatively clear, minimal expiratory phase wheezing.
Good air movement. Mild prolonged expiratory phase.
GI: abdomen soft, nondistended, tender to palpation along right
costal margin along prior surgical scars
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial/DP pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
Psych: Feels overall positive about prognosis, slightly anxious
about leaving the hospital
Pertinent Results:
ADMISSION LABS:
===============
___ 06:50PM BLOOD WBC-14.7* RBC-4.08 Hgb-9.1* Hct-30.0*
MCV-74* MCH-22.3* MCHC-30.3* RDW-18.2* RDWSD-48.5* Plt ___
___ 06:50PM BLOOD Neuts-67.0 ___ Monos-8.4 Eos-1.0
Baso-0.5 Im ___ AbsNeut-9.85* AbsLymp-3.35 AbsMono-1.23*
AbsEos-0.15 AbsBaso-0.07
___ 06:50PM BLOOD Plt ___
___ 06:50PM BLOOD Glucose-94 UreaN-16 Creat-1.1 Na-137
K-4.8 Cl-99 HCO3-21* AnGap-17
___ 06:50PM BLOOD ALT-14 AST-40 LD(LDH)-282* AlkPhos-118*
TotBili-0.2
___ 06:50PM BLOOD cTropnT-<0.01
INTERIM LABS:
=============
___ 06:22AM BLOOD proBNP-1361*
___ 03:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-10
Tricycl-NEG
DISCHARGE LABS:
===============
___ 07:05AM BLOOD WBC-20.6* RBC-3.36* Hgb-7.4* Hct-24.0*
MCV-71* MCH-22.0* MCHC-30.8* RDW-18.3* RDWSD-47.3* Plt ___
___ 07:05AM BLOOD Plt ___
___ 07:05AM BLOOD Glucose-102* UreaN-28* Creat-1.1 Na-138
K-3.8 Cl-93* HCO3-28 AnGap-17
___ 07:05AM BLOOD Calcium-9.1 Phos-4.9* Mg-2.3
PERTINENT IMAGING:
===================
CXR ___:
IMPRESSION:
No evidence of pneumonia or pneumothorax. No significant
interval change
compared to the prior radiograph.
___ Gallbladder US:
IMPRESSION:
No evidence of cholelithiasis or cholecystitis. Tiny 2 mm
gallbladder polyp
___ CXR:
IMPRESSION:
No evidence of acute cardiopulmonary disease.
___ CXR:
IMPRESSION:
Mild new interstitial process in the right lung, query
inflammation or
infection of lower airways versus possibility of very mild
asymmetric
pulmonary edema. Persistent left basilar atelectasis.
___ CXR:
IMPRESSION:
Suspected mild worsening of interstitial process primarily
involving the right lung.
___ CXR:
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Heterogeneous opacification right upper lobe has worsened since
___,
consistent with progressive pneumonia. Left basal atelectasis
reflecting
chronic elevation left hemidiaphragm, unchanged. Pulmonary
vasculature is
engorged and pulmonary edema minimal if any. Mild to moderate
cardiomegaly
stable.
___ TTE:
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved biventricular systolic function. At least moderate
mitral regurgitation. Mild pulmonary hypertension. Compared with
the prior TTE ___, the severity of mitral regurgitation
has minimally decreased.
Brief Hospital Course:
___ year old woman with paroxysmal afib on apixaban, diastolic
HF, COPD, HTN, HL, RA, history of DVT, tracheobronchomalacia s/p
tracheoplasty on ___, who presented with dyspnea and
palpitations, found to have afib with RVR with a hospital course
subsequently complicated development of RUL PNA, COPD
exacerbation and flash pulmonary edema secondary to hypertensive
episodes in the setting of MR. ___ is now s/p diuresis and is on
Ceftaz/TMP-SMX for treatment of her PNA based on prior sputum
cultures. Now feeling back to her baseline.
#Acute intermittent dyspnea
#RUL PNA
#Flash Pulmonary Edema, resolved
#Moderate Mitral Regurgitation/HFpEF
#COPD Exacerbation
#TBM
Patient endorsed DOE on admission but developed worsening
wheezing and dyspnea a few days into admission. CXR notable for
development of a RUL opacity c/f pneumonia and also suggestive
of pulmonary edema. She was diuresed with improvement in her
volume status and was started on IV ceftaz for empiric coverage
of prior GNR in her sputum (E. Coli). Stenotrophomonas coverage
with TMP-SMX was later added given prior grown on brochial
washings and given lack of improvement on Ceftaz alone. She was
also started on high dose steroids with plan for 2 week taper
for COPD exacerbation component. Suspected component of flash
pulmonary edema in the setting of her moderate MR and
hypertensive episodes as well. Also patient with significant
anxiety which is compounding the picture. Her peak dyspnea
correlates with significant anxiety. IP was consulted, who
follows the patient outpatient for her TBM, and felt her
presentation is related to COPD/CHF exacerbation, with
increasing concern for the latter given her moderate/severe MR
and episodes of flash pulmonary edema. TTE was performed which
showed HFpEF with moderate MR, overall unchanged.
# Anxiety/Depression/Multifactorial encephalopathy
Long standing history of anxiety/depression; her mood has been
depressed at times given hospitalization/acute illness.
Psychiatry has given assistance with management. Anxiety about
her dyspnea is a large factor. Of note, on night of ___ she was
found confused walking in the lobby and there was concern she
may have taken oxycodone that was not meant for her. She briefly
endorsed SI without plan or intent at that point but this has
resolved. There is a questionable substance abuse history but
feel that at this time she is not a danger to herself. In terms
of possibly encephalopathy, she briefly
experienced visual hallucinations shortly after starting
steroids, which have since resolved. Her home fluoxetine was
continued throughout admission, Ativan was continued at 1.5mg
TID from 2 at home ___ concerns for excessive somnolence
#DOE
#Palpitations
#AFib
By arrival in ED no longer having palpitations. ECG with NSR at
83 with left bundle morphology. repeat EKG at rate of 68 with
narrowing of QRS and apparent new TWI V1-V4, although upon
inspection of previous EKGs, patient has these TWI present at
lower rates. Trop negative x2, and on apixaban so less concern
for PE. CXR stable, no evidence of volume overlaod. Most likely
patient with symptomatic runs of afib. Unclear trigger, patient
with leukocytosis and positive UA but without any urinary
symptoms or any other infectious symptoms. On exam, euvolemic.
Also, there is likely component of her underlying TBM. She
reverted to sinus rhythm overnight and then had a brief episode
of recurrent atrial fibrillation lasting less than 2 hours
associated with palpitations then remained in sinus for duration
of admission. Initially increased diltiazem to 360 ER from 240
ER but returned to ___ per atrius cards recommendation.
Deferred initiation of an antiarrhythmic at this point as she
historically seems to have had infrequent episodes. Continued on
apixaban and home metoprolol.
# ___
Cr baseline 0.7-0.8, fluctuating this admission. Component of
cardiorenal as Cr up after diuretic held and now stable 0.9-1.1
with restarting. Up to 1.3 on ___ w/ concern for possible
overdiuresis. Pt net +620mL ___ and Cr down to 1.1 ___. Home
Torsemide regimen 20mg Q Day restarted ___.
# Oral Ulcers
Patient complaining of mouth pain during admission. Found to
have
ulcers from poorly fitting dentures in upper oropharynx. Given
lidocaine gel.
#Positive UA
History of E coli, sensitive to CTX. Patient reporting no
symptoms of urgency, frequency, dysuria, or suprapubic pain. Was
given ceftriaxone in ED, but this was discontinued given
negative urine culture and asymptomatic.
#Right sided lower rib cage/upper abdominal pain
Patient endorsed chronic right sided lower rib cage/upper
abdominal pain, localized beneath her right breast,
corresponding with her surgical scars. No nausea, vomiting, or
clear abdominal discomfort.
Of note, she was supposed to have HIDA scan done for
intermittent RUQ pain symptoms. LFTs with mildly elevated alk
phos to 110, normal ALT, AST, and bilirubin. RUQUS without any
cholecystitis, and a tiny 2mm gallbladder polyp. Pain felt to
most likely related to surgery.
TRANSITIONAL ISSUES:
====================
[ ] Antibiotic plan: Sulfameth/Trimethoprim DS 2 TAB PO/NG TID
___, end of therapy ___ CefTAZidime 2 g IV Q12H ___,
end of therapy ___
[ ] Prednisone taper: 60mg x 5 days, 40mg x 3 days, 20mg x 3
days, 10mg x 3 days, 5mg x 3 days (last day of prednisone ___
[ ] Discharge weight: 153lbs
[ ] Discharge diuretic regimen: Torsemide 20mg daily [was on
torsemide 20mg with alternating 10mg daily prior to admission]
Discharge Cr 1.1
[ ] Ensure patient follows up with IP as scheduled (Dr. ___
___
[ ] Ensure patient follows up with Thoracics as scheduled
___
[ ] Ensure patient follows up with Cardiology as scheduled
___
[ ] Ensure patient follows up with Primary Care Physician as
scheduled ___
[ ] Patient would benefit from sleep study and sleep clinic
appointment w/ Dr. ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Acetylcysteine Inhaled - For interventional pulmonary use
only ___ mL NEB Q4H:PRN SOB
3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
4. Apixaban 5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Cyclobenzaprine ___ mg PO HS:PRN muscle spasm
8. Diltiazem Extended-Release 240 mg PO DAILY
9. FLUoxetine 60 mg PO DAILY
10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
11. LORazepam 2 mg PO Q8H:PRN anxiety
12. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain -
Moderate
13. Pantoprazole 40 mg PO Q24H
14. Potassium Chloride 20 mEq PO EVERY OTHER DAY
15. Pregabalin 75 mg PO TID restless leg syndrome
16. Tiotropium Bromide 1 CAP IH DAILY
17. Torsemide 20 mg PO DAILY
18. Sodium Chloride 3% Inhalation Soln 15 mL NEB Q6H
19. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
20. Daliresp (roflumilast) 500 mcg oral DAILY
21. Ferrous Sulfate 160 mg PO 3X/WEEK (___)
22. glimepiride 2 mg oral DAILY
23. Metoprolol Succinate XL 25 mg PO DAILY
24. Vitamin D ___ UNIT PO EVERY 2 WEEKS (___)
25. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
Discharge Medications:
1. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
2. PredniSONE 10 mg PO DAILY Duration: 3 Doses
Take one pill per day from ___
RX *prednisone 10 mg 1 tablet(s) by mouth Daily Disp #*3 Tablet
Refills:*0
3. PredniSONE 5 mg PO DAILY Duration: 3 Doses
Take one pill per day from ___
RX *prednisone 5 mg 1 tablet(s) by mouth Daily Disp #*3 Tablet
Refills:*0
4. PredniSONE 20 mg PO DAILY Duration: 2 Doses
Take one pill per day from ___
RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*2 Tablet
Refills:*0
5. Sulfameth/Trimethoprim DS 2 TAB PO TID Duration: 7 Doses
Please take one pill three times daily until finished. End date
___
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth three times a day Disp #*14 Tablet Refills:*0
6. LORazepam 1.5 mg PO TID anxiety
7. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
8. Acetylcysteine Inhaled - For interventional pulmonary use
only ___ mL NEB Q4H:PRN SOB
9. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
11. Apixaban 5 mg PO BID
12. Aspirin 81 mg PO DAILY
13. Atorvastatin 80 mg PO QPM
14. Daliresp (roflumilast) 500 mcg oral DAILY
15. Diltiazem Extended-Release 240 mg PO DAILY
16. Ferrous Sulfate 160 mg PO 3X/WEEK (___)
17. FLUoxetine 60 mg PO DAILY
18. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
19. glimepiride 2 mg oral DAILY
20. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
21. Metoprolol Succinate XL 25 mg PO DAILY
22. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain -
Moderate
23. Pantoprazole 40 mg PO Q24H
24. Pregabalin 75 mg PO TID restless leg syndrome
25. Sodium Chloride 3% Inhalation Soln 15 mL NEB Q6H
26. Tiotropium Bromide 1 CAP IH DAILY
27. Torsemide 20 mg PO DAILY
28. Vitamin D ___ UNIT PO EVERY 2 WEEKS (___)
29. HELD- Potassium Chloride 20 mEq PO EVERY OTHER DAY This
medication was held. Do not restart Potassium Chloride until a
physician tells you to restart it
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Paroxysmal atrial fibrillation
Acute Kidney Injury
Tracheobronchomalacia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you were having
difficulty breathing and felt your heart beating differently
than normal.
WHILE YOU WERE HERE:
- We changed your blood pressure medications to help control
your fast heart rates and to help your heart pump more
effectively
- We found that you were having a COPD Exacerbation and treated
you with nebulizers, steroids, and antibiotics.
- We found that you likely had a pneumonia and treated you with
antibiotics
- We found that you were retaining too much fluid so we gave you
a medication called lasix to help you pee out the extra fluid.
- We had our psychiatry experts see you to help us treat your
confusion, depression, and anxiety during your stay.
WHEN YOU GO HOME:
- Please continue to take your medications as prescribed.
- Please follow up with the scheduled appointments seen below.
- Please do not drink alcohol or drive while taking Ativan or
oxycodone.
- Please seek care if you are feeling worsening shortness of
breath or you feel otherwise unsafe.
- Weigh yourself every morning after voiding and while wearing
lightweight loose clothing. Please call your primary care
physician if your weight goes up more than 3 lbs in one day or 5
pounds in one week.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10439150-DS-20 | 10,439,150 | 23,526,812 | DS | 20 | 2116-02-17 00:00:00 | 2116-02-17 17:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
___
Attending: ___.
Chief Complaint:
Right critical leg ischemia
Major Surgical or Invasive Procedure:
Right groin cutdown with embolectomy of right SFA and Popliteal
artery
History of Present Illness:
Mr. ___ total is a ___ gentleman with a
history of coronary artery disease status
post a CABG approximately ___ years ago and reported history of
an abdominal aortic aneurysm as well as chronic kidney disease
who presents to the emergency room with a reported history of
12 hours of progressively worsening pain in his right lower
extremity. On exam, the patient was found to have a palpable
femoral pulse on the right, but no palpable or dopplerable
signals throughout the rest of his right leg. The pulses
throughout his left lower extremity were palpable. The patient
had begun to develop decreased sensation in his toes and
forefoot, but was motor intact. We made the decision to proceed
with a right lower extremity embolectomy via a right
femoral exposure.
Past Medical History:
Past Medical History: AAA, CAD w/ MI s/p CABG, CKD, gout, HTN
Past Surgical History: CABG (___)
Social History:
___
Family History:
Family History: non-contributory
Physical Exam:
Vitals: 97.8 117 172 60 17 90%/RA
General: A&O x3, seated comfortably, NAd
HEENT: NCAT, skin anicteric, MMM
CV: RRR
Lungs: breathing unlabored
Extremities: Warm and well perfused, right groin incision, well
approximated with staples, soft, no drainage, slight ecchymosis
Pulses: L - p//p/p; R - //p/p
Pertinent Results:
Labs----------
___ 09:17AM BLOOD WBC-6.9 RBC-3.35* Hgb-10.5* Hct-31.5*
MCV-94 MCH-31.3 MCHC-33.3 RDW-14.2 RDWSD-48.1* Plt ___
___ 01:30AM BLOOD Neuts-60.8 ___ Monos-11.9 Eos-2.5
Baso-0.8 Im ___ AbsNeut-5.35 AbsLymp-1.92 AbsMono-1.05*
AbsEos-0.22 AbsBaso-0.07
___ 09:17AM BLOOD Plt ___
___ 05:59AM BLOOD Glucose-93 UreaN-27* Creat-1.6* Na-138
K-4.8 Cl-102 HCO3-25 AnGap-11
___ 12:24PM BLOOD CK(CPK)-494*
___ 01:30AM BLOOD Lipase-126*
___ 01:30AM BLOOD cTropnT-<0.01
___ 01:30AM BLOOD proBNP-441*
___ 05:59AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.0
___ 07:35AM BLOOD %HbA1c-5.9 eAG-123
Reports---------
Radiology Report CARDIAC PERFUSION PHARM Study Date of
___
IMPRESSION:
1. Normal myocardial perfusion.
2. Normal left ventricular cavity size and systolic function.
---------------
Cardiovascular Report Stress Study Date of ___
PROTOCOL /
STAGE TIME SPEED ELEVATION WATTS HEART BLOOD RPP
(MIN) (MPH) (%) RATE PRESSURE
I ___ 0.4 MG LEXISCAN 70 86/54 6020
TOTAL EXERCISE TIME: 0.33 % MAX HRT RATE ACHIEVED: 48
SYMPTOMS: NONE
ST DEPRESSION: NONE
INTERPRETATION: This ___ yo man with h/o CAD, s/p MI and CABG
___,
and AAA with plan for repair was referred to the lab from the
inpatient
floor following negative serial cardiac enzyme for a pre-op
evaluation.
The patient was administered 0.4 mg Regadenoson (Lexiscan) IV
Bolus over
20 seconds. There were no reports of chest, back, neck, or arm
discomforts during the study. There were no significant ST
changes noted
during infusion or recovery. Rhythm was sinus with no ectopy.
There was
an appropriate heart rate and blood pressure response to the
infusion.
IMPRESSION: No anginal type symptoms or ischemic EKG changes.
Nuclear
report sent separately.
SIGNED: ___ on ___ ___ 2:58 ___ ___
___ on ___ ___ 12:20 ___
Radiology Report CTA CHEST Study Date of ___ 6:57 ___
IMPRESSION:
1. Fusiform infrarenal abdominal aortic aneurysm with extensive
atheromatous
plaque/mural thrombus, measuring up to 5.2 cm in transverse and
AP ___,
and extending into bilateral common iliac arteries, with
dilation of the right
common iliac artery measuring 2.4 cm and dilation of the left
common iliac
artery measuring 1.7 cm.
2. Postsurgical changes of right superficial femoral and
popliteal arteries
embolectomy via right common femoral artery arteriotomy, with
associated
partially visualize soft tissue density along the right common
femoral artery,
likely reflecting a hematoma.
3. Extensive atherosclerotic disease with multifocal stenoses
involving
bilateral iliac arteries as detailed above. Focal moderate
stenosis involving
the proximal left common femoral artery.
4. Extensive, upper lobes predominant centrilobular and
paraseptal emphysema,
with right apical pleuroparenchymal scarring.
Brief Hospital Course:
Mr. ___ total is a ___ gentleman with a
history of coronary artery disease status
post a CABG approximately ___ years ago and reported history of
an abdominal aortic aneurysm as well as chronic kidney disease
who presents to the emergency room with a reported history of
12 hours of progressively worsening pain in his right lower
extremity. On exam, the patient was found to have a palpable
femoral pulse on the right, but no palpable or dopplerable
signals throughout the rest of his right leg. The pulses
throughout his left lower extremity were palpable. The patient
had begun to develop decreased sensation in his toes and
forefoot, but was motor intact. We made the decision to proceed
with a right lower extremity embolectomy via a right
femoral exposure.
Patient underwent a right femoral artery cutdown with an
embolectomy of the right SFA and popliteal artery without
complication on ___ with Dr. ___. For full details
of the surgical procedure please see the dictated operative
report. He was Extubated and taken to PACU in stable condition.
After a brief stay in PACU he was transferred to the vascular
surgery floor where he remained for the rest of his admission.
His diet was advanced to a house diet which he tolerated well.
He was able to void on his own QS. His postoperative pain was
well controlled with acetaminophen only prior to his discharge
home.
He has a history of AAA and on CTA during this admission it was
found to be 5.2 cm at the maximum diameter. Based on patient's
presentation, he will most likely require an open abdominal
aneurysm repair. He was seen by cardiology for initial
evaluation and clearance for this surgery. He underwent a TEE
which showed moderate to severe TR with depressed RV function
and moderate cavity enlargement, but patient appears
compensated.
They recommended a pharmacologic stress test, which was
completed during this admission and found to be negative. He
will require a follow up with his home cardiologist prior to
this procedure. He has an appointment scheduled on ___.
Chronic Issues -
AAA- seen by vascular medicine service and his risk for open AAA
repair was calculated he underwent a pharmacological stress test
which was normal. He also underwent a TTE and was found to have
some tricuspid regurgitation some degree of pulmonary
hypertension. Vascular medicine recommended furosemide 20 mg to
maintain euvolemia and he is to follow-up with his outpatient
cardiologist.
HTN-he will continue his home lisinopril as well as his home
metoprolol. We have increased his dose of atorvastatin to 80 mg
Transitional Issues -
Patient will need to keep appointment with his cardiologist, Dr.
___, prior to AAA repair. He also has an appointment
for a wound check/staple removal and another appointment for RLE
imaging. These appointment times are indicated above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Aspirin 81 mg PO DAILY
3. Ranitidine 150 mg PO BID:PRN dyspepsia
4. Metoprolol Tartrate 25 mg PO BID
5. Lisinopril 5 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. amLODIPine 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/headache
2. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
3. Furosemide 20 mg PO DAILY
Weight yourself daily
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Atorvastatin 80 mg PO DAILY
5. amLODIPine 5 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. Metoprolol Tartrate 25 mg PO BID
9. Ranitidine 150 mg PO BID:PRN dyspepsia
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Critical Limb Ischemia, Abdominal Aortic Aneurysm,
Secondary: CAD s/p CABG, HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital after surgery
on your leg. This surgery was done to improve blood flow to
your leg. You tolerated the procedure well and are now ready to
be discharged from the hospital. Please follow the
recommendations below to ensure a speedy and uneventful
recovery.
Vascular Leg Surgery Discharge Instructions
What to except:
It is normal feel tired for ___ weeks after your surgery
It is normal to have leg swelling. Keep your leg elevated as
much as possible. This will decrease the swelling.
Your leg will feel tired and sore. This usually passes
within a few weeks.
Your incision will be sore, slightly raised, and pink. Any
drainage should decrease or stop with in the first 2 weeks.
If you are home, you will likely receive a visit from a
Visiting Nurse ___. Members of your health care team will
discuss this with you before you go home.
Medications:
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
You have been started on a new blood thinner called Eliquis.
It is very important that you take this medication in addition
to Aspirin every day! You should never stop this medication
before checking with your surgeon.
Pain Management:
It is normal to feel some discomfort/pain following surgery.
This pain is often described as soreness.
You may take Tylenol (acetaminophen ) as needed for pain.
You will also receive a prescription for stronger pain medicine,
if the Tylenol doesnt work, take prescription medicine.
Narcotic pain medication can be very constipating, please also
take a stool softner such as Colace. If constipation becomes a
problem, your pharmacist can suggest additional over the counter
medications.
Your pain medicine will work better if you take it before your
pain gets to severe.
Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
Activity:
Do not drive until your surgeon says it is okay. In general,
driving is not allowed until
-the staples in your leg have been taken out
-your leg feels strong
-you have stopped taking pain medication and feel you could
respond in an emergency
Walking is good because it helps your muscles get stronger and
improves blood flow. Start with short walks. If you can, go a
little further each time, letting comfort be your guide.
Try not to go up and downstairs too much in the first weeks.
Use stairs only once or twice a day until your incision is fully
healed and you are back to your usual strength.
Avoid things that may constrict blood flow or put pressure on
your incision, such as tight shoes, socks or knee highs.
Do not take a tub bath or swim until your staples are removed
and your wound is healed.
When you sit, keep your leg elevated to reduce swelling.
If swelling in your leg is getting worse, lie down with your
leg up on a pillows. If your swelling continues, please call
your surgeon. You may be instructed to use special elastic
bandages or stockings.
Try not to sit in the same position for a long while. For
example, ___ go on a long car ride.
You may go outside. But avoid traveling long distances until
you see your surgeon at your next visit.
You may resume sexual activity after your incisions are well
healed.
Your incision
Your incision may be slightly red around the stitches or
staples. This is normal.
It is normal to have a small amount of clear or light red
fluid coming from your incision.
This will decrease and stop in a few days. If it does not stop,
or if you have a lot of fluid coming out., please call your
surgeon.
You may shower 48 hours after your surgery. Do not let the
shower spray right on the incision, Let the soapy water run
over the incision, then rinse. Gently pat the area dry. Do not
scrub the incision, Do not apply ointment or lotions to the
incision.
You do not need to cover the incision if there is no drainage,
If there is a small amount of drainage, put a small sterile
gauze or Bandaid over the incison.
It is normal to feel a firm ridge along the incision, This
will go away as your wound heals.
Avoid direct sun exposure to the incision area for 6 months.
This will help keep the scar from becoming discolored.
Over ___ months, your incision will fade and become less
prominent.
Diet and Bowels
It is normal to have a decreased appetite. Your appetite will
return over time. Follow a well-balanced, health healthy diet,
without too much salt and fat.
Prescription pain medicine might make you constipated. If
needed, you may take a stool softener (such as Colace) or gentle
laxative (ask your pharmacist for recommendations).
Drinking more fluid may also help.
If you go 48 hours without a bowel movement, or having pain
moving your bowels, call your primary care physician.
Followup Instructions:
___
|
10439374-DS-2 | 10,439,374 | 21,039,029 | DS | 2 | 2141-11-28 00:00:00 | 2141-11-28 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:
L Hip Pain
Major Surgical or Invasive Procedure:
___:
1. Explant, left total hip, including femoral and
acetabular components.
2. Irrigation and debridement, deep pelvic abscess, left
hip, with extensive excisional debridement of left
anterior column.
3. Open biopsy for microbiology and pathology, left hip.
___:
1. Irrigation and debridement of deep abscess with pelvic
osteomyelitis, left anterior acetabulum.
2. Placement of femoral and acetabular components for
Prostalac spacer components, left hip.
History of Present Illness:
___ PMH COPD, HTN, EtOH of previous lumbar fusion and left hip
replacement presents with left hip pain. He states that he had
left hip replacement ___ years ago. He has now had left hip pain
for 6 months that has worsened over the past few days. He has
been to ___ three times for this pain. He states
that each time he goes he is "kicked out of the hospital." He
loudly states that this is because he has no insurance and
shouts that he has worked for the ___ for many years. He
states that he has pain on his left hip, and left thigh that
runs down his entire leg. He claims that he is having
significant difficulty walking. He has not had fevers recently,
but states that he did at ___ to 104 degrees (not
___ and that he was kicked out of the hospital the next day.
He states that at one of the recent admissions he had a tap of
his left hip but was never told the results of the tap. His PCP
has been increasing his opiate prescription as he had been on
oxycodone which had been increased until changing to dilaudid.
His admission to ___ most recently was for a fall and leg
swelling. A CT scan demonstrated medial roatation of prosthesis,
poor position of prosthesis. He has also been seen in the
___ since discharge along with daily call-ins to his PCP.
He also is complaining of five days of left foot swelling and
pain. He states that he had a previous episode of swelling four
days ago.
In the ___, initial vitals were: 98.3 ___ 14 99% RA
- Labs were significant for Hgb 8.8, plats 112, INR 1.6,
Chemistries unremarkable, lactate 1.9. UA with few bacteria, 1
___
- Imaging revealed negative ___, left hip xray no evidence of
hardware infection or perihardware fracture. CT pelvis with the
acetabular cup of the total left hip arthroplasty migrated
superiorly, and tipped medially. Asymmetric size of the iliacus
muscles with possible small fluid collection is incompletely
evaluated without IV contrast.
- The patient was given Dilaudid 1mg IV x3, tylenol ___, 1L
IVF
Vitals prior to transfer were: 98.5 72 122/83 18 97% RA.
- Ortho consulted and requested L hip ___ guided drainage.
Upon arrival to the floor, patient requesting IV benzos for
sleep.
Past Medical History:
L hip replacement
COPD
HTN
Chronic back pain
Insomnia
ETOH abuse
Prediabetes
Anxiety
Avascular necrosis of femoral head
H. pylori infection
Hyperlipemia
Obesity
Social History:
___
Family History:
Heart disease, strokes, colon cancer
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
========================
Vitals: 97.5 148/50 80 18 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses. Left sided hip swelling.
1+ pitting edema in left foot with no edema in right foot. Pain
with minimal palpation or movement of leg. ROM limited by pain.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
========================
DISCHARGE PHYSICAL EXAM:
========================
Vitals: T 97.9F BP 115/60 mmHg P 83 RR 18 O2 98% RA
General: Comfortable appearing, obese, alert.
HEENT: Sclerae anicteric; MMM, OP clear. Poor dentition.
Neck: Supple, no JVD. No LAD.
CV: RRR; no MRGs. Normal S1/S2.
Pulm: CTA b/l; no wheezes, rhonchi or rales.
Abd: Distended abdomen. Evidence of caput medusae. NABS.
Non-tender.
GU: Notable scrotal edema with evidence of maceration.
Ext: L hip site with evidence of skin tears and swelling. No
erythema. JP drain removed. Moderate ecchymoses at left arm near
PICC line, mildly tender.
Neuro: A&Ox3. CNs II-XII grossly intact. Distal sensation intact
to light touch. Gait deferred.
Skin: +spider erythema
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 02:40PM BLOOD WBC-5.3 RBC-3.48* Hgb-8.8* Hct-29.9*
MCV-86 MCH-25.3* MCHC-29.4* RDW-22.9* RDWSD-70.0* Plt ___
___ 02:40PM BLOOD ___ PTT-37.6* ___
___ 02:40PM BLOOD Glucose-117* UreaN-5* Creat-0.4* Na-136
K-3.7 Cl-98 HCO3-27 AnGap-15
___ 07:13AM BLOOD ALT-11 AST-29 AlkPhos-139* TotBili-3.8*
___ 07:13AM BLOOD Albumin-2.7* Calcium-8.5 Phos-3.8 Mg-1.6
============
INTERIM LABS
============
___ 01:27PM BLOOD WBC-3.2* RBC-2.72* Hgb-7.8* Hct-24.3*
MCV-89 MCH-28.7 MCHC-32.1 RDW-18.0* RDWSD-55.8* Plt Ct-66*
___ 11:07AM BLOOD WBC-6.0 RBC-1.87*# Hgb-5.5*# Hct-17.2*#
MCV-92 MCH-29.4 MCHC-32.0 RDW-18.6* RDWSD-54.7* Plt Ct-79*
___ 06:43PM BLOOD WBC-6.1 RBC-2.39*# Hgb-7.1*# Hct-22.0*#
MCV-92 MCH-29.7 MCHC-32.3 RDW-17.5* RDWSD-51.8* Plt Ct-66*
___ 12:54AM BLOOD WBC-4.2 RBC-2.29* Hgb-6.7* Hct-21.2*
MCV-93 MCH-29.3 MCHC-31.6* RDW-18.7* RDWSD-54.7* Plt Ct-67*
___ 04:59AM BLOOD Neuts-67.1 Lymphs-17.4* Monos-9.4 Eos-4.5
Baso-0.5 Im ___ AbsNeut-2.51 AbsLymp-0.65* AbsMono-0.35
AbsEos-0.17 AbsBaso-0.02
___ 03:45PM BLOOD Plt Ct-67*
___ 06:01AM BLOOD ___ PTT-36.2 ___
___ 08:30AM BLOOD ___ PTT-42.5* ___
___ 05:35AM BLOOD Ret Aut-3.4* Abs Ret-0.10
___ 05:35AM BLOOD Glucose-151* UreaN-13 Creat-0.7 Na-139
K-5.2* Cl-106 HCO3-25 AnGap-13
___ 09:36PM BLOOD Glucose-110* UreaN-12 Creat-0.6 Na-137
K-3.9 Cl-102 HCO3-27 AnGap-12
___ 04:49PM BLOOD Glucose-114* UreaN-11 Creat-0.6 Na-133
K-3.7 Cl-97 HCO3-28 AnGap-12
___ 11:07AM BLOOD ALT-8 AST-17 AlkPhos-80 TotBili-2.7*
___ 04:59AM BLOOD ALT-13 AST-21 AlkPhos-122 TotBili-2.5*
DirBili-1.3* IndBili-1.2
___ 05:49AM BLOOD ALT-9 AST-23 AlkPhos-132* TotBili-2.6*
___ 05:35AM BLOOD CK-MB-2 cTropnT-<0.01
___ 08:30AM BLOOD CK-MB-2 cTropnT-<0.01
___ 04:49PM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8
___ 05:49AM BLOOD Albumin-2.5* Calcium-8.1* Phos-3.8 Mg-2.0
___ 08:23AM BLOOD calTIBC-263 Ferritn-39 TRF-202
___ 06:01AM BLOOD HBcAb-NEGATIVE HAV Ab-POSITIVE
___ 04:10AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
___ 06:01AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 06:01AM BLOOD ___
___ 06:01AM BLOOD IgG-904 IgA-422* IgM-75
___ 04:10AM BLOOD HCV Ab-NEGATIVE
___ 11:14AM BLOOD ___ pO2-196* pCO2-37 pH-7.47*
calTCO2-28 Base XS-4 Comment-GREEN TOP
___ 11:14AM BLOOD Lactate-1.3
___ 07:48PM BLOOD Hgb-7.5* calcHCT-23
===============
DISCHARGE LABS:
===============
___ 05:30AM BLOOD WBC-5.3 RBC-2.69* Hgb-8.2* Hct-25.9*
MCV-96 MCH-30.5 MCHC-31.7* RDW-19.6* RDWSD-68.2* Plt Ct-82*
___ 08:30AM BLOOD ___ PTT-42.5* ___
___ 05:30AM BLOOD Glucose-85 UreaN-9 Creat-0.4* Na-137
K-3.3 Cl-108 HCO3-23 AnGap-9
___ 05:30AM BLOOD ALT-10 AST-17 AlkPhos-104 TotBili-1.9*
___ 05:30AM BLOOD Calcium-6.5* Phos-2.8 Mg-1.5*
=================
IMAGING/STUDIES:
=================
HIP UNILAT MIN 2 VIEWS (___):
FINDINGS:
AP pelvis and AP and lateral views of the left hip provided.
Fusion hardware secures the lower lumbar spine. Right hip
aligns normally though there is axial loss of joint space and
mild acetabular spurring. There is left hip arthroplasty
without adjacent fracture seen. However, the position of the
left hip arthroplasty appears abnormal with the left femoral
head prosthesis positioned 5 cm craniad relative to the right.
Additionally, the left acetabular cup is also positioned
superiorly relative to the native acetabulum and slightly
rotated in a counterclockwise direction. Comparison with prior
imaging would be helpful to assess for acute interval changes.
CT PELVIS W/O CONTRAST (___)
IMPRESSION:
1. The acetabular cup of the total left hip arthroplasty has
migrated
superiorly, and tipped medially. There are areas of bony
dehiscence of the
overlying iliac bone. There is lucency along the inferior margin
of the
acetabular cup up to 1.6 cm. The anterior most acetabular cup
screw has
surrounding lucency suggesting loosening and protrudes 1 cm into
the left
hemipelvis.
2. Asymmetric enlargement of the left iliopsoas muscle with
small fluid
collection is incompletely evaluated without IV contrast. This
could reflect reactive bursal fluid or hematoma.
3. Moderate left and small right fat containing inguinal
hernias.
4. Bilateral testicular varicoceles.
UNILAT LOWER EXT VEINS (___):
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins. The left calf veins are not well seen.
INJ/ASP MAJOR JT W/FLUO (___):
IMPRESSION:
1. Imaging Findings - Subluxed and vertically oriented
acetabular component of the left total hip arthroplasty.
2. Procedure - Technically successful left hip aspiration.
CHEST (PORTABLE AP) (___):
IMPRESSION:
Lung volumes have improved substantially, pulmonary edema has
resolved and
cardiomegaly and mediastinal vascular engorgement improved.
SURGICAL PATHOLOGY REPORT (___):
PATHOLOGIC DIAGNOSIS:
1. Soft tissue, left hip, debridement:
- Acute and organizing fibrinous synovitis.
- Skeletal muscle and fibroadipose tissue with focal acute and
chronic inflammation.
2. Bone, left acetabular hole, excision:
- Acute and organizing fibrinous synovitis with abundant acute
inflammation.
- Fragments of bone with remodeling changes; no acute
osteomyelitis identified.
CT PELVIS ORTHO W/O CON (___):
IMPRESSION:
Postsurgical changes from the removal of a left total hip
prosthesis, as
above. Fluid collection in the left hip joint and iliopsoas
bursa is
non-specific, but could be postsurgical. Possibility of
associated infection cannot be excluded on the basis of imaging.
Small areas of cortical destruction are seen in the superomedial
left
acetabular wall with adjacent small fracture fragments and a
small defect in the medial wall of the acetabulum. Separate
from these areas, no bony
destructive changes are identified. Please note that subtle
marrow
abnormality is would not be apparent on CT.
Small amount of free fluid in the pelvis. Graying of abdominal
fat.
CHEST (PORTABLE AP) (___):
IMPRESSION:
Overall cardiac and mediastinal contours are likely unchanged
given lordotic technique. The aorta is unfolded and tortuous.
Lungs are slightly diminished in volume but grossly clear. No
evidence of pulmonary edema, pleural effusions or pneumothorax,
although the sensitivity to detect pneumothorax is diminished
given supine technique.
LIVER OR GALLBLADDER US (___):
IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant
hepatic fibrosis/cirrhosis cannot be excluded on this study.
2. Signs of portal hypertension including mild amount of
ascites and
splenomegaly.
UNILAT UP EXT VEINS US (___):
IMPRESSION:
Deep vein thrombosis of the proximal and mid right brachial
vein.
HIP 1 VIEW (___):
FINDINGS:
The intraoperative images demonstrate a femoral head prosthesis
with what
appears to be cement in both the acetabulum and proximal femur.
A surgical drain is seen. No acetabular prosthesis is
appreciated. Please see the operative report for further
details.
IMPRESSION:
As above.
DX PELVIS & HIP UNILATE (___):
FINDINGS:
There are postsurgical changes at the left hip. There is a
presumed
antibiotic impregnated spacer at the acetabulum were there is a
defect in the medial wall compatible with previous bone
destruction. Residual femoral prosthesis in-situ. Surgical
drain. Moderate right hip osteoarthritis. Lower lumbar spine
fixation hardware.
IMPRESSION:
Postsurgical changes as above.
US ABD LIMIT, SINGLE OR (___):
FINDINGS:
Ultrasound evaluation of all 4 quadrants of the abdomen revealed
moderate
ascites in the right upper and lower quadrants.
IMPRESSION:
Moderate ascites of the right upper and lower quadrants.
DX CHEST PORTABLE PICC (___):
IMPRESSION:
In comparison with the study of ___, the right PICC line
is been
removed and replaced with a left subclavian line that extends to
about the
cavoatrial junction. Low lung volumes accentuate the transverse
diameter of the heart and the degree of pulmonary vascular
congestion. Retrocardiac opacification is consistent with
volume loss in the lower lobe and possible small effusion.
HIP UNILAT MIN 2 VIEWS (___):
FINDINGS:
Similar appearance to prior although there has been interval
removal of
surgical drain. Remodeling of the native left acetabulum, with
breech in the left iliac bone medial cortex, and acetabular
cement spacer appears similar to prior. Femoral prosthesis
appears is satisfactory position. Moderate right hip
osteoarthritis. Fixation hardware in the lower lumbar spine in
addition to background degenerative change in the lumbar spine.
IMPRESSION:
Overall similar appearance to prior, with interval removal of
surgical drain.
============
MICROBIOLOGY
============
__________________________________________________________
___ 11:28 am URINE Source: ___.
URINE CULTURE (Pending):
__________________________________________________________
___ 7:55 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 5:34 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 5:02 pm BLOOD CULTURE Source: Line-PICC.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 6:24 pm BLOOD CULTURE Source: Line-aline.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 7:10 pm TISSUE LEFT ACETABULAR .
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 5:26 pm TISSUE LEFT HIP TISSUE # 3.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 5:36 pm TISSUE HIP CAPSULE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 5:23 pm TISSUE LEFT HIP TISSUE # 2.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 5:04 pm FLUID,OTHER LEFT HIP FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 5:05 pm TISSUE LEFT HIP TISSUE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 11:22 am JOINT FLUID Source: hip.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___. ___ ___ 11:27AM.
HAEMOPHILUS PARAINFLUENZAE. SPARSE GROWTH.
___. ___ (___) REQUESTED SENSITIVITIES
AND
IDENTIFICATION ___. BETA LACTAMASE NEGATIVE.
SENSITIVE TO AUGMENTIN (<=2 MCG/ML), CHLORAMPHENICOL (1
MCG/ML).
Intermediate TO CLARITHROMYCIN (16 MCG/ML).
CEFUROXIME (<=0.5 MCG/ML). Levofloxacin (<= 0.3
MCG/ML).
SULFA X TRIMETH (0.25 MCG/ML). TETRACYCLINE (1
MCG/ML).
SENSITIVITY TESTING PERFORMED AT ___ DIAGNOSTICS.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
HAEMOPHILUS PARAINFLUENZAE
|
AMPICILLIN------------ 0.25 S
AMPICILLIN/SULBACTAM-- <=1 S
CEFTRIAXONE-----------<=0.03 S
CEFUROXIME------------ S
LEVOFLOXACIN---------- S
TETRACYCLINE---------- S
TRIMETHOPRIM/SULFA---- S
Brief Hospital Course:
___ w/ PMH of COPD, HTN, and EtOH cirrhosis, who was admitted
with worsening hip pain and found to have prosthetic joint
infection of the left hip. He underwent device explant and bone
biopsy on ___, with a post-op course complicated by
significant bleeding and hypotension, requiring MICU transfer,
pressor support, and massive transfusion protocol.
===========
MICU COURSE
===========
Chronic L hip pain s/p L hip replacement ___ years ago,
exacerbated by mechanical fall from bed on ___. Joint fluid
culture grew Hemophilus parainfluenza, for which he was treated
with ceftriaxone. Orthopedics took him to the OR ___ for
hardware removal and found evidence of osteomyelitis. The area
was debrided and the patient was taken to the PACU with the plan
for interval further debridement and antibiotic spacer
placement. The patient became hypotensive requiring pressors and
blood transfusions for hemorrhagic shock. Subsequently
hemodynamically stable. For alcohol abuse, he was kept on a CIWA
scale for the first 72 hours of his admission, but never scored
> 10. He was supplemented with folic acid, thiamine, MVI. His
MELD score was 17 on admission. A PICC line was placed for
long-term antibiotics for prosthetic joint infection; however
this was complicated by RUE DVT, which required removal of the
PICC line.
============
FLOOR COURSE
============
# L hip prosthetic joint infection. Mr. ___ returned to the
OR on ___ for irrigation and debridement of his left hip with
spacer placement. His post-op course was complicated by acute
blood loss anemia (please see below). He was treated with
ceftriaxone 2g q24h for a total 6 week course (ending ___.
He was briefly broadened to vanc/cefepime for a post-op fever of
100.8, which did not recur. Blood cultures remained sterile, and
the pt was followed by ID for outpatient antibiotic therapy.
PICC was replaced in the L arm.
# Acute blood loss anemia/coagulopathy. After his second
operation on ___, Mr. ___ experienced significant bleeding
with a Hgb of 5.5, for which he required 8 units pRBCs, 4 units
FFP and 1 units platelets. He recovered appropriately and his
bleeding stabilized. This was thought to be due to his
coagulopathy ___ cirrhosis. He was started on Lovenox 40 mg q24h
for DVT prophylaxis for a 4 week course (please see below,
ending ___.
# Pain control. Mr. ___ has a long history of chronic pain
with opioid dependence. He initially required IV Dilaudid q2h
and PCA immediately after surgery; this was subsequently weaned
to PO Dilaudid ___ mg PO q3h PRN. Please consider weaning
further as he recovers from surgery.
# Cirrhosis. This was thought most likely to be alcoholic
cirrhosis, given a history of drinking multiple bottles of wine
in a single sitting. serologies were negative. He meets criteria
for ___ B cirrhosis for a bilirubin 2.8, albumin 2.9,
INR 1.6, and medically controlled ascites. His RUQ ultrasound
demonstrated moderate ascites. His cirrhosis also likely
contributed to his thrombocytopenia. Physical examination had
clear evidence of portal hypertension with ascites and
splenomegaly. He was initially actively diuresed with Lasix in
the setting of having received numerous blood transfusions,
which was subsequently transitioned to 40 mg Lasix daily and 100
mg spironolactone daily. He was also given lactulose 30 mg TID
and rifaximin 550 mg daily for encephalopathy. He has been
scheduled for outpatient liver follow-up and will require serial
right upper quadrant ultrasounds and EGD for HCC and varices
screening.
# Right arm DVT. As above, this was provoked in the setting of
PICC line. As he requires extended antibiotic therapy for
access; a PICC line was replaced in his left arm, and he will be
continued on Lovenox for four weeks (ending ___.
# Anxiety. Mr. ___ has a significant history of anxiety, and
has not tolerated lorazepam well. He was treated with diazepam 2
mg q6h PRN anxiety. Please consider weaning this medication as
tolerated.
# EtOH abuse: Significant alcohol abuse as above; no withdrawal
during this admission, and he was continued on thiamine, folate,
and a multivitamin.
# COPD: He was continued on albuterol and Advair.
# Pre-diabetes: He was continued on ISS while in house.
# Hyperlipidemia: He was continued on his home simvastatin 40 mg
daily.
====================
TRANSITIONAL ISSUES:
====================
# Antibiotic course: Patient will need a 6 week course of
Ceftriaxone 2g IV q24h, to be completed on ___. Follow-up
with Infectious Disease has been scheduled.
# Lab checks. Please check weekly: CBC with differential, BMP,
AST, ALT, Total Bili, ALK PHOS, ESR, and CRP for monitoring
while on Ceftriaxone. Please fax results to: ATTN: ___
CLINIC - FAX: ___
# Alcoholic cirrhosis. Mr. ___ has outpatient hepatology
follow-up scheduled. He will need an EGD as an outpatient to
screen for varices, as he has never had an EGD before. He will
require hepatic ultrasound and alpha-fetoprotein level every six
months for ___ screening.
# Diuresis. Weight upon discharge was 121 kg. He has been
discharged with 40 mg Lasix daily and spironolactone 100mg po
daily. Please check weekly electrolytes and replete potassium
and magnesium if necessary.
# Anticoagulation. Mr. ___ has been started on Lovenox 40mg
SQ daily for four weeks total, to be completed ___.
# Pain control. Mr. ___ pain was treated with ___ mg PO
Dilaudid q3h PRN; and he was discharged on this regimen, because
of his chronic history of significant opioid use. Please
consider weaning as tolerated.
# Anxiety. Mr. ___ was started on diazepam 2mg po q8h PRN for
anxiety; please consider halting this as tolerated.
# Medication changes. Calcitonin was stopped.
# ETOH Abuse: Pt has history of ETOH abuse, last drink was just
prior to admission. Please continue to encourage abstinence from
alcohol.
# Code status: FULL
# Contact: ___, sister, ___
Billing: >30 minutes spent coordinating discharge from the
hospital
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Naproxen 500 mg PO Q12H
2. Omeprazole 20 mg PO DAILY
3. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN pain
4. Calcitonin Salmon 200 UNIT NAS DAILY
5. Acetaminophen 1000 mg PO Q8H
6. FoLIC Acid 1 mg PO DAILY
7. Thiamine 100 mg PO DAILY
8. Calcium Carbonate 1250 mg PO Frequency is Unknown
9. Vitamin D ___ UNIT PO 1X/WEEK (___)
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob
12. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
13. Melatin (melatonin) 3 mg oral QHS
14. Ferrous Sulfate 325 mg PO DAILY
15. Aspirin 81 mg PO DAILY
16. Docusate Sodium 100 mg PO BID
17. Multivitamins 1 TAB PO DAILY
18. Simvastatin 40 mg PO QPM
19. Spironolactone 25 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob
2. Docusate Sodium 100 mg PO BID
3. Ferrous Sulfate 325 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. FoLIC Acid 1 mg PO DAILY
6. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN pain
RX *hydromorphone 4 mg 0.5 to 1 tablet(s) by mouth every three
hours Disp #*56 Tablet Refills:*0
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Multivitamins 1 TAB PO DAILY
9. Simvastatin 40 mg PO QPM
10. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 (One) tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
11. Thiamine 100 mg PO DAILY
12. CeftriaXONE 2 gm IV Q24H
Complete 6 week course on ___.
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g IV every 24
hours Disp #*35 Intravenous Bag Refills:*0
13. Diazepam 2 mg PO Q6H:PRN anxiety
RX *diazepam 2 mg 1 (One) tablet by mouth every six hours Disp
#*28 Tablet Refills:*0
14. Enoxaparin Sodium 40 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
Complete 4 week course on ___.
RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneously every 24 hours
Disp #*25 Syringe Refills:*0
15. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
16. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 (One) tablet(s) by mouth twice
a day Disp #*60 Tablet Refills:*0
17. Aspirin 81 mg PO DAILY
18. Calcium Carbonate 1250 mg PO DAILY
19. Melatin (melatonin) 3 mg oral QHS
20. Omeprazole 20 mg PO DAILY
21. Vitamin D ___ UNIT PO 1X/WEEK (___)
22. Outpatient Lab Work
Please check weekly: CBC with differential, Chem 7, AST, ALT,
Total Bili, ALK PHOS, ESR, CRP
ICD 10: T84.51XA, Infection due to internal hip prosthesis
FAX TO: ATTN: ___ CLINIC - FAX: ___
23. Lactulose 30 mL PO TID:PRN constipation/hepatic
encephalopathy
24. Acetaminophen 1000 mg PO Q8H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
=================
PRIMARY DIAGNOSES
=================
- left hip prosthetic joint infection s/p explant, irrigation,
debridement, and spacer placement
- alcoholic cirrhosis
- acute blood loss anemia
- right upper extremity DVT
- anxiety
- pain w/ opioid dependence
===================
SECONDARY DIAGNOSES
===================
- alcohol abuse
- chronic obstructive pulmonary disease
- hyperlipidemia
- Pre-diabetes
Infected left hip, with previous explant.
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 because of infection of your
left hip, and you underwent an operation to remove the infected
device and place a new spacer. Because of your liver disease,
you bled a great deal and required a number of blood
transfusions. We treated your liver disease with medications to
remove fluid and toxins from your body. You will be following up
with a liver specialist, an infectious disease specialist, and
your orthopedic surgeon. Instructions for after surgery are
detailed below.
Please continue to take all medications as prescribed. Your
discharge follow-up appointments are outlined below.
We wish you the very best!
Warmly,
Your ___ Team
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated Left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Followup Instructions:
___
|
10439374-DS-3 | 10,439,374 | 20,888,732 | DS | 3 | 2141-12-27 00:00:00 | 2141-12-29 16:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
___:
1. Open drainage of left hip joint, infected hematoma.
2. Application of negative pressure vacuum dressing left hip,
25 x 10 cm wound.
___:
Complex wound closure, left hip.
History of Present Illness:
___ hx COPD, EtOH abuse/ cirrhosis, recent adm ___ for L
hip PJI s/p explant & bone biopsy c/b massive post-loss anemia
requiring MICU stay as well as R arm DVT around PICC that was
replaced on the L, patient discharged to complete CTX and
Lovenox, presents from rehab for AMS. Per ED dashboard, "today
staff noted him to be confused and agitated. No vomiting,
diarrhea, abdominal pain."
In the ED, initial vitals were: 98.9 92 108/56 16 90% RA. He
spiked fever to 101.8
- Labs were significant for H/H 8.3/26.5, PLT 75, INR 1.6, PTT
42.3, CRP 56.3, TBili 2.8, Alb 2.7, UA with Tr Leuk (4 WBC, Few
Bacteria), UTox with POS opiates & benzos
- CXR & Hip XRay were performed, not read.
- Patient assessed by MERIT:
(1) L hip looked swollen, warm - likely source of fever. some
serosanguinous drainage
- Ortho was consulted: NPO, admit to Medicine, pre-op w/u, plan
for I&D in the AM (added on to OR)
- The patient was given: Vanc 1g, Tylenol 1g, 2L NS, Dilaudid
1mg IV x2
Vitals prior to transfer were: 99.6 68 93/51 13 96% on NC
Upon arrival to the floor,
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
L hip replacement
COPD
HTN
Chronic back pain
Insomnia
ETOH abuse
Prediabetes
Anxiety
Avascular necrosis of femoral head
H. pylori infection
Hyperlipemia
Obesity
Social History:
___
Family History:
Heart disease, strokes, colon cancer
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
=======================
DISCHARGE PHYSICAL EXAM
=======================
VS: 98.6 ___ 97-100%RA
I/O: 400/560 (8h), ___ (24 h) + 2 loose BMS, wvac ~100 cc
General: Pleasant, calm, lying in bed, appears comfortable
HEENT: NCAT, MMM
Neck: Supple, JVP not elevated
CV: RRR; no m/r/g. Normal S1/S2.
Pulm: Continued mild crackles R base, mild expiratory wheezes
Abd: Distended abdomen, normoactive bowel sounds, nontender.
Ext: Left hip incision with wound vac in place, serosanguinous
drainage, surrounding edema particularly on anterior aspect.
Continued 2+ pitting edema b/l, L>R.
Neuro: AOx3
Pertinent Results:
==============
ADMISSION LABS
==============
___ 12:20AM BLOOD WBC-4.8 RBC-2.69* Hgb-8.3* Hct-26.5*
MCV-99* MCH-30.9 MCHC-31.3* RDW-19.4* RDWSD-68.9* Plt Ct-75*
___ 12:20AM BLOOD Neuts-81.6* Lymphs-8.3* Monos-9.7
Eos-0.0* Baso-0.2 Im ___ AbsNeut-3.95# AbsLymp-0.40*
AbsMono-0.47 AbsEos-0.00* AbsBaso-0.01
___ 12:20AM BLOOD Plt Ct-75*
___ 12:20AM BLOOD Glucose-122* UreaN-13 Creat-0.6 Na-133
K-4.0 Cl-99 HCO3-30 AnGap-8
___ 12:20AM BLOOD ALT-11 AST-28 AlkPhos-125 TotBili-2.8*
___ 12:20AM BLOOD Lipase-18
___ 12:20AM BLOOD Albumin-2.7*
___ 12:20AM BLOOD CRP-56.3*
___ 12:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:19AM BLOOD Lactate-1.8
============
INTERIM LABS
============
___ 01:20PM BLOOD VitB12-1028*
___ 05:34AM BLOOD CRP-75.5*
___ 07:08AM BLOOD Lactate-1.7
==============
DISCHARGE LABS
==============
___ 05:26AM BLOOD ___
___ 12:08PM BLOOD WBC-5.9 RBC-2.48* Hgb-8.0* Hct-24.2*
MCV-98 MCH-32.3* MCHC-33.1 RDW-19.7* RDWSD-69.7* Plt Ct-60*
___ 12:08PM BLOOD Plt Ct-60*
___ 12:08PM BLOOD ___
___ 12:08PM BLOOD Glucose-140* UreaN-8 Creat-0.7 Na-136
K-3.3 Cl-105 HCO3-20* AnGap-14
===============
IMAGING/STUDIES
===============
CHEST (SINGLE VIEW) (___):
FINDINGS:
A semi-erect frontal chest radiograph demonstrates a left
approach PICC
terminating in the cavoatrial junction/ upper atrium. Lung
volumes are low, exaggerating the cardiac silhouette and
resulting in bronchovascular crowding. Even allowing for this,
the cardiomediastinal silhouette is at least mildly enlarged.
There is mild to moderate vascular congestion and pulmonary
edema. Retrocardiac opacity is is similar to minimally improved
compared to radiograph from early ___. There is no
appreciable right pleural effusion. There may be a small left
pleural effusion. There is no pneumothorax. The visualized
upper abdomen is unremarkable.
IMPRESSION:
Low lung volumes, with vascular congestion and mild pulmonary
edema, similar in appearance compared to the most recent chest
radiograph from early ___. No new consolidation.
HIP (UNILAT 2 VIEW) W/P (___):
FINDINGS:
AP view of the pelvis and two views of the left hip again
demonstrate a left hip prosthesis with placement of an
acetabular cement spacer. There is again remodeling of the
native left acetabulum with a breech in the left iliac bone
medial cortex, unchanged in appearance. There is no acute
fracture or dislocation. Lower lumbar spine fixation hardware
is unchanged. The visualized bowel gas pattern is
nonobstructive. Apparent slight superomedial joint space
narrowing in the opposite right hip
IMPRESSION:
No acute fracture. Unchanged appearance of a left hip
prosthesis and
acetabular cement spacer.
CHEST (PORTABLE AP) (___):
IMPRESSION:
Left subclavian PICC line unchanged in position. Overall
cardiac and
mediastinal contours are stably enlarged. There has been
interval improvement in the mild pulmonary edema with prominence
of the perihilar vasculature suggesting a fluid replete state
but no overt residual edema. No pneumothorax. No large
effusions.
PELVIS XR (___):
There is a cement spacer in the left acetabulum as well as a
cemented right femoral prosthesis. This appears unchanged from
prior. There are moderate degenerative changes of the right hip
joint space with narrowing and spurring.
Spinal fusion hardware is seen of the lower lumbar spine.
Sacroiliac joints are within normal limits.
============
MICROBIOLOGY
============
__________________________________________________________
___ 12:43 pm TISSUE Site: HIP LEFT HIP #3.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
ENTEROCOCCUS SP.. RARE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
__________________________________________________________
___ 12:45 pm TISSUE Site: HIP LEFT HIP #2.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
ENTEROCOCCUS SP.. RARE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
__________________________________________________________
___ 12:42 pm TISSUE Site: HIP LEFT HIP #1.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
Reported to and read back by ___. ___ (___) AT
12:33 ___
___.
ENTEROCOCCUS SP.. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
PENICILLIN G---------- 8 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
__________________________________________________________
___ 1:50 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 1:23 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 12:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
Mr. ___ is a ___ y/o man with a PMH of EtOH cirrhosis,
COPD, chronic pain w/ opioid dependence and recent admission
from ___ for L hip PJI(Haemophilus parainfluenzae) s/p
explant & bone biopsy c/b massive post-op anemia requiring MICU
stay as well as R arm DVT, was re-admitted from his rehab
facility with altered mental status, confusion, pain and fever
s/p drainage of infected hematoma with persistent delirium on
___.
# Toxic metabolic encephalopathy, in setting of hepatic
encephalopathy. Upon presentation, he was agitated, with
hyperactive delirium. This occurred intermittently throughout
hospitalization. Improved with frequent reorientation,
discontinuation of opioids and benzos, and removal of tethers.
Infection, pain, and anxiety were also thought to be
contributing to his presentation.The patient is sensitive to
opioids (sedation), and thus for mental status changes, his
opioids and other sedating meds such as trazodone should be
limited as much as possible and lactulose uptitrated.
# L hip replacement s/p explant c/b surgical site infection,
superinfected hematoma. Underwent drainage of infected hematoma
on ___. Cultures grew ampicillin-sensitive Enterococcus.
Previous cultures grew H. parainfluenzae treated with
ceftriaxone. He was initially treated with
vancomycin/piperacillin/tazobactam, which was narrowed to
ampicillin/sulbactam, for a total six week course ending
___. Ortho followed for wound management. Patient required
prolonged wound vac course as he continued to have edema and
seeping from the wound, likely in setting of underlying
coagulopathy and edema from cirrhosis. Wound vac was removed
prior to discharge. Plan to continue wound care with bacitracin
ointment, xeroform, and ABDs. Patient will follow up with ortho.
# EtOH cirrhosis. He was continued on lactulose, rifaximin 550
mg bid, and lasix and spironolactone for hepatic encephalopathy.
He intermittently refused lactulose. He was continued on
thiamine/folate/multivitamin.
#Anemia: Hb remained between ___, and was macrocytic in the
setting of liver disease. An element of blood loss into his
hematoma as well as hemodilution was thought to be contributing.
He did not require transfusions.
# RUE DVT. Provoked by PICC line on his last hospitalization.
He was treated with therapeutic dose enoxaparin 100 mg bid; this
was subsequently held for oozing from his surgical site per
orthopedics. He was transitioned to Coumadin but this was then
held as his INR was therapeutic in setting of cirrhosis.
# Diarrhea. Brief course of watery diarrhea without nausea,
vomiting, abdominal pain, or fevers. Stool studies pending on
discharged. Likely antibiotic-associated. Diarrhea resolved
prior to discharge.
==============
CHRONIC ISSUES
==============
# COPD: Albuterol and ipratropium nebs.
# dCHF. Demonstrated on TTE from CHA. Diuresed as needed for
volume overload and pulmonary edema. Discharged on home dose
lasix/spironolactone.
# HLD: Continued home statin/aspirin.
# GERD: Continue calcium carbonate, PPI.
===================
TRANSITIONAL ISSUES
===================
# Antibiotic course: Will require 6 weeks of
ampicillin/sulbactam starting from last I&D (end ___. Please
obtain weekly CBC/Diff, Chem 7, and ESR/CRP. Send all results to
ATTN: ___ CLINIC - FAX: ___.
# Alcoholic cirrhosis. Mr. ___ has outpatient hepatology
follow-up scheduled. He will need an EGD as an outpatient to
screen for varices, as he has never had an EGD before. He will
require hepatic ultrasound and alpha-fetoprotein level every six
months for ___ screening.
# Anticoagulation. Anticoagulation held given that patient had
therapeutic INR likely due to cirrhosis. If INR downtrends below
2, he should be restarted on very low dose Coumadin (such as
0.5mg QD warfarin) to maintain INR ___ until ___.
# Volume status. Patient on home diuretic regimen but has had
episodes of pulmonary edema this admission. Please follow volume
status and adjust furosemide/spironolactone as needed.
# Altered mental status. Pt frequently requests more pain
medications, but has become encephalopathic/delirious with
opiates during this admission. Please be very cautious in
increasing trazodone or oxycodone as he has been extremely
confused/agitated when these have been increased.
# Wound care. To left hip incision. Bacitracin, xeroform, and
ABDs.
# Contact: ___, sister, ___
# Code status: FULL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob
2. Docusate Sodium 100 mg PO BID
3. Ferrous Sulfate 325 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. FoLIC Acid 1 mg PO DAILY
6. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN pain
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Multivitamins 1 TAB PO DAILY
9. Simvastatin 40 mg PO QPM
10. Spironolactone 100 mg PO DAILY
11. Thiamine 100 mg PO DAILY
12. CeftriaXONE 2 gm IV Q24H
13. Diazepam 2 mg PO Q6H:PRN anxiety
14. Enoxaparin Sodium 40 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
15. Furosemide 40 mg PO DAILY
16. Rifaximin 550 mg PO BID
17. Aspirin 81 mg PO DAILY
18. Calcium Carbonate 1250 mg PO DAILY
19. Melatin (melatonin) 3 mg oral QHS
20. Omeprazole 20 mg PO DAILY
21. Vitamin D ___ UNIT PO 1X/WEEK (___)
22. Lactulose 30 mL PO TID:PRN constipation/hepatic
encephalopathy
23. Acetaminophen 1000 mg PO Q8H:PRN pain
24. Fleet Enema ___AILY:PRN constipation
25. Ibuprofen 600 mg PO Q6H:PRN pain
26. Milk of Magnesia 30 mL PO DAILY:PRN constipation
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 1250 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. FoLIC Acid 1 mg PO DAILY
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Rifaximin 550 mg PO BID
12. Simvastatin 40 mg PO QPM
13. Thiamine 100 mg PO DAILY
14. Vitamin D ___ UNIT PO 1X/WEEK (___)
15. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob
16. Milk of Magnesia 30 mL PO DAILY:PRN constipation
17. Spironolactone 100 mg PO DAILY
18. Furosemide 40 mg PO DAILY
19. Ibuprofen 600 mg PO Q6H:PRN pain
20. Melatin (melatonin) 3 mg oral QHS
21. Ampicillin-Sulbactam 3 g IV Q6H
Complete six week course on ___.
22. Outpatient Lab Work
Please obtain weekly CBC/Diff, Chem 7, and ESR/CRP. Send all
results to ATTN: ___ CLINIC - FAX: ___.
23. TraZODone 12.5 mg PO QHS:PRN insomnia
RX *trazodone 50 mg ___ tablet(s) by mouth at bedtime Disp #*14
Tablet Refills:*0
24. Lactulose 30 mL PO DAILY
25. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every six (6) hours
Disp #*30 Capsule Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
=================
PRIMARY DIAGNOSES
=================
- hematoma infection in left prosthetic hip (Entercoccus spp)
- toxic metabolic encephalopathy
- alcoholic cirrhosis
- chronic pain, with opioid dependence
- anxiety
===================
SECONDARY DIAGNOSES
===================
- history of deep vein thrombosis of right upper extremity
- chronic obstructive pulmonary disease
- diastolic congestive heart failure, chronic
- hyperlipidemia
- gastroesophageal reflux disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
It was a pleasure caring for you at ___
___. You were admitted because you had another
infection of your left hip. You had surgery to remove the
infected blood, and you were treated with antibiotics. Your
medications were adjusted and you improved.
You will be returning to a rehabilitation facility to continue
your recovery. Please continue to take all medications as
prescribed. Your discharge follow-up appointments are outlined
below.
We wish you the very best!
Warmly,
Your ___ Team
Followup Instructions:
___
|
10439484-DS-24 | 10,439,484 | 25,089,689 | DS | 24 | 2196-08-26 00:00:00 | 2196-08-26 17:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Tetracycline / Penicillins / Statins-Hmg-Coa Reductase
Inhibitors / Bactrim / lisinopril / prednisone
Attending: ___
Chief Complaint:
TIA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old right handed man with a history of
multiple
vascular risk factors, prior stroke and DM who presents with
transient left arm weakness and dysarthria today.
The patient's wife reports that he was sitting in the back seat
of the car and got out to buy milk when she noticed he kept
dropping his wallet and seemed to not be able to use his left
hand. When he spoke to her his voice sounded slurred, like he
"was drunk" and when he got out of the car 2 minutes later he
had
trouble with his left leg. His wife called ___ and by the time
he
was in the ambulance she thought he was back to normal. This was
about ___ minutes. The patient denies slurred speech and says
he had trouble with his arm because he had been leaning on it
while in the car. He denies numbness.
Patient had a cold about a month ago but otherwise has been
well.
He has some memory deficits at baseline (per wife, if he forgets
something he makes up an answer). She helps him with his
medications but otherwise independant.
Past Medical History:
HTN
DM
hyperlipidemia
Infarct in ___ (small, left parietal. Presented with aphasia
and
disorientation)
"mouth cancer" treated at MEEI
PVD
(1.Right common iliac stent in ___.
2.Right common femoral endarterectomy and saphenous vein
patch angioplasty and right common femoral artery to above-
kneepopliteal artery bypass with PTFE
3.Left carotid stent in ___
diabetic neuropathy
Social History:
___
Family History:
father with stroke
Physical Exam:
Admission Physical Exam:
Vitals: 97.6 69 175/82 18 97% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated.
Cardiac: RRR, nl. S1S2
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. There were no paraphasic errors. Pt missed
hammock
and cactus on stroke card (thought cactus was baked beans). Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of neglect.
-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: left NLF flattening but symmetric with activation
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with normal strength
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
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:decreased cold sensation in stocking distribution in
distal legs. No JPS or vibration in left toes, impaired on the
right.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait:defered
Discharge Exam:
- No significant change from admission.
Pertinent Results:
___ 03:27PM BLOOD WBC-9.1 RBC-4.39* Hgb-11.6* Hct-35.5*
MCV-81* MCH-26.4* MCHC-32.6 RDW-15.1 Plt ___
___ 03:27PM BLOOD ___ PTT-27.2 ___
___ 06:08AM BLOOD Glucose-153* UreaN-25* Creat-0.9 Na-141
K-4.0 Cl-108 HCO3-25 AnGap-12
___ 03:27PM BLOOD ALT-18 AST-20 AlkPhos-87 TotBili-0.1
___ 03:27PM BLOOD cTropnT-<0.01
___ 06:08AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.9 Cholest-203*
___ 03:27PM BLOOD Albumin-4.0
___ 06:08AM BLOOD %HbA1c-9.0* eAG-212*
___ 06:08AM BLOOD Triglyc-226* HDL-41 CHOL/HD-5.0
LDLcalc-117
___ 03:27PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Tricycl-NEG
MRI/MRA Brain: IMPRESSION:
1. No acute infarct.
2. Chronic left inferior frontal lobe infarct. Mild to moderate
chronic
microangiopathy.
3. Brain MRA is limited by artifacts.
4. Asymmetrically diminished flow within the petrous, cavernous
and
supraclinoid left internal carotid artery, asymmetrically
diminished flow
within the left middle cerebral artery and its branches, and
possibly
diminished flow in the previously mildly hypoplastic A1 segment
of the left anterior cerebral artery, all new compared to the ___ CTA. This may be related to a true high-grade
stenosis in the proximal petrous internal carotid artery.
5. Apparent signal loss in the proximal aspect of a superior
branch of the right middle cerebral artery is almost certainly
artifactual.
6. Apparent signal loss in the proximal V4 segments of bilateral
vertebral arteries, with normal flow in the visualized distal V3
segments and in the distal V4 segments, is probably artifactual.
Apparent narrowing the proximal P2 segments of the posterior
cerebral arteries, right worse than left, is probably also
artifactual.
CTA Head and Neck ___: IMPRESSION:
1. No acute intracranial abnormality. Chronic left frontal lobe
infarct.
2. Status post left distal common and proximal internal carotid
artery stent. Approximately 40% in-stent stenosis by NASCET
criteria of the distal aspect of the stent.
3. Focal high-grade > 80 % stenosis of the proximal petrous
portion of the left internal carotid artery with atherosclerotic
narrowings of the left A1 anterior cerebral artery and left M1
middle cerebral artery. There is also mild asymmetry in the
arborization of the left middle cerebral artery compared to the
right. Perfusion imaging can help for better assessment of
asymmetry of cerebral blood flow.
4. No stenosis of the right internal carotid artery by NASCET
criteria.
Brief Hospital Course:
# TIA
- Patient presented to the ED as a Code Stroke with NCHCT
negative for acute ischemia. His left sided symptoms were not
present during this hospitalization and resolved prior to his
presentation to the ED. He was admitted to neurology for
further evaluation. His MRI was negative for acute ischemia.
Subsequent MRA revealed and Carotid Duplex were concerning for
flow abnormality through the left carotid. Subsequent CTA of
the head and neck demonstrated Focal high-grade > 80 % stenosis
of the proximal petrous portion of the left internal carotid
artery.
As patient had these symptoms through Aspirin and Plavix, his
regimen was altered to Aggrenox and Plavix. His Triglycerides
were elevated on fasting lab at 226 and he was started on
Gemfibrozil. Notably, he was previously on low dose Simvastatin
10mg QHS with a severe reaction- muscle weakness and diffuse
muscle pain and high dose statin was deferred. Additionally, his
A1C was elevated at 9, and his outpatient insulin regimen will
likely require further tightening, but this was deferred
inpatient given alteration from usual diet. The importance of
dietary control was stressed.
Vascular surgery was consulted regarding his L ICA stenosis and
recommended no surgical intervention at this time, but one month
follow-up with vascular duplex and outpatient clinic.
He was seen by physical therapy who recommended outpatient
physical therapy. Additionally, he was recommended to see and
provided the number to schedule an outpatient Nutrition
appointment.
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 =
117) - () No
5. Intensive statin therapy administered? () Yes - (X) No [if
LDL >= 100, reason not given: prior severe reaction, started on
fibrate]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - (X) No [if no,
reason: (X) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (X) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? () Yes - (X) No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: Prior severe reaction]
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - (X) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Losartan Potassium 25 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Pregabalin 0 mg PO BID
7. NovoLOG (insulin aspart) . Unknown subcutaneous As directed
8. Levemir (insulin detemir) . Unknown subcutaneous As directed
9. Metoprolol Succinate XL 12.5 mg PO DAILY
Discharge Medications:
1. Outpatient Physical Therapy
ICD 9:435.9
Responsible Physician ___. ___
2. NovoLOG (insulin aspart) 0 u SUBCUTANEOUS AS DIRECTED
3. Levemir (insulin detemir) 0 u SUBCUTANEOUS AS DIRECTED
4. Losartan Potassium 25 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Gemfibrozil 600 mg PO 30 MINUTES PRIOR TO BREAKFAST AND
DINNER
RX *gemfibrozil 600 mg 1 tablet(s) by mouth 30 minutes before
breakfast and dinner Disp #*60 Tablet Refills:*3
7. Dipyridamole-Aspirin 1 CAP PO BID
RX *aspirin-dipyridamole [Aggrenox] 25 mg-200 mg 1 capsule(s) by
mouth Twice Daily Disp #*60 Capsule Refills:*3
8. Metoprolol Succinate XL 12.5 mg PO DAILY
9. Pregabalin 0 mg PO AS DIRECTED
Please take as directed by your prescribing physician.
10. Clopidogrel 75 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Transient Ischemic Attack (TIA)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of left sided weakness and
voice change resulting from an Transient Ischemic Attack, a
condition in which a blood vessel providing oxygen and nutrients
to the brain is temporarily blocked. This is sometimes referred
to as a "Mini Stroke". Damage to the brain can result from it
being deprived of its blood supply. Fortunately, your symptoms
resolved and there was no evidence of stroke on your MRI.
Transient Ischemic Attacks can have many different causes, so we
assessed you for medical conditions that might raise your risk
of having stroke. In order to prevent future strokes, we plan to
modify those risk factors. Your risk factors are:
- High Cholesterol
- Peripheral Vascular Disease and Prior Strokes
We are changing your medications as follows:
- Your daily Aspirin is being changed to Aggrenox Twice daily.
Please stop your daily aspirin when you start taking aggrenox.
- We have started a medication for your high cholesterol-
Gemfibrozil 600mg by mouth 30 minutes prior to breakfast and
dinner.
Please take your other medications as prescribed.
Please follow-up with Neurology and your primary care physician
as listed below. Please schedule an appointment with nutrition
(number below) to help you manage your cholesterol in addition
to your medication.
Please follow-up with outpatient physical therapy.
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:
___
|
10439484-DS-26 | 10,439,484 | 25,909,616 | DS | 26 | 2197-04-09 00:00:00 | 2197-04-11 16:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tetracycline / Penicillins / Statins-Hmg-Coa Reductase
Inhibitors / Bactrim / lisinopril / prednisone
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___: Cardiac Catheterization
History of Present Illness:
___ IDDM c/b neuropathy, HTN, hx of stroke presenting with
sudden onset shortness of breath.
Pt reports yesterday while watching football returned from
bathroom but became acutely short of breath. Pt denies
CP/N/V/vision changes/palpitations/dizziness/lightheadedness.
Has never had anything like this before.
He reports recent URI for the past couple weeks that is
resolving otherwise denies diarrhea, fevers, chills, night
sweats.
Pt called ambulance. Received duonebs en route by EMS with some
alleviation.
In the ED, initial vitals were: 97 94 149/82 22 100%
Non-Rebreather
- Labs were significant for: WBC 13.2 H+H 7.1/25.1 K 5.6 Bicarb
13 BUN/Creat 37/1.6, Trop neg, BNP 1254, LFTs wnl, lactate 2.0,
VBG 7.32/___, UA negative for ketones
- Imaging: CXR--Findings most consistent with pulmonary edema,
although underlying consolidation cannot be excluded.
- ECG: NSR @ 97, inferior t wave inversions and T-wave
flattening in lateral leads with RAD that are new compared to
___ EKG.
- The patient was given:
___ 03:13 SC Insulin 46 UNIT
___ 03:58 IV Insulin Regular 4 units
Vitals prior to transfer were: 97.8 75 128/55 18 97% RA
Upon arrival to the floor, pt reports feeling improved. Pt
denies hx of cardiovascular issues. Endorses cough over past 2
days. Notes chronic ___ swelling with strong hx of PVD. Denies
orthopnea, PND.
REVIEW OF SYSTEMS:
(+) Per HPI, occasional constipation, h/o muscle weakness with
statin use, recent URI resolving.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea, or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies current arthralgias or myalgias.
Past Medical History:
HTN
DM
hyperlipidemia
Positive FOB with iron deficiency anemia
Infarct in ___ (small, left parietal. Presented with aphasia
and disorientation)
"mouth cancer" treated at ___
PVD
1.Right common iliac stent in ___.
2.Right common femoral endarterectomy and saphenous vein
patch angioplasty and right common femoral artery to above-
kneepopliteal artery bypass with PTFE
3.Left carotid stent in ___
diabetic neuropathy
Social History:
___
Family History:
Father with stroke
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 98.3 141/62 80 28 95%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP elevated to midneck at 45 degrees, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: mild end expiratory wheeze, b/l basal crackles
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. b/l
1+ ___ edema
Neuro: AAOx3
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: 98.4 129/62(87-137/38-66) 55(55-67), 20, 96% RA
I/O: 400/600(8H), 1285/1250(24H)
Weights: 80<- 81.9 <- 82.1<- 86.9kg->86.6 kg-> 85 kg-> 82.1 kg
(admit 88.5 kg)
General: Alert, oriented x3, conversational, no acute distress
HEENT: MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP 9 cm
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Breathing comfortably, few scattered expiratory wheezes
otherwise clear
Abdomen: Distended, softer than yesterday, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, no clubbing, cyanosis. b/l trace- 1+
___ edema, left foot bandage in place, no drainage
Pertinent Results:
ADMISSION LABS:
===============
___ 09:15AM BLOOD WBC-8.2 RBC-3.68* Hgb-8.9* Hct-28.7*
MCV-78* MCH-24.2* MCHC-31.0* RDW-16.2* RDWSD-45.9 Plt ___
___ 01:20PM BLOOD Neuts-67.3 ___ Monos-9.7 Eos-2.5
Baso-0.5 Im ___ AbsNeut-6.49* AbsLymp-1.89 AbsMono-0.94*
AbsEos-0.24 AbsBaso-0.05
___ 01:43AM BLOOD ___ PTT-34.7 ___
___ 09:15AM BLOOD Glucose-84 UreaN-38* Creat-1.6* Na-142
K-4.2 Cl-109* HCO3-18* AnGap-19
___ 01:20PM BLOOD CK(CPK)-171
___ 12:55AM BLOOD ALT-14 AST-31 AlkPhos-86 TotBili-0.2
___ 09:15AM BLOOD CK-MB-5 cTropnT-0.33*
___ 09:15AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.4
___ 09:28AM BLOOD calTIBC-571* Ferritn-14* TRF-439*
___ 12:00PM BLOOD %HbA1c-7.5* eAG-169*
___ 09:28AM BLOOD Triglyc-88 HDL-45 CHOL/HD-3.2 LDLcalc-81
___ 09:28AM BLOOD Osmolal-302
___ 09:28AM BLOOD TSH-3.5
___ 09:16PM BLOOD ___ pO2-139* pCO2-29* pH-7.37
calTCO2-17* Base XS--6
___ 09:16PM BLOOD Lactate-1.6
___ 10:01AM BLOOD Lactate-2.1*
___ 01:00AM BLOOD Lactate-2.0
___ 03:07AM BLOOD O2 Sat-69
PERTINENT LABS:
===============
Hemoglobin Trend: Admit 6.4-7.1->7.8-> 8.8->->7.4->Discharge Hgb
9.5
Admission Creatinine: 1.6, Peak 2.0, Discharge Creatinine: 1.7
Troponin T: 0.33 on admission->0.5->0.33->0.37->0.20
DISCHARGE LABS:
===============
___ 08:00AM BLOOD WBC-8.3 RBC-3.84* Hgb-9.5* Hct-32.0*
MCV-83 MCH-24.7* MCHC-29.7* RDW-19.5* RDWSD-58.1* Plt ___
___ 08:00AM BLOOD Glucose-141* UreaN-40* Creat-1.7* Na-141
K-4.4 Cl-103 HCO3-24 AnGap-18
___ 08:00AM BLOOD ALT-21 AST-37 AlkPhos-65 TotBili-0.3
___ 08:00AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.1
___ 09:28AM BLOOD calTIBC-571* Ferritn-14* TRF-439*
___ 12:00PM BLOOD %HbA1c-7.5* eAG-169*
___ 09:28AM BLOOD Triglyc-88 HDL-45 CHOL/HD-3.2 LDLcalc-81
___ 09:28AM BLOOD TSH-3.5
___ 12:40PM BLOOD CRP-74.2*
IMAGING / STUDIES:
===================
CXR ___
In comparison to the most recent chest x-ray, the pulmonary
vasculature is indistinct. Possible septal lines are seen.
Consolidation is not entirely excluded. The cardiac silhouette
has remained stable since the prior examination. There may be a
small left pleural effusion.
IMPRESSION:
Findings consistent with pulmonary edema, although underlying
consolidation cannot be excluded. Repeat exam can be considered
after diuresis.
ECHO ___
The left atrium is mildly dilated. There is mild regional left
ventricular systolic dysfunction with mild basal and
mid-inferoseptal hypokinesis (PDA territory). The remaining
segments contract normally (LVEF = 50%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic
dysfunction, c/w CAD.
Compared with the prior study (images reviewed) of ___,
regional LV systolic dysfunction appears new
CXR ___
In comparison with the study of ___, following diuresis
there has been substantial decrease in the degree of pulmonary
vascular congestion.
Enlargement of the cardiac silhouette persists. No acute focal
pneumonia.
___ Cardiac Cath: Dominance: Right, LMCA normal, LAD no
significant disease, ___ diagonal with severe proximal disease.
Circumflex anomalous from RCA ostium, 80% mid lesions. The RCA
is occluded chronically. Successful PTCA of anomalous LCV.
Chronically occluded and collateralized RCA.
___ Foot Xray: No previous images. Extensive vascular
calcifications in small vessels is consistent with diabetes.
There is suggestion of possible erosion involving the lateral
aspect of the base of the proximal phalanx of the first digit,
which could possibly represent a focus of osteomyelitis. If
this or some other side is a region of serious concern for
osteomyelitis, MRI would be far more sensitive for making this
diagnosis.
___ CXR: Mild prominence of the interstitial lung markings may
reflect mild congestive heart failure but no overt pulmonary
edema seen.
Brief Hospital Course:
___ with PMHx of T2Dm c/b neuropathy, HTN, HLD, severe PVD, and
hx of stroke presenting with sudden onset shortness of breath
with elevated JVP, b/l crackles, ___ edema w/ radiographic
evidence of fluid overload, evidence of NSTEMI with EKG changes
in inferior and lateral leads, EF 50%, s/p cath showing
chronically occluded and collateralized RCA. His course was
complicated by anemia, acute kidney injury, encephalopathy and
orthostasis.
# NSTEMI:
Patient presented with acute CHF and EKG changes in inferior and
lateral leads. Repeat troponin x3 was positive for trop of 0.33.
He was continued on Plavix 75 and started on aspirin 81 after
receiving a full dose but was not started on heparin due to high
bleeding risk and dropping H&H, thoguht to be likely a type 2
NSTEMI. His trops, CKMB and EKGs were trended and his troponin
peaked at 0.5 without a rise in CKMB or EKG changes. Once his
H&H stabilized as outlined below he was taken to the cath lab
for cardiac catheterization which showed the RCA occluded
chronically with successful PTCA of anomalous LCV. Patient
continued on ASA 81 and Plavix 75, along with Metoprolol XL 50
BID and Isosorbide Mononitrate 30 mg PO/NG TID. His pravastatin
was increased to 40 mg. He received education regarding NSTEMIs.
# Acute congestive heart failure:
Patient presented with clinical evidence consistent with acute
CHF likely secondary to ischemia given h/o severe vascular
disease. ECHO showed preserved EF of 50% and new inferior wall
motion abnormality. He was diuresed with IV Lasix and repeat CXR
showed substantial decrease in pulmonary edema. Patient was off
diuretics but developed increasing wheezing on exam with
shortness of breath, and was diuresed further for improvement of
clinical exam. Discharge Weight: 80 kg (Admit 88.5 kg).
Patient's course was complicated by symptomatic orthostasis
while working with physical therapy, therefore Torsemide was
held. He can be reassessed for home diuretics as an outpatient.
# Iron deficiency anemia:
Patient presented with anemia and history of positive FOB
without blood in stool or melena being worked up outpatient for
occult GI bleed. Repeat H&H once on the floor came back at 6.4 &
21.8, he was transfused 2 units PRBCs for goal H&H of 8 & 30
given active ischemia. He bumped appropriately to transfusion
and was taken to catheterization. GI was consulted for possible
inpatient EGD and colonoscopy. Patient's CBC stabilized with
transfusions, thus colonoscopy was held given recent NSTEMI. He
was noted to have guaiac positive stools thus CBC was monitored
closely. Patient had outpatient GI appointment scheduled for
follow up. He was started on iron supplementation and also on PO
pantoprazole BID (iron studies showed Ferritin 14, TIBC 571).
#Left foot ulcer: Patient noted to have black necrotic region
over left fourth toe, noted ___. This was thought to be
unlikely to be infected per Infectious diseases, with initial
antibiotics were withdrawn. He was deemed to not needed active
surgical intervention needed. Vascular surgery did not need any
debridement. Patient was scheduled for Vascular follow up as
outpatient to discuss possible procedures.
#Acute kidney injury: Patient's creatinine was trending up to
max of 2.0 thought to be likely pre-renal in setting of diuresis
given orthostatic symptoms. Patient's home Losartan 25 mg daily
was held, to be decided for outpatient lab followup.
#Encephalopathy: Patient had normal FSG, with ABG done showing
no apparent acidemia, assuming likely due to worsening
respiratory status with fluid overload vs delirium from
hospitalization. His mental status appeared resolved on repeat
assessments. Urine analysis and culture were negative. We
avoided sedating medications, so his home Tramadol was held.
#Right brachial hematoma: right arm hematoma was noted after
cathertization, and clinical exam was stable and assessed by
interventional cardiology.
#IDDM A1cx 7.5, episodes of hypoglycemia in the morning were
noted in the hospital, so his long acting basal insulin was
adjusted.
#Recent TIA: Patient had history of right sided weakness with
confusion and trouble speaking when TIAs have occured. He was
continued on home plavix given NSTEMI as above. His home
Aggrenox was held given increased risk of bleeding. He was
scheduled for outpatient neurology followup.
#Discharge planning: Patient was evaluated by physical therapy,
and was recommended to have ___ services at home. His home ___
services were resumed.
TRANSITIONAL ISSUES:
====================
-Discharge Weight: 80 kg (at dry weight)
-Discharge Creatinine: 1.7 (improved from 1.8-2, baseline
appears to be 1.6)
- Discharge H/H 9.5/32, please recheck at followup visit
-New Medications: Isosorbide Mononitrate 30 mg PO daily,
Pravastatin 40 mg (increased dose), Ferrous Sulfate 325 mg TID,
outpatient workup planned with GI appointment scheduled
-Patient's home Losartan 25 mg daily and Torsemide 20mg daily
was held due to ___. Please draw chem panel at followup visit to
decide on resuming medications.
-Discontinued Aggrenox as patient now on Aspirin and Plavix, has
neurology follow up in place
-Patient noted to have wheezing, possibly cardiac wheeze but may
benefit from further PFTs/pulmonary testing given smoking
history
-Full Code
-Contact: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Gemfibrozil 600 mg PO BID
3. Losartan Potassium 25 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Pregabalin 200 mg PO BID
6. TraMADOL (Ultram) 50 mg PO QHS
7. Dipyridamole-Aspirin 1 CAP PO BID
8. detemir 46 Units Bedtime
novolog 8 Units Breakfast
novolog 10 Units Lunch
novolog 12 Units Dinner
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. detemir 30 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
3. Metoprolol Succinate XL 50 mg PO BID
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
4. Pregabalin 200 mg PO BID
5. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth once a day
Disp #*60 Tablet Refills:*0
8. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
9. Pravastatin 40 mg PO QPM
RX *pravastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*60
Tablet Refills:*0
10. Ferrous Sulfate 325 mg PO TID
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
three times a day Disp #*90 Tablet Refills:*0
11. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % (700 mg/patch) Apply to left foot for pain
relief once a day Disp #*5 Patch Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
NSTEMI
Acute congestive heart failure with preserved EF
Left Foot Venous Ulcer
Iron Deficiency Anemia
Orthostatic Hypotension
SECONDARY DIAGNOSES:
Type 2 Diabetes mellitus
Peripheral vascular disease
Hypertension
Hyperlipidemia
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 participating in your care here at ___
___. You came to us with some shortness of
breath and were found to have a silent heart attack with back up
of fluid into your lungs. You also had a low blood count
probably from a slow GI bleed. We transfused you blood and when
you were stable you went for cardiac catheterization.
You also were noted to have a left toe ulcer for which you will
follow up with vascular surgery. Podiatry surgery did not feel
you needed debridement at this time.
We also noted that you had a lot of fluid in your lungs and
legs, so we gave you water medications (diuretics), first by IV
and then by mouth. We have stopped this as you felt dizzy.
Please talk to your primary care doctor before restarting
Losartan or Torsemide.
Please follow up with the GI appointment on ___ to evaluate
your anemia and low blood counts. Until then, we recommend you
take iron supplementation.
Thank you for choosing ___ for your healthcare needs.
Sincerely,
Your ___ Team.
Followup Instructions:
___
|
10439484-DS-29 | 10,439,484 | 26,824,494 | DS | 29 | 2197-06-03 00:00:00 | 2197-06-03 16:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Tetracycline / Penicillins / Statins-Hmg-Coa Reductase
Inhibitors / Bactrim / lisinopril / prednisone / Sulfa
(Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
=======================================================
HMED ADMISSION NOTE
Date of admission: ___
=======================================================
CC: ___
Major ___ or Invasive Procedure:
Laparoscopic extended right colectomy.
History of Present Illness:
___ with history of peripheral vascular disease s/p multiple
stents and bypass, multiple TIAs on pradaxa, diverticulosis and
adenoma on colonoscopy in ___ who was recently admitted to
___ last week for BRBPR found to have transverse colonic
adenocarcinoma diagnosed on colonoscopy with biopsy, initially
planned to have outpatient elective colonic resection on ___
(work up negative for metastases), now presents to the ED s/p
syncopal event at home.
The patient is unable to provide much history, he is forgetful,
does not know why he is here and in fact says "nothing is wrong"
and he denies pain, denies he suffered a fall at home.
I called and spoke to his wife who indicates he has been in his
usual state of health since discharge from the hospital until
today. The patient ambulated to the bathroom independently, used
the toilet but then when walking out of the bathroom, became
"weak all over" and he had to sit down on a push walker. He was
unable to stand up from the seated position and his sons had to
help him up from the chair. Wife also indicates he was more
confused than normal, with a blank stare and minimally
communicative. She reports he never lost consciousness, never
fell to the ground or hit his head. She subsequently called EMS
who evaluated patient and found him hypotensive. Since the event
the patient has been reporting mid-thoracic sharp pain worse
with movement or when seated upright. He denies this to this
provider on admission.
In the ED, initial vitals were: 98 78 163/64 18 97% RA. He was
complaining of thoracic pain so CTA performed revealing a
subsegmental PE. He was started on anticoagulation and medicine
admission requested. Colorectal surgery was consulted in the ED
and recommended medicine admission.
On the floor, he appears overall well, he denies any complaints
though he is a poor historian. He is forgetful and at one point
says he is in the hospital and the next second says he is in his
car driving home.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Otherwise ROS is negative.
Past Medical History:
HTN
hyperlipidemia
DM 2 complicated by PVD and neuropathy
Iron deficiency anemia secondary to chronic GI blood loss
Newly diagnosed colon adenocarcinoma
Prior CVA in ___ (small, left parietal. Presented with aphasia
and disorientation)
PVD
1.Right common iliac stent in ___.
2.Right common femoral endarterectomy and saphenous vein
patch angioplasty and right common femoral artery to
above-knee popliteal artery bypass with PTFE
3.Left carotid stent in ___.
Social History:
___
Family History:
Father with stroke
Physical Exam:
Vitals: 98.1 112/47 84 16 99%RA FS338
Pain Scale: ___
General: Patient appears chronically ill but in no acute
distress, appears overall well given history. Alert, oriented to
person, place ___ but to date he says ___
HEENT: Dry MM, oropharynx clear
Neck: JVP low, no LAD appreciated
Lungs: Clear to auscultation bilaterally, moving air well and
symmetrically, no wheezes, rales or rhonchi appreciated
CV: Regular rate and rhythm, S1 and S2 clear and of good
quality, no murmurs, rubs or gallops appreciated
Abdomen: soft, non-tender, non-distended, normoactive bowel
sounds throughout, no rebound or guarding
Ext: left foot s/p ___ metatarsal resection, superficial
stitches and purulent crusting on gauze pad, no bleeding, foot
is warm but not erythematous. There is also steri-strips
covering a well healed bypass scar on left lower leg. There are
no bruising or bleeding evident on extremities. There is no
tenderness over spine or ribs.
Pertinent Results:
Admission Labs:
___ 10:00PM BLOOD WBC-10.6* RBC-3.39* Hgb-9.5* Hct-30.1*
MCV-89 MCH-28.0 MCHC-31.6* RDW-16.4* RDWSD-53.1* Plt ___
___ 10:00PM BLOOD Neuts-66.8 ___ Monos-7.6 Eos-2.6
Baso-0.4 Im ___ AbsNeut-7.08* AbsLymp-2.33 AbsMono-0.80
AbsEos-0.28 AbsBaso-0.04
___ 10:00PM BLOOD Glucose-297* UreaN-31* Creat-1.2 Na-135
K-4.4 Cl-97 HCO3-25 AnGap-17
___ 10:00PM BLOOD CK(CPK)-42*
___ 10:00PM BLOOD CK-MB-2 proBNP-1340*
___ 10:00PM BLOOD Calcium-8.6 Phos-3.0 Mg-1.8
___ 10:00PM BLOOD cTropnT-<0.01
___ 04:45AM BLOOD cTropnT-<0.01
___ 10:21PM BLOOD Lactate-1.6
Imaging:
CT Head:
1. No acute intracranial abnormalities.
2. Evaluation of intracranial metastases is limited due to lack
of contrast. However there is no secondary signs to suggest
presence of large masses. If there are concerns for
intracranial lesions, MRI is more sensitive.
CTA Chest:
1. Filling defect with mild distension of a right lower lobe
subsegmental artery is concerning for acute pulmonary embolus
(Se 3, Im 159).
2. Moderate colonic stool burden.
3. Small hiatal hernia.
4. T12 vertebral body compression deformity, overall unchanged.
Brief Hospital Course:
ASSESSMENT AND PLAN:
___ man with PMHx of severe PVD (on plavix) s/p multiple recent
vascular interventions, stenting, and toe amputation, NSTEMI in
___ s/p cath and angioplasty, on Pradaxa, IDDM type 2 poorly
controlled and complicated by PVD and neuropathy, history of
CVA, multiple prior TIAs and recent diagnosis of colon cancer
found after admission for acute blood loss anemia presented to
the ED with presyncopal event at home, found to have acute
pulmonary embolism.
# Pre-syncope: Patient never lost consciousness, never fell but
felt lightheaded and was found to be hypotensive. Potentially
related to overdiuresis from Torsemide as evidenced by
hypotension and pre-renal pattern of acute renal failure.
- Hold Torsemide
- IVFs
- Orthostatic vital signs
- ___
# Acute renal failure:
While Cr is within normal range Cr has increased by 50%
suggesting 50% drop in GFR. BUN:Cr ratio >20. Seems pre-renal
given clinical scenario.
- IVFs
- Monitor Cr
- Hold Torsemide
# Thoracic pain: Potentially related to pleuritic pain due to PE
though worsening pain with standing position and after he was
lifted by his sons suggests ___ pain. He is currently
asymptomatic and CT chest did not reveal fractures
- Pain control for now
- ___ consult
# Acute pulmonary embolism:
Right subsegmental, low risk, patient is not tachycardic, has
normal troponins and BNP lower than previous. Aspirin and
Dabigatran held in the outpatient setting in preparation for
surgical intervention this ___
- Continue Heparin drip
- Enoxaparin likely superior given underlying malignancy but
since patient is already therapeutic on Heparin, has not shown
evidence of bleeding and can be discontinued if needed, will
continue heparin pending surgical intervention ___
- Monitor Hct
# Transverse colon adenocarcinoma:
No evidence of metastases on imaging. 4 cm transverse colon mass
seen on colonoscopy ___ s/p biopsy revealing
adenocarcinoma, CEA 7.9. Colorectal surgery, oncology, and
vascular surgery were all involved. Per documentation family
meeting last week decided to pursue surgical intervention,
understanding significant surgical risk given past medical
history. Colorectal surgery already consulted in the ED, plan
for elective surgical transverse colonic resection this ___.
- Colorectal surgery consultation
# Coronary artery disease
# Peripheral Vascular Disease:
Recent POBA (___) for CAD and grafting for PVD
(___). Maintained as an outpatient with ASA, Clopidogrel
and Dabigatran. Per vascular surgery risk of graft failure is
at least 20% without pradaxa and next step would be amputation
of limb. Cardiology recommended minimizing time off of
anticoagulation. Discharged on
Plavix and off of ASA and pradaxa until after his surgery, per
documentation.
- Continue Metoprolol, Isosorbide, Clopidogrel
- Continue to hold aspirin and dabigatran
# DM type II:
Chronic, poorly controlled, insulin dependent, complicated by
neuropathy and peripheral vascular disease. A1c 7.5% in ___.
- Continue Humalog and glargine in place of aspart and glargine
# Constipation:
- Bowel reg
# HTN:
- Holding home BP meds given PE
# Anemia:
Chronic, iron deficiency from chronic GI blood loss and recent
acute blood loss anemia from acute lower GI bleed.
- Monitor hct
#DVT PROPHYLAXIS: [ ] Heparin sc [] Mechanical [X] Therapeutic
anticoagulation
#CODE STATUS: [X] Full Code []DNR/DNI
#DISPOSITION: Inpatient pending surgical intervention ___ and
bridging back to oral anticoagulation
I have discussed this case with [X]patient [X]family
[]housestaff [X]RN []Case Management []Social Work [X]PCP
[]consultants .
Attending Physician ___: ______________________________
___, MD
___ ___
Date: ___
Time: 2300
Colorectal Surgery Hospital Course
Mr. ___ was transferred to the inpatient colorectal surgery
service after a laparoscopic Colectomy for Transverse colon
cancer. On ___ his vitals stable, pain controlled, no
events overnight, and he was transferred to floor. On ___
he tolerated sips without issue, peripheral pulses were viable.
The Central Venous Line was in use. The heparin drip had been
restarted and On ___ PTT was 51 our goal was ___. He was
given clear liquids. PTT 67 and the heparin drip was changed to
1150uniuts. The Foley and Dilaudid PCA was discontinued. On
___ the heparin gtt to 1050. The patient was found to be
orthostatic hypotension and given the patient's cardiac history
a cardiology consult was called. We decreased glargine to 30.
The patients hematocrit was low and cardiology requested
transfusion to hgb above 8. He was given 2 units. On ___
the patient's hematocrit was 28.5, PTT 59.1. The tolerated clear
liquids. Given continued orthostasis all blood pressure
medications and diuretics were held. The patient was to hold
these medications until follow-up with his cardiologist. He was
euvolemic and blood pressure were stable. He was evaluated by
physical therapy who recommended discharge to rehab. ___
the regland was stopped for QTc. He was tolerating a regular
diet, was passing flatus, surgical site was intact. The central
line was removed without issue. Therapeutic Lovenox was started
as anticoagulation for cardiac stents as well as for recent
vascular surgery at the recommendation of Dr. ___. He
will continue Lovenox for 6 months at least until this can be
reevaluated for anticoagulation given recent pulmonary embolism.
___ he was stable for discharge to rehab.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Pravastatin 40 mg PO QPM
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Bisacodyl 10 mg PR QHS:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO TID
7. Isosorbide Mononitrate 30 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
10. Pregabalin 200 mg PO BID
11. Senna 8.6 mg PO BID:PRN constipation
12. Tamsulosin 0.4 mg PO QHS
13. Torsemide 20 mg PO DAILY
14. Pantoprazole 40 mg PO Q12H
15. Levemir 38 Units Bedtime
Novolog 8 Units Breakfast
Novolog 10 Units Lunch
Novolog 12 Units Dinner
Insulin SC Sliding Scale using Novolog Insulin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Pantoprazole 40 mg PO Q12H
3. Pravastatin 40 mg PO QPM
4. Pregabalin 200 mg PO BID
5. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
6. Enoxaparin Sodium 90 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 30 mg/0.3 mL ___very twelve (12) hours
Disp #*360 Syringe Refills:*0
7. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
do not drink alcohol or drive a car while taking this medication
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
8. Docusate Sodium 100 mg PO BID
9. Ferrous Sulfate 325 mg PO TID
10. Nystatin Oral Suspension 5 mL PO TID
should take until 48 hours after symptoms resolve
11. Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Transverse colon cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the inpatient Colorectal Surgery Service
after a Laparoscopic Extended Right Colectomy for surgical
management of your Transverse Colon Cancer. 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 your surgical team.
You will be prescribed narcotic pain medication Oxycodone. This
medication should be taken when you have pain and as needed as
written on the bottle. This is not a standing medication. You
should continue to take Tylenol for pain around the clock and
you can also take Advil. Please do not take more than 3000mg of
Tylenol in 24 hours. 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!
Followup Instructions:
___
|
10439578-DS-14 | 10,439,578 | 25,272,326 | DS | 14 | 2124-02-21 00:00:00 | 2124-02-21 09:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right knee pain, fall
Major Surgical or Invasive Procedure:
___: Right hemiarthroplasty
History of Present Illness:
Ms. ___ is a ___ y/o female with a history of afib on coumadin
who presented with right knee pain after a fall. She notes that
the fall came on ___ night. She went to answer door and
tripped. No headache, focal numbness/weakness. Pain in R knee,
hasn't tried walking on it but pain with any motion. Also with L
facial erythema/swelling, no blurry vision, itching/pain. Bruise
over left forearm, doesn't know how got that. Sister checks in
on patient daily (lives 2 blocks away), this morning pt wasn't
returning phone calls and sister went to check on her, couldn't
open door, fire dept had to crawl through window to get in.
In the ED, initial vital signs were 99.1 85 169/64 18 97%. She
has a head CT which was negative for any acute process. She also
had an x-ray of her knee which showed arthritic changes but no
fracture/dislocation/effusion. Patient was given 1g of tylenol
and 800mg of ibuprfen. She was evaluated by ___ who recommended
that she go to rehab. She unfortunately was turned down due to
concern for alcohol withdrawal. The rehab wanted 24h of CIWA
prior to being accepted. Her INR was noted to be 5.0 and was
given 5mg of vitamin K.
On the floor, 97.5, 142/87, 92, 16, 98% RA. Patient c/o knee
pain and pain all over.
Review of Systems:
(+) see HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Atrial Fibrillation s/p PPM
Osteoporsis
Hypertension
COPD
Alcohol Abuse
Social History:
___
Family History:
Father- ___, multiple family members with CAD
Physical Exam:
Admission:
Vitals- 97.5, 142/87, 92, 16, 98% RA
General- Alert, oriented, anxious appearing, pressured speech
HEENT- Sclera anicteric, MMM, oropharynx clear, L eye slightly
swollen, non tender, red conjunctiva
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- RRR, normal S1 + S2, III/VI crescendo decrescendo murmur
loudest over LUSB
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, bruising over skin
Neuro- CNs2-12 intact, motor function grossly normal
LUE: sking CDI with ecchymoses over ulnar forearm
shoulder, elbow, wrist not painful with ROM
epl/fpl/op/dio/edc/fds+
RA/UA 1+
SILT R/U/M
RLE: skin CDI
extremity shortened and externally rotated
hip: pain with any ROM
ankle not painful with rom
___ +
SILT SPN/DPN/S/S/TN
TP/DP 1+
Pertinent Results:
Admission:
___ 10:45PM URINE GR HOLD-HOLD
___ 10:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:45PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
___ 10:45PM URINE RBC-3* WBC-5 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 10:45PM URINE HYALINE-3*
___ 10:45PM URINE MUCOUS-RARE
___ 09:00PM GLUCOSE-126* UREA N-17 CREAT-0.8 SODIUM-131*
POTASSIUM-4.3 CHLORIDE-91* TOTAL CO2-20* ANION GAP-24*
___ 09:00PM estGFR-Using this
___ 09:00PM NEUTS-85.8* LYMPHS-7.5* MONOS-6.4 EOS-0.1
BASOS-0.2
___ 09:00PM WBC-12.5*# RBC-4.54 HGB-14.6 HCT-42.5 MCV-94
MCH-32.1* MCHC-34.3 RDW-13.3
___ 09:00PM PLT COUNT-222
___ 09:00PM ___ PTT-41.3* ___
Imaging:
Radiology Report KNEE (AP, LAT & OBLIQUE) RIGHT Study Date of
___ 9:20 ___
IMPRESSION: Degenerative changes without signs of fracture,
dislocation, or joint effusion.
___ 9:04 ___
CT HEAD W/O CONTRAST
IMPRESSION:
1. No acute intracranial abnormality.
2. Age-related volume loss and moderate chronic small vessel
ischemic
disease.
___ Imaging PELVIS (AP ONLY)
A right femoral neck fracture is present with associated
superior lateral
displacement of the proximal right femoral shaft with respect to
the femoral neck. Small fracture fragments are identified
adjacent to the major fracture line. Loss of visible bone
architectural element laterally in the femoral neck is probably
due to the comminuted fracture, but a pathological fracture
through a lytic bone lesion could present with a similar imaging
appearance. Assessment of the remaining visualized osseous
structures is remarkable for diffuse bone demineralization.
Vascular calcifications are present in the soft tissues.
___ Imaging HIP UNILAT MIN 2 VIEWS
A right femoral neck fracture is present with associated
superior lateral
displacement of the proximal right femoral shaft with respect to
the femoral neck. Small fracture fragments are identified
adjacent to the major fracture line. Loss of visible bone
architectural element laterally in the femoral neck is probably
due to the comminuted fracture, but a pathological fracture
through a lytic bone lesion could present with a similar imaging
appearance. Assessment of the remaining visualized osseous
structures is remarkable for diffuse bone demineralization.
Vascular calcifications are present in the soft tissues.
___ Imaging ELBOW, AP & LAT VIEWS L
FINDINGS: Radiographs of the left wrist demonstrate an
obliquely oriented fracture through the distal left ulna, with
mild lateral displacement of the distal fracture fragment with
respect to the proximal fracture fragment, as well as overriding
of the fracture fragments by approximately 1 cm with associated
slight foreshortening of the distal ulna with respect to the
carpal bones. Within the radiocarpal joint space,
radiodensities are present suggestive of chondrocalcinosis in
the setting of chondrocalcinosis within the knee joint on recent
knee radiograph dictated separately.
Radiographs of the left elbow demonstrate no evidence of acute
fracture or dislocation. Anterior fat pad displacement is
present without accompanying posterior fat pad displacement,
possibly but not definitely representing a small joint effusion.
Bones are diffusely demineralized.
IMPRESSION: Oblique fracture of distal left ulna.
___ Imaging FOREARM (AP & LAT) LEFT
FINDINGS: Two views of the left forearm demonstrate an
obliquely oriented fracture of the distal ulna with mild lateral
displacement of the distal fracture fragment with respect to the
proximal fracture fragment, as well as overlap of the fracture
fragments with associated slight foreshortening of the ulna.
Small radiodensities in the region of the joint between the
distal ulnas and adjacent carpal bones could potentially
represent chondrocalcinosis, especially given the presence of
chondrocalcinosis on previous knee radiograph. No definite
additional fractures are identified in the remainder of the
forearm, but subtle fracture may be difficult to detect in the
setting of diffuse bone demineralization.
___ Imaging CHEST (PRE-OP AP ONLY)
FINDINGS: Stable cardiomegaly with indwelling permanent
pacemaker in place. Pulmonary vascularity is within normal
limits, and lungs and pleural surfaces are clear.
Brief Hospital Course:
Ms. ___ is a ___ y/o female with a history of afib on coumadin
who presented with right knee pain after a fall. Due to concern
for alcohol withdrawal she was admitted to the medicine service
on ___. She was found to have a right femoral neck hip and
left ulnar shaft fracture. Ortho was consulted on ___ for
management of these fractures. The ulnar shaft fracture was
deemed nonoperative and treated conservatively in a splint. The
hip fracture required surgery but due to a supratherapeutic INR
initially, the surgery was delayed until ___ after reversal
of her coumadin with vitamin K.
# Right femoral neck hip fracture: Patient noted to have
externally rotated right lower extremity on exam. Imaging
revealed right femoral neck fracture with superior lateral
displacement of the proximal right femoral shaft with respect to
the femoral neck. The patient was evaluated by the orthopedic
surgery team. After reversal of the coumadin she was taken to
the operating room on ___ for right hip hemiarthropalst,
which she 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.
#. Ulnar shaft fracture: X-ray showed an oblique fracture of
distal left ulna. Her left upper extremity was initially
splinted in a sugar tong splint. Postoperatively OT was
consulted to place an ulnar gutter splint incorporating the
wrist to allow platform weight bearing.
#. Fall: Patient presented s/p unwitnessed fall of unclear
etiology. CT head without any intracranial abnormality. She was
monitored on telemtry without events. Pacemaker interrogation
showed normally functioning device without any tachyarrhythmias
detected. Patient did not appear volume depleted on exam.
Physical exam was notable for a crescendo decrescendo murmur
loudest over LUSB. Per primary care doctor, patient had an ECHO
___ which showed a mild AS with valve area of 2 and peak
gradient of 2.3m/s2. Given typical progression of aortic
stenosis of 0.1 cm/year, it is unlikely that patient would have
progression of aortic valve disease sufficient to cause
symptoms. Fall may have been multifactorial, due to alcohol
consumption and mechanical.
# Alcohol Withdrawal: Initial concern for alcohol abuse and
withdrawal. Patient stated that she drinks ___ glasses of wine
daily, however family members concerned she may drink more. She
was placed on a CIWA scale and received diazepam on a couple
occasions, however did not go into overt withdrawal. She was
also put on thiamine and folate supplementation while in the
hospital and seen by social work.
# Supratherapeutic INR: Patient was noted to have an INR of 5
when she initially presented. She was reversed with vitamin K
preoperatively and her INR was 1.0 at the time of surgery. The
Medicine service determined that based on her CHADS score she
did not require a heparin bridge while reversed perioperatively.
Postoperatively she was started on prophylactic Lovenox and
restarted on coumadin with a loading dose of 10 mg on POD#0, 5
mg on POD#1, and 1 mg on POD#2. At the time of discharge her INR
was 1.5.
# Atrial Fibrillation: Patient presented with suprtherapeutic
INR of 5. She was reversed with vitamin K pre-operatively. She
was continued on diltiazem for rate control. Her pacemaker was
interrogated as above.
Postoperatively the patient was transferred to the Orthopedic
Surgery service for management. 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 Ancef antibiotics. Her warfarin was restarted with
prophylactic Lovenox as described above. She did complain of a
sense of 'impending doom' on POD#1 and denied any associated
CP/SOB/abd pain/HA/dizziness/confusion. Despite a low suspicion
given the lack of symptoms, an EKG and troponin were checked due
to her cardiac history and both were negative. The patient's
home medications were continued postoperatively. The patient
worked with ___ who determined that discharge to rehab was
appropriate. The patient's postoperative 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 weight bearing as tolerated in the
right lower extremity and platform weight bearing in the left
upper extremity with her splint, and will be discharged on
warfarin for her atrial fibrillation with goal INR ___, with
prophylactic Lovenox for DVT prophylaxis until her INR is
therapeutic. 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.
Transitional Issues:
- Consider outpatient ECHO to follow aortic stenosis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 240 mg PO BID
2. Montelukast Sodium 10 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Lisinopril 10 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO BID
7. Warfarin 2 mg PO MON, FRI
8. Warfarin 1 mg PO SUN, TUES, WED, THURS, SAT
9. Diltiazem 30 mg PO TID:PRN Palpitations
10. Cetirizine *NF* 10 mg Oral daily
11. Alendronate Sodium Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Cetirizine *NF* 10 mg Oral daily
2. Diltiazem Extended-Release 240 mg PO BID
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Lisinopril 10 mg PO DAILY
5. Montelukast Sodium 10 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO BID
8. Warfarin 1 mg PO SUN, TUES, WED, THURS, SAT
9. Warfarin 2 mg PO MON, FRI
10. Diltiazem 30 mg PO TID:PRN Palpitations
11. Polyethylene Glycol 17 g PO DAILY
12. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
13. Acetaminophen 1000 mg PO Q6H:PRN pain
14. Docusate Sodium 100 mg PO BID
15. Senna 2 TAB PO BID
16. Enoxaparin Sodium 40 mg SC DAILY DVT prophylaxis
d/c when INR >=2.0
17. Pravastatin 40 mg PO DAILY
18. Milk of Magnesia 30 mL PO Q6H:PRN constipation
19. Warfarin 5 mg PO DAILY16 Duration: 1 Doses
Give 5 mg on ___
Resume home dosing regimen on ___ and titrate as needed for
goal INR ___
Discharge Disposition:
Extended Care
Facility:
___
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Right hip femoral neck fracture s/p right hemiarthroplasty
Left ulnar shaft fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
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 resume your home warfarin dose for goal INR ___ for
management of your atrial fibrillation
- INR should be checked the day after discharge and on every
___ and ___ and warfarin dose adjusted accordingly
- Questions regarding anticoagulation and ongoing warfarin
management should be directed to Dr. ___ (___)
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- No stitches or staples need to be removed.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated right lower extremity
- Platform weight bearing allowed for left upper extremity with
orthoplast splint in place; no weight bearing through the left
hand or wrist
Followup Instructions:
___
|
10439781-DS-51 | 10,439,781 | 23,617,177 | DS | 51 | 2154-03-30 00:00:00 | 2154-05-02 18:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Prochlorperazine / Remicade / Demerol / Morphine /
Dilaudid / Darvocet-N 100
Attending: ___.
Chief Complaint:
Fever, Lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo F with h/o refractory Crohn's disease
s/p total colectomy and ileostomy c/b recurrent enterocutaneous
fistula, rheumatoid arthritis on prednisone, DVT/PE in ___ (on
coumadin), osteoporosis, ?ILD, and recent hip fx who presents to
the ED for fevers, abdominal pain, and confusion. The patient
had a very similar presentation back in ___ at which time
she had opening of fistula tract that was treated with 3 week
course of Cipro and Flagyl. The patient had been in her USOH
until 1 day prior to admission when she noted intermittent
fevers at home up to 101. The patient's daughter was concerned
because her mental status and attention were off her baseline.
She describes herself as more disoriented. She denies abdominal
pain, but says she does have tenderness to palpation near site
of previous fistula. The patient also complains of longstanding
back pain. The patient denies increase in ostomy output. She
says that she is not having a Crohn's Flare at this time, which
usually involves oral ulcers, dehydration, and abdominal pain.
She has been compliant with her Methotrexate and Flagyl
prophylaxis. Otherwise, the patient denies cough, SOB, chest
pain, rashes, or dysuria.
In the ED, the patient had a fever up to 101. GI was consulted
and they recommended IV vanc and Unasyn for coverage of skin and
gut flora due to ? of evolving fistula or abscess. The patient
had a chest xray which looks like mild pulmonary edema and
stable interstitial markings. The patient was given ABX and
admitted to the floor for further management.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
- Afib
- ILD
-Crohn's dx in ___, c/b pyoderma gangrenosum and recurrent
fistula tract most recently in ___
- Hip Fracture s/p repair
-CVA with deficits in her right frontal lobe.
-Neuropathy
-Restless legs
-h/o DVT in ___
-small, subsegmental PE on ___ CTA
-Rheumatoid arthritis, dx in ___
-Asthma/chronic bronchitis
-Depression/anxiety
-Recent falls
-Osteoporosis with multilevel compression fracture T11-L3
-atrial tach
.
Surgical History:
-___: Laparotomy and extensive lysis of adhesions, Excision of
abdominal wall and en bloc resection of abdominal wall and
smallintestine, Complex abdominal wall closure, Permanent
ileostomy,
Ventral hernia repair with placement of SurgiMend mesh.
-___ - VAC change and debridement
-___ - Wound opening and debridement of devitalized skin and
subcutaneous tissues; Irrigation of the wound; Debridement of
devitalized fascia and removal of some mesh and suture;
placement of VAC.
-s/p multiple abd surgeries (___) ___ procedure
and Parks reversal.
-s/p colectomy/ileostomy
Social History:
___
Family History:
Brothers and sister with heart disease, inc. sister with CABG.
No family history of IBD. Daughters healthy.
Physical Exam:
On Admission:
PHYSICAL EXAMINATION:
VITALS: 99, 118/66, 94, 20, 95% 2L
GENERAL: NAD
HEENT: PERRL, EOMI, no oral ulcers, no thrush, dry MM
NECK: no carotid bruits, JVD not elevated
LUNGS: crackles bilaterally at bases to mid lung fields
HEART: RRR, normal S1 S2, no MRG
CHEST: Power port on left chest that is CDI
ABDOMEN: multiple scars, ileostomy at RLG draining yellow stool,
scarring near site of previous ostomy and fistula tract, slight
TTP at that area, no opening/leakage/expression of bowel
material from the site, no rebound/guarding
EXTREMITIES: ___ pitting edema L>R that is chronic
NEUROLOGIC: A+OX2, some inattention, mild disorientation
On Discharge:
VITALS: 98.9 125/63 88 20 97 RA
GENERAL: AOx3
HEENT- Aphthous appearing ulcer under tongue and over left upper
gumline.
LUNGS - No crackles. No adventitious sounds.
HEART - No murmurs, normal S1 and S2.
ABDOMEN - Pain to palpation suprapubically and around site of
former fistula. Fistula ~1 cm, with stool drainage. No rebound
or guarding. Some erythema suprapubically, no warmth, no
induration, where ostomy bag presses against the skin.
BACK- Pain to palpation over thoracic spine and over left flank.
Pain greatest over left flank.
Pertinent Results:
Admission:
___ 01:50AM BLOOD WBC-16.5*# RBC-3.41* Hgb-9.3* Hct-30.1*
MCV-88 MCH-27.2 MCHC-30.8* RDW-20.5* Plt ___
___ 01:50AM BLOOD Neuts-78.0* Lymphs-11.8* Monos-7.7
Eos-2.1 Baso-0.3
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD ___ PTT-37.5* ___
___ 01:50AM BLOOD Plt ___
___ 01:50AM BLOOD ___ PTT-38.6* ___
___ 06:00AM BLOOD ESR-54*
___ 01:50AM BLOOD Glucose-114* UreaN-23* Creat-0.7 Na-132*
K-4.1 Cl-98 HCO3-24 AnGap-14
___ 01:50AM BLOOD ALT-8 AST-21 LD(LDH)-204 AlkPhos-129*
TotBili-0.5
___ 01:56AM BLOOD Lactate-1.8
___ 06:00AM BLOOD Lipase-25
Discharge:
___ 07:35AM BLOOD WBC-6.7 RBC-3.14* Hgb-8.7* Hct-28.1*
MCV-90 MCH-27.6 MCHC-30.9* RDW-20.9* Plt ___
___ 07:35AM BLOOD Plt ___
___ 07:35AM BLOOD Glucose-82 UreaN-11 Creat-0.6 Na-136
K-4.2 Cl-104 HCO3-30 AnGap-6*
___ 07:35AM BLOOD Calcium-8.4 Phos-2.3* Mg-1.7
Relevant:
___ 01:50AM BLOOD WBC-16.5*# RBC-3.41* Hgb-9.3* Hct-30.1*
MCV-88 MCH-27.2 MCHC-30.8* RDW-20.5* Plt ___
___ 07:35AM BLOOD WBC-6.7 RBC-3.14* Hgb-8.7* Hct-28.1*
MCV-90 MCH-27.6 MCHC-30.9* RDW-20.9* Plt ___
___ 01:50AM BLOOD ___ PTT-38.6* ___
___ 06:00AM BLOOD ___ PTT-37.5* ___
___ 04:06AM BLOOD ___ PTT-37.6* ___
___ 04:48AM BLOOD ___ PTT-34.8 ___
___ 06:38AM BLOOD ___ PTT-32.4 ___
___ 07:35AM BLOOD ___ PTT-33.6 ___
___ 06:00AM BLOOD Lipase-25
___ 01:50AM URINE Color-Yellow Appear-Clear Sp ___
___ 01:50AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 01:50AM URINE RBC-1 WBC-62* Bacteri-NONE Yeast-FEW
Epi-1 TransE-2
___ 1:57 am URINE Site: NOT SPECIFIED
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 1:50 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 2:00 am BLOOD CULTURE PORT.
Blood Culture, Routine (Pending):
___ 6:23 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
___ 11:21 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
___ 11:50 am BLOOD CULTURE Source: Line-port.
Blood Culture, Routine (Pending):
___ 5:39 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
CXR ___:
Moderate to severe pulmonary edema is increased from
the prior examination. No focal consolidation to suggest
pneumonia is seen. No significant pleural effusion or
pneumothorax is present. There is moderate cardiomegaly. A
left-sided port is unchanged. There are multiple
vertebroplasties.
CT ___:
1. There is a wide mouth suprapubic hernia containing matted
loops of bowel. There are proximal dilated bowel loops with
collapsed distal loops near the ileostomy as well as multiple
adhesions. These findings are concerning for partial
small-bowel obstruction.
2. No abscess or fistula.
3. No CT evidence of active Crohn's Disease.
4. There is no CT evidence of osteomyelitis or discitis. If
there is high clinical concern for osteomyelitis, MRI would be a
more sensitive test.
Brief Hospital Course:
Ms ___ is a ___ yo woman with h/o Crohns and recurrent
enterocutaneous fistula who presented with fevers, abdominal
pain around previous fistula, and confusion.
# Fevers, Leukocytosis, Abdominal Pain: The patient had a very
similar presentation 4 months prior at which time she had an
evolving fistula tract that was treated with 3 weeks of cipro
and flagyl. She presented on this admission with pain and
tenderness over the previous tract concerning for evolving
fistula or abscess. While she denied symptoms of active colitis,
acute Crohn's flare and/or infectious colitis was considered.
She also had evidence of pyuria and complained of back pain
concerning for UTI. An abdominal CT revealed a partial SBO, but
no abscess or fistula and no evidence of pyelonephritis. In
addition, her CXR revealed no evidence of pneumonia. RA flare
was also considered, but the patient had no joint pains or other
supportive findings.
During her course, she did develop active drainage from her
previous fistula. She was ultimately treated with IV antibiotics
with coverage for UTIs and colitis. She responded well and was
ultimately discharged on a two week course of Cefpodoxime and
Metronidazole. The final results of her blood, stool, and urine
cultures were all negative.
# Crohns Disease: At the time of presentation there was some
concern for acute Crohn's flare, as noted above. However, CT
abdomen revealed no evidence of this. She did however develop
recurrence of her previous enterocutaneous fistula as well as
apthous ulcerations of the oral mucosa. Nonetheless,
Gastroenterology recommended against treatment with steroids, in
favor of a two week antibiotic course for the fistula. She was
evaluated by the ostomy nurse who reviewed fistula care. Her
weekly methotrexate was also continued (did not require
inpatient dosing). Patient will follow up with GI and wound care
in the outpatient setting.
#Back Pain: Patient complained of low back pain and noted to
have tenderness to palpation over thoracic spine as well as
paraspinal muscle spasms. Given h/o osteoporosis with known
compression fractures, there was some concern for new fracture
vs osteomyelitis or discitis given fever and leukocytosis.
However, CT of the abdomen/pelvis showed no signs of
osteomyelitis or discitis. Her pain was overall felt to be
related to known compression fractures and associated muscle
strain. A trial of Flexeril lead to some drowsiness and
confusion. She was ultimately treated with calcitonin, lidocaine
patch, Ibuprofen and oxycodone.
# Interstitial Lung Disease/CHF: The patient carries a diagnosis
of pulmonary hypertension, interstitial lung disease as well as
diastolic heart failure. She was noted to have some crackles on
lugn exam as well as lower extremity edema. Her CXR revealed
moderate interstitial edema which appeared similar to previous
imaging. Her respiratory status remained stable and she did not
require diuresis during her inpatient course. She was continued
on her home Symbicort.
# Rheumatoid Arthritis:
No evidence of acute flare. She was continued on prednisone QOD,
Ibuprofen, Oxycodone, and lidocaine patch.
# H/O PE:
INR was supratherapeutic on admission so Warfarin dose was
initially held. Patient was discharged on Warfarin 3mg daily
with instructions to follow up closely for further management.
# pAfib:
Continued anticoagulation and metoprolol.
# Restless Leg: Continue Ropinirole.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/CaregiverwebOMR.
1. Lorazepam 1 mg PO HS:PRN insomnia
2. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache
3. Warfarin 4 mg PO DAILY16
4. MetRONIDAZOLE (FLagyl) 250 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Methotrexate 15 mg PO QSUN
7. Omeprazole 20 mg PO DAILY
8. Promethazine 25 mg PO Q6H:PRN nausea
9. Protopic *NF* (tacrolimus) 0.1 % Topical DAILY
10. Ropinirole 2 mg PO BID
11. Ropinirole 1 mg PO QPM
12. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation BID
13. Cyanocobalamin 1000 mcg IM/SC MONTHLY
14. Sertraline 25 mg PO DAILY
15. Gabapentin 300 mg PO HS
16. Ibuprofen 400-600 mg PO TID
17. Lidocaine 5% Patch 2 PTCH TD DAILY
Apply to lower back
18. Loperamide 2 mg PO QID:PRN diarrhea
19. Magnesium Oxide 500 mg PO DAILY
20. Metoprolol Succinate XL 25 mg PO DAILY
21. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
22. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
23. PredniSONE 5 mg PO EVERY OTHER DAY
24. Vitamin A 8000 UNIT PO DAILY
25. potassium *NF* 600 mg Oral DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Gabapentin 300 mg PO HS
3. Ibuprofen 400-600 mg PO TID
4. Lidocaine 5% Patch 2 PTCH TD DAILY
Apply to lower back
5. Lorazepam 1 mg PO HS:PRN insomnia
6. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole 500 mg 1 (One) tablet(s) by mouth three times
a day Disp #*42 Tablet Refills:*0
7. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
8. Omeprazole 20 mg PO DAILY
9. PredniSONE 5 mg PO EVERY OTHER DAY
10. Ropinirole 2 mg PO BID
11. Ropinirole 1 mg PO QPM
12. Sertraline 25 mg PO DAILY
13. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation BID
14. Calcitonin Salmon 200 UNIT NAS DAILY
RX *calcitonin (salmon) 200 unit/dose 1 (One) spray intranasal
once a day Disp #*1 Bottle Refills:*0
15. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 (One) tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
16. Vitamin A 8000 UNIT PO DAILY
17. Protopic *NF* (tacrolimus) 0.1 % Topical DAILY
18. Promethazine 25 mg PO Q6H:PRN nausea
19. potassium *NF* 600 mg Oral DAILY
20. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 2 (Two) tablet(s) by mouth every four (4)
hours Disp #*20 Tablet Refills:*0
21. Metoprolol Succinate XL 25 mg PO DAILY
22. Methotrexate 15 mg PO QSUN
23. Magnesium Oxide 500 mg PO DAILY
24. Loperamide 2 mg PO QID:PRN diarrhea
25. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache
26. Cyanocobalamin 1000 mcg IM/SC MONTHLY
27. Warfarin 3 mg PO DAILY16
28. Outpatient Physical Therapy
Please resume previous physical therapy program
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary Tract Infection
Crohn's Disease Flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___:
You were admitted to the hospital for one day of confusion and
fever. While you were in the hospital we thought your symptoms
were likely due to either a urinary tract infection or a Crohns
disease flare. You were treated with antibiotics and improved by
the time of discharge.
Medications Started:
-Calcitonin (for your osteoporosis).
-Cefpodoxime (for your infection). Continue for two weeks.
Medications Changed:
-Warfarin (for your history of clots). We decreased your dosage.
Please get your INR level rechecked at your PCP ___.
-Metronidazole (for your infection). We increased your dose.
Please continue for two weeks.
Followup Instructions:
___
|
10439781-DS-53 | 10,439,781 | 25,879,590 | DS | 53 | 2154-06-05 00:00:00 | 2154-06-07 15:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Prochlorperazine / Remicade / Demerol / Morphine /
Dilaudid / Darvocet-N 100
Attending: ___.
Chief Complaint:
Bleeding from entero-cutaneous fistula
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with PAF on coumadin, ILD, asthma/chronic
bronchitis, sleep apnea, Crohn's disease c/b pyoderma
gangrenosum and recurrent fistula tract, RA on MTX + prednisone,
h/o CVA, and osteoporosis c/b multiple compression fractures,
re-presents after recent discharge from ___ with increased
bloody and feculant output from her new fistula. While she has
some abdominal pain at baseline, she denies F/C/N/V and any
other complaints.
Her prior hospitalization was notable for fever and
leukocytosis, felt to be multifactorial in etiology (pulmonary
in setting of extensive ILD, Foley catheter complication, GI).
As a result, she was started on broad therapy to all of these
sources with vancomycin/cefepime/flagyl for a 10 day course of
the cefepime and flagyl for suspected GI source, given the newly
discovered enterocutaneous fistula. CT showed Large ventral wall
hernia with area of skin erosion likely leaving the bowel nearly
exposed. Colorectal surgery evaluated and recommended
conservative management. Her hospitalization was also
complicatesd by multifactorial encephalopathy, atrial
fibrillation with RVR, supratherapeutic INR, acute urinary
retention, and acute on chronic diastolic congestive heart
failure. Numerous attempts at MRI to delineate extent of T6
destruction were unsuccessful and conservative management was
deemed appropriate by the Ortho-Spine service.
In the ED, initial VS were: 98.8 84 124/88 20 96% RA. She was
given 10mg oxycodone and Percocet x1 for pain and labs were
notable for improved hematocrit from prior and low bicarbonate.
Surgery was consulted and believed there was no acute issues and
could be discharged from their standpoint.
On arrival to the floor, her vitals are stable, she is in no
acute distress, and is able to relay a coherent history.
REVIEW OF SYSTEMS:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
-paroxysmal atrial fibrillation
-atrial tach
-ILD
-Asthma/chronic bronchitis
-Pulmonary hypertension
-diastolic heart failure
-sleep apnea
- Crohn's dx in ___, c/b pyoderma gangrenosum and recurrent
fistula tract most recently in ___
- Hip Fracture (left intertrochanteric hip fracture), s/p
nailing ___
-CVA with deficits in her right frontal lobe.
-h/o DVT in ___
-small, subsegmental PE on ___ CTA
-Rheumatoid arthritis, dx in ___
-Neuropathy
-Restless legs
-Depression/anxiety
-Recent falls
-Osteoporosis with multilevel compression fracture T11-L3
-history of dehydrationa and poor access s/p porta cath ___
Past Surgical History:
-___: Laparotomy and extensive lysis of adhesions, Excision of
abdominal wall and en bloc resection of abdominal wall and
smallintestine, Complex abdominal wall closure, Permanent
ileostomy,
Ventral hernia repair with placement of SurgiMend mesh.
-___ - VAC change and debridement
-___ - Wound opening and debridement of devitalized skin and
subcutaneous tissues; Irrigation of the wound; Debridement of
devitalized fascia and removal of some mesh and suture;
placement of VAC.
-s/p multiple abd surgeries (___) ___ procedure
and Parks reversal.
-s/p colectomy/ileostomy
Social History:
___
Family History:
Brothers and sister with heart disease. 1 sister with CABG. No
family history of IBD. Daughters healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.8 123/57 86 20 97%RA
General: lying in bed; pleasant
CV: Regular rate and rhythm, S1 S2, ___ systolic ejection murmur
heard best in LUSB
Lungs: no accessory muscle use; bilateraly mild rhonchi and
occasional wheeze
Abdomen: soft, non-tender, right sided ileostomy patent with
ostomy bag draining brown stool. Left sided EC-fistula covered
with clean dressing; bright red with no drainage
Ext: Warm, 2+ pulses, no clubbing, cyanosis or edema
Neuro: CN ___ intact, motor ___ upper extremities, ___ plantar
flexion, slight decrement of great toe extension. Sensory
intact. Deferred gait testing
Back: midline tenderness of spine, in lower cervical/upper
thoracic region
DISCHARGE PHYSICAL EXAM:
VS - 98.3 120s/70s p73 R18 97%RA
General: lying in bed; pleasant
CV: Regular rate and rhythm, S1 S2, ___ systolic ejection murmur
heard best in LUSB
Lungs: no accessory muscle use; bilateraly mild rhonchi and
occasional wheeze
Abdomen: soft, non-tender, right sided ileostomy patent with
ostomy bag draining brown stool. EC-fistula 2.5x5.5 cm pink,
moist, patent with ostomy bag
Ext: 2+ pulses, no clubbing, cyanosis or edema
Neuro: CN ___ intact, motor ___ upper extremities, ___ plantar
flexion, ___ dorsal flexion, ___ great toe extension. Sensory
intact. No sensory deficit/parastethias
Back: midline tenderness of spine, in lower cervical/upper
thoracic region
Pertinent Results:
ADMISSION
___ 06:45PM BLOOD WBC-12.7* RBC-3.34* Hgb-8.6* Hct-29.2*
MCV-88 MCH-25.7* MCHC-29.4* RDW-22.9* Plt ___
___ 11:45PM BLOOD WBC-14.4* RBC-3.37* Hgb-8.5* Hct-29.2*
MCV-87 MCH-25.2* MCHC-29.2* RDW-23.1* Plt ___
___ 06:45PM BLOOD Neuts-73.8* Lymphs-13.5* Monos-8.3
Eos-3.8 Baso-0.6
___ 07:16PM BLOOD ___ PTT-36.2 ___
___ 06:45PM BLOOD Glucose-152* UreaN-12 Creat-0.5 Na-138
K-4.1 Cl-116* HCO3-16* AnGap-10
___ 11:45PM BLOOD Glucose-69* UreaN-11 Creat-0.5 Na-140
K-3.7 Cl-114* HCO3-17* AnGap-13
___ 06:20AM BLOOD Calcium-7.0* Phos-1.6* Mg-1.4*
___ 06:52PM BLOOD Lactate-1.5
INTERVAL
___ 06:20AM BLOOD WBC-12.6* RBC-3.24* Hgb-8.2* Hct-27.7*
MCV-86 MCH-25.5* MCHC-29.8* RDW-22.6* Plt ___
___ 06:20AM BLOOD Glucose-85 UreaN-11 Creat-0.5 Na-140
K-4.0 Cl-113* HCO3-20* AnGap-11
___ 06:07AM BLOOD Calcium-7.5* Phos-2.5* Mg-1.5*
DISCHARGE
___ 05:16AM BLOOD WBC-9.4 RBC-2.90* Hgb-7.3* Hct-24.5*
MCV-85 MCH-25.2* MCHC-29.8* RDW-23.5* Plt ___
___ 12:56PM BLOOD Hgb-7.9* Hct-27.3*
___ 05:16AM BLOOD ___
___ 05:16AM BLOOD Glucose-92 UreaN-10 Creat-0.5 Na-136
K-3.5 Cl-108 HCO3-24 AnGap-8
___ 05:16AM BLOOD Calcium-7.0* Phos-1.6* Mg-2.2
IMAGING:
___ 7:27PM CT ABD & PELVIS WITH CONTRAST FLUROSCOPICALLY
INJECTED IN FISTULA FINDINGS:
Redemonstration of changes of interstitial lung disease in the
lung bases as previously mentioned. Cardiomegaly and coronary
artery disease are noted. No significant pericardial effusion.
The liver is normal without focal lesion. There is prominence
of the
intrahepatic and extrahepatic biliary ducts. Status post
cholecystectomy. This is most likely related to post-surgical
nonobstructive dilatation. The spleen, pancreas, bilateral
adrenal glands are normal. Both kidneys are normal.
A large anterior ventral abdominal wall hernia is noted to
contain a few small bowel loops which are partially herniating
with omental fat through a rectus diastasis. Additionally,
there is contrast opacification within a cutaneous fistula,
which projects along the inferior aspect of this large ventral
hernia in a finger-like projection angled caudally. This
measures about 3 cm in length. There is no evidence of contrast
extravasation into the intraperitoneal space or within
intraluminal portions of the adjacent small bowel on the other
side of the abdominal wall/fascia.
The patient is status post colectomy. Post-surgical changes in
the right
lower quadrant bowel loop most likely represent a ___
pouch. Right
lower quadrant ileostomy is noted. No significant
retroperitoneal
lymphadenopathy is appreciated.
No evidence of inflammatory changes or fat stranding surrounding
the residual bowel.
Moderate atherosclerotic disease is again seen.
CT PELVIS:
Urinary bladder is well distended without wall thickening. No
significant
pelvic lymphadenopathy. Status post hysterectomy.
Left-sided proximal femoral orthopedic hardware and heterotopic
ossification as previously seen. Degenerative changes within
the lower lumbar spine facets. Vertebroplasty changes within
the T11, L1 and L2 vertebral bodies. There is significant
vertebral body height loss involving the L1 vertebral body as
well as suspected height loss of L3 on L4. Demineralization of
the bones is also noted.
These findings are stable since ___.
IMPRESSION:
1. Cutaneous fistula tract terminates within the anterior
abdominal wall
subcutaneous soft tissues without evidence of extravasation
across the
peritoneum or enteric communication. Rectus diastasis and large
ventral
anterior abdominal wall hernia with partial small bowel
herniation resides
near to this tract.
2. No evidence of inflammatory changes within the residual
small bowel to
suggest underlying acute inflammation. No evidence of bowel
obstruction.
.
*We reviewed the imagines with the radiologist (Dr. ___
___. There were no collections or abcesses or fat stranding
to suggest Crohn's Flare. Gastroenterology was also notified,
and felt comfortable with discharge based on the above studies
on empiric antibiotics: Cefepime IV until ___ and
Metronidazole 500mg Q8H PO until patient's followup appointment
with Dr. ___ ___.
Brief Hospital Course:
___ year old female with PAF on coumadin, ILD, asthma/chronic
bronchitis, sleep apnea, Crohn's disease c/b pyoderma
gangrenosum and recurrent fistula tract, RA on MTX + prednisone,
h/o CVA, and osteoporosis c/b multiple compression fractures,
re-presents after recent discharge with increased bloody and
feculant output from her new fistula. The patient was evaluated
by Colorectal surgery (who knows the patient well and again
recommend no operative intervention to her fistula), as well as
Gastroenterology. A CT-scan to define the anatomy of her new
fistula and to assess for abscess was performed, and none was
found. Patient was determined to be safe for discharge back to
rehab with antibiotics continued (cefepime until ___ and
metronidazole until GI follow-up on ___ with outpatient
follow up.
ACTIVE ISSUES
# Entero-cutaneous fistula - This is likely a recurrence of her
past fistula because of its close superficial proximity to her
abdominal facial defect. Her fistula was examined by Colorectal
Surgery, the patient's usual Ileostomy/fistula Care nurse, and
Gastroenterology. The patient is not a surgical candidate at
this time.
.
A CT-Abdomen was performed after fluoroscopy-guided injection of
contrast into the fistula. We reviewed the imagines with the
radiologist (Dr. ___, who added that there were no
collections or abcesses or fat stranding to suggest Crohn's
Flare. The gastroenterology team (fellow Dr ___
subsequently felt comfortable with discharge on antibiotics.
Cefepime Q12H IV until ___ and Metronidazole 500mg Q8H PO
until patient's followup appointment with Dr. ___ ___. An
exact connection to the small bowel was not well visualized.
The fistula, however, was patent and draining stool, with no
sign of bleeding or infection. Hgb/Hct remained stable.
.
Conservative care was recommended, covering the fistula with a
collection bag as if it were a second ostomy. Her normal Ostomy
nurse ___ knows patient well) evaluated and assisted in the
management of her fistula. Patient is high risk for any surgical
procedure and in the past, her fistula has opened and closed
with conservative management. She remained hemodynamically
stable, with no evidence of bleeding. She received her
prednisone and her weekly injection of methotrexate.
.
# Paroxysmal atrial fibrillation on anticoagulation: Patient
rate controlled with metoprolol and anticoagulated with warfarin
for goal INR ___. Warfarin dose management was conducted with
daily INR checks, especially because patient is on antibiotics
that affect its metabolism.
.
# Back pain ___ T6 compression fracture: Continued pain control
with Fentanyl patch, oxycodone and ibuprofen. She should also
continue calcitonin nasal for 4 weeks (End date ___ to
treat her fracture and help reduce pain.
.
# Short Gut Syndrome - Patient was repleted with electrolytes
via IV while in house (usually manifests as low magnesium and
low phosphate, with borderline low corrected Calcium). Her oral
regimen as an outpatient can be titrated. Formulary limitations
kept some of her repletions from being by mouth (did not get
absorbed) but prior to her last admission she was on a stable PO
regimen. Certain tablets may need to be crushed to ensure
adequate breakdown and release of the supplement. Please review
discharge medication list for further details.
.
CHRONIC ISSUES:
# Chronic diastolic CHF: Stable, No current evidence of volume
overload or an acute exacerbation. Continued metoprolol.
.
# Depression and Anxiety - Continued on Zoloft and ativan.
.
# Restless Leg: Continued Sinemet. PCP notes indicate patient
has been tried and failed other therapies. Patient instructed to
follow up as an outpatient with sleep medicine as additional
sinemet and ativan could be causing augmentation of RLS.
.
# Crohns Disease s/p ileostomy and short gut: Continued vitamin
and electrolyte repletion, loperamide, promethazine prn,
omeprazole, prednisone. Management of her fistula as above.
.
# Interstitial Lung Disease/pulmonary hypertension- Temporarily
switched her home symbicort to formulary Advair at
therapeutically equivalent dose.
.
# Rheumatoid Arthritis: No evidence of acute flare. She was
continued on prednisone and pain control. Patient receives
weekly Methotrexate injections
.
# H/O PE: Patient was continued on warfarin (see above re: A-fib
for dosing).
.
# Glaucoma: continued Brimonidine drops
.
TRANSITIONAL ISSUES
===================
1) Anti-coagulation management - INR ___ was 3.3.
Pharmacy Recommendations:
-a) hold warfarin on ___
-b) Check daily INR beginning ___.
-c) When INR is 3 or lower, restart at warfarin 2mg PO daily. Do
not wait for it to drop much lower than 3.
-d) Continue daily INR checks with dose to be adjusted by MD
until stable between ___ INR ___. Then can reduce frequency of
INR checks to every other day or longer, as per MD.
.
2)Ileostomy care
a. Please monitor daily ins/outs while at rehab facility. If she
is net negative substantially, she may need gentle IVF (NS 70
cc/hr, 1 L total) for rehydration.
b. Please monitor chem 10 as patient has required K, Mg, Ca, Ph
repletion.
c. Stoma care
STOMA:
Location: LUQ
Size/shape: ___ inch/round
Level: Flush
Color: Pink
Position of OS: Center
CONDITION OF MUCOCUTANEOUS JUNCTION:INTACT
CONDITION OF PERISTOMAL SKIN:INTACT
EFFLUENT: Loose stool
TREATMENTS/EQUIPMENT/INTERVENTION: Pouched with her own ostomy
equipment brought from home. ConvaTec convex wafer with an Adapt
seal and drainable pouch.
.
3) Fistula Care - Care same as per stoma care above. ___ need to
use larger sized pouch.
.
4) HCP ___ (daughter) home ___, cell
___. Other daughter: ___ ___
.
5) Short Gut Syndrome: Please monitor chem 10 daily through
___ as patient has required K, Mg, Ca, Ph repletion. This
should give a rough estimate of her daily electrylyte repletion
so that an acceptable oral regimen (probably daily dosing) can
be determined. We have been repleting her with PO and IV
electrolytes. Frequency of daily chem 10 dosing can be adjusted
based on this. IV was indicated because some of our formulary
were not absorbed by mouth. If ___ have liquid or crushable
Magnesium, that may be helpful in reducing IV repletion.
Patient's home medications worked for her prior to her back
fracture earlier this month.
Medications on Admission:
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
2. Calcitonin Salmon 200 UNIT NAS DAILY
3. Carbidopa-Levodopa (___) 1 TAB PO BID
4. Ibuprofen 400 mg PO Q4H:PRN Pain
5. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN Pain
6. Loperamide 2 mg PO Q4H:PRN Loose ostomy output
7. Lorazepam 1 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
hold for SBP < 100 or HR < 60
9. Omeprazole 20 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
hold for sedation, RR < 10
11. Promethazine 25 mg PO Q6H:PRN Nausea
12. PredniSONE 5 mg PO EVERY OTHER DAY
13. Sertraline 50 mg PO DAILY
14. Vitamin B Complex w/C 1 TAB PO DAILY
15. Vitamin D ___ UNIT PO DAILY
16. Acetaminophen-Caff-Butalbital 2 TAB PO Q4H:PRN headache
Do not exceed 6 tablets/day.Do not exceed 6 tablets/day. Do not
exceed > 3 grams tylenol per day
17. Azo *NF* (phenazopyridine) 95 mg Oral daily
18. Denosumab (Prolia) 60 mg SC Q6 MONTHS
19. Magnesium Oxide 400 mg PO TID
20. Methotrexate 25 mg IM QSUN
21. nystatin *NF* 100,000 unit/g Topical TID:PRN Rash
22. Nystatin Oral Suspension 5 mL PO DAILY:PRN Thrush
23. potassium gluconate *NF* 595 (99) mg Oral Daily
24. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation 2 puffs BID
25. Vitamin A 0 UNIT PO DAILY
26. Vitamin B-12 *NF* (cyanocobalamin (vitamin B-12)) 1,000 mcg
Oral once a month
1000 mcg/mL solution
27. CefePIME 2 g IV Q12H
d1 = ___
28. Fentanyl Patch 12 mcg/h TP Q72H
hold for sedation, RR < 10
Notify ___ if fever > 102 as patch may need to be removed
29. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
30. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, flush with 10 mL Normal Saline followed by
Heparin as above per lumen.
31. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
Start date: ___
End date: ___ Indication: ? sepsis from GI source
Discharge Medications:
1. Calcitonin Salmon 200 UNIT NAS DAILY Duration: 16 Days
Continue until ___ for back fracture
2. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation BID
2 puffs twice daily
3. Lidocaine 5% Patch 1 PTCH TD DAILY
4. AZO Standard *NF* (phenazopyridine) 95 mg Oral daily
5. Denosumab (Prolia) 60 mg SC Q 6 MONTHS
6. Magnesium Oxide 400 mg PO TID
7. nystatin *NF* 100,000 unit/g Topical TID:PRN rash
8. potassium gluconate *NF* 595 (99) mg Oral daily
9. Vitamin A 0 UNIT PO DAILY
10. Cyanocobalamin 1000 mcg PO Q MONTH
11. ___ MD to order daily dose PO DAILY16
To be started when INR 3 or below for goal INR ___. Acetaminophen-Caff-Butalbital 2 TAB PO Q4H:PRN headache
Do not exceed 6 tablets/day.Do not exceed 6 tablets/day. Do not
exceed > 3 grams tylenol per day
13. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
14. Carbidopa-Levodopa (___) 1 TAB PO BID
15. CefePIME 2 g IV Q12H Duration: 4 Days
Last day ___ (to complete coures from prior discharge D1
___
16. Fentanyl Patch 12 mcg/h TP Q72H
hold for sedation, RR < 10
Notify ___ if fever > 102 as patch may need to be removed
17. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
18. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, flush with 10 mL Normal Saline followed by
Heparin as above per lumen.
19. Ibuprofen 400 mg PO Q4H:PRN Pain
20. Loperamide 2 mg PO QID:PRN loose ostomy output
21. Lorazepam 1 mg PO HS
22. Lorazepam 0.5 mg PO BID:PRN anxiety
23. Methotrexate 25 mg SC 1X/WEEK (FR)
24. Metoprolol Succinate XL 50 mg PO DAILY
hold for SBP < 100 or HR < 60
25. Nystatin Oral Suspension 5 mL PO DAILY:PRN Thrush
26. Omeprazole 20 mg PO DAILY
27. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
hold for sedation, RR < 10
28. PredniSONE 5 mg PO EVERY OTHER DAY
29. Promethazine 25 mg PO Q6H:PRN Nausea
30. Sertraline 50 mg PO DAILY
31. Vitamin B Complex w/C 1 TAB PO DAILY
32. Vitamin D ___ UNIT PO DAILY
33. Calcium Carbonate Suspension 1250 mg PO TID
34. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
Continue until ___ appointment with Dr. ___
35. Miconazole Powder 2% 1 Appl TP QID:PRN Fungal Rash
36. Neutra-Phos 1 PKT PO BID
37. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
38. Azo *NF* (phenazopyridine) 95 mg Oral daily
39. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation 2 puffs BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Enterocutaneous fistula
Secondary: Crohns disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___
___ were admitted to the hospital after your known fistula
appeared to be bleeding. Colorectal Surgeons and
Gastroenterologists evaluated the fistula and thought the
fistula was stable. A CT-scan with contrast in the fistula
confirmed that there were no concerning findings. ___ can care
for it just as ___ care for your ostomy. Your blood count was
also stable.
Please review the medication changes on the attached list
carefully.
Followup Instructions:
___
|
10439781-DS-54 | 10,439,781 | 29,968,806 | DS | 54 | 2154-08-01 00:00:00 | 2154-08-01 17:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Prochlorperazine / Remicade / Demerol / Morphine /
Dilaudid / Darvocet-N 100
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
___ line placement
History of Present Illness:
___ female with history of crohns s/p colostomy placement, RA
on prednisone atrial fibrillation presenting with increasing
weakness x 1 week.
Per patient patient reports admits to poor po intake due to lack
of
appetite and lack of thirst x several weeks with associated
~20lb weight loss.
Reports mild increase in ostomy output no change in quality. No
blood or mucus in output. She also admits to urinary urgency and
frequency since ___. No dysuria. No abdominal pains. Admits
to nausea but no vomiting. Nausea is worse with exertion and
certain foods, which she avoids.
In the ED, initial VS were: 97.6 95 131/72 20 94%. Labs
significant for WBC 16.7, Hct 36.6, plats 378, (73% PMN), INR
2.0, K 5.0, Cr 1.0, lactate 2.4. U/A positive for 55 WBC, few
bacteria, 1 epi. CXR neg for PNA.
On arrival to the floor, VS 98.2, 127/64, 76, 18, 96%
RA.Overnight patient was started on CTX for + UA and flagyl was
increased to 500mg PO Q8hr for increased ostomy output.
This morning this reports continued fatigue and interest in TPN.
REVIEW OF SYSTEMS:
(-) fever, abdominal pain, visions changes, CP, new rashes, new
joint pains
Past Medical History:
-paroxysmal atrial fibrillation
-atrial tach
-ILD
-Asthma/chronic bronchitis
-Pulmonary hypertension
-diastolic heart failure
-sleep apnea
- Crohn's dx in ___, c/b pyoderma gangrenosum and recurrent
fistula tract most recently in ___
- Hip Fracture (left intertrochanteric hip fracture), s/p
nailing ___
-CVA with deficits in her right frontal lobe.
-h/o DVT in ___
-small, subsegmental PE on ___ CTA
-Rheumatoid arthritis, dx in ___
-Neuropathy
-Restless legs
-Depression/anxiety
-Recent falls
-Osteoporosis with multilevel compression fracture T11-L3
-history of dehydrationa and poor access s/p porta cath ___
Past Surgical History:
-___: Laparotomy and extensive lysis of adhesions, Excision of
abdominal wall and en bloc resection of abdominal wall and
smallintestine, Complex abdominal wall closure, Permanent
ileostomy,
Ventral hernia repair with placement of SurgiMend mesh.
-___ - VAC change and debridement
-___ - Wound opening and debridement of devitalized skin and
subcutaneous tissues; Irrigation of the wound; Debridement of
devitalized fascia and removal of some mesh and suture;
placement of VAC.
-s/p multiple abd surgeries (___) ___ procedure
and Parks reversal.
-s/p colectomy/ileostomy
Social History:
___
Family History:
Brothers and sister with heart disease. 1 sister with CABG. No
family history of IBD. Daughters healthy.
Physical Exam:
Gen: Fatigued, NAD, non-toxic appearing
HEENT: anicetric sclera, dry MMM
CV: irreg irereg, nl rate
RESP: anterior fields CTA no audible wheeze, rales
ABD: ostomy in place: dressing c/d/i, mildly distended,
non-tender to light and deep palp
EXT: WWP, no edema
Pertinent Results:
LABs
CBC Trend
___ 09:50PM BLOOD WBC-16.7*# RBC-4.52# Hgb-10.9*# Hct-36.6#
MCV-81* MCH-24.2* MCHC-29.8* RDW-18.9* Plt ___
___ 07:00AM BLOOD WBC-14.1* RBC-3.94* Hgb-9.7* Hct-32.3*
MCV-82 MCH-24.6* MCHC-30.0* RDW-18.7* Plt ___
___ 06:00AM BLOOD WBC-10.4 RBC-3.60* Hgb-8.6* Hct-29.4*
MCV-82 MCH-24.0* MCHC-29.3* RDW-19.2* Plt ___
___ 10:50AM BLOOD WBC-12.7* RBC-3.38* Hgb-8.4* Hct-28.0*
MCV-83 MCH-24.8* MCHC-30.0* RDW-19.1* Plt ___
___ 06:19AM BLOOD WBC-15.2* RBC-3.25* Hgb-7.9* Hct-26.5*
MCV-82 MCH-24.4* MCHC-29.9* RDW-19.3* Plt ___
___ 06:30AM BLOOD WBC-10.5 RBC-3.06* Hgb-7.7* Hct-25.1*
MCV-82 MCH-25.1* MCHC-30.6* RDW-19.2* Plt ___
___ 05:00AM BLOOD WBC-11.8* RBC-3.53* Hgb-8.7* Hct-28.8*
MCV-82 MCH-24.6* MCHC-30.1* RDW-19.5* Plt ___
___ 05:15AM BLOOD WBC-10.2 RBC-3.56* Hgb-8.8* Hct-28.6*
MCV-81* MCH-24.7* MCHC-30.7* RDW-19.4* Plt ___
___ 04:30AM BLOOD WBC-11.6* RBC-3.66* Hgb-9.1* Hct-29.7*
MCV-81* MCH-24.9* MCHC-30.6* RDW-20.1* Plt ___
___ 06:00AM BLOOD WBC-11.4* RBC-3.42* Hgb-8.5* Hct-27.7*
MCV-81* MCH-24.8* MCHC-30.6* RDW-20.4* Plt ___
COAGS (on admisison and discharge)
___ 09:50PM BLOOD ___ PTT-32.1 ___
___ 06:00AM BLOOD ___ PTT-31.3 ___
CHEMISTRY PANEL (on admission and discharge)
___ 09:50PM BLOOD Glucose-135* UreaN-36* Creat-1.0 Na-135
K-5.0 Cl-99 HCO3-22 AnGap-19
___ 06:00AM BLOOD Glucose-124* UreaN-19 Creat-0.6 Na-139
K-4.0 Cl-100 HCO3-31 AnGap-12
___ 07:00AM BLOOD Albumin-3.2* Calcium-8.3* Phos-3.3#
Mg-1.6
___ 06:00AM BLOOD Calcium-7.8* Phos-4.3 Mg-1.9
LFTS (on admission and discharge)
___ 07:00AM BLOOD ALT-8 AST-20 AlkPhos-89 TotBili-0.2
___ 04:30AM BLOOD ALT-4 AST-24 AlkPhos-72 TotBili-0.2
DIGOXIN LEVEL
___ 09:50PM BLOOD Digoxin-0.9
___ 10:01PM BLOOD Lactate-2.4*
LACTATE
___ 07:15AM BLOOD Lactate-2.0
CXR:
FINDINGS: Frontal and lateral views of the chest were obtained.
Left-sided
Port-A-Catheter is similar in position, terminating at the
cavoatrial/rightatrial junction. Patient has diffuse increase
in interstitial markingsbilaterally consistent with patient's
underlying history of chronicinterstitial lung disease with
likely overlying pulmonary edema improved ___, but
similar in appearance as compared to ___. No
definitefocal consolidation or pleural effusion. Multilevel
vertebroplasties are seenalong the thoracic spine, similar to
prior.
IMPRESSION: Pulmonary edema superimposed on known lung fibrosis
PICC Placement
IMPRESSION:
Uncomplicated ultrasound and fluoroscopically guided double
lumen
Preliminary ReportPICC line placement via the right brachial
venous approach. Final internal Preliminary Reportlength is
37.5cm, with the tip positioned in SVC. The line is ready to
use.
Brief Hospital Course:
Ms ___ is a ___ with history of Crohns, ostomy in
place, RA on prednisone, AF on coumadin presenting with
generalized weakness and failure to thrive.
# Weakness/Failure to Thrive. Likely multifactorial with large
component of deconditioning secondary to recent hospitalizations
as well as malabsorption in the setting of short gut syndrome.
No focal weakness to evoke neurologic cause with neuro exam
non-focal. Labs in house with +UA though contaminated Ucx so
unclear role infection may have played. Patient placed on IVF
and nutrition was consulted. Due to concern for malabsorption in
setting of short gut syndrome (electrolyte abnl, persistent
weight loss despite nutritional supplementation with ensure)
decision made to trial TPN after extensive discussion regarding
risks and benefits of TPN as well as goal of care. Family at
this time "not ready to give up". Also discussed enteral
feeding: ___ vs PEG or J tube however due to concern for
malabsorption decided that TPN would be most reliable route of
nutrition. Prior to discharge from ___ placed (as did not
want to compromise single lumen port) and patient was at goal
with feeds. Plan for TPN is to be a transient treatment with
re-evaluation of nutrition state and functional capacity after
4weeks of combination physical therapy and nutrition ___
rehab/TPN. If at that time nutrition and condition remain a
problem discussion regarding goals of care should be readdressed
(which the family is aware of)
OUTPATIENT ISSUES:
[] Readdress weakness after ___ weeks of rehab. Plan to
discontinue supplemental nutrition with TPN at time of discharge
from rehab if not earlier (goal stop date after 4 weeks of TPN:
___
[] Weekly LFTs, lipase, triglycerides while in TPN to monitor
for complications
# Chronic Diastolic Heart Failure. Stable on admisison. Patient
did experience an episode of shortness of breath in house after
several days of gentle IVF. On ___ patient noted increased work
of breathing. IVF were stopped. Patient received 10mg of IV
lasix with immediate relief on ___. She required no further
diuresis in house and is not on diuretics at baseline. FYI
baseline lung exam with bibasilar crackles in setting of
interstitial lung disease. At time of discharge patient
euvolemic. ___ TTE: Moderately dilated and mildly hypokinetic
right ventricle with at least mild tricuspid regurgitation and
mild-moderate pulmonary hypertension. Preserved left ventricular
systolic function)
OUTPATIENT ISSUES:
[] Monitor volume status; responds to 10mg IV lasix if needed
# +UA. Admission UA positive and patient with complaints of mild
dysuria. Patient received CTX x2 days; antibiotics were
discontinued when urine culture returned with mixed colonies. No
further complaints of dysuria in house.
# Atrial Fibrillation. In house rate controlled with metoprolol
and anticoagulation with coumadin. On discharge, HR ~70-80s in
AF; INR 2.4
OUTPATIENT ISSUES:
[] Follow INR weekly with goal INR ___ please check ___ and
weekly thereafter while in rehab (or per rehab schedule)
# Restless leg syndrome. Intermittently problematic and sinemet
increased from two times daily to two-three times daily.
# Chronic pain. Continued on home oxycodone with accompanied
bowel regimen
# RA. Continued on daily prednisone 5mg PO. No suspicion for
adrenal insuffiency in house.
# ILD. Patient continued home regimen of inhalers in house
# PPX: coumadin
# Contact: patient, daugther
# Access: port, PICC
# Dispo: rehab
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin A 8000 UNIT PO DAILY
2. Vitamin D ___ UNIT PO DAILY
3. Magnesium Oxide 400 mg PO BID
4. potassium phosphate, monobasic *NF* 4000 Oral QID
5. Calcium Carbonate 1000 mg PO TID
6. Omeprazole 20 mg PO DAILY
7. Carbidopa-Levodopa (___) 1 TAB PO BID
8. Lorazepam 0.5 mg PO QAM
9. Lorazepam 1 mg PO QPM
10. Sertraline 100 mg PO DAILY
11. PredniSONE 5 mg PO DAILY
12. Warfarin 5 mg PO DAILY16
13. Digoxin 0.125 mg PO DAILY
14. MetRONIDAZOLE (FLagyl) 250 mg PO TID
15. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation BID
16. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
17. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
hold for sedation or RR<10
18. Promethazine 25 mg PO Q6H:PRN nausea
19. Loperamide 2 mg PO QID:PRN diarrhea
20. Vitamin B Complex 1 CAP PO DAILY
21. cyanocobalamin (vitamin B-12) *NF* 1 ml Oral per month
22. Metoprolol Tartrate 25 mg PO BID
23. Ibuprofen 400 mg PO Q8H:PRN pain
24. Acetaminophen-Caff-Butalbital ___ TAB PO DAILY as needed for
headache
up to 4/day
25. Lidocaine 5% Patch 1 PTCH TD DAILY back pain
Discharge Medications:
1. Carbidopa-Levodopa (___) 1 TAB PO TID
2. Lorazepam 1 mg PO QPM
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Hold for sedation, RR<10
4. Warfarin 2.5 mg PO DAYS (___)
5. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
6. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
7. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
8. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
9. cyanocobalamin (vitamin B-12) *NF* 1 ml Oral per month
10. potassium phosphate, monobasic *NF* 4000 Oral QID
11. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation BID
12. Omeprazole 20 mg PO DAILY
13. Calcium Carbonate 1000 mg PO TID
14. Digoxin 0.125 mg PO DAILY
15. Loperamide 2 mg PO QID:PRN diarrhea
16. Magnesium Oxide 400 mg PO BID
17. Metoprolol Tartrate 25 mg PO BID
18. MetRONIDAZOLE (FLagyl) 250 mg PO TID
19. PredniSONE 5 mg PO DAILY
20. Sertraline 100 mg PO DAILY
21. Promethazine 25 mg PO Q6H:PRN nausea
22. Vitamin D ___ UNIT PO DAILY
23. Vitamin B Complex 1 CAP PO DAILY
24. Vitamin A 8000 UNIT PO DAILY
25. Lorazepam 0.5 mg PO QAM
26. Lorazepam 0.5 mg PO ONCE Duration: 1 Doses
27. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
28. Acetaminophen-Caff-Butalbital ___ TAB PO DAILY as needed for
headache
up to 4/day
29. Ibuprofen 400 mg PO Q8H:PRN pain
30. Lidocaine 5% Patch 1 PTCH TD DAILY back pain
31. Outpatient Lab Work
Please check weekly labs:
1. INR, while on coumadin; goal INR ___ in treatment of atrial
fibrillation
2. LFTS (AST, ALT, Total Bilirubin, Alkaline phosphatase),
lipase and triglycerides which receiving TPN
Please fax to primary care doctor; PCP: ___
___: ___
Fax: ___
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary
Crohns Disease
Secondary Disease:
Atrial Fibrillation
Restless Legs
Interstitial Lung Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms ___ it was a pleasure taking care of you.
You were admitted due to worsening weakness and fatigue. Your
infectious work-up was negative and your weakness was thought
secondary to deconditioning and malnutrition. After a thorough
discussion of risks and benefits a PICC was placed and you were
started on supplemental nutrition with TPN. The goal is too
optimize your nutrition and conditioning over the following
weeks at rehab.
While you were hospitalized your previous prescription
medications were continued and your sinemet was increased to
three times daily to treat your restless legs.
Please see your attached medication list.
Followup Instructions:
___
|
10439781-DS-55 | 10,439,781 | 26,150,789 | DS | 55 | 2154-09-06 00:00:00 | 2154-09-06 18:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Prochlorperazine / Remicade / Demerol / Morphine /
Dilaudid / Darvocet-N 100
Attending: ___.
Chief Complaint:
cough, malaise
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: This is a ___ female with history of crohns C/B short gut
syndrome s/p colostomy placement, RA on prednisone, diastolic HF
EF55%, atrial fibrillation on coumadin, restless leg syndrome
presenting with dyspnea and malaise.Discharged to rehab ___
for deconditioning and malnutrition. While at rehab she
developed a right arm cellulitis at ___ site treated with
vancomycin from ___ to ___ with improvement. Per
patient and daughter, patient had been feeling poorly over last
5 days with general sense of malaise.
CBC/diff with patient febrile to 101.7 on ___ revealed a
WBC of 17, with patient started empirically on rocephin ___
which she has been taking daily, with levoquin added ___. She
developed worsening SOB with solumedrol 40mg TID given on
___. Her symptoms did not improve, thus CXR was performed on
___ suggestive of CHF, and she was given lasix 40mg IV x 1.
While she has been on TPN, she has been having breakdown around
ostomy site. Daughter attributes this to more liquid output, but
lacks typical symptoms of crohns flare (no abdominal pain,
output non bloody, no joint pain).
Given her worsening SOB she presented to the ED.
On arrival to the ED, initial vitals were T: 97.7 BP:102/49 HR:
95 RR: 24 97% ___. Exam was notable for wheezing and
tachypnea.
CXR showed new bilateral ground-glass opacity and interstitial
thickening, predominantly radiating from the hila, thought ___
more likely represent pulmonary edema than infecton. BNP 198.
Lactate 2.8 with WBC ___ (N 87) Pt was given vanc/zosyn for
HCAP with blood, DFA performed, UA unremarkable. Dyspnea
improved after receiving prednisone 50mg and
Albuterol/ipratropium nebs.
On arrival to the floor, patients VSS with O2 97% on 2LNC.
ROS: per HPI, denies chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
-paroxysmal atrial fibrillation
-atrial tach
-ILD
-Asthma/chronic bronchitis
-Pulmonary hypertension
-diastolic heart failure
-sleep apnea
- Crohn's dx in ___, c/b pyoderma gangrenosum and recurrent
fistula tract most recently in ___
- Hip Fracture (left intertrochanteric hip fracture), s/p
nailing ___
-CVA with deficits in her right frontal lobe.
-h/o DVT in ___
-small, subsegmental PE on ___ CTA
-Rheumatoid arthritis, dx in ___
-Neuropathy
-Restless legs
-Depression/anxiety
-Recent falls
-Osteoporosis with multilevel compression fracture T11-L3
-history of dehydrationa and poor access s/p porta cath ___
Past Surgical History:
-___: Laparotomy and extensive lysis of adhesions, Excision of
abdominal wall and en bloc resection of abdominal wall and
smallintestine, Complex abdominal wall closure, Permanent
ileostomy,
Ventral hernia repair with placement of SurgiMend mesh.
-___ - VAC change and debridement
-___ - Wound opening and debridement of devitalized skin and
subcutaneous tissues; Irrigation of the wound; Debridement of
devitalized fascia and removal of some mesh and suture;
placement of VAC.
-s/p multiple abd surgeries (___) ___ procedure
and Parks reversal.
-s/p colectomy/ileostomy
Social History:
___
Family History:
Brothers and sister with heart disease. 1 sister with CABG. No
family history of IBD. Daughters healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp: 98.3 BP: 131/68 HR: 95: RR:20 O2-sat 94 % RA
Orthostatics lying to sitting (too weak to stand)
102/68 85 to 112/62 to 85
GENERAL - thin, chronically ill appearing female, comfortable,
appropriate, speaking in full sentences
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric.
DISCHARGE PHYSICAL EXAM:
GENERAL - thin, chronically ill appearing female, comfortable,
appropriate, speaking in full sentences
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric.
Pertinent Results:
ADMISSION LABS:
___ 10:26PM CK(CPK)-27*
___ 10:26PM CK-MB-2 cTropnT-<0.01
___ 10:26PM MAGNESIUM-3.6*
___ 07:52PM ___
___ 10:20AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 10:19AM LACTATE-2.8*
___ 10:10AM GLUCOSE-105* UREA N-30* CREAT-0.8 SODIUM-139
POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-30 ANION GAP-17
___ 10:10AM cTropnT-<0.01 proBNP-198
___ 10:10AM CALCIUM-8.1* PHOSPHATE-3.7 MAGNESIUM-1.8
___ 10:10AM WBC-17.4*# RBC-4.03* HGB-10.2* HCT-33.4*
MCV-83 MCH-25.4* MCHC-30.6* RDW-20.8*
___ 10:10AM NEUTS-87.0* LYMPHS-8.4* MONOS-3.9 EOS-0.2
BASOS-0.5
___ 10:10AM PLT COUNT-248
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Resistant to 500 mcg/ml
of
gentamicin. Screen predicts NO synergy with penicillins
or
vancomycin. Consult ID for treatment options.
HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml
of
streptomycin. Screen predicts NO synergy with
penicillins or
vancomycin. Consult ID for treatment options. .
SENSITIVE TO Daptomycin MIC = 1.5MCG/ML. , Sensitivity
testing
performed by Etest. BETA LACTAMASE NEGATIVE.
STAPHYLOCOCCUS EPIDERMIDIS.
Isolated from only one set in the previous five days.
Reported to and read back by ___. ___ ___
10:55AM.
Sensitivity testing per ___. ___ ___.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
also RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy. FINAL
SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
| STAPHYLOCOCCUS
EPIDERMIDIS
| |
AMPICILLIN------------ <=2 S
CLINDAMYCIN----------- <=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- 8 S
RIFAMPIN-------------- <=0.5 S
VANCOMYCIN------------ 1 S 2 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0130.
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
BLOOD CULTURES ___ TO ___ negative, final
Blood culture ___ no growth to date, pending
MICRO:
___
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Reported to and read back by ___ ___ ___ 1220PM.
POSITIVE FOR INFLUENZA A VIRAL ANTIGEN.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
___ 2:15 pm Influenza A/B by ___
Source: Nasopharyngeal swab.
**FINAL REPORT ___
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
___
AP upright and lateral chest radiographs were obtained. Known
interstitial
lung disease contributes to a bilateral perihilar interstitial
abnormality.
In addition to the chronic findings there is bilateral
ground-glass opacity
and interstitial thickening, predominantly radiating from the
hila.
Cardiomegaly remains moderate. Aortic arch calcifications are
unchanged. A
right-sided PICC line terminates in the low SVC. A left chest
Port-A-Cath
terminates in the right atrium. Vertebroplasty changes are
stable.
IMPRESSION:
New pulmonary parenchymal abnormalities on top of chronic
pulmonary fibrosis
most likely represents pulmonary edema. Infection is less
likely.
TEE ___
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). There
are simple atheroma in the aortic arch. The aortic valve
leaflets (3) are mildly thickened. No masses or vegetations are
seen on the aortic valve. There are filamentous strands on the
aortic leaflets consistent with Lambl's excresences (normal
variant). No aortic valve abscess is seen. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve. No
mitral valve abscess is seen. Mild to moderate (___) mitral
regurgitation is seen. There is no abscess of the tricuspid
valve. No vegetation/mass is seen on the pulmonic valve. There
is no pericardial effusion.
IMPRESSION: No echo evidence of endocarditis.
TTE ___
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size is normal with
low normal free wall motion. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. No valvular
pathology or pathologic flow identified.
Compared with the prior study (images reviewed) of ___,
right ventricular cavity size and free wall motion have
improved.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Brief Hospital Course:
ASSESSMENT & PLAN: ___ female with history of crohns C/B short
gut syndrome s/p colostomy placement, RA on prednisone,
diastolic HF EF55%, atrial fibrillation on coumadin, restless
leg syndrome presenting with dyspnea and malaise.
# Enterococcal Septicemia: The patient was noted to have malaise
and dyspnea on admission with a leukocytosis. Blood cultures
revealed pan sensitive enterococcal infection, with coagulase
negative staphyloccocus likely a contaminant. Infectious Disease
was consulted. The picc line she had was pulled and tip
cultured, negative for infection. It was felt however, that the
PICC was the most likely source of infection, as she had had a
cellulitis around the PICC while at rehab, treated with
vancomycin with the PICC left in place. She had a TTE and a TEE
performed that was negative for endocarditis, indicating that
this was an uncomplicated bacteremia, and her port could be left
in place.She received IV vancomycin (started ___ and
vancomycin locks (started ___ to both be completed ___.
She should have blood cultures checked 4 days after antibitiocs
completed (___) with results faxed to her PCP, Dr
___ review.
.
#Dypsnea: Complex picture with known dCHF, COPD, ILD and PHTN.
Symptoms were most c/w COPD exacerbation (improvement with
nebs/steroids) secondary to influenza (DFA positive) with some
component of pulmonary edema on CXR which may have been masking
underlying infection. She was treated with prednisone taper for
her COPD flare, and tamiflu x 3 days for influenza (outside of
usual treatment window but given that she was on steroids
infectious disease felt this was appropriate). She was retested
for the flu to prove a negative flu test so that she could have
a TEE, as the TEE staff were concerned about an infection
control risk. With the negative repeat flu test, the tamiflu was
stopped. She initially required 3L of NC support on admission,
but was comfortably on room air on discharge. She had an am
cortisol test which was normal. She was discharged on prednisone
10mg daily as it was felt that she would benefit from a higher
maintenance steroid dose than she had previously been on with
her rheumatoid arthritis. Her PCP Dr ___ determine
whether to taper her to prednisone 5mg when she follows up with
her after rehab.
.
# DCHF 55%: The patient did have some pulmonary edema on chest
xray but did not appear to be in acute flare. An Echo revealedd
EF stable at 55%, no structural change. Digoxin levels were
monitored given that she was on antibiotics and remained at non
toxic levels. She continued her metoprolol.
.
# Crohns disease: pt with hx of crohn's disease s/p total
colectomy with colostomy c/b enterocutaneous fistulas,
para-abdominal hernias s/p partial ileectomy c/b short gut
syndrome. Currently no evidence of crohns flare contributing to
symptoms, with peristomal breakdown and more likely ___
liquidity of output. She continued her flagyl 250mg TID, and the
ostomy service cared for her ostomy.
.
# Malnutrition: pt was on TPN on admission given poor absorption
in setting of short gut syndrome, chronically malnourished. She
had been intermittently supplementing TPN with p.o. The TPN PICC
line was believed to be the source of bacteremia and was thus
discontinued. A family meeting was held to determine a nutrition
plan, and it was determined that TPN would not be revisited. A
calorie count was performed by nutrition and showed taking in
well below her nutritional requirement. Per the family meeting
discussion, a doboff was placed and the patient started on tube
feeds. She can take as much oral nutrition as she can while she
has is She will follow up with Dr ___ in gastroenterology ___
discharge to assess her progress with the doboff and to
determine the next step regarding her nutrition. She received
her vitamin B12 monthly injection on ___.
.
#Atrial fibrillation: pt with hx of Afib, on coumadin, currently
anticoagulated, rate controlled with metoprolol. Continued
warfarin (4mg daily at discharge) with INR 1.9 and metoprolol.
.
#Restless leg syndrome: pt with severe RLS, with flares
precipitated by electrolyte abnormalities in the setting of
short gut syndrome, requiring electrolyte control.
She continued carbidopa-levodopa with electrolytes repleted K to
4,Mg to 2, Phos to 5.
#Back pain: continued lidocaine patch, oxycodone 10mg q6 prn
#Depression/Anxiety: continued zoloft, ativan
# RA: Increased prednisone in setting COPD flare with maintance
dose 10mg daily. No current suspicion for adrenal
insufficiency.
# ILD. continue sympbicort.
.
Transitional issues:
She will need blood cultures performed 4 days (___) after
completion of IV Vancomycin and vancomycin locks
She will need INR monitoring, goal INR ___
She will need re-evaluation of her doboff tube and nutritional
intake
She will need assessment of whether she can taper down her
prednisone down to 5mg daily.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. magnesium *NF* 500 mg Oral BID
2. potassium phosphate, monobasic *NF* 8000 MG Oral qid
3. Vitamin A 8000 IUD PO DAILY
4. Vitamin D ___ IUD PO DAILY
5. Cyanocobalamin 1000 mcg IM/SC QMONTH
___ of the month
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN as needed for wheezing
8. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation BID
9. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache
10. FoLIC Acid 1 mg PO DAILY
11. Lidocaine 5% Patch 1 PTCH TD DAILY
mid lower back
12. Lorazepam 0.5 mg PO QAM Start: In am
13. Lorazepam 1 mg PO HS insomnia
hold for sedation, RR< 12
14. Metoprolol Tartrate 50 mg PO BID
hold for BP<100, HR<60
15. MetRONIDAZOLE (FLagyl) 250 mg PO TID
16. Omeprazole 20 mg PO DAILY Start: In am
17. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN PAIN
hold for sedation, RR<12
18. Carbidopa-Levodopa (___) 1 TAB PO TID
19. Digoxin 0.125 mg PO DAILY Start: In am
20. PredniSONE 5 mg PO DAILY Start: In am
21. Sertraline 50 mg PO BID Start: In am
22. Calcium Carbonate 725 mg PO TID
Discharge Medications:
1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN as needed for wheezing
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
4. Calcium Carbonate 725 mg PO TID
5. Carbidopa-Levodopa (___) 1 TAB PO QID
6. Digoxin 0.125 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Lidocaine 5% Patch 1 PTCH TD DAILY
mid lower back
9. Lorazepam 0.5 mg PO QAM
10. Lorazepam 1 mg PO HS insomnia
hold for sedation, RR< 12
11. MetRONIDAZOLE (FLagyl) 250 mg PO TID
12. Omeprazole 20 mg PO DAILY
13. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN PAIN
hold for sedation, RR<12
14. PredniSONE 10 mg PO DAILY
15. Sertraline 50 mg PO BID
16. Vitamin A 8000 IUD PO DAILY
17. Vitamin D ___ IUD PO DAILY
18. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze
19. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB, wheeze
20. Vancomycin 750 mg IV Q 12H
21. Vancomycin-Heparin Lock 10 mg LOCK PRN not in use
Vancomycin 2 mg/mL
+ Heparin 10 units/mL
22. Cyanocobalamin 1000 mcg IM/SC QMONTH
___ of the month
23. magnesium *NF* 500 mg Oral BID
24. potassium phosphate, monobasic *NF* 8000 MG Oral qid
25. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation BID
26. Metoprolol Tartrate 50 mg PO BID
hold for BP<100, HR<60
27. Outpatient Lab Work
Please check blood cultures (one from port, one peripherally)
on ___ and fax results to Dr ___ for
discussion.
Phone: ___
Fax: ___
28. Warfarin 4 mg PO DAILY16
29. Lidocaine Viscous 2% 20 mL PO TID:PRN sore throat
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary
Enteroccocus bacteremia
influenza
failure to thrive
Secondary
Crohns Disease s/p total colectomy, end ileostomy
Short gut syndrome
COPD
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital because you had cough and
malaise. You were found to have the flu and bacteremia. You were
treated with intravenous antibiotics and for the flu you
improved. You will continue vancomycin IV and vancomycin locks
until ___. You should have blood cultures taken 4 days after
the vancomycin is finished (ie on ___ and reviewed by Dr
___. Your TPN was stopped as the PICC line had to be
removed. You had a feeding tube placed to help with your
nutrition. You can continue to eat food of any consistency you
like while you have the feeding tube in.
Followup Instructions:
___
|
10439781-DS-56 | 10,439,781 | 24,011,853 | DS | 56 | 2154-11-14 00:00:00 | 2154-11-14 16:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Prochlorperazine / Remicade / Demerol / Morphine /
Dilaudid / Darvocet-N 100
Attending: ___.
Chief Complaint:
abdominal pain, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F w/ h/o Crohn's disease c/b by fistula formation who
presents with one day of worsening lower abdominal pain that
feels similar to prior episodes when her fistula has opened and
started draining. Starting 1.5 weeks ago, she began experiencing
periodic headaches, intermittent nausea, and decreased
appetite/PO tolerance. She has had subjective fevers and her
stoma output has become much more liquidy. This mornining she
was noted to have some mental status changes when examined by
her visiting nurse, as well as increasing nausea, emesis and
tachycardia to 110s. She went to ___ where a CT showed
bowel wall thickening. The patient requested transfer to ___.
Her gastroenterologist recently decreased her suppressive
metronidazole dosing. Also per daughter pt was on methotrexate
in the past which was d/c'ed per GI as they did not feel this
medication was helping.
In the ED, initial VS were: 97.8 94 122/55 18 97% 1L NC. Labs
were significant for WBC 16.4, CRP 53.8, and lactate 2.1. CT
abd/pelvis showed a tract just to the right of the ventral
hernia with no connection with skin surface. The tract contains
air, suggesting it connects to underlying bowel but no definite
connection was seen.
The case was discussed with GI who recommended ESR, CRP, full
stool studies, continue cipro/flagyl, and will formally evaluate
patient in AM. ___ surgery was consulted who felt that
she is not a surgical candidate at this time.
VS on transfer: 88 ___ 100%. Upon arrival to the floor, pt
was comfortably lying in bed with daughter at bedside. Pt
complaining of abdominal pain as well as HA w/ photophobia.
Of note, the patient had a recent admission from ___, found
to have enterococcal septiciemia likely from her PICC line, as
she had had a cellulitis around the PICC while at rehab, treated
with vancomycin with the PICC left in place. She had a TTE and
a TEE performed that was negative for endocarditis, indicating
that this was an uncomplicated bacteremia, and her port could
be left in place.She received IV vancomycin (started ___
and
vancomycin locks (started ___ to both be completed ___.
Past Medical History:
- Crohn's dx in ___, c/b pyoderma gangrenosum and recurrent
fistula tract most recently in ___
- pAF
-atrial tach
-ILD
-Asthma/chronic bronchitis
-Pulmonary hypertension
-diastolic heart failure
-sleep apnea
- Hip Fracture (left intertrochanteric hip fracture), s/p
nailing ___
-CVA with deficits in her right frontal lobe.
-h/o DVT in ___
-small, subsegmental PE on ___ CTA
-Rheumatoid arthritis, dx in ___
-Neuropathy
-Restless legs
-Depression/anxiety
-Recent falls
-Osteoporosis with multilevel compression fracture T11-L3
-history of dehydrationa and poor access s/p porta cath ___
PSH: (per OMR)
___: Repair of parastomal hernia with graft, lysis of
adhesions, small bowel resection, panniculectomy and
abdominoplasty (Dr. ___
___: Debridement, complex repair
___: Primary right total knee arthroplasty, Primary left total
knee arthroplasty
___: Laparotomy, lysis of adhesions, and reduction of
parastomal hernia, resiting of the ileostomy in the left lower
quadrant, complex closure of the abdominal wall, maturation of
the ileostomy (Dr. ___
___: Debridement of delaminated SIS and ventral hernia repair
using Veritas
___: Wound opening and debridement of devitalized skin and
subcutaneous tissues, debridement of devitalized fascia and
removal of some mesh and suture (Dr. ___
___: T11 vertebral on-patient balloon assisted, T11 biopsy
without significant specimen
___: Laparotomy, extensive lysis of adhesions, excision of
abdominal wall and en bloc resection of abdominal wall and small
intestine for abdominal wall fistula (Dr. ___
Complex abdominal wall closure, with permanent ileostomy.
___: Wound debridement
___: L1 kyphoplasty, Radiographic guidance of intervertebral
device with evaluation
___: L2 kyphoplasty
___: Insertion of left subclavian Port-A-Cath with
fluoroscopy (Dr. ___
___: Intramedullary nailing with cephalomedullary system
Social History:
___
Family History:
Brothers and sister with heart disease. 1 sister with CABG. No
family history of inflammatory bowel disease
Physical Exam:
PHYSICAL EXAM:
VS: 98.4, 138/68, 100, 18 95% RA
GENERAL: frail appearing, lying w/ eyes closed
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: irreg rate, no MRG
ABDOMEN: hypoactive bowel sounds, soft, TTP throughout, erythema
just distal to ostomy site which appears to pt like fistula
which is about to come through skin, TTP over erythema
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake,CNs II-XII grossly intact, sensation grossly intact
throughout
DISCHARGE PHYSICAL EXAM:
VS: T98.4, BP 132/56 (SBP 108-134), HR 73, RR 22, 98%2L (wears
at night)
GENERAL: comfortable, elderly with full face, NAD
HEENT: NC/AT, PERRL at 2mm, sclerae anicteric, MMM
NECK: supple, no LAD
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored
HEART: regular rate, no MRG
ABDOMEN: +bowel sounds, soft, very mild TTP throughout, tender
erythema just distal to ostomy over the suprapubic region
resolving, liquid stool in ostomy
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: A&Ox3, pupils small and equal, subtle L side mouth
weakness
Pertinent Results:
ADMISSION LABS:
___ 07:30PM BLOOD WBC-16.4* RBC-4.54 Hgb-12.7# Hct-40.8#
MCV-90 MCH-27.9# MCHC-31.1 RDW-19.7* Plt ___
___ 07:30PM BLOOD Neuts-76* Bands-6* Lymphs-6* Monos-10
Eos-0 Baso-0 ___ Metas-2* Myelos-0
___ 07:30PM BLOOD ___ PTT-20.7* ___
___ 07:30PM BLOOD Glucose-105* UreaN-29* Creat-0.8 Na-133
K-4.6 Cl-100 HCO3-22 AnGap-16
___ 07:30PM BLOOD ESR-23*
___ 07:30PM BLOOD CRP-53.8*
___ 08:23PM BLOOD Lactate-2.1*
PERTINENT LABS:
___ 10:13AM URINE Color-Yellow Appear-Clear Sp ___
___ 10:13AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
___ 10:13AM URINE RBC-1 WBC-8* Bacteri-NONE Yeast-NONE
Epi-<1
___ 06:40AM BLOOD Digoxin-1.1
___ 06:19AM BLOOD calTIBC-280 Ferritn-116 TRF-215 Iron-41
DISCHARGE LABS:
___ 05:45AM BLOOD WBC-11.6* RBC-3.51* Hgb-10.0* Hct-31.8*
MCV-91 MCH-28.6 MCHC-31.5 RDW-20.5* Plt ___
___ 06:54AM BLOOD ___
___ 05:18AM BLOOD UreaN-12 Creat-0.7 Na-135 K-4.2 Cl-104
HCO3-28 AnGap-7*
___ 05:18AM BLOOD Phos-2.4* Mg-1.9
___ 06:57AM URINE Color-Yellow Appear-Clear Sp ___
___ 06:57AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 06:57AM URINE RBC-<1 WBC-45* Bacteri-NONE Yeast-NONE
Epi-2 TransE-1
___ 06:57AM URINE CastHy-3*
MICRO:
===============
___ 1:53 am STOOL CONSISTENCY: LOOSE Source:
Stool.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ URINE CULTURE-PENDING
___ URINE CULTURE-FINAL {YEAST}
___ Blood Culture, Routine-FINAL NEG
___ Blood Culture, Routine-FINAL NEG
IMAGING:
====================
CT abd ___
IMPRESSION:
1. An aerated tract is seen in the subcutaneous tissues just to
the right of the ventral hernia. Direct connection to overlying
skin and nearby adherent small bowel is not explicitly shown and
thre is no contrast extrasvasation from small bowel. This
suggests however fistulization between the small bowel and
subcutaneous tissue, and possibly the overlying skin. Although
soft tissue thickening along the tract is prominent and briskly
enhancing, suggesting inflammation, the bowel itself shows
little if any inflammatory change aside from the point of direct
contact with the subcutaneous abnormality.
2. Low density material in the left greater saphenous vein as it
enters the common femoral vein. Further evaluation with
ultrasound is recommended to exclude thrombus.
CXR ___
FINDINGS: A Port-A-Cath terminates in the upper right atrium.
The cardiac, mediastinal and hilar contours appear unchanged.
Fine reticulation associated with pulmonary fibrosis appears
very similar within each lung in extent and distribution with no
significant superimposed change. The lung volumes are low.
There is no pleural effusion or pneumothorax. Multiple
compression deformities including lower thoracic
vertebroplasties appear unchanged. IMPRESSION: No evidence of
acute disease. Severe pulmonary fibrosis, not
significantly changed
CTA head and neck ___
1. The distal M1 and proximal M2 segments of the right middle
cerebral artery are not well visualized similar to prior MRA in
the distribution of previous infarct. Further evaluation with
MRI is recommended in order to differentiate acute from chronic
changes.
2. 50% stenosis of the proximal internal carotid artery at the
carotid
bifurcation.
3. Moderate biapical centrilobular emphysema with fibrotic
changes and
traction bronchiectasis.
MR HEAD ___
FINDINGS:There is no evidence for acute ischemia or
hydrocephalus. There is an old right MCA infarction, which
appears to have progressed in extent
compared to ___ suggesting interval ischemia. There are
mild small vessel ischemic changes in the white matter.
Intracranial flow voids are maintained. IMPRESSION:
Motion-degraded study. No evidence for acute ischemia is noted.
Old right MCA infarction.
___ Bilat lower extremity ultrasound
IMPRESSION:
1. New occlusive clot in the left superficial femoral vein.
Small non-occlusive clot is seen in the left popliteal vein,
similar to prior ultrasound, age indeterminant.
2. Nearly occlusive clot extending from the right common femoral
vein to the right superficial femoral vein and small
non-occlusive clot in the right popliteal vein are similar to
prior study, age indeterminant.
EKG ___ 2am
Resting sinus tachycardia with frequent isolated ventricular
premature beats. Left atrial abnormality. Borderline left axis
deviation. Diffuse non-specific ST-T wave changes which could be
due to ischemia, left ventricular hypertrophy, etc. Compared to
the previous tracing of ___ voltage criteria for left
ventricular hypertrophy are no seen. The heart rate is faster.
Ventricular ectopy is now seen. ST-T wave changes which could
due to ischemia are now seen. Voltage criteria for left
ventricular hypertrophy are not met in lead aVL. Clinical
correlation is suggested.
EKG ___ 10am
Sinus rhythm at 80bpm with all ST changes resolved, stable TWI
in III
Brief Hospital Course:
___ yo woman with history of Crohn's disease, afib on coumadin,
remote right frontal CVA, CHF, interstitial lung disease, who
presents with one day of worsening lower abdominal pain,
tachycardia, fever, and lethargy likely secondary to Crohn's
flare.
# Crohn's disease: Long standing crohn's refractory to medical
and surgical treatment. Pt has had fistulas in past also
multiple bowel resections with now short gut. Presented with
abdominal pain, nausea, vomiting, tachycardia and elevated
inflammatory markers with CT abdomen showing impending
enterocutaneous fistualization in the right lower quadrant.
Colorectal surgery evaluated her in the ED and deemed patient to
not be surgical candidate. Also pt was on antibiotic
suppression with metronidazole which was recently decreased. GI
was consulted, diet was advanced as tolerated (did not use TPN
given history of recent line infections. Treated with
metronidazole and ciprofloxacin to be continued at least until
GI appointment, continued 10mg PO BID prednisone, started PCP
prophylaxis with SS bactrim daily. Continued oxycodone for pain.
# EKG changes: Atrial tachycardia and ST and T-wave changes on
EKG on night of admission concerning for ischemia, resolved with
500cc bolus and HR down to ___. Troponins negative. Did not
recur, no chest pain.
# Left sided weakness: most likely related to old R MCA infarct,
symptoms worse when waking patient from sleep, nearly resolved
over the course of a day. She was evaluated by the stroke
consult team and CTA head and neck and MR head did not show any
new lesion. Still with minimal L sided face, arm and leg
weakness.
# Urinary frequency: most likely from IBD flare. UA showed no
infection, culture negative. Foley placed for comfort and
removed the following day. UA was sent overnight on the day
prior to discharge for same complaint, showed leuks again, sent
for culture but no antibiotics started. Medical team will follow
up culture and notify rehab if positive for infection.
# Toxic metabolic encephalopathy (acute): from crohns flare.
Resolved quickly with IVF and antibiotics.
# Atrial fibrillation/atrial tachycarida: In sinus rhythm and
with sinus tachycardia this admission, no afib captured. INR was
subtherapeutic on admission and then mised two doses, so was
bridged with heparin and then with enoxaparain given CHADS2
score of 4 (age, CHF, stroke). Continued metoprolol and digoxin.
# History of DVT/PE: back in ___ had bilateral lower extremity
DVTs, has been on warfarin but was noted to be subtherapeutic
when admitted. US obtained of bilateral lower extremities as CT
abdomen on admission incidentally was suspicious for clot.
Radiology felt clots were similar to prior, with some extension.
Discussed findings with daughter and patient, agree to keep
treating with anticoagulation. Discussed risks/benefits of CTPA,
IVC filter if she appears to be clotting while therapeutic, and
both ___ and ___ feel that she would like to avoid
procedures or imaging that would have potential detrimental
effect on her quality of life right now, though patient still
wishes to be full code.
# Migraine headaches: headaches with photophobia patient says
feel like her usual migraines, treated with fiorecet, zofran,
acetaminophen.
# Interstitial lung disease: wears 2L nasal canula at night.
Intermittently tachypneic during the day but comfortable and not
hypoxic. Continued albuterol, symbicort replaced with advair
while admitted as symbicort unavailable.
# GERD: continued omeprazole
# Restless Legs: continued sinemet, oxycodone, ativan, ibuprofen
# Depression / Anxiety: continued sertraline and ativan prn
TRANSITIONAL ISSUES:
- Polypharmacy: patient very resistant to medication changes
- Residual mild left sided facial, arm, and leg weakness
- Heparin dependent portacath in place
- Code status: Full; HCP is daughter ___
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin A 8000 UNIT PO DAILY
2. Vitamin D ___ UNIT PO DAILY
3. Magnesium Oxide 250 mg PO BID
4. Calcium Carbonate 750 mg PO TID
5. FoLIC Acid 1 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Carbidopa-Levodopa (___) 1 TAB PO TID
8. Lorazepam 1 mg PO HS:PRN insomnia
hold for sedation or RR <10
9. Sertraline 100 mg PO DAILY
10. PredniSONE 10 mg PO BID
11. Warfarin 4 mg PO DAILY16
12. Metoprolol Tartrate 50 mg PO BID
hold for sbp <100 or HR < 60
13. Digoxin 0.125 mg PO DAILY
14. Albuterol Inhaler 2 PUFF IH UNDEFINED
15. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
16. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
hold for sedation or RR <10
17. Promethazine 25 mg PO Q6H:PRN nausea
18. Vitamin B Complex 1 CAP PO DAILY
Vitamin B complex with B12
19. potassium phosphate, monobasic *NF* 1000 mg Oral QID
20. Azo *NF* (phenazopyridine) 95 mg Oral daily
21. MetRONIDAZOLE (FLagyl) 250 mg PO UNDEFINED
DAILY
22. Dronabinol 2.5 mg PO BID
23. Denosumab (Prolia) 60 mg SC TWICE A YEAR
___. Ibuprofen 400 mg PO Q8H:PRN pain
25. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache
26. Loperamide 2 mg PO UNDEFINED high stoma output
27. Protopic *NF* (tacrolimus) 0.1 % Topical DAILY:PRN unknown
28. Lidocaine 5% Patch 1 PTCH TD UNDEFINED pain
DAILY:PRN
29. nystatin *NF* 100,000 unit/g Topical QID:PRN stoma
irritation
30. Nystatin Oral Suspension 5 mL PO QID:PRN mouth sores
31. Cyanocobalamin 1000 mcg IM/SC Q1MO
on the ___ of every month
Discharge Medications:
1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB or wheeze
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
4. Calcium Carbonate 750 mg PO TID
5. Carbidopa-Levodopa (___) 1 TAB PO TID
6. Cyanocobalamin 1000 mcg IM/SC Q1MO
on the ___ of each month
7. Digoxin 0.125 mg PO DAILY
8. Dronabinol 2.5 mg PO BID
before lunch and dinner
9. FoLIC Acid 1 mg PO DAILY
10. Ibuprofen 400 mg PO Q8H:PRN pain
11. Lorazepam 1 mg PO HS:PRN insomnia
12. Magnesium Oxide 250 mg PO BID
13. Metoprolol Tartrate 50 mg PO BID
14. Omeprazole 20 mg PO DAILY
15. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
RX *oxycodone 10 mg 1 tablet(s) by mouth every 4 (four) hours
Disp #*90 Tablet Refills:*0
16. PredniSONE 10 mg PO BID
17. Promethazine 25 mg PO Q6H:PRN nausea
18. Vitamin D ___ UNIT PO DAILY
19. Sertraline 100 mg PO DAILY
20. Azo *NF* (phenazopyridine) 95 mg Oral daily
21. Denosumab (Prolia) 60 mg SC TWICE A YEAR
___. Lidocaine 5% Patch 1 PTCH TD DAILY back pain
23. Loperamide 2 mg PO UNDEFINED high stoma output
24. nystatin *NF* 100,000 unit/g Topical QID:PRN stoma
irritation
25. Nystatin Oral Suspension 5 mL PO QID:PRN mouth sores
26. potassium phosphate, monobasic *NF* 1000 mg Oral QID
27. Protopic *NF* (tacrolimus) 0.1 % Topical DAILY:PRN unknown
28. Vitamin A 8000 UNIT PO DAILY
29. Vitamin B Complex 1 CAP PO DAILY
30. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
31. Warfarin 2 mg PO DAILY16
32. Ciprofloxacin HCl 500 mg PO Q12H
33. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: crohn's disease flare
Secondary: atrial fibrillation, migraine headaches, restless leg
syndrome, left-sided weakness from remote stroke, interstitial
lung disease, chronic deep venous thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___ were admitted with confusion, fast heart rate, and abdominal
pain and were found to have a flare of your Crohn's disease. ___
were seen by the GI doctors who recommended ___ and
continuation of your prednisone. Your pain and appetite improved
and ___ were able to leave the hospital. If the reddened area on
your abdomen opens into a fistula, ___ will need to place an
ostomy bag at the site, as ___ have done in the past. However,
that area appeared improved at the time of discharge. ___ should
continue to take Cipro and Flagyl until ___ see Dr. ___. We
also added bactrim to prevent infections of the lung while on
prednisone.
While ___ were here ___ were found to have left-sided weakness
in your face, arm, and leg, and were evaluated by our
neurologists and with a CT and an MRI of your head, which only
showed your old stroke, and no new stroke.
___ are being discharged to a rehabilitation center to increase
your strength.
Followup Instructions:
___
|
10439790-DS-16 | 10,439,790 | 25,136,652 | DS | 16 | 2168-10-20 00:00:00 | 2168-10-20 12:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
promethazine
Attending: ___.
Chief Complaint:
Right Ankle injury
Major Surgical or Invasive Procedure:
Open reduction and internal fixation of right ankle fracture
History of Present Illness:
___ year old woman who was walking down a set of stairs this
morning when she tripped and fell landing onto her right leg.
She did not strike her head or incur any further injuries. She
was taken by ambulance to ___ where X-Rays were
performed and she was found to have a bimalleolar ankle fracture
dislocation. She was subsequently transported to ___ for
further management.
Past Medical History:
Asthma
Hypercholesterolemia
Pituitary Tumor (benign)
Social History:
___
Family History:
Non contributory
Physical Exam:
T-98.3 HR-60 BP-158/83 RR-17 SaO2-100% RA
A&O x 3
Calm and comfortable
BUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearms are soft
No pain with passive motion
R M U ___
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
RLE skin clean and intact
Marked tenderness deformity and edema appreciated about the
ankle
Thighs and legs are soft
No pain with passive motion
Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire
1+ ___ and DP pulses
Pertinent Results:
___ 07:10PM GLUCOSE-156* UREA N-9 CREAT-0.7 SODIUM-138
POTASSIUM-3.3 CHLORIDE-106 TOTAL CO2-21* ANION GAP-14
___ 07:10PM estGFR-Using this
___ 07:10PM WBC-13.0* RBC-3.99* HGB-11.8* HCT-36.5 MCV-92
MCH-29.5 MCHC-32.3 RDW-15.7*
___ 07:10PM NEUTS-84.2* LYMPHS-13.1* MONOS-2.2 EOS-0.2
BASOS-0.4
___ 07:10PM PLT COUNT-254
___ 07:10PM ___ PTT-27.3 ___
Brief Hospital Course:
The patient was admitted to the Orthopaedic Trauma Service for
repair of a right ankle fracture. The patient was taken to the
OR and underwent an uncomplicated open reduction and internal
fixation. The patient tolerated the procedure without
complications and was transferred to the PACU in stable
condition. Please see operative report for details. Post
operatively pain was controlled with a PCA with a transition to
PO pain meds once tolerating POs. The patient tolerated diet
advancement without difficulty and made steady progress with ___.
Weight bearing status:
Non weight bearing right lower extremity
The patient received ___ antibiotics as well as
Lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis (Aspirin) for 4 weeks post-operatively. All
questions were answered prior to discharge and the patient
expressed readiness for discharge.
Medications on Admission:
Zetia
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for Pain: Do not drink alcohol or drive whil on this
medication.
Disp:*100 Tablet(s)* Refills:*0*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
3. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
___ MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
6. aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 weeks.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right ankle fx s/p ORIF
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:
******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: Please stay in post-operative splint. You may not
get this wet. Can shower, but please keep splint dry. You can
use a plastic bag to cover leg. 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 continued to be non-draining.
******WEIGHT-BEARING*******
Non weight bearing right lower extremity
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Aspirin 325 mg for DVT prophylaxis for 4 weeks
post-operatively.
Followup Instructions:
___
|
10440321-DS-21 | 10,440,321 | 24,398,799 | DS | 21 | 2183-07-02 00:00:00 | 2183-07-05 09:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left sided tingling and weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old man with no medical history who
presents with right lower extremity and right hand parasthesias
and weakness. One week ago, patient was sitting in the
bathroom, sat up, and suddenly felt pain in his left back. He
was evaluated and diagnosed with lumbar spasm. He was
prescribed tizanidine and perocet which somewhat relieved his
symptoms. He does continue to have some "tightness" in his back
with walking around. On ___ morning around 11am, Mr. ___
developed parasthesias in his left lower extremity in a diffuse
pattern and also in his left hand, palmar and dorsal aspect, not
past the wrist. It felt like pins and needles, initially was
mild, but then became more severe and constant. It is worse
when he puts pressure on his leg or hand (aka, walks around).
Yesterday, noted that he had a brief bifrontal headache which
was mild, made him feel "foggy," but resolved with Ibuprofen.
Today, around noon, when he went to move his car, he noticed
that he had some difficulty pressing on the gas pedal with his
left foot. Denies urinary urgency, fecal incontinence, saddle
anaesthesia. No numbness or pain in left leg/hand. Denies any
recent trauma. Does regularly lift heavy objects as he delivers
bread for a living. His right arm/leg are unaffected. Lives in a
rural area, no recent tick bites that he is aware of, no recent
infectious symptoms, no exotic travel.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal numbness. 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:
none
Social History:
___
Family History:
Father-myocardial infarction
No history of strokes, seizures, autoimmune disorders, blood
clots
Physical Exam:
Physical Exam:
Vitals: T 98.6 HR 68 BP 120/80 RR 16 O2 98 RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
GU: rectal done normal, no perianal anaesthesia
Back: tender to palpation at L2 paraspinal region
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. 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. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 4+ 5 4+ 4+ 4+ 4+
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout. No extinction to DSS. (No numbness in
LLE or left hand, just "feels funny" as it exacerbates the
parasthesias to have sensation tested)
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was mute 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. Romberg absent.
Discharge exam:
Strength improved to ___ throughout upper and lower extremities
bilaterally.
Pertinent Results:
___ 02:40AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 10:00PM GLUCOSE-146* UREA N-15 CREAT-1.0 SODIUM-140
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16
___ 10:00PM estGFR-Using this
___ 10:00PM CRP-0.4
___ 10:00PM WBC-8.5 RBC-5.00 HGB-15.4 HCT-42.9 MCV-86
MCH-30.8 MCHC-35.9* RDW-12.2
___ 10:00PM NEUTS-88.2* LYMPHS-10.6* MONOS-0.7* EOS-0.2
BASOS-0.4
___ 10:00PM PLT COUNT-257
___ 10:00PM SED RATE-2
Imaging:
TECHNIQUE: Multi sequence, multiplanar brain MRI is obtained
pre- and post
intravenous administration of 7 cc of data breast contrast. The
following
sequences were utilized: Sagittal T1, axial T1 FLAIR, axial T2
star GRE,
axial FLAIR, axial T2, sagittal MPRAGE post, axial T1 FLAIR
post, and axial T1
post.
COMPARISON: No prior studies available for comparison.
FINDINGS:
The gray-white matter differentiation is normal. There is no
hemorrhage,
mass, hydrocephalus or acute infarct.
There is no abnormal enhancement. The intracranial flow voids
are normal.
There is a right maxillary retention cyst.
IMPRESSION:
There is no infarct or mass.
Right maxillary retention cyst.
TECHNIQUE: Total spine MRI is obtained utilizing the following
sequences
sagittal T2, sagittal STIR, sagittal T1, and axial T2.
COMPARISON: There are no prior studies available for
comparison.
FINDINGS:
The vertebral body heights and disc spaces are maintained. The
bone marrow
and cord signal is grossly normal. However due to mild motion
artifact small
cord signal abnormalites cannot be excluded.
There is mild multilevel degenerative disc disease.
At the C6-7 level, there is righ lateral disc bulge with minimal
canal and
right foraminal stenosis.
There is disc bulge at the T4-5 level with minimal canal
stenosis. The
foramina are unremarkable at this level.
Lumbar spine is unremarkable without significant canal or
foraminal stenosis.
IMPRESSION:
Mild degenerative disc disease as described above without
significant canal or
foraminal stenosis.
No gross cord signal abnormality. However due to mild motion
artifact small
cord signal abnormalities cannot be completely excluded.
Brief Hospital Course:
Admitted to the general neurology service. MRI of the C, T and L
spine as well as MRI of the brain were unrevealing. Tingling of
extremities remained consistent, but weakness improved to normal
the morning after admission. The patient was offered lumbar
puncture for further diagnostic evaluation, but he declined.
Plan was formulated to follow up in neurology clinic to reasess
progress at that time. Patient instructed to return to ED or
call if symptoms worsen.
Medications on Admission:
Tizanidine
Perocent
Ibuprofen
Discharge Medications:
1. Tizanidine 4 mg PO TID PRN pain
2. Ibuprofen 400 mg PO Q8H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Left leg weakness and left sided tingling
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 left leg weakness and left
leg and arm tingling. An MRI of your brain and spine did not
reveal a cause of your symptoms. You were given the option of
lumbar puncture for further work up or discharge to home with
planned follow up in clinic. You chose to go home and wait to
see if the symptoms improve.
No changes were made to your medications.
If your weakness returns or you experience any of the warning
signs below please return to the emergency department.
It was a pleasure taking care of you during this hospital stay.
Followup Instructions:
___
|
10440425-DS-6 | 10,440,425 | 29,361,894 | DS | 6 | 2147-03-23 00:00:00 | 2147-03-24 17:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Visual disturbances in left upper quadrant of vision
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old man who presented to the
hospital
after having increasing frequency of visual events over the past
several weeks. He states that he has noticed that he has been
having increased visual phenomenon that he describes as
kaleidoscopes in his left upper vision. These occur
approximately
___ times per day and he says they last approximately 15
seconds. He sees a kaleidoscope of colors in his left upper
visual field in both eyes (closing either eye does not resolve
visual phenomenon). He says that this has been increasing in
frequency in the past few weeks. On the day of presentation he
also described a headache on the right side of his head near his
eye that feels dull. He says he often gets a dull headache on
that side that is ___ in severity but today he felt it was
___.
In terms of the visual phenomenon, he has had these in the past
and was seen by ___. Following a liver transplant in
___ he had a right temporo-occipital intraparenchymal
hemorrhage
and then developed these visual phenomenon similar in semiology.
He was treated for around ___ year on Dilantin therapy and then
tapered in ___ to intermittent lorazepam to control visual
hallucinations. He was relatively quiescent for several years,
but then over the past few weeks has had an increased frequency
of these events.
He describes no sleep deficits. No infectious symptoms or sick
contacts. No recent changes in medications or diet. He describes
himself as a relatively stress-free person who is happy.
On neuro ROS, the pt denies diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. Denies focal
weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt 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:
- ___ - right occipitotemporal intraparenchymal hemorrhage
following liver transplant
- ? of seizure disorder - noted as kaleidoscope vision of the
left superior quadrant - as described by ___. Prior
treatments with dilantin and keppra
- h/o HCV+EtOH cirrhosis --> OLT @OSH in ___
- orchiectomy as a child
- lung surgery in ___
- mild HTN on ACE (pt thinks his BP has been higher recently,
and this may be the reason for his increased vis halluc.)
- h/o EtOHism and withdrawal seizures, previously on PHT x ___
for that, remote (quit ___ ago)
Social History:
___
Family History:
mother is living at age ___, his father is deceased, he has two
sisters aged ___ and ___, and one brother aged ___. He has a
___ son, ___, and a son who is deceased.
Physical Exam:
Physical Examination on Admission:
Vitals: 99 82 149/83 18 97% r
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. 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. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. left upper quadrant homonymous
quadrantanopia. Funduscopic exam revealed no papilledema,
exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
Admission Labs:
___ 10:45PM BLOOD WBC-4.3 RBC-4.98 Hgb-16.2 Hct-46.0 MCV-92
MCH-32.5* MCHC-35.2* RDW-12.3 Plt ___
___ 10:45PM BLOOD Neuts-71.9* ___ Monos-7.8 Eos-1.1
Baso-0.2
___ 10:45PM BLOOD Glucose-99 UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-25 AnGap-13
___ 05:40AM BLOOD ALT-70* AST-39 LD(LDH)-171 AlkPhos-86
Amylase-61 TotBili-1.2
___ 05:40AM BLOOD Albumin-4.2 Calcium-8.9 Phos-3.3 Mg-1.9
___ 05:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-6*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 12:00AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:00AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Reports:
MRI/MRA head: 1. No acute intracranial abnormality. Chronic
blood products with volume
loss in the right parietal periventricular white matter as
described above. No abnormal enhancement is identified.
Unremarkable MRA of the head.
Liver U/S: 1. Mildly coarsened hepatic architecture with no
focal liver lesion identified. Note is made that this is a right
lobe liver transplant from a living donor. Patent hepatic
vasculature.
EEG ___ and ___: Formal reports pending at the time of
this discharge summary
Brief Hospital Course:
Mr. ___ was admitted to the Neurology wards of the ___
___ for the increasing frequency of
what he described as a kaleidoscopic sensation of colors and
forms in the left upper part of his visual field. These had
occurred in the past and were presumed to be a consequence of a
right occipital intraparenchymal CNS hemorrhage that he
sustained at the time of his liver transplant. They had required
management with AEDs in the past, and had previously also
included some motor involvement of his left arm and leg.
However, over the past several years, the frequency of these
events had improved significantly, such that they would only
occur every several weeks or so. At the time of the ED
presentation, he reported that his visual disturbances could
occur virtually continuously throughout the day, and would at
times be replaced by a sensation of opaque plexiglass in the
left upper visual quadrant. His admission physical examination
is listed above.
There were no major abnormalities noted on his routine
laboratory analysis. He was admitted and was connected to
continuous EEG monitoring which revealed the presence of focal
loss of the alpha rhythm and focal slowing in the right
occipital region, as well as numerous focal seizures from the
right occipital region, spreading to involve most of the right
posterior quadrant. In conjunction with his primary
hepatologist and the transplant team, the decision was made to
initiate therapy with VIMPAT or lacosamide (he had previously
had an adverse mood reaction to keppra, and dilantin has
problematic interactions with cyclosporine). After an
intravenous loading dose of VIMPAT, the frequency of both
clinical and electrographic changes improved significantly. He
was started on a dose of 100mg BID, and instructed to uptitrate
to 150mg BID in ___ days and follow up with Dr. ___
and Dr. ___.
His discharge physical examination was unchanged from prior. He
did complain of some mild right sided tension headaches during
this admission which responded nicely to tylenol. There were no
other medication changes. He received his routinely scheduled
q6month liver ultrasound as an inpatient, which revealed no
focal structural abnormalities in the transplanted liver.
Medications on Admission:
Celexa 20 mg daily
Cyclosporin 75 mg BID
Lisinopril 2.5 mg daily
Cellcept 500 mg BID
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
3. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. cyclosporine modified 25 mg Capsule Sig: Three (3) Capsule PO
Q12H (every 12 hours).
5. lacosamide 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day): Increase to three tablets BID in ___ days if tolerated. .
Disp:*200 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure disorder
History of intraparenchymal hemorrhage in CNS
S/p liver transplant
Hepatitis C infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Neurological Examination: No asterixis or nystagmus,
homonymous quadrantanopia of the left upper quadrant.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during this
hospitalization. You were admitted to the Neurology Wards of the
___ for the increased frequency
of visual kaleidoscopic phenomena that you had been experiencing
over the past two weeks. With the help of physical examinations,
laboratory studies, neuroimaging testing as well as
electroencephalographic (EEG) monitoring, we were able to show
that you were experiencing seizures in your brain, in the region
where you previously experienced hemorrhage. The frequency of
these events improved significantly after we started you on a
medication called VIMPAT or LACOSAMIDE, which is a relatively
new antiepileptic medication. You were started on a dose of
100mg twice daily. We also noted that your blood pressures were
a little on the higher side. Do not adjust your antihypertensive
medications before first consulting with your liver specialists
and your PCP.
- Please take all of your medications as prescribed below. We
made no changes to your medications, except for adding VIMPAT.
- We performed your regularly scheduled liver ultrasound test
during this hospitalization, and it did not identify any
unexpected abnormalities.
- Your brain MRI also did not show any new changes that could
explain worsening seizures.
- If you are able to tolerate this dose of VIMPAT, please
increase to 150mg of VIMPAT twice daily in three-four days.
Remain on this dose until your follow up appointment with Dr.
___.
- Please come to your nearest ER should you experience any of
the below listed concerning or unexplained symptoms.
- Please be sure to contact us if you have any further
questions, and do make your follow up appointments as listed
below.
Followup Instructions:
___
|
10440477-DS-17 | 10,440,477 | 25,073,935 | DS | 17 | 2170-05-15 00:00:00 | 2170-05-15 15:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Trauma: MVC
Left4,5,7 rib fracture
right 5,6 rib fracture
right acetabulum fracture
Inferior sternal fracture
Major Surgical or Invasive Procedure:
___ ORIF right hip
History of Present Illness:
This patient is a ___ year old male who complains of MVC.
Transfer from ___, sternal fx, multiple rib fx,
r acetabular fx, s/p mvc ___ unrestrained driver,+loc, +
etoh (259), r elbow lac not sutured at this time, arrives
with ct(chest/abd/pelvis).
This patient was transferred from outside hospital after a
motor vehicle crash earlier this morning where he was the
unrestrained driver had lost consciousness and was
significantly intoxicated; at the outside hospital he had an
extensive radiographic evaluation including a CT of his
head/C-spine/torso, this revealed fractures involving his
sternum, his ribs 5 and 6 on the right and ribs 4567 on the
left, he also had fractures of the right acetabulum;
Timing: Sudden Onset
Quality: Sharp
Severity: Moderate
Duration: Hours
Past Medical History:
angioplasty, stent, gastritis, gi disease, CAD, HTN
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Temp: 98.8 HR: 106 BP: 104/67 Resp: 20 O(2)Sat: 98
Constitutional: Somnolent but arousable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
Normal
Chest: Breath sounds heard bilaterally, bilateral
tenderness to palpation
Cardiovascular: Tachycardic
Abdominal: Soft, obese, tender to palpation
Pelvic: Pelvis is stable to anterior compression
GU/Flank: Normal
Extr/Back: Normal
Skin: No ecchymoses noted
Neuro: Moving all extremities equally
Physical exmination upon discharge: ___:
vital signs: 98.7, 106/63, hr=108, rr=18 oxygen saturation 99%
___: NAD
CV: ns1, s2, -s3, -s4
LUNGS: clear
ABDOMEN: soft, non-tender
EXT: + dp bil., no pedal edema bil., staples to right hip with
DSD, sutures to laceration right arm
NEURO: alert and oriented via ___ interpreter
Pertinent Results:
___ 01:00PM BLOOD WBC-9.1 RBC-2.73* Hgb-7.8* Hct-23.4*
MCV-86 MCH-28.4 MCHC-33.1 RDW-12.9 Plt ___
___ 07:10AM BLOOD WBC-8.7 RBC-2.52* Hgb-7.4* Hct-21.8*
MCV-86 MCH-29.2 MCHC-33.8 RDW-13.0 Plt ___
___ 01:50PM BLOOD WBC-13.5* RBC-4.93 Hgb-14.2 Hct-42.1
MCV-85 MCH-28.8 MCHC-33.7 RDW-12.5 Plt ___
___ 01:50PM BLOOD Neuts-84.4* Lymphs-11.0* Monos-4.2
Eos-0.2 Baso-0.3
___ 01:00PM BLOOD Plt ___
___ 12:54AM BLOOD ___ PTT-33.7 ___
___ 07:10AM BLOOD Glucose-129* UreaN-9 Creat-1.0 Na-139
K-3.9 Cl-104 HCO3-27 AnGap-12
___ 01:24AM BLOOD CK(CPK)-1653*
___ 05:40PM BLOOD CK(CPK)-1683*
___ 10:20AM BLOOD CK(CPK)-1809*
___ 01:51AM BLOOD CK(CPK)-831* Amylase-32
___ 01:51AM BLOOD Lipase-19
___ 01:24AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:40PM BLOOD CK-MB-2 cTropnT-<0.01
___ 10:20AM BLOOD CK-MB-3 cTropnT-<0.01
___ 12:54AM BLOOD cTropnT-<0.01
___ 08:45AM BLOOD Calcium-7.6* Phos-2.0* Mg-1.9
___ 01:50PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:28PM BLOOD Glucose-129* Lactate-2.1* Na-134 K-3.7
Cl-101
___: chest x-ray:
Limited study given low lung volumes. Interval placement of a
left chest tube which appears to terminate in the mid left lung.
No ptx.
___: x-ray of the pelvis;
Fracture involving the posterior wall of the right acetabulum.
___: lower ext.fluro:
Fluoroscopic views of the right hip were obtained in the OR
without the
presence of a radiologist for documentation of ORIF of the right
acetabulum, placement of plate and screws. Please refer to the
OR note for more detailed description of the procedure.
___: chest x-ray:
The heart size and mediastinum appear to be unchanged. Left
chest tube is in place. There is no pneumothorax. Lung volumes
continue to be low. There is mild vascular engorgement but no
overt pulmonary edema. Bibasal areas of atelectasis are
re-demonstrated
___: CTA chest:
IMPRESSION:
1. No PE detected.
2. Transverse sternal fracture.
3. Small left pneumothorax.
4. Left-sided chest tube terminates in the upper mediastinal
fat, apparently contacting the left internal mammary artery and
vein. Recommend withdrawing approximately 5 cm.
5. Small bilateral pleural effusions, left greater than right
with adjacent atelectasis. More dense consolidation in the left
lower lobe posteriorly with air bronchograms. Infection cannot
be excluded.
___: chest x-ray:
AP and lateral radiographs of the chest demonstrate bilateral
pleural
effusions, at least moderate. No definitive pneumothorax is
seen.
Cardio-mediastinal silhouette is stable. The lung volumes
continue to be very low.
___: chest x-ray:
Continued low lung volumes with no acute pneumonia or
pneumothorax.
Brief Hospital Course:
The patient was admitted to the hospital after a MVC. He
reportedly sustained a loss of consciousness. He was initially
transported to an outside hospital where he underwent imaging
of his head, neck, and torso. He was reported to have bilateral
rib fractures, a sternal fracture, and a right acetabulum
fracture. He was also reported to have acute alcohol
intoxication. Upon arrival to the emergency room he was
hypotensive and had an oxygen desaturation to 88%. On chest
x-ray, he was reported to have a white out of the left lung and
he had a chest tube was placed. After placement of the chest
tube, his hemodynamic status stabilzed. Because of his injuries,
the Orthopedic service was consulted.
The patient was taken to the operating room on HD #2 where he
underwent an open reduction internal fixation of a right
acetabular fracture (posterior wall). His operative course was
stable with a 2500cc blood loss. He was extubated after the
procedure and monitored in the recovery room. He required
additional intravenous fluids and 1 unit packed red blood cells.
His hematocrit has stabilized at 22.7 and he has remainded
hemodynamically stable. He was started on a 1 week course of
levofloxacin for a urinary tract infection. On HD #3, the
patient reported chest discomfort, later reported to be sternal
discomfort. An EKG was done and he was reported to have new
inferior q wave's. His troponins, CK/MB were cycled and were
reported as normal. His repeat EKG showed resolving q waves.
His rib pain has controlled with intravenous analgesia, and he
was later converted to an oral agent.
He was evaluated by occupational and physical therapy with
recommendations for discharge to a rehabilitation facility. The
patient was seen by the social worker prior to discharge after
the patient reported having "nightmares" and concern for
PTSD/depression. The social worker provided outpatient
information to the patient for outpatient follow-up. THe
patient's vital signs have been stable and he has been afebrile.
He has been tolerating a regular diet and out of bed with
assistance. He was discharged to the ___ facility on
POD #4 in stable condition. The orthopedic service recommended
a 2 week course of indocin to facilitate healing. Appointments
for follow-up were made with the Acute care service and with the
Orthopedic service.
Medications on Admission:
ASA 81 daily, Simvastatin 40 daily, Ranitidine 300mg daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Indomethacin 25 mg PO TID
x 2 weeks, last dose ___
6. Levofloxacin 750 mg PO Q24H
7 day course, last dose ___
7. Lidocaine 5% Patch 1 PTCH TD DAILY
8. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 3 hours Disp
#*10 Tablet Refills:*0
9. Ranitidine 300 mg PO DAILY
10. Senna 1 TAB PO BID:PRN constipation
11. Simvastatin 40 mg PO DAILY
12. TraZODone 25 mg PO HS:PRN insomnia
13. Calcium Carbonate 500 mg PO TID:PRN indigestion
14. Heparin 5000 UNIT SC TID
15. Simethicone 40-80 mg PO TID:PRN abd discomfort
16. Ferrous Sulfate 325 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Trauma: MVC
Injuries:
Left 4,5,7 rib fracture
right 5,6 rib fracture
right acetabulum fracture
Inferior sternal fracture
secondary: anemia
Discharge Condition:
Mental Status: Clear and coherent ( ___ speaking)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Clear and coherent ( ___ speaking)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Clear and coherent ( ___ speaking)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Clear and coherent ( ___ speaking)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Clear and coherent ( ___ speaking)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after you were involved in a
motor vehicle accident. You sustained rib fractures and a
fractured hip. You were taken to the operating room to have your
hip repaired. Your vital signs have bee stable and you are now
preparing for discharge.
Followup Instructions:
___
|
10440772-DS-2 | 10,440,772 | 25,162,766 | DS | 2 | 2151-09-12 00:00:00 | 2151-09-12 18:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lower extremity numbness
Major Surgical or Invasive Procedure:
LP
History of Present Illness:
The pt is a ___ y/o right handed man with a history of
psoriasis (not under any treatment currently) who presented to
our ED after having an abnormal MRI.
His story starts off on ___ when during work he suddenly
noticed that the bottoms of his feet felt numb. He thought it
may
have had something to do with his shoes or him being up on his
feet all day and thought it would pass. The symptoms of numbness
in his feet did not progress. He did note on that day as he was
working with a nail gun that he did not have quite the same hand
grip strength as he usually does. He went to sleep and when he
awoke the next day he felt that his legs, arms and torso where
numb (he feels like he is numb up to his nipple line and also
feels like he has an "atomic wedgie" like sensation across his
rectal area). He had no clear paresthesia, or pinprick lick
sensations, and he did not endorse any new weakness other then
his hand grip strength he noticed the day prior. Since ___
morning he has continued numb feeling that has neither
progressed
nor improved. He denies this every happening in the past. He has
no recent history of infections, vaccinations, travel, or new
medications (prescription or over the counter).
He had MRI imaging of his brain and spinal cord at an OSH and
then sent here for evaluation.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, vertigo. Denies
difficulties producing or comprehending speech. Denies focal
weakness (except perhaps his right hand). No bowel incontinence
or retention.
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, or abdominal
pain.
Past Medical History:
Psoriasis
Social History:
___
Family History:
Family Hx: Mom passed away from lung CA.
Physical Exam:
Vitals: 98.2 82 152/74 16 98%
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM.
Neck: Supple. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND.
Extremities: No edema or deformities.
Skin: Silver plaques throughout his arms/ legs/ torso and scalp.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. There were no paraphasic errors. Speech was
not
dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages on the
right, left was difficult to visualize. No RAPD
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No asterixis noted.
Strength is full bilaterally at the upper and lower extremities
in the proximal and distal muscles.
-Sensory: No deficit to pinprick noted throughout.
Proprioception, while everything was ok he was a little hesitant
in answering when tested at the right great toe.
Vibration was 15 seconds on the left and 5 seconds on the right
great toe. Normal at the fingers.
Cold sensation was dull at the feet bilaterally to the level of
the ankles.
-DTRs: ___ 2 throughout
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally. Was slightly clumsy with
fine finger movements on the right hand.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem but was a bit clumsy. Romberg
test
demonstrated sway and corrective step.
Pertinent Results:
Labs on admission:
___ 03:20PM PLT COUNT-351
___ 03:20PM NEUTS-81.3* LYMPHS-13.6* MONOS-4.1 EOS-0.3
BASOS-0.8
___ 03:20PM WBC-10.2 RBC-4.89 HGB-15.1 HCT-40.7 MCV-83
MCH-31.0 MCHC-37.2* RDW-12.0
___ 03:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 03:20PM estGFR-Using this
___ 03:20PM GLUCOSE-89 UREA N-12 CREAT-0.6 SODIUM-139
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
___ 06:46PM ___ PTT-30.7 ___
CSF studies:
WBC: 3
RBC: 8
Protein: 35
Glucose: 67
VZV: pending *****
MS oligoclonal bands: pending*****
Serum studies:
MS oligoclonal bands: pending
Lyme IgG/IgM
Brief Hospital Course:
Mr. ___ was admitted to the hospital for lower extremity
numbness and cervical lesion found on MRI.
He was found to have profound numbness from T2 down with
profound loss of vibration sense in Right ___. He was not found
to have weakness and only slight sway on Romberg testing. He
could walk independently without assistance.
He underwent spinal tap which revealed only WBC 3 (96lymph and
4mono) and RBC 8 with normal glucose and normal protein. Given
that he had recently had episode of shingles, his csf was also
tested for VZV in addition to MS oligoclonal bands (also pending
at the time of discharge).
His serum was tested for LYME (pending)
He will have a scheduled follow up with his Neurologist closer
to his home town.
He was told to return to the emergency department if his
symptoms worsened or if he were to develop new symptoms such as
weakness or bladder/bowel dysfunction or new pain, fever, or any
other concerning symptom.
++++++++++++++++++++++++++
***
Please note that several of his CSF studies are still PENDING
and need to be followed up: specifically VZV, MS ___
bands)
***
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
Tranverse Myelitis
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 concerns regarding lower
extremity weankess and spinal cord lesion on MRI.
You underwent a spinal tap and the fluid was analyzed to
determine the cause of your symptoms. The analysis revealed that
you may have a slight amount of inflammation but not a
concerning active infection.
You were discharged home with Neurology follow up. You will
follow up with the Neurologist you refered you to ___.
Please return to the Emergency department if your symptoms
continue to progress or if you experience any new symptoms such
as weakness or pain or difficulty with your bowel or bladder.
Please make sure that your Neurologist follows up with the final
and full results of your spinal tap.
Followup Instructions:
___
|
10441044-DS-2 | 10,441,044 | 21,256,821 | DS | 2 | 2165-07-09 00:00:00 | 2165-07-22 14:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
iodine
Attending: ___.
Chief Complaint:
S/p motor vehicle collision
Major Surgical or Invasive Procedure:
___ Left ring finger DIP joint primary arthrodesis
History of Present Illness:
Mr. ___ is a ___ male, unrestrained backseat passenger in
rollover MVC on ___. Hypoxic with EMS en route to hospital.
___ Coma Scale on ED arrival was 15, but required intubation
for respiratory distress. He was transported to ___ for
further management.
Past Medical History:
COPD, HTN
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Exam upon presentation:
O(2)Sat: 88 on nonrebreather Low
Constitutional: Boarded, c-collar in place
HEENT: Bilateral periorbital ecchymosis, extraocular
movements intact, midface stable C. collar
Chest: Left chest wall tenderness
Cardiovascular: Regular Rate and Rhythm
Abdominal: Distended, diffusely tender
Pelvic: Stable
Extr/Back: No obvious deformity
Skin: Abrasions on right knee
Neuro: No focal deficits
On discharge:
VS: 98.8, 81, 122/78, 20, 93%/RA
GEN: Comfortable, NAD.
HEENT: C-collar in place
CARDIAC: Normal S1, S2. RRR. No M/R/G
PULM: Lungs diminished at bases. No W/R/R.
ABD: Soft/nontender/nondistended. + bowel sounds.
EXT: + pedal pulses. No edema, cyanosis, clubbing.
NEURO: AAOx4, normal mentation.
Pertinent Results:
___ Echocardiogram
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis by 2D (doppler interrogation of the aortic
valve was not obtained due to poor image quality). The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is a trivial/physiologic pericardial
effusion. There are no echocardiographic signs of tamponade.
___ CT Head
1. Bifrontal hematomas overlying both orbits. No retrobulbar
hematoma or
evidence of traumatic globe injury.
2. No acute intracranial process.
3. Mucosal thickening of the ethmoid air cells, likely related
to intubation, though no air-fluid levels within the sinuses to
suggest occult fracture.
___ CT ___
-Non-displaced fracture of the left pedicle of C7
-Possible non-displaced fracture of the anterior tubercle of the
left
transverse process of C7.
-Vertebral artery on the left at the C7 level (seen on CTA
chest) appears
normal without signs of traumatic injury - though more cephalad
vertebral
artery not imaged.
___ CT Torso
1. Endotracheal tube tip at carina, proximal repositioning is
recommended.
2. Extensive bilateral atelectasis, but no contusion or
hemothorax.
3. Severe mediastinal lipomatosis, though no mediastinal
hematoma. No
evidence of traumatic injury to the thoracic aorta.
4. Fracture of the pedicle of C7 on the left with possible
fracture of the anterior tubercle of the transverse process on
the left, better characterized on cervical spine CT.
Contrast-enhanced vertebral artery at the C7 level appears
normal without evidence of traumatic injury.
5. Numerous bilateral rib fractures as detailed above. No
pneumothorax.
6. Nondisplaced fractures of the left transverse process of the
L1 through L3 vertebral bodies.
7. Fatty liver
___ 6:18 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
BACILLUS SPECIES; NOT ANTHRACIS. MODERATE GROWTH.
CLINICAL SIGNIFICANCE UNCERTAIN.
BACILLUS SPECIES IS A RARE CAUSE OF LIFE-THREATENING
PNEUMONIA IN
THE IMMUNOCOMPROMISED HOST AND THE PREMATURE NEONATE.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Preliminary):
YEAST.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
Reported to and read back by ___
___ @ 05:39,
___.
ACIDFAST BACILLI. FEW seen on concentrated smear.
ACID FAST CULTURE (Preliminary):
MTB Direct Amplification (Final ___:
NEGATIVE FOR M. TUBERCULOSIS BY NAAT. AWAIT CULTURE
RESULTS. TEST
PERFORMED BY ___ ___.
___ Left hand film
Three views of the left hand have no comparisons. There is a
transverse
intra-articular fracture at the base of the distal phalanx of
the ring finger. The fracture line extends to both the volar and
distal aspects of the phalanx with fracture fragments present
along the volar aspect of the joint. No other fractures,
however, the hand and wrist are subopitmally viewed. Mild soft
tissue swelling.
___ CT Torso
1. Moderate-sized left pneumothorax without evidence of
tension. Two left pleural tubes terminate in the posterior left
pleural space.
2. Subtotal atelectasis of bilateral lower lobes is slightly
increased since prior. Ground-glass opacities in the upper
lobes, left greater than right, are nonspecific, but compatible
with aspiration or infection in the correct clinical setting.
3. Small bilateral pleural effusions, right greater than left.
4. New small perihepatic ascites and pelvic fluid.
5. Numerous osseous injuries, similar to prior, including
slightly displaced fracture of the inferior angle of the left
scapula, bilateral rib fractures with segmental fractures of the
left third through fifth ribs, L1-L3 left transverse process
fractures.
___ CT LUE
1. Comminuted, intra-articular fracture of the base of the
distal phalanx of the left ring finger. 0.4 cm ossific fragment
is present dorsal to the distal head of the intact middle
phalanx of this digit.
2. Subcentimeter ossific fragments are also present along the
volar aspect of the distal head of the middle phalanx of left
ring finger. Joint is mild hyperextended.
3. Ovoid 0.6 cm corticated ossific body adjacent to the ulnar /
distal aspect of the capitate of indeterminant chronicity. No
evidence for acute fracture of the capitate.
4. Widening of the scapholunate interval suggestive for
scapholunate ligament injury / disruption. MR examination of
the left wrist would provide further imaging evaluation if
clinically warranted.
___ Echocardiogram
The left ventricular cavity size is normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF 70%). The right ventricular cavity is dilated with
depressed free wall contractility (the apical half of the RV
free wall appears severely hypokinetic. There is no pericardial
effusion.
Impression: RV dysfunction (? RV contusion)
Compared to prior of ___, the RV is still hypokinetic
(infundibular/RVOT free wall was severely hypokinetic in prior
study).
___ MR ___
1. C5-6 interspinous ligamentous edema, consistent with acute
injury;
however, no evidence of ALL or PLL complex or spinal cord
injury.
2. Left C7 pedicle and articular pillar fracture, extending into
superior
articulating facet, without evidence of joint capsular
disruption or alignment abnormality.
3. Moderate C3-4 right neural foraminal narrowing.
___ CTA CHEST W&W/O C&RECONS, NON-CORONARY
Though there has been interval resolution of a left pneumothorax
from
___, there is little change in segmental atelectasis at
the bilateral lower lobes. There is no pulmonary embolus.
___ HAND (AP, LAT & OBLIQUE)
FINDINGS: Again seen is an oblique intra-articular fracture at
the base of the fourth distal phalanx with multiple small
fracture fragments. There continues to be angulation of the
distal fourth digit at the fracture site with associated soft
tissue swelling. No callus formation is visualized.
Brief Hospital Course:
The patient is a ___ M who was an unrestrained back seat
passenger in ___ rollover(serum EtOH 204). He was initially
awake and following commands, but was intubated in the trauma
bay for increasing respiratory distress with possible
aspiration. The patient was subsequently pan-scanned revealing
bifrontal hematomas and rib fractures. He was brought to the
TSICU for further resuscitation and management.
His ICU course as follows by systems:
Neuro: GCS 15 and moving all extremities in the trauma bay, the
patient was intubated for progressive respiratory distress and
was kept intubated and sedated on fentanyl and versed until HD
9. Propofol was also used to facilitate daily wake ups. He
required paralysis with cisatracurium for ventilation until HD
7. A hard collar was in place at all times per spine
recommendations for C7 fracture. NG pain medication was added
HD8. Propofol was discontinued on ___ in order to facilitate
ongoing vent wean. He continued to have his ventilator weaned
and successfully extubated the am of HD 12. On ___ he sustained
a fall and began to complain of thoracic spine tenderness. He
underwent CT imaging showing fracture of the right lateral
aspect of the T12 vertebral body. Spine surgery were
re-consulted and recommended a TLSO brace to be worn while out
of bed.
CV: After being initially hemodynamically stable on admission,
the patient required a Neo-Synephrine drip after intubation.
Echo and CXR were unremarkable, but he required ongoing pressor
support with Levophed until ___. As his respiratory status
improved, his blood pressure stabilized.
Resp: On arrival to the ED, the patient was having difficulty
maintaining his O2 saturation and became tachypneic, likely
secondary to extensive rib fractures. He was intubated in the
trauma bay for respiratory distress. On his initial CT, there
were large dependant fluid collections which were read as likely
atelectasis, but were somewhat concerning for aspiration
pneumonia. He was bronched on arrival to the TSICU for
persistent hypoxia which improved with suctioning. On HD 3, he
began to exhibit symptoms of ARDS, and his CXR was in keeping
with this finding. He was placed in ARDS ventilatory settings
but had an increasing PEEP requirement for adequate oxygenation
complicated by a large left pneumothorax on ___ requiring urgent
chest tube decompression with immediate improvement. He was
aggressively diuresed but required a prolonged wean from the
ventilator. Bronchoscopy with BAL was performed for persistent
RLL collapse on ___ and culture was positive for acid-fast
bacilli. He was placed in respiratory isolation and further
data from the ___ laboratory was negative for TB. Infectious
disease consultation was obtained for presumed aspiration
pneumonia with acid-fast bacilli, and initial empiric vancomycin
and Zosyn were de escalated to Zosyn on ___. On ___, a repeat
CXR revealed increase in a left subpulmonic pneumothorax and a
second, posterior chest tube was placed with satisfactory
resolution. Repeat bronchoscopy was performed on ___ for RLL
collapse on chest CT, with purulent sputum aspirated and sent
for culture. Diuresis continued. On ___, the ventilator was
switched to APRV mode to facilitate weaning and continued
through the morning of ___. PEEP and FIO2 were able to be
weaned, and on ___, he was tolerating pressure support. The
apical chest tube was removed on ___. He extubated on ___ and
tolerated this well and has remained on nasal canula oxygen. He
continued to be weaned off his oxygen requirement, until he was
on room air and oxygen saturations were above > 90%.
GI: While intubated, he was kept NPO. Tube feeds were started
on HD2 and advanced to goal, which he tolerated without
difficulty. Once extubated, he was started on a regular diet
and tolerated this until discharge.
GU: He had a Foley placed in the ED and produced adequate urine
during his ICU stay, responding appropriately to diuresis.
Endo: Sliding scale insulin coverage was provided in the ICU.
Heme/ID: His WBC began to climb though he did not spike any
fevers and none of his cultures came back positive as of HD 5.
He did have a bronch on ___ which showed non-anthracis bacillus.
As noted above, he was treated initially with vancomycin and
Zosyn, then de escalated to Zosyn alone. AFB+ culture data did
not reveal TB. Infectious disease consultation was obtained,
and a 10 day course of Zosyn was completed ___. His
temperature curve was monitored after this.
MSK: Found to have ___ metacarpal and distal phalanx fractures,
splinted by Hand surgery and referred for outpatient follow up.
His floor course as follows:
On HD 14 (___), the patient was transferred to the inpatient
medical/surgical unit for further management. He was continued
on bedrest until he was fitted for a TLSO brace.
On HD ___ he received his TLSO brace and was evaluated by
physical therapy. His oxygen requirement was weaned to room air
and his oxygen saturations were kept above > 90%. His pain was
well controlled with oral medications.
On HD ___ his Foley catheter was discontinued and he was voiding
large amounts of urine without difficulty.
On HD 17 (On ___ he was taken to the OR by Plastics Hand
Surgery for a primary left ring finger distal interphalangeal
joint arthrodesis. He will need to stay in the splint for 2
weeks and then he will need it to be changed to ulnar gutter
type cast to be worn for 4 weeks. He will require a 7 day course
of Keflex antibiotics post-operatively. He will remain non
weight bearing precautions to his left hand but may weight bear
through his forearm. His vitals remained stable and he remained
afebrile up to the day of discharge.
He will require follow up with his PCP upon return to his home
state of ___ - this was explained to patient prior to
discharge. He also understands that he will need to follow up
with an Orthopedic Spine and Plastic Surgeon within the next ___
weeks.
Medications on Admission:
Xanax 1mg Daily
Albuterol prn
Afrin prn
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN wheezing
3. Cephalexin 500 mg PO Q6H Duration: 7 Days
RX *cephalexin [Keflex] 500 mg 1 capsule(s) by mouth four times
a day Disp #*24 Capsule Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Furosemide 40 mg PO DAILY
6. Hydrocortisone (Rectal) 2.5% Cream ___ID
7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 4 hours Disp
#*90 Tablet Refills:*0
8. Milk of Magnesia 30 mL PO Q6H:PRN constipation
9. Senna 1 TAB PO BID constipation
10. TraMADOL (Ultram) 50 mg PO QID
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*120
Tablet Refills:*1
11. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour 1 patch daily Disp #*30 Transdermal
Patch Refills:*1
12. ALPRAZolam 1 mg PO BID:PRN anxiety
RX *alprazolam [Xanax] 1 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Motor vehicle crash
Injuries:
- Bifrontal hematomas
- C7 left pedicle fracture
- L1-L3 transverse process fractures
- Left ___ rib fractures
- Right ___ rib fractures
- T12 vertebral body fracture
- Left ring finger distal phalanx base fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to ___ after you
were involved in a motor vehicle collision. Upon evaluation,
you were found to have the following injuries: fractures of
your cervical (neck) spine bone; rib fractures, mid and lower
spine bones, left ring finger and the bones in your lower back.
Your spine injuries in your neck and mid back did not require
any operations- instead you were fitted for a hard cervical
collar and a corset type brace for your mid back fracture.
Your neck brace needs to be worn at all times for at least
another 2 weeks. You will need to follow up with a Spine surgeon
upon your return to your home in ___ for xrays to determine
if the collar can be removed.
Your corset brace needs to be worn when you are out of bed -
while in bed with your head of bed up on at least 2 full pillows
you do not need to wear the brace. You may apply the brace in a
sitting position on the side of the bed.
You may remove both braces for showering while seated in a
shower chair. It is importnat that someone be with you when
showering to make sure that you have minimal movements.
DO NOT take any tubs baths until all braces no longer need to be
worn.
You will need to keep the splint on your right hand for the next
2 weeks. After that time a short arm cast will need to be
applied that will be worn for 4 weeks.
DO NOT bear any weight on your left hand - you may bear weight
through your left forearm.
* You have 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 are prescribed antibitoics for your left finger injury -
please be sure to complete the entire course as directed.
Followup Instructions:
___
|
10441206-DS-17 | 10,441,206 | 21,838,440 | DS | 17 | 2173-03-18 00:00:00 | 2173-03-18 19:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / etravirine / adhesive tape
Attending: ___.
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
None during this admission. Recent Robotic abdominoperineal
resection, placement of CyberKnife fiducial and parastomal mesh
and a flap closure done on ___.
History of Present Illness:
___ is a ___ PMH HIV (undetectable, on Tivicay &
Descovy), recurrent invasive anal SCC s/p lap/robotic proectomy
w/ end colostomy, V-Y flaps ___ (___), presenting with
fevers. Mr. ___ was discharged home on ___, and initially
did well at home. The day prior to his presentation on ___,
he felt warm and had a temperature of
100.8F. This evening he felt even warmer and had shaking chills,
with a temperature of 101.2F. This prompted him to seek care at
the ___ ED. He reports some increasing pain in the V-Y flap
incisions, some moderate pain in the lower abdomen around bowel
movements, and occasional mild burning with urination. He denies
nausea, vomiting, chest pain, shortness of breath, productive
cough, diarrhea, or bloody bowel movements.
Past Medical History:
PMHx:
HIV, sciatic neuralgia ongoing steroid
injections currently on chronic narcotic
PSHx:
Rectal biopsy ___
Robotic abdominoperineal resection, placement of CyberKnife
fiducial and parastomal mesh and a flap closure done on ___.
Social History:
___
Family History:
Mother: ___ cancer
Physical Exam:
Vitals: ___ 1159 Temp: 98.3 PO BP: 99/68 HR: 99 RR: 18 O2
sat: 93% O2 delivery: RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Regular
PULM: No respiratory distress
ABD: Soft, mildly tender b/l lower quadrants, no rebound, no
guarding, ostomy pink, no stool/gas in bag. Drains serosang.
RECTAL: Flap incision c/d/i. Some edema, especially on R side.
Small focus of erythema L superior aspect, no discharge, no
fluctuance, no induration.
EXT: No ___ edema, ___ warm and well perfused
TLD: JP x2
Pertinent Results:
___ 08:15AM BLOOD WBC-7.6 RBC-4.35* Hgb-13.5* Hct-41.0
MCV-94 MCH-31.0 MCHC-32.9 RDW-14.5 RDWSD-51.0* Plt ___
Brief Hospital Course:
Patient presented to ED with reported fevers at home. Since
admission he had remained afebrile and hemodynamically stable.
His WBC was 8.1, no bands on CBC diff, electrolytes were normal,
urinalysis was normal. He had a CT abdomen and pelvis with
contrast which did not show any abscess or intra-pelvic or
abdominal infection. Patient was evaluated by the colorectal
surgery team who did not believe there was any indication for
admission or surgical intervention, no significant intrabdominal
process. The patient was also evaluated by the plastic surgery
team, who noted well healing ___ flaps without signs of infection
or abscess. They did recommend a short course of bactrim for
prophylaxis and acyclovir due to some small lesions at the flap
and the patient's history of HIV. On imaging workup, CXR showed
left basilar opacity but CT abdomen pelvis showed L lower lung
which showed no consolidation, and patient did not have symptoms
consistent with pneumonia. Patient was admitted for observation,
where he remained afebrile and HDS. His exam was unchanged and
he was in stable condition for discharge home with services. He
was advised to take PO Benadryl PRN for itching at the flap
site.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Enoxaparin Sodium 40 mg SC QPM
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN severe pain
Discharge Medications:
1. Acyclovir 400 mg PO Q8H Duration: 5 Days
RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp
#*15 Tablet Refills:*0
2. 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 #*10 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Enoxaparin Sodium 40 mg SC QPM
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN severe pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Recurrent rectal cancer s/p robotic proctectomy, diverting end
colostomy, perineal ___ flap
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for monitoring, and you have been stable
during this admission and are OK to go back home. Please
continue with the instructions you were given at your prior
discharge (see below).
You may take over the counter oral Benadryl for itching. Do NOT
apply any creams, lotions, or ointments to your wounds.
You were admitted to the hospital after arRobotic
abdominoperineal resection for surgical management of your
recurrent rectal cancer. You have recovered from this procedure
well and you are now ready to return home. Samples of tissue
were taken and has been sent to the pathology department. 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 a new colostomy. It is important to monitor the output
from this stoma. It is expected that the stool from this ostomy
will be solid and formed like regular stool. You should have ___
bowel movements daily. If you notice that you have not had any
stool from your stoma in ___ days, please call the office. You
may take an over the counter stool softener such as Colace if
you find that you are becoming constipated. Please watch the
appearance of the stoma (intestine that protrudes outside of
your abdomen), it should be beefy red/pink, if you notice that
the stoma is turning darker blue or purple, or dark red please
call the office for advice. The stoma may ooze small amounts of
blood at times when touched but this will improve over time. The
skin around the ostomy site should be kept clean and intact.
Monitor the skin around the stoma for any bulging or signs of
infection listed above. Please care for the ostomy as you have
been instructed by the ostomy nurses. ___ the skin around
the stoma for any bulging or signs of infection listed above.
You will be able to make an appointment with the ostomy nurse in
the clinic ___ weeks after surgery. Please call the ostomy
nurses clinic number which is listed in the ileostomy/colostomy
handout packet given to you by the nursing staff. You will also
have a visiting nurse at home for the next few weeks to help
monitor your ostomy until you are comfortable caring for it on
your own.
Currently your colostomy is allowing the surgery in your large
intestine or rectum to heal which does take some time. At your
follow-up appointment in the clinic, the surgeons will determine
the best time for the next step: reversal surgery. Until then,
the healthy intestine is still functioning as it normally would
and continue to produce mucus. Some of this mucus may leak or
you may feel as though you need to have a bowel movement. You
may sit on the toilet and empty this mucus as though you were
having a bowel movement or wear clothing that prevents leakage
of this material such as a disposable pad.
If you have any of the following symptoms please call the office
at ___:
fever greater than 101.5
increasing abdominal distension
increasing abdominal pain
nausea/vomiting
inability to tolerate food or liquids
prolonged loose stool
extended constipation
inability to urinate
Incisions:
* Please monitor your incision lines closely for signs of
infection: opening of the incision, increased redness, increased
pain, if you have a fever greater than 101, swelling of the
tissues around the incision line, drainage of
green/yellow/grey/white/thick drainage, increased pain at the
incision line, or increased warmth.
* You may shower with incisions and drain. Be sure the drain is
secured to you and not left dangling on the shower floor. Let
the warm water run over the incisions and ___ all areas
dry with a clean towel, and keep open to air but as clean and
dry as possible. If the incisions become irritated, you may
apply a dry sterile gauze dressing to the incision line. Please
follow-up with Dr. ___ questions related to your most
current surgery.
* Continue to monitor the flaps that were placed in your
___ area. These should remain warm and a similar color
to the rest of your skin. If you notice that these areas are
changing in color to: red, purplish, blue, black, or pale please
call Dr. ___ immediately.
* Please change position while in bed or in a chair frequently.
Please walk frequently. Please avoid sitting in a chair for the
time being. Please avoid frequent bending at the waist or
lifting anything greater than 5 pounds until cleared by Dr.
___. Please continue good hygiene.
* Please avoid smoking as this will result in poor blood supply
and healing to your surgical areas.
Pain
It is expected that you will have pain after surgery, this will
gradually improve over the first week or so you are home. You
should continue to take 2 Extra Strength Tylenol (___) for
pain every 8 hours around the clock. Please do not take more
than 3000mg of Tylenol in 24 hours or any other medications that
contain Tylenol such as cold medication. Do not drink alcohol
while taking Tylenol. You may also take Advil (Ibuprofen) 600mg
every 8 hours for 7 days, please take Advil with food. If these
medications are not controlling your pain to a point where you
can ambulate and perform minor tasks, you should take a dose of
the narcotic pain medication oxycodone. Please do not take
sedating medications or drink alcohol while taking the narcotic
pain medication. Do not drive while taking narcotic medications.
Activity
You may feel weak or "washed out" for up to 6 weeks after
surgery. Do not lift greater than a gallon of milk for 3 weeks.
At your post op appointment, your surgical team will clear you
for heavier exercise. In the meantime, you may climb stairs, and
go outside and walk. Please avoid traveling long distances until
you speak with your surgical team at your post-op visit. Again,
please do not drive while taking narcotic pain medications.
You will be discharged home on Lovenox injections to prevent
blood clots after surgery. You will take this for 30 days after
your surgery date, please finish the entire prescription. This
will be given once daily. Please follow all nursing teaching
instruction given by the nursing staff. Please monitor for any
signs of bleeding: fast heart rate, bloody bowel movements,
abdominal pain, bruising, feeling faint or weak. If you have any
of these symptoms please call our office or seek medical
attention. Avoid any contact activity while taking Lovenox.
Please take extra caution to avoid falling.
* Drain care:
1. Clean around the drain site(s), where the tubing exits the
skin, with soap and water.
2. Strip drain tubing, empty bulb(s), and record output(s) ___
times per day. Re-establish drain suction.
3. A written record of the daily output from each drain should
be brought to every follow-up appointment. Your drains will be
removed as soon as possible when the daily output tapers off to
an acceptable amount.
Thank you for allowing us to participate in your care, we wish
you all the best!
Followup Instructions:
___
|
10441206-DS-18 | 10,441,206 | 20,173,207 | DS | 18 | 2173-04-22 00:00:00 | 2173-04-22 15:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / etravirine / adhesive tape
Attending: ___.
Chief Complaint:
perineal drainage/infected flap seroma
Major Surgical or Invasive Procedure:
___ aspiration
History of Present Illness:
___ year old man with history of HIV and anal cancer managed
with chemoradiaton and more recently APR and perineal
reconstruction with bilateral ___ advancement flaps/surgimend
sling approximately 6 weeks ago presents with increasing
discomfort and drainage from his perineal wound. He initially
did well but has been developing increasing discomfort in the
perineum. CT pelvis performed ___ demonstrated a 9 x 6 x 5 cm
collection and was thus scheduled for ___ drainage this morning.
He presents to the ER because the wound started to drain within
the last 24 hours. He states that the drainage has been yellow
and clear. He otherwise feels well without fever, chills, weight
change, change in energy.
Past Medical History:
PMHx:
HIV, sciatic neuralgia ongoing steroid
injections currently on chronic narcotic
PSHx:
Rectal biopsy ___
Robotic abdominoperineal resection, placement of CyberKnife
fiducial and parastomal mesh and a flap closure done on ___.
Social History:
___
Family History:
Mother: ___ cancer
Physical Exam:
VS: VSS
Gen: A&Ox3, comfortable-appearing male, in NAD
HEENT: No scleral icterus, no palpable LAD
Pulm: comfortable on room air
CV: NRRR, no m/r/g
Abd: soft, NT/ND, ostomy pink/moist with solid stool output, no
rebound/guarding, no palpable masses
Perinuem: L inferior aspect of flap erythematous and indurated,
___ drain with sanguinous/purulent output, no drainage/induration
at other flap sites
Ext: WWP bilaterally, no c/c/e, no ulcerations
Neuro: moves all limbs spontaneously, no focal deficits
Pertinent Results:
See OMR for all lab and imaging results.
Brief Hospital Course:
Summary: ___ with h/o HIV on HAART, anal SCC s/p chemorads,
robotic APR, end colostomy, perineal V-Y flap ___, p/w painful
perineal drainage, now s/p ___ drainage of infected flap seroma.
Discharged with drain on PO antibiotics and plastics follow up.
Hospital course: Patient was admitted for worsening perineal
pain in the setting of a known fluid collection in the area of
V-Y flap closure of his perineal defect. Patient was seen in
conjunction with plastic surgery at bedside. No fevers, chills,
white count or evidence of systemic infection, with imaging and
clinical evidence demonstrating fluid collection in area of
perineal closure. Given known fluid collection on imaging,
erythema around perineal wound, and ongoing scant drainage ___
aspiration was completed on ___ with approximately 80 cc of
purulent fluid removed and sent for micro evaluation. A drain
was left in place. Patient was started on cipro/flagyl to
complete a 7 day course following discharge. Preliminary cx's
demonstrated e. coli sensitive to cipro. Patient was discharged
with the drain with ___ services for drain care. He will follow
up with plastic surgery regarding final cx results, drain
removal, and further management.
By the time of discharge the patient was tolerating a regular
diet, voiding appropriately and ambulating well. He was
hemodynamically stable and expressed understanding and readiness
at discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dolutegravir 50 mg PO DAILY
2. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
3. TraZODone 25 mg PO QHS:PRN insomnia
4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
5. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
12 hours (twice a day) Disp #*14 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8
hours (three times per day) Disp #*21 Tablet Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*25 Tablet Refills:*0
5. Dolutegravir 50 mg PO DAILY
6. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. TraZODone 25 mg PO QHS:PRN insomnia
9. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
infected flap seroma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted for ___ drainage of an infected flap seroma.
You have a drain in place and will need to follow up with
plastic surgery in one week regarding its removal. You may flush
it daily as per nursing instructions. You will be discharged on
a 7 day course of antibiotics. Your preliminary cultures have
returned sensitive to the antibiotics, but you may also follow
up with plastic surgery regarding this as well. Please follow
the same restrictions you were before admission regarding diet,
activity, pain control, and return precautions as listed below:
Fever greater than 101
Chills
Any other symptoms that concern you
Abdominal pain
Abdominal swelling
Nausea and vomiting
Vomiting blood
Difficulty swallowing
Diarrhea
Constipation
Blood in stool
Black stool
Leg pain
Leg swelling
Leg redness
Shortness of breath
Chest pain
General drain instructions:
You will also be going home with your JP (surgical) drain, which
will be removed at your post-op visit. Please look at the site
every day for signs of infection (increased redness or pain,
swelling, odor, yellow or bloody discharge, warm to touch,
fever). Maintain suction of the bulb. Note color, consistency,
and amount of fluid in the drain. Call the doctor, nurse
practitioner, or ___ nurse if the amount increases significantly
or changes in character. Be sure to empty the drain frequently.
Record the output, if instructed to do so. You may shower; wash
the area gently with warm, soapy water. Keep the insertion site
clean and dry otherwise. Avoid swimming, baths, hot tubs; do not
submerge yourself in water. Make sure to keep the drain attached
securely to your body to prevent pulling or dislocation.
If you have any questions please feel free to contact the
colorectal or plastic surgery offices.
Thank you.
Followup Instructions:
___
|
10441435-DS-16 | 10,441,435 | 27,367,739 | DS | 16 | 2141-05-04 00:00:00 | 2141-05-04 18:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness/lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ pt presents via EMS from PCP office after she was found to
be bradycardic down to 42 in office. Has been complaining of
dizziness and lightheadedness over last 2 days, worse when
standing up, bending down and in the morning. Patient first
noticed when was watching TV in bed after waking up 2 days ago.
In ___, she denied focal neurological signs,headache, nausea or
vomiting. She denied photophobia or diplopia. She denied any
palpitations, chest pain, SOB, polyuria or polydipsia. She
reported no visual changes or worsening of symptoms when moving
head. Denied any cardiac hx. No recent changes in PO intake or
new medications. She didn't have any orthostatic signs
(orthostatic blood pressure 158/73 sitting, 162/95 standing,
pulse 50 sitting, pulse 60 standing). She was transferred via
ambulance to ___ ED.
In the ED, initial VS were 97.8 50 161/81 18 100%. Pt warm, dry
and AOx3 at time of traige. No lightheaded on arrival to ED.
Denied any complaints on presentation to ED. PIV was placed. EKG
showed "Marked sinus bradycardia @40bpm, IV conduction defect".
Labs were remarkable for Hct of 35, wbc 7.9 (eos 6.5%), normal
coags, CK, UA and trop. Pt's K was 2.7 so got and Cr was 1.3
(baseline 0.9-1.1). CXR was unremarkable. Pt was given 40meq PO
given at ___ and a further 20meq in 0.9% NS.
On arrival to the floor, patient was stable. Vitals on transfer
were 98.3 52 18 97 ra. Patient becasme somewhat dizzy while
sitting upright in bed. Otherwise asymptomatic.
Past Medical History:
Asthma
- OA
- Obesity (241 lb) s/p gastric bipass
- Pedal Edema (on lasix)
- Primary Open Angle Glaucoma
Social History:
___
Family History:
daughter went blind in one eye not sure why. One sister had
rheumatic heart disease.
Physical Exam:
Admission Exam:
VS - 98.3 52 18 97 ra
GENERAL - well-appearing woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact
.
Discharge Exam:
VS- 97.5 157/84 60 20 100%RA
Rest of exam unchanged as she was discharged on day of admission
Pertinent Results:
ED Labs:
___ 06:20PM BLOOD WBC-7.9 RBC-4.02* Hgb-11.4* Hct-35.3*
MCV-88 MCH-28.3 MCHC-32.2 RDW-15.1 Plt ___
___ 06:20PM BLOOD Glucose-98 UreaN-19 Creat-1.3* Na-145
K-2.7* Cl-104 HCO3-28 AnGap-16
.
Admission Labs:
___ 07:05AM BLOOD WBC-7.1 RBC-3.53* Hgb-10.4* Hct-31.0*
MCV-88 MCH-29.4 MCHC-33.5 RDW-15.2 Plt ___
___ 07:05AM BLOOD Glucose-89 UreaN-18 Creat-1.0 Na-146*
K-3.2* Cl-109* HCO3-30 AnGap-10
___ 07:05AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.8
.
Discharge Labs:
___ 01:10PM BLOOD WBC-6.9 RBC-3.69* Hgb-10.3* Hct-32.5*
MCV-88 MCH-27.9 MCHC-31.6 RDW-15.1 Plt ___
___ 01:10PM BLOOD Glucose-98 UreaN-18 Creat-1.1 Na-145
K-4.2 Cl-111* HCO3-28 AnGap-10
___ 01:10PM BLOOD Calcium-9.0 Phos-2.2* Mg-1.8
.
Pertinent Labs:
___ 06:20PM BLOOD cTropnT-<0.01
___ 06:20PM BLOOD TSH-0.99
.
Studies:
___ CXR: Frontal and lateral views of the chest. The lungs
are clear. The cardiomediastinal silhouette is within normal
limits. Degenerative changes are noted in the spine. Severe
degenerative changes also noted at the left shoulder. Osseous
and soft tissue structures are otherwise unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Brief Hospital Course:
___ yo F with no significant cardiac history and asymptomatic
bradycardia in the past that presents to ED from PCP office with
48 hour h/o dizziness and lightheadedness in the setting of
sinus bradycardia in the 40's and hypokalemia. Thought that
bradycardia was exacerbated by hypokalemic state, resulting in
symptoms. Repleted with K, and pt remained asymptomatic while
in-house. Discharged home with instructions to follow-up in
Atrius cardiology for holter monitoring
.
Active Issues:
# Sinus Bradycardia: Pt has been noted to have sinus bradycardia
at prior out-patient visits but has been asymptomatic.
Dizziness/lightheadedness started on ___ and persisted
throughout the weekend. At PCP office yesterday, she was found
to be in sinus brady and transferred to ___ given symptoms.
Her orthostatics were negative with PCP. In ED, she had a K of
2.7 and elevated Cr to 1.3. Her hypokalemia was thought to be
___ overdiuresis with 80mg PO lasix, which she takes for chronic
lower extremity lymphedema. Her K was agressively repleted with
IV and PO meds, and she remained asymptomatic in-house. Symptoms
thought to be ___ hypokalemic state. At discharge, she was still
bradycardic, but as she was asymptomatic and at baselin, she was
deemed safe for discharge. If this is symptomatic again, would
recommend evaluation for permanent pacemaker. Given supplemental
KCl 40meq and lasix decreased to 40mg PO daily.
.
# ___: Pt's Cr slightly up at 1.3. Resolved with 500cc KCl.
Likely pre-renal and ___ overdiuresis with PO lasix. (see above)
.
Chronic Issues:
# Asthma: Stable. Continued home ventolin
.
# OA: Stable. Continued ibuprofen
.
Transitional Issues:
#Will need electrolytes check within 48 hours after adding KCl
and decreasing lasix
#Will need holter monitor to evaluate for occult arrhythmia as
cause of symptoms
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 80 mg PO DAILY
2. Fluticasone Propionate 110mcg 2 PUFF IH BID wheezing
3. Ibuprofen 600 mg PO Q8H:PRN pain
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
Discharge Medications:
1. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Fluticasone Propionate 110mcg 2 PUFF IH BID wheezing
3. Ibuprofen 600 mg PO Q8H:PRN pain
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Potassium Chloride (Powder) 40 mEq PO DAILY
RX *potassium chloride [___] 20 mEq 2 packets by mouth
daily Disp #*60 Packet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Symptomatic bradycardia
Hypokalemia
Secondary diagnosis:
osteoarthritis
lymphedema
h/o acute open angle glaucoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at ___. You were admitted for
a slow heart rate coupled with lightheadedness over the weekend.
You have had a slow heart rate for several years now, but never
had any symptoms from it.
When you were seen in the ED your potassium level was
dangerously low. We believe that this may have caused your heart
to slow down even further, making you dizzy when you moved. You
were monitored on the cardiology service, and given potassium
through your veins and by mouth. Your symptoms did not return
after this.
We believe your potassium was low because of your furosemide. We
have decreased this dose, and have also prescribed potassium
supplements for you to take at home.
We would also like to give you an electronic recorder that looks
at your heart rhythm while you are at home. If your symptoms
occur again the recorder will pick up anything abnormal and
allow it to be transmitted to your cardiologist. You will be
called with an appointment to pick up your recorder.
The following medication changes have been made:
START potassium chloride 40meq daily
DECREASE furosemide from 80mg daily to 40mg daily
Followup Instructions:
___
|
10441515-DS-15 | 10,441,515 | 29,334,867 | DS | 15 | 2136-02-01 00:00:00 | 2136-02-03 10:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ hx of COPD, CAD, presented to his PCP ___ 1 week of
abdominal pain. Patient reports pain as constant cramping
sensation that varies in intensity. He is unsure if it
associated with food. He had nausea but no vomiting, chills but
no fevers. He went to ___ where he had an U/S
followed by a CT scan suggestive of cholecystitis. He was given
Levaquin and Flagyl and transferred to ___ for further care.
Past Medical History:
PMH: CAD, MI s/p stent, HLD, COPD
PSH: back surgery
Social History:
___
Family History:
Mother had gallbladder disease
Physical Exam:
Physical Exam upon admission:
Vitals: T 98.7, HR 102, BP 130/90, RR 18, O2 96% 2l
Gen: Alert, NAD
CV: RRR
Pulm: diminished bilaterally
Abd: soft, non-distended, TTP in epigastrium and RUQ. No
rebound/guarding, neg ___ sign.
Ext: w/d
Physical Exam upon discharge:
VS: 98.6, 87, 144/80, 18, 93/RA
Gen: NAD, resting in bed.
Heent: EOMI, MMM
Cardiac: Normal S1, S2. RRR
Pulm: Lungs CTAB. no W/R/R.
Abd: Soft/nontender/nondistended.
Ext: + pedal pulses. No CCE.
Neuro: AAOx4, normal mentation.
Pertinent Results:
___ 05:27AM BLOOD WBC-8.6 RBC-3.84* Hgb-12.1* Hct-38.4*
MCV-100* MCH-31.6 MCHC-31.6 RDW-12.2 Plt ___
___ 08:55AM BLOOD WBC-10.4 RBC-3.86* Hgb-12.5* Hct-38.3*
MCV-99* MCH-32.4* MCHC-32.6 RDW-12.3 Plt ___
___ 10:30PM BLOOD WBC-11.2* RBC-4.39* Hgb-13.6* Hct-42.9
MCV-98 MCH-30.9 MCHC-31.6 RDW-12.0 Plt ___
___ 10:30PM BLOOD Neuts-71.0* ___ Monos-6.5 Eos-2.0
Baso-0.4
___ 05:27AM BLOOD Glucose-65* UreaN-16 Creat-0.8 Na-140
K-5.0 Cl-106 HCO3-26 AnGap-13
___ 08:55AM BLOOD Glucose-80 UreaN-13 Creat-0.9 Na-139
K-4.6 Cl-106 HCO3-25 AnGap-13
___ 10:30PM BLOOD Glucose-91 UreaN-14 Creat-0.8 Na-138
K-4.2 Cl-104 HCO3-26 AnGap-12
___ 10:30PM BLOOD ALT-12 AST-18 AlkPhos-50 TotBili-0.6
DirBili-0.2 IndBili-0.4
___ 05:27AM BLOOD Calcium-8.4 Phos-1.9* Mg-2.0
___ 08:55AM BLOOD Albumin-3.2* Calcium-7.9* Phos-3.0 Mg-1.8
___ 10:30PM BLOOD Albumin-3.6
___ CHEST (PA & LAT)
IMPRESSION:
Hyperexpanded lungs, compatible with underlying chronic
obstructive pulmonary disease. Bronchial wall thickening may
reflect chronic or acute bronchitis.
Brief Hospital Course:
This is a ___ year old male who was transferred from ___
___ for 1 week of abdominal pain. A right upper quadrant
ultrasound revealed "mild gallbladder wall thickening. No
pericholecystic fluid. CBD 5mm". Cat Scan iamging was also
performed and demonstrated "gallbladder with wall thickening
with surrounding stranding. There is a 4mm stone in the
gallbladder neck. There is no ductal dilation". The patient was
admitted to the Acute Care Service for the ___ of acute
cholecystitis. He was initally started on intravenous fluids and
antibiotics and was kept on strict bowel rest. The patient's
pain was well controlled with intravenous pain medications. He
was transitioned to clear lqiuids when his pain improved, which
he tolerated well. The patient's white blood cell count was
normal during his hospitalization, as well as his liver function
tests and bilirubin. Once he was tolerating clear liquids, the
patient was restarted on all home medications and was taking
oral pain medications. The patient was passing flatus and
experiencing bowel movmements without any difficulty. His vital
signs were stable and he was afebrile on the day of discharge.
He was discharged with a 10 day course of Augmentin and a
followup appointment in the ___ to assess need for future
lap cholecystectomy.
Medications on Admission:
Ibuprofen PRN, ASA 81', Combivent IH q6H PRN
Discharge Medications:
1. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN SOB
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*20 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Ibuprofen 400 mg PO Q8H:PRN pain
RX *ibuprofen 400 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*50 Tablet Refills:*0
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 ___ with cholecystitis, an infection of
your gallbladder. You were kept on strict bowel rest and given
intravenous fluids and antibiotics to decrease the inflammation
around your gallbladder. Upon discharge, you were tolerating a
regular diet and your pain has improved. You will be discharged
with a 10 day course of Augmentin and followup in the ___
in 2 weeks.
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in 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 have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Followup Instructions:
___
|
10441850-DS-22 | 10,441,850 | 23,630,171 | DS | 22 | 2148-03-04 00:00:00 | 2148-03-04 15:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F w/ hx of DM, gout, hypothyroidism, PMR, HLD, HTN, and
dementia p/w syncope. The patient states that she began to feel
unwell yesterday with a feeling of a "topsy-turby" stomach. This
morning she felt fatigued but pushed herself to go to church
where she reportedly had a syncopal episode. She does not
remember it but does not think she had any odd feelings leading
up to LOC. She was reportedly lowered to the floor and did not
hit her head. She denies abd pain, nausea, vomiting, diarrhea,
melena, BRBPR, f/c, cough, SOB, cp, palpitations, urinary
frequency/hesitancy, dysuria. She does note some discomfort with
bowel movements as well as some lightheadedness with standing.
Per recent PCP note, family is concerned about Mrs. ___
deteriorating memory and overall function as she is more
dependent on assistance with basic living activities and had a
few recent episodes of urination and defecation. She has not had
good PO intake and appears more forgetful.
In the ED initial vitals were: 97.8 72 154/100 18 99%
- Labs were significant for WBC 11.8 with 54%PMN, H/H 11.8/36.1,
ALT 10 AST 19 AP 132. Mg 1.3 BUN 38 Cr 1.1 (b/l 0.9-1.1). UA
with ___, +Nit, Sm bld, +pro, few bact, 36 WBC. Troponin
negative x2. CT Head negative, CXR with mild pulm edema.
- Patient was given 1g CTX, IVF
Vitals prior to transfer were: 89 151/69 16 99% RA
On the floor, patient notes continued upset stomach but denies
other complaints.
Review of Systems: As per HPI, otherwise negative.
Past Medical History:
CENTRAL RETINAL VEIN OCCLUSION
CHEST PAIN
CHRONIC COUGH
DIABETES MELLITUS
DIVERTICULOSIS
ENCHONDROMA
GOUT
HEADACHE
HEARING LOSS
HYPERLIPIDEMIA
HYPERTENSION
HYPOTHYROIDISM
PANCREATIC INSUFFICIENCY
POLYMYALGIA RHEUMATICA
SQUAMOUS CELL CARCINOMA
ACTINIC KERATOSIS
SEBORRHEIC KERATOSIS
H/O MULTIPLE ABD SURGERIES
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission phsyical exam:
Vitals - T: 97.3 BP: 173/65->148/76 manual HR: 80 RR: 16 02 sat:
99%RA
GENERAL: Well appearing elderly woman lying in bed in NAD
HEENT: AT/NC, EOMI, pupils equally reactive with R pupil 3mm and
L pupil 4mm, anicteric sclera, dry MM
NECK: JVP ~7mm
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: no cyanosis, clubbing or edema, moving all 4
extremities with purpose. Multiple abrasions on ___ bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, AAOx1-2 (not sure which hospital,
couldn't name date/month/year but knew it was football season),
___ strength in UE and ___ bilaterally
SKIN: warm and well perfused, no rashes
Discharged same day
Pertinent Results:
Admission labs:
___ 03:00PM BLOOD WBC-11.8* RBC-3.76* Hgb-11.8* Hct-36.1
MCV-96 MCH-31.4 MCHC-32.7 RDW-17.0* Plt ___
___ 03:00PM BLOOD Neuts-53.9 ___ Monos-5.8
Eos-15.3* Baso-0.4
___ 03:00PM BLOOD Glucose-132* UreaN-38* Creat-1.1 Na-140
K-4.1 Cl-106 HCO3-23 AnGap-15
___ 03:00PM BLOOD ALT-10 AST-19 AlkPhos-132* TotBili-0.1
___ 03:00PM BLOOD cTropnT-<0.01
___ 09:15PM BLOOD cTropnT-<0.01
___ 03:00PM BLOOD Albumin-3.6 Calcium-9.7 Phos-3.1 Mg-1.3*
MICROBIOLOGY: Bcx x2, Ucx pending
IMAGING:
___ CXR
FINDINGS:
PA and lateral views of the chest provided.
There is no focal consolidation, effusion or pneumothorax.
Subtle ground-glass opacities seen within the lungs on the
frontal projection raising potential concern for mild edema.
Thoracic aorta is moderately calcified. Heart size is within
normal limits. Mediastinal contours unremarkable. Bony
structures are intact. No free air below the right
hemidiaphragm.
IMPRESSION:
Possible mild edema.
___ CT Head w/o con
No acute intracranial abnormality. Tiny hypodensity in the left
cerebellar hemisphere stable since ___, likely representing old
infarct.
EKG: NSR 75, RBBB, PR prolongation, no evidence of ischemia.
Since prior ___, new RBBB, no PR prolongation.
Brief Hospital Course:
Brief hospital course:
___ yo F w/ hx of DM, gout, hypothyroidism, PMR, HLD, HTN, and
dementia p/w syncope, found to have UTI, otitis, and worsening
dementia in the setting of poor PO intake. Syncope workup
otherwise negative.
#UTI: Found to have UA positive for nitrates, bacteria, WBC.
Likely symptomatic in the setting of fatigue and syncope.
Received ceftriaxone in ED. No prior urine culture data to
suggest resistance. Narrowed to augmentin to also cover otitis
(see below).
# Ear pain: Patient complaining of left ear pain, has h/o
otitis. Evidence of mild sinus disease with opacification of the
left middle ear cavity on head CT. Selected antibiotic with
coverage for UTI and otitis: augmentin, 7 day course.
#Syncope: Likely related to UTI and hypovolemia given elevated
BUN. She and family report poor PO intake, including rarely
drinking fluids. +LOC but no head strike per report, no acute
pathology on CT Head. Neurologically intact though does have
anisocoria on exam not previously noted in PCP ___. Trop x2
and EKG unremarkable, unlikely cardiac in nature. No evidence of
valvular disease on exam. New RBBB in isolation is not likely to
cause syncopal episode without evidence of other conduction
abnormalities. Orthostatics negative, but s/p IVF; likely
orthostatic component to syncope given history, labs. Treated
UTI, otitis as above. Received 1L IVF. Monitored on telemetry.
Discontinued HCTZ. Recommend outpatient TTE to complete cardiac
workup.
#Eosinophilia. Absolute coung ~ 1500. Unclear etiology. Unlikely
to have parasitemia with no recent travel history of exposure.
AIN or medications may be more likely etiology, though urine
without evidence of eosinophils. Will repeat diff to determine
if workup necessary.
- trend CBC with diff
#Hypomagnesemia:
-4mg IV mag sulfate
#Dementia: Per PCP notes, has been advancing recently. Family
and PCP discussing next steps including referral to neurology.
Patient not fully oriented, has been incontinent recently, has
abrasions of unknown etiology on ___ bilaterally. On exam, AOx1,
couldn't remember where she lived, per family worsening
baseline.
-___ c/s
#HTN: Discontinue HCTZ, given recent orthostasis, syncope. Held
ACE-i pending rehydration given elevated BUN and Cr at higher
end of baseline. Restarted on discharge.
#DM: Noted in hx, not on any medications. Plasma glucose 132 in
ED. While inpatient
FSG QACHS, HISS, Diabetic diet.
#Gout: continued allopurinol (renally dosed). Discharged on home
dose as she is stable on it.
#Central retinal vein occlusion: continued dorzolamide-timolol.
held PreserVision Lutein for formulary reasons.
#COPD: continued fluticasone nasal, advair
#Hypothyroidism: continued levothyroxine
#PMR: continued prednisone
#Pancreatic insufficiency: continued creon
#HLD: continued simvastatin, ASA
#GERD: continued ranitidine
TRANSITIONAL ISSUES:
[]Continued follow up for dementia, chronic medical issues
[]Consider outpatient TTE to complete cardiac eval for syncope.
[]Eosinophilia noted on ___. Should have outpatient follow up
and possible workup if it does not resolve. Differential
includes parasitemia (unlikely), AIN, medications.
[]Readdress code status.
# Emergency Contact: ___ / ___ / ___
___: children
Phone number: ___ (w)
Cell phone: ___
# Code status: confirmed full
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO DAILY
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
3. Fluticasone Propionate NASAL ___ SPRY NU DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Hydrochlorothiazide 25 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Creon 12 1 CAP PO TID W/MEALS
8. Moexipril 7.5 mg PO DAILY
9. PredniSONE 1 mg PO DAILY
10. Ranitidine 300 mg PO BID
11. Simvastatin 5 mg PO QPM
12. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY
13. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg
(1,500 mg)-800 unit oral daily
14. Aspirin 81 mg PO DAILY
15. PreserVision Lutein (vit C-vit E-copper-ZnOx-lutein)
___-200-5-0.8 mg-unit-mg-mg oral daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Creon 12 1 CAP PO TID W/MEALS
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
5. Fluticasone Propionate NASAL ___ SPRY NU DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Levothyroxine Sodium 100 mcg PO DAILY
8. PredniSONE 1 mg PO DAILY
9. Ranitidine 300 mg PO BID
10. Simvastatin 5 mg PO QPM
11. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg
(1,500 mg)-800 unit oral daily
12. Moexipril 7.5 mg PO DAILY
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY
14. PreserVision Lutein (vit C-vit E-copper-ZnOx-lutein)
226-200-5-0.8 mg-unit-mg-mg oral daily
15. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 875 mg by mouth
every twelve (12) hours Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
syncope
urinary tract infection
dementia
otitis
secondary diagnosis:
hypertension
diabetes
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms ___,
It was a pleasure to care for you at ___. You were admitted
after you lost consciousness and had a fall. This is likely
because of dehydration and dizziness. You were also found to
have a urine infection and possible ear infection which may have
contributed to the fall. Your family also notes that you have
been having worsening confusion which also may have contributed
to this episode. We treated you with antibiotics, followed up
all your imaging and labs to ensure they were normal before
discharging you home.
We wish you all the best.
-Your ___ care team
Followup Instructions:
___
|
10441974-DS-4 | 10,441,974 | 25,328,387 | DS | 4 | 2123-11-27 00:00:00 | 2123-11-29 14:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Painless Jaundice
Major Surgical or Invasive Procedure:
___ - ERCP, sphincterotomy, metal stent placement
History of Present Illness:
This is a ___ year old lady who presents w/ jaundice.
She states that this morning she woke up yesterday and noted
that her eyes were yellow. She also endorses dark urine and pale
stools for the past 1 month. She denies abdominal pain or
fevers. Completely pain free, if anything, the best her abdomen
has felt. She denies tylenol ingestion. Went to the ___ in
___ of this year, no other recent travel. No IVDU. Has a
family history of GB cancer in her mother. Rare ETOH.
Of note, she has recently been evaluated by Dr. ___ in
outpt setting for abdominal pain of 6 mo duration. Abdominal
pain epigastric and radiates throughout body. She had recently
w/ Dr. ___ a screening colonscopy which was largely
normal. Her abdominal pain was initially felt to be NSAID
gastropathy and she was started on ppi. After peristence she was
seen in consultation. An upper encoscopy on ___ showed no
ulcers/gerd/gastropathy. Initial lab w/u on ___ revealed mild
ALT elevation 56 but otherwise unremarkable LFTs.
In the ED, initial VS were:99.6 100 148/98 20 98% RA. Exam was
significant for jaundice, no abdominal pain. Labs were
significant for transaminitis (AST 259, AT 164, AP 278, lipase
247 and tbili 4.5). CBC and chem10 were unremarkable. UA
+ketones and trace leuks.
A CT abdomen demonstrated revealed an incompletely characterized
hypodense mass in the midline of the abdomen, which is likely of
pancreatic origin. Also noted, was moderate intra and
extra-hepatic biliary duct dilation; CBD is 14 mm, presumably
from obstruction by the midline mass. Gallbladder sludge and
gravel stones; no evidence of cholecystitis. A medical bed
request was made for evaluation likely malignancy and painless
jaundice.
Vitals on arrival: ___ 129/88 18 99% RA. She is comfratbale and
denies pain
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies cough, 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.
Past Medical History:
HTN
DM: hba1c 6.8: diet and exercise
Social History:
___
Family History:
The patient's mother passed away from gallbladder cancer. The
patient's father passed away ___ accidental causes. He
has no major medical problems. There is no family history of
diabetes, celiac disease, inflammatory bowel disease or
colorectal cancer.
Physical Exam:
VS T98.2, BP 116/18, HR 66, RR 16, 99% O2 sat on RA
GEN Alert, oriented, no acute distress
HEENT sclera icteric, NCAT MMM EOMI OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
Admission Labs:
___ 09:30PM WBC-6.3 RBC-4.37 HGB-13.1 HCT-41.0 MCV-94
MCH-30.0 MCHC-32.0 RDW-13.1
___ 09:30PM NEUTS-64.3 ___ MONOS-5.4 EOS-1.0
BASOS-0.7
___ 09:30PM GLUCOSE-127* UREA N-9 CREAT-0.7 SODIUM-139
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-27 ANION GAP-15
___ 09:30PM ALT(SGPT)-259* AST(SGOT)-164* ALK PHOS-278*
TOT BILI-4.5*
___ 09:30PM LIPASE-247*
___ 09:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-40 BILIRUBIN-SM UROBILNGN-NEG PH-5.5 LEUK-SM
___ 09:30PM URINE RBC-<1 WBC-5 BACTERIA-NONE YEAST-NONE
EPI-1
Imaging:
Abdominal US ___: 1. Hypoechoic mass in the midline abdomen
likely in the pancreas is incompletely characterized. Given the
location, this is concerning for a pancreatic tumor. Further
evaluation with a CTA of the pancreas is recommended. 2.
Moderate intra- and extra-hepatic biliary duct dilation, likely
from obstruction by the poorly characterized midline mass. 3.
Gallbladder sludge and probable small gravel-like stones; no
evidence of cholecystitis. 4. Echogenic liver, likely due to
fatty deposition; more severe forms of hepatic disease such as
cirrhosis or fibrosis cannot be excluded on the basis of this
exam.
Abdominal CT/CTA ___: Large, locally invasive pancreatic head
and uncinate process adenocarcinoma. Complete encasement of the
superior mesenteric artery for several centimeters including the
origins of several jejunal branches and the middle colic artery.
Occlusion of superior mesenteric vein with marked narrowing of
the portal vein
confluence. No evidence of distant metastasis. There are
multiple small regional lymph nodes without internal necrosis.
Biliary obstruction and upstream dilation of the pancreatic
duct. Bilateral ill-defined renal abnormalities could be from
NSAID use or other medications
ERCP ___: The major papilla was extremely stenotic.
Cannulation attempts with a sphincterotome were unsuccessful
secondary to a long intra-duodenal component of the bile duct
and an extremly stenotic papilla. A pre-cut sphincterotomy was
performed in the 12 o'clock position using a needle-knife, after
cannulation. Cannulation of the biliary duct was successful and
deep with a needle knife catheter after a pre-cut was performed.
Contrast medium was injected resulting in complete
opacification. A small injection of the pancreatic duct was made
while cannulating the bile duct. There was a stricture in the
pancreatic duct in the head of the pancreas. The intrahepatics
were mildly dilated. There was a 2 cm distal CBD stricture with
upstream dilation of the bile duct. I supervised the acquisition
and interpretation of the fluoroscopic images. The image quality
was good. Cytology samples were obtained for histology using a
brush in the distal CBD. Given the pancreatic tumor is locally
advanced and unresectable, A 60 mm by 10 mm Wallflex fully
covered metal biliary stent (Ref ___, ___ ___ was placed
successfully under fluoroscopic and endoscopic guidance.
Fluororscopy confirmed excellent position. There was excellent
flow of black bile and contrast post stent placement. Otherwise
normal ercp to second part of the duodenum.
Discharge Labs:
___ 07:10AM BLOOD WBC-6.3# RBC-4.14* Hgb-12.4 Hct-38.9
MCV-94 MCH-29.9 MCHC-31.9 RDW-12.9 Plt ___
___ 07:10AM BLOOD Glucose-118* UreaN-8 Creat-0.6 Na-138
K-3.8 Cl-102 HCO3-24 AnGap-16
___ 07:10AM BLOOD ALT-261* AST-95* AlkPhos-248*
TotBili-2.3*
Brief Hospital Course:
___ woman with a 6 months history of abdominal pain and early
satietywho presents with a 1 day history of painless jaundice,
found to have elevated TBili with new pancreatic mass.
# Painless Jaundice: Likely secondary to obstruction with
elevated bilirubin, and mass on ultrasound. On admission ___,
LFTs showed ALT 259, AST 164, Alk Phos 278 and TBili 4.5. Lipase
was 247. Abdominal US with biliary dialation, abdominal mass,
likely pancratic. Abdominal CTA on ___ showed pancreatic
head/uncinate mass with involvement of celiac artery, SMA and
SMV. She was seen by pancreatic surgery, who reviewing her
imaging thought the mass was not resectable. Tumor markers
___, CEA) were sent on ___, and CEA was normal at 2.2. She
had an ERCP on ___, which showed stenosis of bile duct,
requiring sphincterotomy and fully covered metal stent
placement. Brushings were obtained for cytology and GI will
coordinate follow up with oncology when cytology results are
back. She was started on IV Cipro. She was kept NPO overnight
and was observed without complications. Her diet was advanced on
___ and she was discharged home on PO Cipro, to complete a 5 day
course on ___. She was also seen by Dr. ___ onc surgery,
who will be following the cytology results and will likely
schedule exploratory laparoscopy and porta-cath placement for
early next week.
# DM2: Elevated Hba1c recently. In setting of above findings,
again concerning for developement of pancreatic malignancy
leading to insulin insufficiency. While inpatient, she was
placed on an insulin sliding scale, with minimal insulin
requirement.
# HTN: Continued home lisinopril 10mg.
----
Transitional issues:
New pancreatic mass
- F/u ERCP cytology
- F/u ___
Medications on Admission:
1. Lisinopril 10 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Vitamin D 800 UNIT PO DAILY
4. Ciprofloxacin HCl 500 mg PO/NG Q12H Duration: 4 Days
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Biliary obstruction
Pancreatic mass
Secondary diagnosis:
Hypertension
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ were admitted to the ___ because ___ were jaundiced. ___
were found to have elevated bilirubin and subsequent imaging
showed obstruction of your gallbladder. ___ were also found to
have a new mass in your pancreas. ___ had a stent placed to
release this obstruction. A sample was taken in order to
identify the mass. ___ will receive a call when the results are
back.
___ should follow up with Dr. ___ ___.
It was a pleasure taking care of ___.
Followup Instructions:
___
|
10442299-DS-10 | 10,442,299 | 21,586,839 | DS | 10 | 2134-01-07 00:00:00 | 2134-01-07 18:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
gluten / Coumadin
Attending: ___.
Chief Complaint:
Malnutrition
Major Surgical or Invasive Procedure:
___ Exploratory laparotomy with washout AND ___
gastrojejunostomy
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ male with gastroparesis and celiac disease with
severe malnutrition with chronic NJ tube feeding presenting with
feed intolerance.
Patient was admitted in early ___ for work up of celiac
disease
as well as ongoing nutritional concerns for significant weight
loss. His nutritional deficieny was believed to be
multifactorial
secondary to celiac, mesenteric adenopathy, and gastroparesis
i/s/o Type I DM. He was found at that time on biopsy to have a
variant of Refractory Celiac Disease and was started on
budesonide 9 mg daily (TCR-GR clonal positive). His malnutrition
at that time was otherwise addressed with an NJT placed via
endoscopy and planned for initation with tube feeds with
Glucerna 1.2 at 90 cc/hr, flushes 50 cc q6h, cycled
from 6 ___ to 10 AM. is on chronic NJ feeds.
Unfortunately, since time of discharge patient has had
progressive difficulty with his feeds. He experienced reflux
with
feeds overnight as well as recurrent difficulties with tube
clogging. He was recommended for a video capsule study to
evaluate possible UJ in concurrence with a NJ tube replacement.
NJ tube was replaced with a larger tube by ___, however, he
continued to have nausea and heart burn with epigastric fullness
thereafter with worsening reflux symptoms and esophageal
irritation. Approximately one week ago, patient nausea and
overall dyspepsia worsened and he discontinued his tube feeds.
He
continued regular enteral feeding, however, with reduced
appetite, early satiety and states he has gone days without
eating. Weakness has progressed to the point that he no longer
feels able to stand. His weight has decreased and he is under
100
lb at this time, from 145 ___ years ago. He is additionally
experiencing increasing constipation, without a BM in
approximately 4 days.
Patient outpatient GI provider felt that outpatient management
has become too challenging given his distance from ___ as
well
as dependence on others for rides. He was recommended to present
to ___ for inpatient admission for nutritional support and
further GI work up.
In the ED:
- Initial vital signs were notable for: T: 97.6; BP: 90/51; HR:
90; PO2:99
- Exam notable for: No remarkable findings
- Labs were notable for: Hemoglobin: 11.5; WBC: 4.7; Na: 130
- ED Course: Patient was evaluated by GI and recommended for
admission due to severe malnutrition
Upon arrival to the floor, patient confirms the above history.
Past Medical History:
1. Multicomplicated type I diabetes diagnosed at ___ years old.
Was on an insulin pump that was discontinued in ___.
2. Celiac disease was diagnosed at the age of ___ years old, in
the setting of chronic diarrhea. He initially improved with a
GFD.
3. Hypothyroidism
4. Afib, was initially on warfarin, but because of reduced oral
intake / elevated INR, was discontinued
5. Osteoporosis. s/p right shoulder fracture after a fall
6. Myotonic dystrophy since mid ___. Followed by Dr ___ in
neurology at ___, we do not have these records, but
according to patient, had muscle biopsy and EMG that showed
muscular atrophy. No family history of muscular dystrophy.
Steroids were not tried. No frank dysphagia / aspiration.
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization. No family history of
muscular
dystrophy.
Physical Exam:
ADMISSION EXAM:
VITALS: T: 97.5; BP: 103/63; HR: 120; RR: 18; O2: 95
GENERAL: Cachexia and malnourished, otherwise conversant and
eager to answer questions
HEENT: NCAT. PERRL, EOMI.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No increased work of
breathing.
ABDOMEN: Normal bowels sounds, emaciated. non-tender to deep
palpation in all four quadrants.
EXTREMITIES: Muscle wasting throughout. Able to lift legs to
gravity.
SKIN: Warm. No rash.
NEUROLOGIC: AOx3, symmetric weakness in upper and lower
extremities.
DISCHARGE EXAM:
VITALS: ___ 1532 Temp: 97.4 PO BP: 108/71 HR: 74 RR: 18 O2
sat: 100% O2 delivery: ra
GENERAL: Cachectic male lying in bed in no acute distress
HEENT: MMM, sclerae anicteric
CARDIAC: Soft heart sounds. RRR. No m/r/g appreciated.
LUNGS: CTAB, no w/r/r
ABDOMEN: NABS, soft, nontender, well-healed linear scar in the
mid-abdomen, ___ tube site dressing c/d/i.
EXTREMITIES: warm, no ___ edema. R arm PICC without swelling,
erythema, tenderness.
NEUROLOGIC: AOx3, face symmetric, moves all extremities
Pertinent Results:
ADMISSION LABS:
___ 12:32PM BLOOD WBC-4.7 RBC-3.86* Hgb-11.5* Hct-35.0*
MCV-91 MCH-29.8 MCHC-32.9 RDW-14.1 RDWSD-46.9* Plt ___
___ 12:32PM BLOOD Glucose-213* UreaN-18 Creat-0.7 Na-130*
K-4.3 Cl-98 HCO3-23 AnGap-9*
___ 07:24AM BLOOD ALT-16 AST-26 AlkPhos-124 TotBili-0.8
DISCHARGE LABS:
___ 06:14AM BLOOD WBC-4.5 RBC-3.05* Hgb-9.0* Hct-29.2*
MCV-96 MCH-29.5 MCHC-30.8* RDW-15.2 RDWSD-53.3* Plt ___
___ 06:14AM BLOOD Glucose-253* UreaN-14 Creat-0.4* Na-135
K-5.0 Cl-97 HCO3-24 AnGap-14
___ 06:14AM BLOOD ALT-17 AST-19 AlkPhos-107 TotBili-0.2
___ 06:14AM BLOOD Albumin-3.1* Calcium-8.8 Phos-4.0 Mg-1.6
PERTINENT RESULTS:
___ 04:42AM BLOOD calTIBC-165* VitB12-422 Folate-11
Ferritn-75 TRF-127*
___ 07:15AM BLOOD TSH-10*
___ 07:00AM BLOOD Cortsol-25.0*
___ 06:31AM BLOOD Cortsol-20.7*
___ 06:03AM BLOOD Cortsol-11.3
___ 05:23AM BLOOD CRP-101.3*
___ 05:56AM BLOOD RheuFac-<10
___ 05:56AM BLOOD Lyme Ab-NEG
___ 05:56AM BLOOD HIV Ab-NEG
Small Bowel Enteroscopy: Grade D esophagitis in the distal
esophagus, normal mucosa in the whole stomach, complete villous
blunting, nodularity, and scalloping fold in the second aprt of
duodenum, nodular heaped up mucosa 10 cm in D2; diffuse complete
villous blunting nodularity and scalloping fold of the mucosa
with no bleeding
Perc G/J Tube Check:
IMPRESSION:
Successful placement of a 16 ___ MIC gastrojejunostomy tube
with its tip in the proximal jejunum. The gastric port should
not be used for 24 hours.
CT Abdomen/Pelvis with Contrast:
1. The gastrojejunostomy tube is tracking outside of
gastrointestinal
structures in the abdomen with secondary moderate amount of
free-fluid and
pneumoperitoneum.
2. Portion of free-fluid in the left upper quadrant is rim
enhancing,
concerning for abscesses.
3. The esophagus, stomach, duodenum and jejunum are distended
and fluid-filled
likely secondary to reflex ileus.
4. Bilateral pleural effusions.
CT Chest:
IMPRESSION:
1. No pericardial effusion.
2. Bilateral pleural effusions trace right and large left ,with
adjacent
relaxation atelectasis.
3. No focal consolidation to suggest pneumonia.
Brief Hospital Course:
___ is a ___ man with history of celiac
disease, T1DM, hypothyroidism, Afib not on anticoagulation, and
myotonic dystrophy of unclear etiology, who initially presented
with malnutrition and had ___ tube placed. His course was
complicated by migration of ___ tube, gastric perforation,
peritonitis, which required an Ex Lap/ washout and ___ tube
placement. Cultures from an abscess near the site of gastric
perforation grew lactobacillus and ___, for which he was
treated with antibiotics and antifungals. Patient was followed
by GI and nutrition throughout his hospitalization for treatment
of malnutrition with tube feeds and nutritional supplementation.
He was followed by the ___ management of
his T1DM. He was also started on midodrine for orthostatic
hypotension prior to discharge.
TRANSITIONAL ISSUES:
[] Recommend repeating Chem-10 within 3 days, as patient will
likely require electrolyte repletion.
[] Continue Vital 1.5 Tube Feeds @50 cc/h over 24h for now. GI
will follow up weekly with patient and nurse/ dietitian, and
will help adjust the TFs according to clinical evolution.
[] The patient's Metoprolol was held upon discharge, please
continue to hold until the patient's orthostatic symptoms abate
[] Nutritional Supplementation: to be prescribed by rehab
physician
-- ___ start Vitamin A 10 000 IU daily for 7 days and recheck
the levels
-- Please start Vitamin E 400 IU daily for one month
-- Continue Vitamin D 10 000 IU daily ___ days for a total of 2
months, this regimen was started in ___, so would go up to
___.
-- Continue zinc 220 mg twice daily for one month
-- Resume B12 injection monthly if levels are below normal range
next month
-- Nutritional workup including micronutrients and liposoluble
vitamins in one month.
[] Please repeat TSH on/around ___, per endocrinology
recommendations.
-- Consider referring patient to an endocrinologist for ongoing
management of his hypothyroidism.
[] Please follow up recommendations from ___.
Patient has an appointment scheduled for ___ at
1PM.
[] Please refer patient to a neuromuscular specialist for
further workup/management of his ataxia, as recommended by the
neurologists who saw him as an inpatient.
*GI Contact Info: Mr ___ has our contact information, but
___ can always reach out to us at ___ or
___
MEDICATION CHANGES:
[] Held home budesonide 9mg PO daily
[] Held home metoprolol succinate XL 12.5 mg PO daily
[] Increased levothyroxine from 25 mcg to 50 mcg PO daily
[] Increased zinc sulfate from 220 mg PO daily to BID
[] Started famotidine 20 mg PO QHS
[] Started lansoprazole oral disintegrating tab 15mg (GTube) BID
[] Started midodrine 7.5 mg PO TID
ACUTE/ACTIVE PROBLEMS:
======================
#Celiac Disease
#Severe protein malnutrition
#Weight loss
His weight loss and severe protein calorie malnutrition is
likely multifactorial involving celiac disease, weight loss, and
gastroparesis. He has undergone extensive work up per GI in the
past which was inconclusive for Refractory Celiac Disease with
clonal TCR-GR studies suggestive of refractory disease and/or
collagenous sprue. EGD guided capsule ___ without evidence of UJ
allowing ___ tube placement on ___ c/b ___ tube migration into
the peritoneum. Now with new ___ tube. He was discharged at
goal Tube Feeds (Vital 1.5 @ 50 mL/hr [1800 kcal, 81g pro, 917
mL free H2O]), off TPN ___. He was started on vitamin D and
zinc supplementation. Recommend starting vitamin A
supplementation after discharge. His home budesonide was held
per GI recs.
#Leukocytosis
#Peritonitis/intraabdominal abscess iso ___ tube migration
#S/p ex-lap/washout and ___ tube placement
Gastric perforation s/p ex-lap/washout on ___. Cultures grew
lactobacillus and ___ from abscess near site of gastric
perforation. Completed 10-day course of Fluconazole and Zosyn
(___). Completed 5-day course of ceftaz/flagyl for
peritonitis (___). There was no evidence of leak per CTAP
___, Gastrograffin G-tube study ___.
#Orthostatic Hypotension
Pt was symptomatically hypotensive with sitting up, likely due
to hypovolemia + severe deconditioning vs. dysautonomia. ___
stim test (___) was negative for adrenal insufficiency. Pt has
muffled heart sounds, but CT Chest negative for pericardial
effusion (i.e., no tampanode). He was treated with salt tabs
(NaCl 1g 5x per day and free water flushes through ___ tube 50 mL
Q6H. Started on midodrine on ___ with improvement in
orthostatic symptoms. Patients home Tamsulosin and metoprolol
were held.
#Hyponatremia
Patient with hyponatremia, likely hypovolemic hyponatremia, as
pt is NPO and his Na is responsive to IVF. Treated with salt
tabs and IVF (per above). Sodium stabilized prior to discharge.
#T1DM
Patient was followed closely by ___ during
his hospitalization. He was put on 7U Lantus and insulin sliding
scale. Goal BH 140-180. Prior auth sent for ___ pen
(covered by patient's insurance). Urine albumin showed
microalbuminemia, likely ___ diabetic nephropathy.
#GERD
Patient reports burning in his epigastric area that is constant
and non-radiating. Relieved with daily GTube venting. Treated
with standing lansoprazole, famotidine, and calcium carbonate.
Chloraseptic spray was prescribed for alleviation of throat
irritation.
#BPH:
Initially held home Tamsulosin iso orthostatic hypotension.
Restarted on ___ because of urinary retention.
#Paroxysmal Atrial fib:
Not on anticoagulation given low risk (CHADS2VASC = 1) and
mildly elevated INR ___ malnutrition/Vitamin K absorption. Rates
well controlled off of home metoprolol (held for orthostatic
hypotension).
#Constipation
Treated with miralax, Colace, and senna.
#Acute on Chronic Anemia
No obvious source of bleeding. Iron studies consistent with
mixed picture iron deficiency + anemia of chronic disease (low
TIBC, low serum Fe, normal ferritin, normal MCV, TSAT 17%).
Received 1U pRBCs ___ with appropriate bump. Received 3 doses
of IV iron ___.
#Coagulopathy
Likely ___ vitamin K deficiency iso malnutrition/malabsorption.
s/p 3 doses of Vitamin K ___.
CHRONIC/STABLE/RESOLVED ISSUES:
==============================
#Ataxia: Patient has had difficulty with ataxia since ___ with
extensive outpatient neurology work up notable for axonal
neuropathy of multifactorial etiology. He was evaluated by
neurology inpatient who agree with diagnosis and recommended
laboratory work up below to facilitate outpatient follow up with
neuromuscular specialist:
-MMA (normal), HTLV-1 (neg), HIV (neg), B12 (normal), B1
(elevated), Lyme Ab (normal, RF (normal), SS-A (neg), SS-B
(neg), CK (normal), heavy metals (neg), Copper 70 (low end of
normal).
#Hypothyroidism:
Increased home levothyroxine 25 mcg daily to 50mcg daily given
TSH of 10. Plan for repeat TSH in 5 weeks from ___ (___).
#Nausea/vomiting
Treated with Lorazepam 0.25 mg IV PRN for nausea.
#Hypoxia, resolved
#Third-spacing iso hypoalbuminemia
Hypoxia likely ___ pulmonary edema/pleural effusions due to
hypoalbuminemia from extreme malnourishment ___ severe Celiac
disease and malabsorption. CTAP ___ demonstrating moderate
bilateral pleural effusions and moderate/large ascites.
Interventional Pulm ultrasound ___ showed elevated diaphragms
due to ascites and a L>R pleural effusion. Was saturating well
on room air prior to discharge.
# Peripheral/Scrotal Edema:
Improved, likely in setting of hypoalbuminemia on admission with
increased fluid intake from TPN and PO.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Budesonide 9 mg PO DAILY
2. Calcium Carbonate 500 mg PO QID:PRN dyspepsia
3. Zinc Sulfate 220 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Glargine 12 Units Breakfast
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. Metoprolol Succinate XL 12.5 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Chloraseptic Throat Spray 1 SPRY PO Q6H:PRN throat
irritation
2. Famotidine 20 mg PO QHS
3. GuaiFENesin ___ mL PO Q6H:PRN cough, thin secretions
4. Lansoprazole Oral Disintegrating Tab 15 mg G TUBE BID
5. Midodrine 7.5 mg PO TID
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
7. Vitamin D ___ UNIT PO 5X/WEEK (___) Duration: 8
Weeks
8. Glargine 7 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
9. Levothyroxine Sodium 50 mcg PO DAILY
10. Zinc Sulfate 220 mg PO BID zinc deficiency
11. Calcium Carbonate 500 mg PO QID:PRN dyspepsia
12. Docusate Sodium 100 mg PO BID
13. FoLIC Acid 1 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Tamsulosin 0.4 mg PO QHS
16. HELD- Budesonide 9 mg PO DAILY This medication was held. Do
not restart Budesonide until you talk to your gastroenterologist
17. HELD- Metoprolol Succinate XL 12.5 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until you talk to your primary care doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ACTIVE ISSUES
=========================
#Celiac Disease
#Severe protein malnutrition
#Weight loss
#Peritonitis/intraabdominal abscess
#Gastric perforation
#GERD
#Hypoxia
#Hypoalbuminemia
#T1DM
#Hyponatremia
#Constipation
#Coagulopathy
#Anemia of Chronic Disease
#Iron Deficiency Anemia
#hypothyroidism
#Atrial Fibrillation
#Scrotal Edema
#Hiatal hernia
#Gastroparesis
#Refeeding syndrome
#Vitamin D Deficiency
CHRONIC ISSUES:
#Ataxia
#BPH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You came to the hospital because you were not getting enough
nutrition.
What did you receive in the hospital?
- You had a new feeding tube placed which unfortunately caused a
complication and you had to have surgery to fix what happened.
- You got a new feeding tube.
- You received antibiotics for your abdominal infection
- You received nutrition
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:
___
|
10442386-DS-11 | 10,442,386 | 28,296,526 | DS | 11 | 2179-03-14 00:00:00 | 2179-03-14 14:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
novocaine with adrenaline
Attending: ___.
Chief Complaint:
Right femoral neck fracture
Major Surgical or Invasive Procedure:
Right hip hemiarthroplasty ___
History of Present Illness:
___ otherwise healthy with recent left femoral neck fracture
s/p left hip hemiarthroplasty (Dr. ___,
___ from ___ s/p mechanical
trip and fall from standing with a right displaced femoral neck
fracture. She was out getting coffee at ___ after visiting
the dentist in ___ when she called for a cab to take her
back home to ___. When the cab arrived, it did not pull up
next to the curb, and when she gave the cab driver her walker to
put in the car, she sustained a mechanical trip and fall and
landed directly onto her right hip. Immediate right hip pain and
inability to bear weight. Denies HS or LOC, remembers the entire
event. Denies weakness, numbness, or tingling. Denies pain
elsewhere. Denies other complaints.
Of note, she ambulates with a walker at baseline. Community
ambulatory. Lives at an assisted living facility, ___, in ___ since ___.
Past Medical History:
Herpes zoster
Osteoporosis
Social History:
___
Family History:
___
Physical Exam:
Gen: elderly female in no acute distress
Neuro: alert and interactive
CV: palpable DP pulses bilaterall
PULM: no respiratory distress on room air
RLE: dressing CDI, SILT: MP/LP/SP/DP, Motor: fires
___, palpable DP
Pertinent Results:
___ 11:30AM BLOOD WBC-9.7 RBC-3.95 Hgb-10.9* Hct-33.6*
MCV-85 MCH-27.6 MCHC-32.4 RDW-13.7 RDWSD-42.9 Plt ___
___ 11:30AM BLOOD Glucose-100 UreaN-9 Creat-0.5 Na-133
K-3.3 Cl-95* HCO3-27 AnGap-14
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right hip hemiarthroplasty, which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight-bearing as tolerated in the right lower extremity, and
will be discharged on lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth every
12 hours as needed for constipation Disp #*20 Capsule Refills:*0
3. Enoxaparin Sodium 40 mg SC Q24H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous daily Disp #*14
Syringe Refills:*0
4. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every ___
hours as needed for pain Disp #*30 Tablet Refills:*0
5. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weight-bearing as tolerated right lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- 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:
weight-bearing as tolerated right lower extremity, activity as
tolerated right lower extremity
Treatments Frequency:
daily dry sterile dressing changes
Followup Instructions:
___
|
10442595-DS-11 | 10,442,595 | 26,064,864 | DS | 11 | 2170-10-07 00:00:00 | 2170-10-07 18:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / doxycycline / NSAIDS (Non-Steroidal Anti-Inflammatory
Drug)
Attending: ___.
Chief Complaint:
Dyspnea, recurrent pleural effusion
Major Surgical or Invasive Procedure:
Right sided ___ chest tube insertion (___). removal ___
History of Present Illness:
Ms. ___ is a ___ year old female with PMHx sig for high speed
___ w/9 rib fractures on R side, lung laceration,
grade 3 liver laceration, grade 2 splenic laceration, pubic rami
and left acetabular fractures, post-d/c course complicated by
dyspnea w/R-sided thoracentesis of 1200cc blood tinged fluid on
___, who p/w recurrent dyspnea and OSH CXR showing recurrent
R-sided pleural effusion. Pt denied f/c/ha/abd pain/n/v/d/c. Pt
endorsed pain around site of prior thoracentesis (right
mid-scapular low thoracic region of back).
Past Medical History:
___: ___ ___ resulting in R1-9 Rib fractures, lung
contusion/laceration, liver laceration, splenic laceration;
basal cell carcinoma, H. pylori, HPV, seborrheic keratosis,
dermatitis
PSH: lap chole, basal cell carcinoma excision, lipoma excision,
breast biopsy
Social History:
___
Family History:
Father and mother - HTN, CAD, Osteoarthritis, T2DM, basal and
squamous cell ca. Grand parents - lung CA and HTN, CHF.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.9 107 113/64 22 100% 2L NC
GENERAL: Uncomfortable appearing woman sitting at the bedside
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: Decreased breath sounds on the right, dimmest over the R
lower lung fields, now wheezes, rales or rhonchi
ABDOMEN: nondistended, nontender
BACK: tender to palpation over the R posterior back near the
site
of the chest tube without palpable hematoma
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,
several
atypical nevi and some seborrheic keratosese on the back
LINES: Chest tube in R posterior mid-scap is intact, c/d/I, and
draining with 1000cc of blood-tinged fluid in the Pleurex, to
water seal
discharge:
VS: 97.8PO 121 / 81 R Sitting 71 18 98 Ra
General: resting in bed comfortably
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: no JVD
Lungs: Diminished breath sounds R>L, dull to percussion. Shallow
breaths.
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, no ___ edema
Neuro: A&Ox3, motor function grossly normal. moving all
four extremities.
Pertinent Results:
BLOODWORK
___ 07:49PM BLOOD WBC-11.7* RBC-4.47 Hgb-11.9 Hct-36.8
MCV-82 MCH-26.6 MCHC-32.3 RDW-13.5 RDWSD-40.8 Plt ___
___ 06:07AM BLOOD CRP-125.9*
___ 06:07AM BLOOD Triglyc-131
___ 07:00AM BLOOD WBC-6.3 RBC-4.45 Hgb-11.4 Hct-37.6 MCV-85
MCH-25.6* MCHC-30.3* RDW-13.4 RDWSD-41.4 Plt ___
PLEURAL FLUID TEST RESULTS
___ 06:27PM PLEURAL TNC-___* ___ HCT-LESS THAN
POLYS-39* LYMPHS-30* MONOS-16* EOS-6* MACROPHAG-9*
___ 06:27PM PLEURAL TOT PROT-4.9 GLUCOSE-115 LD(LDH)-253
ALBUMIN-3.2 ___ MISC-BODY FLUID
___ 07:09PM OTHER BODY FLUID PH-7.42
___ 07:10PM PLEURAL TRIGLYCER-64
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Cytology: negative
IMAGING:
Post-Chest Tube CXR:
FINDINGS:
Right-sided pleural catheter seen projecting over the right lung
base. There
is no pneumothorax. Degree of right basilar opacity is similar
compared to
prior exam. Multiple posterior and lateral right rib fractures
are again
noted. Left lung is grossly clear noting low lung volumes.
Cardiomediastinal
silhouette is within normal limits.
CXR: ___
FINDINGS:
Right-sided pigtail pleural drainage catheter remains in similar
position.
Cardiomediastinal silhouette is within normal limits. Small to
moderate
right-sided effusion with subjacent right lower and right middle
lobe
atelectasis is similar in appearance. Left lung remains grossly
clear. No
pneumothorax is seen. Multiple displaced right upper rib
fractures are
unchanged.
CXR: ___
The right-sided pigtail catheter is unchanged.
Cardiomediastinal silhouette
is stable. There are displaced multiple right-sided rib
fractures. Small left
pleural effusions unchanged. No pneumothorax is seen.
Chest CT: ___
1. Interval improvement in right upper and lower lobe
parenchymal contusions
with persistent consolidation in the right lower lobe and
lateral right middle
lobe respectively.
2. There is persistent pleural effusion within the right major
fissure which
is new compared to the prior exam with near complete resolution
of the free
pleural effusion within the right pleural space secondary to
placement of a
right-sided chest tube with tiny locules of air within the right
pleural space
as expected from chest tube placement. The chest tube is
appropriately
positioned within the right pleural space.
3. Unchanged appearance of fractures involving the right first
through ninth
ribs with the right third through ninth ribs being segmental.
Nondisplaced
fractures of the left first and third ribs.
CXR: ___
Right pleural or extrapleural collection increased in the right
lower
hemithorax between ___ and ___ despite the right
basal pigtail
pleural drainage catheter. There has been no subsequent change.
No
pneumothorax. Right lower lobe is better aerated today than it
was on ___. Atelectasis is mild at the base the left lung. Upper lung
clear. Left
pleural effusions small if any. Borderline enlargement of the
cardiac
silhouette exaggerated by low lung volume, is stable since
___.
Pelvic XR ___:
The patient's left sacral fracture and left acetabular fracture
are not well
seen and was best evaluated on the patient's prior CT scan.
Comminuted
fracture left pubic symphysis and the left pubic rami, with mild
displacement
of the fracture fragments, similar to previous. An IUD is
noted. The SI
joints demonstrate normal morphology. Fracture left L5
transverse process.
IMPRESSION:
Multiple fractures.
CXR ___
Slight interval decrease in volume of small to moderate sized
right pleural
effusion. Otherwise stable examination.
Brief Hospital Course:
___ yo F admitted for shortness of breath, dyspnea on exertion,
and recurrent right sided pleural effusion in the setting of
recent polytrauma (MVC ___- resulting in extensive right
sided rib fractures, lung laceration/contusion, liver
laceration, splenic laceration, pelvic fractures.
Ms. ___ was admitted for recurrent right sided pleural
effusion in the setting of R1-9 rib fracture secondary to a
motor vehicle accident. She was seen by interventional
pulmonology upon presentation and treated with a right sided
chest tube, with output of 500cc of fluid. She was admitted to
the medicine service for respiratory monitoring and pain
control. Pleural fluid analysis was consistent with an exudative
effusion (no evidence of infection, cylothorax, malignancy,
presumed to be non-infectious inflammatory effusion). Her
pleural effusion appeared loculated, and she was treated with
tPA via chest tube on ___ with some improvement in chest tube
output. She had minimal residual pleural fluid as of ___ as
detected on lung ultrasound, and was clinically well appearing
(minimal dyspnea on exertion, no oxygen requirement, no
increased work of breathing), and thus her chest tube was felt
to be safe to pull on ___. She tolerated the removal of the
chest tube, and did not develop worsening SOB or DOE for several
hours thereafter. She was started on colchicine for presumed
sympathetic pleural effusion 1 day prior to chest tube removal,
and has been instructed to continue taking 0.6mg cholchicine BID
until her interventional pulmonology follow up in 2 weeks. She
is being discharged with instructions to follow up with
interventional pulmonology in 2 weeks with repeat CXR prior to
appointment. She was also seen by orthopedic surgery as an
inpatient for her pelvic fractures. A pelvic x-ray on ___
revealed normal healing of her pelvic fractures, and she was
given approval to advance to weight bearing as tolerated.
Ms. ___ was continued on her home pain regimen as an
inpatient (tramadol, tizanadine, Tylenol) plus morphine for
break through pain.
TRANSITIONAL ISSUES
[] IP follow up in 2 weeks, plan for repeat XR at that time
-planning to take colchicine for sympathetic effusion until this
follow up
[] currently on tramadol, tizanidine and Tylenol for pain
management. given one week Rx for PRN morphine breakthrough.
Please follow up pain control from chest tube and rib fractures
and its effect on inspiratory effort
[] ortho Surgery follow up for pelvic fractures (scheduled)
-Med changes: added colchicine and PRN morphine for pain
#CODE: Full (presumed)
#CONTACT: ___, mother (___) ___, sister
(___)
=====
Greater than 30 minutes was spent on discharge coordination and
planning.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO TID
2. TraMADol 25 mg PO BID
3. Tizanidine 2 mg PO QHS
4. Tizanidine 2 mg PO BID:PRN pain
5. Ranitidine 150 mg PO QAM
6. melatonin 5 mg oral QHS
Discharge Medications:
1. Colchicine 0.6 mg PO BID pleural effusion
Take 0.6mg by mouth BID (two times a day)
RX *colchicine 0.6 mg 1 (One) capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
2. Morphine Sulfate ___ 15 mg PO Q8H:PRN BREAKTHROUGH PAIN
Duration: 10 Doses
RX *morphine 15 mg 1 tablet(s) by mouth Q8H PRN Disp #*14 Tablet
Refills:*0
3. Acetaminophen 1000 mg PO TID
4. melatonin 5 mg oral QHS
5. Ranitidine 150 mg PO QAM
6. Tizanidine 2 mg PO QHS
7. Tizanidine 2 mg PO BID:PRN pain
8. TraMADol 25 mg PO BID
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
Exudative pleural Effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were hospitalized for management of a recurrent right sided
pleural effusion (fluid between the lungs and rib-cage) in the
setting of recent trauma to the ribs from a motor-vehicle
accident. Your pleural effusion was managed with a chest tube.
Tests on the pleural fluid did not show any signs of infection.
Your effusion was thought to be sympathetic in nature (secondary
to the recent trauma to your ribs and lungs). You were given a
medicine through the chest tube to break up any fibrous
connections that may have been preventing the fluid from
draining. This medicine (tPA) helped to remove additional
pleural fluid. You were subsequently started on colchicine, a
drug to decrease inflammation, for your pleural effusion. You
will continue taking this medication after discharge. Your chest
tube was removed on the day of your discharge by the
inteventional pulmonologists. The interventional pulmonology
team would like you to follow up in clinic in 2 weeks.
You were also seen by the orthopedic team as an inpatient. They
took an x-ray of your pelvis which showed good healing of your
pelvic fractures. You were advanced to weight-bearing as
tolerated status.
Your pain was managed with your home regimen of tramadol,
tizanadine, Tylenol, and morphine as needed. You will be
discharged with a short supply of morphine, and your home
prescriptions for tramadol, tizanadine, and Tylenol.
Should you develop any new or worsening shortness of breath or
new or worsening pain with breathing, you should seek medical
attention. You should also seek medical attention if you develop
fever or any new, concerning signs/symptoms.
Followup Instructions:
___
|
10442625-DS-9 | 10,442,625 | 21,242,977 | DS | 9 | 2171-05-08 00:00:00 | 2171-05-08 14:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 11:15AM BLOOD WBC-4.4 RBC-3.67* Hgb-10.0* Hct-31.8*
MCV-87 MCH-27.2 MCHC-31.4* RDW-12.1 RDWSD-38.2 Plt ___
___ 11:15AM BLOOD Neuts-64.1 ___ Monos-7.3 Eos-2.1
Baso-0.7 Im ___ AbsNeut-2.80 AbsLymp-1.12* AbsMono-0.32
AbsEos-0.09 AbsBaso-0.03
___ 05:11AM BLOOD ___ PTT-25.3 ___
___ 11:15AM BLOOD UreaN-11 Creat-0.6 Na-142 K-4.2 Cl-105
HCO3-25 AnGap-12
___ 11:15AM BLOOD ALT-13 AST-12 AlkPhos-59 TotBili-0.2
___ 11:15AM BLOOD Lipase-70*
___ 11:15AM BLOOD Albumin-4.5 Calcium-9.3
___ 12:35PM BLOOD Lactate-1.2
DISCHARGE LABS:
===============
___ 05:15AM BLOOD WBC-30.9* RBC-3.30* Hgb-9.0* Hct-28.8*
MCV-87 MCH-27.3 MCHC-31.3* RDW-12.6 RDWSD-39.4 Plt ___
___ 05:15AM BLOOD Neuts-87* Bands-9* Lymphs-3* Monos-1*
Eos-0* Baso-0 AbsNeut-29.66* AbsLymp-0.93* AbsMono-0.31
AbsEos-0.00* AbsBaso-0.00*
___ 05:15AM BLOOD Plt Smr-NORMAL Plt ___
___ 05:15AM BLOOD ___ PTT-23.0* ___
___ 05:15AM BLOOD Glucose-121* UreaN-7 Creat-0.6 Na-140
K-3.4* Cl-105 HCO3-25 AnGap-10
___ 05:11AM BLOOD ALT-9 AST-9 LD(LDH)-169 AlkPhos-49
TotBili-0.5
___ 05:15AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.2
MICROBIO:
=========
Urine/Blood cultures negative to date (from ___ to ___
IMAGING:
========
___ Doppler US ___. No evidence of deep venous thrombosis in the visualized right
or left lower
extremity veins.
2. Limited evaluation of the right peroneal veins.
CXR ___
IMPRESSION:
Lungs are clear. Heart size is normal. There is no pleural
effusion. No
pneumothorax is seen. No evidence of pneumonia. There is a
right-sided
Port-A-Cath with its tip in the SVC.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
======================
Ms ___ is a ___ year old woman with Stage IIA ER+PR+HER2- G3 IDC
of the L breast s/p L partial mastectomy x 2 + SLN bx, with C1D1
ddAC who presents with nausea, vomiting, and fever at home. Was
given dexamethasone, Compazine and Ativan with improvement in
her symptoms.
TRANSITIONAL ISSUES:
====================
[] Came in because of nausea/vomiting, fatigue and myalgias in
setting of chemotherapy, seems like was not taking all of her
antinausea medications. Had great improvement with Compazine and
helped simplify her antinausea regimen. F/u nausea, myalgias and
fatigue
ACTIVE ISSUES:
==============
# Nausea and vomiting
Most likely secondary to chemotherapy administration. Only took
one dose of Zofran and dexamethasone at home. Inpatient was
started on her home dexamethasone 4mg BID x 2 days, Compazine,
and Ativan with improvement in her symptoms. She did not have
any benefit from ondansetron so it was stopped. By discharge she
was able to eat a regular diet without vomiting.
# Fever (resolved)
# Leukocytosis
Unclear etiology for fever but could be related to chemotherapy.
Leukocytosis well explained by neulasta, especially with
continued trend upwards to ___ w/o localizing signs or symptoms.
Flu is negative. Cultures were all negative and antibiotics were
not started.
# Hyponatremia, hypovolemic
Likely secondary to nausea and vomiting. Gave IVF with
improvement.
# Anemia
Long standing since at least ___. Reported as iron deficient.
# Stage IIA ER+PR+HER2- G3 IDC L breast
s/p first dose of doxorubicin and cyclophosphamide on ___.
Greater than 30 min were spent in discharge coordination and
counseling
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Dexamethasone 4 mg PO DAILY
Tapered dose - DOWN
2. Ibuprofen Suspension 600 mg PO Q8H:PRN Pain - Mild
3. LORazepam 0.5 mg oral qhs:prn
4. ondansetron 4 mg oral q6-8h:PRN nausea/vomiting
5. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
6. Vitamin E 1000 UNIT PO DAILY
7. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
2. LORazepam 0.5 mg oral qhs:prn
RX *lorazepam [Ativan] 0.5 mg 1 tablet(s) by mouth at bedtime
Disp #*15 Tablet Refills:*0
3. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
4. Vitamin E 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
# Nausea/Vomiting
SECONDARY DIAGNOSES:
====================
# Fever
# Leukocytosis
# Hyponatremia, hypovolemic
# Anemia
# Stage IIA ER+PR+HER2- G3 IDC L breast
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 IN THE HOSPITAL?
- You were admitted for nausea and vomiting
WHAT HAPPENED TO ME IN THE HOSPITAL?
- In the hospital we got blood tests and exams to find out why
you were vomiting. We determined that the nausea and vomiting
was due to your recent chemotherapy. We gave you medications
that helped with your nausea and vomiting and you were able to
eat.
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:
___
|
10442795-DS-20 | 10,442,795 | 25,135,363 | DS | 20 | 2169-06-12 00:00:00 | 2169-06-12 15:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain, BRBPR, nausea/vomiting
Major Surgical or Invasive Procedure:
EGD ___
Colonoscopy ___
History of Present Illness:
HPI(4): Ms. ___ is a ___ female with a history of
Crohn's colitis s/p terminal ileum resection ___ and colectomy
in ___ who presented with abdominal pain and BRBPR.
About 2 days ago on ___, she started to have dark-colored
stools, which are very unusual for her, and then BRBPR (drops of
blood in the toilet and blood on the toilet paper). At baseline,
she normally has ___ stools a day, but sometimes it goes up to
___. She feels like her frequency of stooling is slightly
above
baseline and greater than 10 per day. At the same time that she
developed the bloody stools, she started to have LLQ pain as
well
as rectal pain. The pain is both aching and sharp, constant, and
non-radiating. It does feel like her Crohn's. Nothing makes it
significantly better or worse. The pain has been associated with
nausea and vomiting. She has had a few bouts of emesis with
bright red blood. Her last PO intake was a shake on ___
afternoon. On ___ she was able to eat a meatball and some
carrots.
She woke up sweaty and hot on ___ night. She did not take
her temperature.
Her frequency of stooling has been at her baseline of ___ stools
per day. She also started to have LLQ pain associated with
nausea, vomiting, and coffee-ground emesis. She has only been
able to take in Pedialyte for the past 2 days. She has been
having subjective fevers at home.
Since arrival in the ED, her pain is unchanged. She feels a
little less nauseated since receiving antiemetics and pain meds.
She denies lightheadedness, dizziness, chest pain, shortness of
breath, or palpitations. No coughing. No dysuria. No rashes or
skin changes. No lower extremity edema. She has been walking
around without issues.
For her Crohn's, she is followed by Dr. ___ at the
___. She last saw her about 6 months ago and had a
sigmoidoscopy which appeared normal.
Currently she takes nutraceutical supplements for her Crohn's.
The last time she was on therapy for her Crohn's was ___ years
ago when she was on Remicaide. It worked well for her Crohn's
but
she developed sinus infections so discontinued it. Her Crohn's
has been in remission since then.
Prior to Remicaide she was on ___, and prior to that she was on
Pentasa.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
ED COURSE:
VS: Tmax 98.6, HR ___, BP ___, RR ___, SpO2
96-100% on RA
Exam: Exam notable for significant LLQ TTP w/o R/G.
Labs: CBC wnl, chem7 wnl, AST 98 otherwise LFTs wnl, lipase 61,
CRP 1, UA bland
Imaging: CT abd/pelvis with contrast: s/p total colectomy, no
bowel obstruction
Interventions:
- morphine 4 mg IV x2
- ondansetron 4 mg IV x2
- normal saline 1L x2
- hydromorphone 0.5 mg IV x3
- paroxetine 40 mg PO x1
- pantoprazole 40 mg IV x1
- Lorazepam 0.5 mg IV x1
Consultants: GI - initial recommendations:
-Please send CRP
-IV PPI
-If clinical concern for SBO would have low threshold to place
NGT to Low intermittent suction especially given report of
emesis.
-NPO for now, IVF
Past Medical History:
Crohn's s/p terminal ileum resection ___ and colectomy in ___
Depression and anxiety
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
ADMISSION EXAM(8)
VITALS: T 98.4, HR 94, BP 112/69, RR 16, SpO2 96% on RA
GENERAL: Alert, NAD, appears comfortable laying in bed
EYES: Anicteric, PERRL
ENT: mmm, OP clear
CV: NR/RR, no m/r/g
RESP: CTAB, no wheezes, crackles, or rhonchi
ABD/GI: Soft, ND, TTP in LLQ without guarding or rebound
tenderness, normoactive bowel sounds
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
VASC/EXT: No ___ edema, 2+ DP pulses
SKIN: No rashes or lesions noted on visible skin
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
moves all limbs
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
98.8 PO 115 / 77 76 18 97 RA
GENERAL: Alert, NAD, appears comfortable laying in bed
EYES: Anicteric, PERRL
ENT: mmm, OP clear
CV: NR/RR, no m/r/g
RESP: CTAB, no wheezes, crackles, or rhonchi
ABD/GI: Soft, ND, mild TTP in LLQ without guarding or rebound
tenderness, normoactive bowel sounds
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
VASC/EXT: No ___ edema, 2+ DP pulses
SKIN: No rashes or lesions noted on visible skin
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 02:45AM BLOOD WBC-6.3 RBC-4.14 Hgb-13.2 Hct-40.0 MCV-97
MCH-31.9 MCHC-33.0 RDW-13.6 RDWSD-48.2* Plt ___
___:45AM BLOOD Glucose-84 UreaN-14 Creat-0.8 Na-135
K-6.7* Cl-100 HCO3-24 AnGap-11
___ 02:45AM BLOOD ALT-30 AST-98* AlkPhos-80 TotBili-0.2
___ 02:45AM BLOOD Albumin-4.7
IMAGING:
CT ABD/PELVIS:
1. No findings to explain the patient's symptoms. Specifically,
no bowel obstruction.
2. Status post total colectomy.
EGD: Mild gastritis likely due to NSAID use.
Colonoscopy: Mild stable ulcer in the rectum previously biopsied
with outpatient GI provider. No other findings.
DISCAHRGE LABS:
___ 06:55AM BLOOD WBC-4.5 RBC-3.37* Hgb-10.7* Hct-33.2*
MCV-99* MCH-31.8 MCHC-32.2 RDW-13.5 RDWSD-48.6* Plt ___
___ 06:45AM BLOOD Glucose-83 UreaN-8 Creat-0.7 Na-142 K-3.9
Cl-106 HCO3-29 AnGap-7*
Brief Hospital Course:
___ female with a history of Crohn's colitis s/p
terminal ileum resection ___ and colectomy
in ___ who presented with abdominal pain and BRBPR.
# Crohn's colitis
# LLQ abdominal pain
# BRBPR
# Nausea/vomiting, ?hematemesis
Unclear etiology of abdominal pain, BRBPR, and nausea/vomiting.
The patient has had recent work up at ___ without clear
etiology. CRP is 1. CT abd/pelvis was unrevealing for etiology
of the patient's pain and symptoms. GI consulted and
EGD/Colonosocppy was negative unremarkable. She was tapered off
opiate pain medication given lack of source for pain. She was
offered non-narcotic pain control with acetaminophen, bentyl,
simethicone, and gabapentin. She reported continued nausea and
pain at tme of discharge but was hemodynamically stable and able
to tolerate PO and maintain hydration without need for IV
fluids. She reported nausea but no vomiting.
CHRONIC/STABLE PROBLEMS:
# Anxiety/depression - Continued home mirtazapine and paroxetine
Greater than 30 minutes was spent in care coordination and
counseling on the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mirtazapine 15 mg PO QHS
2. PARoxetine 40 mg PO DAILY
3. VSL#3 (Lactobac #2-Bifido #1-S. therm) 112.5 billion cell
oral DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*50 Tablet Refills:*0
2. DICYCLOMine 10 mg PO TID
RX *dicyclomine 10 mg 1 tablet(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
3. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*60 Capsule Refills:*0
4. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*28
Capsule Refills:*0
5. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *ondansetron 4 mg 1 tablet(s) by mouth Every 8 hours as
needed Disp #*10 Tablet Refills:*0
6. Mirtazapine 15 mg PO QHS
7. PARoxetine 40 mg PO DAILY
8. VSL#3 (Lactobac #2-Bifido #1-S. therm) 112.5 billion cell
oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms ___,
It was a pleasure taking care of you while you were in the
hospital. You were admitted with abdominal pain and underwent an
evaluation for the cause. You underwent an EGD and Colonoscopy
to evaluate the cause. This did not show a cause of your pain
that would need intervention. You were tapered off of the
narcotic pain medication and started on several other
medications for your pain.
Please take you medications as directed and follow up as noted
below.
Followup Instructions:
___
|
10443924-DS-2 | 10,443,924 | 24,252,593 | DS | 2 | 2172-12-13 00:00:00 | 2172-12-13 16:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain and fever
Major Surgical or Invasive Procedure:
Liver biopsy
History of Present Illness:
This is a year-old with the history below who presented to
___ with abdominal pain. Pt says the pain is in
the RUQ and radiates across the abdomen, constant with
intermittent worsening, not a/w n/v but with poor PO intake. He
notes regular stools w/o diarrhea or blood in them, no jaundice.
He does endorse 2 days of cough w/o sputum production. Denies
fevers, dysuria, increased urine frequency. Given the language
barrier, I was unable to obtain more detailed information.
He presented to ___ today with stable vitals. Labs showed
WBC 14, UA with 14 WBCs, Na 129, Cr 1.1, Hb ___. CT Abd w/
contrast showed liver with innumerable heterogeneous masses and
a destructive lytic lesion at T11 with marked cortical
thickening and suspected cortical breakthrough. Also noted R>L
basilar lung consolidation c/f atelectasis v. pna. Pt
transferred to ___ for further w/u.
On arrival here, febrile but stable VS. Labs noted WBC 16, H/H
10.2/31, INR 1.4, UA with no WBCs, CXR with R>L basilar
opacities.
Past Medical History:
Hypothyroidism
Hyperlipidemia
Iron Deficiency Anemia
s/p L TKR
Social History:
___
Family History:
Has 3 healthy daughters
Physical ___:
ADMISSION
VS: Febrile on arrival to ER.
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: dry mm, oropharynx without exudate or lesions, no
supraclavicular or cervical lymphadenopathy, no JVD, no carotid
bruits, no thyromegaly or palpable thyroid nodules
Respiratory: CTA b/l with good air movement, decreased breath
sounds both bases.
Cardiovascular: RR, S1 and S2 wnl, +mitral murmur,
Gastrointestinal: liver palpable 3-4 cm below costal margin,
ttp.
+b/s but diminished, soft
Extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date. ___ strength
throughout. Psychiatric: pleasant, appropriate affect
GU: no catheter in place
DISCHARGE:
VS: 97.4, 158/78, 92, 16, 96% on RA
Gen: Lying in bed, comfortable appearing, thin elderly male
HEENT: EOMI, MMM, PERRL, anicteric
CV: RRR, normal s1s2, no m/r/g
Pulm: Decreased breath sounds R base, otherwise CTA
Abd: Soft, mildly tender to deep palpation
MSK: TLSO brace in place
Skin: No rashes
EXT: 2+ DP/radial pulses
Neuro: AOx3, no focal deficits
Pertinent Results:
ADMISSION LABS:
===============
___ 08:00PM GLUCOSE-122* UREA N-18 CREAT-1.1 SODIUM-131*
POTASSIUM-4.8 CHLORIDE-94* TOTAL CO2-23 ANION GAP-19
___ 08:00PM estGFR-Using this
___ 08:00PM ALT(SGPT)-148* AST(SGOT)-182* ALK PHOS-498*
TOT BILI-1.6*
___ 08:00PM LIPASE-21
___ 08:00PM ALBUMIN-3.3* CALCIUM-9.4 PHOSPHATE-3.2
MAGNESIUM-1.8
___ 08:00PM WBC-16.0* RBC-3.55* HGB-10.2* HCT-31.1*
MCV-88 MCH-28.7 MCHC-32.8 RDW-15.8* RDWSD-50.4*
___ 08:00PM NEUTS-80.8* LYMPHS-9.7* MONOS-8.5 EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-12.96* AbsLymp-1.55 AbsMono-1.37*
AbsEos-0.01* AbsBaso-0.05
___ 08:00PM PLT COUNT-265
___ 08:00PM ___ PTT-34.9 ___
================================================
DISCHARGE LABS:
===============
___ 07:19AM BLOOD WBC-12.0* RBC-3.51* Hgb-10.1* Hct-30.7*
MCV-88 MCH-28.8 MCHC-32.9 RDW-18.2* RDWSD-57.7* Plt ___
___ 07:19AM BLOOD ___ PTT-34.8 ___
___ 07:19AM BLOOD Glucose-103* UreaN-13 Creat-0.6 Na-128*
K-4.6 Cl-
93* HCO3-22 AnGap-18
___ 07:19AM BLOOD ALT-76* AST-189* AlkPhos-720* TotBili-1.5
___ 07:19AM BLOOD Calcium-9.7 Phos-2.7 Mg-1.8
___ 06:40AM BLOOD calTIBC-209 Ferritn-2851* TRF-161*
___ 06:44AM BLOOD CEA-4.2*
___ 06:40AM BLOOD PSA-5.8*
CA ___: Negative
LIVER BIOPSY (___):
Liver, core needle biopsy:
- Poorly differentiated carcinoma (See note).
- GATA3 positive
Note: Immunohistochemical stains are performed. The tumor cells
are positive for cytokeratin AE1/3&CAM5.2, CK7, glypican (focal)
and p63 (patchy). The tumor is negative for CK20, TTF-1, Napsin,
CDX-2, chromogranin, synaptophysin, PSA, and PSAP. HepPar shows
rare cells with
positive staining possibly entrapped hepatocytes. Possible
primaries include urothelial, upper GI, and pancreatobiliary
sites. A liver primary cannot be completely ruled out.
Additional stains (GATA3, CD10, Arginase 1) will be performed
and reported as an addendum.
RUQ ULTRASOUND (___):
1. Heterogeneous appearance of the liver compatible with
intrahepatic
metastases. No intrahepatic biliary dilation.
2. Reversal of flow in the main and right portal veins, which
are patent.
CT CHEST WITH CONTRAST (___):
1. No primary pulmonary mass identified.
2. 6 mm nodular opacity in the left lung apex and 4 mm nodule in
the right
upper lobe.
3. Peribronchiolar nodularity in the lateral left upper lobe may
be infectious or inflammatory.
4. Right lower lobe consolidation, unclear if due to adjacent
small right
pleural effusion. However, this would be slightly greater than
expected for the amount of pleural fluid.
5. No mediastinal or hilar lymphadenopathy. Enlarged left
axillary lymph
nodes and lymph nodes along the left internal jugular chain.
6. Lytic osseous lesion involving the right pedicle and
transverse process of the T11 vertebral body.
MRI THORACIC AND LUMBAR SPINE (___):
1. Right T11 pedicle expansile enhancing lesion, without extra
osseous
extension, and right T10 enhancing 6 mm pedicle lesion
concerning for osseous metastatic disease.
2. Nonspecific diffuse nonenhancing marrow signal concerning for
hematopoietic marrow, with infiltrative process less likely.
Recommend clinical correlation and correlation with CBC.
3. Limited liver imaging demonstrates numerous nonspecific
enhancing lesions.
4. 6 mm left upper lobe pulmonary nodule and small right pleural
effusion with adjacent atelectasis and/or airspace disease.
Please refer to chest CT performed on same day this examination
for description of non thoracic spine structures.
5. Multilevel degenerative changes of lumbar spine in addition
to congenitally short pedicles, as described, greatest from
L3-S1 where there is between moderate and severe spinal canal
stenosis.
RECOMMENDATION(S): Nonspecific diffuse nonenhancing marrow
signal concerning for hematopoietic marrow, with infiltrative
process less likely. Recommend clinical correlation and
correlation with CBC.
Brief Hospital Course:
This is a ___ year old male with past medical history of recent
knee replacement, hypothyroidism, who presented with progressive
back and abdominal pain, found to have new liver, lung and
vertebral findings concerning for metastatic process.
# LIKELY METASTATIC UROTHELIAL CANCER:
As above, patient presented with progressive back and abdominal
pain and was found to have diffusely metastatic disease to the
lung, liver and spine. Heme/Onc was consulted, who recommended
liver biopsy. A liver biopsy was performed, which showed poorly
differentiated adenocarcinoma. GATA3 stain was positive, which
confirmed urothelial cancer. Negative tests included CEA, PSA,
CA ___, and other immunohistochemical stains as above. Patient
was seen by spine surgery, who recommended TLSO brace, but did
not feel any intervention was necessary at this time. He was
seen by physical therapy, who recommended rehab after discharge.
He was written for morphine PRN, however he required it very
rarely. The heme/onc team recommended that patient first go to
rehab prior to any decision regarding chemotherapy, as they felt
he would need to improve his strength first. He was scheduled
for oncology follow-up on ___ at 9AM with Dr. ___.
# TRANSAMINITIS:
Patient was found to have abnormal LFTs with elevated alkaline
phosphatase, likely related to his metastatic liver disease.
Liver ultrasound was obtained which did not show any reason for
this transaminitis other than metastatic disease, without
evidence of obstruction. There may also be some component of
skeletal alkaline phosphatase given the known skeletal mets,
however GGT was also elevated, suggesting liver origin.
# HYPONATREMIA:
Patient's sodium varied between 128 and 132. He had no symptoms
of hyponatremia. Urine lytes showed a FeNa of <1%, suggesting
volume depletion. He was given normal saline boluses, however
had minimal improvement. There is likely some component of both
volume depletion with appropriate ADH release, and possible
SIADH related to his newly diagnosed malignancy. His sodium
should be rechecked within a few days after discharge to ensure
it is improved or at least relatively stable. Consider renal
consultation if hyponatremia worsens.
# COMMUNITY ACQUIRED PNEUMONIA:
Patient had possible pneumonia on chest x-ray for which
treatment was initiated at He was treated for community acquired
pneumonia as was noted initially at ___. He
completed a 7 day course of levofloxacin. It may be that his
initial fever was related to his metastatic disease, though he
did not have any other fevers after completing antibiotics.
TRANSITIONAL ISSUES:
[ ] Please check sodium in 3 days to ensure it is improved or at
least relatively stable.
[ ] Make sure patient comes to ___ Oncology appointment to
discuss treatment options.
[ ] Titrate pain meds as needed. Patient has required minimal
pain medication while in the hospital.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Zolpidem Tartrate 5 mg PO QHS
2. Simvastatin 40 mg PO QPM
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Simvastatin 40 mg PO QPM
4. Zolpidem Tartrate 5 mg PO QHS
5. Lorazepam 0.5 mg PO BID:PRN Anxiety/dyspnea
RX *lorazepam [Ativan] 0.5 mg 1 tab by mouth BID:PRN Disp #*10
Tablet Refills:*0
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Q6H:PRN Disp #*10 Tablet
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Metastatic cancer, likely urothelial origin
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 for abdominal pain. We found that you had
several areas in the liver, the lungs, and the spine that were
concerning for cancer. We performed a biopsy of your liver that
showed this was cancer. We discussed this with you and your
family.
You will be seeing the cancer doctors in the ___ on ___ to
discuss this new diagnosis further. They will discuss the
possible treatment options with you at that time.
Before you can get treatment, you first need to go to rehab to
work on increasing your strength. If you do receive treatment
for your cancer, it will be important that you be as strong as
possible so that you tolerate the treatment.
Because of the area in your spine involved by the cancer, we put
a brace on you to help support you when you sit up or walk.
Physical therapy has recommended that you go to a rehab to get
stronger.
You have been started on a medication to help with your pain
(oxycodone). If you have pain, please let your doctors and
___ know so that it can be treated appropriately.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10444108-DS-19 | 10,444,108 | 29,709,801 | DS | 19 | 2117-05-29 00:00:00 | 2117-05-30 11:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
left TPC placement
History of Present Illness:
___ yo M with a history of metastatic renal cell cancer s/p L
nephrectomy ___ followed by RML and RL lobectomy in ___
followed by a drug trial at ___ with Atezolizumab and
Bevacizumab stopped in ___ who presents with worsening
SOB.
Patient described a productive cough and progressive SOB since
___. Also gives history of central chest pain that started
in 9 AM and resolved completely at 12 p.m.
In the ED, initial VS were 0 98.1 72 130/78 18 98% RA .
Exam notable for not recorded
Labs showed WBC 11.7, BNP 2550,
Imaging showed
IMPRESSION:
No substantial interval change from the previous exam status
post right middle and lower lobectomies. Small loculated right
hydropneumothorax, as seen previously and similar small left
pleural effusion with bibasilar atelectasis.
Received Benadryl
Transfer VS were 0 97.7 76 141/72 15 96% Nasal Cannula
IP were consulted
On arrival to the floor, patient reports that he has had SOB x
several months. It was a little worse prior to presentation. He
has no other associated sx. Denies F/C, N/V, SOB (current),
chest pain/dizziness, constipation/diarrhea, abdominal pain.
Past Medical History:
Dementia
Hearing loss
Cervical radiculopathy
Lumbar radiculopathy
Raynaud's disease
Pyelonephritis
Malignant neoplasm of prostate
Multiple lung nodules on CT
Malignant neoplasm of skin
Adenomatous polyp of colon
Sleep apnea
Primary malignant neoplasm of left kidney with metastasis from
kidney to other site
Renovascular hypertension
Shortness of breath
Acute-on-chronic kidney injury
Rash
Atrial fibrillation
Encounter for counseling for care management of patient with
chronic conditions and complex health needs using nurse-based
model Cough
CMTD ___ disease)
Status post partial lobectomy of lung
Routine health maintenance
Goals of care, counseling/discussion
Acute cystitis
Localized edema
Atherosclerosis of native coronary artery without angina
pectoris
Mild cognitive impairment
Simple chronic bronchitis
Pleural effusion
s/p left radical nephrectomy
___
Social History:
___
Family History:
Mother: ___ cancer
Father: ___ cancer
Sister: ___
Sister: COPD - non-smoker
Sibling: Passed age ___ Leukemia
Son: OSA, rheumatoid arthritis, sjogrens
Physical Exam:
Admission Physical Exam:
===============
VS: 98.2 Axillary 148 / 78 64 18 96 2L NC
GENERAL: NAD, sleepy but arousable
HEENT: AT/NC
NECK: supple
HEART: RRR, distant heart sounds
LUNGS: NC in place, decreased breath sounds at bases, no
wheezes, breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: 1+ edema
NEURO: A&O, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical Exam:
===============
VITALS: 98.1 114/74 76 20 95% 2L NC
GENERAL: Alert, no acute distress and tachypnea much improved
HEENT: oropharynx clear
NECK: Supple, JVP is elevated
RESP: able to take deep breaths, crackles present ___ but
improving, no wheeze
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
ABD: soft.
GU: no foley
EXT: 1+ pitting edema to mid calf
NEURO: grossly normal
Pertinent Results:
Admission Labs:
=========
___ 06:25PM BLOOD WBC-11.7* RBC-5.24 Hgb-13.2* Hct-41.4
MCV-79* MCH-25.2* MCHC-31.9* RDW-15.2 RDWSD-43.5 Plt ___
___ 06:25PM BLOOD Neuts-83.2* Lymphs-9.5* Monos-5.0 Eos-1.5
Baso-0.3 Im ___ AbsNeut-9.75* AbsLymp-1.12* AbsMono-0.59
AbsEos-0.18 AbsBaso-0.04
___ 06:25PM BLOOD ___ PTT-26.8 ___
___ 06:25PM BLOOD Glucose-121* UreaN-17 Creat-1.1 Na-135
K-4.9 Cl-100 HCO3-24 AnGap-16
Discharge Labs:
=========
___ 06:57AM BLOOD WBC-18.3*# RBC-4.98 Hgb-12.3* Hct-39.0*
MCV-78* MCH-24.7* MCHC-31.5* RDW-15.2 RDWSD-42.9 Plt ___
___ 06:57AM BLOOD Glucose-132* UreaN-29* Creat-1.5* Na-132*
K-4.5 Cl-96 HCO3-27 AnGap-14
Other Pertinent Labs:
=============
___ 06:25PM BLOOD cTropnT-<0.01 proBNP-2550*
___ 10:00PM BLOOD CRP-44.1*
Imaging:
=====
CXR ___:
No substantial interval change from the previous exam status
post right middle
and lower lobectomies. Small loculated right hydropneumothorax,
as seen
previously and similar small left pleural effusion with
bibasilar atelectasis.
CXR ___:
Portable left lateral decubitus view of the chest .
Left chest tube is seen. There are small layering left pleural
effusion.
Small 2 moderate right pleural effusion is stable.
Cardiomediastinal
silhouette stable.
IMPRESSION:
Small left pleural effusion. Small to moderate right pleural
effusion
Brief Hospital Course:
Mr. ___ is a ___ yo M with a history of metastatic renal cell
cancer s/p L nephrectomy ___ followed by RML and RL lobectomy
in ___ followed by a drug trial at ___ with Atezolizumab and
Bevacizumab stopped in ___ who presented with worsening
SOB. He was enrolled in a clinical trial for a left TPC (chest
tube) on ___. Following the procedure he had some chest
discomfort.
In regards to his RCC the family expressed wanting to see an
oncologist at ___ for another opinion regarding his treatment
options. However, on day 2 we had a goals of care discussion
with patient and his family, he would like to be made
comfortable and is not interested in seeing new physicians. He
is not leaving on hospice but may transition moving forward.
Finally, on day of discharge his crt was 1.5. He received 500 cc
bolus as this was thought to be due to prerenal from poor PO
intake following chest tube placement and pain. He should have ___
repeat crt check in 1 week.
Transitional Issues:
===================
- would recommend continued discussions regarding goals of care,
patient and family expressed interest in learning more about
hospice
- Daily drainage until follow-up appointment with IP, drain
until patient reports discomfort or cough
- please repeat chem panel in 1 week
- patient given script for oxygen so he could have smaller
portable tank
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO DAILY
RX *bisacodyl [Correctol] 5 mg 1 tablet(s) by mouth daily PRN
Disp #*30 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Stool Softener] 100 mg 1 capsule(s) by
mouth twice a day Disp #*60 Capsule Refills:*0
4. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*10 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 10 mg PO Q3H:PRN Pain - Severe
Try acetaminophen first.
RX *oxycodone 5 mg ___ capsule(s) by mouth every 3 hours Disp
#*20 Capsule Refills:*0
6. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [Senna Lax] 8.6 mg 1 capsule by mouth twice a day
Disp #*60 Tablet Refills:*0
7. Omeprazole 40 mg PO DAILY
8.oxygen
Titrate patient to keep saturation above 90% and evaluate
patient for portable oxygen concentrator.
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary diagnosis:
malignant effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
Why was I here?
- You had shortness of breath.
What was done while I was here?
- You got a chest tube put in to help with your shortness of
breath.
What should I do when I get home?
- Take all your medicine as prescribed.
Followup Instructions:
___
|
10444108-DS-21 | 10,444,108 | 22,306,794 | DS | 21 | 2118-08-10 00:00:00 | 2118-08-10 20:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___
___ Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with metastatic RCC (s/p L
nephrectomy, RML and RLL lobectomy, previously on
atezolizumab/bevacizumab but stopped ___ SOB), cognitive
impairment, CKD (b/l Cr ~1.0), HTN, Afib (not on AC), and
multiple recent admissions for multifactorial SOB (s/p RML/RLL
resection, pleural effusions, ?HFpEF, ?PNA) who presented again
with worsening SOB and was found to be hyponatremic (Na 119) and
so admitted to ___, now improving and transferred to floor.
He was recently admitted ___ with multifactorial SOB. He was
diuresed and discharged on Lasix 20mg PO QD (new med), treated
for PNA, and discharged back on RA/home 1L NC. GOC conversations
this admission resulted in patient electing to be DNR/DNI with
plans for further discussion with outpatient providers before
considering hospice.
He returned to the hospital with two weeks of worsening
shortness
of breath. In the ED, labs showed WBC 15.9 and Na 119. CTA chest
showed possible RUL PNA. CTH showed possible brain mets. Given
significant hyponatremia he was admitted to the FICU.
In the ICU, for his hyponatremia renal was consulted. Serum Osm
255, Urine Osm 365, Urine Na 65 overall c/w multifactorial HoNa
related to diuretic use w/ low solute intake, SIADH related to
PNA, malignancy w/ brain mets, cerebral salt wasting, and
possibly oxcarbazepine (longstanding medication). He was treated
with fluid restriction and Na improved from 119 --> 129 over the
next ___ hours (4pm yesterday to 8am this AM). Given c/f
overcorrection renal recommeneded removing fluid restriction and
last Na at 1pm 128.
For his dyspnea, he was treated with vancomycin and levofloxacin
for PNA seen on CTA. Of note, UCx from ___ growing
>1000 CFU klebsiella sensitive to cipro/levo, cefazolin,
bactrim,
zosyn.
On encounter this afternoon he reports that his breathing feels
somewhat "labored", but much improved from when he arrived. He
denies pain anywhere. He is not sure of the circumstances
surrounding why he came to the hospital.
Past Medical History:
Dementia
Hearing loss
Cervical radiculopathy
Lumbar radiculopathy
Raynaud's disease
Pyelonephritis
Malignant neoplasm of prostate
Multiple lung nodules on CT
Malignant neoplasm of skin
Adenomatous polyp of colon
Sleep apnea
Primary malignant neoplasm of left kidney with metastasis from
kidney to other site
Renovascular hypertension
Shortness of breath
Acute-on-chronic kidney injury
Rash
Atrial fibrillation
Encounter for counseling for care management of patient with
chronic conditions and complex health needs using nurse-based
model Cough
CMTD ___ disease)
Status post partial lobectomy of lung
Routine health maintenance
Goals of care, counseling/discussion
Acute cystitis
Localized edema
Atherosclerosis of native coronary artery without angina
pectoris
Mild cognitive impairment
Simple chronic bronchitis
Pleural effusion
s/p left radical nephrectomy
___
Social History:
___
Family History:
Mother: ___ cancer
Father: ___ cancer
Sister: ___
Sister: COPD - non-smoker
Sibling: Passed age ___ Leukemia
Son: OSA, rheumatoid arthritis, sjogrens
Physical Exam:
GENERAL: Alert and in no apparent distress, chronically ill
appearing elderly man, conversant, laying in bed
EYES: Anicteric
ENT: Ears and nose without visible erythema, masses, or trauma.
Hard of hearing. Oropharynx without visible lesion, erythema or
exudate.
CV: RRR, no murmur. 2+ radial and pedal pulses bilaterally.
RESP: Lungs clear to auscultation bilaterally, no
wheezes/crackles, but decreased breath sounds. Breathing
is non-labored on room air. Speaking in full sentences.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No Foley
MSK: Neck supple, moves all extremities, trace bilateral ankle
edema.
SKIN: No rashes. Blanchable erythema over sacrum with no open
areas.
NEURO: Alert, oriented to person/place, face symmetric, EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect, calm, cooperative
Pertinent Results:
ADMISSION LABS:
___ 10:28AM WBC-15.9* RBC-4.92 HGB-13.3* HCT-38.4*
MCV-78* MCH-27.0 MCHC-34.6 RDW-14.4 RDWSD-40.3
___ 10:28AM NEUTS-90.7* LYMPHS-2.8* MONOS-5.6 EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-14.37* AbsLymp-0.45* AbsMono-0.89*
AbsEos-0.02* AbsBaso-0.03
___ 10:28AM PLT COUNT-224
___ 10:28AM ___ PTT-28.7 ___
___ 10:28AM GLUCOSE-111* UREA N-16 CREAT-1.0 SODIUM-122*
POTASSIUM-5.4 CHLORIDE-84* TOTAL CO2-24 ANION GAP-14
___ 10:28AM estGFR-Using this
___ 10:28AM ALT(SGPT)-16 AST(SGOT)-17 CK(CPK)-30* ALK
PHOS-166* TOT BILI-0.6
___ 10:28AM CK(CPK)-33*
___ 10:28AM cTropnT-0.02*
___ 10:28AM CK-MB-4 proBNP-6131*
___ 10:28AM ALBUMIN-3.9 CALCIUM-10.1 PHOSPHATE-3.7
MAGNESIUM-2.0
___ 10:39AM ___ PO2-32* PCO2-53* PH-7.35 TOTAL
CO2-30 BASE XS-1 INTUBATED-NOT INTUBA
___ 10:37AM LACTATE-1.4
___ 10:42AM URINE RBC-4* WBC-6* BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:42AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD*
___ 10:42AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:42AM URINE OSMOLAL-365
___ 10:42AM URINE HOURS-RANDOM CREAT-34 SODIUM-65
CHLORIDE-70
___ 03:45PM OSMOLAL-255*
___ blood culture no growth
MRSA swab positive
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
DISCHARGE LABS:
___ 07:37AM BLOOD WBC-9.1 RBC-4.36* Hgb-11.6* Hct-34.6*
MCV-79* MCH-26.6 MCHC-33.5 RDW-14.4 RDWSD-41.5 Plt ___
___ 08:52PM BLOOD Neuts-88.1* Lymphs-3.8* Monos-7.1
Eos-0.2* Baso-0.2 Im ___ AbsNeut-11.36* AbsLymp-0.49*
AbsMono-0.91* AbsEos-0.03* AbsBaso-0.03
___ 07:37AM BLOOD Plt ___
___ 06:52AM BLOOD Glucose-103* UreaN-21* Creat-1.1 Na-135
K-4.9 Cl-97 HCO3-25 AnGap-13
___ 07:37AM BLOOD Calcium-10.3 Phos-3.4 Mg-2.1
IMAGING:
CXR (___):
There is stable volume loss in the right hemithorax pleural
thickening pleural effusion on the right. The left loculated
effusion has improved. The component within the fissure is no
longer seen. Cardiomediastinal silhouette is stable.
Interstitial edema has slightly worsened. No pneumothorax is
seen. No new consolidations concerning for pneumonia.
CTA Chest (___):
1. Ground-glass opacities and partial nonenhancing consolidation
of the right upper lobe, likely represents infection, likely
also with a component of atelectasis.
2. In comparison with prior, there has been an interval decrease
in size of the right hydropneumothorax. Persistent thickening
of
the pleura at the right base may reflect prior intervention
however metastatic disease cannot be excluded.
3. Postsurgical changes from right lower and middle lobectomies
are noted.
4. Small left pleural effusion with a loculated component at the
lung apex.
CTH (___):
1. No acute hemorrhage or mass effect.
2. 0.7 cm oval nodule in the posterior body of the right lateral
ventricle, unclear whether a metastasis or a primary lesion.
3. Nonspecific supratentorial white matter hypodensities most
likely represent sequela of chronic small vessel ischemic
disease
in this age group. However, this may mask small foci of edema
related to small metastases.
4. Multiple circumscribed lucent lesions in the calvarium. A
0.8
cm right parietal bone lesion demonstrating thinning of the
inner
table and a defect in the outer table, concerning for a
metastasis. The other lesions could represent metastases or
arachnoid granulations.
RECOMMENDATION(S): Recommend brain MRI for better assessment of
the calvarial lesions, with intravenous contrast if not
contraindicated for better assessment of the right
intraventricular lesion, to be performed within approximately
one
week or at the discretion of the treating physician.
Brief Hospital Course:
___ w/ metastatic RCC (s/p L nephrectomy, RML
and RLL lobectomy, previously on atezolizumab/bevacizumab but
stopped ___ SOB), cognitive impairment, CKD (b/l Cr ~1.0), HTN,
Afib (not on AC), and multiple recent admissions for
multifactorial SOB (s/p RML/RLL resection, pleural effusions,
HFpEF, PNA) who presented again with worsening SOB and was
found to be hyponatremic (Na 119, multifactorial, with pneumonia
and a urinary tract infection.
#Hyponatremia:
The etiology was thought to be multifactorial related to
diuretic use w/ low solute
intake, SIADH secondary to PNA, malignancy w/ brain mets,
cerebral
salt wasting, and possibly oxcarbazepine (longstanding
medication).
The patient was initially placed on a fluid restriction and
Lasix and oxcarbazepine were stopped. After goals of care
discussion which resulted in a decision to pursue hospice, the
fluid restriction was lifted and labs were no longer checked.
Patient and family are pursuing comfort measures. Oxcarbazepine
was restarted to help with his facial pain at family's request.
#PNA
The patient presented with SOB and leukocytosis. A CT chest
showed ground glass in the right upper lobe. His MRSA swab was
positive. He was treated with Levofloxacin and completed the 7
day course while in the hospital. He was not hypoxic.
#Urinary Tract infection
He presented with dysuria. His urine culture from ___
___ was growing > 100K klebsiella with typical sensitivity.
He was continued on levofloxacin x 7 days.
#Metastatic RCC
#GOC
A CT head obtained at admission showed signs of new calvarial
lesions suggesting metastasis to the brain. The family was
informed of this finding. In keeping with his goals of care, no
further investigation was done. He was continued on his home
fentanyl Patch 12 mcg/h TD Q72H.
#GERD:
- Continue home Omeprazole 40 mg PO DAILY
- Continue home Ranitidine 150 mg PO/NG BID
#Social issues:
- Discharge was very difficult as he was originally supposed to
go home with hospice with Care ___. However, the problem
was that he needed ___ care and his wife said this was not
feasible financially (for private care). Care ___
withdrew services because his family's goals were not consistent
with hospice plan and philosophy of care. His family requested
___ with ___ at home instead. His family demanded he
be discharged home on ___ and referral was made to ___
___ for ___ to start on ___. His family expressed
understanding that he was being discharged prior to securing
___ and that if it is not secured, then they'll
need to work with his PCP's office to arrange ___.
Check if applies: [X] Mr. ___ is clinically stable for
discharge today. The total time spent today on discharge
planning, counseling and coordination of care today was greater
than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. omeprazole 40 mg oral DAILY
2. Furosemide 40 mg PO DAILY
3. Fentanyl Patch 12 mcg/h TD Q72H
4. OXcarbazepine 300 mg PO BID
5. Ranitidine 150 mg PO BID
6. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
Over the counter
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
Over the counter
RX *bisacodyl [Ducodyl] 5 mg 1 tablet(s) by mouth daily prn Disp
#*30 Tablet Refills:*0
3. Fentanyl Patch 12 mcg/h TD Q72H
RX *fentanyl 12 mcg/hour 1 patch every 72 hours Disp #*15 Patch
Refills:*0
4. omeprazole 40 mg oral DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
5. OXcarbazepine 300 mg PO BID
6. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
7. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
RX *sennosides [Senna Concentrate] 8.6 mg 1 tab by mouth daily
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
Urinary tract infection
Hyponatremia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance, mostly in bed
Discharge Instructions:
You came to the hospital with shortness of breath and pain with
urination. You were found to have a pneumonia and a urinary
tract infection. You were treated with antibiotics while you
were in the hospital. You no longer have evidence of an active
infection.
You were also found to have low sodium levels. For this
problem, you were seen by our kidney doctors. ___ recommended
stopping the Lasix and oxcarbazepine medications. However, the
oxcarbazepine was restarted to help your facial pain.
During your time in the hospital, we discussed the best plan for
your care moving forward. You and your family decided that you
would not return to the hospital if you had worsening symptoms,
but would focus on making you as comfortable as possible at
home. Visiting nurse services are being set up to assist you
and your family, but they will not be present all day and night,
so your family will help take care of you when they are not
present.
Followup Instructions:
___
|
10444265-DS-16 | 10,444,265 | 23,320,630 | DS | 16 | 2172-03-19 00:00:00 | 2172-03-19 21:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Male witha history of known sickle cell disease
presents with 24 hours of epigastric/chest pain which radiates
to the back, chills and fever. The patient states the symptoms
have worsened over the 24 hours prior to admission. The patient
states he has not had a chest crisis before. He reports taking
his hydroxyurea and lisinopril. He normally gets his care over
at ___ with Dr. ___ ___.
In the ED his initial vitals were 100.2, 75, 135/71, 18, 98%RA.
Got 2L of IV fluids, morphineoxygen and
ceftriaxone/azithromycin. He underwent CTA-Chest seend as below
Past Medical History:
Sickle Cell Disease
Sickle Nephritis
?History of QTC prolongation
Immunization:
Pneumovax 1: ___
PNeumovax 2: ___
Mening Hx: ___
MCV4 next due: ___
Flu vax: ___
Social History:
___
Family History:
Mother: Healthy
Father: ___
Brother: Died of influenzae in the ___ (also with sickle
cell disease)
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
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 98.4, 145/82, 71, 18, 99%RA
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Non-Focal
Exam on discharge:
Exam:
Vitals: Tmax: 101 VSS
Gen: NAD, lying in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear, no cervical LAD
___: RRR, no MRG, full pulses, no edema
Resp: Clear b/l on auscultation. No wheezes or rhonchi.
GI: soft, NT, ND, no rebound or guarding +BS
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect
Pertinent Results:
___ 05:52PM BLOOD WBC-16.5* RBC-3.03* Hgb-11.9* Hct-31.8*
MCV-105* MCH-39.3* MCHC-37.4* RDW-16.6* RDWSD-62.5* Plt ___
___ 05:52PM BLOOD Neuts-77* Bands-0 Lymphs-14* Monos-8
Eos-0 Baso-0 ___ Metas-1* Myelos-0 NRBC-10* AbsNeut-12.71*
AbsLymp-2.31 AbsMono-1.32* AbsEos-0.00* AbsBaso-0.00*
___ 05:52PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Target-2+
Sickle-1+ Schisto-1+ Pappenh-1+ Ellipto-1+
___ 05:52PM BLOOD Ret Aut-10.4* Abs Ret-0.32*
___ 05:52PM BLOOD Glucose-116* UreaN-8 Creat-0.7 Na-136
K-4.1 Cl-95* HCO3-33* AnGap-12
___ 09:18PM BLOOD ALT-26 AST-49* LD(LDH)-1067* AlkPhos-126
TotBili-2.9*
___ 09:18PM BLOOD Lipase-12
___ 09:18PM BLOOD Albumin-4.0
___ 05:52PM BLOOD Calcium-9.6 Phos-3.4 Mg-1.8
___ 09:18PM BLOOD Ferritn-948*
___ 07:57PM BLOOD Lactate-1.4
___ 08:07PM URINE Color-Yellow Appear-Clear Sp ___
___ 08:07PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 08:07PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 5:52 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
CHEST (PA & LAT) Study Date of ___ 9:15 ___
Preliminary Report
IMPRESSION:
No acute cardiopulmonary abnormality.
CHEST XRAY: ___
Unchanged mild cardiomegaly. Normal mediastinal and hilar
contours.
Unchanged thoracic scoliosis. Blunting of the left costophrenic
angle
suggests a small left pleural effusion with underlying
atelectasis and
possible superimposed pneumonia. No definite soft tissue
abnormalities.
IMPRESSION:
Given the clinical history, there is concern for left lower lobe
pneumonia.
CT abdomen: ___
IMPRESSION:
Shrunken spleen, measuring up to 5.6 cm. No abnormalities or
focal lesions seen within the splenic parenchyma.
Brief Hospital Course:
___ M with history of sickle cell disease who presents with
abdominal pain and chest pain and lab values concerning for
vasoocclusive crisis and pneumonia
# Sickle Cell Crisis
Patinet admitted with pain and laboratory evidence of sickle
cell pain crisis. Imaging was not concerning for acute chest
syndrome. He was seen by hematology who recommended no changes
to his regimen of hydroxyurea. He was given IV fluids and pain
medications (of which he used little). He was also given and IS
and maintatined on oxygen. His pain improved quickly. He is
interested in transfering care to ___ and a follow up
appointment was made in hematology with Dr. ___.
#Fever
?#Pneumonia, bacterial
During the patient's hospitaliation he devloped fevers and
decreased breath sounds on exam. A repeat chest xray was
concerning for pneumonia therefore Ceftriaxone and Azithromycin
which were started on discharge were continued. He did not have
a cough but he did feel better after initation of antibiotics.
He will be discharged on oral cefpodoxime to complete a ___zithromycin was given in the hospital. Levaquin was
avoided given history of? prolonged QTC (although EKG here with
QTC of 425)
#Transaminitis
Developed transaminitis during hospitalization. A RUQ was
completed which some sludge. The patient ws otherwise
asymptomatic. Likely medication related from either CTX or
azithromycin. The patient had negative HIV testing at ___.
Recommend repeat LFTs at outpatient follow up next week.
#Hypertension
Blood pressure slightly elevated during hospitalziation (to
140s-150s systolic) but improved on day of discharge. The
patient was continued on his current dose of lisinopril.
# Chronic Kidney Disease/ Sickle Nephropathy
Continued lisinopril during hospitalization.
Transitional issues:
- Please check LFTs at PCP follow up
- Consider increasing Lisinopril if BP elevated
- Records from ___ hematology are being scanned into OMR
Medications on Admission:
No Meds
Discharge Medications:
1. Hydroxyurea ___ mg PO DAILY
2. Lisinopril 2.5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 3 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth Q12hrs Disp #*12
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Sickle cell crisis
Pneumonia
Elevated liver function tests
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with pain, due to your
sickle cell disease. You were treated with intravenous fluids
and your pain improved. Your Hydroxyurea was continued. You were
seen by the hematologists and will need to follow up with Dr.
___ hematology. You were also treated for pneumonia. You
will need an additional 3 days of antibiotics. You were also
found to have slightly elevated liver function tests. An
ultrasound did not show any concerning findings. You will need
to follow up with your new PCP next week to have your liver
tests checked.
Take care,
Your ___ Care Team
Followup Instructions:
___
|
10444265-DS-18 | 10,444,265 | 23,507,773 | DS | 18 | 2175-09-28 00:00:00 | 2175-09-28 17:38:00 |
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/chills
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with PMHx of SCD (HGB SC) presenting with fever/chills.
Patient was in his usual state of health until the morning of
admission when he awoke and felt like he had a fever (felt warm
and had chills). Additionally noted lower back "soreness",
non-productive cough, and emesis x1. No recent travel, did get
the flu vaccine this year.
Otherwise on ROS, patient denies headache, vision changes, chest
pain, abdominal pain, shortness of breath, changes in urinary or
bowel habits, extremity pain.
Of note, patient had a similar episode and admission ___. He
presented with fever and chest pain, found to have small LLL
opacity on CXR, diagnosed with pneumonia.
ED COURSE
- Initial Vitals in the ED: Temp 103 HR 118 RR 20 BP 102/51
- Exam notable for: uncomfortable appearing,
tachycardia/tachypnea
- Relevant labs/imaging: CXR unremarkable (no ACS) and +flu A
swab. His Hgb was noted to be 8.5, retic 3.8%, LDH 666.
- Patient Received: IVF, zofran, CTX, Tamiflu, tyelnol with
improvement in back pain, nausea
- Consults: hematology, who rec: admission to medicine, continue
Tamiflu, CTX, no indication for transfusion currently
Upon arrival to the floor, patient endorses hx above and states
he is still feeling feverish but no chest pain, extremity pain,
shortness of breath.
REVIEW OF SYSTEMS:
Complete 10pt ROS obtained and is otherwise negative.
PAST MEDICAL HISTORY:
- Chronic kidney disease (with proteinuria)
- Mildly prolonged QTc.
- Sickle Cell as below
HEMATOLOGIC HISTORY (previously cared for at ___, from hem
note):
- Sickle cell disease: with HGB F determinations at ___, our
lab reports Sebia capillary electrophoresis findings c/w
compound
heterozygous HGB SC, which explains his relatively robust HGB
levels. Note that an ultrasound in ___ showed a shrunken
spleen measuring 4.6 cm.
- Per prior documentation, notable for at least 3 prior pRBC
transfusions: one during a hospitalization for pharyngitis in
childhood, another for fever, leukocytosis, and hypoxia in
___, and a third during admission for URI and hypoxia
in ___.
- Patient has been on hydroxyurea since age ___. There is
documentation of a HbF level greater than 30%. He denies
complications related to hydroxyurea use.
- Hospitalized at ___ from ___ to ___ for an acute
vaso-occlusive pain crisis thought to be triggered by
dehydration.
- Hospitalized ___ though ___ with acute on chronic
anemia with a hemoglobin of 4.5 g/dl and platelet count of
91,000. At the time he felt relatively well though had a
gastrointestinal illness with fever and diarrhea, which had
resolved prior to presentation. Decline in his blood counts was
attributed to hydroxyurea which was discontinued. He was
transfused with 3 units of red cells and discharged.
- Resumed hydroxyurea at a reduced dose of 500 mg daily in
___ with subsequent dose escalation to his present dosing
level of ___ mg once daily.
Past Medical History:
- sickle cell disease w/ 3 pRBC transfusions since childhood and
admission in ___ for acute vaso-occlusive crisis
- chronic kidney disease (w/ proteinuria)
- mildly prolonged QTc
Social History:
___
Family History:
- mother: sickle cell trait
- father: sickle cell trait, DM
- brother: sickle cell disease (HbSS, died in ___ of influenza)
- sister: sickle cell trait
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___ @ 2222)
Temp: 102.8 (Tm 102.8), BP: 105/46, HR: 105, RR: 18, O2 sat:
95%, O2 delivery: Ra, Wt: 184.7 lb/83.78 kg
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
CARDIAC: Regular rhythm, normal rate. Soft II/VI systolic flow
murmur. Audible S1 and S2.
LUNGS: Coarse throughout. No wheezes, rhonchi or rales. No
increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. Moving all four extremities
spontaneously. AOx3.
DISCHARGE PHYSICAL EXAM:
Vitals: ___ 0300 Temp: 99.5 PO BP: 119/64 RR: 18 O2 sat:
95% O2 delivery: RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
CARDIAC: Regular rhythm, normal rate. Soft II/VI systolic flow
murmur. Audible S1 and S2.
LUNGS: Coarse throughout. No wheezes, rhonchi or rales. No
increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: Moving all extremities spontaneously. AOx3.
Pertinent Results:
ADMISSION
___ 04:40PM RET AUT-3.8* ABS RET-0.07
___ 04:40PM PLT SMR-HIGH* PLT COUNT-492*
___ 04:40PM ANISOCYT-2+* POIKILOCY-3+* MACROCYT-2+*
TARGET-3+* SICKLE-1+* TEARDROP-1+* RBCM-SLIDE REVI
___ 04:40PM NEUTS-67 ___ MONOS-12 EOS-1 BASOS-1 NUC
RBCS-116* AbsNeut-3.08 AbsLymp-0.87* AbsMono-0.25 AbsEos-0.02*
AbsBaso-0.02
___ 04:40PM WBC-2.1* RBC-1.91* HGB-8.5* HCT-23.1*
MCV-121* MCH-44.5* MCHC-36.8 RDW-17.3* RDWSD-75.9*
___ 04:40PM LD(LDH)-666*
___ 04:40PM estGFR-Using this
___ 04:40PM GLUCOSE-94 UREA N-6 CREAT-0.8 SODIUM-135
POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-22 ANION GAP-13
___ 05:00PM LACTATE-1.7
___ 05:00PM OTHER BODY FLUID FluAPCR-POSITIVE*
FluBPCR-NEGATIVE
DISCHARGE LABS
___ 06:45AM BLOOD WBC-3.7* RBC-1.79* Hgb-8.1* Hct-21.7*
MCV-121* MCH-45.3* MCHC-37.3* RDW-17.2* RDWSD-74.7* Plt ___
___ 06:45AM BLOOD Neuts-39 Lymphs-56* Monos-5 Eos-0* Baso-0
NRBC-10.6* AbsNeut-1.44* AbsLymp-2.07 AbsMono-0.19* AbsEos-0.00*
AbsBaso-0.00*
___ 07:00AM BLOOD Hb A-PND Hb S-PND Hb C-PND Hb A2-PND Hb
F-PND
___ 06:45AM BLOOD Ret Aut-2.1* Abs Ret-0.04
___ 06:45AM BLOOD Glucose-105* UreaN-5* Creat-0.7 Na-137
K-3.8 Cl-101 HCO3-23 AnGap-13
___ 07:00AM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG & IGM)-PND
CXR PA and Lateral ___
There is no focal consolidation, effusion, or pneumothorax.
There are no
signs of congestion or edema. The cardiomediastinal silhouette
is normal.
Imaged osseous structures are intact. Thoracic spinal
dextroscoliosis noted. No free air below the right
hemidiaphragm is seen.
CXR PA and Lateral ___
In comparison with the study of ___, there is little
change and no
evidence of acute cardiopulmonary disease. Specifically, no
evidence of acute focal pneumonia.
Brief Hospital Course:
This is a ___ year old male with past medical history of sickle
cell disease (SS vs SC on hydroxyurea, admitted ___ with
sepsis secondary to influenza A infection, without signs of
sickle cell crisis, improving on oseltamivir and able to be
discharged home
#Sepsis secondary to
# Influenza A Pneumonia
Patient was admitted with fevers, tachycardia, and leukopenia,
found to have Influenza A PCR positive. Patient received IV
fluids and was treated with Tamiflu. Also received single dose
of antibiotics around time of admission--given no signs of
concurrent bacterial infection on imaging, this was
discontinued. Tachycardia and respiratory symptoms resolved
over subsequent 48 hours. Ambulating without issue.
Discharged to complete Tamiflu 75 BID (Day ___, goal for 5
days ending ___. Parvovirus antibodies pending at discharge.
After nadir of 2.1k, leukopenia improved to 3.7k at discharge.
# Sickle cell anemia
Patient with baseline Hgb ___, admitted with Hb 8.1, LDH 666,
retics 3.8%. Chest xray without signs of pneumonia or acute
chest. Patient was seen by inpatient hematology consult
service who agreed no signs of sickle cell crisis or acute
chest. Treated as above with IV fluids and Tamiflu. Per
review of chart, there seemed to be some ambiguity about if
patient was SS vs SC--per discussion with hematology consult
service, hemoglobin elecctropheresis was sent. As above,
patient improved without additional intervention. Continued
home hydroxyurea 2000mg QD, vitamin D 2000u QD, folic acid 3mg
QD. Hb 8.1 on time of discharge.
# CKD stage I with proteinuria
Held home lisinopril 2.5mg QD with instructions to restart once
influenza treatment course was complete.
Transitional Issues
====================
[] would consider repeating CBC at PCP follow up (at discharge
Hb 8.1, WBC 3.7)
[] would follow-up pending electropheresis and parvovirus
serologies
[] would ensure patient up to date on appropriate vaccines for
someone with functional asplenia
#CODE: full confirmed
#CONTACT: Mother, ___ ___
> 30 minutes spent on discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1
Start: ___, First Dose: Next Routine Administration Time
2. Hydroxyurea ___ mg PO DAILY
3. Vitamin D ___ UNIT PO DAILY
4. FoLIC Acid 3 mg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
2. OSELTAMivir 75 mg PO BID
RX *oseltamivir 75 mg 1 capsule(s) by mouth twice a day Disp #*6
Capsule Refills:*0
3. FoLIC Acid 3 mg PO DAILY
4. Hydroxyurea ___ mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. HELD- Lisinopril 2.5 mg PO DAILY This medication was held.
Please restart on ___ after finishing course of Tamiflu
Discharge Disposition:
Home
Discharge Diagnosis:
# Influenza A Pneumonia
# Sepsis, resolved
# Sickle cell anemia
# CKD stage I with proteinuria
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 had the flu
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were treated for the flu
- the hematology team saw you and did not think you needed any
blood transfusions or addition treatment for your sickle cell
disease
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- If you have worsening chest pain, cough, shortness of breath,
or persistent fevers, please seek immediate medical attention.
- Please resume your home Lisinopril once you are finished with
your Tamiflu course
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10444484-DS-28 | 10,444,484 | 27,257,637 | DS | 28 | 2181-10-26 00:00:00 | 2181-10-26 15:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
sulfamethizole
Attending: ___.
Chief Complaint:
small bowel obstruction
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w h/o cholecystitis managed with cholecystostomy tube p/w
abd pain, N,V x1 day found to have SBO.
Pt reports that the pain started last night. He describes the
pain constant, crampy, all over the abdomen, more prominent in
the lower abdomen associated with abdominal distention. He
reports having bowel movement last time yesterday before the
pain
started, although he thinks he has been passing flatus. He also
notes nausea and vomiting this morning.
He had CT a/p in ER which showed small bowel obstruction with
transition point within the left lower quadrant. An NG tube was
placed which drained about 1L feculent looking brown fluid.
Past Medical History:
HTN, HLD, A-fib, alcoholism, BPH, MRSA & strep bacteremia,
cholecystitis s/p percutaneous cholecystomy tube ___, LGI
bleed,
CHF
PSH:
___ left- Intramedullary nailing tibia, closed treatment of
fibula
___- Intramedullary nailing, right tibia, plate fixation of
right fibular shaft fracture
___- s/p right shoulder surgery, Right shoulder removal &
insertion of Osteonics hemiarthroplasty, right shoulder
___- I&D of right shoulder
___ - s/p take back of wound dehisence; TURP
Social History:
___
Family History:
Mother with arthritis and gallbladder dz.
Father with prostate and gastrointestinal problems
Physical Exam:
Admission Exam:
Vitals:98.3 96 123/80 21 97%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, distended, mildly tender, no rebound
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
Admission Labs:
136 93 16
----------<169 21.8>47.1<202 Lactate 1.6 INR 3.4
4.2 30 1.3
ALT:26 AST:34 AP:90 TB:0.4 Lip:21
CHEST (PORTABLE AP) Study Date of ___ 10:18 AM
IMPRESSION:
Low lung volumes with bibasilar atelectasis
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 12:06 ___
IMPRESSION:
1. Small-bowel obstruction with transition point within the
left lower
quadrant. No pneumatosis or fat stranding.
2. Heterogeneous area within the gallbladder fossa is worrisome
for an acute
on chronic cholecystitis given adjacent fat stranding. Although
less likely
differential includes gallbladder carcinoma given irregularity
of wall. In a
few of the patient's reports there is the history of prior
cholecystectomy and
if so this 6.9 cm heterogeneous area would be worrisome for a
collection.
4. 1.8 cm linear hyperdensity within the third portion the
duodenum and cecum
is suggestive of ingestion material such as a small animal bone.
5. Trace ascites
GALLBLADDER SCAN Study Date of ___
Impression
Non visualization of the gallbladder 30 min after morphine
administration is compatible with acute cholecystitis.
Brief Hospital Course:
Given findings of small bowel obstruction with transition point
and abdominal exam reassuring, patient was admitted to the Acute
Care Surgery service for
non-operative management with NPO/IVF and NGT and serial
abdominal exam with the understanding that if he fails to
resolve then operative intervention will be indicated. His
hospital course is detailed below:
Neuro: Pain was initially managed with IV narcotics and then
transitioned to oral pain regimen once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. The patient
INR on admission was supratherapeutic at 3.4 and his coumadin
was held for consideration of possible operative intervention.
It was restarted on ___ once it was clear that operative
intervention was no longer indicated. Given his high risk of
clot formation, he was given lovenox when INR was
subtherapeutic. However, given persistent WBC count and findings
of acute cholecystitis, patient received 4 units of FFP for
planned ___ procedure on ___. His INR was therapeutic 2.6 at
discharge on ___ (coumadin to be held ___ hours post
procedure) and he will restart coumadin with regular INR checks
at rehabiliation following discharge. He was restarted on all
home cardiac medications
Details of coumadin regimen and events were discssed with
___ who manages Patient's coumadin
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. The patient
intermittently required O2 initially, following ___ drain
placement, with mild wheezing that resolved with nebulizer
treatment. He was weaned to room air on POD1.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. On ___ patient
self-removed the NGT, therefore, the diet was advanced
sequentially to a Regular diet, which was well tolerated.
Patient's intake and output were closely monitored. Given
history of known duodenal adenoma, which per patient/patient's
HCP for which patient was supposed to f/u for repeat colonoscopy
and re-evaluation, we recommended patient follow up with his
PCP/Regular physician/GI doctor ___ stated
preference) for further evaluation.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. His WBC remained
persistently elevated during the hospitalization. His UA was
equivocal with some evidence of hematuria (which appeared to
resolve later in hospitalization). Given concerning findings for
cholecysitis on admission CT Abd/Pelvis and known chronic
cholecysitis a gallbladder study (HIDA) was performed on ___
which was consistent with acute cholecystitis. In the context of
significant inflammation CT, hx of chronic cholecystitis, RUQ
pain on deep palpation, the decision was made to decompress the
gallbladder with percutaneous cholecystostomy tube placement.
This was performed on ___ without significant complications
(see interventional radiology record for complete details). 23cc
for thick purulent drainage was elicited and cultures were sent.
THe patient was started on empirice Augmentin which he will
continued for 1 week upon discharge. Patient report increased
comfort following procedure and had improved leukocytosis.
Patient will follow up in clinic in ___ weeks and discuss
interval cholecystectomy at that time.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin/coumadin
(when therapeutic) and ___ dyne boots were used during this
stay and was encouraged to get up and work with ___ as early as
possible. Discharge to rehabilitation was recommended per
Physical Therapy team.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
working closely with physical therapy, voiding without
assistance, and pain was well controlled. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
2. 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 #*14 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Carbidopa-Levodopa (___) 1 TAB PO QHS
5. Diltiazem Extended-Release 300 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Fluticasone Propionate 110mcg 1 PUFF IH BID
8. FoLIC Acid 1 mg PO DAILY
9. Furosemide 40 mg PO DAILY
10. Doxycycline Hyclate 50 mg PO DAILY
11. Magnesium Oxide 400 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. Pravastatin 40 mg PO QPM
14. Sertraline 25 mg PO DAILY
15. Tolterodine 2 mg PO QHS
16. Dexilant (dexlansoprazole) 30 mg oral DAILY
17. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
do not use with alcohol or while driving
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*30
Tablet Refills:*0
18. Warfarin 3 mg PO DAILY16
dose based on regular INR checks
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Small Bowel Obstruction
Acute/Chronic Cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were evaluated by the ___ Acute Care Surgery Team. You
were found to have a small bowel obstruction that was managed
conservatively with a nasogastric tube. The small bowel
obstruction resolved over a few days. You were also found to
acute and chronic cholecysitis which require placement of a
cholecystotomy tube/drain.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
10444484-DS-29 | 10,444,484 | 22,441,451 | DS | 29 | 2181-11-07 00:00:00 | 2181-11-07 14:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
sulfamethizole
Attending: ___.
Chief Complaint:
Percuatenous cholecystotomy tube misplacement
Major Surgical or Invasive Procedure:
___ - open cholecystectomy
History of Present Illness:
___ is an ___ year old male with history of acute
on chronic cholecystitis that has been managed with a
cholecystostomy tube most recently hospitalized from ___
with a small bowel obstruction, and s/p placement of
percutaneous
cholecystotomy tube on ___ following a HIDA scan that was
concerning for acute cholecystitis within the context of chronic
cholecystitis. He was started on augmentin on that date, with
plans to continue antibiotics for one week.
He presents today with following the incidental dislocation of
his percutaneous cholecystostomy tube. He denies any nausea,
vomiting, fevers, chills, or any other symptoms.
Past Medical History:
HTN, HLD, A-fib, alcoholism, BPH, MRSA & strep bacteremia,
cholecystitis s/p percutaneous cholecystomy tube ___, LGI
bleed,
CHF
PSH:
___ left- Intramedullary nailing tibia, closed treatment of
fibula
___- Intramedullary nailing, right tibia, plate fixation of
right fibular shaft fracture
___- s/p right shoulder surgery, Right shoulder removal &
insertion of Osteonics hemiarthroplasty, right shoulder
___- I&D of right shoulder
___ - s/p take back of wound dehisence; TURP
Social History:
___
Family History:
Mother with arthritis and gallbladder dz.
Father with prostate and gastrointestinal problems
Physical Exam:
Admission PE:
97.7 97 130/85 18 96% ra
Gen: no acute distress, alert, responsive
Pulm: unlabored breathing
CV: regular rate and rhythm
Abd: soft, nontender, nondistended, prior perc chole site
without
any erythema or drainage
Ext: warm and well perfused
Discharge PE:
98.8/98.2 ___ 16 98% on RA
Gen: A&Ox3
Cardiac: RRR
Lungs: No respiratory distress
Abd: soft, non-tender, non-distended
Wound: no erythema/induration, JP w/ serosang drainage, minimla
Extremities: 2+ dp/radial b/l
Pertinent Results:
___ 03:00AM BLOOD WBC-11.9* RBC-4.73 Hgb-14.3 Hct-41.5
MCV-88 MCH-30.3 MCHC-34.5 RDW-15.0 Plt ___
___ 04:45PM BLOOD WBC-23.0*# RBC-4.34* Hgb-13.2* Hct-37.5*
MCV-86 MCH-30.4 MCHC-35.1* RDW-14.7 Plt ___
___ 06:20AM BLOOD WBC-12.3* RBC-4.18* Hgb-12.5* Hct-35.7*
MCV-86 MCH-30.0 MCHC-35.0 RDW-15.0 Plt ___
___ 03:00AM BLOOD ___ PTT-41.1* ___
___ 05:38AM BLOOD ___ PTT-37.8* ___
___ 03:00AM BLOOD Glucose-119* UreaN-12 Creat-0.9 Na-138
K-3.5 Cl-101 HCO3-22 AnGap-19
___ 06:20AM BLOOD Glucose-119* UreaN-7 Creat-0.8 Na-139
K-4.0 Cl-103 HCO3-27 AnGap-13
___ 03:00AM BLOOD ALT-68* AST-41* AlkPhos-85 TotBili-0.5
___ 09:20AM BLOOD ALT-20 AST-24 AlkPhos-59 TotBili-0.4
SURGICAL PATHOLOGY REPORT - Final
PATHOLOGIC DIAGNOSIS:
Gallbladder, open cholecystectomy:
- Acute and chronic cholecystitis with xanthogranulomatous
inflammation.
OPERATIVE REPORT
___.
**NOT REVIEWED BY ATTENDING**
Name: ___ Unit No: ___
Service: Date: ___
Date of Birth: ___ Sex: M
Surgeon: ___, MD ___
SEX: Male.
PREOPERATIVE DIAGNOSIS: Acute cholecystitis.
POSTOPERATIVE DIAGNOSIS: Acute cholecystitis.
NAME OF OPERATION: Open cholecystectomy.
FIRST ASSISTANTS:
___, MD.
2. ___.
INDICATIONS: This man has had recurrent cholecystitis and it
was thought that he needed to have his gallbladder removed.
He was taken to the operating room, placed in the supine
position, given a general anesthetic. The abdomen was
prepped and draped using ChloraPrep.
After appropriate time-out, we carried out a right paramedian
incision, deepening it down to the level of the anterior
rectus sheath. The rectus sheath was opened. We entered the
rectus sheath and mobilized the rectus muscle and retracted
it laterally and then entered the posterior rectus sheath and
entered the abdominal cavity. The following findings were
noted: The liver was sealed to the right peritoneal parietal
peritoneum and with numerous adhesions right along its edge
and there was pus around the gallbladder, when we had broken
into the pus pocket we found that, and the gallbladder itself
was basically necrotic looking and was very inflamed.
PROCEDURE IN DETAIL: We entered the abdominal cavity and
identified the gallbladder. It was palpable __________ a
hard mass beneath some omentum. We then dressed the liver.
We could not put our hand above the liver to allow for air to
come above it, so we lysed the adhesions that were holding
the liver to the abdominal sidewall for a good portion of its
length. That at least exposed the anterior part of the liver
as well as the anterior part of the gallbladder, which was
very necrotic looking and inflamed. We were able to
carefully remove by blunt dissection some tissue from the
undersurface of the gallbladder and push it backwards, coming
down and displaying a ___ pouch. This allowed us to
then use a right angle to come up and separate the liver,
basically cracking it off of the side of the gallbladder, and
then we decided to try and take the gallbladder down from
above. We did that basically but found that the gallbladder
was so inflamed and necrotic that pieces of the gallbladder
just came off with ___ clamp that was placed on it; but
we then persisted anyway and then we left the posterior wall
of the gallbladder against the undersurface of the liver.
This was intentional. We came around the bottom part of the
gallbladder and we were able to bring it down to a small
centimeter in diameter neck and we placed the right-angle
clamp across that and divided it. The specimen was sent for
pathologic examination. We suture ligated the base of the
gallbladder with a 0 Vicryl suture.
My suspicion is that this is likely going to leak anyway, so
we left a #19 ___ drain, passing it through the abdominal
sidewall, through a stab incision, and bringing it into the
gallbladder bed and left that there. We used the argon beam
to coagulate the gallbladder bed and any remaining mucosa
that was attached to the undersurface of the liver. We then
carried out inspection for hemostasis and, of course, there
was considerable bleeding because of the inflammation;
however, by this time in the procedure it was becoming under
control and we then used a Surgicel dressing for the lower
part of the gallbladder bed, not wishing to use the argon
beam near the duodenum. Once this was done, we then
irrigated the abdomen with warm saline, checked for
hemostasis, this time it was excellent, and then closed the
abdominal wall with a 0 Vicryl suture starting at either end
of the wound and ending in the middle for the posterior
sheath and, after irrigation again with normal saline, we
closed the anterior rectus sheath with a running #1 looped
PDS starting at either end of the wound and ending in the
middle. The estimated blood loss was 250 mL. The
gallbladder was sent for pathologic examination as well as a
culture of the pus that we encountered around the wall of the
gallbladder as we dissected it out.
Brief Hospital Course:
___ w/ Acute on chronic cholecystitis s/p perc cholecystotomy on
___ presented with displaced perc chole tube and recommendation
for open cholecystectomy. Patient was made NPO and taken to the
OR for an uncomplicated open cholecystectomy with gangrenous
gall bladder. Cefpodoxime should conintue until ___. JP drain
was placed intraoperatively to monitor for a leak; patient is
bing discharged with drain, which will be removed in clinic. No
leak was evident while inpatient. Patient's pain was managed
adequately postoperatively. Diet was sequentially advanced and
tolerated. Patient was voiding prior to discharge. Physical
therapy evaluated the patient adn felt he should return to
rehab. Coumadin was restarted prior to discharge and therapeutic
at time of discharge x 3 days.
Transitional Issues
- please check INR on ___, adjust as needed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
3. Aspirin 81 mg PO DAILY
4. Carbidopa-Levodopa (___) 1 TAB PO QHS
5. Diltiazem Extended-Release 300 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Fluticasone Propionate 110mcg 1 PUFF IH BID
8. FoLIC Acid 1 mg PO DAILY
9. Furosemide 40 mg PO DAILY
10. Doxycycline Hyclate 50 mg PO DAILY
11. Magnesium Oxide 400 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. Pravastatin 40 mg PO QPM
14. Sertraline 25 mg PO DAILY
15. Tolterodine 2 mg PO QHS
16. Dexilant (dexlansoprazole) 30 mg oral DAILY
17. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
18. Warfarin 3 mg PO DAILY16
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain, fever
2. Aspirin 81 mg PO DAILY
3. Carbidopa-Levodopa (___) 1 TAB PO QHS
4. Doxycycline Hyclate 50 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. Fluticasone Propionate 110mcg 1 PUFF IH BID
7. FoLIC Acid 1 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. Magnesium Oxide 400 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4-6h:prn Disp #*30
Tablet Refills:*0
12. Pravastatin 40 mg PO QPM
13. Sertraline 25 mg PO DAILY
14. Tolterodine 2 mg PO QHS
15. Warfarin 3 mg PO DAILY16
16. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 3 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth every twelve (12)
hours Disp #*4 Tablet Refills:*0
17. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*0
18. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
19. Senna 8.6 mg PO BID:PRN Constipation
20. Dexilant (dexlansoprazole) 30 mg oral DAILY
21. Diltiazem Extended-Release 300 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute on chronic cholecystitis s/p perc cholecystotomy with
dislocation of tube on ___, now s/p open cholecystectomy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to have your gall bladder removed following an
infection of your gall bladder. You tolerated the operation well
and were stable post-operatively. Physical therapy evaluated
you and determined you should return to rehab. Please follow
the instructions listed below:
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red aroudn the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
Do not remove steri-strips for 2 weeks. (These are the thin
paper strips that might be on your incision.) But if they fall
off before that that's okay).
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing r clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluitds and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
IF you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
In some cases you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
10444656-DS-20 | 10,444,656 | 20,597,177 | DS | 20 | 2137-12-05 00:00:00 | 2137-12-06 00:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Diclofenac / Oxycodone
Attending: ___
Chief Complaint:
syncope, anemia, facial fracture
Major Surgical or Invasive Procedure:
EGD (endoscopy)
History of Present Illness:
Pt is an ___ yo man with hx stage 4 lung cancer with recent ___
___, OSA, COPD who was transferred from ___
following a syncopal episode and facial fracture. The syncopal
episode occurred in the bathroom after straining on the toilet
and fell. Pt does not recall event well and says he lost
balance. Wife was in another room when she heard loud noise.
Awake upon her discovery, no bowel/bladder incontinence. Pt
noted to have right head abrasion and also found to have
multiple facial fractures at OSH including right orbital wall
and maxillary sinus fractures. ENT there recommended max/facial
CT and CTAs to rule out carotid injury. Of note, ROS was
notable for black stools x ___ days and significant anemia noted
at OSH with Hct 20. He has had black stools several weeks ago
and received transfusion ___ weeks ago at the ___ clinic.
He received facial CT and CTA head/neck here which showed right
orbital floor fracture, minimally depressed. No carotid injury.
He was seen by Plastics in our ED who recommended conservative
management, Augmentin, and f/u in 10 days in their clinic.
ROS: Per family, notable for altered MS, some confusion and
unsteady gait in last ___ days since starting fentanyl patch.
(Patch was removed in ED). Complains of being poorly positioned
in bed. Reports right shoulder and right wrist pain s/p fall.
Denies fever, chills, lightheadedness, chest pain, palpitations,
dyspnea, cough, abdominal pain, diarrhea/constipation, dysuria.
All other ROS negative.
PCP ___ Dr. ___ both at ___
Past Medical History:
Stage 4 lung cancer (large cell), diagnosed ___ and has been
receiving chemotherapy at ___ (Dr. ___. Per
son, ___ protocol changed recently and last dose given ___
OSA, not able to tolerated BiPap
COPD/emphysema
GERD
Hx melena requiring PRBC
Social History:
___
Family History:
not contributory to current presentation
Physical Exam:
T 97.7 BP 104/53 HR 97 RR 20 96%RA
Gen: alert, restless but in no acute distress
HEENT: right forehead laceration s/p suture, EOMi
Neck: supple
CV: RRR, normal S1 S2, no m/r/g
Lungs: clear bilaterally
Abd: soft, nontender
Extrem: warm, trace pedal edema
Neuro: oriented to self, ___, not date; 4 extremities with
normal gross motor strength
Skin: right foreheard laceration as above
Musculoskel: right shoulder very minimal abrasion, ?pain with
shoulder rotation but full intact ROM; right wrist mild TTP,
good ROM
Pertinent Results:
___ 04:30AM WBC-6.2 RBC-2.26* HGB-6.3* HCT-20.6* MCV-91
MCH-27.8 MCHC-30.4* RDW-15.7*
___ 04:30AM NEUTS-84.3* LYMPHS-9.8* MONOS-5.1 EOS-0.2
BASOS-0.6
___ 04:30AM PLT COUNT-206
___ 04:30AM GLUCOSE-119* UREA N-35* CREAT-0.8 SODIUM-134
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-28 ANION GAP-9
___ 04:36AM LACTATE-2.0
___ 04:30AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 04:30AM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-0
___ 04:30AM URINE MUCOUS-RARE
EKG sinus tachycardia
small Qs III, aVF (no olds)
CT facial:
IMPRESSION: Right orbital floor and lateral wall fractures with
fracture of
the right medial and lateral wall of the maxillary sinuses.
Hemorrhage and
air within the maxillary sinus, ethmoid and left sphenoid
sinuses.
CTA head and neck
IMPRESSION:
No evidence of arterial stenosis, dissection, or occlusion.
Atrophy without evidence of intracranial hemorrhage or
contusion.
CT neck
IMPRESSION: No evidence of fracture or malalignment. Multilevel
degenerative
changes.
Right wrist and right shoulder Xray
IMPRESSION:
1. Calcific tendinopathy and chondrocalcinosis involving the
right
glenohumeral joint. No evidence of an acute displaced fracture
or dislocation
on the two submitted images.
2. No evidence of displaced fracture or dislocation involving
the right
wrist. Mild degenerative changes of the first carpometacarpal
joint.
3. Fullness of the right hilar area on the shoulder images for
which further
imaging evaluation with a PA and lateral chest film should be
considered to
exclude a hilar mass. This recommendation was submitted to the
critical
results dashboard on ___ at 3:48 p.m.
___ EGD:
A ulcerated 7 cm mass of malignant appearance with oozing blood
and overlying clot was found at the cardia and fundus.
Normal mucosa in the whole esophagus
Ulcerations with overlying clots at the palate were seen on
introduction of the endoscope.
Medium hiatal hernia
Mass in the cardia and fundus (biopsy)
Normal mucosa in the proximal bulb to second part of the
duodenum
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
___ yo man with metastatic stage 4 lung cancer, OSA, COPD,
admitted with fall and presumed syncopal episode at home, found
to have right orbital floor fracture and anemia concerning for
GI bleed
# Preyncope vs syncope, fall - seems to have several
contributing factors including significant anemia, recent
fentanyl initiation (which family reports made him feel
unsteady) and possibly defecation related/vasovagal (less
likely). Anemia treated as below. Fentanyl discontinued by ED.
No s/sx of ACS on this admission.
# Acute blood loss anemia
# Upper GI bleed
- per history, recent hx of black stools requiring transfusion
and wife reports he has had continued black stools at home.
Initially we hoped to avoid any invasive procedures but his Hct
did not respond appropriately to transfusion and he had
continued black tarry stools on floor. EGD revealed large 7 cm
gastric mass, malignant appearing. Biopsy pending and GI fellow
plans to forward results to pt's primary oncologist (contact
info given). It is not clear whether this is a second primary
malignancy vs. metastatic disease from lung ca.
He is hemodynamically stable. His Hct is now stable, Hct 27 on
day of discharge. He received total of 2 units PRBC. Pt will
be seen in ___ clinic next week with repeat Hct.
# Right orbital floor and lateral wall fractures with fracture
of the right medial and lateral wall of the maxillary sinuses.
He was evaluated by Plastics. Based on minimal displacement of
fracture, plan for conservative management. Augmentin x 7 days,
keep head of bed elevated, no drinking straws
- f/u in their clinic next ___
# Right forehead laceration, s/p sutures by Plastics
# Stage 4 metastatic lung cancer (adrenal mets), recently
received ___
Discussed with primary oncologist, who is now updated on the
events of hospitalization. Pt will f/u closely next week in
clinic. His wife and daughter are open to possible transition
to hospice care, though they would like to discuss this further
with PCP.
# Delirium - mildly confused and restless on presentation which
seemed to worsen in-house with episodes of sundowning.
Initially believed he may have some contribution from fentanyl
patch (family confirms he has been off his baseline for ~3 days
which correlated with initiation of fentanyl patch) but this has
since been removed and he remains delirious. No sign of
infection (U/A, CXR). Although his delirium is not yet
resolved, both pt and family very much wished for him to return
home, which we supported as it seems the hospital environment
worsened his confusion.
# Unsteady gait - evaluated by ___ who recommended continued ___
at home.
CHRONIC ISSUES:.
# COPD/emphysema - stable. Appears not to be on home meds
# OSA: reportedly does not use Bipap/CPAP due to intolerance
CODE: FULL for now, confirmed with wife. ___ that they
will discuss again with his outpt oncologist on f/u visit, in
light of his overall worsened condition and new gastric mass.
Contact: wife: ___ (h) and ___ (cell)
Medications on Admission:
dexamethasone 2 mg po daily
tylenol prn
wife is unsure of other medications but believes he has stopped
his other meds and supplements (vitamins, glucosamine)
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Amoxicillin-Clavulanic Acid ___ mg PO Q8H
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth every eight (8) hours Disp #*12 Tablet Refills:*0
3. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth twice a day Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
Acute anemia secondary to blood loss
Gastrointestinal bleed
Gastric mass
Syncope/presyncope
Fractures of right orbital floor and maxillary sinus
Delirium
Secondary:
Metastatic lung cancer
Discharge Condition:
condition: fair
mental status: alert but confused, anxious
ambulating with assistance
Discharge Instructions:
You were admitted after a fall at home in the bathroom. It is
likely that this was due to significant anemia and GI bleed.
You received 2 units of blood transfusion and underwent an
endoscopy, which revealed a 7 cm mass in the stomach.
Unfortunately this has the appearance of a malignancy. The
biopsy sample is pending and your oncologist will receive an
update on the results from our GI fellow when it returns. We
have notified your oncologist of this new development.
We also discovered a fracture of your orbital bone as well as
the maxillary sinus. Our plastic surgery team evaluated you and
your CT scans. They recommend continuing antibiotics as a
precaution, refrain from using drinking straws, sleep with 2+
pillows under your head. If you have bouts of sneezing, please
use over the counter Afrin spray to prevent further sneezing.
Plastics recommends followup in their clinic and suture removal
(forehead laceration) at that time.
You should see your ___ clinic early next week for lab
draw to check your anemia. He is aware of the details of this
admission. Please bring this paperwork to all your
appointments.
Followup Instructions:
___
|
10444770-DS-11 | 10,444,770 | 20,693,957 | DS | 11 | 2159-08-27 00:00:00 | 2159-08-28 13:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / Avelox / tetanus toxoid, adsorbed / benzoin /
lidocaine
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
___ percutaneous nephrostomy tube replacement
History of Present Illness:
___ female past medical history significant for morbid
obesity, diabetes, A. fib, hyperlipidemia, hypertension
presenting to the emergency department with acute onset altered
mental status and A. fib with RVR. Patient is normally AAO x2
but
was only AO x1 earlier today. Patient is febrile but with no
other signs and symptoms.
In the ED, initial vitals: 98.4, 96, 165/96, 22, 97% 4L NC
- Exam notable for: Morbidly obese woman, obtunded, normal
cardiopulmonary exam other than tachycardia. Abdomen soft,
nontender, distended, multiple clean ulcers over abdomen, R
nephrostomy tube w/o signs of infection.
- EKG: Atrial fibrillation with rapid ventricular response to
159 bpm. Left axis deviation. Slow R wave progression with
possible old anterior infarct. Old inferior infarct.
Non-specific
t-wave changes may be related to increased demand.
- Labs notable for:
Hgb: 11.7, WBC: 18.0
Na 133, BUN/Cr ___
HCO3 21, GAP 18
TSH:2.3
Dig: 1.0
Lactate:2.5
UA with 300 Glucose, 10 Ketones, few bacteria
Urine tox negative
- Imaging notable for:
CT ABDOMEN/PELVIS:
1. Possible dislodgement of the right percutaneous nephrostomy
tube with moderate hydronephrosis and perinephric fluid and
stranding. No organized fluid collection is demonstrated.
2. High-density material within the mid ureter is nonspecific
but could represent an obstructing calculus or sequela from
prior
procedure. Additional stranding along the anterior aspect of the
psoas could represent a nidus of obstruction or
inflammatory/phlegmonous changes. No intra psoas abscess is
demonstrated.
3. Numerous cutaneous defect along the right anterior abdominal
wall with mild soft tissue stranding underneath. No focal fluid
collections. A small amount of subcutaneous emphysema is
demonstrated near one of the abdominal wall defects along the
anterior pannus (series 2 image 83), recommend correlation with
prior incision or procedure.
4. Moderate stool ball with mild enhancement of the rectal wall
is concerning for component of stercoral colitis.
CXR:
No acute intrathoracic process.
- ACS, colorectal, urology, and ___ were consulted. Urology
recommended obtaining outside records re. indication for
nephrostomy tube placement and agreed with ___ consult for
replacement of PCN.
- Pt given:
Acetaminophen IV 1000 mg
CefePIME 2 g IV ONCE
Vancomycin 1 g IV ONCE
MetroNIDAZOLE 500 mg IV ONCE
Metoprolol Tartrate 5 mg IV ONCE
NS 1000 mL
Metoprolol Tartrate 75 mg PO ONCE
Insulin 4U SC ONCE
Fentanyl Citrate 25 mcg IV TWICE
Magnesium Sulfate 2 g IV ONCE
Pt was taken for nephrostomy tube replacement by ___ this AM
during which she received fentanyl.
On arrival to the floor s/p nephrostomy placement the pt is
obtunded and cannot provide further history. She will arouse
only
to hard sternal rub and followed command for thumbs up ___ x1.
Pupils were dilated and briskly reactive.
Given ongoing obtundation even after fentanyl should have worn
off, pt was sent for HCT which revealed no acute abnormalities.
At 3 pm, she spontaneously was alert, oriented to hospital, and
was able to speak in full sentences. She reported feeling
confused. She denied pain. She wasn't sure where she was, but
was
orientable to ___. She knew she was at rehab previously.
REVIEW OF SYSTEMS:
Limited by pt's mental status
Past Medical History:
1. Paroxysmal Atrial Fibrillation
2. Depression
3. Type II Diabetes
4. Hypercholesterolemia
5. Hypertension
6. Meniere's Disease
7. Obesity
8. Seasonal Allergies
9. Vitamin D Deficiency
10. Migraine Headaches
11. Carpal Tunnel Syndrome
12. Chronic Low Back Pain
13. Lactose Intolerance
PAST SURGICAL HISTORY:
1. Appendectomy
2. Tonsillectomy
3. Hysterectomy
Social History:
___
Family History:
- Mother ___ ___
ABDOMINAL AORTIC ANEURYSM
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
- Father ___ ___
TRANSIENT ISCHEMIC ATTACK
ABDOMINAL AORTIC ANEURYSM
HYPERTENSION
SEIZURE DISORDER
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Temp: 98.2 (Tm 99.6), BP: 110/75 (103-135/59-84), HR:
110 (101-110), RR: 20 (___), O2 sat: 91% (91-100), O2
delivery:
Ra (2L NC-3L), Wt: 277.78 lb/126 kg
General: obtunded, responsive only to hard sternal rub,
occasionally will ask "What"
HEENT: cannot comply with neck exam. Pupils dilated by briskly
reactive.
CV: Irregular and bounding pulse
Lungs: Anterior lung fields are clear
Abdomen: Obese abdomen with pannus with two chronic wounds on R
abdomen, superior one is linear with packing - clean edges with
minimal drainage. Inferior one is round with ?tunneling, also
with clean edges.
GU: Foley is present. R nephrostomy tube is present. There is no
sacral ulcer
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: Unable to reliable follow commands, will only to hard
physical stimulation ask "WHAT" or answer no to questions.
Sometimes she will grimace.
DISCHARGE PHYSICAL EXAM:
tele with rates ___
___ 0725 Temp: 98.6 PO BP: 143/74 HR: 114 RR: 17 O2 sat:
92%
O2 delivery: Ra FSBG: 185
___ Total Intake: 2614.6 PO Amt: 1480ml IV Amt Infused:
1134.6
___ Total Output: 1350ml Urine Amt: 150ml R nephrostomy:
1200ml
General: comfortable appearing obese female in no acute distress
CV: Irregular rhythm, no murmurs appreciated
Lungs: Anterior lung fields are clear
Abdomen: Obese abdomen with pannus with two chronic wounds on R
abdomen, dressings clean dry intact
GU: R nephrostomy tube is present
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: alert, oriented x3. attentive with good memory for recent
events. no clonus
PICC dressing CDI
Pertinent Results:
ADMISSION LABS:
===============
___ 07:05PM BLOOD WBC-18.0* RBC-4.26 Hgb-11.7 Hct-35.9
MCV-84 MCH-27.5 MCHC-32.6 RDW-14.8 RDWSD-45.3 Plt ___
___ 07:05PM BLOOD Neuts-86.5* Lymphs-5.3* Monos-7.5
Eos-0.0* Baso-0.2 Im ___ AbsNeut-15.53* AbsLymp-0.95*
AbsMono-1.34* AbsEos-0.00* AbsBaso-0.04
___ 07:05PM BLOOD ___ PTT-26.6 ___
___ 07:05PM BLOOD Glucose-293* UreaN-10 Creat-0.7 Na-133*
K-4.4 Cl-94* HCO3-21* AnGap-18
___ 07:05PM BLOOD ALT-8 AST-12 AlkPhos-95 TotBili-1.1
___ 07:05PM BLOOD Lipase-6
___ 07:05PM BLOOD CK-MB-<1 cTropnT-0.01
___ 07:05PM BLOOD Albumin-2.9* Calcium-9.6 Phos-3.8 Mg-1.3*
___ 07:05PM BLOOD TSH-2.3
___ 07:05PM BLOOD Digoxin-1.0
___ 07:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 07:09PM BLOOD ___ pO2-51* pCO2-37 pH-7.44
calTCO2-26 Base XS-0
___ 07:09PM BLOOD Lactate-2.5* Creat-0.6 K-3.8
___ 11:57AM BLOOD Lactate-1.6
DISCHARGE LABS:
=========================
___ 08:20AM BLOOD WBC-8.0 RBC-3.64* Hgb-9.8* Hct-31.3*
MCV-86 MCH-26.9 MCHC-31.3* RDW-14.5 RDWSD-45.3 Plt ___
___ 08:20AM BLOOD Glucose-186* UreaN-6 Creat-0.5 Na-142
K-3.4* Cl-103 HCO3-26 AnGap-13
___ 08:20AM BLOOD Calcium-9.3 Phos-3.2 Mg-1.6
MICRO:
======
___ 7:45 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
___ 6:15 am URINE R NEPHROSTOMY TUBE.
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 0.5 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
IMAGING:
========
___ Imaging CHEST (PORTABLE AP:
No acute intrathoracic process
___BD & PELVIS WITH CO
1. Dislodgement of the right percutaneous nephrostomy tube with
moderate
hydronephrosis and perinephric fluid and stranding. No
organized fluid
collection is demonstrated.
2. High-density material within the mid ureter is nonspecific
but could
represent an obstructing calculus or sequela from prior
procedure. Additional stranding along the anterior aspect of
the psoas could represent a nidus of obstruction or
inflammatory/phlegmonous changes. No intra psoas abscess is
demonstrated.
3. Numerous cutaneous defects along the right anterior abdominal
wall with
mild soft tissue stranding underneath. No focal fluid
collections. A small amount of subcutaneous emphysema is
demonstrated near one of the abdominal wall defects along the
anterior pannus (series 2 image 83), recommend correlation with
prior incision or procedure.
4. Moderate stool ball with mild enhancement of the rectal wall
could reflect early stercoral colitis.
___ Imaging CT HEAD W/O CONTRAST:
Patient head tilt slightly limits evaluation. Streak artifact
from dental
amalgam further limits evaluation of the lower portion of the
posterior fossa. Otherwise, there is no evidence for acute
intracranial hemorrhage, mass effect, or acute major vascular
territorial infarction. Extensive
hypodensities in the subcortical, deep, and periventricular
white matter of the cerebral hemispheres are nonspecific but
likely sequela of chronic small vessel ischemic disease in this
age group. There is moderate global
parenchymal volume loss with prominent ventricles and sulci.
No evidence for suspicious bone lesions. Mild mucosal
thickening in the
ethmoid air cells. Rightward nasal septal deviation. Mastoid
air cells are grossly unremarkable allowing for absence of
dedicated bone algorithm images. The orbits appear grossly
unremarkable.
IMPRESSION:
No evidence for acute intracranial abnormalities.
___ Imaging DX CHEST PORT LINE/TUBE:
In comparison with the study of ___, there has been
placement of a
right subclavian PICC line that extends to the mid to lower SVC.
Continued low lung volumes. The cardiomediastinal silhouette is
stable and there is no evidence of vascular congestion. There is
suggestion of mild asymmetry of opacification in the left mid
zone. In the appropriate clinical setting, this would be
worrisome for aspiration/pneumonia.
___ Cardiovascular Transthoracic Echo Report:
The left atrial volume index is normal. The right atrium is
moderately enlarged. There is mild symmetric left ventricular
hypertrophy with a normal cavity size. There is normal regional
and global left ventricular systolic function. There is
beat-to-beat variability in the left ventricular contractility
due to the irregular rhythm. The visually estimated left
ventricular ejection fraction is >=55%. Left ventricular cardiac
index is low normal (2.0-2.5 L/min/m2). There is no resting left
ventricular outflow tract gradient. Normal right ventricular
cavity size with normal free wall motion. The aortic sinus
diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch diameter is normal. There
is no evidence for an aortic arch coarctation. The aortic valve
leaflets (?#) are mildly thickened. There is no aortic valve
stenosis. There is no aortic regurgitation. The mitral valve
leaflets are mildly thickened with no mitral valve prolapse.
There is moderate mitral annular calcification. There is mild to
moderate [___] mitral regurgitation. Due to acoustic shadowing,
the severity of mitral regurgitation could be UNDERestimated.
The tricuspid valve leaflets appear structurally normal. There
is mild [1+] tricuspid regurgitation. The estimated pulmonary
artery systolic pressure is normal. There is a trivial
pericardial effusion. There is a prominent anterior fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/ global biventricular systolic
function. Mild to moderate mitral regurgitation.
Brief Hospital Course:
___ female past medical history significant for morbid
obesity, diabetes, A. fib, hyperlipidemia, hypertension
presenting to the emergency department with acute onset altered
mental status and A. fib with RVR found to have dislodgement of
the right percutaneous nephrostomy tube with moderate
hydronephrosis and perinephric fluid and stranding, s/p
nephrostomy tube replacement found to have urosepsis and
pseudomonal bacteremia.
ACUTE/ACTIVE PROBLEMS:
# Sepsis, urinary source with pseudomonas
# Pseudomonas bacteremia
# Ureter obstruction s/p PCN exchange ___
# Toxic metabolic encephalopathy
Patient presented with fever, tachycardia, altered mental
status, leukocytosis, elevated lactate in the setting of
dislodged perc nephrostomy tube and inflammatory UA from
nephrostomy tube. She underwent percutaneous nephrostomy
exchange ___. Cultures from urine and blood grew
pansensitive pseudomonas. She was treated with cefepime (___), with plan to narrow to ceftazidime (due to documented
moxifloxacin allergy preventing use to cipro) to complete 14 day
course (last day ___. Mental status improved. PICC should
be removed after course of antibiotics.
# Atrial fibrillation:
CHADSVASC 4. Chronic, on home metoprolol tartrate 75 mg BID,
digoxin. Previously on Xarelto which was held in ___
prior to nephrostomy placement at ___. Previously cardioverted
at ___ in ___. On presentation with rapid ventricular
response in the setting of urosepsis. Home metoprolol was
uptitrated and she was continued on digoxin. Her rates were
difficult to control after initial improvement in her sepsis,
and in this context she was placed on heparin drip in
anticipation of possible initiation of amiodarone, and
cardiology was consulted. TTE was obtained which was without any
clear structural cause of AF ___ normal, though with mild to
moderate MR.) Rates improved. Cardiology follow up was arranged
at discharge. Of note, she has listed diltiazem allergy but she
cannot recall what this was and may benefit from allergy
testing.
# Depression
# Likely mild Serotonin syndrome
On presentation, patient was noted to have paradoxically dilated
pupils and ankle clonus on admission exam, hyperthermia (in the
setting of fever from
sepsis), but without rigiditiy. She was noted to be on
venlafaxine 150 mg ER BID, and recorded as receiving
aripiprazole at rehab. Given unusual presentation
with severe obtundation as described above, there was concern
for serotonin syndrome and psychiatry was consulted. Home
venlafaxine was held. Mental status cleared with treatment of
sepsis; clonus improved. She was felt to have mild serotonin
syndrome. Of note, patient denied being treated with ariprazole.
Per psychiatry, it would be reasonable to rechallenge with
venlafaxine in outpatient setting if indicated after further
discussion with patient.
# Chronic abdominal wounds
Patient with two large, minimally draining abdominal wounds on
exam. Per rehab note, these are chronic. Wounds did not appear
infected. She was covered with vancomycin for 24 hours then this
was discontinued. Wound care was consulted and recommendations
for care followed.
# DM Type II
Home Lantus was titrated, home insulin and sliding scale.
#CONTACT: ___ ___
___ ___ ___
TRANSITIONAL ISSUES:
====================
[] Per psychiatry, it would be reasonable to rechallenge with
venlafaxine in outpatient setting if indicated after further
discussion with patient. Would avoid combination of abilify with
SSRI.
[] Consider allergy testing given multiple antiobiotic
allergies, diltiazem allergies
[] Please remove PICC after completion of antibiotics
[] Patient noted intermittent dizziness, may consider vestibular
testing as an outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 20 Units Bedtime
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
2. Atorvastatin 40 mg PO QPM
3. Digoxin 0.25 mg PO QHS
4. Metoprolol Tartrate 75 mg PO BID
5. Oxybutynin 5 mg PO DAILY
6. dulaglutide 1.5 mg/0.5 mL subcutaneous 1X/WEEK
7. Venlafaxine XR 150 mg PO BID
8. Ascorbic Acid ___ mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. CefTAZidime 2 g IV Q8H
3. Metoprolol Succinate XL 150 mg PO Q12H
4. Polyethylene Glycol 17 g PO DAILY
5. Rivaroxaban 20 mg PO DINNER
6. Senna 8.6 mg PO BID
7. Glargine 25 Units Bedtime
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. Ascorbic Acid ___ mg PO DAILY
9. Atorvastatin 40 mg PO QPM
10. Digoxin 0.25 mg PO QHS
11. dulaglutide 1.5 mg/0.5 mL subcutaneous 1X/WEEK
12. Oxybutynin 5 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. HELD- Venlafaxine XR 150 mg PO BID This medication was
held. Do not restart Venlafaxine XR until you discuss the risks
and benefits of this with your doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Urosepsis
Pseudomonal Blood stream infection
Atrial fibrillation
Serotonin syndrome, mild
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 IN THE HOSPITAL?
- You were confused. You were found to have a urinary infection
and that your nephrostomy tube was displaced.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had your nephrostomy tube replaced.
- You were started on intravenous antibiotics for your
infection
- Because of your infection, your atrial fibrillation (your
heart rhythm) became fast. We increased some of your medications
for this.
- You had some signs your venlafaxine had built up to higher
levels in your blood, so you were seen by our psychiatry team.
We held this medication, but your primary care doctor can
discuss trying to start it at a lower dose later
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please take your medications and go to your follow up
appointments as described in this discharge summary.
- If you experience any of the danger signs listed below,
please call your primary care doctor or go to the emergency
department immediately.
- Consider getting allergy tested to see if you are no longer
allergic to antibiotics.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10444770-DS-12 | 10,444,770 | 24,501,601 | DS | 12 | 2159-09-07 00:00:00 | 2159-09-07 17:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / Avelox / tetanus toxoid, adsorbed / benzoin /
lidocaine
Attending: ___.
Chief Complaint:
agitation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with history of morbid
obesity, DMII, HTN, HLD, atrial fibrillation recent admission
for
altered mental status and sepsis due to Pseudomonas UTI and
bacteremia now presenting again with report of altered mental
status.
Per review of the medical record, the patient was recently
admitted from ___ for altered mental status, found to
have sepsis secondary to Pseudomonas UTI and bacteremia for
which
she was given a 14-day course of ceftazidime (Last day: ___.
She was also found to have ureteral obstruction s/p PCN
exchange.
Patient also thought to have mild serotonin syndrome; psychiatry
consulted and venlafaxine was discontinued.
Per notes from ___, the patient was referred to the ED
today because she became "agitated, aggressive, and combative."
Per notes, she "refused to be washed and changed and began
throwing things and the aides. Resident began to kick and
scream.
___ at the edge of the bed knowing it's difficult for her to
ambulate." Per paper medication records, the patient was
receiving "ceftriaxone 2 gm IV Q8H." However, I spoke with
___ and confirmed that this is in error and the patient has in
fact been receiving ceftazidime 2 gm IV Q8H as prescribed upon
discharge from the hospital for her Pseudomonal UTI and
bacteremia. The patient has not been restarted on her
venlafaxine.
In the ED, vitals notable for:
Labs notable for: K 3.4, Mg 1.5, digoxin 0.5, trop <0.01,
lactate
1.5; UA no bacteria, 28 WBC, large leuk, neg nitrites;
Utox, Serumtox negative
Exam notable for: Obese abdomen with pannus with two chronic
wounds on R abdomen - clean edges with minimal drainage.
Responds
in one-word answers. Oriented to name but not to place or date.
Uncooperative with exam. Eyes closed but opens in response to
name and commands.
Imaging notable for:
- NCHCT negative for acute process
- CT A/P: 1. Appropriately positioned right nephrostomy tube
with
no evidence of hydronephrosis. Perinephric stranding at the
right
kidney has improved. 2. Focal stranding with multiple punctate
hyperdensities anterior to the right psoas muscle is unchanged.
3. No new acute process within the abdomen and pelvis.
Consults: ___: CT reviewed by ___ attending, no hydronephrosis,
PCN
appears positioned well. On exam suture in place, PCN attached
to
bag, no leakage noted. No indication for PCN exchange.
Patient given:
___ 03:40 IV CefePIME 2 g
___ 04:07 IM LORazepam 2 mg
___ 04:07 IM Haloperidol 5 mg
___ 07:53 IV Metoprolol Tartrate 5 mg
___ 12:30 IV CefePIME 2 g
___ 13:27 IV Metoprolol Tartrate 5 mg
___ 14:51 IV Potassium Chloride
___ 18:33 IV Digoxin .2 mg
___ 19:52 IV Metoprolol Tartrate 5 mg
___ 19:58 IV Potassium Chloride 40 mEq
While in the ED, patient became combative and agitated, and
received chemical sedation as noted above.
The patient is an antagonistic and evasive historian, but
provides the following history. She reports that she has been in
her usual state of health in the days leading up to admission.
She specifically denies any fevers, chills, nausea, vomiting,
abdominal pain, flank pain, diarrhea, dysuria, frequency, cough,
shortness of breath, chest pain, palpitations. She reports that
she has been eating and drinking normally. She tells me that
they
have been trialing meclizine for her intermittent dizziness, but
this is not helping. She tells me that she is not dizzy at
present. No other medication changes as far as she is aware. She
recounts that she was recently hospitalized for urinary tract
infection for which she is receiving antibiotics. She states
that
when she gets UTIs she usually gets a fever but does not get
dysuria.
She is unable to state why she was referred to the hospital
today. She similarly does not recall her episode of agitation in
the ED. When asked about the reported agitation she states that
she cannot recall. When asked orientation questions she
initially
provides answers such as ___ for location, but when
pressed she admits that she knows this is ___. During the
interview, the repeatedly requests more food, specifically
requesting that we order her Domino's pizza and to "send an aide
out for cheese." The patient was provided with two boxed
dinners,
but her other requests could not be fulfilled.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
1. Paroxysmal Atrial Fibrillation
2. Depression
3. Type II Diabetes
4. Hypercholesterolemia
5. Hypertension
6. Meniere's Disease
7. Obesity
8. Seasonal Allergies
9. Vitamin D Deficiency
10. Migraine Headaches
11. Carpal Tunnel Syndrome
12. Chronic Low Back Pain
13. Lactose Intolerance
PAST SURGICAL HISTORY:
1. Appendectomy
2. Tonsillectomy
3. Hysterectomy
Social History:
___
Family History:
- Mother ___ ___
ABDOMINAL AORTIC ANEURYSM
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
- Father ___ ___
TRANSIENT ISCHEMIC ATTACK
ABDOMINAL AORTIC ANEURYSM
HYPERTENSION
SEIZURE DISORDER
Physical Exam:
VITALS: 94.5 112/69 110-145 in afib 18 94 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 irregular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen obese, soft, non-distended, non-tender to palpation.
Bowel sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: Two wounds on upper and lower abdomen, both with red
granulation tissue, no purulence, no drainage
NEURO: Alert, oriented to self, place, month, day and year; able
to perform months of year backwards (although states "eggroll"
instead of ___, face symmetric, gaze conjugate with EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout,, no meningismus
PSYCH: Antagonistic
Pertinent Results:
___ 04:21AM BLOOD WBC-7.8 RBC-3.65* Hgb-9.9* Hct-33.1*
MCV-91 MCH-27.1 MCHC-29.9* RDW-16.0* RDWSD-53.0* Plt ___
___ 04:21AM BLOOD Glucose-140* UreaN-9 Creat-0.5 Na-143
K-3.7 Cl-106 HCO3-25 AnGap-12
___ 11:36PM BLOOD ALT-21 AST-17 AlkPhos-155* TotBili-0.4
___ 11:36PM BLOOD Lipase-12
___ 11:36PM BLOOD cTropnT-<0.01
___ 04:21AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.6
___ 04:54PM BLOOD HBsAg-NEG
___ 04:54PM BLOOD HIV Ab-NEG
___ 11:36PM BLOOD Digoxin-0.5*
___ 04:54PM BLOOD HCV Ab-NEG
___ 11:36 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ =>___BD:
IMPRESSION:
1. Appropriately positioned right nephrostomy tube with no
evidence of
hydronephrosis. Perinephric stranding at the right kidney has
improved.
Focal stranding with multiple punctate hyperdensities anterior
to the right
psoas muscle is unchanged.
2. Small left and trace right pleural effusions.
3. 4 mm left lower lobe pulmonary nodule with follow-up
recommendations below.
RECOMMENDATION(S): For incidentally detected nodules smaller
than 6mm in the
setting of an incomplete chest CT, no CT follow-up is
recommended.
ABD CT
FINDINGS:
There is no evidence of large territorial
infarction,hemorrhage,edema, or
mass. There is prominence of the ventricles and sulci
suggestive of
involutional changes, unchanged. Bilateral periventricular
subcortical white
matter hypodensities are nonspecific but most likely represent
sequela of
chronic small vessel ischemic changes. Bilateral carotid siphon
calcifications are noted.
There is no evidence of fracture. The visualized portion of the
paranasal
sinuses, mastoid air cells, and middle ear cavitiesare
essentially clear. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process.
Brief Hospital Course:
Ms. ___ is a ___ woman with morbid obesity, DMII,
HTN, HLD, atrial fibrillation recent admission for
encephalopathy and sepsis due to Pseudomonas UTI and bloodstream
infection now presenting with combativeness/agitation from
rehab. She improved spontaneously and work up remained
negative.
# Acute encephalopathy:
Patient presenting from rehab with combativeness. After 24 hrs
she seemed calm and largely back to her baseline. Extensive
work up was performed which was negative for new infection,
acute metabolic derangement, acute CNS injury, or other acute
process. Patient reported only recent medication change was
meclizine although this was not documented in the MAR provided
by her rehab. She had not been restarted on venlafaxine. Some
of her encephalopathy could be related to medication effects.
In addition, it was possible that she was experiencing
neurotoxicity from her Ceftazidime, whose course has now been
completed. She is now at her baseline. She completed her
antibiotics. Her venlafaxine and meclizine will continue to be
held.
# Pyuria/Enterococcal bacteriuria:
# Recent Pseudomonas UTI:
Patient noted on admission to have urinalysis with pyuria. She
has now completed a 14 day course of ceftazidime. CT A/P showed
improvement from prior. Patient was asymptomatic, afebrile, and
had no leukocytosis. Moreover, her UA was improved from prior UA
when she had her infection. Given this, I suspected that her
enterococcus was a colonizer and I will not treat unless she
further declares herself to be infected. Should she develop
symptoms of UTI, would consider treating this enteroccus x7 days
based on the sensitivities above - ie LINEZOLID
# Atrial fibrillation with rapid ventricular rates:
Rates initially poorly controlled. Now her rate are largely in
the 100-110 range. She was asymptomatic. We continued her
metoprolol and digoxin as well as her rivaroxaban
# Ureteral obstruction s/p PCN:
# Renal mass s/p resection:
CT A/P demonstrated appropriately placed right PCN with no
evidence of hydronephrosis. Seen by ___ in the ED, and no role
for PCN exchange. She has a urologist at ___ who performed
her surgery. It is unclear how long she will need her PCN. She
will need to return per above for ___ follow up. We also
strongly recommend follow up with her urologist at ___
# Overactive bladder:
- Will resume oxybutynin with caution
# Intermittent dizziness: This is noted in the patient's prior
discharge summary, and patient reports that she was started on
meclizine at rehab (although not noted in rehab MAR). She denied
dizziness at present.
- Defer meclizine for now
CHRONIC/STABLE PROBLEMS:
# Chronic abdominal wounds: Per review of prior notes, seem to
be stable from prior. No current evidence of superinfection.
Topical Therapy:
1.Commercial wound cleanser or normal saline to cleanse wounds.
Pat the tissue dry with dry gauze.
2.Apply protective barrier wipe to periwound tissue and air dry.
3.Pack wounds loosely with barely moistened (Normal saline) AMD
Kerlix. Cover with ABD pad. Secure with Medipore tape.
Change dressing daily
*AMD Kerlix ___ ___.
If still on back order, may use Kerlix, at bedside
# Anemia: Chronic, stable from prior.
- Trend CBC
- T+S
# Depression:
- Held venlafaxine
# DMII:
- Continued Lantus plus hISS
- Held dulaglutide as NF
# Hypertension:
- Continued metoprolol
# Hyperlipidemia
- Continued statin
# Vitamin D deficiency:
- Continued vitamin D
PICC was removed prior to DC
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 40 mg PO QPM
2. Digoxin 0.25 mg PO QHS
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Rivaroxaban 20 mg PO DINNER
5. Senna 8.6 mg PO BID
6. Polyethylene Glycol 17 g PO DAILY
7. Metoprolol Succinate XL 150 mg PO Q12H
8. Ascorbic Acid ___ mg PO DAILY
9. dulaglutide 1.5 mg/0.5 mL subcutaneous 1X/WEEK
10. Oxybutynin 5 mg PO DAILY
11. Venlafaxine XR 150 mg PO BID
12. Vitamin D 1000 UNIT PO DAILY
13. CefTAZidime 2 g IV Q8H
14. Glargine 25 Units Bedtime
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Sarna Lotion 1 Appl TP QID:PRN itch
2. Glargine 25 Units Bedtime
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Ascorbic Acid ___ mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Digoxin 0.25 mg PO QHS
7. dulaglutide 1.5 mg/0.5 mL subcutaneous 1X/WEEK
8. Metoprolol Succinate XL 150 mg PO Q12H
9. Oxybutynin 5 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY
11. Rivaroxaban 20 mg PO DINNER
12. Senna 8.6 mg PO BID
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute metabolic encephalopathy
Atrial fibrillation
Chronic R ureteral obstruction with PCN tube
DM2
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Patient admitted with agitation and transient confusional state
that resolved. Work up did not show any acute infection. It is
possible that medication effects contributed to her state. We
have made some changes, please see medication list for details.
We recommend that she follow up with her PCP and urologist at
___ in the next ___ weeks to discuss her care further
Followup Instructions:
___
|
10444770-DS-13 | 10,444,770 | 27,603,622 | DS | 13 | 2160-02-11 00:00:00 | 2160-02-13 09:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / Avelox / tetanus toxoid, adsorbed / benzoin /
lidocaine / diltiazem / adhesive tape
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
PCN replacement ___
Right-sided thoracentesis (___)
Pigtail catheter placement into perinephric and paralumbar
abscesses (___)
History of Present Illness:
History Obtained From: Nursing staff in ___
Ms. ___ is a ___ year-old with past medical history of
obesity, DMII, HTN/HLD, afib on xarelto, and multiple sepsis
admissions including recent admission in ___ for
enterococcus UTI w/ ureteral obstruction s/p PCN, who presents
for altered mental status.
Per nursing staff in ___, patient has been confused for
a week and was transferred twice to ___, where she got
nitrofurantoin(?) and ciprofloxacin (?) and was discharged to
the
extended care facility. Patient also had a witnessed fall while
trying to stand up (although she is chair-bound). Per nursing
staff, whenever patient is confused, she tries to stand up and
tries to go to the bathroom, although she is not physically
capable of doing so. Patient has hit her head but without LOC.
Throughout last week, patient complained of dyuria and vague
abdominal pain. Due to concerns of altered mental status and
sepsis (as she had that before), patient was transferred to the
___ for further management.
At baseline, patient is AOx3 and non-ambulatory due to obesity.
She has right abdominal surgery at ___ (details are not clear)
with wound on her right abdominal wall.
In the ED, initial vitals: initial vitals were T 99.6, HR 152,
BP
177/100, RR 24, O2 96% on 2L.
- Exam notable for:
Exam was notable for RUQ and epigastric tenderness; small wounds
over R abdomen w/ surrounding erythema; no obvious neurological
deficits.
- Labs notable for:
WBC: 17.1 | H/H: 10.2/33 | Plt 280
134 | 93 | 0.8
---------------<217 INR: 1.8
4.4 | 28 | 11
- U/A w/ >100 WBCs, mod bact, lg leuks, many yeast, +prot
- Imaging notable for:
- CT A&P with dislodged R PCN w/ the tip in the posterior
abdominal wall w/ secondary R hydronephrosis and multiple rim
enhancing fluid collections in abdomen and retroperitoneum
concerning for abscesses
- CT head w/o acute intracranial abnormality
- CT Cspine w/o acute fracture or malalignment
- Pt given:
While in the ED, the pt spiked a fever to 103 and was noted to
be
in afib w/ RVR to rates in 150s, though hemodynamically stable.
The patient was given:
- 12.5mg PO metoprolol
- 5mg IV metoprolol
- 1L LR x 3
- 600mg IV linezolid
- 2gm IV cefepime
Upon arrival to the floor, the patient reports non-specific
chest
pain with point tenderness. She denies shortness of breath or
increased work of breathing. Patient initially was confused and
AOx1, but later became AOx3.
REVIEW OF SYSTEMS:
10-point review of systems is negative except per HPI.
Past Medical History:
1. Paroxysmal Atrial Fibrillation
2. Depression
3. Type II Diabetes
4. Hypercholesterolemia
5. Hypertension
6. Meniere's Disease
7. Obesity
8. Seasonal Allergies
9. Vitamin D Deficiency
10. Migraine Headaches
11. Carpal Tunnel Syndrome
12. Chronic Low Back Pain
13. Lactose Intolerance
PAST SURGICAL HISTORY:
1. Appendectomy
2. Tonsillectomy
3. Hysterectomy
Social History:
___
Family History:
- Mother ___ ___
ABDOMINAL AORTIC ANEURYSM
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
- Father ___ ___
TRANSIENT ISCHEMIC ATTACK
ABDOMINAL AORTIC ANEURYSM
HYPERTENSION
SEIZURE DISORDER
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
============================
VITALS: Temp: 98.8 (Tm 99.9), BP: 143/81 (143-174/80-81), HR:
123
(121-123), RR: 18 (___), O2 sat: 94% (94-96), O2 delivery: 2L
General: Alert, oriented
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Irregularly irregular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Decreased air entry on the right lower lung field with
dullness to percussion.
Abdomen: Soft, non-tender, left abdominal bulging mass, right
abdominal wound, covered. Right PCN tube. No rebound or
guarding, BS+
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, Upper and lower extremities
DISCHARGE PHYSICAL EXAM:
Vitals: ___ 0313 Temp: 98.0 PO BP: 163/109 HR: 88 RR: 20 O2
sat: 91% O2 delivery: Ra
General: Alert and oriented, not in acute distress.
HEENT: Sclerae anicteric, MMM, oropharynx clear.
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Diffusely diminished breath sounds, crackles at R base.
Abdomen: Soft, non-tender, non-distended. No rebound or
guarding, BS+
Drains: Right PCN tube draining light red colored fluid. R lat
perinephric tube with yellow clear fluid.
Ext: Warm, no edema.
Neuro: A&Ox3, conversant, moving all extremities.
Pertinent Results:
ADMISSION LABS:
==============
___ 10:23PM BLOOD WBC-17.1* RBC-4.36 Hgb-10.7* Hct-34.9
MCV-80* MCH-24.5* MCHC-30.7* RDW-15.1 RDWSD-44.0 Plt ___
___ 10:23PM BLOOD Neuts-84.9* Lymphs-6.4* Monos-7.7
Eos-0.2* Baso-0.2 Im ___ AbsNeut-14.54* AbsLymp-1.09*
AbsMono-1.32* AbsEos-0.03* AbsBaso-0.04
___ 10:23PM BLOOD ___ PTT-30.4 ___
___ 10:23PM BLOOD Glucose-217* UreaN-11 Creat-0.8 Na-134*
K-4.4 Cl-93* HCO3-28 AnGap-13
___ 10:23PM BLOOD ALT-12 AST-18 AlkPhos-83 TotBili-0.7
___ 10:23PM BLOOD Albumin-3.2* Calcium-9.8 Phos-3.1 Mg-1.3*
___ 10:23PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 10:24PM BLOOD Lactate-1.9
DISCHARGE LABS:
==============
___ 07:05 WBC-8.0RBC-3.79*Hgb-9.3*Hct-31.2*Plt
___
___ 06:00
Glucose-180*1UreaN-10Creat-0.5Na-141K-3.8Cl-101HCO3-28
___ 06:00 Calcium-9.4Phos-4.1Mg-1.5*
PLEURAL FLUID LABS:
=================
___ 05:37PM PLEURAL TNC-1821* RBC-570* Polys-35* Lymphs-40*
___ Meso-15* Macro-6* Other-4*
___ 05:37PM PLEURAL TotProt-3.6 Glucose-216 Creat-0.6
LD(LDH)-101 Amylase-22 Albumin-1.6
___ 11:21AM PLEURAL TNC-1789* RBC-52* Polys-7* Lymphs-37*
Monos-0 Eos-3* Macro-37* Other-16*
___ 11:21AM PLEURAL TotProt-3.7 Glucose-204 Creat-0.4
LD(LDH)-109 Amylase-27 Albumin-1.6 Cholest-35 proBNP-2306
___ CYTOLOGY - NEGATIVE
MICROBIOLOGY:
=============
-URINE CULTURE (Final ___: YEAST. >100,000 CFU/mL.
-Blood Culture, Routine (___): NO GROWTH.
-Source: Lateral perinephric fluid collection - ___
- GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
- FLUID CULTURE (Final ___:
___ ALBICANS. SPARSE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # ___ ___.
- ANAEROBIC CULTURE (Final ___: NO ANAEROBES
ISOLATED.
-Source, Right paralumbar collection - ___
- GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
- FLUID CULTURE (Final ___:
___ ALBICANS. SPARSE GROWTH.
Susceptibility testing requested by ___. ___ ___
___.
Yeast Susceptibility:.
Fluconazole MIC OF 0.5 MCG/ML SUSCEPTIBLE.
Results were read after 24 hours of incubation.
test result performed by Sensititre.
- ANAEROBIC CULTURE (Final ___: NO ANAEROBES
ISOLATED.
- Pleural fluid - ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
- Pleural fluid - ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
URINE CULTURE (Final ___: NO GROWTH.
Blood Culture, Routine (___): NO GROWTH.
- SOURCE: Right psoas collection. ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
___ ALBICANS, PRESUMPTIVE IDENTIFICATION. SPARSE
GROWTH.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
IMAGING:
=======
CT C-SPINE WITHOUT CONTRAST - ___
1. No acute fracture or malalignment.
2. Moderate to severe cervical spondylosis with severe central
canal and neural foraminal narrowing at C5-6 and C6-7.
CT HEAD WITHOUT CONTRAST - ___
No acute intracranial abnormality.
CT TORSO W/ CONTRAST - ___
1. Dislodged posterior approach right percutaneous nephrostomy
tube with the tip in the posterior abdominal wall with secondary
severe right proximal hydroureteronephrosis.
2. Urothelial thickening and enhancement suggests infection.
3. Multiple rim enhancing fluid collections in the abdomen and
retroperitoneum are concerning for abscesses.
4. Non simple fluid in the pelvis, concerning for superinfected
free-fluid.
5. Worsened mesenteric, retroperitoneal, pelvic and retrocrural
lymphadenopathy, possibly reactive.
6. Moderate right pleural effusion with associated atelectasis
in the right lower lobe.
NEPHROSTOMY REPLACEMENT - ___
INDINGS:
dislodged existing PCN retracted to the soft tissues
Successful rescue of the tract with placement of 10 ___ PCN.
IMPRESSION:
Successful rescue of a right PCN. 10 ___ PCN placed. Note,
a modified PCNU may be a better alternative given the patient's
continued retractions of this PCN, however she could not
tolerate attempts to cannulate the ureter. If this is to be
attempted, recommend bringing the patient back with anesthesia
for further manipulation.
CT-GUIDED ABDOMINAL COLLECTION DRAINAGE - ___
FINDINGS:
1. Preprocedural imaging demonstrates a moderate-size right
pleural effusion, a well-circumscribed right paralumbar
collection and a large right lateral perinephric Fluid
collection with significant surrounding fat stranding obscuring
its margins.
2. Periprocedural CT fluoroscopic images demonstrate sequential
advancement of hyper dense needle into the targeted Fluid
collections. Subsequent images demonstrate coiling of the
___ Wire and the collection. Final images demonstrate
coiling of the drains within the collections.
3. Final images post thoracentesis demonstrates resolution of
pleural effusion without evidence of pneumothorax.
IMPRESSION:
1. Successful CT-guided placement of an ___ pigtail
catheter into the right lateral perinephric collection. Samples
were sent for microbiology evaluation.
2. Successful CT-guided placement of an ___ pigtail
catheter into the right medial paralumbar collection. Samples
were sent for microbiology evaluation.
3. Successful CT-guided thoracentesis. Samples were sent for
microbiology and chemistry evaluation.
CXR ___
The cardiac silhouette is at the upper limits of normal or
mildly enlarged with mild elevation of pulmonary venous
pressure. Opacification at the right base with poor definition
of the hemidiaphragm is consistent with layering pleural
effusion and atelectatic changes. Mild atelectatic changes are
seen at the left base. No evidence of acute focal consolidation.
CXR - ___
Compared to a chest radiograph ___.
Mild cardiomegaly and moderate right pleural effusion have
increased. No
pulmonary edema. Some right basal atelectasis or consolidation
is presumed,
but the diaphragmatic region is obscured by the ab. Left lung
however is
clear and there is no left pleural abnormality.
CT HEAD WITHOUT CONTRAST - ___
No acute intracranial abnormalities.
CT ABD & PELVIS WITH CO ___
1. Percutaneous nephrostomy tube in appropriate location in the
right kidney.
Heterogeneous enhancement of the right kidney, likely due to
areas of
nephritis and scarring changes.
2. Pigtail in appropriate location within the right medial
paralumbar
collection, which has significantly decreased compared to prior
study. The
other collection bordering the right psoas measuring up to 6.6
cm is
unchanged. It is unclear if this communicates with the
previously mentioned
collection.
3. Pigtail in the ill-defined right lateral perinephric
collection, which is
also significantly decreased.
CHEST (PORTABLE AP) - ___
Lungs are low volume with bibasilar atelectasis. Small right
pleural effusion
is unchanged. There is subsegmental atelectasis in the right
lung base.
There is mild interstitial edema. Cardiomediastinal silhouette
is stable. No
pneumothorax
Brief Hospital Course:
SUMMARY:
==========
Ms. ___ is a ___ year-old with past medical history of
obesity, DMII, HTN/HLD, afib on xarelto, and h/o RCC s/p partial
right nephrectomy c/b ureteral stricture s/p right-sided PCN
placement, who presented to the ED from rehab facility with
altered mental status following fall. Patient was found to have
right pleural effusion, dislodged right PCN, and multiple
rim-enhancing fluid collections in the abdomen/RP c/f abscesses.
Now s/p PCN replacement (___), right-sided thoracentesis
(___), and pigtail catheter placement into perinephric and
paralumbar abscesses (___). Cultures from the abscesses and
urine growing C. albicans for which patient was started on
fluconazole x planned 4-week course.
TRANSITIONAL ISSUES:
====================
[] Continue fluconazole for at least 4 weeks (D1 ___ -
___ pending follow-up with ID
[] Discharge with PCN tube and perinephric drain in place,
follow-up with ___
[] Started on amlodipine 2.5 mg for hypertension, follow-up
blood pressures and titrate as needed
[] Metoprolol dose decreased from 150 mg twice daily to 125 mg
twice daily due to bradycardia with 2 to 3-second pauses
[] Consider outpatient sleep study for OSA
ACTIVE ISSUES:
==============
# Pyuria/Candiduria:
# Dislodged PCN tube s/p replacement:
# Abdominal abscesses:
# Abdominal lymphadenopathy on CT:
Patient presented with altered mental status and, fever of ___ F
and leukocytosis to 21K. UA on admission showed pyuria and
bacteriuria. CT A/P R PCN w/ the tip in the posterior abdominal
wall w/ secondary R hydronephrosis and multiple rim enhancing
fluid collections in abdomen and retroperitoneum concerning for
abscesses. Patient had multiple hospital admissions with similar
presentation and urosepsis with VRE and pseudomonas. Patient was
started on linezolid and vancomycin pending cultures with
improvement in WBC and mental status. Patient underwent PCN
replacement on ___, and pigtails were placed in the perinephric
and paralumbar collections on ___. Urine and abscess cultures
grew C. Albicans. Subsequently, patient was started on
fluconazole and antibiotics were discontinued given that
cultures at the ___ and ___ grew C. albicans. Patient then
had another episode of confusion and CT scan from ___ showed
a collection bordering the right psoas muscle that was
aspirated. The paralumbar drain continued expressing clear
yellow-colored fluid that had creatinine. Subsequently, a
nephrogram on ___ showed complete obstruction of the right
proximal ureter and connection of the right renal collecting
system to at least 1 retro-peritoneal abscess collection.
Attempts at crossing the site of obstruction with a combined
hydrophilic wire, catheter, and sheath, were unsuccessful.
Patient was not a surgical candidate given obesity and multiple
co-morbidities. She was discharged with fluconazole x at least a
4 week course from ___ (date of abscess drainage by ___ to
___.
# Hx Renal mass s/p resection:
# Ureteral obstruction s/p PCN:
# Right abdominal wound:
Renal cell carcinoma s/p right partial nephrectomy and
marsupialization of right renal cyst ___ ___ c/b by
malpositioned nephrostomy tube. Her post-operative course has
been complicated by stent malpositioning and subsequent ureteral
perforation treated with stent removal (___) and
nephrostomy tube placement (___) with multiple exchanges.
Right abdominal wound was followed by wound care.
# Acute encephalopathy:
___ without acute intracranial pressure. Acute encephalopathy
is likely toxic-metabolic encephalopathy in the setting of
urosepsis. Patient improved initially with antibiotics (as
above) and IV fluids. Patient was AOx3 on discharge.
# Recurrent right moderate pleural effusion s/p thoracentesis on
___
# S/p chest tube on ___
Presented with shortness of breath, cough, new oxygen
requirement. CT chest with right moderate pleural effusion with
lower lobe atelectasis. TTE from ___ was normal EF of 55%.
Patient had thoracentesis on ___ with subsequent improvement
in her breathing status. Repeat chest x-rays from ___ showed
reaccumulation of right effusion. Patient had chest tube placed
on ___ and removed on ___. Pleural fluid was borderline
exudative with lymphocytic predominance on ___ and ___. No
evidence of empyema. Cultures on both dates did not show
evidence of growth. Patient breathing improved with occasional
oxygen requirement at night thought to be related to OSA. CXR
from ___ showed small pleural effusion. Patient to follow-up
with interventional pulmonary team.
# Atrial fibrillation
# History of rapid ventricular rates:
On home dose of metoprolol (300mg/day), patient's HR was in the
70-80s; however, she had frequent pauses of ___ seconds on
telemetry. Hence, metoprolol tartrate dose was decreased to 125
mg BID with heart rate in the ___. On heparin drip
___, discharged on home rivaroxaban.
CHRONIC ISSUES:
===============
# Overactive bladder:
- Initially held home oxybutynin due to mental status, restarted
at discharge
# Anemia: Chronic, stable from prior.
# Depression:
- Continued home venlafaxine
# DMII:
- Lantus 16 Units at bedtime (home dose 22U nightly)
- ISS while in ___
- Held dulaglutide while inpatient, resumed at discharge
# Hyperlipidemia
- Continued atorvastatin 40mg daily
# Vitamin D deficiency:
- Continued vitamin D
# Hypertension
- Continued metoprolol, added amlodipine 2.5 mg
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Vitamin D 1000 UNIT PO DAILY
3. Polyethylene Glycol 17 g PO DAILY
4. Senna 8.6 mg PO BID
5. Rivaroxaban 20 mg PO DAILY
6. Venlafaxine 75 mg PO DAILY
7. Glargine 22 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
8. Ascorbic Acid ___ mg PO DAILY
9. Digoxin 0.25 mg PO DAILY
10. Divalproex (DELayed Release) 250 mg PO DAILY
11. dulaglutide 1.5 mg/0.5 mL subcutaneous 1X/WEEK
12. Magnesium Oxide 400 mg PO DAILY
13. Metoprolol Succinate XL 150 mg PO BID
14. Oxybutynin 5 mg PO DAILY
Discharge Medications:
1. amLODIPine 2.5 mg PO DAILY
2. Fluconazole 400 mg PO Q24H
3. Glargine 22 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
4. Metoprolol Succinate XL 125 mg PO BID
5. Ascorbic Acid ___ mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Digoxin 0.25 mg PO DAILY
8. Divalproex (DELayed Release) 250 mg PO DAILY
9. dulaglutide 1.5 mg/0.5 mL subcutaneous 1X/WEEK
10. Magnesium Oxide 400 mg PO DAILY
11. Oxybutynin 5 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Rivaroxaban 20 mg PO DAILY
14. Senna 8.6 mg PO BID
15. Venlafaxine 75 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
=================
Candiduria / pyuria
Abdominal abscesses
SECONDARY DIAGNOSES:
====================
Pleural effusion
Acute encephalopathy
Atrial fibrillation
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at the ___.
- WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You came to the hospital because you were confused.
- WHAT HAPPENED WHILE YOU WERE ADMITTED?
- You were started on antibiotics for suspected blood stream
infection.
- You underwent CT imaging for your chest and abdomen and you
nephrostomy tube was found to be dislodged. Additionally, two
collections were found around the kidney concerning for
abscesses along with fluid around your lung.
- The nephrostomy tube was replaced and two drains were placed
in the collections.
- The fluid around your right lung was drained as well using a
chest tube.
- Your urine and abscess cultures grew yeast. Subsequently, you
were started on anti-fungal medication, called fluconazole. The
antibiotics were discontinued.
- Due to intermittent confusion, you had a second CT abdomen
that showed new small collections.
- These collections were drained with a fine needle.
- You underwent another procedure called nephrogram, where a
contrast agent is injected into your urinary system through your
nephrostomy tube. Your right ureter was found to be totally
occluded and there was communication between your urinary system
and one of the collections.
- WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- Please continue to follow with your doctors as ___.
- Please take all your medications as prescribed, including your
fluconazole for fungal infection.
Followup Instructions:
___
|
10444908-DS-21 | 10,444,908 | 26,001,691 | DS | 21 | 2138-08-07 00:00:00 | 2138-08-07 16:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Iodine
Attending: ___.
Chief Complaint:
R femoral fracture, UTI.
Major Surgical or Invasive Procedure:
R hip arthroplasty.
History of Present Illness:
___ y/o woman with history of dementia and non-biopsy proven MDS,
receiving transfusional support with 2 units PRBCs every 4
weeks, with recent admission for pneumonia and discharge to
rehab. At rehab, she was noted to screaming in pain in bed with
ecchymosis on the right hip. CT scan revealed right femoral neck
fracture. Seen by ortho in ED with plans to pin femur on ___.
In the ED, initial VS were 102.3 96 117/56 16 95% Nasal Cannula.
UA was +. CXR was not obtained. In the ED, she was given ctx,
lorazepam, zyprexa, and tylenol.
On arrival to floor, patient was unable to answer any questions.
She knew her name, but thought she was still in Rehab. She was
unable to answer any questions regarding how she was feeling.
Per the daughter, the patient is demented at baseline. She is
always alert to herself and sometimes is forgetful regarding
where she is. Often, she does not remember the date. At
baseline, she gets around with a walker and participates in the
activities at her assisted living. Per the daughter, the patient
had a negative UA on ___ at her facility. Was not catheterized
there.
While on the Ortho service, the patient was noted to have
significant bandemia as well as grossly positive UA. ___ was
consulted and given that patient appeared to be septic, she was
broadened to cefepime given her recent hospitalizations and
concern for resistant organisms and promptly transferred to
Medicine.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- history of anemia at least since ___, with Hgb usually in the
9.1-11.8 range
- ___, during an admission to OSH for a fall, her Hgb was low
enough to require a blood transfusion
- patient has been transfusion dependent since - requiring 2
units of pRBCs on average every 6 ___,
___.
- ___ - peripheral smear at that time was notable for
anoisopoikilocytosis, rare macroovalocytes, decreased
granulation
of the neutrophils with ome pelgeroid forms and occasional large
platelets = findings were consistent with an underlying MDS and
___ daughter declined a bone marrow biopsy to confirm the
diagnosis
- ___, the patient was started on Aranesp every two
weeks, in an attempt to decrease her transfusion requirements--
after three doses of 300mcg with inadequate response, the dose
was increased to 600mcg on ___ --> medication was not
effective in raising
her red blood cell count, and as such, the ESA was discontinued
PAST MEDICAL HISTORY:
- Dementia
- MDS
- Diverticulosis
- Thyroid nodules, s/p patial thyroidectomy
- Pelvic fracture
- L ankle and R wrist fractures
- GERD
- Memory loss
- Osteoporosis
- Frequent falls
Social History:
___
Family History:
The patient is ___ of six sisters. Another sister is alive in
her ___, the other four are deceased and they all died in their
___. One sister had lung cancer. Another sister had gastric
cancer. No known family history of hematologic disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: 99.5 127/70 100 18 100 3L
GENERAL: AOx1, in no acute distress, pleasantly demented
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. R hip with mild swelling, no erythema or induration.
DISCHARGE PHYSICAL EXAM
=========================
VS: 97.4 137/71 75 95% RA
GENERAL: AOx1, in no acute distress, pleasantly demented
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: Supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Irregularly irregular, normal S1 S2, III/VI SEM best heard
at LUSB, no rubs, gallops
ABD: Soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
___ edema. R hip with dressing, which has small amount of serous
fluid on it, wound underneath is healing well without erythema
or exudate. Area is TTP, though patient is quite tender
throughout her body with only light touch.
Pertinent Results:
ADMISSION LABS
=================
___ 09:40AM BLOOD WBC-5.5 RBC-2.20* Hgb-6.9* Hct-21.4*
MCV-97 MCH-31.4 MCHC-32.2 RDW-22.1* Plt ___
___ 01:15PM BLOOD Neuts-67 Bands-9* Lymphs-16* Monos-6
Eos-1 Baso-1 ___ Myelos-0
___ 01:15PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL
Schisto-OCCASIONAL
___ 10:38AM BLOOD Glucose-123* UreaN-22* Creat-0.9 Na-138
K-4.7 Cl-107 HCO3-20* AnGap-16
___ 10:38AM BLOOD ___ PTT-31.4 ___
___ 01:29PM BLOOD Lactate-1.7
DISCHARGE LABS
================
___ 06:25AM BLOOD WBC-5.9 RBC-3.19* Hgb-9.6* Hct-28.9*
MCV-90 MCH-29.9 MCHC-33.1 RDW-17.8* Plt ___
MICRO LABS
===========
Time Taken Not Noted Log-In Date/Time: ___ 1:25 pm
URINE TAKEN FROM CHEM ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 16 I
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 1:15 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
PROBABLE MICROCOCCUS SPECIES.
Isolated from only one set in the previous five days.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ (___) AT
8:18AM ON
___.
___ 8:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
Time Taken Not Noted Log-In Date/Time: ___ 2:03 am
BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING
========
CT PELVIS ___:
IMPRESSION:
1. Right femoral neck fracture with impaction and relative
foreshortening in the presence of diffuse osteopenia. No soft
tissue or osseous mass lesion is identified and no other
fractures are present.
2. Degenerative changes at the lumbosacral spine.
3. Sigmoid diverticulosis with no diverticulitis
CT Chest ___
The heart size is enlarged. There is no pericardial effusion.
There
is no significant mediastinal, hilar, or axillary
lymphadenopathy.
The visualized portions of the thyroid demonstrate some
ill-defined nodularity of the left lobe.
The central airways are patent. The lungs are clear. There are
trace bilateral pleural effusions. The liver appears hyperdense.
A cyst arising off the upper pole of the left kidney is
partially visualized.
The visualized upper abdominal structures are otherwise
unremarkable. The osseous structures demonstrate multilevel
degenerative changes within the thoracic spine. No acute
fractures are identified. Old fractures of the left ribs are
noted.
Brief Hospital Course:
___ y/o woman with history of dementia, non-biopsy proven MDS,
receiving transfusional support with 2 units PRBCs every 4
weeks, with recent admission for pneumonia and discharge to
rehab and moderate-severe MR now presenting with right femur
fracture and sepsis from likely UTI.
ACUTE ISSUES
# R femoral neck fracture: Patient presented with R hip
fracture. Patient was originally on the Orthopedic Surgery
service and is now s/p R hemiarthroplasty by Dr. ___ on
___, which was uncomplicated. Patient is RLE WBAT. Pain
control with Tylenol PO 1G Q8H standing, tramadol PRN, and
oxycodone PRN. Continue ppx lovenox through ___.
# Sepsis from urinary source: Patient with bandemia and prior to
R hip arthroplasty tachycardia. Bandemia could have been
slightly complicated by her known MDS, however grossly positive
UA suggested infectious source. Urine cx with > 100,000 e. coli.
No other notable sources of infection were present. Patient did
not meet criteria for severe sepsis or septic shock. Patient
received IVF resuscitation with normal saline and was started on
cefepime. Tachycardia resolved and bandemia improving. Once
urine culture sensitivities, ___ antibiotics were narroed
to ceftriaxone. She will be transitioned to cefpodoxime at
discharge with plan to complete a 10 day course on ___.
# Positive blood cultures: Patientw as noted to grow Micrococcus
on 1 out of 5 sets of blood cultures. Given this finding,
patient was briefly treated with IV vancomycin, but as this is a
known skin flora and is most likely to be a contaminant,
vancomycin was stopped at discharge.
# Leg Swelling: Patient noted to have bilateraly pitting edema
of the lower extremities during her admission. This was thought
to potentially be due to element of ___, as patient has a known
history of MR, which could lead to some diastolic dysfunction.
This was thought to be exacerbated by the IVF volume she
received while septic. She is on furosemide PO as an outpatient,
but she was diursed with IV furosemide briefly and then
transitioned back to home PO dose at discharge.
# Mitral Regurgitation: Known mitral regurgiation. Discussed
above as possible precipitant for element of diastolic
disfunction, but no acute issue at this time. Can follow up as
an outpatient for repeat ECHO.
CHRONIC ISSUES
# MDS: Nonbiopsy proven for which patient has required a
transfusion every 4 weeks. She has not been responsive to
therapy in the past. The patient was transfused with 3 u PRBC
this hospitalization with appropriate bump. Her last transfusion
was on ___. Hct at discharge was 28.9. Patient should have
H/H checked on ___ to ensure ongoing stability.
# Dementia: Chronic dementia. Patient requires frequent
re-orientation and resassuance.
TRANSITIONAL ISSUES
- Medications added: tylenol, tramadol, oxycodone, senna,
colace, enoxaparin, cefpodoxine.
- Continue cefpodoxime 400 mg Q12H PO through ___ to
complete 10 day course.
- Continue enoxaparin through ___.
- Please check CBC on ___ to ensure stability. Patient has
MDS and is transfusion dependant. Last transfusion was on
___. Hct at discharge was 28.9.
- Full code
- Contact: ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benzonatate 100 mg PO TID:PRN cough
2. Guaifenesin ___ mL PO Q6H:PRN cough
3. Furosemide 10 mg PO DAILY
Discharge Medications:
1. Furosemide 10 mg PO DAILY
2. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*90 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Enoxaparin Sodium 30 mg SC Q24H
Start: ___, First Dose: First Routine Administration Time
Continue through ___.
RX *enoxaparin 30 mg/0.3 mL 30 mg SC Q24H Disp #*22 Syringe
Refills:*0
5. 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 #*20 Tablet Refills:*0
6. Senna 17.2 mg PO HS
RX *sennosides [senna] 8.6 mg 2 tab by mouth HS Disp #*60
Capsule Refills:*0
7. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*80 Tablet Refills:*0
8. Cefpodoxime Proxetil 400 mg PO Q12H
Continue through ___.
RX *cefpodoxime 200 mg 2 tablet(s) by mouth every twelve (12)
hours Disp #*20 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
1. R hip fracture
2. Urinary tract infection
3. Acute on chronic ___ excacerbation
Secondary:
1. Dementia
2. MDS
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
You were admitted with a right hip fracture. This was repaired
surgically without complication. During your admission you were
also noted to have a urinary tract infection, which was treated
with antibiotics.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10445502-DS-21 | 10,445,502 | 25,637,489 | DS | 21 | 2163-03-27 00:00:00 | 2163-03-27 12:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
___: T8-L3 Fusion, T11 corpectomy
History of Present Illness:
Otherwise healthy ___ F transferred from OSH with back pain and
CT scan showing lytic bone lesions of C6, T11 and L1 in the
setting of new cervial lymphadenopathy, abdominal fullness, and
weight loss.
She has been experiencing back pain starting in ___, when,
after lifting some heavy objects she felt that she had "pulled
her back." This was treated conservatively but the pain did not
get better. During her conservative management she also saw a
chiropractor.
Concurrently to this she also noticed new right cervical
lymphadenopathy, non-tender. No B symptoms. Because of the
continued back pain and lymphadenopathy she presented to her PCP
in late ___ and was referred to an ENT for the lymphadenopathy,
who per notes determined that the nodes were borderline in size
to be concerning for lymphoma. As back pain persisted over the
following months, and an elevated ESR (26) and CRP (5.89) were
noted, a Cervical and Chest CT was done on ___ which
revealed lytic lesions of the C6 transverse process, T11 and L1
vertebral body with accompanying compression fracture of L1 with
moderate spinal stenosis.
Appointments were made by her PCP for ENT ___ follow up at
___ on ___ at 2pm with Dr. ___, ENT. Patient
wanted a more expedited work up so she self-presented to the ___.
___ yesterday to initiate work-up there, on referral
from her neighbor who is a retired ___ oncol___. There
a Spine MRI was done, and she was ___ transferred to
___ for evaluation by spine surgery and oncology. Patient
denies numbness/weakness/paresthesias. No loss of bowel/bladder
control. Of note, she endorses new GERD-like symptoms in the s/o
recent ibuprofen use to control her pain, as well as abdominal
fullness x1 week. Normal BMs. Also reports 7 lb weight loss
over an unspecified period of time.
In the ED her vitals were stable and she was seen by the spine
service who recommended repeat imaging and bed rest. Later, it
was determined that she should have surgery to stabilize her
spine.
Past Medical History:
Breast lump excised in ___ - fibroadenoma
BCC of the nose s/p Moh's surgery
Psoriasis - no meds
Social History:
___
Family History:
Mother ___ cancer in her ___, treated, relapsed in her ___.
No other FHx of cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 98.3F, BP 116/67 , HR 63 , R 18, O2-sat 100% RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - multiple, non-tender, mobile lymph nodes in the R
anterior cervical chain
LUNGS - CTAB
HEART - RRR, no m/r/g, nl S1-S2
ABDOMEN - soft, NT/ND, no masses or HSM, prominent abdominal
aorta
EXTREMITIES - WWP, no c/c/e
SKIN - small psoriasis rash on LUE
NEURO - awake, A&Ox3, non-focal
DISCARGE PHYSICAL EXAM:
incision is c/d/i, well approximated with steri strips in place
Motor is ___ bilaterally
Sensory intact to light touch
Pertinent Results:
ADMISSION LABS:
___ 10:45AM BLOOD WBC-5.4 RBC-4.27 Hgb-12.8 Hct-37.7 MCV-88
MCH-30.0 MCHC-33.9 RDW-12.9 Plt ___
___ 10:45AM BLOOD Glucose-92 UreaN-17 Creat-0.7 Na-141
K-3.8 Cl-102 HCO3-28 AnGap-15
___ 10:45AM BLOOD ALT-22 AST-29 AlkPhos-81 TotBili-0.9
___ 10:45AM BLOOD TotProt-6.7 Albumin-4.4 Globuln-2.3
Calcium-9.9 Phos-3.8 Mg-1.9
___ ___- IMPRESSION: Normal study.
___ CT Torso- IMPRESSION:
1. Multiple lytic lesions within the spine. Pathologic
compression fracture at T11 with soft tissue density extending
into the spinal canal causing mass effect on the spinal cord.
2. No adenopathy or suspicious mass identified within the
visceral chest,
abdomen, and pelvis.
3. Indeterminate subcentimeter lesions within the liver, likely
representing cysts.
___ L-spine Xray: IMPRESSION: Post-surgical changes at the
thoracolumbar junction with alignment maintained and hardware
appearing intact.
Brief Hospital Course:
Otherwise healthy ___ F transferred from OSH with back pain and
CT scan showing lytic bone lesions of C6, T11 and L1 in the
setting of new cervial lymphadenopathy, abdominal fullness, and
weight loss.
# L1 Spine compression fracture - this was thought secondary to
lytic bone lesions which are most consistent with metastases
from an unknown primary cancer. Imaging from the outside
hospital as well as repeat imgaing here showed mild evidence of
spinal canal stenosis at the level of the fracture but she did
not report any symptoms of cord compression. She was seen by the
spine surgery service who determined that she should have
surgery for stabilization. Her pain was well controlled on
tylenol and oxycodone.
# Lytic bone lesions - again, most concerning for cancer
metastases, especially in the setting of lymphadenopathy,
abdominal fullness, and weight loss. She had a CT
Brain/Chest/Abdomen/Pelvis which showed lymphadenopathy
consistent with her clinical exam but no masses anywhere.
Patient was taken to the operating room for a T8 to L3 fusion.
Part of the L1 pedicle was noted to be infiltrated with tumor,
but removal of the tumor was not possible for fear that it would
become unstable. Patient was extubated post operatively in the
intensive care unit. On post operative day one the patient
remained on Neo for blood pressure support, her hematocrit had
droped to 23, she was transfused with one unit of blood and was
able to maintain a normal blood pressure off of pressors.
On ___ She was mobilized. Medical Oncology and Radiation
Oncology were contacted for consults and treatment planning. Her
blood pressure continued to be stabilized. Medicine continued to
follow the patient and give recommendations.
On ___ her hct dropped to 23 so she was started on BID checks
and iron supplementation. She was encouraged to get OOB and
worked with ___.
On ___ her pain medications were converted to PO and muscle
relaxant was changed due to sedation. Her HCT was stable at 24
and her bowel regimen was increased. She was again encouraged to
get OOB.
On ___ she again worked with physical therapy who recommended
discharge to rehab. HCT was stable 24%.
Now dod, pt is afebrile, VSS, and neurologically unchanged.
Pain is well controlled on PO regimen. her incision is without
evidence of infection. She is set for d/c to rehab in stable
condition.
Medications on Admission:
Ibuprofen 400mg BID PRN
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/temp
2. Bisacodyl 10 mg PO DAILY constipation
3. Docusate Sodium 100 mg PO BID
4. Heparin 5000 UNIT SC TID
5. Methocarbamol 750 mg PO QID
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
7. Pantoprazole 40 mg PO Q24H
8. Senna 1 TAB PO DAILY constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
T6, L1, L4 Lytic lesions on spine
T11 pathologic compression fracture
Supraventricular tachycardia
Post operative Anemia
hypotension
constipation
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
Dr. ___
Do not smoke.
Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
If you have steri-strips in place, you must keep them dry for
72 hours. Do not pull them off. They will fall off on their own
or be taken off in the office. You may trim the edges if they
begin to curl.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
Have a friend or family member check your incision daily for
signs of infection.
Wear your back brace as instructed.
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
Do not take any medications such as Aspirin unless directed by
your doctor.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Followup Instructions:
___
|
10445576-DS-13 | 10,445,576 | 29,504,729 | DS | 13 | 2133-01-06 00:00:00 | 2133-01-09 21:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ibuprofen
Attending: ___.
Chief Complaint:
CC: vague abdominal pain found to be an SMV thrombus and
metastatic, poorly differentiated pancreatic neuroendocrine
malignancy
Major Surgical or Invasive Procedure:
Liver biopsy
History of Present Illness:
Ms. ___ is a ___ yo F with history of leiomyoma s/p resection
in the past, reported L kidney mass of unknown etiology, HTN,
and
bipolar disorder, who came to the ED with ___ days of vague
abdominal cramping and pain at work, 'gas' pain. She took
peptobismal without improvement. No relation to eating/drinking.
Had a similar episode about 3 months ago that self resolved. No
changes in weight, no changes in bowel habits (once every
morning) no diarrhea, steatorrhea, melena, nausea,vomiting. No
fatigue. Had a viral illness a few days ago with fevers that
self-resolved (without other symptoms). Her last visit to her
urologist for L kidney mass was in ___.
In the ED, initial VS were 97.0 66 157/96 16 100% RA
Exam notable for patient appearing uncomfortable, in diffuse abd
pain.
Labs showed trop negative x 2, normal BMP, LFTs notable for
ALT/AST 63/69. Normal AP, Tbili, Alb, lipase of 38. CBC with WBC
13.3, H/H 10.7/32.6, platelets 236. UA negative. CEA sent and
pending
Imaging:
IMPRESSION:
1. Multiple hepatic hypodense lesions concerning for metastatic
disease.
Possible primary tumor within the pancreatic uncinate process.
Further evaluation with MRI is recommended.
2. SMV thrombus.
3. Fat containing left renal lesion is concerning for AML, this
lesion can also be further assessed at the time of MRCP.
4. Small fat containing lesion within the pancreatic midbody,
attention on follow-up MR.
5. Fibroid uterus.
6. Facet arthropathy in the lower lumbar spine with grade 1
anterolisthesis of L3 on 4 and L4 on 5.
Received IVF and given heparin bolus and then gtt.
Transfer VS were 99.1 72 136/81 18 97% RA
___ surgery was consulted, recommended MRCP vs. ___nd admission to medicine for further workup.
On arrival to the floor, patient reports her pain has
disappeared.
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
Hypertension
History of homelessness
Leiomyoma s/p resection ___
Knee surgery
Bipolar disorder, previously on treatment
Known L kidney mass, with workup in ___ (unknown pathology)
Social History:
___
Family History:
Per surgical note:
Mother had leukemia, unknown otherwise, does not think there is
a
history of GI malignancies.
Physical Exam:
================
Admission Physical Exam
================
ADMISSION PHYSICAL EXAM:
VS: 98.7 138/73 67 16 98% Ra
GENERAL: NAD, appears somewhat frustrated throughout the exam.
HEENT: anicteric sclera, pink conjunctiva, MMM
NECK: supple
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, breathing comfortably without use of accessory
muscles
ABDOMEN: nondistended, soft, no rebound or guarding. There is
tendernesss to deep palpation, especially on the R side, but
upper and lower.
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
===================
Discharge Physical Exam
===================
O:
Vitals: Temp: 98.8
BP 129/76
HR 74
RR ___ Ra
General: Patient is a well appearing female lying in bed in her
street clothes in no apparent pain or distress
HEENT: eyes anicteric, no scleral injection, oral mucosa is pink
and moist, EOM grossly intact. Patient is partially edentulous,
with poor dentition and concern for caries. No tenderness to
palpation on gingivae. No fluctuant masses.
CV: regular rate and rhythm, no murmurs gallops or rubs, normal
S1 and S2, distal pulses radials are 2+
Pulm: Lungs are clear to auscultation in posterior and anterior
lung fields, no wheezes or rhonchi
abd: soft, non-tender to palpation, palpable liver mass below
the
right costal margin
Neuro: AO x3, moves all extremities independently
Psych: affect is angry and distrustful, mood is "frustrated,"
goal directed thought process, laconic this morning
Pertinent Results:
===========
Admission Labs:
===========
___ 12:00AM PTT-67.2*
___ 05:30PM PTT-29.4
___ 07:40AM GLUCOSE-84 UREA N-10 CREAT-0.7 SODIUM-139
POTASSIUM-3.3 CHLORIDE-98 TOTAL CO2-23 ANION GAP-21*
___ 07:40AM ALT(SGPT)-171* AST(SGOT)-170* LD(LDH)-467*
ALK PHOS-61 TOT BILI-0.7
___ 07:40AM CK-MB-2 cTropnT-<0.01
___ 07:40AM ALBUMIN-3.9 CALCIUM-9.4 PHOSPHATE-3.6
MAGNESIUM-1.9
___ 07:40AM WBC-9.4 RBC-3.82* HGB-9.8* HCT-29.7* MCV-78*
MCH-25.7* MCHC-33.0 RDW-13.7 RDWSD-38.8
___ 01:25AM cTropnT-<0.01
___ 06:50PM LIPASE-38
___ 06:50PM cTropnT-<0.01
___ 06:50PM CEA-2.3
Imaging on Admission:
CT Abd ___
IMPRESSION:
1. Multiple hepatic hypodense lesions concerning for metastatic
disease.
Possible primary tumor within the pancreatic uncinate process.
Further
evaluation with MRI is recommended.
2. SMV thrombus.
3. Fat containing left renal lesion is concerning for AML, this
lesion can
also be further assessed at the time of MRCP.
4. Small fat containing lesion within the pancreatic midbody,
attention on
follow-up MR.
5. Fibroid uterus.
6. Facet arthropathy in the lower lumbar spine with grade 1
anterolisthesis of
L3 on 4 and L4 on 5.
CT Chest w/o contrast
IMPRESSION:
1. 2 indeterminate small lung nodules, larger measures 0.3 cm..
No
adenopathy.
2. Small volume perihepatic ascites. Please refer to the recent
CT abdomen
and pelvis for further evaluation of the intra-abdominal
structures.
MRCP
IMPRESSION:
1. Pancreatic head mass measuring 3.1 x 2.7 cm with associated
dilation of the
uncinate pancreatic duct, concerning for primary pancreatic
malignancy. This
mass contacts the distal superior mesenteric artery and encases
a thrombosed
superior mesenteric vein. There also smaller thrombosed
adjacent mesenteric
venous branches.
2. Multiple hepatic metastatic lesions.
3. Segment VII hepatic lesion located adjacent to the liver
capsule is in
association with a likely subcapsular hematoma. Along the
superior aspect of
this lesion there is unusual enhancement, which progressively
increases on
delayed phase imaging, and could abnormal enhancement related to
the
underlying lesion, however the possibility of active bleeding
should be
considered.
4. Left renal angiomyolipoma.
5. Trace ascites.
RECOMMENDATION(S): CTA pancreas for staging purposes, at the
time of the
study a non contrast and delayed phase is recommended to
evaluate for active
bleeding in hepatic segment VII lesion.
===========
Discharge Labs:
===========
___ 08:40AM BLOOD WBC-15.7* RBC-3.21* Hgb-7.9* Hct-25.2*
MCV-79* MCH-24.6* MCHC-31.3* RDW-14.1 RDWSD-40.2 Plt ___
___ 08:40AM BLOOD Plt ___
___ 08:40AM BLOOD Glucose-147* UreaN-17 Creat-0.8 Na-138
K-4.0 Cl-94* HCO3-26 AnGap-18*
___ 08:40AM BLOOD ALT-90* AST-28 LD(LDH)-406* AlkPhos-85
TotBili-0.6
BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Urine Cx; negative
Liver biopsy:
POSITIVE FOR MALIGNANT CELLS,
consistent with poorly differentiated carcinoma.
Brief Hospital Course:
Patient Summary:
___ yo woman with a few-month history of diffuse, vague abdominal
pain found to have an SMV thrombus and pancreatic and liver
masses on imaging confirmed on FNA to be poorly differentiated
carcinoma and now with active extravasation into subcapsular
hematoma that resolved without intervention, with stable anemia
at discharge.
===============================
Acute Medical Issues Addressed
===============================
#Subscapular hematoma Resolved:
#Acute blood loss anemia:
Noticed on CTA abdomen/pelvis. Patient's hematocrit has
stabilized after it was trending down over ___ days. Nadir was
~7.7 from 9.0. On Discharge hgb was 8.1. ___ was involved but
based on hgb stability and hemodynamic stability they felt that
the bleed resolved without intervention.
#Fevers:
Patient was febrile nights of ___ to 100.8. Blood and
urine cultures showed no growth and X-ray also negative for
pneumonia. No localizing symptoms. Patient also reported tooth
pain but no clear abscess or source of infection. Ultimately,
these low-grade fevers were likely ___ malignancy.
#Pancreatic Carcinoma poorly differentiated
Imaging findings concerning for pancreatic adenocarcinoma with
metastases to the liver. Comfirmed on liver biopsy by ___ and
Core needle biopsy which were both communicated to patient
during admission prior to dischaqrge. ___ within normal
limits. Patient met with case management and social work prior
to discharge to assess ability to cope with new diagnosis. She
was discharged with plan to follow up in multi-disciplinary
pancreatic center.
#SMV thrombosis
Noted on CT. ___ be contributing to pain. Most likely related to
direct compression of pancreatic Ca as evidenced by encasing of
artery with mass based on imaging. Treated with heparin gtt and
transitioned to apixiban at discharge after discussion with
patient about risks/benefits of DOAC vs Warfarin including lack
of data of effectiveness of DOACs for this particular disease
process.
TRANSITIONAL ISSUES:
- Please follow-up final pathology from liver biopsy.
- Patient has follow-up scheduled in oncology
- Please follow-up final blood cultures
- Recommend to consider repeat CBC within ___ days of discharge
- Patient started on apixiban during this admission. She was
instructed to take 10mg BID from ___ then 5mg BID after
that for SMV thrombosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) unknown
mg oral unknown
3. Fish Oil (Omega 3) Dose is Unknown PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
3. Maalox/Diphenhydramine/Lidocaine 30 mL PO Q4H:PRN
Indigestion/stomach pain
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Senna 8.6 mg PO BID:PRN constipation
6. Simethicone 40-80 mg PO QID:PRN abdominal discomfort
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) unknown
oral Frequency is Unknown
9. Hydrochlorothiazide 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
#Pancreatic carcinoma poorly differentiated with metastasis
#Superior Mesenteric Venous Thrombosis
#Subscapular Hematoma
#Acute on chronic anemia from blood loss
Secondary Diagnosis:
#Hypertension
#Leiomyoma status post resection
#Renal mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for letting us take care of you during your time at
___.
What Happened on this hospital stay:
- You were diagnosed with a blood clot in a vein in your abdomen
- You were also diagnosed with Pancreatic Cancer with spread to
your liver
- You had scans of your abdomen to help stage the cancer
- You were treated with intravenous medications to help thin
your blood and prevent the blood clot from getting worse
What needs to be done once you leave the hospital:
-It is important that you follow up with your primary care
doctor
-___ is also important that you go to your Appointment with the
Cancer Doctors ___ for ___ at 1:00pm at ___.
- If is important that you take all of your prescribed
medications especially the blood thinning medication apixiban
- You should take apixiban 10mg (two pills) twice daily until
___. After this date, you should 5mg (one pill) twice
daily.
- If you continue to have pain in your teeth, please see your
dentist, as this may be a source of potential infection. One
suggestion for this resource is:
___
___
It was a privilege to participate in your care.
Best wishes,
Your ___ Team
Followup Instructions:
___
|
10445927-DS-11 | 10,445,927 | 23,084,259 | DS | 11 | 2165-11-23 00:00:00 | 2165-11-26 21:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Skelaxin / Augmentin / latex
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Flexible Scope bronchscopy with balloon dilation on ___
History of Present Illness:
Ms ___ is a ___ with h/o chronic
cough, DOE, frequent resp infections, tracheal stenosis and
severe tracheomalacia.
She underwent a bronchoscopy ___ which noted tracheomalacia
mid trachea, tracheal scarring, purulent bronchitis, RMS
bronchial compression (posterior pulsatile extrinsic compression
narrowing lumen by half). The larynx appearance suggested
chronic
inflammation from GERD so the bronchoscope was advanced into the
esophagus and that appeared normal.
She also underwent laryngoscopy on ___ which showed b/l
vocal cord atrophy.
She underwent EGD recently which showed no abnormality.
She reports that her symptoms started ___ years ago and gradually
got worse but more notably within the last ___. She gets short of
breath after walking ___, she is always fatigued. She
notes
that she coughs all day along, mostly dry cough, occasionally
with clear sputum.
Y stent was placed in ___ at ___, but it was
removed 10 days later because the patient could not tolerate it.
Tracheal dilation was also tried in ___ with no improvement per
patient.
Past Medical History:
Cervical tracheal stenosis- 4.5 cm on bronchoscopy 2.5 cm from
carina
Tracheobronchomalacia
Obesity
Chronic pain
OA
DMI
Seasonal allergies
histoplasmosis
IgG deficiency
COPD
Septicemia (pseudomonas)
clotting disorder
depression
migraines
anxiety
obesity
coma
asthma
pneumonia
SOB
cough
chicken pox
aspergillus fumigatus
rhizopus infection
s/p C-birth x ___
s/p bronchoscopy x 7
odontectomies
portacath
tracheal stent
Social History:
___
Family History:
___ 1-antitrypsin, DM
Father-HTN
___ 1-antitrypsin, Dm
Offspring-asthma
Other
Pertinent Results:
___ 12:50PM WBC-7.1# RBC-4.00* HGB-12.3 HCT-38.0 MCV-95
MCH-30.8 MCHC-32.5 RDW-13.3
Brief Hospital Course:
Mrs. ___ was admitted on ___. Patient was recently
discharged on ___ s/p tracheobronchoplasty. Patient was
admitted for worsening productive cough and shortness of breath.
Patient was seen in the ED, chest xray did not show any
abnormalities. It was felt that it would be necessary to admit
patient. Intervention pulmonary medicine was consulted on day of
admission. It was felt that it would be important to scope Mrs.
___. After discussion with IP, we scheduled patient for
bronchoscopy and patient was made NPO overnight.
On ___, bronchoscopy showed stenosis of distal trachea.
Severe malacia was noted bilaterally in the mainstem bronchi.
Subsequently balloon dilation was performed in the stenosis
region of the trachea. Patient was transported back to the
floors in stable condition. Regular diet was restarted.
Respiratory medicine was consulted, so patient could work on her
breathing.
On ___, patient felt much better. Patient denied shortness
of breath. Patient was not using oxygen. Patient denies much
productive cough. Respiratory therapy continued to work with
Mrs. ___. Prior to admission, patient was started on a 14 day
course of Augmentin. Augmentin was discontinued after speaking
with pulmonary medicine. Patient was discharged in stable
condition. Mrs. ___ will return to clinic to see both
Pulmonary medicine and Thoracic surgery. Patient will also have
IgG infusion prior to her clinical appointments.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
2. Benzonatate 200 mg PO TID
3. Budesonide 0.5 mg PO BID
4. Duloxetine 60 mg PO DAILY
5. Gabapentin 300 mg PO TID
6. Hydrocortisone 15 mg PO QAM
7. Hydrocortisone 5 mg PO HS
8. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Target glucose: 80-180
9. Xopenex Neb 1.25 mg/3 mL inhalation 2 PRN
10. Montelukast 10 mg PO DAILY
Discharge Medications:
1. Benzonatate 200 mg PO TID
2. Gabapentin 300 mg PO TID
3. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every six (6) hours Disp #*60 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 #*50 Capsule Refills:*0
5. Guaifenesin ER 1200 mg PO Q12H
RX *guaifenesin [Mucinex] 1,200 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth Q3H Disp
#*50 Tablet Refills:*0
7. Omeprazole 40 mg PO DAILY
8. Budesonide 0.5 mg PO BID
9. Duloxetine 60 mg PO DAILY
10. Xopenex Neb 1.25 mg/3 mL inhalation 2 PRN
11. Hydrocortisone 5 mg PO HS
12. Hydrocortisone 15 mg PO QAM
13. Montelukast 10 mg PO DAILY
14. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Target glucose: 80-180
15. Topiramate (Topamax) 200 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Tracheobronchomalacia
Discharge Condition:
Patient discharged in stable conditions
Full mental capacity
Ambulatory at discharge
Discharge Instructions:
Patient was admitted for shortness of breath and increasing
productive cough. Patient is discharged in stable conditions.
patient should continue to do deep breathing. Otherwise can
tolerate a regular diet. Patient can manage own insulin pump.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Difficult or painful swallowing
-Nausea, vomiting
-Increased shortness of breath
Followup Instructions:
___
|
10446182-DS-22 | 10,446,182 | 22,485,609 | DS | 22 | 2154-12-08 00:00:00 | 2154-12-11 12:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Percocet /
Neurontin
Attending: ___.
Chief Complaint:
cough/weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ HIV not on HARRT w/ recent CD4 14, VL 2.67 million p/w 1
month of progressive weakness, fatigue, decreased appetite,
failure to thrive. Also having cough productive of yellow/brown
sputum (nonbloody) and dyspnea on exertion. Persistent nausea
with decreased appetite and weight loss although cannot
quantify. Only reportedly taking dapsone and valacyclovir. Has
not been taking azithromycin. Denies fever, chills, headache,
chest pain, abd pain, dysuria, hematuria. No rashes. Had
granddaughter that was hospitalized 1 month ago for pneumonia or
flu which was her only sick contact.
Was seen in ID urgent care clinic today and was referred to the
ED from there.
Also sas chronic neuropathic pain in lower extremities but other
than some vague myalgias, no other focal pain. Neuropathic pain
is currently severe and has been off narcotics for lsat ___
months. It makes it difficult for her to sit or lie on her back
due to pain. When asked if she feels more depressed, she says
that she is because of her illness but got ill and then more
depressed, not vice versa. No new substance uses and no other
new/different medications.
Denies HA, neck stiffness, change in vision, change in hearing,
disorientation, black/bloody stools, dysuria, urinary frequency,
acute skin rash.
In the ED, initial VS: 96.6 117 ___ 100% RA. CXR showed no
acute process. Labs notable for Hct of 33.5 (from 41.6 ___.
ECG with sinus tachycardia to 104. UA showed 4 wbcs, patient was
to be given cipro, but since blood cultures were not drawn, this
was not given. VS prior to transfer: 98.5 100-130/86 spo2=100
pain = 9
Currently, patient feels overall unwell and fatigued.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
- HIV/AIDs with complications of CMV viremia, Eosinophilic
Dermatitis, Zoster infections. Has been non-compliant or
unwilling to take medications in the past. Currently not on
HAART. As above last CD4 was ___.67 million on ___.
- Neuropathic Pain thought ___ to past VZV infections
- Presumed PCP ___ ___
- HTN (not on medications)
- Depression
- MSSA bacteremia ___
- Status post TAH/BSO ___ years ago for a uterine fibroid
- History of gonorrhea treated at the age of ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
VS - Temp 98.4F, BP 107/91, HR 102, R 18, O2-sat 100% RA
GENERAL - cachectic ___ female in NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
without thrush
NECK - supple, no thyromegaly, no JVD, no cervical
lymphadenopathy
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - dry, no acute rashes, chronic diffuse scarring from prior
eosinophilic folliculitis
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
admission labs
___ 03:25PM BLOOD WBC-5.2 RBC-3.91* Hgb-10.4* Hct-33.5*
MCV-86 MCH-26.7* MCHC-31.1 RDW-18.2* Plt ___
___ 03:25PM BLOOD Neuts-90* Bands-0 Lymphs-5* Monos-5 Eos-0
Baso-0 ___ Myelos-0
___ 03:25PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Pencil-OCCASIONAL
Fragmen-OCCASIONAL
___ 05:40AM BLOOD ___ PTT-31.9 ___
___ 03:25PM BLOOD Glucose-76 UreaN-8 Creat-0.7 Na-136 K-4.7
Cl-98 HCO3-22 AnGap-21*
___ 03:25PM BLOOD ALT-12 AST-27 AlkPhos-78 TotBili-0.6
___ 05:40AM BLOOD LD(LDH)-262* CK(CPK)-41
___ 03:25PM BLOOD Albumin-4.1 Iron-21*
___ 03:25PM BLOOD calTIBC-250* VitB12-388 Ferritn-839*
TRF-192*
___ 05:40AM BLOOD TSH-1.3
___ 05:40AM BLOOD Cortsol-26.6*
.
discharge labs
___ 11:40AM BLOOD WBC-6.9 RBC-3.71* Hgb-9.7* Hct-32.1*
MCV-87 MCH-26.0* MCHC-30.0* RDW-17.4* Plt ___
___ 11:40AM BLOOD Glucose-93 UreaN-6 Creat-0.7 Na-137 K-3.6
Cl-97 HCO3-25 AnGap-19
___ 11:40AM BLOOD Calcium-8.9 Phos-2.5* Mg-2.1
.
urine
___ 05:44PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:44PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-80 Bilirub-SM Urobiln-4* pH-6.0 Leuks-NEG
___ 05:44PM URINE RBC-1 WBC-4 Bacteri-FEW Yeast-NONE Epi-0
TransE-<1
___ 05:44PM URINE CastHy-7*
.
micro
URINE CULTURE (Final ___: <10,000 organisms/ml.
.
CMV Viral Load (Final ___:
CMV DNA not detected.
.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
Blood culture x 2 - NGTD
.
TOXOPLASMA IgG ANTIBODY (Pending):
TOXOPLASMA IgM ANTIBODY (Pending):
.
CXR: IMPRESSION: No evidence of acute disease.
.
Brief Hospital Course:
___ yo F h/o HIV/AIDS not taking HAART who presents with one
month of progressive dyspnea on exertion, fatigue and decreased
appetite.
# cough/shortness of breath/weakness - unclear etiology. chest
xray was clear and her o2 sats were in high ___ on room air.
Differential included infection (bacterial, viral, fungal) vs
underlying lung disease (long term smoker) vs CHF (although no
signs of volume overload on exam) vs deconditioning and anemia.
The infectious disease team was consulted. During admission,
patient appeared to be in no repiratory distress and noted
improvement in her symptoms. Her infectious workup was negative
for 48 hours (final blood and fungal cultures, toxo, parvovirus
studies pending at time of discharge). TSH and AM cortisol were
within normal limits. She worked with ___ and reported no dyspnea
on exertion and was determined safe for home DC with no further
___ needs. Of note she was noted to tachycardic and orthostatic
by heart rate but not blood pressure. She refused IV access and
additional IV fluid resuscitation. She was asymptomatatic and
demonstrated that she was able to take adequate po intake. The
patient was discharged home with scheduled outpatient ID follow
up.
# HIV/AIDS - not currently on HAART. She was continued on
Dapsone and acyclovir for prophylaxis while in house. She was
discharge on dapsone and valtrex with scheduled ID follow up.
# depression/chronic pain - Patient reported that she had not
been taking her lyrica for 1 week prior to admission. She was
restarted on lyrica at a reduced dose of 75 mg twice daily with
plans to uptitrate in ___ weeks. She was also continued on
tylenol as needed.
# anemia - found to be iron deficient and was started on iron
supplementation.
Transitional Issues
- final blood and fungal cultures, toxo, parvovirus studies
pending at time of discharge
Medications on Admission:
AZITHROMYCIN - 600 mg Tablet - 2 Tablet(s) by mouth 1X/WEEK (TH)
(not taking)
DAPSONE - 100 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
EMTRICITABINE-TENOFOVIR [TRUVADA] - 200 mg-300 mg Tablet - 1
Tablet(s) by mouth QAM (once a day (in the morning)) - not
taking as prescribed
ETRAVIRINE [INTELENCE] - 100 mg Tablet - 2 Tablet(s) by mouth
twice a day Take 2 tablets twice daily (200mg by mouth twice
daily)(not taking as prescribed)
PREGABALIN [LYRICA] - 75 mg Capsule - 2 Capsule(s) by mouth
twice
a day (had stopped taking for 1 week prior to admission)
RALTEGRAVIR [ISENTRESS] - 400 mg Tablet - 1 Tablet(s) by mouth
twice a day (not taking as prescribed)
VALACYCLOVIR - 1,000 mg Tablet - 1 Tablet(s) by mouth daily
Discharge Medications:
1. dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO once a day.
3. pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*0*
4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*100 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
primary diagnosis: cough, shortness of breath
secondary diagnosis: HIV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you while you were admitted to
___. You were admitted from the infectious disease clinic for
further workup of your symptoms. All infectious workup has been
negative to date and you clinically improved.
.
The following changes have been made to your medication regimen
Please START taking iron tablets once daily.
.
Please CHANGE lyrica to 75 mg twice daily (discuss with your
doctor when it is safe to increase your dose back to 150 twice
daily).
.
Please take the rest of your medications as prescribed and
follow up with your doctors as ___.
Followup Instructions:
___
|
10446182-DS-24 | 10,446,182 | 27,396,804 | DS | 24 | 2155-02-14 00:00:00 | 2155-02-14 15:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Percocet /
Neurontin
Attending: ___.
Chief Complaint:
Worsening CMV viremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with history of AIDS (recently restarted
HAART, CD4+ 9 on ___, HIV VL 1,006,686 copies/ml ___, +
hx ___ OI's), HTN, depression, neuropathic pain,
fatigue, thrombocytopenia. Recently admitted for failure to
thrive; found to have CMV viremia to 150,000; ___ in blood and
lungs. Restarted ARVs, and on IV ganciclovir and ___ meds. Had
repeat CMV VL that is now >1,000,000 copies/mL and CBC showing
thrombocytopenia to 30's. ED call in by Dr. ___ aggressive
CMV evaluation, and for ganciclovir to be changed to foscarnet.
In the ED, vitals 97.4 88 116/91 18 100%. Initial labs
significant for thrombocytopenia to 33, leukopenia WBC 1.2, UA
+10 ketones, mild transaminitis. CXR 1. No acute cardiopulmonary
process. 2. PICC terminates in the upper SVC.
On arrival to the floor, vs 97.6 120/82 80 16 99 RA. Patient
reports fatigue and neuropathic pain in R leg. No other
complaints at this time. ROS positive for cough productive of
white sputum.
Past Medical History:
- HIV/AIDs with complications of CMV viremia, PCP, ___,
___, Zoster infections. Has been non-compliant or
unwilling to take medications in the past. Recently restarted on
HAART, reports compliance since last hospitalization. As above
last CD4 was 9 and VL > 1 million earlier this month)
- Neuropathic Pain thought ___ to past VZV infections
- Presumed PCP ___ ___
- HTN
- Depression
- MSSA bacteremia ___
- Status post TAH/BSO ___ years ago for a uterine fibroid
- History of gonorrhea treated at the age of ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 97.6 120/82 80 16 99 RA
GEN Chronically ill appearing, cachectic, A+O x 2 (missed date,
knew day of week and year), intermittently moaning, in mild
distress due to R leg pain
HEENT Hair loss diffusely, MMM EOMI, sclera anicteric, no oral
lesions appreciated
NECK supple, no JVD, no LAD
PULM Poor air movement but CTAB (?effort)
CV RRR normal S1/S2, no mrg
ABD scaphoid NT ND normoactive bowel sounds, no r/g
EXT WWP 1+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN diffuse hyperpigmented scarring attributed to zoster
DISCHARGE PHYSICAL EXAM:
VS
GEN
HEENT
EXT 2+ pitting edema bilateral lower extrem, WWP, 1+ distal
pulses bilaterally, + tenderness to palpation and movement right
lower extremity
GU Two clean based ~5mm ulcerations c/w skin breakdown from
excess urine production.
RECTAL One centimeter hemorrhoid, not bleeding
All other findings unchanged from admission exam
Pertinent Results:
NOTABLE LABS DURING ADMISSION:
___ 04:25PM BLOOD WBC-1.2*# RBC-3.08* Hgb-7.7* Hct-25.2*
MCV-82 MCH-25.1* MCHC-30.6* RDW-21.6* Plt Ct-33*
___ 04:25PM BLOOD Neuts-86.5* Lymphs-6.9* Monos-1.9*
Eos-4.3* Baso-0.4
___ 04:25PM BLOOD ___ PTT-38.7* ___
___ 04:25PM BLOOD Glucose-55* UreaN-5* Creat-0.4 Na-134
K-3.3 Cl-99 HCO3-26 AnGap-12
___ 04:25PM BLOOD ALT-20 AST-56* AlkPhos-76 TotBili-0.4
___ 04:25PM BLOOD Albumin-2.5*
___ BLOOD CMV Viral Load 1,060,000 copies/mL
___ BLOOD HIV Viral Load 106,839 copies/ml.
STUDIES:
___ CXR: 1. No acute cardiopulmonary process. 2. PICC
terminates in the upper SVC.
___ CXR 2. Small bilateral effusions. No definite
consolidation.
___ CXR 3. Probable bilateral lower lobe infiltrates.
___ CT Head: Grossly unchanged bilateral thalamic and deep
white matter hypodensities compared to the ___ MRI, allowing
for differences in modalities. The
supratentorial lesions are nonspecific, but commonly seen in PML
or HIV
encephalopathy. The thalamic lesions, without extensive basal
ganglia
involvement, may be seen in viral encephalitis, such as ___ virus and
___ encephalitis. No new abnormalities are detected,
though MRI would be
more sensitive for further evaluation, if indicated.
DISCHARGE LABS:
___ 06:01AM BLOOD WBC-2.3* RBC-3.05* Hgb-8.1* Hct-24.9*
MCV-82 MCH-26.6* MCHC-32.7 RDW-19.8* Plt Ct-56*
___ 06:01AM BLOOD Glucose-50* UreaN-6 Creat-1.5* Na-145
K-2.5* Cl-106 HCO3-27 AnGap-15
___ 06:20AM BLOOD ALT-18 AST-54* AlkPhos-74 TotBili-0.3
___ 06:08AM BLOOD Lipase-11
___ 06:01AM BLOOD Calcium-8.0* Phos-4.5# Mg-1.5*
___ 05:39AM BLOOD TSH-0.86
___ 05:39AM BLOOD Cortsol-16.0
___ CMV Viral Load 5,510 copies/ml.
Brief Hospital Course:
___ year old female with history of AIDS (recently restarted
HAART, CD4+ 9 on ___, HIV VL 1,006,686 copies/ml ___, +
hx ___ OI's), HTN, depression, neuropathic pain,
fatigue, thrombocytopenia. Diagnosed with CMV viremia to 150,000
during recent admission and now readmitted here with worsening
CMV viremia in spite of gancyclovir therapy to ___.
ACTIVE ISSUES:
1. CMV viremia- Patient failed gancyclovir with significant
worsening of viremia. ID was consulted. Ganciclovir was
discontinued and Foscarnet was initiated at 90 mg/kg IV q12.
Patient was counseled on importance of concomitant adherence to
HAART because Foscarnet unlikely to effectively treat CMV in
absence of treatment of underlying HIV. Upon starting
Foscarnet, patient's Ca, Mg, Phos, lipase, Cr, and glucose were
monitored closely, with repletion of Ca, Phos, K and glucose.
During prior admission, Ophtho determined no sign of CMV
retinitis. Re-consult was considered given worsening viremia,
and reconfirmed no active retinitis. Patient received Zofran PRN
nausea. The patient tolerated the increased fluid application of
this medication. Patient failed foscarnet therapy due to ___, so
therapy switched to valganciclovir 450mg q24 (induction dose).
CMV viral load fell from 1,060,00 on ___ to 900s copies ___.
Plan to continue valganciclovir, cmv vl on ___, follow up with
___ clinic.
2. Fatigue- Patient's fatigue was felt to be most likely due to
her chronic HIV infection, current uncontrolled CMV viremia, and
pancytopenia in the setting of advanced HIV and nutritional
deficiency. She received IVF. She was evaluated for swallowing
status, which she demonstrated competency. A CT head was
obtained to rule out hemorrhage in the setting of low platelets
and fluctuating mental status/fatigue. The image showed no
hemorrhage, but did have evidence of hypodensities that matched
findings on an MRI on ___ that are consistent with PML or
HIV encephalitis.
3. ___ - Patient was diagnosed with pulmonary and hematogenous
___ last admission. She was continued on Azithromycin 500 mg
daily, Ethambutol 800 mg daily, and Rifabutin 300 mg daily,
although she was often not taking her oral Ethambutol and oral
Rifabutin. She was maintained on IV azithromycin during her
admission.
4. Thrombocytopenia- Patient was thrombocytopenic to low 20's,
but maintained in the 30's and 40's. This was most likely
multifactorial in the setting of advanced viral illness and
multiple medications capable of producing thrombocytopenia;
however, medications producing thrombocytopenia could not be
discontinued given active infections. Patient't platelets
remained stable, without signs of spontaneous bleeding, and she
did not require platelet transfusions.
5. HIV- Recently restarted HAART for this admission. Getting PCP
ppx with monthly pentamidine. Patient was continued on home
HAART regimen of Truvada (emtricitabine-tenofovir 200 mg-300 mg
PO QAM), Etravirine 200 mg PO BID, Raltegravir 400 mg PO BID.
However, the patient repeatedly refused all oral HAART
medications, even when modified to liquid and IV formulations.
6. Hypothermia: The patient became hypothermic, requiring
continual heating pad support to maintain physiologic
temperatures. No clear acute infectious etiology was identified,
and it was felt that this hypothermia could be related to her
end-stage AIDS.
7. Fluid Overload: The patient developed frank edema and
pulmonary edema on CXR due to the constant infusion of IVF from
electrolyte repletion and ___ from Foscarnet therapy. The
patient responded to a dose of ethacrynic acid, with repeat CXR
showing clear lungs bilaterally and marked decrease in
peripheral edema.
8. Goals of care: Patient DNR/DNI. Patient has advanced AIDS
and has struggled for years to adhere to her ART regimen. We
agreed that medicatins they could still be offered, but without
the push that has been present up until now. Her husband
believes that meds should still be offered, that if they are not
offered at all, she will be even more emotionally compromised
and feel given up on. Palliative care was involved during her
care at ___. Plan to transition to rehab for short term with
___ involved with palliative care, then
transition to home with hospice. After discussion with patient
and her husband, it was determined that rehospitalization is not
consistent with her goals and would unlikely to benefit her.
CHRONIC ISSUES:
1. Neuropathic pain- due to prior zoster infection. Patient was
continued on Dilaudid at home dose, pregabalin, and lidocaine
patch.
2. Constipation- Patient was continued on a standing bowel
regimen, but she refused all PO formulations in setting of
regular Dilauded use.
TRANSITIONAL ISSUES:
Labs ___
CBC, Na, K, Cl, HCO3, BUN, Cr, gluc, CMV viral load
Results faxed to:
___
___ Disease
___
Office Location:E/Sl 431 B
Office ___
Office ___
Patient ___
# Constipation
- Bowel regimen PR if patient tolerates
# Medication changes:
- Started Valgancyclovir and amlodipine
# Code status: DNR/DNI/DNH
# Doctor of record for patient: ___ MD ___
# Patient and husband agree not to rehospitalize
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Azithromycin 500 mg PO DAILY
2. Ethambutol HCl 800 mg PO DAILY
3. Ganciclovir 250 mg IV Q12H
4. Ondansetron 4 mg PO Q8H:PRN nausea
can give this medication 30min prior to giving medications to
prevent nausea
5. Pregabalin 150 mg PO BID
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
7. Etravirine 200 mg PO BID
8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
9. Docusate Sodium 100 mg PO BID constipation
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Rifabutin 300 mg PO DAILY
12. Raltegravir 400 mg PO BID
13. Senna 1 TAB PO BID:PRN constipation
14. Pentamidine-Inhalation 300 mg IH QMONTH PCP ppx
FOR INHALATION ONLY
*Admin/Prep Precautions*
15. HYDROmorphone (Dilaudid) 2 mg PO Q12H:PRN pain
16. Lidocaine 5% Patch 1 PTCH TD DAILY pain
17. Bisacodyl 10 mg PR HS:PRN constipation
Discharge Medications:
1. Bisacodyl 10 mg PR HS:PRN constipation
2. Docusate Sodium 100 mg PO BID constipation
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
4. Ethambutol HCl 800 mg PO DAILY
5. Etravirine 200 mg PO BID
6. HYDROmorphone (Dilaudid) 2 mg PO Q12H:PRN pain
7. Lidocaine 5% Patch 1 PTCH TD DAILY pain
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Raltegravir 400 mg PO BID
10. Rifabutin 300 mg PO DAILY
11. Senna 1 TAB PO BID:PRN constipation
12. Hemorrhoidal Suppository ___AILY
13. Hydrocortisone Cream 0.5% 1 Appl TP TID:PRN pain, discomfort
___ apply to vulvar lesions if patient experiencing discomfort.
14. Mirtazapine 7.5 mg PO HS
15. ValGANCIclovir 450 mg PO Q24H
16. Azithromycin 500 mg PO DAILY
17. Ondansetron 4 mg PO Q8H:PRN nausea
can give this medication 30min prior to giving medications to
prevent nausea
18. Pentamidine-Inhalation 300 mg IH QMONTH PCP ppx
FOR INHALATION ONLY
*Admin/Prep Precautions*
19. Pregabalin 150 mg PO BID
20. Amlodipine 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
HIV
CMV viremia
___
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your admission to ___
___. You were admitted for worsening
of your CMV infection. During your stay, we stopped your
ganciclovir and gave you a new medication for CMV called
valganciclovir. You will be going to a short term skilled
nursing facility to continue you care, then home with hospice
and assistance.
We made the following changes to your medications:
STARTED valganciclovir
RESTARTED amlodipine
Followup Instructions:
___
|
10446183-DS-19 | 10,446,183 | 27,656,390 | DS | 19 | 2126-09-06 00:00:00 | 2126-09-06 20:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/type type B aortic dissection. Patient had epigastric and
midline back pain onset 6am this morning while waiting for the
bus. Went to the Ed, where he self-induced vomiting because he
thought it would help him feel better. Urine output has been
normal per report, no pain in legs, and currently no abdominal
or back pain. He was transferred from ___ after a CTA torso,
which was very poor quality, showed a dissection described to be
starting at the origin of the common carotid artery on the arch,
but calling it a type B dissection. On esmolol gtt, still
hypertensive to 170s. Bowel movements have been normal,
nonbloody.
Past Medical History:
HTN, HLD, obesity, venous stasis ulcers LLE
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, nontender
Ext: ___ warm and well perfused, pulse exam: b/l
p/p/p/p
Discharge:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: No respiratory distress
Ext: Extensive ___ edema, ___ warm and well perfused
pulse exam: b/l p/p/p/p
Pertinent Results:
___ 02:51PM BLOOD WBC-12.7*# RBC-4.94 Hgb-14.1 Hct-44.3
MCV-90# MCH-28.6 MCHC-31.8 RDW-13.6 Plt ___
___ 02:51PM BLOOD Neuts-84.7* Lymphs-10.2* Monos-4.9
Eos-0.1 Baso-0.2
___ 02:51PM BLOOD ___ PTT-31.6 ___
___ 02:51PM BLOOD Glucose-120* UreaN-18 Creat-1.4* Na-142
K-3.5 Cl-102 HCO3-31 AnGap-13
___ 10:35PM BLOOD Calcium-8.8 Phos-3.1 Mg-2.0
___ 02:48PM BLOOD Lactate-2.0
___ 07:20AM BLOOD WBC-9.1 RBC-3.99* Hgb-11.3* Hct-35.4*
MCV-89 MCH-28.3 MCHC-31.9 RDW-13.5 Plt ___
___ 07:20AM BLOOD Plt ___
___ 07:20AM BLOOD Glucose-91 UreaN-18 Creat-1.6* Na-138
K-3.9 Cl-102 HCO3-27 AnGap-13
___ 07:20AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.9
Brief Hospital Course:
Mr. ___ was transferred to ___ from ___ on
___ after a CT Scan showed an aortic dissection. He was
admitted to the ICU. BP was controlled with an esmolol drip. CTA
torso was repeated, which confirmed a Type B aortic dissection.
He was transitioned off of the esmolol drip and onto PO pain
medications, transferred out of the ICU when he was deemed
stable. Urine culture was positive and the patient was started
on antibiotics. Nephrology was consulted for elevated creatinine
and assistance with blood pressure control. They recommended
starting lasix. The patient worked with physical therapy. When
his blood pressure medication regimen was stabilized and his
pressures remained within the desired tight parameters, he was
diuresing successfully, and he was able to walk and climb stairs
without developing significant shortness of breath or
hypertension, he was discharged home. Arrangements were made for
visiting nurse to monitor blood pressures and labs, home
physical therapy to continue increasing his activity while
keeping his blood pressure controlled, primary care follow up to
monitor and adjust his anti-hypertensives and diuretics, follow
up with nephrology, and follow up with vascular surgery,
including a repeat CT scan to monitor his dissection.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H
4. Furosemide 60 mg PO BID
5. HydrALAzine 40 mg PO Q6H
6. Labetalol 800 mg PO QID
7. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Type B Aortic Dissection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Monitor your blood pressure at home. Your systolic pressure (the
higher number) should ideally be 120-140. If you do not have a
home blood pressure monitor, please get one. A prescription for
the correct size blood pressure cuff has been provided. Please
work with your visiting nurse to keep track of your blood
pressure. Learn from them how to do this yourself. This is
something you will need to be aware of for the rest of your
life. Work with your primary care doctor to manage your blood
pressure medications. We have you on a regimen that is working
for now, but it will need to be continuously checked and
adjusted by your primary care doctor over the weeks, months and
years to come.
Monitor the swelling in your legs. As explained by the
Nephrologists, you should take your lasix 60mg twice a day with
edema, if edema goes down, take 60mg once a day, when you are no
longer edematous, you may stop taking it. Work with your
visiting nurse to monitor your edema. Work with your primary
care doctor to monitor your edema and adjust your medications
over time. Follow up with the Nephrologists here at ___.
Regarding your urinary tract infection, continue your
antibiotics as prescribed until ___. Have your primary care
doctor check your prostate as prostate issues are a common cause
of urinary tract infections in men your age.
Your doctor or visiting nurse should check your labs on a weekly
basis. These labs need to include Creatinine.
Work with the physical therapist daily.
Discuss cardiac rehab with your primary care doctor.
Keep your appointments with your primary care doctor, the ___
Nephrologist and our clinic. You will also need a follow up CT
Scan. This is scheduled for ___. You will need to come in
ahead of time for IV fluids and stay afte the scan for fluids to
help protect your kidneys from the IV contrast. All appointments
have been scheduled and details are listed below.
Followup Instructions:
___
|
10446183-DS-20 | 10,446,183 | 27,401,948 | DS | 20 | 2126-10-02 00:00:00 | 2126-10-02 16:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Acute Kidney Injury
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with a past medical history of hypertension,
CKD III, who was recently admitted with a type B aortic
anerurism complicated by contrast induced nephropathy. Patient
was in his usual state of health when upon lab check by his PCP
he was noted to have a CR >4.
Notably patient was admitted in ___ for a type B aortic
dissection treated non-operatively. His clinical course was
complicated by contrast induced nephropathy, however his Cr
normalized to his baseline 1.3-1.4 before discharge.
In the ED intial vitals were: 98.4 62 150/79 16 100% RA
- Labs were significant for BUN 62 Cr 4.3, UA with lg leuk and
mod bacteria.
- Patient was given ceftriaxone and 1L NS
On the floor patient has no complaints. NOtes he has dry mouth,
but denies NSAID use. No foul odor to urine, no decrease in
urination.
Review of Systems:
(+)
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
-Hypertension, diagnosed in his ___, was taking medications from
___, stopped last year.
-Hyperlipidemia
-Obesity
-Venous stasis ulcers status posts skin graft
-CKD stage III
-Aortic Dissection (Type B), managed non-operatively -dissection
tracks inferiorly just beyond the bilateral iliac bifurcations
Social History:
___
Family History:
Father with hypertension died age ___, mother died at age ___ of
lung cancer (smoker) and had hypertension. He has two brothers
and one sister, all of them are healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals- 98.1 143/62 67 16 99RA
General- ___ male, in no distress
HEENT- oropharynx clear, no LAD
Neck- no JVD
Lungs- CTA ___
CV-RRR, ___ systolic murmur @ ___
Abdomen- soft, nt, nd, no organomegaly, no abdominal bruits
GU- no foley
Ext- dry ___, no CCE
Neuro- moves all 4 extremities purposefully and without
incident, no facial droop
DISCHARGE PHYSICAL EXAM:
========================
VS: T98.4 BP152/90 P74 RR18 98RA
GENERAL: Laying in bed, irritable, no acute distress.
NECK: No JVD.
CV: RRR, normal S1, S2. ___ systolic murmur at LUSB.
RESP: Clear to auscultation bilaterally. No wheezes, crackles,
or rhonchi.
ABD: +BS, soft, nondistended, nontender to palpation.
EXT: Xerotic skin.
NEURO: CN II-XII grossly intact. Moves all extremities grossly.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:38PM BLOOD WBC-9.5 RBC-4.60 Hgb-12.8* Hct-40.3
MCV-87 MCH-27.7 MCHC-31.7 RDW-12.8 Plt ___
___ 09:38PM BLOOD Neuts-62.3 ___ Monos-7.7 Eos-1.6
Baso-0.6
___ 09:38PM BLOOD Plt ___
___ 09:38PM BLOOD Glucose-104* UreaN-62* Creat-4.3*# Na-140
K-4.3 Cl-98 HCO3-26 AnGap-20
DISCHARGE LABS:
===============
___ 07:20AM BLOOD WBC-7.6 RBC-4.09* Hgb-11.7* Hct-36.5*
MCV-89 MCH-28.7 MCHC-32.2 RDW-12.8 Plt ___
___ 07:20AM BLOOD Glucose-92 UreaN-36* Creat-2.8* Na-142
K-4.5 Cl-106 HCO3-31 AnGap-10
___ 07:20AM BLOOD Calcium-9.9 Phos-3.6 Mg-2.1
URINE STUDIES:
=============
___ 01:31AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 01:31AM URINE RBC-2 WBC-130* Bacteri-MOD Yeast-NONE
Epi-8
___ 11:05AM URINE Hours-RANDOM UreaN-801 Creat-138 Na-<10
K-35 Cl-<10 TotProt-10 Prot/Cr-0.1
___ 09:42PM URINE Osmolal-335
MICROBIOLOGY:
=============
___ 9:42 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
============
Renal Ultrasound w/ dopplers (___):
FINDINGS:
The right kidney measures 12.2 cm. The left kidney measures 12.4
cm. There is no evidence of hydronephrosis, nephrolithiasis, or
renal masses bilaterally. The corticomedullary differentiation
is well preserved. Patent renal artery and vein are detected
bilaterally with appropriate arterial and venous waveforms on
Doppler examination.
IMPRESSION:
Normal renal ultrasound exam.
Brief Hospital Course:
Mr. ___ is a ___ male with a past medical history of
hypertension, CKD III, who was recently admitted with a type B
aortic aneurysm complicated by contrast induced nephropathy who
presents with ___ on CKD and UTI.
# Acute on Chronic Kidney Disease:
The patient had a recent increase in his diuretic regimen
several weeks prior. Outpatient routine labs by his PCP showed ___
creatinine of 4.6 and calcium of 10.7. He was sent into the ED
for further evaluation, given the recent dissection history and
previous normalization of his creatinine to 1.3-1.4 prior to
discharge. Cr notably 4.3 on arrival with normalization of
calcium. Patient was evaluated with renal ultrasound which did
not show any evidence of renal artery dissection or stenosis.
Urinalysis showed pyuria and hyaline casts. Lisinopril,
spironolactone and torsemide were held and patient was given 2
liters of fluid overnight with subsequent improvement in
creatinine. Renal was consulted and urine sediment revealed
evidence of infection but no evidence of intrinsic renal causes.
He was felt to have been overly diuresed as evidenced urine
electrolytes (FENa 0.03%), and responsed to fluid resuscitation.
There has been no recent contrast load to cause CIN. Creatnine
on discharge was 2.8 and patient was scheduled to follow up with
outpatient nephrology with outpatient labwork.
# Bacteruria and pyuria:
The patient was asymptomatic with no leukocytosis but given his
urinalysis and the fact that he is male, he was started on
ceftriaxone empirically for complicated UTI vs. pyelonephritis.
Urine culture grew showed contamination, and IV antibiotics were
discontinued. Should the patient develop recurrent urinary tract
infections, urology evaluation with diagnostic pyelogram or
cystoscopy is recommended as outpatient.
# Essential Hypertension:
The patient has difficult to control hypertension. Torsemide,
lisinopril, HCTZ, and sprionolactone were held in the setting of
___. Labetolol, amlodipine, and hydralazine were continued.
Blood pressure control was maintained below SBP<140. Restarting
lisinopril and diuretics will be done on an outpatient basis.
# CKD III:
Not associated with proteinuria, Albumin-to-creatinine atio at
microalbuminuric range but on the lower ___.
Etiology of CKD is likely uncontrolled hypertension which was
worsenend by the recent contrast exposure leading to contrast
induced nephropathy. Repeat urine protein to creatnine ratio was
0.1. Continued aggressive blood pressure control and lifestyle
modifications recommended with outpatient nephrology follow up.
# Type B aortic aneurysm:
No further chest pain. The patient has a scheduled chest CT with
contrast on ___, however will hold on study until renal
recovery is achieved back to baseline. No evidence based on u/s
that aneurysm has extended to renal arteries. Vascular surgery
recommended continued medical management. The patient will need
precontrast hydration prior to study at 3.2ml/Kg/hour one hour
before the procedure, followed by 1.2mg/kg/hour 6 hours after
the contrast load as was recommended by nephrology.
TRANSITIONAL ISSUES:
====================
* Diuretics (torsemide and spironolactone) held upon discharge.
Nephrology will restart these medications as outpatient
* Restart lisinopril as outpatient when creatinine near
baseline.
* If creatinine does not continue to improve, would recommend
moving forward with the CTA torso, following the pre-hydration
protocol as spelled out in his most recent ___ clinic
note (3.2ml/Kg/hour one hour before the procedure, followed by
1.2mg/kg/hour 6 hours after the contrast load). Otherwise, would
hold off until his creatinine trends to his baseline.
* If patient develops recurrent UTI, would recommend outpatient
urology work up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. HydrALAzine 40 mg PO Q6H
4. Labetalol 800 mg PO QID
5. Spironolactone 25 mg PO DAILY
6. Torsemide 40 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. HydrALAzine 40 mg PO Q6H
4. Labetalol 800 mg PO QID
5. Outpatient Lab Work
Please check Chem 7 (Na, K, Cl, HCO3, BUN, Cr) on ___. Fax
records to PCP ___. Fax # ___
ICD 9: 584.9
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Acute on chronic kidney injury
Urinary tract infection, complicated
Essential Hypertension
Type B aortic dissection
Secondary:
Venous stasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___:
It was a pleasure taking care of you during your hospitalization
at ___. You were asked to come afer your renal function was
noted to be severely decreased on recent laboratories. We did an
ultrasound of your kidneys which was normal and not concerning.
We had the kidney doctors ___ and they felt that your
diuretic regimen had dried you out too much. We gave you IV
fluids and you improved.
Regarding your aortic aneurysm, this remained stable, and we
tried to keep your blood pressure less than 140 systolic.
However, many of your home blood pressure meds had to be held
because of the damage to your kidneys, so you were placed on
several new blood pressure meds to replace them. Your blood
pressures were in the 150s when you were discharged with the
understanding that your medications would need to be adjusted
further as an outpatient with close follow up. We stopped your
diuretics due to dehydration.
Please follow up with your appointments as outlined below.
Thank you,
Followup Instructions:
___
|
10446418-DS-8 | 10,446,418 | 21,894,718 | DS | 8 | 2142-11-09 00:00:00 | 2142-11-09 22:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with castrate-resistant prostate CA metastatic to bone who
presents to the ER with cough. He is s/p cycle 5 of chemo
protocol ___ on ___ he is a pt of Dr. ___ his
CA which has metastasized to his scapula,T/L vert bodies, R
iliac, sternum and sacrum. Per the ER note, "he endorses a dry
cough x10 days which is associated with fatigue but he denies
fever, chills, aches, GI distress, urinary symptoms." On arrival
to the floor, translation is assisted by our staff. He states
to me that he ha had a cough for 3 months and that for one day
prior to admission, it has worsened. He denies any rinorrhea,
sore throat, headaches, myalgias, fevers, sputum production, or
sick contacts, but states that he feels fatigued as his PO
intake has been poor recently. By his report, his next chemo is
scheduled for ___. Vitals in the ER: 100.0 103 117/71 16 100%
2L. He did not receive any medications.
.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, nausea, vomiting, rashes, diarrhea,
orthopnea, chest pain. All other ROS negative
.
Past Medical History:
hyperlipidemia, HTN, GERD, CAD, seizure disorder (last seizure
over ___ years ago), vertigo and glaucoma
.
Social History:
___
Family History:
son is in good health
.
Physical Exam:
Vitals: T 99.3 bp 145/75 HR 98 RR 22 SaO2 100 2L NC
GEN: NAD, awake, alert
HEENT: supple neck, dry mucous membranes, no oropharyngeal
lesions; no JVD appreciable
PULM: normal effort, CTAB
CV: RRR, no r/m/g/heaves
ABD: soft, obese, NT, ND, bowel sounds present
EXT: normal perfusion
SKIN: warm, dry
NEURO: AOx3, no focal sensory or motor deficits
PSYCH: calm, cooperative
Pertinent Results:
___ 12:29PM UREA N-13 CREAT-0.7 SODIUM-137 POTASSIUM-4.5
CHLORIDE-99 TOTAL CO2-28 ANION GAP-15
___ 12:29PM ALT(SGPT)-19 AST(SGOT)-23 ALK PHOS-70 TOT
BILI-0.4
___ 12:29PM WBC-1.2*# RBC-3.52* HGB-10.0* HCT-30.3*
MCV-86 MCH-28.3 MCHC-32.9 RDW-17.4*
___ 12:29PM NEUTS-25* BANDS-3 LYMPHS-56* MONOS-14* EOS-0
BASOS-1 ___ METAS-1* MYELOS-0
___ 12:29PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+
TEARDROP-OCCASIONAL
___ 12:29PM PLT SMR-NORMAL PLT COUNT-174
.
CXR: no acue cardiopulmonary process
.
Brief Hospital Course:
Mr. ___ is a ___ year old man with castrate-resistant
prostate cancer, metastatic to bone on chemo protocol admitted
with neutropenia and T 100. His rapid influenza test was
negative and he later spiked a fever and was found to have a
LLL/lingular infiltrate and was started on broad spectrum
antibiotics (CefePIME, levofloxacin, vancomycin). He did well
and when his WBC recovered, he was transitioned to oral
levofloxacin to complete a 7 day course.
.
He complained of LH and was noted to be orthostatic on the day
of discharge. His ___ was discontinued and he got 1 L of IVF
and was no longer orthostatic and felt much better. He was
advised to NOT take his ___ at this time and his son reported to
the RN that they would monitor his BP at home and call Dr. ___
___ his BP was elevated. He was encouraged to increase his PO
fluid intake.
.
Mr. ___ requested an ___ appt with Neurology to discuss
his AED and this was arranged.
The discharge instructions were provided to Mr. ___ and his
family with ___ speaking RN who reported excellent
command of ___. (Hospital interpreter was not available
on-site as it was after 5 pm).
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Finasteride 5 mg PO DAILY
2. PredniSONE 10 mg PO DAILY
3. Valsartan 80 mg PO DAILY
4. Carbamazepine 200 mg PO Frequency is Unknown
5. Loperamide 2 mg PO QID:PRN diarrhea
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. Ranitidine 150 mg PO Frequency is Unknown
8. Rosuvastatin Calcium 20 mg PO DAILY
9. Naproxen 250 mg PO Q12H:PRN pain
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Carbamazepine 200 mg PO BID
3. PredniSONE 10 mg PO DAILY
4. Prochlorperazine 10 mg PO Q6H:PRN nausea
5. Ranitidine 150 mg PO DAILY
6. Rosuvastatin Calcium 20 mg PO DAILY
7. Levofloxacin 750 mg PO DAILY Duration: 3 Days
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth once a
day Disp #*3 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
## Community acquired pneumonia in an immunocompromised host
## Neutropenia secondary to chemotherapy, resolved
## prostate cancer
## h/o essential HTN
## hypokalemia
## Seizure disorder
## LH, low-nL BP (often is), maybe no longer requires ___ with
poor po intake
## Orthostatic hypotension - resolved with IVF, likely secondary
to dehydration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a fever and found to have pneumonia.
Your white blood cells were very low while you were here because
of the medicine for your prostate cancer. The white blood cell
count improved while you were here to normal levels. You were
given an antibiotic for the pneumonia and continued to improve.
You asked for a referral to a Neurologist to discuss your
epilepsy and we have made an appointment for you (as listed
below).
You are being discharged on an antibiotic called Ciprofloxacin.
This
medication can weaken your tendons while taking it, so you
should avoid strenuous sports or activities. If you feel
palpitations in your heart, contact your doctor or go to the
Emergency Room. Finish all this medication even if you feel
better.
**WE STOPPED your blood pressure medicine - VALSARTAN *** Your
blood pressure was low on this medication and it may be that you
no longer need it. You should monitor your symptoms and see how
you feel without it. It may be one of the reasons you were
feeling weak.
**You were dehydrated here, so please try to drink plenty of
non-alcoholic, non-caffinated drinks each day.
Followup Instructions:
___
|
10446418-DS-9 | 10,446,418 | 25,826,802 | DS | 9 | 2143-12-13 00:00:00 | 2143-12-13 22:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Line site erythema
Major Surgical or Invasive Procedure:
___ ___ Removal of Port-a-cath
History of Present Illness:
___ year old male with a history of prostate cancer on docetaxel
who presents with erythema and pruritis around his port site.
The patient has had his port for about one year without
complication. His port was last used on ___ for cycle 14 of
docetaxel. He then developed pain, itching, and mild eryethema
at port site last night. He denies fevers, chills, headache,
chest pain, dyspnea, abdominal pain, nausea, diarrhea, dysuria.
In the ED, initial VS were T 98.3, HR 91, BP 124/70, RR 16, O2
96% RA. Exam was significant for erythema, warmth, and
induration without fluctuance at his right chest port site.
Labs were significant for normal WBC, anemia at baseline.
Electrolytes were unremarkable. The patient was discussed with
___ who recommended flow study with SVC gram which
showed a normally functioning right IJ port-a-cath without
evidence of leak. The patient was given 1g vancomycin for
potential line infection. Blood cultures x 2 were sent.
Currently, he has no problems other than an occasional cough,
which is dry.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache. Denies chest pain or tightness,
palpitations, lower extremity edema. Denies cough, shortness of
breath, or wheezes. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, melena, hematemesis, hematochezia.
Denies dysuria, stool or urine incontinence. Denies arthralgias
or myalgias. Denies rashes or skin breakdown. All other systems
negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
The patient has histologically confirmed prostate cancer,
___ 9 documented in ___. He has metastatic disease that
was documented today with a bone scan. He has rising PSAs with a
PSA of 143 in ___ in ___, and on ___.
He has testosterone levels that are less than 50. He has never
had any chemotherapy. He has never had radiation therapy. He has
had no prior isotope therapies. He is greater than 18. His ECOG
performance status is 0. He has no history of brain mets or no
other prior malignancies that would make him ineligible. He has
not had any cardiac issues in the last six months. In ___
___, he had had an angioplasty. He has had no issues since
then. He does not have AIDS. He does not have gastritis or
erosive gastritis or any other inflammatory bowel disease that
would make him ineligible. He does not have pulmonary embolism.
He does not have any illness that in my estimation would make
him ineligible to be involved in the treatment. He does have
people at home that can help him with the ___
translation because there are forms that need to be filled out
by the patient on the trial. As far as hemoglobin, platelet
counts, and transaminases, these have been done on ___
and at least at that point were fine and within normal limits.
He does not have any peripheral neuropathy. He does not have a
history of hypersentivity to docetaxel or polysorbate 80 and
has no contraindications to the use of corticosteroids.
- Then started on ___ protocol ___. This is
the cabazitaxel versus docetaxel for metastatic prostate cancer.
-Current treatement docetaxol, C14D1 ___
PAST MEDICAL HISTORY:
-prostate cancer as above
-hyperlipidemia
-HTN
-GERD
-CAD
-seizure disorder (last seizure over ___ years ago)
-vertigo
-glaucoma
Social History:
___
Family History:
son is in good health
Physical Exam:
ADMISSION EXAM:
----------------
Vitals - T: 98.1 BP: 132/74 HR: 82 RR: 20 02 sat: 97% on RA
GENERAL: NAD, appears comfortable
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
MMM, good dentition, nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmers, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
----------------
Vitals: 98.5/98.3 124/82 81 20 96RA
GENERAL: NAD, appears comfortable
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
MMM, good dentition, nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmers, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
CHEST: Port site covered with bandage c/d/i, non-tender,
induration which extends over the port site to the clavicle with
brawny skin changes, non-tender, non-fluctuant, stable
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
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
--------------
___ 05:45PM BLOOD WBC-5.5 RBC-4.31* Hgb-12.6* Hct-36.9*
MCV-86 MCH-29.1 MCHC-34.0 RDW-16.0* Plt ___
___ 05:45PM BLOOD Neuts-77.1* ___ Monos-3.6 Eos-0.2
Baso-0.1
___ 05:45PM BLOOD Glucose-100 UreaN-10 Creat-0.6 Na-140
K-4.9 Cl-102 HCO3-24 AnGap-19
DISCHARGE LABS
--------------
___ 07:50AM BLOOD WBC-1.4* RBC-4.02* Hgb-11.6* Hct-34.6*
MCV-86 MCH-28.8 MCHC-33.4 RDW-15.4 Plt ___
___ 07:50AM BLOOD Neuts-25* Bands-0 Lymphs-72* Monos-1*
Eos-0 Baso-0 Atyps-2* ___ Myelos-0
___ 07:50AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-1+ Polychr-NORMAL
___ 07:50AM BLOOD Plt Smr-NORMAL Plt ___
___ 07:50AM BLOOD UreaN-8 Creat-0.6 Na-137 K-4.4 Cl-100
HCO3-27 AnGap-14
___ 07:50AM BLOOD Mg-2.1
___ 07:45AM BLOOD Vanco-11.5
MICROBIOLOGY
--------------
___ BODYGRAM STAIN Source: port.
GRAM STAIN (Final ___:
TEST CANCELLED, PATIENT CREDITED.
GST NOT DONE ON FOREIGN BODY.
Reported to and read back by ___ @ 16:55 ON
___.
WOUND CULTURE (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Sensitivity testing per ___ ___ (___).
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
TETRACYCLINE---------- 2 S
___ CULTUREPENDING
___ CULTUREPENDING
___ CULTUREPENDING
IMAGING/STUDIES
--------------
CVL INJ/EVAL INCLUDES FLUORO/IMAGES/REPORTStudy Date of
___ 2:10 ___
FINDINGS: No evidence of contrast extravasation from the port.
Red and slightly indurated skin around the port site.
IMPRESSION: Normally functioning right IJ Port-A-Cath without
evidence of leak.
REMOVE TUNNELED CENTRAL/PICC W/PORTStudy Date of ___
2:22 ___
IMPRESSION: Successful removal of a right upper chest port.
Brief Hospital Course:
___ y/o male with a history of prostate cancer on docetaxel (last
recieved ___ who presented with erythema and puritis
around port site now s/p port removal and foreign body growing
GPC.
# Line site erythema: likely secondary to line tunnel infection
given erythema and swelling. No chest pain, tenderness,
fluctuance, or discharge but significant induration and skin
discoloration tracking up to his clavicle which was not present
during his chemotherapy session on ___. No murmur to suggest
valvular infection . Seen by ___, had normal SVC
study, but on re-examination of his port site was concerned for
a tunnel line infection. Patient had an ___ port removal on ___
which grew coag neg staph. He was initially treated empirically
with IV vanc and switched to levoquin once his sensitivities
returned for a ___fter his port removal. Patient
remained afebrile and did not have a leukocytosis. Blood
cultures NGTD at the time of discharge.
# Prostate cancer: on leuprolide and docetaxel. Patient of Dr.
___, continued on home finasteride, antiemetics and
prednisone
# Seizure disorder: patient was weaning off eslicarbazepine,
unable to reach family to bring in this medication and per
patient he was never taking this medication and taking something
else, but now only on carbamazepine. Continued 200mg
carbamazepine ER bid per last neurology notes
# Hypertension: not on therapy, will monitor
# CAD: continue home aspirin
# GERD: continue home ranitidine
TRANSITIONAL ISSUES
# Continue levaquin until ___ for 7 day course
# Per ___ recs: please contact after f/u apt on
___ regarding rescheduling his port
# Please f/u blood cultures
# Had some serosanguinous drainage from port removal site,
arranged for ___ to monitor the site and assist with dressings
until seen for follow up.
# patient will f/u in 1 week with PCP and with onc on ___
# started on carbamazepine 200mg bid per last neuro note
# CODE: full code, confirmed; EMERGENCY CONTACT: ___,
___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Finasteride 5 mg PO DAILY
2. PredniSONE 10 mg PO DAILY
3. Ranitidine 150 mg PO DAILY
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, dyspnea
5. Aspirin 81 mg PO DAILY
6. loperamide 1 mg/5 mL oral unknown
7. Leuprolide Acetate 22.5 mg IM Frequency is Unknown
8. Carbamazepine (Extended-Release) 300 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, dyspnea
2. Aspirin 81 mg PO DAILY
3. Carbamazepine (Extended-Release) 200 mg PO BID
RX *carbamazepine 200 mg 1 (One) capsule, ER multiphase 12 hr(s)
by mouth twice a day Disp #*60 Tablet Refills:*0
4. Finasteride 5 mg PO DAILY
5. PredniSONE 10 mg PO DAILY
6. Ranitidine 150 mg PO DAILY
7. Levofloxacin 500 mg PO Q24H
Please take until ___
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth daily
Disp #*2 Tablet Refills:*0
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every 6
hours Disp #*15 Tablet Refills:*0
9. Leuprolide Acetate 22.5 mg IM AS INSTRUCTED BY YOUR
ONCOLOGIST
10. loperamide 1 mg/5 mL ORAL PRN diarrhea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagonosis: Port infection
Secondary diagnosis: Prostate cancer, seizure disorder,
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the inpatient oncology service because of
itching and skin changes around your port site. You had your
port removed on ___ and we started you on antibiotics for an
infection of your port. You do not have an infection in your
blood. Please continue to take antibiotics for a total of 7 days
after your port is removed (until ___. Please talk to your
oncologist during your follow up appointment about re-placing
your port. It was a pleasure taking care of you!
Followup Instructions:
___
|
10446442-DS-17 | 10,446,442 | 24,138,420 | DS | 17 | 2158-06-02 00:00:00 | 2158-06-02 20:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
lisinopril
Attending: ___
Chief Complaint:
Acute lower extremity weakness/ Concern for
GBS
Major Surgical or Invasive Procedure:
LP ___
History of Present Illness:
___ is a ___ R handed woman with a past
medical history significant for uterine cancer s/p total
hysterectomy in ___, obesity and hypertension. She presents
from
the ___ neurology office by Dr. ___ one month
of
progressive ascending weakness and sensory changes.
Briefly the patient states that at baseline she has a small
amount of difficulty walking due to swelling in her feet and
knee
pain. Around ___ the patient started to note numbness in her
feet and finger tips. Over the course of a few days this
progressed to the point where she had difficulty ambulating due
to feeling off balance. A week later she felt that the weakness
and loss of sensation ascended to just below her knees. She also
has had difficulty "controlling" her fingers over the past few
days. She then proceeded to see her PCP at the end of ___
for these symptoms. Her PCP sent her to get an MRI brain and MR
___
spine without contrast which showed mild degenerative changes
but
no other acute pathology. She also apparently had an EMG on ___
but the report is not available and was "incomplete".
Since this time, the weakness has progressed to the point that
she cannot walk. She has been using a computer chair with wheels
to get around her home. She has had increasing difficulty using
her fingers as well. She has not had any changes in her bowel or
bladder function but she has difficulty getting to the bathroom
due to inability to walk.
She was seen in the neurology office today by Dr. ___
immediately sent to the ER for further neurologic evaluation.
In regards to prior history, the patient states she had ___ days
of diarrhea on ___ after attending a party that
self-resolved. She did not have any other URI/flu symptoms
preceeding the start of her symptoms. She had a flu shot on
___ after the symptoms had started. No recent travel, no
tick
bites or other risk factors.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. No bowel or bladder
incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies 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:
1. HTN
2. Obesity
3. R rotator cuff tear
4. Hysterectomy s/p uterine cancer ___, now in remission
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam
========================
Vitals: T 97.7, HR 76, BP 155/99, RR 18, 96% on RA
General: awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx
Neck: supple, no nuchal rigidity, ___ flexion and extension
Pulmonary: breathing comfortably on room air . Able to count
to
26 in one breath.
Cardiac: RRR, nl
Abdomen: soft, NT/ND
Extremities: warm, well perfused
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Alert, oriented x self, date, location. 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. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. Athetosis in the fingers when testing pronator
drift
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 4- 4- ___ 2 2
R 4* ___ ___ 4- 4- ___ 2 2
*Has prior rotator cuff injury
-Sensory: decreased pin prick in feet and legs up to knees
bilaterally. Absent vibration in toes, ankles, knees, returns in
MCP joint. Proprioception absent in big toes bilaterally, errors
with testing in ankles and fingers. Returns at wrists.
-DTRs:
Bi Tri ___ Pat Ach
L 0 0 0 0 0
R 0 0 0 0 0
Plantar response was mute on R, tonically upgoing on L
-Coordination: No intention tremor, no dysdiadochokinesia
noted.
No dysmetria on FNF
-Gait: deferred
Discharge Physical Exam
========================
24 HR Data (last updated ___ @ 850)
Temp: 98.4 (Tm 98.6), BP: 115/72 (103-145/69-88), HR: 88
(84-102), RR: 18 (___), O2 sat: 92% (91-96), O2 delivery: Ra
Gen: awake, alert, obese, comfortable, in no acute distress
HEENT: normocephalic atraumatic, no oropharyngeal lesions, MMM
CV: warm, well perfused
Pulm: breathing non labored on room air
Extremities: no cyanosis/clubbing, 1+ bilateral pitting edema in
bilateral lower extremities in feet
Neurologic:
-MS: Awake, alert, oriented. Attentive to interview.
Cooperative,
friendly. Speech fluent, no dysarthria. No evidence of
hemineglect.
-CN: Gaze conjugate, PERRL, EOMI, no nystagmus, face symmetric,
palate elevates symmetrically, tongue midline. SCM and trapezius
strength ___
bilaterally.
-Motor: normal bulk and tone. No tremor. ___nd
flexion, no pronator drift
Delt Bic Tri WE FEx IP Quad Ham TA Gas
L 5 5 ___ 4+ 5- 4+ 4- 5
R 5 5 ___- 5- 5- 5- 4- 5-
-DTRs: 0 other than Left patella 2+
-Sensory: decreased sensation to pinprick and light touch in
bilateral lower extremities on right up to upper calf, on left
above ankle
-Coordination: deferred.
-Gait: deferred
Pertinent Results:
Admission Labs
===============
___ 10:36AM BLOOD WBC-9.3 RBC-4.84 Hgb-15.1 Hct-45.0 MCV-93
MCH-31.2 MCHC-33.6 RDW-13.1 RDWSD-44.2 Plt ___
___ 10:36AM BLOOD Neuts-77.0* Lymphs-12.0* Monos-7.5
Eos-2.6 Baso-0.4 Im ___ AbsNeut-7.18* AbsLymp-1.12*
AbsMono-0.70 AbsEos-0.24 AbsBaso-0.04
___ 10:36AM BLOOD Glucose-100 UreaN-11 Creat-0.6 Na-142
K-3.9 Cl-101 HCO3-26 AnGap-15
___ 10:36AM BLOOD ALT-29 AST-24 AlkPhos-71 TotBili-0.5
___ 10:22AM BLOOD Calcium-9.5 Phos-4.0 Mg-1.7
___ 10:36AM BLOOD VitB12-647 Folate->20
___ 10:36AM BLOOD CRP-13.3*
___ 10:36AM BLOOD IgA-430*
CSF studies
============
___ 08:55AM CEREBROSPINAL FLUID (CSF) TNC-44* ___
Polys-73 ___ Monos-5 Eos-2 Basos-1
___ 08:55AM CEREBROSPINAL FLUID (CSF) TNC-6* RBC-3325*
Polys-37 ___ Monos-7 Eos-1
___ 08:55AM CEREBROSPINAL FLUID (CSF) TotProt-84*
Glucose-67
Discharge Labs
===============
___ 05:15AM BLOOD WBC-7.4 RBC-4.37 Hgb-13.7 Hct-40.3 MCV-92
MCH-31.4 MCHC-34.0 RDW-13.0 RDWSD-43.6 Plt ___
___ 05:15AM BLOOD Glucose-102* UreaN-10 Creat-0.6 Na-143
K-3.5 Cl-99 HCO3-25 AnGap-19*
___ 10:22AM BLOOD Calcium-9.5 Phos-4.0 Mg-1.7
___ 12:08PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*
___ 12:08PM URINE RBC-1 WBC-13* Bacteri-MANY* Yeast-NONE
Epi-7
Micro
======
___ 10:36 am Blood (LYME)
**FINAL REPORT ___
Lyme IgG (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
Lyme IgM (Final ___:
NEGATIVE BY EIA.
___ 8:55 am CSF;SPINAL FLUID Source: LP.
Enterovirus Culture (Preliminary): No Enterovirus
isolated.
___ 8:55 am CSF;SPINAL FLUID Source: LP.
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 white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
___ Urine culture: pending
Imaging
========
MRI C spine w/ and w/o ___
CERVICAL:
Cervical alignment is anatomic. Vertebral body heights are
preserved. No
suspicious marrow lesion. Degenerative loss of disc height at
C5-C6 and C6-C7 is moderate. The visualized posterior fossa is
unremarkable. There is no abnormal signal or enhancement of the
cord.
C2-C3: Significant spinal canal or neural foraminal narrowing.
C3-C4: Uncovertebral and facet arthropathy results in mild to
moderate right neural foraminal narrowing. No significant
spinal canal or left neural foraminal narrowing.
C4-C5: A right eccentric central protrusion and intervertebral
osteophyte
results in mild spinal canal narrowing, remodeling the right
ventral aspect of the cord. Uncovertebral and facet arthropathy
appears to result in severe right neural foraminal narrowing and
mild left neural foraminal narrowing. C5-C6: A central
protrusion with thickening of the ligamentum flavum results in
moderate spinal canal narrowing remodeling the ventral aspect of
the cord. Uncovertebral and facet arthropathy results in mild
to moderate left and mild right neural foraminal narrowing.
C6-C7: A central protrusion and thickening of the ligamentum
flavum results in moderate spinal canal narrowing.
Uncovertebral and facet arthropathy results in moderate
bilateral neural foraminal narrowing.
C7-T1: No significant spinal canal or neural foraminal
narrowing.
THORACIC:
Thoracic alignment is anatomic. Vertebral body heights are
preserved. No
focal suspicious marrow lesion. Multilevel the osseous
hemangiomas most
prominently noted at the T8, T10 and L1 vertebral bodies
identified. Mild
degenerative changes do not result in significant spinal canal
or neural
foraminal narrowing. There is no abnormal signal or enhancement
of the cord.
OTHER:
Limited evaluation of the lumbar spine on sagittal scout images
(series 4,
image 3) suggests that there may be moderate to severe spinal
canal narrowing at the L2-L3 and L3-L4 levels, not within the
field of view of diagnostic images. This could be further
evaluated with dedicated lumbar spine imaging.
Bilateral glenohumeral joint effusions are identified. The
esophagus is
mildly patulous at the T4-T5 level.
IMPRESSION:
1. Multilevel cervical spondylosis most prominent at C5-C6 and
C6-C7 where
there is moderate spinal canal narrowing. At C4-C5 there is
severe right
neural foraminal narrowing.
2. No significant spinal canal or neural foraminal narrowing of
the thoracic spine.
3. No evidence of cord compression. No abnormal signal or
enhancement of the cord.
4. Incompletely evaluated is likely lumbar spondylosis with
potentially
moderate to severe spinal canal narrowing at L2-L3 and L3-L4 on
scout
localizer images, not within the field of view of diagnostic
images. This
could be further evaluated with dedicated MRI lumbar spine.
5. Additional findings described above.
Brief Hospital Course:
Ms. ___ is a ___ R handed woman with a past
medical history of HTN and uterine cancer in remission who
presents with progressive weakness and sensory loss first
starting in her feet and finger tips about 4-weeks ago.
#Weakness and sensory loss
#guillain ___ syndrome: patient was evaluated by neurology as
an outpatient and sent to ED because patient could not walk.
Exam was notable for lower> upper extremity weakness, dropped
reflexes and decreased sensation up to knees bilaterally and
loss of proprioception. Felt that this was consistent with GBS
and she was started on IVIG. She had MRI C and L spine that
showed degenerative changes but no evidence of cord compression
or signal change or enhancement of cord to explain her symptoms.
LP was done and was traumatic tap but not consistent with
infection. Patient's sensory symptoms improved to ankles
bilaterally, she continued to have decreased proprioception in
bilateral lower extremities. Her upper extremity weakness
improved almost to full prior to discharge other than finger
extensor weakness. She was monitored with NIF and VC without
issues. She completed 5 days of IVIG and was discharged to
rehab.
#UTI
#Urinary Retention: Foley was placed due to urinary retention
upon admission. Foley was able to be removed with PVR 300. She
was able to void on her own but had some incontinence episodes.
patient developed dysuria and bladder pain iso having foley
placed. UA was c/w infection after foley was removed. She was
started on Cipro for 3 day course.
#HTN: Patient was continued on antihypertensive medications with
her home Metoprolol Succinate changed to Metoprolol Tartrate.
She had some fluctuating BPs that required holding some of her
antihypertensive at times. Due to fluctuating blood pressure her
metoprolol was held at time of discharge. She was continued on
HCTZ and amlodipine.
Transitional Issues
====================
[] Follow up with Neurology
[] Restart home metoprolol succs 200mg if needed for BP control.
Held at discharge.
[] Consider sleep study for workup of OSA
[] patient had macroscopic hematuria with foley placement likely
from traumatic foley. Please monitor for hematuria and urine
output.
[] Please monitor PVR if low urine output and straight cath prn
or replace foely if needed. She had urinary retention during
admission.
[] continue Cipro until ___ (3 day course)
#Contact: ___
Relationship: Daughter
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Metoprolol Succinate XL 200 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. ginkgo biloba 60 mg oral DAILY
7. echinacea purpurea extract ___ mg oral daily
8. ginseng 100 mg oral DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Glucosamine-MSM Complex
(glucos-msm-C-Mn-herb#21;<br>glucos-msm-collagen-C-Mn-hrb21)
500-333-5 mg oral DAILY
11. Ascorbic Acid ___ mg PO DAILY
12. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth twice a day
Disp #*9 Tablet Refills:*0
2. amLODIPine 5 mg PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. echinacea purpurea extract ___ mg oral daily
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. ginkgo biloba 60 mg oral DAILY
9. ginseng 100 mg oral DAILY
10. Glucosamine-MSM Complex
(glucos-msm-C-Mn-herb#21;<br>glucos-msm-collagen-C-Mn-hrb21)
500-333-5 mg oral DAILY
11. Hydrochlorothiazide 25 mg PO DAILY
12. Vitamin D ___ UNIT PO DAILY
13. HELD- Metoprolol Succinate XL 200 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until you are instructed to restart this
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
==================
guillain ___ syndrome
Secondary Diagnosis
====================
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___!
Why were you admitted?
You were admitted because you were having tingling in your hands
and feet and difficulty walking.
What happened while you were here?
You were diagnosed with guillain ___ syndrome , a disease
where inflammation breaks down the material that surrounds your
nerves that helps them function.
- You had imaging of your spine that showed some mild
degenerative changes but nothing to explain your symptoms
- You had a lumbar puncture that was negative for infection
- You were given a medication called IVIG. This helped reduce
your sensory changes and make you stronger.
What should you do when you get home?
- continue to work with ___ and get stronger
- Follow up with Neurology as an outpatient
All the best,
Your Neurology Care Team
Followup Instructions:
___
|
10446602-DS-8 | 10,446,602 | 28,695,859 | DS | 8 | 2149-04-18 00:00:00 | 2149-04-18 12:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Cephalosporins / Codeine / Benzodiazepines
Attending: ___.
Chief Complaint:
L hip pain
Major Surgical or Invasive Procedure:
___ - ORIF L femur fracture
History of Present Illness:
___ yo woman with Alzheimer dementia, HTN, aortic stenosis
with a recent history of substernal chest pain, GERD, recent
subdural hematoma and R displaced superior and inferio pubic
rami
fx s/p a fall, presents to the ___ as a transfer from ___
with a L femur periprosthetic spiral fracture. She is a nursing
___ resident, and this fall was a witnessed fall in the
bathroom. Her assistant caught her mid-fall; she twisted and was
able to sit on the ground. Noted immediate thigh pain and
inability to bear weight. No headstrike or LOC.
Past Medical History:
Alzheimer's dementia
HTN
Aortic stenosis
GERD
Recent subdural hematoma
h/o UTI's,
Left ear hearing loss due to nerve tumor
Colon cancer
H/o L hip fx s/p short TFN
H/o of a L humeral fx
Social History:
___
Family History:
NC
Physical Exam:
99.1 87 138/68 16 98%
NAD. Pleasant but disoriented elderly lady. Comfortable in the
gurney. Oriented to person only.
LLE: in buck's traction currently. SILT SP/DP/S/S. Fires
___. 1+ ___ pulses.
Buck's traction removed on exam, skin examined and noted to be
intact without ecchymosis or breakdown. A long knee immobilizer
was applied that spans from upper third of the thigh to the
lower
third of her leg.
Pertinent Results:
12.9>38.2<373
___
INR 1.1
UA turbid, with ___ WBC's, few bacteria, + for leuk esterase
AP L Hip: comminuted and displaced fracture of the distal
femoral diaphysis.
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service on
___ with L femur periprosthetic fracture. Patient was
taken to the operating room and underwent ORIF L femur
fracture. Patient tolerated the procedure without difficulty
and was transferred to the PACU, then the floor in stable
condition. Please see operative report for full details.
Musculoskeletal: prior to operation, patient was NWB LLE.
After procedure, patient's weight-bearing status was
transitioned to TDWB LLE. Throughout the hospitalization,
patient worked with physical therapy.
Neuro: post-operatively, patient's pain was controlled by
Morphine IV and oxycodone and was subsequently transitioned to
just oxycodone with good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient was transfused 2 units of blood for
acute blood loss anemia on ___. Her HCT responded
appropriately. Her most recent HCT at the time of discharge was
29.5.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection. She also received bactrim for a UTI developed
postoperatively (she received 3 of 6 total doses while in
house).
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #4, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating with ___, voiding without assistance,
and pain was well controlled. The incision was clean, dry, and
intact without evidence of erythema or drainage; the extremity
was NVI distally throughout. The patient was given written
instructions concerning precautionary instructions and the
appropriate follow-up care. The patient will be continued on
chemical DVT prophylaxis for 2 weeks post-operatively. All
questions were answered prior to discharge and the patient
expressed readiness for discharge.
Medications on Admission:
Labetalol 50mg BID
Omeprazole 20mg daily
Tramadol
Tylenol
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aluminum-Magnesium Hydrox.-Simethicone ___ ml PO Q6H:PRN
Dyspepsia
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 40 mg SC DAILY Duration: 14 Days
6. Miconazole Powder 2% 1 Appl TP PRN rash
7. Milk of Magnesia 30 ml PO BID:PRN Constipation
8. Omeprazole 20 mg PO DAILY
9. Senna 1 TAB PO BID
10. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Doses
11. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L femur periprosthetic fracture
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Discharge Instructions:
******SIGNS OF INFECTION********
- Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
********Wound Care********
- You can get the wound wet/take a shower starting from 3 days
post-op. No baths or swimming for at least 4 weeks. Any stitches
or staples that need to be removed will be taken out at your
2-week follow up appointment. No dressing is needed if wound
continues to be non-draining.
******WEIGHT-BEARING*******
Touchdown weight bearing, Left lower extremity
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
- Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- ***Take Lovenox for DVT prophylaxis for 2 weeks
post-operatively***
Physical Therapy:
Patient will require daily inpatient physical therapy at rehab.
Focus should be on bed mobility, transfer training, gait
training, balance training, ___ Ther Ex, activity tolerance.
Thank you.
Treatments Frequency:
Daily dressing change - dry, sterile overlying dressing
Sutures OK to be removed at POD 14 or at 2 week follow-up
appointment
Followup Instructions:
___
|
10446818-DS-15 | 10,446,818 | 24,231,127 | DS | 15 | 2188-02-29 00:00:00 | 2188-03-01 12:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Fall, Bilateral wrist pain, jaw pain
Major Surgical or Invasive Procedure:
___: Closed reduction with maxillomandibular fixation via
___ arch bars.
___: ORIF Bilateral Distal Radius Fracture
History of Present Illness:
___ is a ___ yo female with non-contributory PMHx who
presents to ___ as a transfer from OSH. Pt endorses falling
down ___ steps early this morning. +EtOH use. -LOC. Left
condylar fracture was discovered during trauma workup at ___.
___ was consulted re: left condylar fracture.
Past Medical History:
Denies history
Social History:
___
Family History:
alcohol abuse. other non-contributory.
Physical Exam:
Admission Physical Exam:
Gen: AAOx3, lying in bed
___: RR, no peripheral edema can be appreciated at this time.
Resp: breathing appears unlabored
Neuro: C-collar in place, CN V, VII grossly intact
HEENT: Eyes: EOMI, PERRL. Nose: midline, without gross injury or
deformity. Ears: edema can be appreciated anterior to L ear.
Area
is TTP. R ear is without gross injury or deformity.
EOE: ecchymosis can be appreciated at the chin, extending
superiorly to the lower lip and distally to the left mandible.
IOE: No intraoral lacerations, ulcerations, lesions can be
appreciated. Dentition is grossly intact. ___: approximately
20-25mm. Anterior open bite. FOM soft, non-elevated. Midline-
mandible is 8mm to the left. Premature left sided premolar
contacts.
GI: abdomen is soft, non-distended.
Musc: moves all extremities
Discharge Physical Exam:
Gen: AAOx3, lying in bed
___: RRR
Resp: breathing unlabored, CTA ___
Neuro: CN ___ grossly intact
HEENT: Eyes: EOMI, PERRL. Ears: edema can be appreciated
anterior to L ear. Area
is TTP. R ear is without gross injury or deformity. Jaw with
elastic bands, unable to open jaw, edema and pen markings on
Left side, mildly tender. Able to move lips and cheeks.
GI: abdomen is soft, non-distended.
Musc: moves all extremities
Pertinent Results:
Admission Labs:
===============
___ 03:10PM BLOOD WBC-4.5 RBC-4.01 Hgb-13.1 Hct-39.4 MCV-98
MCH-32.7* MCHC-33.2 RDW-11.4 RDWSD-41.6 Plt ___
___ 03:10PM BLOOD Neuts-75.1* Lymphs-16.7* Monos-6.9
Eos-0.0* Baso-0.9 Im ___ AbsNeut-3.37 AbsLymp-0.75*
AbsMono-0.31 AbsEos-0.00* AbsBaso-0.04
___ 03:10PM BLOOD ___ PTT-27.1 ___
___ 03:10PM BLOOD Glucose-86 UreaN-9 Creat-0.5 Na-143 K-4.3
Cl-106 HCO3-23 AnGap-14
___ 03:10PM BLOOD Calcium-8.5 Phos-3.2 Mg-2.1
___ 03:10PM BLOOD ASA-NEG ___ Acetmnp-NEG
Tricycl-NEG
___ 03:15PM BLOOD ___ pO2-90 pCO2-42 pH-7.37
calTCO2-25 Base XS-0 Intubat-NOT INTUBA
___ 03:15PM BLOOD Glucose-84 Lactate-2.9* Na-145 K-4.0
Cl-106
___ 03:15PM BLOOD Hgb-13.4 calcHCT-40 O2 Sat-95 COHgb-2
MetHgb-0
___ 03:15PM BLOOD freeCa-1.02*
IMAGING:
Displaced fracture of the left condyle can be appreciated with
medial displacement of the left condylar head. No other facial
fractures can be appreciated at this time.
Right Wrist Xray:
IMPRESSION:
Interim reduction of the comminuted intra-articular distal right
radial and ulnar fractures, with improved alignment some
residual dorsal tilt.
___ CT Left Scaphoid:
Minimally displaced comminuted intra-articular fractures of the
distal radius and ulna. The fracture fragments do involve the
radial styloid, may predispose to impingement on the first
extensor tendons.
No scaphoid fracture.
___ Chest Xray: No acute cardiopulmonary process.
___ Wrist:
1. Comminuted intra-articular fracture of the distal right
radius with
continued impaction and new dorsal displacement and angulation
of the dominant distal fracture fragment.
2. Similar alignment of comminuted distal right ulnar fracture.
3. Unchanged minimally displaced left distal radial fracture
without
intra-articular extension and nondisplaced left ulnar styloid
fracture.
Discharge Labs:
===============
___ 07:15AM BLOOD WBC-6.8 RBC-3.64* Hgb-12.1 Hct-35.3
MCV-97 MCH-33.2* MCHC-34.3 RDW-11.0 RDWSD-39.7 Plt ___
___ 07:15AM BLOOD Glucose-168* UreaN-3* Creat-0.4 Na-139
K-2.9* Cl-96 HCO3-31 AnGap-12
___ 07:15AM BLOOD Calcium-9.2 Phos-2.0* Mg-2.5
Brief Hospital Course:
Ms. ___ is a ___ year old female with a history of
alcohol use who was admitted to the Acute Care Surgery Service
on ___ after a fall sustaining fractures to her right and
left distal radius and ulna and a Left mandible subcondylar
fracture. She was taken to the operating room and had a Closed
reduction with maxillomandibular fixation via ___ arch bars
and had open reductions and internal fixation of both bones in
the right forearm and the radius in the left. She recovered well
from both procedures and spent time with the physical therapists
and occupational therapists to help her learn techniques to care
for herself when home. Given the degree of her recovery, being
able feed herself, having multiple supports in the area, a plan
for the patient to follow up with both surgical clinic in the
next ___ days was made. The patient was discharged with pain
controlled on medications, tolerating a full liquid diet,
feeling well and overall doing better.
Active Issues:
=============
# Bilateral Arm Fractures: Patient was admitted and had both
comminuted intra-articular distal right radial and ulnar
fractures and Minimally displaced left distal radial fracture
without intra articular extension and nondisplaced left ulnar
styloid fractures repaired with orthopedics on ___.
# Left Mandibular Condyle Fracture: Patient was evaluated by the
Oral and Maxillofacial surgery team and had her mandible
repaired on ___. She is to have follow up with the Oral
and maxillofacial surgery department at ___.
# Orthostatic Hypotension: Patient was noted to be orthostatic
on ___. She was encouraged to drink more fluids and was given
IV fluids. She responded well and had no further episodes.
# Fall/deconditioning: Patient was evaluated by the physical
therapy department and was provided with exercises and
techniques to treat and prevent deconditioning.
# Alcohol dependence: Patient was regularly evaluated for signs
and symptoms of alcohol withdrawal.
Chronic Issues:
==============
NA
Transitional Issues:
===================
# Follow up with the Oral and Maxillofacial surgery team at ___
# Follow up with the Orthopedics department at ___
# Medication Changes:
NEW:
Acetaminophen (Liquid) 650 mg PO Q6H
Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
Docusate Sodium 100 mg PO BID
OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line
Senna 8.6 mg PO BID:PRN Constipation - First Line
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate [Periogard] 0.12 % Gargle 15ml orall
twice a day Refills:*0
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
do no operate machinery while taking, stop if slow breathing, or
low blood pressure
RX *oxycodone 5 mg 1 tablet(s) by mouth Q6H:PRN Disp #*5 Tablet
Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home
Discharge Diagnosis:
- Comminuted intra-articular distal right radial and ulnar
fractures
- Minimally displaced left distal radial fracture without intra
articular extension and nondisplaced left ulnar styloid fracture
- Left Mandibular Condyle Fracture
- Fall
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 sustaining bilateral wrist fractures and a jaw
fracture. You were taken to the operating room and had your jaw
fixed and will continue to have elastics to keep your jaw in
proper alignment while it heals. Additionally, you had both of
your wrists surgically repaired by the orthopedic surgeons. You
will continue to wear your casts and should not bear weight with
them. Elevate your arms on pillows when able. You should not
press down with either of your hands as this could result in
damage to your wrists and disrupt your healing. You may have a
full liquid diet. Please see the attached information for
recommendations on how to meet your nutritional needs with a
full liquid diet. You
You are now doing better, tolerating a full liquid diet, and
your pain is controlled on oral medications. You are now ready
to be discharged from the hospital to continue your recovery.
Please note the following discharge instructions:
Please maintain meticulous oral hygiene with twice daily
brushing and by using the prescribed mouth rinse (Peridex ___
BID) twice daily. Rinse with warm salt water after meals.
Follow up with a Oral and maxillofacial surgeon to Replace
Elastics and manage replacement for 10 days and then guiding
elastics, in ___.
Do not smoke while your surgical sites are healing. Smoking will
significantly affect the healing and affect your sinuses.
Please do not drive while taking narcotic medications as these
medications can slow your reaction time and be sedating. If you
feel you do not need this narcotic medication, then you may take
tylenol only.
No strenuous activity or heavy lifting greater than 10 lbs for
the next 6 weeks.
Please maintain a strict non-chew full liquid diet for 4 weeks
or until advised otherwise by your surgeon. A diet package will
be provided to you for helpful ideas of liquid meals.
Take your stool softeners daily to prevent constipation. Keep
your stools loose to prevent bearing down or straining.
You have stitches in your mouth. These will dissolve on their
own within ___ weeks.
Call your doctor or go to the nearest ER for the following:
- Fevers > ___
- Increased pain, redness, swelling of the wound
- Drainage, pus from the wound
Contact ___ oral surgery with questions about care of this
patient at any time ___, ask the operator to page the
Oral Surgery resident on call.
Please refer to the provided jaw surgery instruction sheet for
further details regarding post-operative care.
Please maintain meticulous oral hygiene with twice daily
brushing
and by using the prescribed mouthrinse twice daily. Rinse with
warm salt water after meals.
Please do not smoke while your surgical sites are healing.
Smoking will significantly affect the healing and affect your
sinuses.
Please do not drive while taking narcotic medications as these
medications can slow your reaction time and be sedating. If you
feel you do not need this narcotic medication, then you may take
tylenol only.
No strenuous activity or heavy lifting greater than 10 lbs for
the next 6 weeks.
Please maintain a strict non-chew full liquid diet for 4 weeks
or
until advised otherwise by your surgeon. A diet package will be
provided to you for helpful ideas of liquid meals.
Take your stool softeners daily to prevent constipation. Keep
your stools loose to prevent bearing down or straining.
You have stiches in your mouth. These will dissolve on their own
within ___ weeks.
Call your doctor or go to the nearest ER for the following:
- Fevers > ___
- Increased pain, redness, swelling of the wound
- Drainage, pus from the wound
Contact ___ oral surgery with questions about care of this
patient at any time ___, ask the operator to page the
Oral Surgery resident on call.
Please refer to the provided jaw surgery instruction sheet for
further details regarding post-operative care.
WOUND CARE:
Your wounds need to be kept clean and dry. You may shower, but
you are not to soak your wounds in the bathtub, swimming pool,
or
hot tub for about four weeks. You are to inspect your wounds
daily for signs and symptoms of infection, these include:
increased pain or tenderness on or near the wounds, increased
redness or swelling around the wounds, drainage from the wounds,
reopening of the wounds, or an oral temperature of 101.5 degrees
F or more. If you develop any of these signs of infections
please
return to the emergency room.
CONTINUED CARE:
You may take Tylenol for pain. If you require pain medicine more
frequently than every 6 hours, you may alternate with Motrin
every 6 hours in between so that you are getting a form of pain
medicine every 3 hours. Initially you may need to take pain
medications on a regular basis. Once your pain improves you may
stop taking them based on your symptoms.
Please do not drive while taking narcotic medications as these
medications can slow your reaction time and be sedating
Wired Jaw Care
You may have your jaw wired shut for many reasons, including a
broken jaw or jaw surgery. The wires help hold your jaw in place
while you heal.
HOW TO CARE FOR YOUR WIRED JAW
Keep your mouth clean.
·Rinse your mouth with warm salt water after eating or drinking
anything. To make salt water, mix ½ tsp of salt in one cup of
warm water.
·Brush the front of your teeth with a child-sized, soft
toothbrush after you eat.
·If you need to vomit, bend over and open your lips. Always
rinse out your mouth and brush your teeth after vomiting.
Take care of swelling.
·Follow your health care provider's instructions about how to
help the swelling go down.
·Sit up or prop yourself up with pillows behind your back to
help with swelling.
Take care of pain and discomfort.
·Do not drive or operate heavy machinery while taking pain
medicine.
·Use petroleum jelly on your lips to keep them from drying and
cracking.
·Cover the wire with dental wax if any wires are poking into
your lips or gums.
Follow your health care provider's instructions.
·Follow your health care provider's directions about what you
can and cannot eat.
·Take medicines only as directed by your health care provider.
·Keep all follow-up visits as told by your health care
provider.
This is important.
Only cut wires in an emergency.
·Keep wire cutters with you at all times. Use them only in an
emergency to cut the wires that hold your jaw together.
·Do not cut the wires:
Even if you are tired of having your jaw wired.
Even if you are hungry.
Even if you need to vomit.
·You may cut the wires that hold your jaw together only:
If you have trouble breathing.
If you are choking.
·Do not cut the wires that connect to your back teeth (arch
wires). If you must cut the wires in an emergency, cut straight
across the wires that hold your mouth closed. These are the
wires
that are connected to the arch wires.
SEEK MEDICAL CARE IF:
·You have a fever.
·You feel nauseous or you vomit.
·You feel that one or more wires have broken.
·You have fluid, blood, or pus coming from your mouth or
incisions.
·You are dizzy.
SEEK IMMEDIATE MEDICAL CARE IF:
·You had to cut the wires that hold your jaw together.
·Your pain is severe and is not helped with medicine.
·You faint.
This information is not intended to replace advice given to you
by your health care provider. Make sure you discuss any
questions
you have with your health care provider.
Document Released: ___ Document Revised: ___
Document Reviewed: ___
___ Patient Information ___.
Fractured-Jaw Meal Plan
The purpose of the fractured-jaw meal plan is to provide foods
that can be easily blended and easily swallowed. This plan is
typically used after jaw or mouth surgery, wired jaw surgery, or
dental surgery.
Foods in this plan need to be blended so that they can be sipped
from a straw or given through a syringe. You should try to have
at least three meals and three snacks daily. It is important to
make sure you get enough calories and protein to prevent weight
loss and help your body heal, especially after surgery. You may
wish to include a liquid multivitamin in your plan to ensure
that
you get all the vitamins and minerals you need. Ask your health
care provider for ___ recommendation.
HOW DO I PREPARE MY MEALS?
All foods in this plan must be blended. Avoid nuts, seeds,
skins,
peels, bones, or any foods that cannot be blended to the right
consistency. Make sure to eat a variety of foods from each food
group every day. The following tips can help you as you blend
your food:
·Remove skins, seeds, and peels from food.
·Cook meats and vegetables thoroughly.
·Cut foods into small pieces and mix with a small amount of
liquid in a food processor or blender. Continue to add liquid
until the food becomes thin enough to sip through a straw.
·Adding liquids such as juice, milk, cream, broth, gravy, or
vegetable juice can help add flavor to foods.
·Heat foods after they have been blended to reduce the amount
of
foam created from blending.
·Heat or cool your foods to lukewarm temperatures if your teeth
and mouth are sensitive to extreme temperatures.
WHAT FOODS CAN I EAT?
Make sure to eat a variety of foods from each food group.
Grains
·Hot cereals, such as oatmeal, grits, ground wheat cereals, and
polenta.
·Rice and pasta.
·Couscous.
Vegetables
·All cooked or canned vegetables, without seeds and skins.
·Vegetable juices.
·Cooked potatoes, without skins.
Fruit
·Any cooked or canned fruits, without seeds and skins.
·Fresh, peeled soft fruits, such as bananas and peaches, that
can be blended until smooth.
·All fruit juices, without seeds and skins.
Meat and Other Protein Sources
·Soft-boiled eggs, scrambled eggs, powdered eggs, pasteurized
egg mixtures, and custard.
·Ground meats, such as hamburger, ___, sausage, and
meatloaf.
·Tender, well-cooked meat, poultry, and fish prepared without
bones or skin.
·Soft soy foods (such as tofu).
·Smooth nut butters.
Dairy
·All are allowed.
Beverages
·Coffee (regular or decaffeinated), tea, and mineral water.
Condiments
·All seasonings and condiments that blend well.
WHEN MAY I NEED TO SUPPLEMENT MY MEALS?
If you begin to lose weight on this plan, you may need to
increase the amount of food you are eating or the number of
calories in your food or both. You can increase the number of
calories by adding any of the following foods:
·Protein powder or powdered milk.
·Extra fats, such as margarine (without trans fat), sour cream,
cream cheese, cream, and nut butters, such as peanut butter or
almond butter.
·Sweets, such as honey, ice cream, blackstrap molasses, or
sugar.
This information is not intended to replace advice given to you
by your health care provider. Make sure you discuss any
questions
you have with your health care provider.
DRINK TO YOUR HEALTH
30 Nutritional and Tasty Recipes for Blended Diets
General Considerations:
Physical activity should be minimized for ___ weeks following
surgery or as recommended by your surgeon. This includes all
activities where your face and/or jaw would have a tendency to
be
hit. Strenuous work, such as lifting heavy objects, could cause
stress, bleeding, or possible displacement of the healing
segments.
If you are having surgery on your TMJ joints, it is essential
that you follow a soft diet for about 3 weeks. The joints take a
long time to heal and under stress on the joints from biting on
hard foods, or opening mouth wide, can cause terrific amount of
pain. Do not become over confident about healing ability of your
joints one month after the surgery and being eating solid foods.
Go slowly!
Almost anything you are accustomed to eating or drinking can be
blended and thinned to the right consistency for you. Some foods
may require use of metal strainer as well! Bon Appetit!
Following each meal, clean your mouth properly. Child size
toothbrush is appropriate and easy to use. A water pik may be
used beginning one week after surgery. A solution is made of
four
parts of water and/or mouthwash and one part of hydrogen
peroxide.
Avoid relying solely on food containing high amount of sugar.
Sugar increases the chance of cavities and contains few
nutrients.
If the teeth are sensitive to extreme temperatures, serve foods
___ warm or slightly chilled.
Your surgeon may prescribe Peridex, a special mouthwash that
helps plaque and debris from the teeth and braces. Peridex may
leave a stain on your teeth, which can be removed by general
dentist.
Soups
Asparagus soup (good source of protein, Calcium, vitamin A and
Iron)
10 ¾ oz can cream of asparagus soup
1 cup milk
1 Tbsp mayonnaise
Dash of Worcestershire sauce
Heat all ingredients in saucepan. Pour into blender - blend
until
smooth.
450 calories
Avocado at Sea (good source of protein, Calcium, vitamin A)
1 cup of condensed clam chowder (from a can)
10 ¾ oz can chicken broth
½ cup half & half
½ ripe avocado, mashed
Heat all ingredients in saucepan. Pour into blender - blend
until
smooth.
600 calories
Avocado chicken soup (good source of protein, Potassium)
10 ½ oz can cream of chicken soup (reconstitute with ¾ cup
water)
3 cups chicken bouillon
1 ripe avocado, mashed
½ cup celery, finely chopped
1 tbs liquid vegetable oil
½ tsp salt
Heat all ingredients in saucepan. Pour into blender - blend
until
smooth.
600 calories
Cauliflower soup (good source of protein, Calcium, vit A, C,
Potassium)
10 oz pkg frozen cauliflower, cooked
1 cup half & half
3 slices ___ cheese
1 tsp flour
1 tsp butter
Dash of Worcestershire sauce
Heat butter and flour in a saucepan until smooth; add remaining
ingredients. Do not boil. Pour into blender - blend until
smooth.
755 calories
Cheddar Cheese soup (good source of all nutrients)
11 oz can Cheddar Cheese soup
½ cup vanilla Ensure
½ cup water
1 tsp Worcestershire sauce
Salt, ___ to taste
Heat all ingredients in saucepan. Pour into blender - blend
until
smooth.
480 calories
Crabmeat soup (good source of protein, Calcium, vit A, Iron)
2 cups of half & half
10 ½ oz can cream of mushroom soup
10 ½ oz can cream of asparagus soup
1 cup chopped crabmeat
½ cup water
Dash of white ___
Heat all ingredients in saucepan. Pour into blender - blend
until
smooth. ___ require straining.
1200 calories
Cream Cheese soup (good source of protein, vit A)
3 oz pkg of cream cheese, softened
1 ½ cups beef bouillon
Dash of curry powder, garlic, ___
Blend until smooth - may be served cold or hot.
200 calories
Creamed Curry soup (good source of protein, Calcium)
1 cup plain yogurt
1 cup beef bouillon
1 tsp liquid vegetable oil
¼ tsp curry powder
Dash of garlic salt
Heat all ingredients in saucepan. Do not boil. Pour into blender
- blend until smooth.
200 calories
Cucumber soup (good source of protein, Calcium)
___ medium cucumber, peeled, seeded, chopped
¼ cup milk
½ cup chicken bouillon
1 tsp each - cottage cheese, sour cream, minced onion, dash
salt, ___
Blend until smooth - may be served cold or hot.
200 calories
Shrimp soup (good source of protein, Calcium, Iron)
1 cup milk
4 ½ oz can broken shrimp, drained
1 tsp flour
1 tsp butter
Dash of Tabasco
Heat butter and flour in a saucepan until smooth; add remaining
ingredients. Do not boil. Pour into blender - blend until
smooth.
325 calories
Spinach soup (good source of protein, Calcium, Iron, vit A)
10 oz pkg frozen chopped spinach, cooked
10 ½ oz can chicken broth
1 cup half & half
½ cup milk
1 tsp butter
1 tsp flour
Salt to taste
Heat butter and flour in a saucepan until smooth; add remaining
ingredients. Do not boil. Pour into blender - blend until
smooth.
525 calories
Tomato Cheese soup (good source of protein, Calcium, vit A & C)
10 ½ oz can tomato soup - reconstituted with ___ cup water
1 cup milk
½ cup shredded cedar cheese
1 tbsp mayonnaise
1 tsp ___ juice
Dash of Worcestershire sauce, salt & ___ to taste
Heat all ingredients in saucepan. Pour into blender - blend
until smooth.
675 calories
___ Clam Chowder (good source of protein, Calcium, vit
A,
Iron)
10 ½ oz can minced clams, completely drained
½ cup milk
½ cup half & half
¼ cup mashed potatoe
1 tbsp liquid vegetable oil
½ tsp onion juice
Salt & ___ to taste
Heat all ingredients in saucepan. Pour into blender - blend
until
smooth.
500 calories
Potato soup (good source of protein, Calcium, vit A & C,
Potassium)
10 ¾ oz can chicken broth
1 cup canned potato salad
½ half & half
1 tsp pickle juice
Dash of smoked-flavored salt
Heat all ingredients in saucepan. Pour into blender - blend
until
smooth.
560 calories
Desserts
Peaches and Cream (good source of protein, calcium, vit A)
1 cup milk
1 cup canned peaches in light syrup
1 cup vanilla ice cream
¼ tsp salt
2 drops vanilla extract
Blend until smooth. 630 calories
___- Upper (good source of all nutrients due to Ensure)
1 cup Dr ___
¾ cups vanilla ice cream
½ cup Ensure
Strawberry-Pear Cooler (good source of protein, calcium,
potassium)
2 caned pear halves
½ cup cottage cheese
½ cup strawberry yogurt
½ cup milk
1 tbsp sugar
2 drops almond extract
Blend - 400 calories
Vanilla Milkshake (good source of protein, potassium, vit A)
3 cups vanilla ice cream
1 ¼ cups milk
1 banana
1 egg
½ tsp vanilla extract
Blend - 1500 calories.
Best Banana Bisque (good source of protein, vit A, Potassium)
1 ½ cup crushed ice
1 cup half & half
1 large ripe banana, pealed
½ cup vanilla ice cream
1 slice white bread - remove crust
2 tbsp sugar
1 tsp liquid vegetable oil
Dish of cinnamon
Drop of vanilla extract
Blend. 750 calories
Buttermilk Yogurt (good source of protein, Calcium)
1 cup vanilla yogurt
¾ cup club soda
¾ cup crushed ice
1 tbsp sugar
2 drops vanilla extract
Dash of salt
Blend. 250 calories
Cantaloupe Shake (good source of protein, Calcium, Vit A & C)
1 ½ cups vanilla ice cream
½ medium ripe cantaloupe - peeled, seeded, chopped
¼ cup milk
1 tbsp sugar
2 tsp lemon juice
¼ tsp vanilla extract
Blend. 620 calories
___ Cream Berries (good source of protein, Calcium, vit C)
1 ¼ cups strawberries
1 ¼ cups milk
1 cup crushed ice
½ cup ___ cheese
½ cups sugar
1 tbsp chocolate chips
½ tsp vanilla extract
Blend. 660 calories
Lemon Lift (good source of protein, Potassium, Calcium)
1 cup lemon yogurt
¾ cup milk
1 banana, peeled
Few drops vanilla extract
Blend. 450 calories
Lime Whip (good source of protein, Calcium, vit C)
1 cup liquid lime Jell-O
½ cup pineapple juice
½ cup cottage cheese
½ cup half & half
2 drops vanilla extract
Blend. 480 calories.
Malted Milk (good source of protein, Calcium, vit A)
1 cup milk
½ cup vanilla ice cream
¼ cup half & half
2 tbsp malted milk powder
½ tsp vanilla extract
Blend. 520 calories
Fruit Punches
Fruit has little protein, so whenever possible combine with
yogurt, en egg, or half & half.
Apple Frizzy (good source of protein, Calcium, Potassium)
¾ cup club soda
½ cup vanilla yogurt
3 oz frozen apple juice concentrate
Blend until smooth.
190 calories
Banana Daiquiri (good source of cit C, Potassium)
2 cups apple juice
1 ripe banana
15 raisins
1 tbsp sugar
½ tsp cinnamon
Blend until smooth.
395 calories
Cranberry Fruit punch (good source of vit C)
1 ½ cups orange sherbet
1 ½ cups cranberry juice
1 ½ cups crushed pineapple
½ cup water
1 tbsp sugar
Blend until smooth.
900 calories
Fruit punch (good source of vit C, Potassium)
1 cup gingerale
½ cup applesauce, unsweetened
½ cup orange juice (no pulp)
½ cup tea (brewed)
½ cup sugar
___ cup lemon juice
Blend. 390 calories
Orange Berry Punch (good source of vit C)
1 ¼ cups orange juice (no pulp)
10 oz pkg sweetened berries (slightly frozen)
1 cup orange sherbet
Blend until smooth.
770 calories
Pear Icy (good source of Potassium)
4 cups pear halves, drained
1 cup crushed ice
¼ cup sugar
1 tbsp lemon juice
Blend until smooth.
380 calories
High Fiber Foods
Cooked fruits
Applesauce
Prunes
Apricots
Figs
Muffins
Bran
Soups
Fresh vegetable soup with dries peas, lentils, barely
Cooked Vegetables
Baked potato
Celery
Tomatoes
Lettuce
Cabbage
Scallions
Steamed Vegetables
Baked potato
Squash
Broccoli
Green beans
Onions
Spinash
Postoperative instructions following jaw surgery
Wound care: Do not disturb or probe the surgical area with any
objects. The sutures placed in your mouth are usually the
type that self dissolve. If you have any sutures on the skin of
your face or neck, your surgeon will remove them on the day of
your first follow up appointment. SMOKING is detrimental to
healing and will cause complications.
Bleeding: Intermittent bleeding or oozing overnight is normal.
Placing fresh gauze over the area and biting on the gauze for
___ minutes at a time may control the bleeding. If you had
nasal surgery, you may have occasional slow oozing from your
nostril for the first ___ days. Bleeding should never be severe.
If bleeding persists or is severe or uncontrollable, please call
our office immediately. If it is after normal business hours,
please come to the emergency room and request that the oral
surgery resident on call be paged.
___: Normal healing after oral surgery should be as follows:
the first ___ days after surgery, are generally the most
uncomfortable and there is usually significant swelling. After
the first week, you should be more comfortable. The remainder
of your postoperative course should be gradual, steady
improvement. If you do not see continued improvement, please
call
our office.
Physical activity: It is recommended that you not perform any
strenuous physical activity for a few weeks after surgery. Do
not lift any heavy loads and avoid physical sports unless you
obtain permission from your surgeon.
Swelling & Ice applications: Swelling is often associated with
surgery. Swelling can be minimized by using a cold pack, ice
bag or a bag of frozen peas wrapped in a towel, with firm
application to face and neck areas. This should be applied 20
minutes on and 20 minutes off during the first ___ days after
surgery. If you have been given medicine to control the
swelling, be sure to take it as directed.
Hot applications: Starting on the ___ or ___ day after surgery,
you may apply warm compresses to the skin over the areas of
swelling (hot water bottle wrapped in a towel, etc), for 20
minutes on and 20 min off to help soothe tender areas and help
to
decrease swelling and stiffness. Please use caution when
applying
ice or heat to your face as certain areas may feel numb after
surgery and extremes of temperature may cause serious damage.
Tooth brushing: Begin your normal oral hygiene the day after
surgery. Soreness and swelling may nor permit vigorous
brushing, but please make every effort to clean your teeth with
the bounds of comfort. Any toothpaste is acceptable. Please
remember that your gums may be numb after surgery. To avoid
injury to the gums during brushing, use a child size
toothbrush and brush in front of a mirror staying only on teeth.
Mouth rinses: Keeping your mouth clean after surgery is
essential. Use teaspoon of salt dissolved in an 8 ounce glass
ofwarm water and gently rinse with portions of the solution,
taking 5 min to use the entire glassful. Repeat as often as you
like, but you should do this at least 4 times each day. If your
surgeon has prescribed a specific rinse, use as directed.
Sleeping: Please keep your head elevated while sleeping. This
will minimize swelling and discomfort and reduce pain while
allowing you to breathe more easily. One or two pillows may be
placed beneath your mattress at the head of the bed to prop the
bed into a more vertical position.
Diet: Non-chew, soft food diet until instructed otherwise
Nausea/Vomiting: Nausea is not uncommon after surgery. Sometimes
pain medications are the cause. Precede each pill with a small
amount of soft food. Taking pain pills with a large glass of
water can also reduce nausea. Try taking clear fluids and
minimizing taking pain medications, but call us if you do not
feel better.
If your jaws are wired shut with elastics and you experience
nausea/vomiting, try tilting your head and neck to one side.
This
will allow the vomitus to drain out of your mouth. If you feel
that you cannot safely expel the vomitus in this manner, you can
cut elastics/wires and open your mouth. Inform our office
immediately if you elect to do this. If it is after normal
business hours, please come to the emergency room at once, and
have the oral surgery on call resident paged.
___: Depending on the type of surgery, you may have
elastics
and/or wires placed on your braces. Before discharge from the
hospital, the doctor ___ instruct you regarding these
wires/elastics. If for any reason, the elastics or wires break,
or if you feel your bite is shifting, please call our office.
Medications: You will be given prescriptions, some of which may
include antibiotics, oral rinses, decongestants, nasal
sprays and pain medications. Use them as directed. A daily
multivitamin pill for ___ weeks after surgery is recommended but
not essential.
If you have any questions about your progress, please call our
office at ___ (dental school) or ___
(___). After normal business hours or on weekends, call the
page operator at ___ ___ and have
them
page the on call Oral & Maxillofacial Surgery resident.
Please inform the resident on call that your operation was done
at ___ and provide your ___
Record Number if it is available. If you are already seen by us
at ___ after the surgery and has ___ Record Number,
please inform the resident the most recent visit/surgery.
- In case of seizure and severe EtOH withdrawal, one may easily
cut elastic with any sharp instrument. Scissor should be at
patient's bedside.
- It is not urgent to replace elastic in case of emergency case
(seizure and withdrawal)
- ___ will cut elastic morning of ___ for ease of anesthesia
during Orhto case
- Start with clear liquid diet and can advance to full liquid
diet as patient tolerates
- No Abx indicated from ___ perspective
- If follow up appointment information is not provided in her
OMR
prior to her discharge, she will be contacted directly
Best,
Your ___ Team
Followup Instructions:
___
|
10447190-DS-14 | 10,447,190 | 26,350,801 | DS | 14 | 2179-06-18 00:00:00 | 2179-06-28 23:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
metformin
Attending: ___
Chief Complaint:
Shortness of breath, chest pressure
Major Surgical or Invasive Procedure:
___: Cardiac catheterization
History of Present Illness:
___ complains of several months of sharp chest pain without
radiation and shortness of breath when exercising, relieved upon
stopping of exercise. Over the past ___ days, he reported
burping a lot, shortness of breath, and chest pressure at rest.
The shortness of breath was worse when laying down and relieved
when sitting up. However, the chest pressure was constant and
typically went away on its own after ___ minutes. Last night,
he noted severe chest pressure, like something was "sitting on
his chest" for hours, unrelieved until he took aspirin in the
ED. The shortness of breath was also worsened when lying down,
but relieved with sitting up and walking. He notes a very mild
cough, but otherwise denies fevers, chills, nausea, vomiting,
abdominal pain.
He reports past medical history of hypothyroidism, pre-diabetes,
borderline hypercholesterolemia. He denies any previous history
of CAD.
In the ED, initial vitals were BP 135/56 RR 18 SaO2 99% on RA HR
79, with ___ chest pressure. He was given aspirin 325 mg. CXR
revealed low lung volumes, with no acute chest pathology. After
his biomarkers were negative, he underwent stress testing which
provoked anginal type symptoms with ischemic EKG at a fair
workload, prompting admission to the Cardiology Service.
After arrival to ___ 3, he reported shortness of breath when
lying down, improved with sitting up. He denied chest pain.
Cardiac review of systems negative for syncope, presyncope,
palpiations, swelling.
Past Medical History:
1. CAD RISK FACTORS: +Pre-Diabetes, +Dyslipidemia, -Hypertension
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:
Hypothyroid
Vitamin D deficiency
Social History:
___
Family History:
DM, CHF, MI in father, who died at age ___. No family history of
early MI, arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory.
2 childen: 1 boy age ___ 1 girl age ___, in good health.
Physical Exam:
GENERAL: Middle aged South Asian man in NAD. Oriented x3. Mood,
affect appropriate.
VS: T=97.2 BP=136/86 HR=72 RR=18 O2 sat=98% on RA
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7-8 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs, rubs or gallops. No
thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits. No renal bruits.
EXTREMITIES: No clubbing, cyanosis or edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
No significant changes in physical examination at time of
discharge. Small hematoma over right radial arteriotomy site.
Pertinent Results:
___ 04:20AM WBC-7.3 RBC-4.28* HGB-13.2* HCT-38.3* MCV-89
MCH-30.8 MCHC-34.4 RDW-13.7
___ 04:20AM NEUTS-59.6 ___ MONOS-6.9 EOS-2.2
BASOS-0.3
___ 04:20AM PLT COUNT-289
___ 04:20AM ___ PTT-33.3 ___
___ 04:20AM GLUCOSE-138* UREA N-16 CREAT-0.9 SODIUM-136
POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-24 ANION GAP-12
___ 04:26AM GLUCOSE-135* NA+-139 K+-4.1 CL--102 TCO2-26
Cardiac Biomarkers:
___ 04:20AM cTropnT-<0.01 proBNP-20
___ 10:08AM cTropnT-<0.01
___ 07:10PM CK-MB-6 cTropnT-<0.01
Lipids/A1C:
___ 07:10PM %HbA1c-6.8* eAG-148*
___ 07:10PM TRIGLYCER-81 HDL CHOL-44 CHOL/HDL-3.7
LDL(CALC)-102 ___
Other labs:
___ 07:10PM D-DIMER-<150
___ 07:10PM ALT(SGPT)-69* AST(SGOT)-57* CK(CPK)-505*
___ 06:50AM CK(CPK)-412*
___ 06:50AM TSH-7.9* Free ___ ECG:
Sinus rhythm. Poor R wave progression. Non-specific T wave
flattening in leads III, aVL and V5-V6.
___ ETT:
This was a ___ y/o man with obesity and a sedentary lifestyle who
was referred to the lab from the ED after negative serial
cardiac enzymes presents for evaluation of chest pain and
shortness of breath. Patient completed 6.5 minutes of ___
protocol, representing a fair exercise tolerance for his age; ~
___ METS. Test was stopped due to patient's request and fatigue.
He complained of progressive mid-scapular discomfort starting
near 4 minutes of exercise at an intensity of ___, which
increased to ___ at peak exercise and resolved completely by 3
minutes of recovery. At the start of exercise, there was noted
the development of inverion of the inferolateral T waves. At
peak exercise, there was the development of 1-1.5mm horizontal
to downsloping ST depression noted in these same leads. The ST
segment depression nearly resolved by 5 minutes of recovery,
however the biphasic T waves re-appeared in the same leads at
that time. All ST segment and T wave changes resolved back to
baseline by 10 minutes of recovery. Rhythm was sinus with no
ectopy. Heart rate responded appropriately to exercise. The
blood pressure was mildly blunted.
IMPRESSION: Fair functional exercise capacity. Anginal type
symptoms with ischemic EKG changes to achieved workload. Blunted
blood pressure response to exercise. Appropriate hemodynamic
response to exercise.
___ Chest X-Ray:
Frontal and lateral chest radiograph demonstrates clear lungs
with low lung volumes, which accentuate the pulmonary
vasculature. There is no effusion or pneumothorax. The heart
size is normal and mediastinal contours are unremarkable.
___ Cardiac catheterization:
1. Selective coronary angiography of this right dominant system
demonstrated no angiographically-apparent significant disease.
The ___ was patent. The LAD, LCX and RCA had no
angiographically-apparent significant disease. There was
sluggish flow consistent with microvascular dysfunction.
2. Limited resting hemodynamics revealed mildly elevated left
ventricular filling pressures with LVEDP 25 mmHg. There was
normal systemic arterial pressures at the central aortic level
104/71 mmHg. There was no gradient across the aortic valve upon
pullback of the angled pigtail catheter from LV to ascending
aorta.
3. Left ventriculography revealed normal ejection fraction 65%.
FINAL DIAGNOSIS:
1. Coronary arteries had no angiographically-apparent flow
limiting disease.
2. Left ventricular diastolic dysfunction.
3. Normal ventricular ejection fraction.
Brief Hospital Course:
___ yo man with diabetes mellitus, reported borderline
hypercholesterolemia and hypothyroidism on levothyroxine
presents with symptoms suggestive of unstable angina and a
positive exercise tolerance test. Cardiac catheterization
revealed no significant epicardial stenoses, but sluggish flow
throughout consistent with microvascular disease, as well as
left ventricular diastolic dysfunction.
# ? Coronary artery disease: Patient with several risk factors
for CAD and symptoms of dyspnea and chest discomfort concerning
for unstable angina. Biomarkers, however, were negative despite
having ___ days of chest pressure and worsening shortness of
breath. Oddly, the shortness of breath was relieved by both
nitroglycerin and GI cocktail when he was in the hospital. His
symptoms were not clearly worsened by physical activity.
Non-imaging stress test was positive for ischemic symptoms and
ECG abnormalities, with Duke treadmill score of -9. Given lack
of ongoing symptoms, no biomarker elevation, and no EKG changes
at rest, heparin was not started. The patient underwent
catheterization via the right radial artery which revealed no
flow-limiting disease, but sluggish flow throughout consistent
with microvascular disease as well as left ventricular diastolic
dysfunction (LVEDP 20-25 mm Hg post-angiography), with normal
LVEF. It is unclear what was causing this patient's symptoms of
chest pressure, particularly while at rest. The abnormal stress
test result could be easily attributed to his microvascular
dysfunction and thus small vessel ischemia at increased cardiac
workloads, resulting in both worsened diastolic heart failure
leading to dyspnea and angina. Patient did not report any more
of these symptoms while in the hospital after receiving 1 dose
of nitroglycerin and GI cocktail. The plan is to initiate
primary prophylaxis for CAD with high dose aspirin and
atorvastatin as the patient already does have some evidence of
non-flow limiting microvascular dysfunction, control the
patient's hypertension and attempt to improve diastolic
functioning with ACE-HCTZ and diltiazem, and give the patient
nitroglycerin for as needed symptom management. Most
importantly, the patient will need to engage in lifestyle
changes, including exercising and losing weight. D-dimer was
negative in patient with low suspicion for pulmonary embolus. No
findings suggestive of pericarditis (no rub, no ECG changes) or
aortic dissection.
# Left ventricular diastolic dysfunction: LVEDP post-angiography
(not at rest) was 20-25 mm Hg. As above, he had improved blood
pressure control with lisinopril-hydrochlorothiazide ___ and
diltiazem extended release 120 mg.
# Dyspnea: Patient's LVEF during ventriculography estimated to
be 65%. BNP was 20, chest X-ray clear, no JVD, and clear breath
sounds on exam, NOT consistent with flagrant diastolic heart
failure at presentation. Unfortunately, LVEDP was measured only
after contrast angiography and not at baseline, so difficult to
determine extent of diastolic dysfunction in a truly resting
state. He was treated for diastolic dysfunction as above. Given
patient's body habitus, obstructive sleep apnea may be present.
# Rhythm: NSR throughout his admission.
# Diabetes Mellitus: HgbA1c of 6.8%. He was not started on any
medications in the hospital. He may be able to control his DM if
he exercises, improves eating habits, and loses weight.
Follow-up with his primary care provider in ___ was
recommended.
# Dyslipidemia: Given DM and evidence of microvascular disease
on cardiac catheterization, target LDL<100. Patient was started
on atorvastatin 40 mg daily.
# Elevated LFTs and CPK: Unclear cause. CPK downtrending. LFTs
perhaps evidence of fatty liver disease. Free T4 within normal
limits (arguing against myopathy from hypothyroidism). He was
advised to follow-up with his primary care provider about these
abnormalities.
# Hypothyroidism: High TSH, normal free T4; continued home
levothyroxine dose.
# Vitamin D deficiency: On weekly vitamin D supplementation.
Transitional: Patient should focus on healthy life style. Needs
follow up for elevated CPK which was down-trending in hospital,
unclear why it was elevated in first place, mildly elevated
LFTs, and subclinical hypothyroidism. A sleep study might also
be revealing in this patient given risk for OSA.
# Code status: Full, confirmed with patient
# CONTACT: Patient, wife ___ ___
Medications on Admission:
Vitamin D
Synthyroid ___ mcg
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. lisinopril-hydrochlorothiazide ___ mg Tablet Sig: One (1)
Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2*
3. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. diltiazem HCl 120 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day. Disp:*30 Capsule, Ext
Release 24 hr(s)* Refills:*2*
5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab
Sublingual prn as needed for chest pain: can take 3 pills over
15 minutes. Disp:*30 tablets* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1) Biomarker negative unstable angina with abnormal exercise
stress test
2) Microvascular coronary artery dysfunction without
angiographically-apparent flow-limiting coronary artery disease
3) Left ventricular diastolic dysfunction
4) Diabetes mellitus
5) Dyslipidemia
6) Hypothyroidism
7) Laboratory evidence of myositis
8) Elevated hepatic transaminases
9) Vitamin D deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
You were admitted for chest pain and shortness of breath. A
cardiac catheterization revealed no significant coronary artery
disease, but there was sluggish flow consistent with
microvascular disease. Also, you were found to have elevated
filling pressures of your left ventricle, which is a marker of
heart dysfunction. This is most likely a function of underlying
hypertension with possibly some contribution from the
microvascular disease.
You were also found to have diabetes based on your hemoglobin
A1c. Given your diabetes, your bad cholesterol is not at goal
currently and this need to be further discussed with your
primary care provider. Your CPK was elevated as well--typically
a marker of muscle breakdown. This should be follow up on by
your PCP as you are starting medications that can sometimes
further elevate these values. Your liver enzymes were also
mildly elevated and will need to be further evaluated. We will
be sending your information to your primary care provider.
Please measure your blood pressure within the next few days and
contact Dr. ___ your SBP (top number)<100 or DBP (lower
number)<60.
The following changes were made to your medications:
START Aspirin for prevention of heart disease
START Diltiazem for blood pressure control.
START Lisinopril-HCTZ combination for blood pressure control
Followup Instructions:
___
|
10447601-DS-20 | 10,447,601 | 29,470,102 | DS | 20 | 2149-11-08 00:00:00 | 2149-11-08 17:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Dilaudid / IVP dye / Sulfa (Sulfonamide Antibiotics) / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug)
Attending: ___
Chief Complaint:
left hemibody numbness, gait unsteadiness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo right handed woman with pmhx of protein s deficiency with
prior unprovoked DVT on coumadin and fibromyalgia who was
transfered from an OSH for evaluation of possible TIA.
She reports being in her usual state of health when walking home
from work yesterday at 730pm. During this walk, while crossing
the street, she noticed she was "walking funny" (lilting to the
left). She could correct for this consciously, but was
concerned.
She took the bus to the bank and when she bent over, he
reported onset of an unusual headache (all over, "heavy
feeling", resolved spontaneously upon standing).
She went home and her reoommates noted that she appeared yellow
and ill. She subjectively reports that her voice sounded funny
and she was talking slowly. There was no mention made from her
roommates of facial asymmetry. It was around this time that she
noted that her right face felt funny and numb.
EMS was called and she was brought to the hospital.
ROS otherwise only notable for moving black spots spots in her
vision during this episode.
On neuro ROS, the pt denies loss of consciousness or vision,
blurred vision, diplopia, dysphagia, lightheadedness, vertigo,
or hearing difficulty. Denies focal weakness. No bowel or
bladder incontinence or retention.
On general review of systems, the pt denies cough, shortness of
breath, chest pain or tightness, palpitations.
Past Medical History:
- Protein S deficiency (reported diagnosed ___ genetic testing),
on lifelong coumadin with prior unprovoked DVTs.
- Major Depress Dis
- s/p gastric bypass for obesity
- GERD
- Hyperlipidemia LDL goal < 130
- Carpal tunnel syndrome
- Postsurgical hypothyroidism
- Vitamin D deficiency
- Internal hemorrhoids
- Periodic limb movement sleep disorder
- Varicose veins
- Fibromyalgia
- Open-angle glaucoma
- Ovarian teratoma
- Constipation
Social History:
___
Family History:
- Maternal grandmother and biological father with stroke
- Very strong family history of CAD with multiple family members
deceased at relatively young ages from MI.
Physical Exam:
ADMISSION EXAM:
Vitals:
Temp ___, Hr 86, BP 138/74, RR 16, 96% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: Obese, soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and most low frequency
objects (did not get feather from NIHSS). Able to read without
difficulty. Speech was not dysarthric. Able to follow both
midline and appendicular commands. Attentive, able to name ___
backward without difficulty. Pt. was able to register 3 objects
and recall ___ at 5 minutes. There was no evidence of apraxia
or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Reports 50% facial sensation on Left compared to right.
VII: ? mild L ptosis, appears to correct later during exam.
Otherwise facial musculature symmetric and ___ strength in upper
and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, and is equal ___ strength
bilaterally as evidenced by tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
Exam very painful ___ fibromyalgia. Requires coaching.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 3 1 1
R 2 2 2 1 1
- Toes difficult. ticklish withdrawal. L toe mute. R toe
difficult to tell, question of upgoing
-Sensory: Reports decreased sensation to light touch, pinprick
and cold sensation on Left side. Does NOT split the midline.
proprioception intact throughout. No extinction to DSS.
-Coordination: No intention tremor. Mild left sided dysmteria
when touching her nose with her eye closed. However, on FNF not
present or much less mild.
-Gait: Good initiation. moderate-based, short stride. Unable to
walk in tandem. Romberg absent.
DISCHARGE EXAM:
L NLF flattening which activates symmetrically
LUE pronator drift (mild), otherwise, full strength throughout
Decreased senation in L face/arm/leg compared to right
Mild dysmetria on FNF on L
Gait is narrow based, steady
Pertinent Results:
Admission labs:
___ 11:17PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 11:17PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 11:17PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 05:25AM LACTATE-1.1
___ 05:15AM GLUCOSE-130* UREA N-19 CREAT-0.8 SODIUM-140
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-31 ANION GAP-11
___ 05:15AM ALT(SGPT)-17 AST(SGOT)-23 ALK PHOS-134* TOT
BILI-0.4
___ 05:15AM cTropnT-<0.01
___ 05:15AM ALBUMIN-3.7 CALCIUM-9.0 PHOSPHATE-3.6
MAGNESIUM-2.3 CHOLEST-244*
___ 05:15AM TRIGLYCER-233* HDL CHOL-45 CHOL/HDL-5.4
LDL(CALC)-152*
___ 05:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 05:15AM WBC-7.7 RBC-4.21 HGB-12.2 HCT-39.0 MCV-93
MCH-29.0 MCHC-31.2 RDW-15.1
___ 05:15AM NEUTS-54.7 ___ MONOS-3.8 EOS-6.6*
BASOS-0.3
___ 05:15AM PLT COUNT-285
___ 05:15AM ___ PTT-31.0 ___
Imaging:
MRI brain w/o contrast (our read)
No acute ischemic stroke, FLAIR without any prior infarcts, no
abnormalities
MRA head/neck
Vessels are patent without any stenosis
Brief Hospital Course:
Ms. ___ is a ___ yo right handed woman with pmhx of Protein
S deficiency with prior unprovoked DVT on coumadin and
fibromyalgia who was transfered from an OSH for evaluation of
possible TIA with symptoms of gait instability, left sided
numbness. Her exam was relevant for left face/arm/leg decreased
sensation, left upper extremity mild pronator drift, and mild
dysmetria on FNF on left. MRI brain did not show an acute
ischemic stroke. On admission, her INR was 1.6 (notes she
missed several doses). Given subtherapeutic INR and suspicion of
stroke in this setting, Lovenox 1mg/kg q12h was started. MRI
head and MRA brain and neck on ___ did not show any signs of an
acute process. LDL was 152 and she was started on Lipitor 40mg
daily given concern for stroke risk. HgA1c was pending at time
of discharge. The patient was monitored with telemetry
throughout her hospitalization, no atrial fibrillation noted.
Although no stroke was seen on MRI, given multiple risk factors
as well as objective exam findings, suspect that patient had an
MRI negative stroke. As Adderall can cause vasoconstriction and
further increase the risk of stroke, it was discontinued here.
Patient would like to continue taking it as it gives her energy.
I explained to her the risks associated with this. She will
think about it and decide at home. She was discharged with a
lovenox bridge on coumadin as INR was still low at 1.4.
TRANSITIONS OF CARE:
- will follow up in her ___ clinic early this week; until
INR therapeutic, will continue lovenox
- HbA1c pending at time of discharge
- will follow up in stroke clinic with Dr. ___
___ on Admission:
latanoprost (XALATAN) 0.005 % ophthalmic solution Place 1 drop
into both eyes nightly. Disp: 2.5 mL Rfl: 0
pramipexole (MIRAPEX) 0.125 MG tablet Take 2 tablets by mouth
every evening. Disp: 60 tablet Rfl: 11
amphetamine-dextroamphetamine (ADDERALL, 10MG,) 10 MG tablet One
in morning, may have also half in afternoon prn Disp: 45 tablet
Rfl: 0
ergocalciferol (DRISDOL) 8000 UNIT/ML drops Take 1 mL by mouth
daily. Disp: 60 mL Rfl: 11
warfarin (COUMADIN) 5 MG tablet 2.5 mg ___ and 5 mg x 5 days
(30 mg/week) or as directed for INR goal ___ Disp: 90 tablet
Rfl: 3
levothyroxine (SYNTHROID, LEVOTHROID) 150 MCG tablet Take 1
tablet by mouth daily. Dose increase Disp: 30 tablet Rfl: 12
amitriptyline (ELAVIL) 25 MG tablet Take 3 tablets by mouth
nightly. At bedtime Disp: 270 tablet Rfl: 3
Calcium Carbonate-Vitamin D (CALCIUM 600+D) 600-400 MG-UNIT TABS
Tablet Take 1 tablet by mouth 2 (two) times daily. Disp: 60
tablet Rfl: 73
omeprazole (PRILOSEC OTC) 20 MG tablet Take 1 tablet by mouth
daily. Disp: 60 tablet Rfl: 5
Discharge Medications:
1. Enoxaparin Sodium 120 mg SC BID
Start: Today - ___, First Dose: Next Routine Administration
Time
2. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
3. Mirapex (pramipexole) 0.25 mg oral HS home med
4. Vitamin D 800 UNIT PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Levothyroxine Sodium 150 mcg PO DAILY
7. Warfarin 5 mg PO 5X/WEEK (___)
8. Warfarin 2.5 mg PO 2X/WEEK (MO,FR)
9. Ferrous Sulfate 325 mg PO DAILY
10. Amitriptyline 25 mg PO HS
11. Calcium Carbonate 600 mg PO BID
12. Atorvastatin 40 mg PO DAILY
RX *atorvastatin [Lipitor] 40 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
MRI negative ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with numbness on the left side
of your body, droopiness of your left face and mild clumsiness
in your left arm. We were concerned about a stroke as your INR
(or Coumadin level) was slightly low. An MRI of your brain did
not show a stroke. However, some strokes are too small to be
seen on MRI and we think this is the likely case with you. It
is very important to prevent further blood clots and strokes in
the future. To do this, your Coumadin has to be at a good
level. While it is a little low, we will send you home with
Lovenox injections (blood thinner) which you will continue until
the INR is at goal. It is VERY important to take the Coumadin
and Lovenox regularly.
Your cholesterol level was VERY high, which increases your risk
of stroke. So, we have started you on a medicine called
Lipitor. Please take this every evening.
You should STOP taking Adderoll for the time being as this can
also increase your risk of stroke.
As we discussed, please change your appointment in ___
clinic from next ___ to early this week.
We have made the following changes to your medications:
START
Lovenox twice per day (until Coumadin level is at goal)
Lipitor 40mg daily
STOP
Adderall
On discharge, please call to schedule an appointment in
neurology stroke clinic with Dr. ___ at ___.
Followup Instructions:
___
|
10447634-DS-21 | 10,447,634 | 20,212,982 | DS | 21 | 2164-08-27 00:00:00 | 2164-08-28 20:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / Bactrim / aspirin / Motrin / Toradol / Vistaril /
NSAIDS
Attending: ___
Chief Complaint:
Neck Pain
Major Surgical or Invasive Procedure:
Left neck mass biopsy
Mechanical Intubation
History of Present Illness:
Pt is a ___ y.o female with h.o hypothyroidism, Crohns, back
pain, seizures, with recent h.o neck pain/thyroid mass s/p
thyroid bx ___ with cytology that returned as "atypical
lymphocytes" who has had increase pain (stabbing ___
with talking radiates to L.neck/face/posterior neck), dysphagia,
odynophagia, SOB, inability to tolerate any PO, n/v with leaning
forward. Pt reports that her pain was not controlled with PO
oxycodone at home. Pt also reports cough, productive of phlegm.
She also reports L.ear pain with decreased hearing on the L.side
since this am. Symptoms started about ___ weeks ago, but then
increasingly worsened over the last ___ days. Pt reports feeling
feverish, heat intolerance, abdominal cramping, and
?palpitations with 10lb weight loss over last month. However,
she denies headache, dizziness, blurred vision, CP, abdominal
pain, constipation, melena, brbpr, dysuria, hematuria, joint
pain, skin rash, paresthesias, or weakness.
.
In the ED, INitial vitals:
T 98.2, BP 118/95, HR 91, RR 22, sat 97% on RA
recent 97.4, BP 129/97, HR 84, RR 14, sat 99% on RA
___ was given morphine and zofran. ENT evaluated the pt at
bedside, L.vocal cord is paramedial, airway not compromised, no
airway edema. CT scan revealed large fluid/air space collection
with mass effect, ddx includes infection mass. Neighboring
enlarged necrotic nodes are present.
Past Medical History:
thyroid mass
HTN
Hypothyroid
Crohn's Dz
Two herniated disc, unoperable
Anxiety
Seizures- last ___ ago
Endometriosis
L IM Nail (___)
Laparascopy for endometriosis
C-sections x 5
Social History:
___
Family History:
Uncle with lung cancer
Aunt with esophageal/throat ca
Sister with hyperthyroidism
Cousin with lupus
Physical Exam:
Admission Exam:
GEN: appears anxious and tearful
vitals: T 99, BP 113/70, HR 82, RR 20, sat 100% on RA
HEENT: ncat eomi anicteric MMM, tongue midline
neck: +L.sided neck fullness and tenderness to palpation along
the anterior and L.side of the neck/posteriorly and up to the
L.ear. No ear tenderness. No noticable bruits
chest: b/l ae no w/c/r
heart: s1s2 no m/r/g
abd: +bs, soft, NT, ND, no guarding or rebound
ext: no c/c/e 2+pulses
skin: no apparent rash
neuro: AAOx3, CN2-12 intact, motor ___ x4, sensation intact to
LT, no tremor
psych: calm, cooperative
.
Discharge Exam:
Vitals: T 99, BP 113/70, HR 82, RR 20, sat 100% on RA
GEN: NAD
HEENT: ncat eomi anicteric MMM, tongue midline
neck: +L. sided neck fullness and tenderness to palpation along
the anterior and L.side of the neck/posteriorly and up to the
L.ear. No ear tenderness. No noticable bruits
chest: b/l ae no w/c/r
heart: s1s2 no m/r/g
abd: +bs, soft, NT, ND, no guarding or rebound
ext: no c/c/e 2+pulses
skin: no apparent rash
neuro: AAOx3, CN2-12 intact, motor ___ x4, sensation intact to
LT, no tremor
psych: calm, cooperative
Pertinent Results:
Admission Labs:
___ 02:07PM LACTATE-1.3
___ 02:00PM GLUCOSE-79 UREA N-15 CREAT-0.7 SODIUM-134
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-26 ANION GAP-15
___ 02:00PM estGFR-Using this
___ 02:00PM CALCIUM-8.6 PHOSPHATE-3.3 MAGNESIUM-2.3
___ 02:00PM URINE HOURS-RANDOM
___ 02:00PM URINE HOURS-RANDOM
___ 02:00PM URINE UCG-NEGATIVE
___ 02:00PM URINE GR HOLD-HOLD
___ 02:00PM WBC-8.0 RBC-4.05* HGB-11.8* HCT-37.9 MCV-94
MCH-29.1 MCHC-31.1 RDW-13.4
___ 02:00PM NEUTS-70.3* ___ MONOS-4.3 EOS-5.7*
BASOS-0.3
___ 02:00PM PLT COUNT-427
.
___ CT NECK
Small fluid collection just anterior to the left
sternocleidomastoid muscle
and deep to the platysma muscle now measures 1.1 x 0.9 cm,
previously 2.1 x
1.1 cm (2:47). There is continued improvement in the small
fluid collection abutting the posterolateral aspect of the
cricoarytenoid cartilage, which now only measures 0.4 cm,
previously 1.2 x 0.4 cm (2:56). Several locules of gas persist
in the surrounding area. Mild soft tissue stranding and
thickening surrounds common carotid and internal jugular vessels
decreased from initial study; vessels appear patent. Extensive
cervical lymphadenopathy seen on ___ exam has decreased and
stable comapred to ___.
.
Airway is patent. Cervical vessels demonstrate normal
opacification. No
flow-limiting stenosis is noted. Submandibular Salivary glands
are normal in appearance; fatty change is noted in parotids.
.
Near complete opacification of the left maxillary sinus has
resolved with only mild mucosal thickening of its posterior wall
remaining (2:24). Inspissated secretions of the left sphenoid
sinus persists. Otherwise, paranasal sinuses and mastoid air
cells are well aerated. Limited views of the brain are
unremarkable. Partially imaged lungs are clear. There is no
pneumothorax.
.
C5/6: Disc-osteophyte complex indenting the ventral thecal sac;
mild foraminal narrowing.
IMPRESSION:
Continued improvement of left cervical inflammatory changes when
compared to ___ exam with details as above with some
residual abnormalities.
.
___ CT NECK
Overall, much improved appearance of the inflammatory and
necrotic changes from the prior study. There remain two small
fluid
collections which still exert some regional mass effect on the
esophagus, but no airway compromise at this stage. Continued
close surveillance with followup ultrasound and/or CT is
recommended.
.
___. Although incompletely evaluated, multiple necrotic lymph
nodes are again noted in the left neck, better delineated on
dedicated neck study from ___. Nodularity is also noted
at the left thyroid lobe, and a focal lesion cannot be excluded.
As a result, a dedicated thyroid ultrasound is recommended in a
non-emergent setting.
2. No evidence of malignant disease in the chest, abdomen, or
pelvis
otherwise.
3. Aerosolized secretions are noted in the distal esophagus and
may be
representative of reflux in the proper clinical setting.
.
Discharge Labs:
___ 12:00AM BLOOD WBC-4.2 RBC-3.23* Hgb-9.6* Hct-29.8*
MCV-92 MCH-29.7 MCHC-32.2 RDW-14.9 Plt ___
___ 12:00AM BLOOD Neuts-59 Bands-2 ___ Monos-4 Eos-1
Baso-0 ___ Metas-3* Myelos-1* NRBC-1*
___ 12:00AM BLOOD Plt Smr-NORMAL Plt ___
___ 12:00AM BLOOD Glucose-120* UreaN-13 Creat-0.6 Na-137
K-4.1 Cl-95* HCO3-30 AnGap-16
___ 12:00AM BLOOD ALT-30 AST-16 LD(LDH)-241 AlkPhos-189*
TotBili-0.3
___ 12:00AM BLOOD Calcium-8.9 Phos-4.7* Mg-2.2
___ 04:32AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
Brief Hospital Course:
___ yo F with newly diagnosed DLBCL in the neck, admitted to the
FICU for airway compromise.
#Diffuse large B cell lymphoma: Patient was transferred to the
FICU for airway protection after a large left sided neck mass
was noted on exam and on CT of the neck. She was intubated on
___ with ENT and anesthesia present for airway protection
given the extrinsic compression from this mass as well as
concern for laryngeal edema. The biopsy of the neck mass showed
diffuse large B cell lymphoma and she was started on R-CHOP
therapy by the hematology/oncology team. Her neck mass was
markedly reduced in size with this intervention. She was noted
to have a cuff leak and was successfully extubated on ___,
again with ENT and anesthesia present. She was called out to
the ___ team for ongoing managent of her lymphoma.
.
She was subsequently transfrred to the FICU a second time for
worsening hoarseness and dysphagia after extubation. She had a
CT neck on ___ which showed no airway compromise and
markedly improved edema compared to the prior study. She was
also seen by ENT who also say no evidence of airway compromise
during laryngoscopy. Her symptoms remained stable and she was
transferred back to the floor.
.
She remained stable on the floor and received a second cycle of
CHOP. Her pain improved as the mass continued to recede. She was
discharged home with close Heme/Onc follow up.
.
# TMJ: She complained of significant left ear pain. ENT was
consulted and felt her pain was most consistent with TMJ
dysfunction. She was put on jaw rest with a pureed diet and
prescription Oxycodone was provided at the time of discharge.
.
#Pneumonia: There was an equivocal LLL infiltrate on her CXR and
the decision was made to treat her for pneumonia given that she
was to be started on chemotherapy and would be immunosuppressed.
She was treated with vanc and Zosyn for an 8 day course.
Sputum culture was negative during this admission.
.
# UTI: Pt complained of dysuria and UA revealed UTI. Cultures
grew pan sensitive E Coli and she was given a 5d course of
Ciprofloxacin.
.
# Hypothyroidism
Continued on levothyroxine.
.
# Crohns disease
Continued asacol (held while intubated)
.
# Seizure disorder
Continued trileptal
.
# Depression/anxiety
Continued seroqual and clonazepam.
.
# HTN
Continued clonidine
.
TRANSITIONAL ISSUES: Patient has endorsed decreased hearing in
her left ear, likely due to compression from the mass. She will
need an audiology assessment as an outpatient. She was afebrile
and HD stable at the time of discharge. She will follow up with
Heme/Onc within 5d of discharge.
Medications on Admission:
seroquel 300mg, 2 tabs at bedtime
seroquel 50mg TID
trileptal 600mg BID
clonidine 0.1mg QID
klonapin 1mg QID
prazosin 1mg QHS
asacol 400mg TID
soma 350mg QID
synthroid ___ daily
levsin 0.125mg, 2 tabs prn
percocet 2 tabs ___ prn
Discharge Medications:
1. quetiapine 300 mg Tablet Sig: Two (2) Tablet PO at bedtime
for 30 days.
Disp:*60 Tablet(s)* Refills:*0*
2. quetiapine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) for 30 days.
Disp:*90 Tablet(s)* Refills:*0*
3. oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO twice a
day for 30 days.
Disp:*60 Tablet(s)* Refills:*0*
4. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO three times a
day for 30 days.
Disp:*90 Tablet(s)* Refills:*0*
5. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day) for 30 days.
Disp:*120 Tablet(s)* Refills:*0*
6. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO TID (3 times a day) for 30
days.
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day for 30 days.
Disp:*30 Tablet(s)* Refills:*0*
8. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) PO DAILY
(Daily).
Disp:*300 ml* Refills:*0*
9. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*0*
10. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*0*
11. Ensure Liquid Sig: Four (4) bottles PO once a day.
Disp:*120 bottles* Refills:*0*
12. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3
days.
Disp:*6 Tablet(s)* Refills:*0*
13. oxycodone 5 mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for pain for 10 days.
Disp:*80 Tablet(s)* Refills:*0*
14. Senna Concentrate 8.6 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day) as needed for constipation for 30 days.
Disp:*60 Tablet(s)* Refills:*0*
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
16. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 30 days.
Disp:*60 Tablet(s)* Refills:*0*
17. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for N/V for 30 days.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Diffuse Large B Cell Lymphoma
Urinary tract infection
TMJ
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to the hospital with swelling in your neck,
which was biopsied and found to be lymphoma. You went to the ICU
to be intubated, and were given chemotherapy to reduce the size
of your cancer.
You also had a Urinary tract infection for which we started you
on Ciprofloxacin - you will need to complete a 5 day course of
this.
Please note the following changes to your medications:
STARTED Ciprofloxacin for 5 days
STARTED Oxycodone ___ by mouth every 6 hours as needed for
pain
Followup Instructions:
___
|
10447634-DS-22 | 10,447,634 | 21,771,547 | DS | 22 | 2164-09-03 00:00:00 | 2164-09-04 16:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / Bactrim / aspirin / Motrin / Toradol / Vistaril /
NSAIDS
Attending: ___
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old woman with new diagnosis of DLBCL,
recently initiated on R-CHOP (day1, cycle2 ___, Crohn's
Disease, who presents with fever at home x 1 day, measured to
101.5F as well as general malaise, non-productive cough,
shortness of breath and dyspnea on exertion. She also reports
nausea and vomiting x2 episodes, nonbloody, nonbilious. No
diarrhea or bloody stools. She was feeling well on ___ upon
discharge from prior hospitalization but reports persistent
dysuria, though somewhat improved from a few days ago before
starting ciprofloxacin.
.
Patient was diagnosed with DLBCL one month ago after biopsy of
large left sided neck mass and started on R-CHOP during last
hospitalization ___. She was intubated for airway
protection on ___ because of extrinsic compression and
concern for potential laryngeal edema. She was started on R-CHOP
while intubated which successfully reduced the size of the
tumor. She received a second cycle of R-CHOP prior to discharge
on ___. Of note, she was treated with an 8 day course of
Vancomycin and Zosyn during that hospitalization for ?LLL
pneumonia; it was felt pneumonia was unlikely, but because she
was to start chemotherapy, she was treated to prevent worsening
infection in setting of immunosuppression. She was also
discharged on ciprofloxacin for three more days to complete UTI
treatment course.
.
In the ED, initial vitals are as follows: 98.8 117 137/61 18
100%RA. Exam notable for mild RLQ tenderness and guaic negative
brown stool. She also has LLE edema, which she states is chronic
since injuring her LLE in past and having surgery. Labs notable
for WBC 3.9k with 51% PMNs, 3% bands, Hct 29.2, AST/ALT 46/54,
Alk Phos 192. The pt underwent CT abdomen/pelvis which showed no
acute intra-abdominal process but prominent appearing CBD, as
well as RLL consolidation and trace pleural effusion. The pt
received a dose of vancomycin and levofloxacin in the ED to
treat for pneumonia. She also received zofran as well as
morphine and dilaudid. Vitals prior to transfer 100.8, 101, 18,
117/65, 98% RA, ___ pain.
.
Currently, she feels unwell. She reports shortness of breath,
non-productive cough and fever x 1 day, as above. She reports
new RLQ pain since coming to the ED last night, but symptoms
were not present earlier in the day.
.
ROS: She does report shortness of breath, as above, with
difficulty finishing her sentences and dyspnea on exertion. She
does report sore throat that burns. She feels like she will have
difficulty swallowing. She feels that her neck mass is larger
than it was upon discharge a couple of days ago. She also
reports left jaw pain consistent with her TMJ; she was
discharged with oxycodone which was not helping at all for her
pain. Endorses Right flank pain. Endorses persistent dysuria,
though improved from a few days ago prior to starting
ciprofloxacin.
Endorses significant night sweats after starting chemotherapy.
She does have some mild constipation.
Denies headache, vision changes, rhinorrhea, congestion, chest
pain, nausea, vomiting, diarrhea, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
Diffuse Large B Cell Lymphoma
- Neck mass biopsied ___
- Hospitalized ___ to start R-CHOP, which markedly reduced
the size of her neck mass; needed to be intubated initially for
airway protection
thyroid mass
HTN
Hypothyroid
Crohn's Dz
Two herniated disc, unoperable
Anxiety
Seizures- last ___ ago
Endometriosis
L IM Nail (___)
Laparascopy for endometriosis
C-sections x 5
Social History:
___
Family History:
Uncle with lung cancer
Aunt with esophageal/throat ca
Sister with hyperthyroidism
Cousin with lupus
Physical Exam:
Admission PE:
Vitals - 99.0 114/63 103 20 98% RA
GENERAL: alert, pleasant, young overweight woman seated upright,
appearing tired an uncomfortable, wearing head scarf
HEENT: mmm, (pt reports multiple oral and nasal ulcers,
difficult to visualize with small flashlight), mild conjunctival
pallor, no scleral icterus
CARDIAC: reg rhythm, normal rate
NECK: left neck scar healing ; left sided neck mass
LUNG: diffuse harsh inspiratory and expiratory wheezing
ABDOMEN: mild to moderate distension, hyperactive bowel sounds,
+RLQ tenderness to palpation, echymosis at sq heparin injections
EXT: palpable DP pulses bilaterally ; LLL tender to palpation
with 1+ edema (chronic tenderness and edema, per patient, since
surgery)
PSYCH: Listens and responds to questions appropriately, pleasant
.
Discahrge PE:
GENERAL: NAD
HEENT: MMM, mild conjunctival pallor, no scleral icterus
CARDIAC: RRR, normal s1/s2, no s3/s4, no m/r/g
NECK: left neck scar healing; left sided neck mass
LUNG: CTAB, no increased WOB, no w/r/r
ABDOMEN: NABS, mild +RLQ tenderness to palpation, echymosis at
sq heparin injections
EXT: palpable DP pulses bilaterally ; LLL tender to palpation
with 1+ edema (chronic tenderness and edema, per patient, since
surgery)
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admission Labs:
___ 08:56PM BLOOD WBC-3.9* RBC-3.24* Hgb-9.1* Hct-29.2*
MCV-90 MCH-28.2 MCHC-31.2 RDW-16.4* Plt ___
___ 08:56PM BLOOD Neuts-51 Bands-3 ___ Monos-8 Eos-0
Baso-0 ___ Metas-11* Myelos-2* NRBC-1* Other-1*
___ 08:56PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Stipple-OCCASIONAL
___ 08:56PM BLOOD Plt Smr-HIGH Plt ___
___ 08:56PM BLOOD Glucose-135* UreaN-8 Creat-0.6 Na-139
K-4.5 Cl-98 HCO3-26 AnGap-20
___ 08:56PM BLOOD ALT-54* AST-46* AlkPhos-192* TotBili-0.3
___ 08:56PM BLOOD Albumin-4.2
___ 08:56PM BLOOD Lipase-11
___ 09:02PM BLOOD Lactate-2.2*
Discharge Labs:
___ 05:40AM BLOOD WBC-6.6 RBC-3.05* Hgb-8.6* Hct-27.4*
MCV-90 MCH-28.4 MCHC-31.5 RDW-16.8* Plt ___
___ 05:40AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Schisto-OCCASIONAL Tear
Dr-1+
___ 05:40AM BLOOD Plt Smr-VERY HIGH Plt ___
___ 05:40AM BLOOD ___ PTT-42.6* ___
___ 05:40AM BLOOD Glucose-110* UreaN-5* Creat-0.5 Na-139
K-4.2 Cl-103 HCO3-26 AnGap-14
___ 05:40AM BLOOD ALT-44* AST-40 LD(LDH)-258* AlkPhos-148*
TotBili-0.3
___ 05:40AM BLOOD Calcium-8.6 Phos-5.0* Mg-2.0
___ 09:20PM BLOOD Vanco-4.4*
CXR (___): No acute cardiopulmonary process
.
CT A/P (___):
1. No acute process, specifically no appendicitis or abscess.
2. Marked fecal loading.
3. Continued mild prominence of common bile duct. Correlate
with liver
function tests.
4. Right lower lobe aspiration and trace effusion.
5. Borderline splenomegaly.
.
___ (___):
Near-occlusive thrombus in the right peroneal veins
.
CXR (___):
Frontal and lateral views of the chest demonstrate an infiltrate
best seen on the lateral film. On the frontal film, there are
areas of increased opacity in both lower lobes. By the CT, the
infiltrate was in the right lower lobe; however, there may be a
left lower lobe component as well. The upper lungs are clear.
Brief Hospital Course:
Primary Reason for Admission: ___ with hx of new diagnosis of
diffuse large B cell lymphoma, presenting with fever to ___ and
worsening cough after intial improvement, found to have RLL
consolidation on abdominal CT, being treated as new HAP.
.
Active Problems:
.
# Fever: Not neurtopenic on admission. CT chest showed RLL
consolidation concerning for HCAP vs aspiration PNA. CT abdomen
did not show signs of cholecystitis or pyelonephritis. She does
have a history of Crohns disease as well, but CT did not show
any evidence of Chrons flare, so this is unlikely to be
contributing. She was also found to have DVT in RLE. Source of
fever more likely to be infectious in setting of 12% bandemia,
but DVT could be contributing as well. She was initially treated
for HCAP with Vanc/Cefepime/Flagyl/Levofloxacin, and was
subsequently narrowed to Levofloxacin/Flagyl prior to discharge.
She was also started on Lovenox for her DVT. She remained
afebrile for the remaineder of her course, all cultures
negative.
.
# RLE DVT: Shortly after admission, pt complained of RLE pain
behind the right knee. ___ showed peroneal vein DVT. She was
started on BID Lovenox and was sent home with Lovenox and
teaching. She was not tachycardic or hypoxic during her course,
suspicion was low for PE, no CTPA was obtained.
.
# Diffuse large B cell lymphoma: Patient was diagnosed with
DLBCL one month ago after biopsy of large left sided neck mass
and started on R-CHOP s/p 2 cycles during last hospitalization
___ with successful decrease in the size of her neck
mass. Day1 of cycle 2 is ___. Her respirations were
unlaboured throughout her course and there was no stridor during
this admission. We continued prophylactic fluconazole,
acyclovir, atovaquone. She will follow up with Heme/Onc (see d/c
paperwork) for ongoing management.
.
# Dysphagia/Sore Throat: Likely multifactorial, secondary to
compressive mass and recent intubation. Cephacol and dilaudid
were used for pain control. Also has new TMJ diagnoised by ENT
on recent admission.
.
Chronic Problems:
.
# Transaminitis: Mild chronic transaminitis, unclear etiology.
Could be medication or chemotherapy induced vs NASH. She did
have mild transaminitis after her first round of R-CHOP as well.
Constellation of LFTs not consistent with choledodolithiasis, no
e/o infection on CT A/P.
.
# Crohns disease
CT abdomen did not reveal any flare of Crohns, though she had
mild tenderness to palpation on exam. We continued
Asacol/Mesalamine. CT did show fecal loading, and her bowel
regemin was increased with some improvement in her symptoms.
.
# Hypertension: We continued continue home clonidine
.
# TMJ: Patient reported some jaw pain on presentation to the ED.
She reportedly complained of similar pain as well as significant
left ear pain during last hospitalization, was diagnosed with
TMJ by ENT. She was put on jaw rest with a pureed diet and
prescribed oxycodone on discharge as needed. Pain contol with PO
Dilaudid.
.
# Hypothyroidism: We continued her home levothyroxine
.
# Seizure disorder: We continued Trileptal/Oxcarbazepine
.
# Depression,anxiety: We continued Seroquel and Clonazepam.
.
Transitional Issues: She will f/u with Dr. ___
___ on Admission:
1. quetiapine 600mg QHS
2. quetiapine 50 mg Tablet PO TID
3. oxcarbazepine 600 mg Tablet PO BID
4. clonidine 0.1 mg Tablet PO TID
5. clonazepam 1 mg Tablet PO QID
6. mesalamine 400 mg Tablet, Delayed Release (E.C.) PO TID
7. levothyroxine 150 mcg Tablet PO daily
8. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) PO DAILY
(Daily).
9. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H
10. fluconazole 200 mg Tablet PO Q24H
11. Ensure Liquid Sig: Four (4) bottles PO once a day.
12. Cipro 500 mg Tablet BID x 3 days (discharged ___
13. oxycodone 5 mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for pain for 10 days.
14. Senna Concentrate 8.6 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day) as needed for constipation
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
16. famotidine 20 mg Tablet PO Q12H
17. ondansetron HCl 4 mg Tablet PO Q8H (every 8 hours) as needed
for N/V
Discharge Medications:
1. quetiapine 25 mg Tablet Sig: ___ (24) Tablet PO QHS
(once a day (at bedtime)).
2. quetiapine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. oxcarbazepine 300 mg/5 mL Suspension Sig: Two (2) PO BID (2
times a day).
4. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
6. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
7. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY
(Daily).
9. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
10. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
11. Ensure Liquid Sig: One (1) bottle PO four times a day.
Disp:*120 bottles* Refills:*0*
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
15. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*60 * Refills:*0*
16. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
17. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
18. hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for severe pain: do not take if drowsy or
driving.
Disp:*30 Tablet(s)* Refills:*0*
19. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for nausea.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Aspiration Pneumonia
Deep Vein Thrombosis
Secondary Diagnosis:
Diffuse Large B Cell Lymphoma
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 the ___
___. You were admitted for fever. We found you have a
pneumonia, which may have been related to the difficulty you
have with swallowing foods. For this, we started you on
antibiotics. We also found you have a blood clot in your right
leg. For this, we started you on a medication called Lovenox.
You will need to continue taking this twice a day until
instructed to stop by your doctor. You are now safe to return
home.
You were seen by our physical therapists, who recommended
physical therapy at home; however you declined this.
During this admission, we made the following changes to your
medications:
STARTED:
-Enoxaparin
-Levofloxacin
-Metronidazole
-Dilaudid
STOPPED:
-Oxycodone
-Ciprofloxacin
Followup Instructions:
___
|
10447634-DS-24 | 10,447,634 | 21,981,012 | DS | 24 | 2164-10-29 00:00:00 | 2164-10-31 15:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / Bactrim / aspirin / Motrin / Toradol / Vistaril /
NSAIDS
Attending: ___.
Chief Complaint:
Leg Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year-old Female with PMH significant for high-grade
diffuse large B-cell lymphoma of thyroid and neck diagnosed in
___ (stage Ib) s/p extensive hospitalization with intubation
and completion of 3-cycles of R-CHOP who now presents with left
leg swelling and pain.
.
She notes the pain and left leg swelling began yesterday morning
and has worsened to the point of her having difficulty with
ambulation. She notes that it feels as though her left leg
"weigth 1000 pounds". She presented to ___
on ___ and radiographs were reassuring; similarly a LLE
ultrasound was reassuring, but it was only performed to above
the knee. She denies fevers or chills. She has no overlying
erythema or induration. She dnies chest pain or trouble
breathing. She has been taking her Dilaudid for pain control,
which was prescribed by her PCP, and this provides some relief.
She now notes some tingling in the distal left extremity, but
has the ability to mobilize her digits and has intact sensation;
she also notes a burning sensation in the upper thigh.
.
Of note, she remains on Coumadin bridge with Lovenox for prior
right upper and lower extremity deep venous thrombosis.
.
Importantly, she also has a history of left lower extremity
orthopedic intervention with hardware placement after an ORIF
for tibial fracture. She also saw her NP from Oncology on
___ with complaints of LLE pain at that time and was
encouraged to follow-up with Orthopedic surgery, elevated her
extremities and she was continued on Dilaudid.
.
In the ___ ED, initial VS 98.0 101 139/82 18 100% RA.
Laboratory data notable for WBC 7.9, HCT 34.2% and INR of 3.0.
LFTs and Troponin reassuring. Lactate 0.8. A CXR was reassuring
and left lower extremity radiographs were negative for fracture
or malalignment. A CTA of her chest, abdomen and pelvis was
without pulmonary embolism or pelvic venous clot burden. She
received Zofran 4 mg IV x 2 and Dilaudid 1 mg x 3 in the ED
prior to transfer.
Past Medical History:
- HTN
- Hypothyroidism
- Crohn's Diseae
- Hernia discs x 2
- Anxiety
- Seizure disorder(last in ___
- Endometriosis
- Left IM Nail (___)
- Laparascopy for endometriosis
- C-sections x 5
- diffuse large B-cell lymphoma stage IB
- TMJ
Social History:
___
Family History:
-Uncle with lung cancer
-Aunt with esophageal/throat ca
-Sister with hyperthyroidism
-Cousin with lupus
Physical Exam:
PHYSICAL EXAM on Admission:
VITALS: 98.0 77 ___ 100% RA
___: Appears in no acute distress. Alert and interactive,
but fatigued and anxious with emotional lability.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. Alopecia.
NECK: supple without lymphadenopathy. JVD not elevated. Thyroid
barely palpable.
___: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles. Stable inspiratory
effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs. Some areas of
ecchymoses at site of anticoagulation injections.
EXTR: no cyanosis, clubbing; 1+ peripheral edema to upper thigh
is bilateral (L > R) and similar to prior exams, 2+ peripheral
pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs
2+ throughout, strength ___ bilaterally, sensation grossly
intact. Gait deferred. Exam limited by pain only.
.
Physical Exam on Discharge:
O: AF 98.0 110-120/60-70s HR 70-90s sat 94-96% on RA
Gen: NAD, alert and oriented
HEENT: moist mucosa
NECK: no masses, no lymphadenopathy
CV: normal rate, regular rhythm, no murmur
Pulm: few crackles in bases, no wheezes
Abd: ND, some tenderness of subcutaneous tissue where lovenox
injected, soft
Ext: Left leg is mildly larger than right, no pitting edema, no
erythema, diffuse tenderness to palpation, good distal pulses.
Neuro: decreased sensation in left toes to light touch, unable
to lift left leg off bed, able to move at ankle joint; toes
downgoing
Skin: no skin lesions noted; strength in right leg is ___ with
intact sensation.
Pertinent Results:
___ 04:00PM WBC-5.4 RBC-3.44* HGB-9.7* HCT-30.6* MCV-89
MCH-28.2 MCHC-31.8 RDW-18.3*
___ 04:00PM ___
___ 09:45AM GLUCOSE-105* UREA N-10 CREAT-0.7 SODIUM-138
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
___ 08:10PM ALT(SGPT)-36 AST(SGOT)-72* ALK PHOS-127* TOT
BILI-0.4
___ 08:10PM LIPASE-19
___ 08:10PM cTropnT-<0.01 proBNP-17
MRI L spine:
IMPRESSION:
1. No evidence of intraspinal hematoma, enhancing mass, or
high-grade thecal
sac compression.
2. Small disc protrusion at L5-S1 level without compression of
descending or
exiting nerve roots.
3. No evidence of paraspinal soft tissue abnormalities
including no evidence
of paraspinal enhancement or hematoma.
CT Torso:
IMPRESSION:
1. No acute pulmonary embolism.
2. No lymphadenopathy or pelvic venous clot.
3. Moderate amount of stool within the colon.
___ Ultrasound:
IMPRESSION: No evidence of deep vein thrombosis in the left
lower extremity
veins.
Brief Hospital Course:
Ms. ___ is a ___ with high-grade diffuse large B-cell
lymphoma of thyroid and neck diagnosed in ___ (stage Ib) s/p
extensive hospitalization with intubation and completion of
3-cycles of R-CHOP, recent hx of DVT x2 in past month on
coumadin & lovenox who now presents with left leg swelling and
pain for 2 days in the setting of negative doppler x2 of left
lower extremity and CT con abd/pelv, and MRI L-spine. Patient
was able to ambulate with assistance on discharge.
PLAN:
# LEFT LOWER EXTREMITY PAIN, SWELLING - No cause was determined
despite left leg Xray, CT abd/pelv w/ contrast, doppler of left
lower extremity x2, and MRI of L-spine. We effectively ruled out
any concerning causes of leg pain/weakness including clot,
neoplasm and venous obstruction. This seemed like an acute
process per history. Patient did have some lower extremity pain
on ___ per Oncology notes. Most concerning would be
metastatic disease involving spinal cord/nerve roots.
Differential diagnosis includes bleeding into her thigh with INR
3.0 since H&H is trending down to 9.4 on ___, however plain
film on ___ did not show an obvious hematoma. Patient has
long hx of herniated discs in "lower back." Myositis is possible
but less likely. CT abd/pelv w/cont reviewed with radiology on
___ and they did not believe there is a need for MR venous
of lower extremities based on quality of vessel view with CT
abd/pelv w/cont. Mild elevated CK of 269 on ___ speaks
against myositis as cause. She does have a history of hardware
in left lower leg for internal fixation for tibial fx, however
is AF without leukocytosis or sx infection on exam.
- continued home Dilaudid 4 mg PO Q4H PRN pain
- ___ consulted, patient denied home services
- followed H&H to watch for signs of bleeding into thigh, H&H
was stable
- ordered MRI L-spine w/&w/o STAT to eval for nerve root
compression which showed no abnormalities
- Ortho consulted and saw patient; believed there is no acute
hardware issue and she will be scheduled up for outpatient
follow up.
# HISTORY OF RIGHT UPPER, LOWER EXTREMITY DVT - Discovered on
previous admission, with subsequent improvement in edema. Has
been maintained on Lovenox ___ mg SC Q12 hours and Coumadin
bridge - all occurred in the setting of known malignancy.
- d/c lovenox on ___ as INR therapeutic x2
- continued Coumadin 5mg PO daily, but home dose found to be
increased to 10mg po daily per PCP
-___ was given 5mg daily while in the hospital, but per Dr.
___ had been recently increased to 10mg daily prior to
hospitalization. We discussed starting discharge dose of 7.5mg
daily with INR recheck on ___ at ___ near her
house for which she has requisitions for per pt and PCP.
# DIFFUSE LARGE B-CELL LYMPHOMA - History of high-grade diffuse
large B-cell lymphoma of thyroid and neck diagnosed in ___
(stage Ib) s/p extensive hospitalization with intubation and
completion of 3-cycles of R-CHOP. Clinically without evidence of
residual disease. CT imaging in the ED reassuring. Recently saw
Radiation Oncology and deemed a reasonable candidate for
adjuvant involved field radiation to complete definitive
combined modality treatment.
- outpatient radiation treatments to be scheduled; per patient
radiation will begin on ___
- ___ fellow was aware of patient, who contacted outpt
oncologist
# HYPERTENSION - BP appears stable. Continued Clonidine 0.1 mg
PO QID.
# HYPOTHYROIDISM - Last TSH 42 and levothyroxine had been
increased.
-Continued home Levothyroxine 150 mcg PO daily.
# SEIZURE DISORDER - No clinical evidence of seizure activity.
Continued Oxcarbazepine.
# DEPRESSION, ANXIETY - Continued Seroquel and Clonazepam.
# FEN/GI - Regular diet, IVF and electrolyte repletion as needed
# COMMUNICATION - ___ (mother)- ___
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
2. carisoprodol *NF* 350 mg Oral QID
3. Clonazepam 1 mg PO QID:PRN anxiety
4. CloniDINE 0.1 mg PO QID
5. Enoxaparin Sodium 120 mg SC Q12H
6. Famotidine 20 mg PO BID
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain
Monitor for sedation or RR < 8
9. Hyoscyamine 0.125 mg PO TID:PRN abdominal cramps
10. Levothyroxine Sodium 150 mcg PO DAILY
11. Mesalamine 400 mg PO TID
12. Ondansetron 4 mg PO Q8H:PRN nausea
13. Oxcarbazepine 300 mg PO BID
liquid suspension
14. Prazosin 1 mg PO HS
15. Quetiapine Fumarate 50 mg PO TID
16. Quetiapine Fumarate 600 mg PO HS
17. TraMADOL (Ultram) 100 mg PO Q6H:PRN pain
18. Docusate Sodium 100 mg PO BID
19. Senna 1 TAB PO BID
20. Warfarin 5 mg PO DAILY16
Discharge Medications:
1. Enoxaparin Sodium 120 mg SC Q12H
RX *enoxaparin 120 mg/0.8 mL every 12 hours for total of twice
per day Disp #*14 Syringe Refills:*0
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
3. carisoprodol *NF* 350 mg Oral QID
4. Clonazepam 1 mg PO QID:PRN anxiety
5. CloniDINE 0.1 mg PO QID
6. Docusate Sodium 100 mg PO BID
7. Famotidine 20 mg PO BID
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain
Monitor for sedation or RR < 8
10. Hyoscyamine 0.125 mg PO TID:PRN abdominal cramps
11. Levothyroxine Sodium 175 mcg PO DAILY
12. Mesalamine 400 mg PO TID
13. Ondansetron 4 mg PO Q8H:PRN nausea
14. Oxcarbazepine 300 mg PO BID
liquid suspension
15. Prazosin 1 mg PO HS
16. Quetiapine Fumarate 50 mg PO TID
17. Quetiapine Fumarate 600 mg PO HS
18. Senna 1 TAB PO BID
19. TraMADOL (Ultram) 100 mg PO Q6H:PRN pain
20. Warfarin 7.5 mg PO DAILY16
RX *Coumadin 7.5 mg 1 tablet(s) by mouth once per day Disp #*7
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Leg Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory with minimal assistance.
Discharge Instructions:
Ms. ___, you were admitted to ___
___ on ___ for left leg pain and weakness. While you were
here, we did several imaging studies that came back normal.
These include: doppler ultrasound of left leg, Xray of left leg,
CT scan of abdomen/pelvis. Please follow up with your primary
care provider for management of your coumadin and leg pain. As
discussed, please go to ___ on ___
___ to have blood drawn for INR using requisition forms given
to you by your primary care provider. Please also see your
hematologist and orthopedist as listed below. If pain/swelling
continues or fails to resolve, please discuss possible repeat
ultrasound of leg. You informed us that you were not currently
interested in any home services such as physical therapy or home
nursing.
Followup Instructions:
___
|
10447698-DS-13 | 10,447,698 | 29,572,014 | DS | 13 | 2181-07-09 00:00:00 | 2181-07-09 11:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
latex
Attending: ___.
Chief Complaint:
right distal radius fracture
Major Surgical or Invasive Procedure:
Open reduction, internal fixation, right intra-articular distal
radius fracture
History of Present Illness:
The patient is a ___ yo RHD F who presents with right wrsit pain
after mechanical trip and fall down approximately 8 stairs. She
fell hitting her outstrectched right hand as well as her chest.
She denies any numbness or paresthesias in the right hand.
Past Medical History:
HTD
HLD
LBP
Paroxysmal SVT
Papillary thyroid cancer s/p total thyroidectomy in ___
Bilateral oophorectomy
Social History:
___
Family History:
non-contributory
Physical Exam:
At presentation to the ED:
T: 97.5 HR: 65 BP: 159/65 RR: 22 SAT: 96%
NAD, AOx3
R wrist deformity with volar swelling and ecchymosis with small
area of superficial abrasion
Tenderness to palpation of wrist
Arms and forearms are soft
No tenderness and non-painful ROM at elbow
R M U SITLT
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
Contralateral extremity examined with good range of motion,
SILT,
motors intact and no pain or edema
Pertinent Results:
___ 07:00AM GLUCOSE-94 UREA N-16 CREAT-0.6 SODIUM-143
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-31 ANION GAP-14
___ 07:00AM CALCIUM-9.3 PHOSPHATE-3.5 MAGNESIUM-2.1
___ 07:00AM WBC-8.7# RBC-4.34 HGB-13.1 HCT-38.9 MCV-90
MCH-30.3 MCHC-33.8 RDW-13.0
___ 07:00AM PLT COUNT-222
___ 07:00AM ___ PTT-33.6 ___
Brief Hospital Course:
The patient was admitted to the Orthopaedic Trauma Service for
repair of a right distal radius fracture. The patient was taken
to the OR and underwent an uncomplicated ORIF right distal
radius fracture. The patient tolerated the procedure without
complications and was transferred to the PACU in stable
condition. Please see operative report for details. Post
operatively pain was controlled with a PCA with a transition to
PO pain meds once tolerating POs. The patient tolerated diet
advancement without difficulty.
Weight bearing status: non-weight bearing right upper extremity.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. All questions were answered prior to discharge
and the patient expressed readiness for discharge.
Medications on Admission:
ATENOLOL - 25 mg Tablet - 1 (One) Tablet(s) by mouth once a day
BACLOFEN - (Prescribed by Other Provider) - 10 mg Tablet -
Tablet(s) by mouth
HYDROCHLOROTHIAZIDE - 12.5 mg Tablet - one Tablet(s) by mouth
once a day
LEVOTHYROXINE [LEVOXYL] - 125 mcg Tablet - 1 Tablet(s) by mouth
once a day, ___ tab sun - No Substitution
ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 20 mg
Tablet - 1 Tablet(s) by mouth once a day
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Baclofen 10 mg PO TID
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Levothyroxine Sodium 125 mcg PO DAILY
5. Rosuvastatin Calcium 20 mg PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
right distal radius fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. No baths or swimming for at least 4 weeks.
Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment. No dressing is needed
if wound continued to be non-draining.
******WEIGHT-BEARING*******
Non-weight bearing right upper extremity
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
Followup Instructions:
___
|
10447734-DS-3 | 10,447,734 | 25,043,605 | DS | 3 | 2118-01-24 00:00:00 | 2118-01-25 15:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Left lower leg infection and fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
In brief, this patient is a ___ y/o IDDM, HTN, HLD, obesity who
initially presented from ___ with left leg infection and
sepsis. Patient initially had skin tear on left lower extremity
for about 3 weeks ago of unknown cause. On ___, patient
awoke with red swelling and noted streaking from above knee into
left medial groin + fevers, nausea/dry heaves. Went to an
Outside Hospital ED, where patient was noted to be febrile,
hypotensive with WBC of 16.4, Lactate of 2.3 and given 4L NS and
started on levophed drip and subsequently transferred to ___
MICU with concern for sepsis. Patient was initially on pressors
from outside hospital given hypotension (unclear what lowest BP
was) but has been normotensive here. Of note, received 4L NS at
outside hospital, and some additional fluid here, and developed
hypoxia and O2 requirement. CXR showing congestion with mild
interstitial edema. He has been on IV zosyn and vanc. Patient
felt overall improved on arrival to the floor, still with LLE
pain, ___, mostly at hip. He was transitioned to IV unasyn and
vanc, and then to oral Augmentin as his clinical status
improved.
Past Medical History:
Hypertension
Hyperlipidemia
Type 2 Diabetes
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 99.0 81 111/78 93% 5L
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: scant crackles at bases, no wheezes, rales, ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, ___, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. LLE with ~2 cm scabbed lesion around shin, and streaking
erythema surrounding extending towards hip. No significant
warmth or tenderness. Full ROM on LLE. RLE with some venous
stasis changes.
Neuro: ___ intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
========================
Vitals: T ___ BP ___ HR ___ RR 18 O2 sat ___
RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Lungs: CTAB, no wheezing
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, ___, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. LLE with ~2 cm scabbed lesion around shin, and streaking
erythema now confirmed to the area around the scab. No
tenderness to palpation. No significant warmth or tenderness.
Full ROM on LLE. RLE with some venous stasis changes.
Skin: erythematous patch on upper back, no tenderness or warmth
Pertinent Results:
ADMISSION LABS:
===============
___ 10:38PM ___
___ 10:28PM ___ UREA ___
___ TOTAL ___ ANION ___
___ 10:28PM ___ this
___ 10:28PM ___
___
___ 10:28PM ___
___ IM ___
___
___ 10:28PM PLT ___
DISCHARGE LABS:
===============
___ 07:24AM BLOOD ___
___ Plt ___
___ 07:24AM BLOOD ___
___ Im ___
___
___ 07:24AM BLOOD Plt ___
___ 07:24AM BLOOD ___
___
___ 07:24AM BLOOD ___
IMAGING:
========
___: CXR
FINDINGS:
AP portable upright view of the chest. Lung volumes are low.
Heart size
appears normal. Hilar congestion is noted with mild
interstitial pulmonary edema. No gross evidence for
superimposed pneumonia. No large effusion or pneumothorax.
Imaged osseous structures are intact.
IMPRESSION:
Congestion with mild interstitial edema.
___: CT PELVIS
Official read pending
Preliminary wet read with no concerning findings
___: ECHO
IMPRESSION: Preserved biventricular systolic function. No
clinically significant valvular disease. Indeterminate pulmonary
artery systolic pressure.
Brief Hospital Course:
___ y/o male with insulin dependent diabetes, hypertension,
hyperlipidemia, and obesity who presented with left leg
infection and hypotension concerning for sepsis, status post
fluid resuscitation and pressors, now normotensive with erythema
in LLE with ongoing antibiotic treatment.
ACTIVE ISSUES:
# CELLULITIS - Patient had a left lower leg scab for about 3
weeks of unknown etiology, and on ___, he woke up with
left lower extremity pain and infection that appears to have
began around the scab, but moved upwards toward hip. He
presented to OSH with fevers and hypotension, concerning for
sepsis. No crepitus, tenderness or extreme pain to suggest
necrotizing fasciitis, and patient improved with vanc/zosyn.
Given hip pain, CT pelvis ordered, and baseline CRP obtained.
Per OSH report, DVT work up negative. Blood cultures to date
have not grown anything. Patient received Tylenol as needed for
pain. As clinical status improved, we stopped vancomycin
(___), switched from zosyn (___) to unasyn
(___) and eventually to Augmentin PO with plan to continue
treatment for the next 7 days after discharge (___). On
discharge, the erythema and pain had improved significantly, and
he was able to walk normally.
# HYPOXIA- patient had new O2 requirement with some mild
pulmonary edema in setting of fluid resuscitation. No history of
heart disease. He received Lasix 10 mg IV daily for diuresis for
two days. His work of breathing significantly improved and he
was weaned off oxygen to room air. A TTE showed no evidence of
structural heart disease.
# IDDM - continue home insulin management
CHRONIC ISSUES:
# HYPERTENSION - We held amlodipine and lisinopril secondary to
sepsis on arrival, given low blood pressures and need for
pressors and fluid resuscitation. Currently blood pressures are
___, and we will plan to hold the medications with
plan to restart outpatient at recommendations of PCP.
# HYPERLIPEDEMIA - We continued simvastatin
TRANSITIONAL ISSUES:
- Follow up outpatient appointment with PCP
- ___ antibiotics (Augmentin) 875 mg Q12 (last day ___ for
a total of 10 days of antibiotics.
- Consider restarting Lisinopril and Amlodipine as needed per
PCP
___ on ___:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. GlipiZIDE 5 mg PO QHS
3. Januvia (SITagliptin) 100 mg oral DAILY
4. Lisinopril 40 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Simvastatin 20 mg PO QPM
7. Glargine 70 Units Bedtime
8. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL intramuscular PRN
Discharge Medications:
1. ___ Acid ___ mg PO Q12H
RX ___ clavulanate 875 ___ mg 1 tablet(s) by
mouth twice a day Disp #*15 Tablet Refills:*0
2. Sarna Lotion 1 Appl TP QID:PRN itching
3. Glargine 70 Units Bedtime
4. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL intramuscular PRN
5. GlipiZIDE 5 mg PO QHS
6. Januvia (SITagliptin) 100 mg oral DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Simvastatin 20 mg PO QPM
9. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until recommended by PCP
10. HELD- Lisinopril 40 mg PO DAILY This medication was held.
Do not restart Lisinopril until recommended by PCP
___:
Home
Discharge Diagnosis:
Left lower leg cellulitis
Hypoxia
Insulin dependent diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for fevers and a skin infection (cellulitis)
in the leg. You were treated with IV antibiotics (Zosyn, Unasyn,
Vancomycin) and your symptoms improved. You developed some
shortness of breath and low oxygen levels, which improved over
time. You will be discharged on oral antibiotics (Augmentin) for
the next 7 days, ending on ___. If you have any recurrence
of fevers or worsening of your infection, please see a doctor
emergently.
The ultrasound of your heart (ECHO) showed no evidence of any
structural heart disease.
It was a pleasure to take care of you. We wish you all the best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10448039-DS-2 | 10,448,039 | 23,532,612 | DS | 2 | 2156-12-30 00:00:00 | 2156-12-30 21:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Code stroke/or stroke
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Neurology at bedside for evaluation after code stroke
activation/consult within: 5 minutes
Time (and date) the patient was last known well: 15:10 on ___
(24h clock)
___ Stroke Scale Score: 2
t-PA given: Yes Time t-PA was given 16:10 (24h clock)
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
The NIHSS was performed:
Date: ___
Time: 16:00
(within 6 hours of patient presentation or neurology consult)
___ Stroke Scale score was : 2
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 1
10. Dysarthria: 1
11. Extinction and Neglect: 0
___ is an ___ R-handed woman with a past
medical history significant for aortic stenosis with plan for a
TAVR in the near future, anxiety, mild cognitive impairment, and
history of breast cancer s/p bilateral masectomy over ___
years ago. She presents with acute onset of difficulty speaking
at approximatley 15:10 pm while she was with her daugther in the
car driving home from an appointment at ___.
Briefly, the patient's daughter states that the patient was in
her usual state of health today. They went to an appointment at
___ to have pulmonary function test done as part of some
pre-operative testing for a potential TAVR for her aortic
stenosis. The patient and her daughter were in the car driving
back home when at approximately 15:10, she stopped responding to
her daughter. At first her daughter thought that she just was
slow to respond which occasionally the patient is known to do,
however after about a minute of poor response, her daugther knew
something was off. The patient then started to try and speak but
she said nonsensical words. There was no facial droop
appreciated. They were luckily driving by ___ at this exact
time so her daughter decided to bring her into the ED for rapid
evaluation. On arrival, a code stroke was called.
On arrival the patient was noted to be speaking slowly , non
fluently and speaking out of context. She was able to lift her
arms but seemed weak in both legs, unable to hold them
antigravity. The patient underwent stat imaging and was brought
back to her room. On return from the scanner, the patient had
improved and was speaking fluently. She was able to say where
she
was, repeat sentences, and follow commands. She was lifting all
four extremities antigravity. Two minutes later, the patient
again became mildly aphasic, and was unable to name any words,
saying nonsensical words. Her speech also became dysarthric.
NIHSS was performed and was scored at 2 for aphasia and
dysarthria. She was given TPA at approx___ 16:10. The
patient
then improved again with only mild dysarthria after TPA bolus
went in.
On speaking with her daugther, she states that the patient has
been quite healthy. She has never had any stroke/TIA symptoms
nor
any seizures in the past. She was recently diagnosed with aortic
stenosis but otherwise has not had any other cardiac issues. Her
EF is unknown by the daugther, and she receives the majority of
her care at ___ and ___. In regards to her breast cancer,
she
had a double masectomy around ___ years ago. In ___ she had a
recurrence of some breast cancer cells in her "mid section" that
was treated, however the exact details are unknown.
The patient has been living in assisted living for ___ years now.
She ambulates with a walker due to bilateral arthritis in her
knees. She requires assistance wth bathing, but otherwise can
dress and feed herself. The patient reports feeling well at the
time of TPA administration.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysphagia, lightheadedness, vertigo, tinnitus
or hearing difficulty. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the 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:
1. Constipation
2. L hip replacement
3. Breast cancer s/p bilateral masectomy
4. Aortic stenosis, needs TAVR
5. anxiety
Social History:
Patient lives in ___ Living in
___. She is very close to her daughter and son-in-law.
She is a retired ___. She quit smoking at
age ___. She does not drink ETOh or partake in illicit drugs
- Modified Rankin Scale:
[] 0: No symptoms
[X] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
No significant family history of neurologist disorders
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: BP 119/78, Aefebrile, HR 80
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: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x self, day of the week, month,
year, and "Hospital". Inattentive unable to ___ backwards.
Language is fluent with intact repetition and comprehension,
however she has paraphasic errors with naming, stated "heel"
instead of palm. She could not find the word for knuckles. She
could however name pen, ball point, and identify the color. She
was minimally dysarthric with labial sounds. Able to read
without difficulty. Able to follow both midline and
appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 4 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
Mild head essential tremor noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ ___ 4 5 5 5
R 5 ___ ___ 4 5 5 5
* poor effort in legs, holding them up antigravity easily but
couldnt not participate in full motor testing in the legs
-Sensory: No deficits to light touch, pinprick, cold sensation.
No extinction to DSS. Romberg absent.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 0 0
R 1 1 1 0 0
Plantar response was mute bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: deferred
==================================
DISCHARGE PHYSICAL EXAM:
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: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: AO x3. Language is fluent with intact
repetition
and comprehension, no paraphasic errors. No dysarthria noted.
Able to read without difficulty. Able to follow both midline
and
appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3.5 to 3mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally although bilateral cupping noted.
Mild head essential tremor noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation.
No extinction to DSS. Romberg absent.
-DTRs:
___
___ response were upgoing bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: deferred
Pertinent Results:
ADMISSION LABS:
___ 03:30PM BLOOD WBC-5.6 RBC-3.79* Hgb-12.5 Hct-38.1
MCV-101* MCH-33.0* MCHC-32.8 RDW-14.0 RDWSD-51.2* Plt ___
___ 03:30PM BLOOD Neuts-40.9 ___ Monos-18.2*
Eos-2.4 Baso-0.9 Im ___ AbsNeut-2.24 AbsLymp-2.05
AbsMono-1.00* AbsEos-0.13 AbsBaso-0.05
___ 03:30PM BLOOD ___ PTT-26.0 ___
___ 03:30PM BLOOD Glucose-95 UreaN-20 Creat-0.9 Na-138
K-5.0 Cl-99 HCO3-15* AnGap-24*
___ 06:04AM BLOOD ALT-9 AST-18 LD(LDH)-268* AlkPhos-60
TotBili-0.6
___ 03:30PM BLOOD Albumin-4.0 Calcium-9.0 Phos-4.0 Mg-2.0
___ 06:04AM BLOOD %HbA1c-4.9 eAG-94
___ 06:04AM BLOOD TSH-2.9
___ 03:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
CTA HEAD AND NECK ___:
1. Motion limited examination without evidence for frank
intracranial
hemorrhage or large vascular territorial infarction within
confines of CT.
2. Multifocal atherosclerotic disease throughout the
intracranial and cervical vasculature without high-grade
stenosis, occlusion, or aneurysm greater than 3 mm.
3. Nondiagnostic CT perfusion examination secondary to poor
bolus tracking.
4. Additional findings, as above.
CXR ___:
Minimal bibasilar atelectasis.
CT HEAD ___:
No acute intracranial abnormality.
MRI HEAD ___:
1. No evidence for acute intracranial hemorrhage or infarction.
2. Global parenchymal volume loss and evidence of chronic small
vessel
ischemic disease.
TTE ___:
The left atrial volume index is normal. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is ___ mmHg.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets are severely
thickened/deformed. There is very severe aortic valve stenosis
(Vmax ___ or mean gradient >=60mmHg; valve area <1.0cm2). No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Very severe aortic valve stenosis. Mild symmetric
left ventricular hypertrophy with preserved regional and global
biventricular systolic function. Moderate PA systolic
hypertension.
CLINICAL IMPLICATIONS:
The patient has very severe aortic valve stenosis. Based on ___
ACC/AHA Valvular Heart Disease Guidelines, if the patient is a
surgical or TAVR candidate, an evaluation for a mechanical
intervention is recommended.
Brief Hospital Course:
Ms. ___ is an ___ old right handed woman, developed
sudden onset acute slurred and nonsensical speech on ___ s/p
tPA.
# Symptomatic hypotension in the setting of severe aortic
stenosis:
The symptoms fluctuated somewhat but she was symptomatic with a
NIHSS of 2 on presentation to the ER. Given the nature of the
deficit (language) a decision was made to proceed with IV tPA
after discussing with patient and family. CTA head and neck
revealed multifocal atherosclerotic disease throughout the
intracranial and cervical vasculature without high-grade
stenosis, occlusion. MRI wo contrast showed no evidence of acute
infarcts. She was subsequently seen to have asymptomatic
hypotension with systolics in the lows ___, but at times in
70-80s. Etiology of her presentation was thought to be secondary
to global hypoperfusion in the setting of known aortic stenosis.
Inpatient cardiology was consulted and recommended treating her
SBP for values lower than 85 or symptomatic BPs with small
boluses of 250cc normal saline. She was initially placed with
head of bed flat and her speech deficits improved with improving
blood pressures. Her activity was subsequently liberalized and
she tolerated physical therapy evaluation without issue. ___
recommended home with home services.
In discussion with the cardiology team, patient had a TTE which
showed an EF of 70%, very severe aortic valve stenosis (valve
area 0.6cm), mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function
and moderate PA systolic hypertension. Given that she is
preparing for TAVR as outpatient at ___, patient will follow-up
with her outpatient cardiologists for surgical management,
scheduled next week. Her outpatient cardiologist was updated
regarding the hospitalization.
Transitional Issues
====================
[] Please consider using holter monitor to rule out afib.
[] Please consider urgent TAVR for patient given above sx
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D Dose is Unknown PO 1X/WEEK (SA)
2. Aspirin 81 mg PO DAILY
3. Venlafaxine 50 mg PO BID
4. Senna 17.2 mg PO DAILY
5. RisperiDONE 1.25 mg PO QHS
6. Mirtazapine 30 mg PO QHS
7. LORazepam 1.25 mg PO QHS
8. Ipratropium Bromide MDI 2 PUFF IH BID
9. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Senna 8.6 mg PO BID
2. Vitamin D ___ UNIT PO 1X/WEEK (___)
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Ipratropium Bromide MDI 2 PUFF IH BID
6. LORazepam 1.25 mg PO QHS
7. Mirtazapine 30 mg PO QHS
8. RisperiDONE 1.25 mg PO QHS
9. Venlafaxine 50 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Severe Aortic Stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital after you experienced
difficulty with your speech. You received a clot breaking
medication since these symptoms were concerning for a stroke.
However, further imaging of your brain ruled out a stroke. You
also had an echocardiogram of your heart that showed severe
narrowing of one of the valves of your heart that can result in
low blood pressure, and is the most likely cause of your
symptoms.
Please take your other medications as prescribed.
Please follow up with cardiology 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:
___
|
10448039-DS-3 | 10,448,039 | 26,080,841 | DS | 3 | 2158-05-11 00:00:00 | 2158-05-15 11:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
unwitnessed fall
Major Surgical or Invasive Procedure:
None performed.
History of Present Illness:
HISTORY OF PRESENT ILLNESS: Ms. ___ is an ___
female with severe aortic stenosis post ___ 23 mm
aortic valve replacement in ___, resides at ___, where she sustained an unwitnessed fall
yesterday evening. She carries a diagnosis of mild cognitive
impairment so the circumstances surrounding her fall are not
entirely clear. According to collateral from her daughter, she
was last seen leaving dinner with her rolling walker around
17:00
on ___. She was found down an estimated two hours later on
her side by her walker. ___ cannot elaborate about what
transpired other than she was listening to a book on tape. She
told other providers that she landed on her buttocks. She tells
this writer she did not lose consciousness. She offered no other
concerns. She was hemodynamically stable on arrival. She has
minor leukocytosis to 11.7 with neutrophilic predominance. She
is
hyponatremic to 129. She does not have explanatory
electrocardiographic changes. Telemetry in the emergency
department was likewise unrevealing. A trauma survey including a
CT of her head and cervical spine are unremarkable.
REVIEW OF SYSTEMS: ___ does endorse nasal congestion and
unproductive cough for about a week or so, which is improving.
According to ___ records, a chest x-ray was negative for
pneumonia. She denies lightheadedness or cardiopulmonary
symptoms
at present. She does not think she had any the preceded the fall
but cannot recall entirely. She denies gastrointestinal or lower
urinary tract symptoms. She has no bony pains.
Past Medical History:
1. Constipation
2. L hip replacement
3. Breast cancer s/p bilateral masectomy
4. Aortic stenosis, needs TAVR
5. anxiety
Social History:
___
Family History:
No significant family history of neurologist disorders
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
VITALS: T 97.9, HR 96, BP 146/51, RR 18, 97% RA
GENERAL: Elderly female in no apparent physical distress.
HEENT: Anicteric sclerae. Oropharynx is dry.
NECK: JVP is undetectable.
CV: Regular rate and rhythm. Loud S2. Systolic murmur across
precordium. No gallop.
PULM: Comfortable. Lungs are clear.
ABDOMEN: Soft. Non-distended. Non-tender.
EXTREMITIES: No peripheral edema.
SKIN: Within normal limits.
NEURO: There are involuntary facial movements but otherwise
non-focal.
DISCHARGE PHYSICAL EXAM
==========================
VS: ___ 0736 Temp: 97.8 PO BP: 163/82 HR: 73 RR: 18 O2 sat:
96% O2 delivery: Ra
GENERAL: NAD, elderly female with baseline involuntary facial
movements, comfortably undergoing TTE
HEENT: AT/NC, anicteric sclera, dry oropharynx
NECK: supple, no LAD
CV: RRR, loud S2. systolic murmur across precordium. no gallop.
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, involuntary
facial movements at baseline
Pertinent Results:
LABS ON ADMISSION
===================
___ 08:50PM BLOOD WBC-11.7* RBC-3.53* Hgb-11.3 Hct-33.9*
MCV-96 MCH-32.0 MCHC-33.3 RDW-12.5 RDWSD-43.7 Plt ___
___ 08:50PM BLOOD Plt ___
___ 08:50PM BLOOD Glucose-84 UreaN-17 Creat-1.1 Na-129*
K-5.0 Cl-92* HCO3-23 AnGap-14
___ 08:50PM BLOOD Glucose-84 UreaN-17 Creat-1.1 Na-129*
K-5.0 Cl-92* HCO3-23 AnGap-14
LABS ON DISCHARGE
==================
___ 06:15AM BLOOD WBC-6.0 RBC-3.58* Hgb-11.3 Hct-34.7
MCV-97 MCH-31.6 MCHC-32.6 RDW-13.0 RDWSD-45.9 Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD Glucose-86 UreaN-13 Creat-0.8 Na-134*
K-4.6 Cl-98 HCO3-25 AnGap-11
___ 06:15AM BLOOD CK(CPK)-681*
MICRO
======
None
IMAGING
========
TTE ___:
Well seated, normal functioning ___ 3 TAVR with normal
gradient and no
aortic regurgitation. Mild functional mitral stenosis from
mitral annular calcification. Mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global biventricular
systolic function.
Compared with the prior TTE (images reviewed) of ___ ,
the aortic valve has been replaced
with a normal functioning TAVR with no aortic regurgitation and
mild functional mitral stenosis is now
identified.
CT CHEST WITH CONTRAST ___:
IMPRESSION:
1. Multiple scattered calcific foci within the bilateral lung
parenchyma,
around the bilateral hila, and in the liver and spleen, likely
representing
calcified granulomas.
2. 5 mm pleurally based right upper lung nodule. No
intraparenchymal
pulmonary nodules are seen.
3. Dilated right pulmonary artery, measuring up to 4.0 cm in
diameter.
4. Compression deformities of T12 through L2, of uncertain
chronicity.
CT C-SPINE W/O CONTRAST ___:
IMPRESSION:
No acute fracture or traumatic malalignment. Multilevel
degenerative changes as stated above.
CT HEAD W/O CONTRAST ___:
IMPRESSION:
1. No acute intracranial process. No evidence of intracranial
hemorrhage or fracture.
2. Prominent lateral ventricles, although this finding is
nonspecific, can be seen in patients with NPH in the appropriate
clinical setting, please correlate.
Brief Hospital Course:
___ female with severe aortic stenosis post-TAVR who
presented after sustaining an unwitnessed fall on ___. Fall
ultimately felt to be mechanical in nature, although
polypharmacy may have been contributing factor.
ACTIVE ISSUES
===============
#Mechanical fall - Based on the patient's history, it is most
likely this was a mechanical fall due to walker instability. She
had a past fall that led to hemiarthroplasty. CT head negative
for acute events, CT spine negative for any acute fractures. TTE
demonstrated well seated aortic valve with no increase in
stenosis and normal EF at 65%. Would consider re-evaluation of
home psychotropics to prevent excessive sedation that may
precipitate additional falls. Orthostatics performed with no
evidence of orthostatic hypotension. Per ___ evaluation, her
ambulation was deemed stable for discharge back to her rest
home, with home ___.
#Hyponatremia - Presented with sodium of 129 on admission which
increased to 134 at discharge. The patient remained asymptomatic
throughout her admission. Urine
sodium 48 within normal limits, demonstrating active ADH. She
was encouraged to maintain good PO intake to maintain her sodium
levels. Suspect that patient may have SIADH due to risperidone,
although fluid intake did improve slightly after mild IVF
resuscitation, suggesting that there may have been a component
of poor PO intake/volume depletion. No fluid resuscitation was
initiated.
# Mild Functional Mitral Stenosis - noted on TTE, from mitral
annular calcification. Unlikely to be related to her fall, but
will require follow-up with her cardiologist at ___.
# Nodules on Chest CT - Patient noted on chest CT; multiple
scattered calcific foci within the bilateral lung parenchyma,
around the bilateral hila, and in the liver and spleen, likely
representing calcified granulomas. 2.5 mm pleurally based right
upper lung nodule also noted. No intraparenchymal pulmonary
nodules were seen. Thought to be unlikely to be related to fall,
possibly concerning for SIADH but thought to more likely be an
effect from her psychotropic medications. Consider follow-up
imaging going forward.
CHRONIC/STABLE ISSUES
=======================
#Severe aortic stenosis: Post ___ 23 mm aortic valve
replacement. TTE demonstrated well seated valve with no evidence
of vegetations or worsening stenosis. EF of 65%. We continued
aspirin and metoprolol succinate during her admission. The
aortic stenosis likely did not contribute to her fall.
#Mixed mood and anxiety disorder with psychosis: On an extensive
med list including venlafaxine, mirtazapine, risperidone,
lorazepam, and melatonin. She may be at risk of polypharmacy and
sedation due to this meds, increasing risk of fall. We would
recommend consolidating the medicine list, with possibly
transitioning off to an new antipsychotic like Abilify to avoid
further risk of tardive dyskinesia as this may contribute to
instability.
TRANSITIONAL ISSUES
=====================
[ ] Please consider transitioning to a new antipsychotic to
reduce risk of tardive dyskinesia, and to reduce risk of
hyponatremia. Can consider Abilify.
[ ] Her Ativan was decreased to 0.5mg during this admission.
Consider continuing with decreased dose if tolerated, and
possibly discontinuing all together.
[ ] Recommend consolidation of psychotropic medications if
possible to reduce sedation risk that may contribute to fall
risk.
[ ] Continue to encourage good nutritional intake and hydration
to maintain appropriate electrolyte levels.
[ ] Please recheck Basic Metabolic Panel within one week of
discharge to ensure stability in sodium levels. If sodium
down-trending, consider initiation fluid restriction for
presumed SIADH, likely induced by risperidone.
[ ] Please consider filling out MOLST with patient and her
health care proxy.
[ ] Please ensure follow-up with cardiology at ___ given new
diagnosis of mild functional mitral stenosis seen on TTE.
[ ] Consider follow-up chest imaging for
calcifications/granulomas seen on chest CT.
CODE: Full (presumed)
CONTACT: ___, daughter (___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Metoprolol Succinate XL 12.5 mg PO DAILY
3. Omeprazole 20 mg PO BID
4. guaiFENesin 200 mg oral TID:PRN Cough
5. Mirtazapine 37.5 mg PO QHS
6. LORazepam 1 mg PO QHS
7. Ramelteon 8 mg PO QHS
8. Senna 8.6 mg PO DAILY
9. Docusate Sodium 100 mg PO DAILY
10. RisperiDONE 0.25 mg PO QHS
11. Venlafaxine XR 150 mg PO DAILY
Discharge Medications:
1. LORazepam 0.5 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO DAILY
4. guaiFENesin 200 mg oral TID:PRN Cough
5. Metoprolol Succinate XL 12.5 mg PO DAILY
6. Mirtazapine 37.5 mg PO QHS
7. Omeprazole 20 mg PO BID
8. Ramelteon 8 mg PO QHS
9. RisperiDONE 0.25 mg PO QHS
10. Senna 8.6 mg PO DAILY
11. Venlafaxine XR 150 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
==================
1. Mechanical Fall
2. Hyponatremia
SECONDARY DIAGNOSES
====================
1. Severe Aortic Stenosis s/p TAVR
2. Mitral Stenosis
3. Mixed mood and anxiety disorder with psychosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
You were in the hospital because you had a fall at your nursing
home.
WHAT HAPPENED TO ME IN THE HOSPITAL?
At the hospital, you had a CT of your head and of your back
which showed no bleeding or fractures. Also, you had an
echocardiogram of your heart which showed that your TAVR was
well-seated and your heart was functioning normally, although
you did have some new mitral stenosis. We think that your fall
was most likely caused due to your walker, not due to feeling
faint or having palpitations. We also took a closer look at a
nodule on your right lung with a CT and did not think it was a
major concern.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
Please continue to take all of your medications and follow-up
with your appointments as listed below.
Please follow-up with your cardiologist at ___ regarding the
findings of mitral stenosis on your echocardiogram.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10448327-DS-14 | 10,448,327 | 24,753,789 | DS | 14 | 2149-11-25 00:00:00 | 2149-11-25 13:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Ciprofloxacin /
antihistamines / Benadryl / atenolol / Fosamax / lisinopril /
Norvasc / nitrofurantoin / ALL CILLINS
Attending: ___
Chief Complaint:
Obstructing right ureter stone
Major Surgical or Invasive Procedure:
Right ureteral stent placement
History of Present Illness:
HISTORY OF PRESENT ILLNESS: This is a ___ year old female with
history of nephrolithiasis who presents with sudden onset right
flank pain associated with nausea and urinary frequency. Pain
initially started yesterday evening, was originally associated
with some hematuria but that has now resolved. Denies dysuria,
fevers/chills. Her flank pain is much improved with IV pain
medications she has received in the ED.
She has a long history of nephrolithiasis. Most recently
required ureteroscopy with laser lithotripsy ___. She also
recently had reported gross hematuria for which she underwent a
diagnostic flexible cystoscopy 2 days ago with Dr. ___ was
negative for any intravesicular pathology. She denies history of
metabolic workup for stone disease. Denies any previous history
of UTIs.
She has received IV ceftriaxone in the ED empirically.
Past Medical History:
PMH: OA right hip, dyslipidemia, HTN, moderate AS ___ ECHO)
and mild/mod AR, EF 65-70% ___ TEE ECHO), EKG NSR
(___), heart murmur (AS/AR), CVA (? TIA over ___ years ago,
CVA w/u neg), kidney stone/calculi, anxiety, motion sickness
PSH: Surgical hx: Lithotripsy, Bunionectomy x2 left, x1 right,
Tubal ligation, B/L cataract extractions.
Social History:
___
Family History:
Non-contributory
Physical Exam:
Normal exam
No CVA tenderness
Pertinent Results:
___:15AM BLOOD WBC-8.9 RBC-3.83* Hgb-11.1* Hct-35.3
MCV-92 MCH-29.0 MCHC-31.4* RDW-14.0 RDWSD-47.2* Plt ___
___ 06:15AM BLOOD Glucose-111* UreaN-15 Creat-0.7 Na-141
K-4.5 Cl-106 HCO3-23 AnGap-12
Brief Hospital Course:
Patient presented with obstructing right ureteral stone and
concern for possible UTI. She was taken to the OR for a right
ureteral stent which was uncomplicated. She was admitted to the
floor following the operation. There were no issues overnight.
She was discharged home on POD1 after her foley was removed and
she voided. She will follow up with Dr. ___ definitive
management of her stone in ___ weeks. She was given a script for
Keflex x 5 days for possible UTI with urine cultures pending.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 25 mg PO DAILY
2. Phenazopyridine 100 mg PO TID
3. Carvedilol 6.25 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Atorvastatin 20 mg PO QPM
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Cephalexin 500 mg PO Q12H UTI
RX *cephalexin 500 mg 1 capsule(s) by mouth twice a day Disp
#*10 Capsule Refills:*0
3. Phenazopyridine 100 mg PO TID Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth TID PRN Disp
#*30 Tablet Refills:*0
4. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin [Flomax] 0.4 mg 1 capsule(s) by mouth Daily Disp
#*30 Capsule Refills:*0
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 20 mg PO QPM
7. Carvedilol 6.25 mg PO BID
8. Docusate Sodium 100 mg PO BID
9. Losartan Potassium 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Right obstructing ureteral stone
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent. You may aslo experience some
pain associated with spasm of your ureter.
-The kidney stone may or may not have been removed AND/or there
may be fragments/others still in the process of passing.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
AVOID lifting/pushing/pulling items heavier than 10 pounds
(or 3 kilos; about a gallon of milk) or participate in high
intensity physical activity (which includes intercourse) until
you are cleared by your Urologist in follow-up.
-No DRIVING for THREE WEEKS or until you are cleared by your
Urologist
-You may shower normally but do NOT immerse your nephrostomy
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest emergency room.
Followup Instructions:
___
|
10448831-DS-12 | 10,448,831 | 21,509,199 | DS | 12 | 2156-05-08 00:00:00 | 2156-05-16 17:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Lisinopril / Percocet / amlodipine / nifedipine
Attending: ___.
Chief Complaint:
Lethargy, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ CAD, pAF, LBBB and advanced sHF (EF 30%) w/ biV pacer who
presented to ___ office with one month of progressive fatigue
and malaise, found to have hypotension.
Per daughter, at baseline patient is independent in ADLS, has
baseline dementia with short term memory loss. Over the past
month he has steadily been more lethargic, getting out of bed
less. In the past 10 days he was noted to have intermittent
fevers, congestion and cough. Five days ago he was also noted
to have some leg swelling, but this has since improved. On ___
___ had BP of 80/60 with repeat 90/60 and since then patient
continued to have decreased PO intake and mobility.
He was brought into HCA today by his daughter for worsening
lethargy and was found to have hypotension to 70/60, manual
repeat 90/60 and 93% on RA. He was transferred to the ED for
further evaluation.
In the ED, initial vitals: 97.9 85 83/57 18 95% RA.
-WBC 8.8, H/H 12.9/36.7 and Plt 320. INR 3.8. Trop was 0.02
and BNP 550. His CXR was concerning for pna and he was given 1L
NS total (500ml x 2), levofloxacin 750 mg, ceftriaxone 1gm x 1.
-His BP improved to 100s-120s/50-70s. O2 sats were 96-100% on 3L
NC (had dropped to 92% RA).
-CT head without contrast was negative.
-He is being admitted to the MICU for hypotension despite
improvement with fluid boluses given his initial trigger on
arrival, and felt to be too tenuous for admission to the floor.
On transfer, vitals were: T98.1 70 104/64 18 100% 3L.
On arrival to the MICU, T97.8 110/50 95 18 96% on RA. Patient
complained of feeling tired but had no other complaints, denies
any chest pain, shortness of breath.
Review of systems:
(+) Per HPI
(-) Denies night sweats. Denies headache, sinus tenderness.
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:
- Advanced Heart Failure: BiV pacing, EF 30%
- Afib on coumadin
- CAD PCI to LAD in ___ on plavix
- sinus node dysfunction s/p pacer
- RCC s/p cyberknife ___
- HTN
- GERD
Social History:
___
Family History:
Mother had liver cancer, father had CVA.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T97.8 110/50 95 18 96% on ___
GENERAL: Lying in bed flat, no acute distress, coughing.
HEENT: Sclera anicteric, MM dry, oropharynx clear
NECK: supple, JVP is flat, no LAD
LUNGS: Bibasilar crackles, good air movement
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, 1+ pulses, no clubbing, cyanosis.
Trace pedal edema
SKIN: No rashes
NEURO: Alert and oriented to self and ___ and hospital, not
to date which daughter states is baseline. Moving all four
extremities symmetrically.
DISCHARGE PHYSICAL EXAM:
Vitals: 97.5 - 149/81 - 87 - 20 - 100RA; BPs yest ___ yest
AM ___ 194
___ yest ___
General- Alert, oriented to hospital in ___, ___, sleeping
comfortably in bed in no acute distress
HEENT- Sclera anicteric, sleeping on left side with left eye
non-purulent crusting, MMM, oropharynx clear
Neck- supple, no LAD
Lungs- lungs clear; no crackles or rhonchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- face symmetric (after clearing eye crust)
Pertinent Results:
ADMISSION LABS:
___ 12:50PM BLOOD WBC-8.8 RBC-3.95* Hgb-12.9* Hct-36.7*
MCV-93 MCH-32.7* MCHC-35.3* RDW-14.4 Plt ___
___ 12:50PM BLOOD Neuts-70.5* ___ Monos-6.3 Eos-1.1
Baso-0.3
___ 12:50PM BLOOD ___ PTT-44.8* ___
___ 12:50PM BLOOD Glucose-141* UreaN-29* Creat-2.1* Na-136
K-3.6 Cl-100 HCO3-24 AnGap-16
___ 12:50PM BLOOD ALT-35 AST-31 CK(CPK)-122 AlkPhos-71
TotBili-0.4
___ 12:50PM BLOOD CK-MB-2 cTropnT-0.02* proBNP-550
___ 08:57PM BLOOD CK-MB-2 cTropnT-0.01
___ 12:54PM BLOOD Glucose-132* Lactate-1.7 K-3.7
URINE
___ 04:35PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:35PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:35PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
CXR ___
AP portable upright view of the chest. Pacemaker again noted
projecting over the left chest wall with pacer leads extending
to the region of the right atrium and right ventricle as well as
the coronary sinus. Heart remains mildly enlarged. The aorta is
unfolded. Lung volumes are low with probable bibasilar
atelectasis, possibly also with tiny bilateral pleural
effusions. No
large pneumothorax. No overt edema. No convincing signs of
pneumonia. Bony structures appear intact.
PORTABLE CXR ___
IMPRESSION: As compared to ___ radiograph, cardiomegaly
is accompanied by pulmonary vascular congestion and worsening
interstitial edema. More confluent opacity at the left lung
base has improved, and small left pleural effusion has
apparently decreased in size. Persistent small right pleural
effusion.
CT HEAD WITHOUT CONTRAST ___
No acute intracranial abnormality.
EKG: HR 61 bpm, paced rhythm, with RBBB no changes from prior,
Qtc 499
DISCHARGE LABS
___ 06:25AM BLOOD WBC-7.4 RBC-3.67* Hgb-11.9* Hct-34.3*
MCV-93 MCH-32.3* MCHC-34.6 RDW-14.6 Plt ___
___ 06:25AM BLOOD ___ PTT-37.7* ___
___ 06:25AM BLOOD Glucose-84 UreaN-25* Creat-1.6* Na-144
K-4.2 Cl-106 HCO3-24 AnGap-18
___ 06:25AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.0
MICROBIOLOGY
___ 07:59PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-POSITIVE
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
___ BLOOD CULTURE Blood Culture, Routine-FINAL
___ 12:50PM estGFR-Using this
Brief Hospital Course:
BRIEF HOSPITAL COURSE
======================
___ CAD, pAF, LBBB and advanced sHF (EF 30%) w/ biV pacer who
presented to PCP office with one month of progressive fatigue
and malaise, found to have hypotension and Influenza B.
Per daughter, at baseline patient is independent in ADLS, has
baseline dementia with short term memory loss. Over the past 10
days prior to admission he was noted to have intermittent
fevers, congestion and cough. On ___ ___ had BP of 80/60 with
repeat 90/60. He was referred to clinic where he was found to by
hypotension to 70/60, manual repeat 90/60 and 93% on RA. He was
transferred to the ED for further evaluation. He was found to be
Influenza B positive. His blood pressure improved with IVF,
although due to tenuous clinical exam he was admitted to the
MICU for further monitoring. He was started on oseltamavir 75mg
po daily x 5 days for treatment of flu. Clinically he improved
and was transferred to the floor and finished his course. There,
he was stable and evaluated by ___ who recommended home with home
___. He was very lethargic in the mornings; per discussion with
his family, he was close to his most recent baseline (has been
sleeping most of the day for the last ~2 mos).
ACTIVE MEDICAL ISSUES
======================
# Hypotension: He was hypotensive on admission, likely
secondary to both dehydration as well as SIRS reponse in setting
of flu. His blood pressure responded well to fluids. He did not
require pressors while in the ICU. He was normotensive on the
floor.
# Influenza B: Pt found to be flu positive. He was treated with
tamiflu (75 mg daily x 5 days ___, renally dosed) and
symptomatic management. His antibiotics were stopped as his
infectious symptoms were felt to be primarily due to a viral
processes.
# Lethargy: Ongoing lethargy exacerbated by flu. CT head in ED
was negative. Appears he had been on methylphenidate for
lethargy over the past several years as well, which is
nonformulary and does not seem to have helped recently. Less
likely due to CHF exacerbation as he appears dry on exam, and
BNP 550. His ___ notes that for the past two months, he has
slept most of the day (is arousable at home and in hospital),
and this is near his recent baseline.
# Afib: CHADS2 VASC of 4. Presented with supratherapeutic INR to
3.8, which subsequently trended up in the setting of illness and
antibiotics. Currently paced. Warfarin held during
hospitalization as supratherapeutic; we asked patient to restart
warfarin ___. Discussed via phone w HCA ACMS who will
contact patient and coordinate with ___ to draw next INR. We
also emailed Dr. ___ patient's son's wishes
to have patient started on digoxin per his request.
CHRONIC MEDICAL ISSUES
========================
# CAD: He is s/p PCI to LAD in ___, unclear why he is still on
plavix as opposed to asa, but given risk of bleeding with triple
therapy it is reasonable
# HF with decreased EF 30%: No lower extremity edema and
clinically does not appear fluid overloaded in the setting of
his hypotension. We restarted his metoprolol and torsemide on
the floor.
# Hypertension: Presented hypotensive, which responded to
fluids. Restarted metoprolol and valsartan on the floor.
# CKD: Baseline Cr of 1.7-2.0 in the past year, with admission
Cr 2.1. Cr improved to 1.6 with fluids. Discharged at baseline.
# Mild trop elevation: Trop 0.02 on arrival, likely secondary
to CKD. There were no EKG changes, and no CP. Troponin trended
down.
TRANSITIONAL ISSUES
====================
- Code status: Full code, confirmed.
- HCP: ___, daughter: ___
- Studies pending on discharge: ___ Blood cultures x 2.
- Patient's son/family would like to discuss initiating digoxin.
We emailed Dr. ___ this, patient will see him in
clinic next month.
- INR 3.2 on discharge; asked patient to restart warfarin
___. Discussed via phone w HCA ACMS who will contact patient
and coordinate with ___ to draw next INR.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
5. Metadate ER (methylphenidate) 20 mg oral QAM
6. Metoprolol Succinate XL 50 mg PO QHS
7. Nitroglycerin Patch 0.2 mg/hr TD Q24H
8. Torsemide 5 mg PO DAILY
9. Valsartan 20 mg PO QPM
10. Warfarin 2.5 mg PO 6X/WEEK (___)
11. Vitamin D 1000 UNIT PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. bimatoprost 0.01 % ophthalmic QHS
14. Warfarin 3.75 mg PO 1X/WEEK (TH)
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
5. Multivitamins 1 TAB PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. bimatoprost 0.01 % ophthalmic QHS
8. Metadate ER (methylphenidate) 20 mg oral QAM
9. Warfarin 2.5 mg PO 6X/WEEK (___)
start ___
10. Warfarin 3.75 mg PO 1X/WEEK (TH)
11. Metoprolol Succinate XL 50 mg PO QHS
12. Torsemide 5 mg PO DAILY
13. Valsartan 20 mg PO QPM
14. Nitroglycerin Patch 0.2 mg/hr TD Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Influenza B, Hypotension, Coagulopathy, Acute
kidney injury
Secondary Diagnosis: Lethargy; atrial fibrillation;
supratherapeutic INR; Coronary artery disease; systolic
congestive heart failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for
fatigue and weakness. In your primary care office you were noted
to have a low blood pressure so you were referred to the
Emergency Department where it was discovered that you had the
flu (Influenza.) You were started on oseltamavir to help reduce
the length of your symptoms. Because of your low blood pressure
you were admitted to the ICU and given IV fluids. Your blood
pressure improved so you were called out to the floor. On the
floor you were evaluated by physical therapy who recommended you
were safe to be discharged home with home physical therapy. You
can restart your warfarin on ___, and the HCA
anticoagulation management clinic is aware of this and will
follow up with you tomorrow to have your INR rechecked with your
___. Regarding starting digoxin, we emailed your cardiologist
who can address this at your follow-up next month.
It was a pleasure taking care of you,
Your ___ Team
Followup Instructions:
___
|
10448831-DS-15 | 10,448,831 | 21,546,366 | DS | 15 | 2157-09-04 00:00:00 | 2157-09-04 14:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Lisinopril / Percocet / amlodipine / nifedipine
Attending: ___.
Chief Complaint:
left leg pain
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ speaking ___ M w/ CAD, Afib, SSS, chronic LBBB, CHF w/
biventricular pacer, renal cell carcinoma, ___ Body dementia,
presents to ED w/ left leg pain after unwitnessed fall 5d
previously and mild CHF exacerbation.
Patient does not recall fall. At baseline cognition, is not
oriented to location/city/year, requires a walker to ambulate.
Per daughter & ___ facility, patient was found in the
middle of the night ___t that time,
patient reported falling when returning to bed from the
bathroom. Evaluation by the rehab physician at that time noted
scrape to the coccyx and redness of the R flank, with some
bruising on the back the next day. Records from the rehab center
did not describe any trauma to head/face. Patient appeared to be
in his baseline state of health until ___ when he complained of
left leg pain and inability to bear weight.
Patient does not report any SOB, chest pain, does not think his
feet are more swollen than usual. Occasional dizziness with
standing up. No bruises seen on head/neck/face.
In the ED, initial vitals were Temp 97, HR 81, BP 96/57, Resp 20
O(2)Sat 100%. Imaging was notable for left fibula proximal
fracture. Labs were notable for slight increase in Cr from
baseline (2.4 up from baseline of 2.0). Patient's leg was
splinted in the ED and he was admitted to general medicine.
On arrival to the floor, pt is in no acute distress. Vitals on
arrival are T 98.1. BP 106/66, HR 71, RR 18, SpO2 98% RA.
Past Medical History:
- Advanced Heart Failure: BiV pacing, EF 30%
- Afib on coumadin
- CAD PCI to LAD in ___ on plavix
- sick sinus syndrome, chronic LBBB ___ CRT-P
pacer device)
- RCC ___ cyberknife ___
- HTN
- GERD
- ___ Body Dementia
- Depression
Social History:
___
Family History:
Father: CVA
Mother: liver cancer
Physical Exam:
===============
ADMISSION PHYSICAL EXAM
===============
Vitals: T 98.1. BP 106/66, HR 71, RR 18, SpO2 98% RA
General: Alert, not oriented to hospital/city/year, no acute
distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, L upper molar
looks crooked (possibly loose?)
Neck: supple, JVP 7cm above sternal notch
Lungs: CTAB no wheezes/crackles
CV: RRR, S1/S2, no murmurs
Abdomen: soft, NT/ND, bowel sounds present, no rebound
tenderness or guarding
GU: no foley on admission
Ext: somewhat cool but 1+ pulses & well perfused, splint in
place on LLE (unable to assess for edema), trace pitting edema
up to ankles/mid-shin level of RLE, intact sensation
Neuro: CN2-12 intact, no focal deficits
===============
DISCHARGE PHYSICAL EXAM
===============
Vitals: 97.8 93/67 74 16 96% RA
General: Very sleepy all day (minimal change from his baseline,
per family), not oriented to hospital/city/year, no acute
distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP at clavicles
Lungs: clear breath sounds anteriorly w/o crackles
CV: RRR, S1/S2, no murmurs
Abdomen: soft, NT/ND, bowel sounds present, no rebound
tenderness or guarding
GU: condom catheter
Ext: somewhat cool but 1+ pulses & well perfused, tender over
mid-lateral LLE (unable to assess for edema), trace pitting
edema up to mid-shin level of RLE
Neuro: No focal deficits, PERRL. Intermittent napping all day,
but arousable. ___ strength ___ all muscle groups
Pertinent Results:
===============
ADMISSION LABS
===============
___ 02:17PM BLOOD WBC-10.1*# RBC-4.81# Hgb-13.7 Hct-43.3
MCV-90 MCH-28.5 MCHC-31.6* RDW-16.7* RDWSD-55.9* Plt ___
___ 02:17PM BLOOD Neuts-69.3 ___ Monos-7.2 Eos-0.1*
Baso-0.2 Im ___ AbsNeut-7.03* AbsLymp-2.31 AbsMono-0.73
AbsEos-0.01* AbsBaso-0.02
___ 02:17PM BLOOD ___ PTT-48.5* ___
___ 02:17PM BLOOD Glucose-160* UreaN-36* Creat-2.4* Na-135
K-6.5* Cl-98 HCO3-25 AnGap-19
___ 02:17PM BLOOD ___ 07:24PM BLOOD K-3.5
===============
DISCHARGE LABS
===============
___ 05:48AM BLOOD WBC-7.9 RBC-4.54* Hgb-13.6* Hct-42.6
MCV-94 MCH-30.0 MCHC-31.9* RDW-17.4* RDWSD-59.5* Plt ___
___ 05:48AM BLOOD ___ PTT-30.8 ___
___ 05:48AM BLOOD Glucose-77 UreaN-45* Creat-2.1* Na-139
K-4.1 Cl-97 HCO3-23 AnGap-23*
___ 05:48AM BLOOD Calcium-9.7 Phos-3.3 Mg-2.3
===============
IMAGING
===============
#CXR ___: PA and lateral views of the chest provided. Left
chest wall pacer device is again seen with leads extending to
the region the right atrium, right ventricle and coronaries
sinus. The heart remains enlarged with hilar congestion and
mild interstitial edema. No large effusion or pneumothorax is
seen. Bony structures are intact.
#LLE X-ray ___: Acute fracture involving the proximal to mid
shaft of the left fibula.
#RLE X-ray ___: No fracture or dislocation.
Brief Hospital Course:
BRIEF SUMMARY
================
___ speaking ___ gentleman with history of CAD, Afib, CHF,
renal cell carcinoma, and ___ Body dementia, presents to ED w/
left leg pain after unwitnessed fall 5d previously and mild CHF
exacerbation w/ mild ___. Leg fracture was managed
non-operatively by splinting, and CHF exacerbation was addressed
with diuresis.
ACTIVE ISSUES
=============
#Left fibular fracture: Patient fell 5 days prior to admission
(fall was unwitnessed, unknown trigger). Patient subsequently
felt generally well until the day of admission, when he
complained of left leg pain and was brought to the ___ Emergency
Department. In the ED, his left lower leg was splinted.
Orthopedic surgery was consulted, and recommended conservative
management (no surgery indicated, no cast, ambulate as
tolerated, follow-up with ___ clinic in two
weeks). Patient's pain was well-controlled with acetaminophen.
#CHF exacerbation w/ biventricular pacing, mild ___ on CKD:
Patient was clinically mildly hypervolemic on admission (CXR w/
hilar congestion and mild interstitial edema, trace lower
extremity edema on exam), but did not report any shortness of
breath, orthopnea, nor chest pain. Patient also had mild acute
kidney injury in background of chronic kidney disease (Cr 2.4 on
admission, increased from baseline of Cr 2.0), likely reflecting
cardiorenal syndrome in the setting of CHF exacerbation.
Patient's volume status was tracked by physical exam and serum
Cr. Urine output was difficult to accurately measure as a urine
catheter was felt to pose a risk of exacerbating any delirium,
given patient's history ___ Body Dementia. Patient was
diuresed with IV Lasix, and was transitioned back to torsemide
40 mg daily (which should start on ___ given mild overdiuresis
at time of discharge).
___ Body Dementia: Per daughter/HCT, at baseline, patient is
not oriented to city/day/year, naps frequently during the day
and has difficulty sleeping through the night. During his
admission, he was often sleepy but always rousable to voice.
Home dose of quetiapine was held briefly and there were no
issues with agitation during this admission.
CHRONIC ISSUES:
===============
___ Body Dementia: At baseline, patient not oriented to
place/city/year. Recognizes his daughter (also HCP) & other
family members. At baseline per family.
#Atrial fibrillation: INR 3.7 on admission, so Coumadin was held
briefly and then restarted.
TRANSITIONAL ISSUES:
====================
# Crooked molar in left upper jaw, unclear if it is loose. Needs
dental follow-up. Ground solids, thin liquids, crushed meds w/
close supervision per speech and swallow evaluation.
# Please monitor daily weights (discharge weight of 92.94 kg).
___ call MD if increases 3 pounds over 3 days as he may need
adjustment of diuretic dose. He should resume dose of torsemide
40 mg starting on ___ (dose on ___ held in setting of mild
overdiuresis).
# Please draw Chem10 on ___ to monitor electrolytes and
creatinine.
# CODE STATUS: DNR/DNI
# CONTACT: ___ (daughter, HCP, ___, Dr. ___
___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Divalproex Sod. Sprinkles 125 mg PO BID
2. QUEtiapine Fumarate 25 mg PO Q6H:PRN agitation
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
5. Digoxin 0.125 mg PO EVERY OTHER DAY
6. Warfarin 3 mg PO 3X/WEEK (___)
7. Torsemide 40 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE DAILY
10. TraZODone 12.5 mg PO QHS:PRN insomnia
11. Levothyroxine Sodium 12.5 mcg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
14. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze/sob
16. Warfarin 2.5 mg PO 4X/WEEK (___)
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Clopidogrel 75 mg PO DAILY
4. Digoxin 0.125 mg PO EVERY OTHER DAY
5. Divalproex Sod. Sprinkles 125 mg PO BID
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE BID
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze/sob
8. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE DAILY
9. Levothyroxine Sodium 12.5 mcg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. QUEtiapine Fumarate 25 mg PO Q6H:PRN agitation
12. Torsemide 40 mg PO DAILY
13. TraZODone 12.5 mg PO QHS:PRN insomnia
14. Vitamin D 1000 UNIT PO DAILY
15. Warfarin 3 mg PO 3X/WEEK (___)
16. Warfarin 2.5 mg PO 4X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
Left fibular fracture
CHF
___ w/ CKD
Afib on Coumadin
SECONDARY DIAGNOSES:
====================
___ Body Dementia
HTN
GERD
Sick sinus syndrome, LBBB w/ pacemaker
Renal cell carcinoma ___ cyberknife ___
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
We saw you in the hospital for your broken left leg and for
heart failure. This injury likely happened when you fell on
___. X-rays of you leg showed a recent break in the one of
the bones in your calf. You also had x-rays of your chest that
indicated very mild worsening of your heart failure.
Your leg was splinted in the Emergency Department to protect it.
The Orthopedic doctors ___ and recommended no surgery,
instead physical therapy and following up with them in clinic
later. Please take special care when you return to the ___
___ facility to walk carefully to avoid falls and follow the
recommendations of the physical therapists. Always call for help
if you feel unsteady.
Due to your history of heart disease, you received diuretic
medications to help remove extra fluid from your body. As the
extra fluids were removed, the very mild decrease in kidney
function resolved and your kidney returned to their baseline
level of function. You should continue your home dose of
torsemide 40 mg daily starting on ___.
Please follow-up with your primary care doctor to optimize your
heart medications and monitor your Coumadin anticoagulation and
the orthopedic doctor as scheduled to make sure that your left
leg heals as expected.
It was a pleasure to participate in your care!
Sincerely,
Your ___ team
Followup Instructions:
___
|
10448881-DS-14 | 10,448,881 | 21,851,066 | DS | 14 | 2180-09-30 00:00:00 | 2180-10-03 14:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Bactrim / clarithromycin / Sulfa
(Sulfonamide Antibiotics) / Penicillins / trimethoprim /
Amoxicillin
Attending: ___
Chief Complaint:
Jaundice and diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a recent diagnosis (___) of autoimmune hepatitis
secondary to presumed medication reaction, who was transferred
from ___ with diarrhea. Patient reports she was seen at
___ for diarrhea generalized fatigue and
jaundice was found to be hyponatremic with a rising T. bili and
was subsequently transferred here as her liver physicians are at
this facility. She denied abdominal pain, nausea, vomiting,
blood in her stool, black stool, fevers, chills, cough, chest
pain, shortness of breath, flank pain, dysuria.
In the ED, initial vitals were 98.2 70 125/51 16 97% RA. Labs
were notable for essentially stable CBC without leukocytosis,
INR 1.1, Na 132 (131 in clinic ___, bicarb 18, AST/ALT 362/430
(down from 604/586), AP 260 (down from 300), T bili 19.0, up
from 18.3. UA clean, CT abd/pelvis unremarkable. She was seen by
hepatology fellow who recommended admission and c diff rule out.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
1. Diabetes.
2. Hypertension.
3. Hyperlipidemia.
4. h/o c diff ___ years ago
Social History:
___
Family History:
No GI disease
Physical Exam:
Admission physical exam
VS: 97.5 119/61 78 18 97%RA
General: Jaundiced, comfortable, crying, alert and oriented, no
asterixis
HEENT: OP clear, MMM
Neck: No JVD
CV: RRR, no murmurs
Lungs: CTA bilaterally, no wheezes/crackles
Abdomen: Soft, not distended, nontender, absent BS, no fluid
wave
GU No foley
Ext: 1+ edema b/l ___ to mid tibia
Skin: To petechia, telangiectasia
Discharge physical exam
VS: 98.1, 104/56 69 18 99% on RA
General: Jaundiced and in no acute distress
HEENT: sclera icteric, oral mucosa moist, EOMI
Neck: Supple, no jVD
CV: RRR, no murmurs
Lungs: CTAB, no wheezes, no crackles
Abdomen: Soft, nondistended, nontender
Ext: 1+ edema bilaterally to knees
Skin: spider angiomata on back
Pertinent Results:
Admission labs
___ 05:53PM BLOOD WBC-10.1 RBC-4.02* Hgb-13.8 Hct-42.5
MCV-106* MCH-34.5* MCHC-32.6 RDW-16.6* Plt ___
___ 05:53PM BLOOD ___ PTT-26.9 ___
___ 05:53PM BLOOD Glucose-270* UreaN-15 Creat-0.7 Na-132*
K-4.6 Cl-103 HCO3-18* AnGap-16
___ 05:53PM BLOOD ALT-430* AST-362* AlkPhos-260*
TotBili-19.0* DirBili-15.3* IndBili-3.7
___ 05:53PM BLOOD Albumin-2.8* Calcium-8.7 Phos-2.9 Mg-2.0
___ 02:30AM BLOOD HAV Ab-NEGATIVE
___ 12:53PM BLOOD AMA-NEGATIVE
___ 12:53PM BLOOD tTG-IgA-15
Discharge labs
___ 05:06AM BLOOD WBC-8.5 RBC-3.54* Hgb-12.2 Hct-37.0
MCV-105* MCH-34.5* MCHC-32.9 RDW-16.1* Plt ___
___ 05:06AM BLOOD ___ PTT-46.8* ___
___ 05:06AM BLOOD Glucose-118* UreaN-18 Creat-0.9 Na-134
K-4.6 Cl-101 HCO3-25 AnGap-13
___ 05:06AM BLOOD ALT-343* AST-321* AlkPhos-245*
TotBili-15.2*
___ 05:06AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.9
CT of abdomen
IMPRESSION:
1. No acute intra-abdominal process, specifically no evidence of
colitis.
2. Mild ectasia of the infrarenal abdominal aorta measuring up
to 2.8 cm in maximum diameter. Follow-up ultrasound
surveillance is recommended in ___ year.
Brief Hospital Course:
___ F with diabetes and drug induced autoimmune hepatitis on
prednisone presenting with diarrhea.
# Diarrhea: Etiology was unclear however it completely resolved
prior to discharge. Likely culprits include medication induced
(ursodiol) vrs viral gastroenteritis, no sick contacts except
daughter with diarrhea and recent diagnosis of celiac. Negative
CT reassuring, no melena. Urosodiol was stopped. No diarrhea to
check for c.diff.
# Autoimmune hepatitis: Apparently began in ___ Likely drug
induced (bactrim and chlarythromycin), improving with steroid
treatment; note patient didn't tolerate azathioprine or
ursodiol. Held off on starting cellcept for outpatient as
patient also concerned about more diarrhea and wanted a minor
break. No hepatic encephalopathy, no ascites, no renal failure.
# Diabetes: Reduced glargine to 30 given low AM sugars,
Increased sliding scale since she's on increased prednisone.
Glargine reduced 45->30 units HS. D/c on 30 units given low
morning sugars to ___.
### TRANSITIONAL ISSUES:
- Autoimmune hepatitis: On 40mg prednisone.
- will have MRI of liver prior to ___ appointment. On
day of MRCP will be NPO so will take only ___ of lantus before
MRI. Will need close sugar follow up.
- f/u w/ ___ ___
- could consider Mycophenolate for Autoimmune hepatitis per Dr.
___
- ursodiol discontinued since ___ be source of her diarrhea
- f/u IgA, tTG
- f/u CMV viral load
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 45 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
2. Lisinopril 20 mg PO DAILY
3. Lorazepam 0.5 mg PO HS:PRN insomnia
4. PredniSONE 40 mg PO DAILY
5. Propranolol LA 120 mg PO DAILY
6. Ursodiol 500 mg PO BID
Discharge Medications:
1. Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Lisinopril 20 mg PO DAILY
3. Lorazepam 0.5 mg PO HS:PRN insomnia
4. PredniSONE 40 mg PO DAILY
5. Propranolol LA 120 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Diarrhea
Autoimmune Hepatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___ were admitted to ___
___ with diarrhea which improved. ___ will continue your
Prednisone and follow up with the ___ at ___
___. ___ will also have an MRI of your liver prior to your
appointment. Please only take 20 units of Lantus the night
before your MRI since ___ should not eat after midnight. Also
bring juice with ___ in case your blood sugars are low.
Followup Instructions:
___
|
10448910-DS-18 | 10,448,910 | 22,470,405 | DS | 18 | 2127-09-13 00:00:00 | 2127-09-14 00:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ man with HTN and HLD who presents
with nausea and vomiting x 2 days. He reports that 2 days ago he
and his family ate at a restaurant, and that evening he
developed lower abdominal cramping accompanied by severe chills.
Patient reports that he soaked through multiple sheets that
evening. The following morning he begun to have nausea and
vomiting, with persistent rigors. He therefore came to the ED,
and in triage had an episode of bilious emesis. No CP or SOB. No
orthopnea or PND. He has no subjective fevers, no urinary
symptoms. No cough or hemoptysis. No recent sick contacts though
he lives at a senior home.
In the ED, initial vital signs were: T 98, HR 109, BP 160/81, RR
18, SaO2 95% RA. Rectal temp 101. Tmax 101.8, HR 93, BP 108/57
RR 20 SaO2 95% on RA.
- Exam notable for: dry lips, lightheadness when sitting up.
- Labs were notable for WBC 11.9, H/H 15.2/44.1, ALT/AST 55/54,
Amylase 424, Lipase 487, Tbili 1.1. Lactate 3.4 10:40 AM > 2.8
11:32 AM. Potassium 2.8. BUN/Cr ___. blood cx pending.
- Studies performed include CXR c/f LLL pneumonia. CT abdomen
w/contrast showed no acute intra-abdominal process. The pancreas
is normal in attenuation and there is no peripancreatic fat
stranding or pancreatic ductal dilatation.
- Patient was given CTX 1gm IV Q24H x1/azithromycin 500mg x1, 3L
NS IVF, K repletion with KCl 60mEq, MgSO4 2gm IV x 1, Tylenol
___ mg PR x1.
- Vitals on transfer: T 98, HR 82, BP 106/60, RR 16, SaO2 95% on
RA
Upon arrival to the floor, the patient hemodynamically stable,
reports ___ headache.
ROS: 10-point ROS NEGATIVE except as noted above in HPI
Past Medical History:
Hypertension
Hyperlipidemia
Social History:
___
Family History:
Denies any significant FH.
Physical Exam:
ON ADMISSION:
======================
Vitals: T 97.8, BP 106/57, HR 77, RR 16, SaO2 96% on RA
GENERAL: Resting comfortably, in no acute distress.
HEENT: NC/AT. Neck supple, JVD flat. No carotid bruits.
PULM: CTAB, no wheezes.
CARDIAC: RRR, normal S1/S2, III/VI SEM @ LUSB radiating to the
carotids.
ABD: Soft, nontender, nondistended, bowel sounds hypoactive. No
rebound or guarding.
EXT: WWP, no c/c/e.
NEUROLOGIC: A&Ox3. CNII-XII grossly intact. ___ strength
througout. Normal sensation.
ON DISCHARGE:
======================
Vitals: Tc 99, BP 140/65, HR 63, RR 16, 96% RA
GENERAL: Resting comfortably, in NAD.
HEENT: NC/AT. Neck supple, JVD flat. No carotid bruits.
PULM: CTAB, no wheezes.
CARDIAC: RRR, normal S1/S2, III/VI SEM at LUSB radiating to the
carotids.
ABD: BS+, soft, NTND
EXT: WWP, no c/c/e.
NEUROLOGIC: A&Ox3. CNII-XII grossly intact. ___ strength
throughout. Normal sensation.
Pertinent Results:
ADMISSION LABS:
==================
___ 10:40AM BLOOD WBC-11.9*# RBC-5.03 Hgb-15.2 Hct-44.1
MCV-88 MCH-30.2 MCHC-34.5 RDW-13.3 RDWSD-42.4 Plt ___
___ 10:40AM BLOOD Neuts-87.9* Lymphs-6.6* Monos-4.3*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-10.47* AbsLymp-0.78*
AbsMono-0.51 AbsEos-0.00* AbsBaso-0.02
___ 10:40AM BLOOD Plt ___
___ 07:15PM BLOOD Plt ___
___ 10:40AM BLOOD Glucose-148* UreaN-21* Creat-1.1 Na-138
K-2.8* Cl-99 HCO3-22 AnGap-20
___ 10:40AM BLOOD ALT-55* AST-54* CK(CPK)-154 AlkPhos-60
Amylase-424* TotBili-1.1
___ 10:40AM BLOOD Lipase-487*
___ 07:15PM BLOOD Lipase-231*
___ 10:40AM BLOOD CK-MB-2
___ 10:40AM BLOOD cTropnT-0.21*
___ 10:40AM BLOOD Albumin-4.2
___ 07:15PM BLOOD Albumin-3.1* Calcium-7.6* Phos-1.8*
Mg-2.1 Cholest-138
___ 07:15PM BLOOD Triglyc-78 HDL-51 CHOL/HD-2.7 LDLcalc-71
LDLmeas-77
===================
PERTINENT RESULTS:
===================
LABS:
===================
___ 10:40AM BLOOD CK-MB-2
___ 10:40AM BLOOD cTropnT-0.21*
___ 09:45PM BLOOD CK-MB-4 cTropnT-0.12*
___ 05:59AM BLOOD CK-MB-3 cTropnT-0.08*
===
___ 07:15PM BLOOD Triglyc-78 HDL-51 CHOL/HD-2.7 LDLcalc-71
LDLmeas-77
===
___ 10:40AM BLOOD Lipase-487*
___ 07:15PM BLOOD Lipase-231*
===
___ 11:32AM BLOOD Lactate-3.4*
___ 12:31PM BLOOD Lactate-2.8*
___ 05:13PM BLOOD Lactate-2.8*
___ 02:22AM BLOOD Lactate-1.1
===================
MICROBIOLOGY:
===================
Blood culture ___ 11:04 am): ESCHERICHIA COLI.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- <=1 S
====================================
Blood cultures (___) x 2 more sets: No growth (FINAL)
Blood cultures (___) x 4 sets: No growth (FINAL)
Urine culture (___): No growth.
===================
IMAGING/STUDIES:
===================
CXR (___):
1. Left lower lobe opacity concerning for infection or sequelae
of aspiration in the appropriate clinical setting.
2. Possible trace left pleural effusion.
3. Bronchial wall thickening in the lower lobes is suggestive
small airways disease.
===================
CT Abdomen With Contrast (___):
1. No acute intra-abdominal process. The pancreas is normal in
attenuation and there is no peripancreatic fat stranding or
pancreatic ductal dilatation.
2. Mild bibasilar atelectasis more marked on left.
====================
RUQ US (___):
1. Mildly distended gallbladder with sludge balls/tumefactive
sludge, but no evidence of gallbladder wall edema or
pericholecystic fluid to suggest acute cholecystitis.
2. Small right pleural effusion.
3. Stable hepatic cyst.
===================
EKG (___): NSR at 70 bpm. Normal axis. First degree AV block
with PR 234. TWIs in II, III, aVF.
===================
DISCHARGE LABS:
===================
___ 06:40AM BLOOD WBC-6.6 RBC-4.04* Hgb-12.2* Hct-35.8*
MCV-89 MCH-30.2 MCHC-34.1 RDW-13.5 RDWSD-43.7 Plt ___
___ 06:40AM BLOOD Glucose-88 UreaN-13 Creat-0.8 Na-136
K-3.4 Cl-106 HCO3-21* AnGap-12
___ 06:40AM BLOOD Calcium-7.9* Phos-2.2* Mg-1.9
Brief Hospital Course:
Mr. ___ is an ___ y/o man with a history of hypertension and
hyperlipidemia who presented with nausea, vomiting, and
abdominal pain and found to have pancreatitis likely caused by
biliary sludge and with subsequent E. coli bacteremia.
==================
ACTIVE ISSUES:
==================
# Pancreatitis, mild, likely gallstone
# Cholangitis
# Sepsis
The patient presented with nausea, vomiting, and abdominal pain.
His lipase was elevated to 487. LFTs on admission showed total
bilirubin of 1.1 and mild transaminitis (AST 54/ALT 55). CT
abdomen was without intraabdominal process. However, right upper
quadrant ultrasound showed sludge balls. Although he had no
radiographic findings of acute pancreatitis, he did have classic
abd pain and elevated lipase, thereby he qualifies for acute
pancreatitis with 2 of 3 criteria. Ultimately, it was thought
that his pancreatitis was due to transient obstruction from
biliary sludge (essentially a gallstone pancreatitis); he had no
other clear etiology of acute pancreatitis (normal Ca, normal
___. Although he had rapid improvement of his symptoms
(resolved essentially on transfer from ED to floor) and his
transaminases returned to ___ the following day (T. Bi and Alk
Phos were always WNL), the fact that he presented with sepsis
(leukocytosis, fever, chills, end-organ damage with ___ and had
elevated transaminases on labs and sludge seen in RUQ
ultrasound, as well as subsequently identified bacteremia, he
also had acute cholangitis. At the time, given his mild
pancreatitis course and rapid resolution of his cholangitis,
further detailed evaluation of his CBD was not done with ERCP.
Of note, he never had obvious sustained CBD obstruction as his
LFT's downtrended quickly and his CBD was noted to be WNL on CT
and RUQ US. The patient was given supportive care with IVF
hydration. By day of discharge, the patient was tolerating a
bland diet without nausea or abdominal pain. We recommend an
outpatient eval by Surgery for lap CCY consideration. We also
discussed his case with ERCP and are working to schedule an
outpatient ERCP before his evaluation by Surgery.
# Acute blood stream infection: One out of three sets of blood
cultures from day of admission grew E. coli. The patient was
initially started on broad-spectrum antibiotics and then
narrowed to ciprofloxacin based on sensitivities to complete a
10-day course (Last day ___. His transient bacteremia was
likely caused by his pancreatitis/bile duct obstruction /
cholangitis as above.
# NSTEMI: On admission, the patient was noted on EKG to have T
wave inversions in leads II, III, aVF. He denied chest pain.
Troponins were found to be elevated to .21->.12->.08, CK-MB
normal. Repeat EKG on day of discharge showed improvement in
these T wave inversions. The patient denies any known history of
CAD, but he does carry risk factors of HTN and HLD. Of note, he
had no chest pain prior to presentation or during his
hospitalization. The patient may benefit from further work-up
and cardiovascular risk stratification with stress testing.
Recommend outpatient echocardiography and re-checking a lipid
panel. We also started a daily aspirin and resumed his home
statin at discharge. Beta-blocker therapy should be considered
at PCP ___.
# ___: Although his Cr on presentation was WNL, he also had
elevated BUN at 21. In setting of sepsis, this likely
represents ___ / ARF. This was further supported by improvement
of hi Cr to 0.7 - 0.8 after receiving IVF.
# Anemia: The patient's H/H on admission was was 15./44.3. He
subsequently developed a mild anemia that was initially
attributed to hemodilution from aggressive IVF hydration for
pancreatitis. However, his hematocrit did not improve after
stopping IVF; H/H on day of discharge was 12.2/35.8. More
likely he was hemoconcentrated on admission from acute
pancreatitis with volume depletion, and his subsequent anemia is
likely his baseline and chronic. He should have a CBC
re-checked at PCP ___ and further work-up as indicated.
Of note, his most recent available bloodwork in OMR shows a HCT
of 45 in ___. He does not appear to have had a
colonoscopy, so a colonoscopy should be considered as an
outpatient for anemia work-up.
=======================
CHRONIC ISSUES:
=======================
# Hyperlipidemia: Patient's statin was initially held in the
setting of mild transaminitis. His transaminitis resolved, and
his statin was restarted upon discharge.
# Hypertension: Patient's antihypertensive was held during
admission. The patient was normotensive at discharge, so this
was not restarted.
=======================
TRANSITIONAL ISSUES:
=======================
- Patient to complete 10-day course of ciprofloxacin for E. coli
bacteremia (Last day: ___
- Patient found to have biliary sludge balls that may have been
the cause of his pancreatitis. He will follow up with surgery to
discuss possible cholecystectomy once his bacteremia has
resolved.
- he will need an ERCP evaluation to clear his CBD prior to lap
CCY evaluation.
- For his NSTEMI, recommend outpatient echo, patient may benefit
from beta blocker and ace inhibitor as well as consideration of
stress testing in the future for further cardiovascular risk
stratification.
- Of note, patient endorsed taking what may have been an herb
prior to admission. We stressed the importance of the patient
taking only medications prescribed by his doctors.
- Please repeat CBC and evaluate patient's anemia as
appropriate. H/H on discharge 12.2/35.8.
- Holding patient's anti-hypertensive regimen on discharge,
consider switching to metoprolol if patient is found to have
underlying heart disease.
- Emergency Contact: ___ (daughter) ___
- Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO QPM
2. Omeprazole 20 mg PO DAILY
3. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*1
2. Ciprofloxacin HCl 500 mg PO Q12H
Last day ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth Twice a day
Disp #*14 Tablet Refills:*0
3. Omeprazole 20 mg PO DAILY
4. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
==============
Pancreatitis, gallstone
Acute blood stream infection
SECONDARY:
=============
Non-ST-Segment Elevation Myocardial Infarction
Transaminitis
Hypokalemia
Acute kidney injury
Anemia
Hypertension
Hyperlipidemia
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. You came to the hospital
because you were having nausea and vomiting. We found that you
had pancreatitis, likely caused by gall stones. We also found
that you had an infection in your blood and we gave you
antibiotics to treat this. Please continue to take your
medications as prescribed. Your new medications are:
Ciprofloxacin 500 mg twice per day (Last day: ___
Aspirin 81 mg daily
Please only take medications prescribed by your doctors.
We wish you the best of health.
- Your ___ Team
Followup Instructions:
___
|
10448948-DS-21 | 10,448,948 | 23,644,178 | DS | 21 | 2128-05-28 00:00:00 | 2128-06-02 23:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
fenofibrate / Statins-Hmg-Coa Reductase Inhibitors / Vytorin
Attending: ___
Chief Complaint:
tingling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ (BID #: ___) is a ___ year old male with a
history of aortic stenosis s/p replacement and CAD s/p CABG who
presents to the ED for evaluation of subarachnoid hemorrhage.
His history begins six weeks ago when he was in ___
visiting his daughter. He was sitting and talking to her when he
suddenly noticed an abnormal sensation in his right hand. He
describes this as a "tensing up" but denies numbness, pins and
needles, or other abnormal sensation. The feeling was located
only in the ___ and ___ digits, and when he looked at them he
noticed that they had involuntarily contracted in such a manner
that the ___ digit was overlapping the ___. Within a matter of
seconds, he then experienced a "tightening" of the right side of
his face, which he describes as occurring in the V2-V3
distribution, sparing the forehead. Again, he denies any other
abnormal sensory phenomena. He states that he began slurring his
words. He reports that his daughter told him his face looked
abnormal, but did not overtly say it was drooping. During this
time, he denies any headache, diplopia, blurry vision, abnormal
tastes or smells, tinnitus, vertigo, lightheadedness, hearing
loss, dysphagia. There was no other area of weakness, including
in the other digits of the hand. He was able to walk without
difficulty. The episode lasted about 10 minutes and resolved
spontaneously, after which point he was completely back to
normal.
He did not seek any medical attention at the time, but did
mention it to his primary care physician back in ___. An MRI
was obtained, and showed leptomeningeal susceptibility artifact
on gradient imaging, left slightly greater than right in the
frontal and parietal region, suggestive of superficial
siderosis.
No medication changes were made at that time.
He did not have any further episodes until tonight at around
10:30pm, when he was with his girlfriend at her home and again
developed a sensation of "tightening" in his right hand. This
time however, the entire hand below the wrist was involved. He
states that his fingers felt stiff and were difficult to move,
but he was able to do so. Again he denies any other abnormal
sensory or motor phenomena. About 60 seconds later, he again
developed "stiffness" of the right side of the face in the V2-V3
distribution. He did not say anything or look at his girlfriend,
so he is unsure if there was any dysarthria or facial droop.
This
episode lasted 5 minutes and resolved spontaneously, after which
he returned to normal. This time, he decided to present to the
ED. He went initially to ___, where a
non-contrast head CT a left convexal subarachnoid hemorrhage. He
was subsequently transferred to ___.
On arrival to ___, he remains asymptomatic.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysphagia, lightheadedness, vertigo, tinnitus
or hearing difficulty. Denies difficulties comprehending speech.
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:
Recent diagnosis of severe aortic stenosis
GERD
Hyperlipidemia
Osteoarthritis
Hard of hearing (bilateral hearing aids)
Varicose veins
Hx of Vertigo
Past Surgical History:
Left hand surgery at the age of ___
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM:
===============
Vitals: T 98.1 HR 71 BP 165/99 RR 18 SpO2 95% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ forward but
refuses to do them backward. 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 within limits of educational
level. Speech was not dysarthric. Able to follow both midline
and
appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Visual acuity
___ bilaterally. Fundoscopic exam limited by cataracts but
otherwise revealed no papilledema, exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibration, proprioception throughout. No extinction to DSS.
Romberg absent.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty.
DISCHARGE EXAM:
==============
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ forward but
refuses to do them backward. 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 within limits of educational
level. Speech was not dysarthric. Able to follow both midline
and
appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Visual acuity
___ bilaterally. Fundoscopic exam limited by cataracts but
otherwise revealed no papilledema, exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibration, proprioception throughout. No extinction to DSS.
Romberg absent.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty.
Pertinent Results:
ADMISSION LABS:
===============
___ 02:20AM BLOOD WBC: 7.0 RBC: 4.25* Hgb: 14.2 Hct: 41.9
MCV: 99* MCH: 33.4* MCHC: 33.9 RDW: 12.4 RDWSD: 44.___
___ 02:20AM BLOOD ___: 10.8 PTT: 28.8 ___: 1.0
___ 02:20AM BLOOD Glucose: 116* UreaN: 24* Creat: 1.3* Na:
138 K: 4.9 Cl: 99 HCO3: 24 AnGap: 15
___ 02:20AM BLOOD Calcium: 9.7 Phos: 3.7 Mg: 2.1
Radiologic Data:
Noncontrast CT: There is small subarachnoid hemorrhage involving
the left hemispheric vertex sulci, specifically involving the
sulci of the precentral gyrus and postcentral gyrus ___
and
2:25, respectively). There is possible increase in the
subarachnoid hemorrhage involving the postcentral gyrus (02:26),
however this may be due to differences in technique of studies
(compared to 201:43 from outside institution head CT).
CTA: No evidence of dissection, occlusion, aneurysm >3mm, or
flow
limiting stenosis. No evidence of active extravasation.
MRI:
1. There is prominent gradient echo susceptibility artifact with
associated
FLAIR hyperintense signal and subtle diffusion-weighted
hyperintense signal
within the sulci of the left central and postcentral sulci
corresponding to
subarachnoid hemorrhage demonstrated on recent CTs.
2. In addition, there appears to be superficial siderosis
involving the
bilateral frontal, left frontal parietal and right temporal
parietal lobes, as
well as a punctate focus of gradient echo susceptibility in the
right inferior
parietal lobule. Overall, the findings raises the suspicion for
amyloid
angiopathy and repeated subarachnoid hemorrhage. Vasculitis is
a differential
consideration.
3. There is associated sulcal enhancement corresponding to the
region of new
subarachnoid hemorrhage, felt likely to be reactive hyperemia.
4. No cortical FLAIR signal abnormality to suggest underlying
infarct as
etiology of hemorrhage.
5. Superimposed periventricular and subcortical rounded and
confluent T2/FLAIR
white matter hyperintensities are nonspecific, but compatible
with chronic
microangiopathy in a patient of this age.
6. Additional findings described above.
Brief Hospital Course:
___ is a ___ year old male who presents to the ED after
an episode of right hand stiffness followed by right-sided
facial tensing with NCHCT showing cSAH.
#cSAH
On admission to the hospital, his neurologic exam was normal and
he was not experiencing right hand stiffness. He had an MRI,
which showed superficial siderosis and new subarachnoid
hemorrhage on the left. Etiology of this bleed was thought to be
either traumatic given patient's history of mild head trauma vs.
secondary to cerebral amyloid angiopathy. There were no
microbleeds on GRE, and patient does not have cognitive deficits
(although does have frontal release signs on exam) which argues
against CAA. RCVS thought to be less likely as patient never
experienced thunderclap headache. For this, his aspirin was
stopped given SAH and risk for bleeding. Please continue to
discuss risk and benefits as an outpatient.
#Spreading cortical depression
Regarding his sensory symptoms, likely etiology is cortical
spreading depression. We obtained a routine EEG which showed no
seizure. Given the risk of seizure, he was started on Keppra 500
mg BID with plan to taper off over the next month.
TRANSITIONAL ISSUES:
[] Ensure he has obtained a hard hat to prevent traumatic bleed
[] Follow-up with neurology
[] Follow-up final EEG read
[] Follow-up Cr as outpatient given ___ during admission (normal
on discharge)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ranitidine 150 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Aspirin 81 mg PO DAILY
5. Vitamin E 400 UNIT PO DAILY
6. Glucosamine Chondroitin MaxStr (glucosamine-chondroit-vit
C-Mn) 500-400 mg oral DAILY
Discharge Medications:
1. LevETIRAcetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Glucosamine Chondroitin MaxStr (glucosamine-chondroit-vit
C-Mn) 500-400 mg oral DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Ranitidine 150 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Vitamin E 400 UNIT PO DAILY
7. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until told to resume by your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
convexal subarachnoid hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital because you had an abnormal sensation
in your right hand and face. You had a CT scan of your brain at
___, which showed blood in the subarachnoid space (around
your brain). You were transferred to ___ for further workup.
We did an MRI of your brain, which did not show any clear reason
for you to have this bleeding. You have hit your head a few
times at work, and although minor, this trauma may be the cause
of your brain bleed. Some people can have brain bleeding in
relation to dementia, but you don't show any signs of dementia
so we think this is less likely. Since you have had bleeding in
the brain, you should avoid medications that thin the blood or
interfere with platelet function, such as aspirin or Coumadin.
Given your risk of seizures when blood is in your head, you were
started on Keppra 500 mg BID to prevent seizures. We did an EEG,
which showed no evidence of seizures.
You should start taking these medications:
- Keppra 500 mg twice a daily
**This medication will be tapered as follows***
- Take Keppra 500 mg (1 tablet) twice a day for 21 days
- Then, take Keppra 250 mg ___ tablet) twice a day for 7 days
- Then, stop taking this medication
You should stop taking these medications:
- Aspirin 81 mg daily
It was a pleasure taking care of you and we wish you the best!
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10448948-DS-22 | 10,448,948 | 24,341,079 | DS | 22 | 2128-08-30 00:00:00 | 2128-11-19 13:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
fenofibrate / Statins-Hmg-Coa Reductase Inhibitors / Vytorin /
ezetimibe
Attending: ___
Chief Complaint:
Right sided paresthesias
Major Surgical or Invasive Procedure:
none
none
History of Present Illness:
Patient is an ___ year old right handed man with past medical
history of recent admission left convexal subarachnoid
hemorrhage
(___), AS s/p replacement, and CAD s/p CABG whom presents
with right sided paresthesias for the last three days.
Patient reports that his right face, hand, and leg have had
intermittent sensation of tightness and numbness for the last
three days. Patient had two episodes of leg numbness today that
each lasted five to fifteen minutes. Patient states that one
episode the feeling started at his right mid thigh and over
minutes moved down to his ankle. The second episode was the
opposite with the episode starting at the ankle and moving up to
the mid thigh. Patient's numbness/tightness is described as
circumferential and non dermatomal. Denies triggers.
Patient reports that in the two previous days he has had the
same
symptoms, sometimes though involving the face and arm. Patient
became frustrated when examiner asked him to clarify these
episodes. He refused to elaborate further, but did suggest that
sometimes all three parts are affected at the same time and
sometimes only one or two parts are affected.
Patient, additionally, reported that this evening before he
presented to outside hospital he had a ___ minute episode where
he was having difficulty with speaking and feels the character
of
his voice changed.
Pertinently, patient was admitted here ___ and the following
is documented in his discharge summary:
Convexal subarachnoid hemorrhage:
On admission to the hospital, his neurologic exam was normal and
he was not experiencing right hand stiffness. He had an MRI,
which showed superficial siderosis and new subarachnoid
hemorrhage on the left. Etiology of this bleed was thought to be
either traumatic given patient's history of mild head trauma vs.
secondary to cerebral amyloid angiopathy. There were no
microbleeds on GRE, and patient does not have cognitive deficits
which argues against CAA. RCVS thought to be less likely as
patient never experienced thunderclap headache. For this, his
aspirin was stopped given subarachnoid hemorrhage and risk for
bleeding.
#Spreading cortical depression
Regarding his sensory symptoms, likely etiology is cortical
spreading depression. We obtained a routine EEG which showed no
seizure. Given the risk of seizure, he was started on
levetiracetam 500 mg BID with plan to taper off over the next
month.
Pertinently, since discharge patient has not restarted aspirin
81
mg daily and he has not taken levetiracetam in about one month.
ROS:
On neurological review of systems, the patient denies headache,
confusion, difficulties producing or comprehending speech, loss
of vision, blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. Denies
focal weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the patient denies recent fever,
chills, night sweats, or recent weight changes. Denies cough,
shortness of breath, chest pain or tightness, palpitations.
Denies nausea, vomiting, diarrhea, constipation or abdominal
pain. Denies dysuria, or recent change in bowel or bladder
habits. Denies arthralgias, myalgias, or rash.
Past Medical History:
Left convexal subarachnoid hemorrhage (___)
Aortic stenosis, post replacement
Coronary artery disease, post bypass
GERD
Hyperlipidemia
Osteoarthritis
Hard of hearing (bilateral hearing aids)
Varicose veins
Hx of Vertigo
Past Surgical History:
Left hand surgery at the age of ___
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission PHYSICAL EXAMINATION:
General examination:
General: Comfortable and in no distress
Head: No irritation/exudate from eyes, nose, throat
Cardio: Regular rate and rhythm, warm, no peripheral edema
Lungs: Unlabored breathing
Abdomen: Soft, non tender, non distended
Skin: No rashes or lesions
Neurologic:
Mental Status:
Alert, oriented x 3. Able to relate history without difficulty.
Attentive, able to name ___ backward without difficulty.
Language
is fluent with intact repetition and comprehension. Normal
prosody. There were no paraphasic errors. Able to name both high
and low frequency objects. Able to read without difficulty. No
dysarthria. Able to follow both midline and appendicular
commands. Able to register 3 objects and recall ___ at 5
minutes.
There was no evidence of apraxia or neglect.
Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Visual acuity
___ bilaterally.
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. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
Sensory:
No deficits to light touch, pinprick, temperature, vibration,
or
proprioception throughout. No extinction to DSS.
Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
Coordination:
No intention tremor. Normal finger-tap bilaterally. No dysmetria
on FNF or HKS bilaterally.
Gait:
Deferred.
Discharge PHYSICAL EXAMINATION:
Vitals: 24 HR Data (last updated ___ @ 836)
Temp: 97.5 (Tm 98.3), BP: 108/70 (108-135/70-86), HR: 65
(55-65), RR: 18 (___), O2 sat: 94% (92-96), O2 delivery: RA
General: Comfortable and in no distress
Head: No irritation/exudate from eyes, nose, throat
Cardio: Regular rate and rhythm, warm, no peripheral edema
Lungs: Unlabored breathing
Abdomen: Soft, non tender, non distended
Skin: No rashes or lesions
Neurologic:
Mental Status:
Alert, oriented x 3. Able to relate history without difficulty.
Attentive, Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects.
Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
Motor:
Normal bulk and tone throughout. No pronator drift. Able to hold
all extremities antigravity and spontaneous
Sensory:
No deficits to light touch, pinprick.
Reflexes: deferred
Coordination:
No intention tremor. Normal finger-tap bilaterally. No dysmetria
on FNF
Gait: able to stand up from bed without assistance, normal gait
with normal stride lengths, able to walk on toes
Pertinent Results:
___ 04:40AM BLOOD WBC-7.2 RBC-3.88* Hgb-13.1* Hct-39.5*
MCV-102* MCH-33.8* MCHC-33.2 RDW-12.7 RDWSD-47.5* Plt ___
___ 04:40AM BLOOD ___ PTT-27.5 ___
___ 04:40AM BLOOD Glucose-92 UreaN-22* Creat-1.2 Na-140
K-4.4 Cl-101 HCO3-24 AnGap-15
___ 11:13PM BLOOD ALT-15 AST-24 AlkPhos-85 TotBili-0.2
___ 04:40AM BLOOD Cholest-200*
___ 04:40AM BLOOD %HbA1c-6.3* eAG-134*
___ 04:40AM BLOOD Triglyc-249* HDL-29* CHOL/HD-6.9
LDLcalc-121
MR ___ ___ IMPRESSION:
1. Previously seen left vertex subarachnoid hemorrhage has
decreased with new
small area of subacute subarachnoid hemorrhage developing since
prior. Subtle
adjacent cortical FLAIR hyperintensity. Differential
considerations are
amyloid related Angiitis or CAA related inflammation.
2. Extensive superficial siderosis cerebral hemispheres, can be
seen with
amyloid angiopathy.
3. Findings consistent with severe chronic small vessel ischemic
changes.
FINDINGS:
CONTINUOUS EEG: with video and 23 electrode EEG ___ electrode
placement,
T1, T2) and additional EOG and EKG, is recorded from 7:00 on
___ the same day. The background is characterized by a
low voltage,
fairly symmetric 9 Hz posterior rhythm. There are occasional
periods of mild
focal slowing in the left temporal region best seen during
drowsiness.
SLEEP: Elements of drowsiness are seen; however clear sleep
architecture was
not seen.
PUSHBUTTON ACTIVATIONS: There are no push button activations.
SPIKE DETECTION PROGRAMS: There are no file entries.
SEIZURE DETECTION PROGRAMS: There is one detection for muscle
artifact.
QUANTITATIVE EEG: Trend analysis is performed with Persyst Magic
Marker
software. Panels included automated seizure detection, rhythmic
run detection
and display, color spectral density array, absolute and relative
asymmetry
indices, asymmetry spectrogram, amplitude integrated EEG, burst
suppression
ratio, envelope trend, and alpha delta ratios. Segments showing
abnormal
trends are reviewed.
CARDIAC MONITOR: Shows a generally regular rhythm with an
average rate of
50-65 bpm.
IMPRESSION: This EEG monitoring study was abnormal due to:
Occasional mild
focal slowing in the left temporal region seen during
drowsiness, indicating
an underlying area of subcortical dysfunction. Of note the EKG
at times shows
bradycardia. There were no electrographic seizures or
epileptiform discharges.
Compared to the prior day's recording, the study is largely
unchanged.
CT ___ ___ IMPRESSION:
No significant change in small volume subarachnoid hemorrhage at
the left
vertex. No new hemorrhage.
Brief Hospital Course:
___ year old right handed man with past medical history of recent
admission left convexal subarachnoid hemorrhage (___), AS
s/p replacement, and CAD s/p CABG whom presented with right
sided paresthesias for three days and
possible episode of aphasia/dysarthria prior to admission.
#Convexal SAH: Imaging showed recurrence of left convexal SAH.
MRI showed evidence of CAA with superficial siderosis. Repeat CT
showed stability of SAH. He was monitored without recurrence of
symptoms he presented with. Bleed was felt to be secondary to
CAA.
#Paresthesias: Sensations that were present initially on
admission did not recur after admission. He had EEG done that
was negative for epileptiform activity. Unlikely that these
episodes represent seizures as they are not stereotyped, change
location and evolution and have no other associated symptoms.
Likely symptoms from spreading cortical depression from SAH and
CAA. He was not restarted on Keppra.
#CAD s/p CABG: held aspirin on admission and patient should not
restart given recurrence of SAH and high risk of subsequent
bleeds given CAA. He was continued on metoprolol.
Transitional Issues
====================
[] Please avoid anticoagulation or antiplatelets in this patient
in the future. He is at high risk of recurrence of bleeding due
to CAA
[] Metoprolol XL was continued at half dose 25mg daily. Please
adjust as appropriate.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No. If
no, reason why:
2. DVT Prophylaxis administered? () Yes - (x) No. If no, why not
(hemorrhage)
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form?
(x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? () Yes - (x) No. If no, why not? Patient at baseline
function
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Ranitidine 150 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Aspirin 81 mg PO DAILY
5. Glucosamine Chondroitin MaxStr (glucosamine-chondroit-vit
C-Mn) 500-400 mg oral DAILY
6. Vitamin E 400 UNIT PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*2
2. Glucosamine Chondroitin MaxStr (glucosamine-chondroit-vit
C-Mn) 500-400 mg oral DAILY
3. Ranitidine 150 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Vitamin E 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
==================
Convexal subarachnoid hemorrhage
CAA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were hospitalized due to symptoms of numbness and tingling
in your arm and leg resulting from an subarachnoid hemorrhage.
This was in the same area you already had bleeding a few months
ago. We think the bleeding is caused by build up of abnormal
protein in the blood vessels in your ___ that make them break
easily and cause bleeding. This is called cerebral amyloid
angiopathy.
We are not changing any of your medications
- please do NOT take aspirin
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:
___
|
10449236-DS-6 | 10,449,236 | 27,662,581 | DS | 6 | 2179-10-08 00:00:00 | 2179-10-10 16:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o anxiety, HTN, HLD, rheumatoid arthritis on
Methotrexate and recently started Enbrel (___), hepatitis C,
cervical cancer s/p hysterectomy and chemoradiation, former
smoker who presents to the ED with c/o shortness of breath.
The patient is a very poor historian but reports 4-days of
fatigue worsening dyspnea on exertion for the past dizziness,
and pleuritic chest pain. She describes the painpain does not
radiate around to the back, is constant, with no exacerbating or
alleviating factors. She reports feeling more short of breath
with exertion and is having difficulty lying flat at night. She
reports that she feels "dizzy" like she might pass out, and has
to hold onto things to prevent herself from falling. She has
been in contact with her PCP who encouraged her to come to the
ED for further evaluation. She denies any fevers, chills,
abdominal pain, nausea, vomiting, or leg swelling. Denies sick
contacts or recent travel.
In the ED,
- Initial Vitals: 98.3 99 93/47 22 91% RA
- Exam:
Mild respiratory distress, speaking in ___ word sentences
Head NC/AT
Tachycardic, no murmur
Diminished breath sounds bilaterally, no appreciable crackles or
wheezing
Obese, abdomen soft, focal tenderness in the LUQ, no rebound or
guarding
Skin warm and dry, no notable peripheral edema
- Labs: BNP 399, otherwise labs unremarkable
- Imaging: CXR:
New, severe pulmonary interstitial edema. Of note, superimposed
infection cannot be excluded. Probable small bilateral pleural
effusions.
- Consults: None
- Interventions: Given CTX/azithro, 40 IV Lasix, Zofran
On arrival to the MICU, patient reports she feels better than
when she presented. She endorses the history above.
Past Medical History:
- Abnormal infiltrative marrow process involving the sacrum,
iliac bones, acetabuli, and visualized lumbar spine, concerning
for malignancy.
- Pathologic fractures of the bilateral sacral ala and left
iliac bone.
- Stage IB adenocarcinoma of the cervix treated with a radical
TAH in ___ followed by sensitizing chemotherapy with WP
radiation (followed by Dr. ___ at ___
___). She was last seen by ___ in ___ (per scanned
note in OMR) and had scraping done that were negative for
malignancy.
- Iron deficiency anemia, does not tolerate oral iron
- Hepatitis C with negative viral loads
- Rheumatoid arthritis (diagnosed at ___) previously treated with
gold shots, etanercept (enbrel), and adalimumab (humera), but
currently on oral methotrexate and restarted on Enbrel
- Constipation
- GERD
- Osteoporosis
- Previous opioid addiction to percocet
- Dyslipidemia
- skull fracture s/p MVC with tympanoplasty and resultant
left-sided hearing loss
- Fall with right tib/fib fracture s/p surgical repair
- Left ankle fracture
- Wrist fracture
- Diverticulosis
Social History:
___
Family History:
-Mother: CAD/MI
-Father: ___ (smoker)
-Sister: ___
-Brother: ___ Aunt: ___ cancer
-___ Uncle: ___ cancer
Physical Exam:
ADMISSION EXAM:
VS: Reviewed in MetaVision
GEN: NAD, speaking in full sentences, intermittently tachypenic
EYES: EOMI, PERRLA
HENNT: MMM, no OP lesions
CV: RRR nl S1/S2, no m/r/g, difficult to appreciate JVD
RESP: decreased BS at the bases b/l
GI: soft, NT/ND
NEURO: AAOx3
EXT: warm, well perfused, no peripheral edema
DISCHARGE EXAM:
Vital signs: 24 HR Data (last updated ___ @ 732)
Temp: 97.9 (Tm 98.3), BP: 105/74 (91-114/58-78), HR: 79
(77-88), RR: 16 (___), O2 sat: 93% (93-95), O2 delivery: Ra,
Wt: 197.97 lb/89.8 kg
GENERAL: Alert and in no apparent distress
HEENT: NC/AT
CV: RRR, no m/r/g
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.
SKIN: No rashes or ulcerations noted
EXTR: possible trace ___ edema, no calf tenderness noted
NEURO: Non-focal
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 12:37PM BLOOD WBC-5.4 RBC-3.85* Hgb-11.4 Hct-34.3
MCV-89 MCH-29.6 MCHC-33.2 RDW-16.0* RDWSD-52.4* Plt ___
___ 12:37PM BLOOD Neuts-72.8* Lymphs-13.8* Monos-11.6
Eos-0.7* Baso-0.7 Im ___ AbsNeut-3.90 AbsLymp-0.74*
AbsMono-0.62 AbsEos-0.04 AbsBaso-0.04
___ 12:37PM BLOOD ___ PTT-30.5 ___
___ 12:37PM BLOOD Glucose-106* UreaN-14 Creat-0.7 Na-136
K-3.7 Cl-102 HCO3-21* AnGap-13
___ 02:57PM BLOOD Lactate-1.4
DISCHARGE LABS:
___ 09:20AM BLOOD WBC-3.4* RBC-3.62* Hgb-10.5* Hct-33.0*
MCV-91 MCH-29.0 MCHC-31.8* RDW-15.9* RDWSD-53.3* Plt ___
___ 09:20AM BLOOD Neuts-38.2 ___ Monos-13.4*
Eos-9.3* Baso-2.1* Im ___ AbsNeut-1.28* AbsLymp-1.23
AbsMono-0.45 AbsEos-0.31 AbsBaso-0.07
___ 09:20AM BLOOD Glucose-96 UreaN-18 Creat-0.9 Na-136
K-5.0 Cl-104 HCO3-24 AnGap-8*
___ 09:20AM BLOOD Calcium-9.4 Phos-2.9 Mg-2.1
OTHER PERTINENT ___:
___ 02:33AM BLOOD ALT-8 AST-15 LD(LDH)-307* AlkPhos-111*
TotBili-0.6
___ 04:36PM BLOOD cTropnT-<0.01
___ 12:37PM BLOOD cTropnT-<0.01
___ 12:37PM BLOOD proBNP-399*
___ 11:45AM BLOOD B-GLUCAN-Negative
URINE STUDIES:
___ 04:30PM URINE Color-Straw Appear-Clear Sp ___
___ 04:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 09:04PM URINE Streptococcus pneumoniae Antigen
Detection-NEGATIVE
___ 04:00PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
Sputum Cx - contaminated x 2
MRSA Swab positive
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
URINE CULTURE (Final ___: NO GROWTH.
BLOOD CX x 3 - NEGATIVE
================================================================
IMAGING:
CXR ___ - IMPRESSION:
1. New, severe pulmonary interstitial edema. Of note,
superimposed infection cannot be excluded.
2. Probable small bilateral pleural effusions.
CTA CHEST ___ - IMPRESSION:
1. Breathing motion limits evaluation for distal filling defects
however there is no central or small segmental pulmonary
embolism.
2. Multifocal heterogeneously enhancing consolidations are
concerning for pneumonia. Bilateral hilar adenopathy. An
element of mild pulmonary edema could also be considered
although thought to be less likely given a normal heart size and
lack of pleural effusions.
3. Mild underlying emphysema.
TTE ___ - CONCLUSION:
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is ___ mmHg. There is normal left ventricular
wall thickness with a normal cavity size. There is suboptimal
image quality to assess regional left ventricular function.
Overall left ventricular systolic function is normal. The
visually estimated left ventricular ejection fraction is >=60%.
Left ventricular cardiac index is normal (>2.5 L/min/m2). There
is no resting left ventricular outflow tract gradient. No
ventricular septal defect is seen. Normal right ventricular
cavity size with normal free wall motion. Tricuspid annular
plane systolic excursion (TAPSE) is normal. The aortic sinus
diameter is normal for gender. The aortic arch diameter is
normal with a mildly dilated descending aorta. There is no
evidence for an aortic arch coarctation. The aortic valve
leaflets (?#) are mildly thickened. There is no aortic valve
stenosis. There is no aortic regurgitation. The mitral valve
leaflets appear structurally normal with no mitral valve
prolapse. There is trivial mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion. There is a
prominent anterior fat pad.
IMPRESSION: Normal biventricular cavity sizes and
regional/global biventricular systolic function. No valvular
pathology or pathologic flow identified. Normal estimated
pulmonary artery systolic pressure.
CXR ___ - IMPRESSION:
Compared to chest radiographs ___ and ___.
Previous pulmonary edema has resolved. Heart size, mediastinal
and hilar caliber have returned to normal. Moderate
interstitial abnormality persists on the left and should be
followed to exclude other causes such as pulmonary hemorrhage or
infection. No appreciable pleural effusion.
Brief Hospital Course:
___ with h/o anxiety, HTN, HLD, rheumatoid arthritis on
Methotrexate and recently started Enbrel (___), hepatitis C,
cervical cancer s/p hysterectomy and chemoradiation, former
smoker who presents to the ED with c/o shortness of breath,
found to be in hypoxic respiratory failure ___ PNA and possible
component of pulmonary edema.
# Acute hypoxemic respiratory failure
# Community acquired pneumonia
Required up to 10L/NRB to maintain O2 sats in the mid ___ on
presentation. CXR showed severe interstitial pulmonary edema.
CTA without PE but showing bilateral posterior, dependent areas
of parenchymal consolidations c/w pneumonia with only mild
pulmonary edema though obtained s/p IV diuresis. Patient was
treated with for CAP initially with CTX/azithro which was
ultimately changed to levofloxacin ___ concern for neutropenia
___ CTX (see below). Of note, MRSA swab was positive; however,
suspicion for MRSA PNA was low. BNP 399, no known diagnosis of
CHF, and TTE with normal heart function. Unclear precipitant of
exacerbation with absence of other clinical signs suggestive of
this diagnosis. Trop x2 negative, no ischemic changes noted on
EKG. Low suspicion for flare of RA associated ILD based on CT
appearance as affected areas are mostly dependent, lower lobes
and ground glass better explained by infection. Following
diuresis, patient symptomatically much improved and O2
requirement improved. Repeat CXR showed interval improvement in
pulmonary edema. She completed a 7 day course of abx and was
satting well on RA at the time of discharge. Patient should have
repeat CXR in ___ weeks to ensure resolution
# Neutropenia: Suspect this was likely medication related
(?CTX). ANC reached a low of 740 but improved after changing
from CTX to levofloxacin. ANC was 1280 on discharge. The patient
should have repeat CBC with diff at PCP ___ appointment to
ensure continued improvement.
# Seropositive RA:
On Enbrel/methotrexate as per recent rheum notes though patient
reports that she has not been taking methotrexate recently.
Given recent infection, instructed patient continue to hole
Enbrel and MTX until further instructions from her
rheumatologist. Rheum will be notified of this via email. She
was treated with Tylenol and ibuprofen for pain as well as PRN
tramadol. She was given small Rx for Tramadol for pain control
at discharge. PMP reviewed.
# Anxiety/depression: Continue home duloxetine
# History of abnormal infiltrative marrow process involving the
sacrum, iliac bones, acetabuli, and visualized lumbar spine,
concerning for malignancy: Per records. The patient should
continue to follow up with her PCP regarding this, with further
evaluation as warranted.
TRANSITIONAL ISSUES:
- Please repeat ANC at follow up appointment.
- Enbrel and methotrexate remain on hold pending further
instructions from patient's rheumatology team.
- Please consider further evaluation of reported abnormal
infiltrative marrow process as warranted.
- Please note that LDH and alk phos were mildly elevated during
admission. Would consider repeating in the outpatient setting.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. metHOTREXate sodium 15 mg oral 1X/WEEK
2. etanercept 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
3. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
4. DULoxetine 90 mg PO DAILY
5. TraZODone ___ mg PO QHS:PRN insomnia
6. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. TraMADol 25 mg PO Q6H:PRN Pain - Severe
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6
hours as needed Disp #*8 Tablet Refills:*0
2. DULoxetine 90 mg PO DAILY
3. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
4. Omeprazole 40 mg PO DAILY
5. TraZODone ___ mg PO QHS:PRN insomnia
6. HELD- etanercept 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
This medication was held. Do not restart etanercept until you
discuss with your rheumatologist.
7. HELD- metHOTREXate sodium 15 mg oral 1X/WEEK Duration: 1 Dose
This medication was held. Do not restart metHOTREXate sodium
until you discuss with your rheumatologist.
8.DME
Pediatric Rolling Walker
Dx: unsteady gait
Px: Good
___: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
Neutropenia
Rheumatoid Arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You presented to the hospital with respiratory distress and were
found to have pneumonia. You were treated with antibiotics, and
your breathing improved. You are now being discharged home.
Of note, while you were here, your white blood cell count
dropped. This was felt to likely be related to one of the
antibiotics, and it improved after your antibiotics were
changed. You will need to have your while blood cell count
re-checked next week at your PCP follow up appointment to make
sure it has returned to normal. Until that time, please avoid
sick people or too much contact with many people to avoid your
risk of getting sick.
Followup Instructions:
___
|
10449318-DS-11 | 10,449,318 | 21,460,563 | DS | 11 | 2150-11-30 00:00:00 | 2150-11-30 13:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left hand/foot numbness and visual changes
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
HPI:
Mr. ___ is a ___ year-old ___ man with a
history
of congenital aortic stenosis s/p mechanical AVR (on coumadin
and
asa 81) and migraine headaches who presents with one week of
left
hand and foot parethesias and a transient episode of right upper
visual field deficit (unclear if monocular vs binocular).
History is obtained from the patient with the help of and ED
resident who provides ___ interpretation.
One week ago, he developed pins and needles in his left hand and
foot. He is clear that the two developed together, but he is
unclear if the paresthesia developed suddenly or insidiously.
There was no ___ of the paresthesias and he denies numbness
when he touched the areas. The paresthesias remained present
for
the past week, but would wax and wane in a pattern of couple
minutes more intense, than minutes to hours of being barely
perceptible, and so on. There were no neurological deficits or
alteration of consciousness during this time.
Two days ago, he went to see a ___ for the first time
because of his paresthesias. Unclear if a manipulation was
performed. This did not impact his paresthesias.
Yesterday, at 10pm, he had a 2 minute transient episode of
darkening of the right upper quadrant of his visual field. He
describes this as one large "spot" blocking his vision. He felt
that his vision normalized if he covered his right eye. There
was no eye pain or blurring. His vision completely returned to
normal after 2 minutes. There was no associated headache with
the
vision change or the paresthesias of the week prior.
Today, he was seen by his PCP, ___ referred him to
the ED for further evaluation. He continues to have left hand
and foot paresthesias without weakness or numbness. No further
visual changes. No headache.
With regards to his anticoagulation, he tells us he has a
"plastic" valve and has been on coumadin since that time.
Initially, INR goal was 2.5-3.0, but after significant
epistaxis,
this was reduced to 2.0-2.5. In the past 3 weeks INRs have been
within the ___ range. He was subtherapeutic on ___ with
an
INR of 1.5 and his coumadin dose was readjusted. In the past
month, he missed only one dose of coumadin.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies blurred vision, diplopia,
vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia.
Denies focal muscle weakness. Denies loss of sensation. Denies
bowel or bladder incontinence or retention. Denies difficulty
with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough. Denies nausea, vomiting,
diarrhea, constipation, or abdominal pain. No recent change in
bowel or bladder habits. Denies dysuria or hematuria. Denies
myalgias, arthralgias, or rash.
Past Medical History:
- chronic migraines
- congenital aortic stenosis, s/p AVR in ___. Patient says
this
is a "plastic valve." Original INR goal was 2.5-3.0, but after
significant epistaxis, his INR goal is 2.0-2.5.
Social History:
___
Family History:
Parents healthy. He is unaware of any family
member with a stroke, seizure or neurological condition.
Physical Exam:
Vitals: 99.6 80 124/89 16 98%
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G, I cannot appreciate an audible mechanical
click.
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema
Neurologic Examination:
Awake, alert, oriented x 3. Able to relate history without
difficulty. Attentive during course of the exam. Speech is
fluent
with full sentences, intact repetition, and intact verbal
comprehension. Naming intact in ___ and high frequency
items
in ___. No paraphasias. No dysarthria. Normal prosody. No
apraxia. No evidence of hemineglect. No left-right confusion.
Able to follow both midline and appendicular commands.
- Cranial Nerves - Fundoscopy not performed as patient in bright
ED core and awaiting ophtho exam. PERRL 4->2 brisk. VF full to
number counting and red saturation. EOMI, no nystagmus. V1-V3
without deficits to light touch or pin 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, pin, or proprioception
bilaterally. No exinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 2
R 2 2 2 1 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. Stable without sway.
Tandem walks without difficulty. Negative Romberg.
Pertinent Results:
___ 02:30PM ___ PTT-44.8* ___
CT/CTA: Noncontrast head: No acute intracranial process.
Head CTA: No evidence of occlusion, stenosis, dissection, or
aneurysm > 3mm in the great vessels of the head and neck. Fetal
origin of the right PCA is incidentally noted.
CXR: As compared to the previous radiograph, no relevant change
is seen. Metallic aortic valve. Normal alignment of the
sternal wires. No pulmonary edema. No pneumothorax, no
pneumonia. Normal size of the cardiac silhouette.
Brief Hospital Course:
Mr. ___ was admitted to the Stroke Neurology service for
management. CT/CTA showed no acute stroke or vessel occlusion.
Stroke workup was significant for:
Total cholesterol 153
___ 156 (not fasting)
LDL 50
HDL 72
CRP 0.3
Hgb A1C pending
Echocardiogram and MRI were not completed secondary to patient
anxiety. After a long discussion the patient decided to leave
the hospital against medical advice. He wanted to pursue medical
care in ___, which we urged he have completed as soon as
possible.
We discussed the hospitalization with his PCP. No medication
changes were made.
Medications on Admission:
- coumadin 3mg ___
- coumadin 2mg ___
- ASA 81mg QPM
- Carvedilol 6.250mg QPM
Discharge Medications:
1. Aspirin 81 mg PO QPM
2. Carvedilol 6.25 mg PO QPM
3. Warfarin 3 mg PO 6X/WEEK (___)
4. Warfarin 2 mg PO 1X/WEEK (MO)
Discharge Disposition:
Home
Discharge Diagnosis:
Anxiety
Unknown cause of transient parasthesias (TIA vs. endocarditis
vs. anxiety)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because of episodes of left
hand and foot numbness, and visual changes. We did a number of
tests to determine whether or not you had a stroke. Your CT scan
was negative.
We were planning to do an echocardiogram and an MRI to determine
whether or not you had a stroke or had endocarditis (infection
of the heart valves). Because you felt anxious and wanted to go
back to ___ to complete your workup, we did not complete these
exams. After discussion, you agreed to leave the hospital
against medical advice.
We wish you the best as you go forward. Please do not hesitate
to contact us with any questions or concerns.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10449497-DS-20 | 10,449,497 | 22,199,718 | DS | 20 | 2159-04-07 00:00:00 | 2159-04-08 21:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
DVT
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an ___ year old female with advanced dementia and
history of prior DVT/PE who presents from her nursing facility
with a right lower extremity DVT. She has no other current
complaints.
.
The patient was in her usual state of health until this AM, when
she was seen by the NP at her nursing facility and complained of
right leg pain. An ultrasound was done at the nursing home which
showed a likely partial DVT on the right. She was sent to the ED
for further management. She has not been immobile or less active
recently and does not have any other clear triggers.
.
Initial vitals in ED triage were T 98.6, HR 76, BP 121/58, RR
16, and SpO2 99% on RA. Labs were unremarkable with normal CBC,
coags, and chemistry panel. She had creatinine 0.9 with eGFR ~60
per OMR. UA showed WBC 8 and few bacteria. Lower extremity
ultrasound showed a right popliteal DVT. She was given
Enoxaparin 60 mg SC and Warfarin 4 mg PO.
.
She was admitted to Medicine for further management of her right
popliteal DVT. Per CM, she would be unable to obtain ___ over
the weekend and meets inpatient admit criteria. Vitals prior to
floor transfer were T 98.3, BP 127/67, HR 70, RR 20, and SpO2
100% on RA. On reaching the floor, she denied any current
complaints except that she has some pain behind her knees when
she bends them.
Past Medical History:
# Alzheimers Dementia
# DVT/PE History
# Hyperlipidemia
# Left Hip Fracture
# C Diff Infection
Social History:
___
Family History:
Unable to obtain.
Physical Exam:
VS: T 99.9, 71, 113/62, 18, 99% on RA
Gen: Elderly female in NAD. Oriented to person only. Pleasant
and uninhibited. Sitting in chair with stuffed monkey.
HEENT: Sclera anicteric. PERRL, EOMI. MMM, OP benign.
Neck: JVP not elevated. No cervical lymphadenopathy.
CV: Somewhat distant heart sounds. RRR with normal S1, S2. No
M/R/G appreciated.
Chest: Breathing with pursed lips. CTAB without crackles,
wheezes or rhonchi.
Abd: Normal bowel sounds. Soft, NT, ND.
Ext: WWP. No edema noted. Very sensitive to touch on bilateral
___.
Neuro: CN II-XII grossly intact. Moving all extremities. Normal
speech.
Pertinent Results:
Admitting Labs:
___ 05:45PM GLUCOSE-90 UREA N-10 CREAT-0.9 SODIUM-140
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-28 ANION GAP-11
___ 05:45PM WBC-5.4 RBC-4.77 HGB-14.8 HCT-44.7 MCV-94
MCH-31.0 MCHC-33.1 RDW-13.4
___ 05:45PM NEUTS-73.0* LYMPHS-16.1* MONOS-7.2 EOS-3.3
BASOS-0.5
___ 05:45PM PLT COUNT-264
___ 05:45PM ___ PTT-28.1 ___
___ 04:09PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:09PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
___ 04:09PM URINE RBC-<1 WBC-8* BACTERIA-FEW YEAST-NONE
EPI-<1
Relevant Labs:
___ 06:40
BASIC COAGULATION ___, PTT, PLT, INR)
___ 12.1 9.4 - 12.5 sec
PERFORMED AT ___ LAB
PTT 31.9 25.0 - 36.5 sec
PERFORMED AT ___ LAB
___ 1.1 0.9 - 1.1
Discharge Labs:
-none
Pertinent Micro/Path:
-none
Pertinent Imaging:
-Lower Extremity US ___:
IMPRESSION: 4-cm span of non-occlusive thrombus in the right
popliteal vein.
Brief Hospital Course:
Pt is ___ year old woman with R poplitial vein DVT identified at
outside facility presenting for initiation of anticoagulation
therapy also with advanced dementia.
Active Diagnosis
1: DVT. Pt with no known precipitating factors complained of
pain in her Right leg. This prompted an US scan that identified
a non-occlusive 4 cm thrombus in the right poplitial vein. She
has a history of DVT in the past in the setting of a hip
replacement about ___ years ago for which she was anticoagulated
until about 18 months ago. US in the emergency department
confirmed the diagnosis and she was started on coumadin and
lovenox. Her assisted living center was not able to provide
nursing assistance for the administration of the lovenox, but
arrangements were made to have ___ deliver one dose and her
daughter, a physician, deliver the other dose to achieve twice
daily dosing until her INR becomes therapeutic.
2: Dementia. She has fairly advanced dementia. She is fully
conversant, but somewhat disinhibited and required frequent
re-orientation. Unnecessary tethers (tele, ect) were avoided,
she was reoriented frequently, efforts were made to maintain her
sleep/wake cycle, and she was occupied with tasks such as
coloring and folding towels. Home Risperidone was given early
on one occasion due to irritability and home donepezil was
continued.
Chronic Diagnosis:
3: Pulmonary Disease. Pt has a long smoking history. She had
no pulmonary complaints and never complained of being short of
breath. She was often noted to be purse-lipped breathing. Home
Tiotropium Bromide and Guaifenesin were continued.
Transitional Issues:
1: Maintain lovenox until 1 day after INR becomes theraputic
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Landmark records.
1. ammonium lactate *NF* 12 % Topical BID
to both legs
2. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral BID
3. Donepezil 10 mg PO HS
4. Loratadine *NF* 10 mg Oral DAILY
5. Risperidone 0.25 mg PO HS
6. Tiotropium Bromide 1 CAP IH DAILY
7. Acetaminophen 500 mg PO TID:PRN pain
8. Guaifenesin 5 mL PO Q6H:PRN cough
Discharge Medications:
1. Acetaminophen 500 mg PO TID:PRN pain
2. Donepezil 10 mg PO HS
3. Guaifenesin 5 mL PO Q6H:PRN cough
4. Loratadine *NF* 10 mg Oral DAILY
5. Risperidone 0.25 mg PO HS
6. Tiotropium Bromide 1 CAP IH DAILY
7. Enoxaparin Sodium 50 mg SC Q12H
Please take the first shot tonight at about 8:00 pm
RX *enoxaparin 100 mg/mL Take 50 mg ___ mL) twice a day Disp
#*6 Syringe Refills:*1
8. Warfarin 4 mg PO DAILY16
RX *Coumadin 4 mg 1 tablet(s) by mouth once a day Disp #*15
Tablet Refills:*0
9. ammonium lactate *NF* 12 % Topical BID
to both legs
10. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral BID
11. Outpatient Lab Work
Please draw ___ ___ and fax results to Dr.
___ at ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R popliteal DVT
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were seen at the hospital because your leg hurt and we found
a clot there. We started you on two medicines to make sure that
the clot does not move. You will only need to take the lovenox
for a few days but will need to be on the coumadin for a long
time. Your PCP can help you decide how long this needs to be.
Followup Instructions:
___
|
10449497-DS-21 | 10,449,497 | 24,613,656 | DS | 21 | 2159-12-07 00:00:00 | 2159-12-07 17:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Lethargy and decreased PO intake
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an ___ year old female with advanced dementia and
history of prior DVT/PE who presents from her nursing facility
with confusion and AMS.
Per report, there was report of decreased p.o. intake from her
facility with altered mental status. Of note, history taken from
daughter. Per daughter who is HCP, she has had decreased PO
intake ever since she started on ultram ~5 days ago for back
spasm that started over ___. She was in USOH until
that date when she complained of back pain. Her daughter states
that she is quite dramatic when she has pain. The last two days,
she was switched to oxycodone, and her NP also noted she had
thrush (but her daughter ___ see this, and her daughter is a
___). Per daughter, she continued to be fatigued, but
doesn't seem to be off her baseline. In the ED, her daughter
thought she may have had some shaking chills. She is not on O2
at baseline at home. The back pain was not worked up, and there
was no trauma to the back prior.
Initial vitals in ED triage were T 99.5 80 126/66 22 100%. Labs
were notable for mild leukocytosis (11.7), + UA with Mod ___, few
bacteria, 6 wbc, and hyponatremia with na at 132. She was given
1 dose of ctx 1 g and was admitted to Medicine for further
management of her confusion and UTI.
Vitals prior to floor transfer were T 98.7 83 107/62 18 94%.
On reaching the floor, she denied any current complaints, but
was noted to c/o back pain with the RN while I was in the room.
REVIEW OF SYSTEMS:
(+) Per HPI. Trouble remembering things.
(-) No fevers or chills. No current chest pain, SOB, or cough
that daughter could remember. No dysuria (unsure if really able
to assess).
Past Medical History:
# Alzheimers Dementia
# DVT/PE History
# Hyperlipidemia
# Left Hip Fracture
# C Diff Infection
Social History:
___
Family History:
Unable to obtain.
Physical Exam:
Admission Exam:
VS: T98.5, BP 102/62, 81, 24, 85-95/RA
Gen: Elderly female in NAD. Oriented to person and place.
Pleasant.
HEENT: Sclera anicteric. PERRL, EOMI. MMM, OP clear.
Neck: JVP not elevated. No cervical lymphadenopathy.
CV: Somewhat distant heart sounds. RRR with normal S1, S2. No
M/R/G appreciated.
Chest: Respiration unlabored. CTAB without crackles, wheezes or
rhonchi.
Abd: Normal bowel sounds. Soft, NT, ND.
Ext: WWP. Trace ___ edema.
Neuro: A+Ox2, MAE, slightly somnolent appearing
.
Discharge Exam:
VS: 97.5 158/53 71 18 93%RA
Gen: NAD. A&Ox1. Conversive
HEENT: MMM> NCAT
CV: RRR. NS1&S2. NMRG
Resp: CTAB. No rales/rhonchi/wheeze
GI: BS+4. S/NT/ND
Ext: No c/c/e
Back: Mild TTP along T11-L1
Pertinent Results:
Admission Labs:
___ 02:10PM BLOOD WBC-11.7*# RBC-4.39 Hgb-13.5 Hct-41.7
MCV-95 MCH-30.7 MCHC-32.3 RDW-13.2 Plt ___
___ 02:36PM BLOOD ___ PTT-37.5* ___
___ 02:10PM BLOOD Glucose-112* UreaN-11 Creat-1.0 Na-132*
K-5.0 Cl-95* HCO3-26 AnGap-16
___ 06:50AM BLOOD Calcium-8.2* Phos-2.2* Mg-1.8
___ 02:22PM BLOOD Lactate-1.8
Discharge Labs:
___ 07:15AM BLOOD Calcium-8.9 Phos-2.2* Mg-1.9
___ 07:15AM BLOOD Glucose-82 UreaN-8 Creat-0.6 Na-140 K-3.5
Cl-107 HCO3-21* AnGap-16
___ 07:15AM BLOOD ___ PTT-34.7 ___
___ 07:15AM BLOOD WBC-5.0 RBC-4.22 Hgb-13.0 Hct-39.9 MCV-94
MCH-30.8 MCHC-32.6 RDW-13.2 Plt ___
Urine Studies:
___ 02:30PM URINE RBC-1 WBC-6* Bacteri-FEW Yeast-NONE
Epi-<1
___ 02:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
Micro:
___ Blood Culture, Routine-PENDING INPATIENT
___ Blood Culture, Routine-Pending
___ URINE CULTURE-Neg
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
Imaging
___ CT Head: No acute intracranial abnormality.
___ L-spine XR: Mild anterior wedging of T11. Mild
posterior facet arthropathy in the lower lumbar spine.
Osteoporosis.
___ CXR:
Again, the patient is kyphotic. Diffusely increased
interstitial markings bilaterally are again seen, likely due to
chronic lung disease. There are relatively low lung volumes.
Streaky left base retrocardiac opacity is again seen most likely
atelectasis/scarring. Right lung base opacity may also be due
to atelectasis in underlying consolidation or infection or
aspiration is not excluded. There are trace pleural effusions.
The aorta remains tortuous.The cardiac silhouette is mildly
enlarged.
Brief Hospital Course:
___ with baseline adavanced dementia presents from nursing
facility for lethargy and decreased PO intake in the setting of
recent narcotic pain med administration for new onset back pain.
Narcotics held, and pain controlled with PO tylenol. Lethargy
improved and patient returned to baseline.
.
#Lethargy/Decreased PO intake: Concerned for delirium in the
setting of narcotic analgesic administration, as symptom onset
occured in temporal fashion with new narcotic prescription.
Narcs held, and analgesia transitioned to tylenol. Initially
concerned for UTI and placed on ceftriaxone, but urine cx
negative, so ceftriaxone discontinued. Also mildly concerned for
subdural head bleed, but NCCT head negative for acute processes.
Remained somnolent for several days, but cleared on day of
discharge. Appetite had greatly improved prior to discharge.
.
#Compression Fracture: Patient c/o back pain to family beginning
over ___ weekend. She was placed on oxycodone for this, which
was thought to be cause of lethargy (see above). Transitioned to
650mg TID tylenol and increased to 1000mg TID by discharge.
L-spine XR demonstrated anterior wedging of T11 consistent with
compression fracture of unknown acuity. Given recent onset of
back pain, this seems most consistent with acute fracture. No
neuro deficit or red flag to warrant CT or MRI. Patient was
continued on Vitamin D and Calcium supplementation, and scheduld
with PCP for further osteoporosis work-up. Evaluated by ___
in-house, with recommendation to d/c to assisted living facility
with ___. Pain well controlled at rest with mild discomfort with
movement at time of discharge.
.
# H/o ___ DVT: Last admission here in ___ showed DVT, on
coumadin. Continued 2mg coumadin in-house and INR remained
within goal ___.
.
# Dementia: She has advanced dementia per daughter. She is
conversant, but somewhat disinhibited. Continued home Donepezil
10 mg PO QHS. Continued home Risperidone 0.25 mg PO QHS
.
#SOB: C/o SOB intermittently during stay. Per daughter, this is
common complaint. EKG and CE WNL. Admission CXR with
interstitial markings likely due to chronic lung disease. O2
sats remaine >90% on RA and no evidence of respiratory distress.
.
# Hyponatremia: Hyponatremic to 132 on admission. Resolved with
IVF. Likely from hypovolemia given poor PO intake.
.
Transitional Issues:
#Patient has T11 compression fracture. Please continue 1000mg
TID acetaminophen and attempt to avoid narcotics. Will follow-up
with PCP ___: additional osteoporosis work-up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q8H:PRN pain
2. Donepezil 10 mg PO HS
3. Loratadine *NF* 10 mg Oral daily
4. Risperidone 0.25 mg PO HS
5. Tiotropium Bromide 1 CAP IH DAILY
6. Warfarin 2 mg PO DAILY16
7. ammonium lactate *NF* 12 % Topical bid
8. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral bid
9. Balmex *NF* (white petrolatum;<br>zinc oxide-vitamin B5-vit
E) 11.3 % Topical bid
10. Clotrimazole Cream 1 Appl TP DAILY
11. Nystatin Oral Suspension 10 mL PO TID:PRN thrush
12. Trixaicin *NF* (capsaicin) 0.025 % Topical bid
13. Loperamide 2 mg PO BID:PRN diarrhea
14. OxycoDONE (Immediate Release) 5 mg PO BID:PRN pain
Discharge Medications:
1. Clotrimazole Cream 1 Appl TP DAILY
2. Donepezil 10 mg PO HS
3. Loratadine *NF* 10 mg Oral daily
4. Risperidone 0.25 mg PO HS
5. Tiotropium Bromide 1 CAP IH DAILY
6. Warfarin 2 mg PO DAILY16
7. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral bid
8. Balmex *NF* (white petrolatum;<br>zinc oxide-vitamin B5-vit
E) 11.3 % Topical bid
9. ammonium lactate *NF* 12 % Topical bid
10. Nystatin Oral Suspension 10 mL PO TID:PRN thrush
11. Loperamide 2 mg PO BID:PRN diarrhea
12. Trixaicin *NF* (capsaicin) 0.025 % Topical bid
13. Acetaminophen 1000 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Lethargy
subacute compression fracture of T11
Osteoporosis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a plesaure caring for you at ___. You were admitted
because you were very tired and complaining of back pain at your
retirement facility. We believe you were tired because the pain
medications you received can cause you to be sleepy. We stopped
these medications and you returned to your baseline according to
your healthcare proxy. We were also concerned you may have a
urinary tract infection, but your urine did not grow any
bacteria, so antibiotics were stopped. We also looked at your
head to make sure there was no bleed, which there was not.
In regards to your back pain, we took an x-ray of your lower
back which showed a possible fracture of one of your vertebra.
We are not sure whether this is old or new, but is the most
likely cause of your pain. We started you on tylenol, and your
pain greatly improved. You were continued on supplemental
calcium and vitamin D for presumed osteoporosis. Please
follow-up with your primary care physician to determine if any
other tests for osteoporosis are needed, and whether or not you
should start additional medications.
Medications to START:
START Tylenol ___ three times daily
Medications to STOP:
STOP ultram
STOP oxycodone
Followup Instructions:
___
|
10449497-DS-22 | 10,449,497 | 28,806,371 | DS | 22 | 2159-12-10 00:00:00 | 2159-12-11 14:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an ___ year-old female with advanced dementia and
history of prior DVT/PE (on coumadin) who presents from assisted
living after an unwitnessed fall. The patient is unable to
provide any history of the event. According to the patient's
daughter, the patient was at home <12 hours, when she was found
by a staff member on the floor of the bathroom. It was uncertain
if the patient experienced loss of consciousness, though she was
found awake and alert. The patient's daughter believes the fall
was mechanical.
Of note, the patient was recently admitted to ___ from ___ -
___ with lethargy and decreased PO intake in the setting of
narcotic administration for new onset back pain. During the
admission, the patient's narcotics were held, and pain was
controlled with PO tylenol. The patient's lethargy improved and
patient returned to baseline.
In the ED, initial vitals: 97.2 80 122/71 20 98% RA. UA showed
WBC 56 and pos lek esterase. CT head showed no intracranial
process. CT C-spine showed no fracture, but did show
degenerative disc disease. CT abd/pelvis showed multiple
fractures of unknown chronicity. The patient was evaluated by
the spine consult team, but felt there was no acute indication
for surgical intervention. Vitals prior to transfer: 98 79
124/74 23 95% RA. The patient was admitted to medicine for
syncopal work-up.
Currently, the patient is unable to provide any further history.
Past Medical History:
# Alzheimers Dementia
# DVT/PE History
# Hyperlipidemia
# Left Hip Fracture
# C Diff Infection
Social History:
___
Family History:
Unable to obtain.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.7 154/84 81 26 97%2L
GENERAL: NAD, A+O X 1 (knows her name)
___: NC/AT, PERRLA, EOMI, MM dry, OP clear
HEART: RRR, nl S1-S2, no MRG
LUNGS: CTAB, no r/rh/wh, resp unlabored
ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN: macular erythema beneath breasts bilaterally
NEURO: awake, CNs II-XII grossly intact, muscle strength ___
throughout, sensation grossly intact throughout, gait not
assessed
Pertinent Results:
ADMISSION LABS:
___ 10:20AM BLOOD WBC-8.3# RBC-4.40 Hgb-13.8 Hct-41.5
MCV-94 MCH-31.3 MCHC-33.3 RDW-13.5 Plt ___
___ 10:20AM BLOOD Neuts-89.3* Lymphs-4.5* Monos-4.1 Eos-1.8
Baso-0.3
___ 10:20AM BLOOD ___ PTT-36.9* ___
___ 10:20AM BLOOD Glucose-86 UreaN-11 Creat-0.8 Na-138
K-3.5 Cl-103 HCO3-23 AnGap-16
DISCHARGE LABS:
___ 08:05AM BLOOD WBC-6.2 RBC-4.19* Hgb-13.0 Hct-39.6
MCV-95 MCH-31.0 MCHC-32.7 RDW-13.6 Plt ___
___ 07:15AM BLOOD ___ PTT-44.7* ___
___ 07:15AM BLOOD Glucose-82 UreaN-11 Creat-0.8 Na-141
K-3.3 Cl-103 HCO3-22 AnGap-19
MICROBIOLGY:
URINE CULTURE:
PROBABLE ENTEROCOCCUS. ~1000/ML.
IMAGING:
CT HEAD:
No evidence of acute intracranial injury.
CT ABDOMEN/PELVIS/CHEST:
1. Small-to-moderate bilateral non-hemorrhagic pleural
effusions with adjacent areas of atelectasis.
2. Emphysema.
3. Cholelithiasis without evidence of acute cholecystitis.
4. Sigmoid colon diverticulosis without associated inflammatory
changes.
5. Renal hypodensities, likely cysts.
6. Compression deformities involving T5, 6, 7, 8, 9 and 11
vertebral bodies of uncertain chronicity.
CT C-SPINE:
1. No evidence of a displaced fracture allowing for
demineralized bones.
2. Mild anterolisthesis at C3-C4 and mild retrolisthesis at
C5-6, unknown chronicity without prior studies, but probably
degenerative.
3. Multilevel degenerative disease.
CXR:
IMPRESSION:
1. Bilateral pleural effusions with concurrent bibasilar
atelectases, right worse than left.
2. Increased interstitial and bronchovascular markings might
represent fluid overload/interstitial edema.
Brief Hospital Course:
The patient is an ___ year-old female with advanced dementia and
history of prior DVT/PE (on coumadin) who presents from assisted
living after an unwitnessed fall.
# Unwitnessed fall: Unclear etiology; patient unable to provide
reliable history. No localizing symptoms of infection.
Urinalysis with WBC 56, mod leuk, but no nitrites/bacteria.
While awaiting culture results, the patient was treated
initially with ceftriaxone, and subsequently transitioned to
ciprofloxacin to complete a 3 day course (last day ___. Urine
culture grew <1000 colonies of enterococcus. No cardiac history;
EKG with 1st degree AV block, but no e/o ischemia. No focal
weakness or neurologic deficits on exam. No evidence of
orthostatis.No events on telemetry.
# Compression Fractures: During recent admission, L-spine XR
demonstrated anterior wedging of T11 consistent with compression
fracture of unknown acuity. CT during this admission showed
compression deformities of T5-9 and 11 vertebral bodies of
uncertain chronicity. Do not suspect these are new in setting of
fall. Seen by spine surgery team, who felt that there was no
acute indication for surgical intervention. She was continued on
standing tylenol 1 g TID for pain.
# H/o ___ DVT: INR supratherapeutic at 4.7 at presentation.
Coumadin was held during her inpatient stay. At the time of
discharge, INR 4.2. Please re-check INR on ___. Goal INR
2.0-3.0.
# Dementia: She is conversant, but not oriented. She was
continued on Donepezil 10 mg PO QHS and Risperidone 0.25 mg PO
QHS.
TRANSITIONAL ISSUES:
# CODE STATUS: DNR/DNI (confirmed with daughter)
# CONTACT: ___, daughter, Cell phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Clotrimazole Cream 1 Appl TP DAILY
2. Donepezil 10 mg PO HS
3. Loratadine *NF* 10 mg Oral daily
4. Risperidone 0.25 mg PO HS
5. Tiotropium Bromide 1 CAP IH DAILY
6. Warfarin 2 mg PO DAILY16
7. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral bid
8. Balmex *NF* (white petrolatum;<br>zinc oxide-vitamin B5-vit
E) 11.3 % Topical bid
9. ammonium lactate *NF* 12 % Topical bid
10. Nystatin Oral Suspension 10 mL PO TID:PRN thrush
11. Loperamide 2 mg PO BID:PRN diarrhea
12. Trixaicin *NF* (capsaicin) 0.025 % Topical bid
13. Acetaminophen 1000 mg PO TID
14. Lidocaine 5% Patch 1 PTCH TD DAILY
Apply to back daily
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Clotrimazole Cream 1 Appl TP DAILY
3. Donepezil 10 mg PO HS
4. Lidocaine 5% Patch 1 PTCH TD DAILY
5. Nystatin Oral Suspension 10 mL PO TID:PRN thrush
6. Risperidone 0.25 mg PO HS
7. Tiotropium Bromide 1 CAP IH DAILY
8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 1 Days
Last day: ___. ammonium lactate *NF* 12 % Topical bid
10. Balmex *NF* (white petrolatum;<br>zinc oxide-vitamin B5-vit
E) 11.3 % Topical bid
11. Caltrate 600 + D *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral bid
12. Loperamide 2 mg PO BID:PRN diarrhea
13. Loratadine *NF* 10 mg Oral daily
14. Trixaicin *NF* (capsaicin) 0.025 % Topical bid
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Unwitnessed Fall
Urinary Tract Infection
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted to
the hospital after a fall at your assisted living facility. We
were unable to determine the reason for this fall with
certainty, however you were noted to have a urinary tract
infection. You were treated with antibiotics, which you will
continue for an additional day once at rehab.
Please follow-up with your doctor at rehab.
Followup Instructions:
___
|
10449660-DS-16 | 10,449,660 | 22,143,737 | DS | 16 | 2198-01-20 00:00:00 | 2198-01-20 21:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
cephalexin / Bactrim / clindamycin
Attending: ___.
Chief Complaint:
Gastroenteritis, Drug Rash, Cellulitis/Abscess
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Female who presents after undergoing I&D of an
buttocks abscess on ___, initially on Bactrim/Keflex, and
developed a drug drash, and returned to the ED on ___ and
was transitioned to clindamycin, who now returns the following
day with nausea/vomiting/diarrhea. The rash didn't change in the
interval, however after taking 2 doses of clindamycin she
developed gastroenteritis. She reports ___ episodes of emesis.
Emesis is non-bloody/non-bilious.
In the ED initial vitals are 98.2, 106, 128/76, 17, 97%. She was
given 2L of IV fluids and 1 dose of IV vancomycin.
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, + Vomiting, + Diarrhea, - 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
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
Past Medical History:
1. Preseptal cellulitis, ___.
2. Diabetes ___ type 1 since age ___. Followed by ___
___.
3. Hypothyroidism.
4. Down syndrome.
Social History:
___
Family History:
Father: diabetes ___
Strong family history on the father's side for diabetes.
Physical Exam:
ADMISSION
VSS: 99, 115/57, 100, 20, 96%
GEN: NAD, Obese
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: firm, NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: answers only limited questions, at baseline per mother,
___
DERM: 2cm open wound draining mild amounts of pus 1cm
surrounding induration, confluent maculo-papular non-blanching
rash b/l ___ to mid calf on anterior surface
DISCHARGE
VS: 97.9 121/75 80 19 96%RA
___ - ___
Gen - ambulating from bathroom to bed comfortably
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender, normoactive bowel sounds
Ext - no edema
Skin - L buttock abscess s/p I&D w healthy granulation tissue,
no purulence; no surrounding erythema or induration; lower
extremities with resolving macular rash
Vasc - 2+ DP/radial pulses
Neuro - moving all extremities; answering basic questions
Psych - pleasant
Pertinent Results:
ADMISSION
___ 05:40PM BLOOD WBC-8.0 RBC-3.83* Hgb-12.8 Hct-38.0
MCV-99* MCH-33.4* MCHC-33.7 RDW-12.9 RDWSD-46.3 Plt ___
___ 05:40PM BLOOD Neuts-86.2* Lymphs-8.1* Monos-4.9*
Eos-0.2* Baso-0.4 Im ___ AbsNeut-6.93* AbsLymp-0.65*
AbsMono-0.39 AbsEos-0.02* AbsBaso-0.03
___ 05:40PM BLOOD Glucose-220* UreaN-9 Creat-0.8 Na-141
K-4.3 Cl-104 HCO3-26 AnGap-15
DISCHARGE
___ 06:55AM BLOOD WBC-6.4 RBC-4.00 Hgb-13.3 Hct-39.7
MCV-99* MCH-33.3* MCHC-33.5 RDW-12.4 RDWSD-44.8 Plt ___
___ 06:55AM BLOOD Glucose-164* UreaN-6 Creat-0.7 Na-140
K-4.2 Cl-102 HCO3-27 AnGap-15
CT Abd/Pelvis ___
No abscess. Small dependent pleural effusions.
Indeterminate single small areas of hypodensity within bilateral
kidneys.
These could be the sequela of ischemic injury or possibly
sequela of
medication. Pyelonephritis is not likely.
Large fibroid uterus.
Brief Hospital Course:
This is a ___ year old female with past medical history of type I
diabetes, Down syndrome, recent buttock abscess s/p I&D
___, recent drug rash while on Bactrim/Keflex, admitted
___ with nausea, vomiting and diarrhea while on
clindamycin, clinically improving, course otherwise notable for
insulin regimen change per ___ service
# Left buttock abscess / Sepsis - patient admitted with fever
and tachycardia, as well as cellulitis around site of buttock
abscess s/p outpatient incision and drainage; patient failed
oral therapy as outpatient as below. She was treated with IV
vancomycin and IV unasyn from ___ with good response.
Discharged with ___ for wound care.
# Drug Rash - as outpatient patient developed drug rash while on
bactrim keflex, specifically a confluent maculopapular rash over
lower extremities; no blisters or necrosis; resolved during this
admission; allergies updated
# Nausea and Vomiting - patient developed nausea and vomiting to
while on oral clindamycin, which prompted her admission in part.
This was added to her medication list. While she did have
occassional regurgitation, patient did not have any additional
episodes of nausea and vomiting while on IV antibiotics. As
part of workup, patient LFTs and lipase were wnl, CT abdomen
without causative process.
# Diarrhea - had diarrhea around time of admission; infectious
workup negative; most likely related to antibiotic-associated
diarrhea. It resolved with discontinuation of clindamycin on
admission. .
# Hypokalemia - mild, repleted as needed; secondary to GI
losses;
# DM type I with hyperglycemia - course was complicated by
poorly controlled fingersticks; she was seen by ___
and transitioned from NPH based regimen to lantus regimen with
both scheduled and sliding scale humalog. Patient and family
seen by diabetic educator during this admission. Discharged
with close ___ follow-up within 48 hours of discharge.
# Regurgitation - patient noted to have intermittent episodes of
regurgitation of small amounts of food; these were observed and
were distinct from initial nausea and vomiting, with small
amount of chewed food and clear liquid, and without dry heaving
or other signs to suggest vomiting. Suspected to be related to
the hiatal hernia she was noted to have on CT scan, which may be
resulting in GERD. She was started on PPI trial. Can reassess
as outpatient.
# Hypothyroidism - Continued her home synthroid.
TRANSITIONAL ISSUES
- Discharged home with services
- Incidental finding on CT scan: "No abscess. Small dependent
pleural effusions. Indeterminate single small areas of
hypodensity within bilateral kidneys. These could be the sequela
of ischemic injury or possibly sequela of medication.
Pyelonephritis is not likely. Large fibroid uterus." PCP
contact at time of findings
- Changed over to lantus based regimen as described above;
discharged with close ___ follow-up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbamide Peroxide 6.5% ___ DROP AD TWICE MONTHLY
2. NPH 16 Units Breakfast
NPH 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Levothyroxine Sodium 125 mcg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 125 mcg PO DAILY
2. Carbamide Peroxide 6.5% ___ DROP AD TWICE MONTHLY
3. Glargine 18 Units Bedtime
Humalog 5 Units Breakfast
Humalog 6 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL 18 units SC At bedtime
Disp #*5 Vial Refills:*0
4. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Diabetes type 1 with hyperglycemia
# L Buttock Abscess and cellulitis
# GERD / Hiatal Hernia
# Nausea / vomiting
# Hypothyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___:
It was a pleasure caring for you at ___. You were admitted
with nausea, vomiting, and diarrhea--we think this was caused by
a reaction to the antibiotics that you were on for your skin
infection. You had a CAT scan that did not show any concerning
abnormalities. The antibiotics were stopped and you improved.
You are now ready for discharge.
Regarding your skin infection. It continued to improve after
you stopped antibiotics. You will have a visiting nurse to help
with your wound care.
Please remember, the antibiotics Bactrim and Keflex gave you a
rash, and the antibiotic clindamycin made your nauseous.
While you were in the hospital, you had several episodes of
regurgitation--we think this is the result of a "hiatal hernia"
of your esophagus, a condition that can cause regurgitation. We
started you on treatment for this, with a medication called
pantoprazole (protonix). You should discuss this further with
your primary care doctor.
You were also seen by a doctor from ___, who recommended an
improved insulin regimen with glargine/lantus and Humalog. We
have scheduled you for close follow-up at ___.
Followup Instructions:
___
|
10449660-DS-18 | 10,449,660 | 29,975,519 | DS | 18 | 2200-12-07 00:00:00 | 2200-12-07 20:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
cephalexin / Bactrim / clindamycin
Attending: ___.
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with h/o type I DM, Down syndrome,
hypothyroidism, macrocytosis, hiatal hernia, achalasia
presenting
to the emergency department with weakness. Mom notes that the
patient is acting off of her baseline today. She feels that her
daughter is more weak. She has had sick contacts at her care
center. Review of systems is positive for cough and diminished
p.o. intake. Also positive for diarrhea. Patient is currently on
her menses. Denies any falls or trauma. No fevers.
In the ED:
Initial vital signs were notable for:
Pain 0 Temp 98.7 HR 102 BP 132/86 RR 18 pO2 97% RA
Exam notable for: none noted
Labs were notable for:
WBC 3.2
ALT/AST 303/563
Flu: Positive
pH 7.36, pCO2 47
BMP wnl, glucose 331, Agap 12
UA: ketone 10, glucose 1000, protein trace, WBC 17, RBC 73
UCG negative
Studies performed include:
___ RUQUS
1. No findings of cholelithiasis or cholecystitis identified.
2. Hyperechoic focus in the right hepatic lobe is stable when
compared to CT of ___, and nonspecific though likely
benign, given ___ year stability.
___ CXR
Right lower lobe pneumonia. Retrocardiac opacity likely
represents atelectasis though additional site of pneumonia
cannot
be excluded.
Patient was given:
___ 10:50 IVF NS 1000 mL
___ 11:28 SC Insulin 8 Units
___ 11:51 PO/NG OSELTAMivir 75 mg
___ 11:51 PO Doxycycline Hyclate 100 mg
___ 18:17 SC Insulin 2 Units
Consults: non
Vitals on transfer:
Temp 99.5 HR 91 BP 131/92 RR 18 pO2 96% RA
Upon arrival to the floor, the patient was unable to elaborate
on
her HPI given neurologic deficits.
Past Medical History:
- Preseptal cellulitis, ___.
- Diabetes ___ type 1 since age ___. Followed by ___
___.
- Hypothyroidism.
- Down syndrome.
- Fibroid uterus
- Achalasia with botox treatment
- Hiatal Hernia
Social History:
___
Family History:
Father: diabetes ___
Strong family history on the father's side for diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 98.3 PO BP 123/80 L Lying HR 96 RR 24 pO2 91 Ra
GENERAL: Alert and interactive but limited speech. Feels warm,
mildly diaphoretic. In no acute distress. Smiling and pleasant.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD. No JVP elevation.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, moderately distended, non-tender
to deep palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact grossly. Moving all extremities
appropriately.
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 641)
Temp: 98.0 (Tm 98.9), BP: 125/87 (114-125/80-87), HR: 97
(91-97), RR: 18 (___), O2 sat: 97% (94-97), O2 delivery: Ra,
Wt: 154.1 lb/69.9 kg
GENERAL: eating breakfast and watching cartoons, NAD
HEENT: anicteric sclerae, MMM
NECK: supple
CARDIAC: RRR, S1 and S2
LUNGS: CTAB, no wheezes or crackles
ABDOMEN: soft, moderately distended, non-tender, BS+
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm and well perfused, no rashes
NEUROLOGIC: alert, Moves all four extremities with purpose
Pertinent Results:
ADMISSION LABS:
===============
___ 09:45AM BLOOD WBC-3.2* RBC-3.96 Hgb-13.4 Hct-40.0
MCV-101* MCH-33.8* MCHC-33.5 RDW-12.9 RDWSD-48.4* Plt ___
___ 09:45AM BLOOD Neuts-65.6 ___ Monos-9.6 Eos-0.0*
Baso-0.0 Im ___ AbsNeut-2.11 AbsLymp-0.79* AbsMono-0.31
AbsEos-0.00* AbsBaso-0.00*
___ 09:45AM BLOOD Glucose-331* UreaN-8 Creat-0.8 Na-140
K-4.6 Cl-103 HCO3-25 AnGap-12
___ 09:45AM BLOOD ALT-303* AST-563* AlkPhos-59 TotBili-0.7
___ 09:45AM BLOOD Lipase-14
___ 09:40PM BLOOD Calcium-9.2 Phos-3.5 Mg-2.0
___ 09:45AM BLOOD Albumin-3.5
___ 09:40PM BLOOD TSH-0.31
___ 09:40PM BLOOD T4-10.5
___ 09:40PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
___ 09:40PM BLOOD HCV Ab-NEG
___ 10:45AM BLOOD ___ pO2-33* pCO2-47* pH-7.36
calTCO2-28 Base XS-0
___ 10:19PM BLOOD ___ pO2-87 pCO2-40 pH-7.39
calTCO2-25 Base XS-0
___ 10:19PM BLOOD Lactate-2.3*
___ 09:54AM BLOOD Lactate-1.2
___ 11:47AM URINE Color-Straw Appear-Clear Sp ___
___ 11:47AM URINE Blood-MOD* Nitrite-NEG Protein-TR*
Glucose-1000* Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.0
Leuks-NEG
___ 11:47AM URINE RBC-73* WBC-18* Bacteri-FEW* Yeast-NONE
Epi-2
___ 11:47AM URINE Mucous-OCC*
___ 11:47AM URINE UCG-NEGATIVE
___ 02:12AM URINE Streptococcus pneumoniae Antigen
Detection-Test - NOT DETECTED
___ 10:20AM OTHER BODY FLUID FluAPCR-POSITIVE*
FluBPCR-NEGATIVE
MICROBIOLOGY:
=============
___ 9:45 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 11:47 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 9:40 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 3:00 pm MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Pending):
Brief Hospital Course:
Ms. ___ is a ___ with h/o type I DM, Down syndrome,
hypothyroidism, macrocytosis, hiatal hernia, achalasia
presenting
to the emergency department with weakness, who was found to have
pneumonia and influenza which were treated with levofloxacin and
Tamiflu, and hyperglycemia.
ACUTE ISSUES:
=============
#Pneumonia
#Influenza:
Presented with weakness, diarrhea, cough, and decreased PO
intake. Flu +. Patient found to have RLL PNA. Treated with
levofloxacin x5d, ___ and Tamiflu x5d.
#Transaminitis: AST and ALT elevation without history of liver
disease except for benign stable hyperechoic focus in
hepatic lobe. LFTs wnl ___. Differential include shock liver
vs. viral hepatitis vs. fatty liver vs transient elevation in
setting of flu. No cholecystitis noted on RUQUS. Nontender on
exam. Hepatitis A, B, C serologies negative. LFTs downtrended
without further intervention.
#Ketouria
#DM1: The patient has brittle Type 1 DM, followed by ___, who had ketones in urine in ED but otherwise no evidence
of DKA. Last A1C 8.9% in ___. Treated with Zofran for
nausea. Continued glargine and Humalog SSI. Her glargine dose
was increased to 18 U qhs due to persistently elevated FSBG.
CHRONIC ISSUES:
===============
#Hypothyroidism
Continued home levothyroxine
TRANSITIONAL ISSUES:
====================
[] Lantus dose was increased to 18 units. Please continue to
monitor her glucose levels and titrate as needed.
[] Consider f/u LFTs to document resolution of transaminitis.
[] levofloxacin and Tamiflu course: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 137 mcg PO DAILY
2. Basaglar 16 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. Polymyxin B -Trimethoprim Ophth Soln 1 DROP BOTH EYES QID
4. Artificial Tears ___ DROP BOTH EYES TID
5. MetFORMIN (Glucophage) 500 mg PO QHS
6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY AM Duration: 2 Doses
RX *levofloxacin 750 mg 1 tablet(s) by mouth DAILY AM Disp #*2
Tablet Refills:*0
2. OSELTAMivir 75 mg PO BID
RX *oseltamivir 75 mg 1 capsule(s) by mouth twice a day Disp #*4
Capsule Refills:*0
3. Glargine 18 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Artificial Tears ___ DROP BOTH EYES TID
5. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
6. Levothyroxine Sodium 137 mcg PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO QHS
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
9. Polymyxin B -Trimethoprim Ophth Soln 1 DROP BOTH EYES QID
(maximum of 6 doses per day)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- Influenza A
- RLL Pneumonia
- Hyperglycemia
- Type 1 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 taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for the flu, pneumonia, and high blood
sugar.
What was done for me while I was in the hospital?
- You were treated with antibiotics and Tamiflu.
- Your insulin dosing was adjusted because your blood sugars
were high.
- You were given medication for nausea.
What should I do when I leave the hospital?
- Continue to monitor your blood sugar regularly with meals and
at bedtime.
- Take your medications as prescribed.
- Keep all of your follow-up appointments.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10449873-DS-22 | 10,449,873 | 22,101,155 | DS | 22 | 2158-10-07 00:00:00 | 2158-10-09 07:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Loss of consciousness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of hypertension, hyperlipidemia, and remote
history of chest pain who presents to the ED after an episode of
syncope. She reports that she was sitting eating lunch today
when she had a syncopal episode. She reports that she felt that
she ate too much at lunch. There was no associated chest pain,
shortness of breath or palpitations. She denies any prodrome,
loss of bowel or bladder control, or post-ictal state, but she
does report that she had some lightheadedness prior to passing
out. She remained in the chair, and did not fall out, so there
was no associated trauma. She remembers waking up in the
ambulance. Of note, she has been on metoprolol chronically, and
continued to take that medication today prior to the episode of
syncope. ___ daughter, ___ ___, dispenses ___ pills into weekly
pill boxes, but the patient administers ___ own pills (as she
lives in an assisted living facility).
In the ED, ___ initial vitals were T 97.7 HR 50 BP 152/67 RR 18
SaO2 93% on RA. She reportedly was bradycardic to 37 bpm. Labs
were notable for troponin-T <0.01, Cr 1.4 (baseline 1.3), INR
0.9. EKG showed sinus bradycardia, with a rate of 45. CXR was
clear. She was evaluated by the Electrophysiology Service, who
felt that she should be admitted to the ___ service for
monitoring and discontinuation of ___ beta-blocker. Review of
prior records showed admissions in ___ for sick sinus syndrome
(leading to discontinuation of ___ beta-blocker) and for
syncope. Holter monitoring in ___ and ___ showed sino-atrial
exit block, isolated APBs, and multiform VPBs. Prior episodes of
lightheadedness correlated with both sinus rhythm without ectopy
and with sinus rhythm with APBs. There was also suggestion of a
wandering atrial pacemaker on one ECG.
Prior to transfer, ___ vitals were HR 64 BP 118/63 RR 20 SaO2
99%. Upon arrival to the floor she denied any chest pain,
shortness of breath, or lightheadedness.
Past Medical History:
1. CAD RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG: no
- PERCUTANEOUS CORONARY INTERVENTIONS: no
- PACING/ICD: no
3. OTHER PAST MEDICAL HISTORY:
- Hypertension
- Hypercholesterolemia
- h/o GI Bleed with EGD diagnosed peptic ulcer disease
- GERD
- Osteoporosis
- Hiatal Hernia
- Gout
- Anemia, iron deficiency
- Hyperparathyroidism, S/P parathyroidectomy (3.5)
- chronic constipation
- S/P bilateral cataract removal with IOL implant
- glaucoma
Social History:
___
Family History:
Father who had asthma in his youth and a mother who died in ___
___ secondary to a fall.
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: Elderly Caucasian woman in NAD, pleasant, alert and
oriented.
VS: T 97.8, BP 149/72, HR 58, RR 22, SaO2 99% on RA
HEENT: NCAT, Sclera anicteric.
NECK: Supple with no JVD.
CARDIAC: RRR; No murmurs, rubs or gallops (although the
attending reported a II/VI SEM at the base and LLSB with an S4)
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB--no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, non-tender, not distended. No HSM or tenderness.
EXTREMITIES: No clubbing, cyanosis or edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
DISCHARGE PHYSICAL EXAM:
GENERAL: NAD, pleasant.
VS: T 97.8 BP 156/87 (SBP 137-189), HR 78, RR 20, SaO2 95% on RA
Wt: 50.8 <- 51.2kg
I/O: 1140mL/1625mL
Examination was unchanged from admission.
Pertinent Results:
ADMISSION LABS:
___ 01:00PM WBC-6.6 RBC-3.96* Hgb-11.5* Hct-36.8 MCV-93#
MCH-29.1 MCHC-31.2 RDW-12.8 Plt ___
___ 01:00PM NEUTS-70.5* ___ MONOS-4.0 EOS-2.9
BASOS-0.7
___ 01:00PM ___ PTT-27.7 ___
___ 01:00PM GLUCOSE-155* UREA N-35* CREAT-1.4* SODIUM-138
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15
___ 01:00PM CALCIUM-9.6 PHOSPHATE-3.5 MAGNESIUM-2.3
___ 01:00PM cTropnT-<0.01
___ 01:00PM TSH-1.9
ECG ___ 12:53:36 ___
Extensive baseline artifact is present precluding accurate
evaluation. Probable sinus bradycardia. Anteroseptal myocardial
infarction, age indeterminate. Probable J point elevation in the
lateral leads. Compared to the previous tracing of ___ sinus
bradycardia is now present. Precordial ST segment elevations
appear slightly more prominent raising concern for an acute
transmural ischemia. Clinical correlation is suggested.
CXR ___
Heart size remains mildly enlarged. A large hiatal hernia is
re-demonstrated within the air-fluid level noted. The aorta
remains mildly tortuous. Widening of the superior mediastinum
likely reflects a combination of an enlarged thyroid gland with
tortuous right brachiocephalic vessel. Clip is noted within the
left superior mediastinal compatible with prior parathyroid
surgery. Pulmonary vascularity is normal. Except for minimal
linear atelectasis or scarring within the left lung base, the
lungs are clear without focal consolidation. No pleural
effusion or pneumothorax is seen. No acute osseous abnormalities
are detected.
Echocardiogram ___
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%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. There are three aortic valve leaflets.
The aortic valve leaflets are moderately thickened. There is
mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
Brief Hospital Course:
___ with a history of hypertension, dyslipidemia and remote
history of chest pain, sick sinus syndrome, sino-atrial exit
block (prompting previous discontinuation of beta-blockers), and
atrial as well as ventricular ectopy, who presents to the ED
after an episode of post-prandial syncope without trauma with
subsequently diagnosed bradycardia.
# Syncope: On admission, she presented with one episode of
post-prandial syncope, which was not associated with any
prodrome, bowel or bladder incontinence, or post-ictal state.
She was not wearing a tight collar at the time to suggest
carotid body hypersensitivity, and she did not report any
bladder or rectal urgency that would have suggested a vagotonic
state. Poorly controlled glaucoma might be a contributing
factor. ___ dementia medication was not an anti-cholinergic,
merely a medium chain triglyceride that should not affect
cardiac conduction. ___ TSH was normal. Echocardiogram did NOT
show significant aortic stenosis nor occult left ventricular
systolic dysfunction to suggest a ventricular arrhythmia. Thus,
the most likely etiology of ___ syncope was a brady-arrhythmia.
She has been taking metoprolol for hypertension and reports that
she took this medication on the morning of admission. ___
metoprolol was discontinued, and she was monitored on telemetry.
She had a few brief ___ second pauses, which appeared to be
consistent with sinus exit block vs. blocked (but not readily
visible) PACs on EKG. She did not have any additional episodes
of syncope on this admission. She told the Electrophysiology
Service that she was NOT interested in implantation of a
permanent pacemaker.
# Bradycardia: The patient was noted to be in sinus bradycardia
on EKG in the ED. This was most likely due to exacerbation of
___ underlying sick sinus syndrome and sinus exit block by
chronic beta-blockade from metoprolol. There was no evidence of
ischemia on EKG, signs or symptoms of recent infections, or
electrolyte abnormalities, and TSH was normal. As above,
metoprolol was stopped, and ___ bradycardia resolved.
Echocardiogram showed preserved LV systolic function, no left
ventricular hypertrophy, with mild aortic stenosis and
regurgitation and mild mitral regurgitation, as well as
borderline elevation of pulmonary artery systolic pressures and
suggestion of elevated left-sided filling pressures.
# Hypertension: She was found to be persistently very
hypertensive during this hospitalization, despite treatment with
___ home antithypertensive medication regimen (including ACE-I,
___, and thiazide). She was started on amlodipine in place of
___ beta-blocker, with prn doses of hydralazine IV for marked
systolic arterial hypertension. ___ HCTZ dose was increased, and
she was maintained on ___ home doses of lisinopril and
valsartan.
# Bactiuria: The patient's urinalysis showed large amount of
leukocyte esterase, 1 epi, 110 RBC and 17 WBC per HPF with no
bacteria or yeast. She was empirically treated with a short
course of antibiotics without urine culture.
CHRONIC ISSUES:
# CKD: Serum creatinine seems at baseline. All medications were
renally dosed, and ___ renal function was closely monitored.
# Dyslipidemia: Continued statin. ___ aspirin regimen was
simplified.
# Glaucoma: Continued home eyedrops.
# GERD: Continued omeprazole.
# Code Status: The patient confirmed ___ desire to be DNAR/DNAI.
As such, the transcutaneous pacing pads were removed.
TRANSITIONAL ISSUES:
- BP control has been difficult on this admission. ___ goal SBP
is 150, given ___ age and risk for orthostatic hypotension. She
may require addition of yet another agent and/or evaluation for
secondary causes of hypertension if she remains persistently
more hypertensive.
- The Electrophysiology Service was willing to offer the patient
a permanent pacemaker, but the patient was not interested in
pursuing this at present.
Medications on Admission:
The Preadmission Medication list is accurate and complete (per
___ PCP's office).
1. Aspirin 325 mg PO DAILY
2. Ascorbic Acid ___ mg PO Frequency is Unknown
3. Lisinopril 30 mg PO BID
4. Pantoprazole 40 mg PO Q24H; Take ___ hour before breakfast
5. Simvastatin 40 mg PO HS
6. Metoprolol Tartrate 25 mg PO BID
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. Valsartan 160 mg PO BID
9. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
10. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
11. Axona *NF* (nut.tx, metab.dis, mv & min #2) 20 gram/40 gram
Oral daily
12. Aspirin 81 mg PO DAILY
13. Docusate Sodium 100 mg PO QID:PRN constipation
14. Vitamin D 1000 UNIT PO DAILY
15. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE TID
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H
3. Docusate Sodium 100 mg PO QID:PRN constipation
4. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE TID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
6. Lisinopril 30 mg PO BID
7. Pantoprazole 40 mg PO Q24H
8. Simvastatin 40 mg PO HS
9. Valsartan 160 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. Aspirin 325 mg PO DAILY
12. Axona *NF* (nut.tx, metab.dis, mv & min #2) 20 gram/40 gram
Oral daily
13. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
14. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
15. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Syncope
-Sinus bradycardia with sinus exit block and possibly blocked
atrial premature beats, exacerbated by chronic beta-blocker
therapy
-Hypertension, difficult to control
-Hyperlipidemia
-Asymptomatic bactiuria and urinary tract infection
-Gastroesophageal reflux disease
-Glaucoma
-Aortic stenosis and regurgitation, mild
-Chronic kidney disease, stage 3
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 for evaluation of your episode
of syncope. While you were here you were noticed to have a very
slow heart rate, which probably caused your syncope. The most
likely cause of your very slow heart rate is from a medication
that you have been taking called metoprolol. You should STOP
taking metoprolol. We also found that you have a urinary tract
infection. You should take Bactrim for the next 7 days as
prescribed below.
While you were here you had an echocardiogram (ultrasound
picture of your heart) which showed that your heart is working
normally.
Additionally, while you were here your blood pressure was noted
to be very high. As a result we increased your dose of
Hydrochlorothiazide, and started you on a new medication called
amlodipine. Please continue taking these medications as an
outpatient. Your goal systolic blood pressure is 150.
Followup Instructions:
___
|
10450072-DS-14 | 10,450,072 | 22,846,686 | DS | 14 | 2185-10-08 00:00:00 | 2185-10-11 16:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
Flex Sig ___
History of Present Illness:
___ y.o. man visiting from ___ with HTN, HL, and ulcerative
colitis on mesalamine, azathioprine, and methylprednisolone
taper presenting with nausea, vomiting, and diarrhea.
The patient was diagnosed with ulcerative colitis in ___ during
which he presented with hematochezia and abdominal pain. He was
initially managed on mesalamine and at some point azathioprine
was added to his regimen. In the past year, the patient reports
increasing UC flares (about ___ per year) and is intermittently
managed with methylprednisolone tapers. The patient and his
family reports that his gastroenterologist plans to start a
biologic when he returns to the ___. He reports a mild to
moderate UC flare in mid ___ during which he was
started on Methylpred taper at 60 mg PO QDaily. The patient
reports he has regular surveillance colonoscopies and denies any
complications
such as bowel obstructions, stenosis, or extraintestinal
manifestations of UC.
The patient came to the ___.S. to visit his daughter. He arrived
on ___. Shortly after, he started to experience nausea and
nonbloody, nonbilious emesis. Patient reports emesis became
progressively darker in color but no frank blood. This was
followed by several episodes of watery, voluminous stool
(reports every hour). He denied any associated abdominal pain,
hematochezia, or melena. The patient reports that due to his
nausea and vomiting, he has not been able to successfully take
his medications including his methylprednisolone. He denies any
associated fevers, chills, joint pain, or rashes.
With these symptoms, the patient was seen at ___
urgent care on ___. Labs were notable for Cr 1.8 and the
patient received IV fluids. He returned to urgent care and found
to have Cr 2.8. Stool O+P and infectious stool studies
reportedly sent. In the setting of worsened ___ and continued
symptoms, the patient presented to the ___ ED.
In ED, initial VS were: T 97.2 HR 97 BP 109/65 RR 16 SpO2 100%
RA. Exam notable for guiaic positive stools but no major
abdominal pain. Initial labs notable for Na 127, Cr 1.5, H/H
14.6/43.8, and lactate 3.8. Lactate improved to 1.8 with fluids.
UA bland. Abd CT notable for wWall thickening involving the
sigmoid colon and rectum with prominence of the Vasa recta and
mild surrounding inflammation compatible with active colitis. In
the ED, the patient received 2L NS, IV Zofran 4 mg, PO Diazepam
5 mg, IV Cipro 400, IV Flagyl 500, IV D5NS + 20 mEq K.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
-Hypertension
-Hyperlipidemia
-Ulcerative Colitis (diagnosed in ___ on Asacol/Azathioprine,
on
methylpred taper)
Social History:
___
Family History:
Denies family history of IBD or other GI disorder. Brother with
cardiac valvular disease requiring aortic valve replacement
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T 97.2 HR 97 BP 109/68 RR 16 SpO2 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated
CV: tachycardic normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: WWP, 2+ DP,
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
DISCHARGE PHYSICAL EXAM:
Vitals: T: 98.1 BP: 116/71 P: 88 R: 18 O2: 94%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTA b/l, no wheezes, rales, rhonchi
CV: RRR, nl S1 S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: WWP, DP 2+ b/l, no edema
Skin: no rash
Neuro: CN ___ grossly intact
Pertinent Results:
ADMISSION LABS:
___ 01:45AM BLOOD WBC-8.3 RBC-4.45* Hgb-14.6 Hct-43.8
MCV-98 MCH-32.8* MCHC-33.3 RDW-13.3 RDWSD-48.6* Plt ___
___ 01:45AM BLOOD Neuts-77.5* Lymphs-8.1* Monos-14.0*
Eos-0.1* Baso-0.1 Im ___ AbsNeut-6.43* AbsLymp-0.67*
AbsMono-1.16* AbsEos-0.01* AbsBaso-0.01
___ 01:45AM BLOOD Glucose-114* UreaN-45* Creat-1.5* Na-127*
K-3.4 Cl-86* HCO3-26 AnGap-18
___ 06:05AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.0
___ 01:57AM BLOOD Lactate-3.8*
PERTINENT INTERVAL LABS:
___ 06:05AM BLOOD CRP-18.2*
___ 06:05AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative HAV Ab-Positive* IgM HAV-Negative
___ 06:05AM BLOOD HCV Ab-Negative
___ 06:12AM BLOOD Lactate-1.8
DISCHARGE LABS:
___ 03:18PM BLOOD WBC-5.8 RBC-3.40* Hgb-11.6* Hct-33.8*
MCV-99* MCH-34.1* MCHC-34.3 RDW-13.4 RDWSD-49.1* Plt ___
___ 06:05AM BLOOD Glucose-98 UreaN-23* Creat-0.9 Na-135
K-4.1 Cl-102 HCO3-26 AnGap-11
MICROBIOLOGY:
___ 10:10 am STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT ___
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
___ BLOOD CULTURE: NEGATIVE
___ 6:05 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 2:59 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
FEW POLYMORPHONUCLEAR LEUKOCYTES.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
IMAGING/STUDIES:
CT ABD/PELVIS ___. Wall thickening involving the sigmoid colon and rectum with
prominence of the Vasa recta and mild surrounding inflammation
compatible with active
colitis.
2. Chronic changes of ulcerative colitis including loss of
normal colonic fold pattern and mild wall thickening of the
entire colon.
3. No evidence of intra-abdominal abscess.
4. Infrarenal abdominal aortic ectasia measuring 2.9 cm.
Brief Hospital Course:
___ year old man visiting from ___ with HTN, HL, and ulcerative
colitis
on mesalamine, azathioprine, and methylprednisolone taper
presenting with nausea, vomiting, and diarrhea, found on CT
abdomen and pelvis to have some areas of chronic and acute
inflammation in the colon. These were evaluated by GI with a
flex sig which showed findings more consistent with
gastroenteritis rather than an acute flare of ulcerative
colitis. The patient was managed with IVF, anti-emetics and high
dose steroids x1 day and his symptoms improved.
# Nausea, vomiting, diarrhea: The patient presented with nausea,
vomiting and diarrhea, concerning for gastroenteritis vs. flare
of underlying ulcerative colitis. The patient was evaluated with
CT abdomen and pelvis which showed chronic inflammation
throughout colon as well as areas of active inflammation in the
sigmoid and rectum. The patient was evaluated with stool
studies, which were negative for campylobacter, O+P, E coli
0157:H7, vibrio and norovirus. Flex sig on ___ was thought to be
more consistent with infectious gastroenteritis than with UC
flre. The patient was treated with 1 day of high dose steroids
transitioned back to his home regimen at the time of discharge.
Symptoms were managed with anti-emetics and the patient received
IVF for volume resuscitation see below. The patient was
evaluated with hepatitis serologies in preparation for possible
biologic agent for treatment in the future. These were negative
with the exception of HAV Ab+ (HAV IgM negative). Quantiferon
gold was indeterminate. The patient was discharged on his home
regimen of azathioprine and mesalamine with instructions to
follow up with his GI doctor upon return home to the ___.
# Acute Kidney Injury: pt presented with Cr elevated to 1.5 from
recent baseline 0.9-1.0. This was thought to be pre-renal in
origin given history of nausea, vomiting and diarrhea. Pt was
treated with IVF and his Cr improved.
# Hypertension: The patient's home nifedipine was held in the
setting of volume depletion. Given nl BPs at the time of
discharge, this was held on discharge and the patient was
advised to f/u in urgent care early next week for BP check and
re-initiation of BP meds as needed (pt unable to f/u with PCP
given he is from out of the country and will be in the ___
for another week).
# HLD: continued atorvastatin
Transitional Issues:
- CT abdomen pelvis remarkable for infrarenal abdominal aortic
ectasia measuring 2.9cm, please monitor with US in ___ yr, pt and
daughter notified
- CT abdomen and pelvis showed multiple hypodensities in the
kidneys compatible with cysts as well as a 7mm hypodensity in
the head of the pancreas. Please follow up with non-urgent MRI.
Pt and daughter notified.
- f/u mucosal biopsy from flex sig
- f/u BCx, vibrio fecal culture and O+P x1
- consider initiation of additional agent for further management
of patient's ulcerative colitis
- pt with f/u with PCP and GI as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mesalamine 800 mg PO TID
2. prednisoLONE 30 mg oral QAM
3. Azathioprine 50 mg PO BID
4. Atorvastatin 20 mg PO QPM
5. NIFEdipine CR 30 mg PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Azathioprine 50 mg PO BID
3. Mesalamine 800 mg PO TID
4. NIFEdipine CR 30 mg PO DAILY
5. prednisoLONE 30 mg oral QAM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Acute Gastroenteritis, Ulcerative Colitis, Acute Kidney
Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure having you here at the ___
___. You were admitted after you were experiencing
nausea, vomiting and diarrhea. You were evaluated with lab tests
which showed that your kidney function was slightly decreased,
this was likely due to dehydration. You were evaluated with
stool studies which showed no specific viral infection in your
stool. The bacterial studies remain pending. You had a CT scan
which showed some chronic inflammation in your colon as well as
some acute inflammation at the end of your colon. Our
gastroenterologists evaluated you with a flex sigmoidoscopy
which showed mainly chronic changes from your ulcerative
colitis. We managed your nausea and vomiting with anti-emetic
medications. We gave you IV fluids. We treated you with a higher
dose of steroids for 1 day.
After discharge, you should continue to take all of your
medications. You should continue to monitor your symptoms of
nausea and vomiting. You should try to keep up with your fluid
intake so as not to become dehydrated. You should follow up with
your gastroenterologists at home to consider addition of new
medications to better control your symptoms.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10450386-DS-13 | 10,450,386 | 24,628,515 | DS | 13 | 2157-05-03 00:00:00 | 2157-05-03 16:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
___ EVD placement
___ suboccipital craniectomy
History of Present Illness:
___ yo M presents as a transfer from ___ for
neurosurgical evaluation after a large cerebellar hemorrhage was
found on ___. Patient reports he fell down a flight of stairs
today around 2pm. He had difficulty getting back up and called
EMS for c/o of generalized weakness, falls x2, HA and blurred
vision. Upon evaluation patient reports right occipital
headache,
bilateral horizontal double vision. He denies nausea, numbness,
tingling or weakness. Of note patient takes Coumadin for a
mechanical aortic valve. He received 10mg Dexamethasone, 100g
Mannitol, and Kcentra at the OSH prior to transfer.
Past Medical History:
Mechanical Aortic Valve repair
Atrial flutter
High Cholesterol
Hx SOB, CP
Social History:
___
Family History:
nc
Physical Exam:
ON ADMISSION:
Gen: Obese male lying on stretcher. WD/WN, comfortable, NAD.
HEENT: Pupils: 3mm-->2mm EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception bilaterally.
Toes downgoing bilaterally
Coordination: positive dysmetria in RUE on finger-nose-finger,
very minimal dysmetria is LUE. rapid alternating
movements intact, heel to shin- unable to assess secondary to
body habitus.
ON DISCHARGE:
Alert and oriented x3. PERRL. Pupils 3-2mm and brisk. EOMS
intact. No longer appreciate lateral gaze restriction. Resting
nystagmus R>L. Mild Right dysmetria. No pronator drift. Moves
all extremities ___. Staples intact on R crani.
Pertinent Results:
___ CT C-SPINE
1. No evidence of acute traumatic fracture or malalignment.
2. A central protrusion at C4-C5 appears result in mild to
moderate spinal
canal narrowing. If clinically symptomatic, MRI would better
evaluate for
spinal canal and neural foraminal stenosis, assuming no
contraindications.
3. Known right cerebellar intraparenchymal hemorrhage is better
evaluated on HEAD CT ___.
___ CT TORSO
1. A tiny amount of tubular branching air within the
nondependent portion of the liver is consistent with portal
venous gas without findings to explain the etiology.
Specifically, no signs of pneumatosis or bowel wall thickening
that are concerning for a ischemia.
2. No evidence of trauma.
3. Indeterminate renal lesions bilaterally likely represent
hyperdense cysts, however confirmation with MRI should be
considered.
4. Diverticulosis without evidence of diverticulitis.
___ CTA HEAD W/ WO CONTRAST
1. No aneurysms. Patent circle of ___. No evidence of
underlying vascular malformation.
2. Unchanged, acute intraparenchymal hematoma in the right
cerebellar
hemisphere with stable surrounding edema, local mass effect, and
partial
effacement of the fourth ventricle.
___ CT HEAD WO CONTRAST POST-OP
IMPRESSION:
Expected postsurgical changes of suboccipital craniectomy for
evacuation of large right cerebellar hemorrhage.
___ FEMUS AP/LATERAL
No comparison. 4 projections of the left lower extremity are
provided. The neck of the femur more can not be sufficiently
assessed, given massive
overlying soft tissues. The shaft of the femur or shows no
evidence of
fracture. Mild degenerative articular disease at the level of
the knee.
___ ECHO
A well seated mechanical aortic valve is seen with normal
gradients and no paravalvular aortic regurgitation. Image
quality did not allow assessment of clot on the aortic valve.
___ ___
IMPRESSION:
1. Unchanged ventricular size and configuration status post
clamping of
ventriculostomy tube.
2. Increased subgaleal hematoma/soft-tissue swelling overlying
the
suboccipital craniectomy site.
3. Decreased right cerebellar hyperdense blood products and
pneumocephalus
status post suboccipital craniectomy.
4. Slight increase in vasogenic edema along the ventriculostomy
tube tract
with decrease in associated hyperdense blood products.
Brief Hospital Course:
___ yo M presents as a transfer from ___ for
neurosurgical evaluation after a large cerebellar hemorrhage was
found on ___. Patient was transferred to ___ for further
neurosurgical care and evaluation. Patient went to the OR
emergently with neurosurgery for suboccipital craniectomy and
EVD placement. Post-operatively patient was admitted to the ICU
for further care and management.
On ___, patient remains neurologically stable. Diet was advanced
and patient OOB with nursing staff.
On ___, patient remains neurologically and hemodynamically
stable. Patient continues with resting nystagmus and nystagmus
to the right, mild dysarthria, mild right dysmetria, denies
diplopia on exam, motor exam ___. Will continue to monitor the
patient every 2 hours.
On ___ the patient was neurologically stable and working with
___. His EVD remained at 10cm H20 and he was complaining of
slight headache.
On ___ Patient was neurologically stable. EVD was raised to 20.
Incision remained dry, clean and intact.
On ___ A clamp trial of EVD was initiated. Incision remained
dry, clean and intact.
An ECHO was done to assess mechanical valve which revealed good
placement of valve and no regurgitation. Overnight CPP dropped
to 45 so EVD was opened for 30 mins.
On ___ EVD re-clamped and clamp trial re-initated. Patient
remained neurologically intact.
On ___, the clamp trial continues. A CT head was obtained, his
ventricles are stable. The EVD was removed.
On ___, the patient remained neuro stable. He was transferred
to step-down unit. His incision is c/d/I without drainage. We
added a low dose of flexeril for complaints of left leg
radicular pain. We ordered to d/c foley for void trial (he
failed on ___.
On ___ the patient was recommended to go to rehab by ___. He was
restarted on Coumadin with a Lovenox 40mg bridge.
On ___ his INR was 1.1. He remains neuro intact. Per Dr.
___ may get his MRI as an outpatient. Cardiology
confirmed the type of valve to be a 27 St. ___ Valve which is
compatible per radiology. He is ordered to take 3mg Coumadin
starting tonight. He is being discharged to rehab with follow-up
with Dr. ___ with non-contrast head CT and MRI with and
without contrast in 4 weeks. He may also follow-up in the ___
clinic. His INR should be monitored during the Lovenox to
Coumadin bridge. A CT head should be a obtained for any
concerning neurological changes.
Medications on Admission:
Coumadin 5mg daily
furosemide 40mg daily
Lopressor 50 mg BID
Lipitor 10mg daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain/fever
Do not exceed 4gm in 24 hours
2. Atorvastatin 10 mg PO QPM
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Cyclobenzaprine 5 mg PO TID:PRN back pain
5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
6. Docusate Sodium 100 mg PO BID
7. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
Until INR is therapeutic (___)
8. Furosemide 40 mg PO DAILY
9. Glucose Gel 15 g PO PRN hypoglycemia protocol
10. Insulin SC
Sliding Scale
Fingerstick QACHS, QPC2H, HS, QAM, 3AM
Insulin SC Sliding Scale using REG Insulin
11. Metoprolol Tartrate 50 mg PO TID
12. Milk of Magnesia 30 mL PO DAILY:PRN constipation
13. Mineral Oil ___ mL PO DAILY:PRN constipation
14. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Senna 8.6 mg PO BID:PRN constipation
17. Tamsulosin 0.4 mg PO QHS
18. Warfarin 3 mg PO DAILY16
INR goal ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cerebellar Hemorrhage
Hydrocephalus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Surgery
· You underwent a surgery called a craniectomy to have blood
removed from your brain.
· Please keep your sutures or staples along your incision
dry until they are removed.
· It is best to keep your incision open to air but it is ok
to cover it when outside.
· Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
· We recommend that you avoid heavy lifting, running,
climbing, or other strenuous exercise until your follow-up
appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
· No driving while taking any narcotic or sedating
medication.
· If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
· No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
· Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix) until cleared by the neurosurgeon. You have
been cleared to take Lovenox to Coumadin bridge for your 2
mechanical valves.
· 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.
· You may also experience some post-operative swelling
around your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
· You may experience soreness with chewing. This is normal
from the surgery and will improve with time. Softer foods may be
easier during this time.
· Constipation is common. Be sure to drink plenty of fluids
and eat a high-fiber diet. If you are taking narcotics
(prescription pain medications), try an over-the-counter stool
softener.
Headaches:
· Headache is one of the most common symptoms after a brain
bleed.
· Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
· Mild pain medications may be helpful with these headaches
but avoid taking pain medications on a daily basis unless
prescribed by your doctor.
· There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the
incision site.
· Fever greater than 101.5 degrees Fahrenheit
· Nausea and/or vomiting
· Extreme sleepiness and not being able to stay awake
· Severe headaches not relieved by pain relievers
· Seizures
· Any new problems with your vision or ability to speak
· Weakness or changes in sensation in your face, arms, or
leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
· Sudden numbness or weakness in the face, arm, or leg
· Sudden confusion or trouble speaking or understanding
· Sudden trouble walking, dizziness, or loss of balance or
coordination
· Sudden severe headaches with no known reason
Followup Instructions:
___
|
10450513-DS-8 | 10,450,513 | 28,723,883 | DS | 8 | 2128-10-01 00:00:00 | 2128-10-02 16:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pre-syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year old female with a past medical history
significant for afib on eliquis, HTN, HLD, CAD, history of
carotid endarterectomy, CKD III who presents after a fainting
episode. She was walking around with her walker around 8 AM this
morning when she felt lightheaded and that her legs were going
to
give out underneath her. She said she felt everything becoming
dark around her and she was able to slide herself down to the
floor. She does not believe that she actually lost
consciousness.
She denies head strike. She laid down on the floor and crawled
to
a phone and called her son. She had several episodes of diarrhea
today and an episode of vomiting. Family notes that she has been
regurgitating some pills and food contents more frequently in
the
mornings recently. Denies abdominal pain. She then had another
similar episode while walking with her walker to the bathroom.
Her son was there and was able to lower her to the floor. She
denies any chest pain or palpitations prior to episodes of
syncope. There was no tongue biting, eye rolling, bowel or
bladder incontinence.
Overall the last month, she has felt much weaker and more
dyspneic with exertion. She is normally very active for her age
and still drives. Her son at bedside and daughter in law both
note that she has been much more lethargic and less energetic
than usual. She was hospitalized at the beginning of ___ for
afib and pneumonia at ___. Following the hospitalization she was
supposed to take antibiotics to finish her course but was taking
the wrong week of medications from her pill box after she was
discharged. Her family is concerned that she did not properly
finish her course of azithromycin. She denies having any recent
fevers, cough, chills, or rigors.
In the ED initial vitals were: T 97.6 HR 86 BP 122/66 RR 18 O2
sat 99% RA
EKG: SR 83 bpm, nl axis and intervals, NS anterior T waves
Labs/studies notable for:
CT Head W/O Contrast
1. No acute intracranial findings.
2. Chronic subcortical white matter changes from likely
microangiopathy.
CT C-Spine W/O Contrast
No cervical spine fracture. Mild anterolisthesis of C4 on C5
most
likely degenerative.
Chest (Pa & Lat)
Focal opacity at the posterior costophrenic angle on the lateral
view, likely localizing to the left. The exact etiology is
uncertain based on plain film.
Underlying parenchymal consolidation or mass lesion is possible.
Nonurgent chest CT is suggested. This is less likely a
Bochdalek's hernia given density.
BUN/Creatinine 35/2.1
WBC 12.6
Vitals on transfer: HR 70 BP 185/77 RR 20 O2 sat 95% RA
On the floor, she is feeling better than she was earlier in the
day. No other new symptoms.
REVIEW OF SYSTEMS:
Positive per HPI.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, ankle edema, or palpitations.
On further review of systems, denies fevers or chills. Denies
any
prior history of stroke, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains,
cough, hemoptysis, black stools or red stools. Denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- Coronary artery disease
- Paroxysmal Atrial fibrillation
- History of carotid endarterectomy
3. OTHER PAST MEDICAL HISTORY
- Osteoarthritis
- CKD III
Social History:
___
Family History:
Father passed away in early ___. No known premature CAD, history
of arrhythmia or heart failure.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
==============================
VS: T 98.2 BP 208/90 HR 74 RR 20 O2 sat 95 RA
GENERAL: Well developed, well nourished in NAD. Mood and affect
appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP of 10 cm.
CARDIAC: Normal rate, irregular rhythm. No murmurs, rubs or
gallops
LUNGS: Bibasilar crackles, otherwise CTAB
ABDOMEN: soft, mildly TTP in RUQ, no guarding or rebound
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAMINATION:
==============================
24 HR Data (last updated ___ @ 805)
Temp: 98.0 (Tm 98.1), BP: 204/78 (126-222/61-97), HR: 67
(65-82), RR: 16 (___), O2 sat: 93% (93-96), O2 delivery: Ra,
Wt: 143.96 lb/65.3 kg
Fluid Balance (last updated ___ @ 739)
Last 8 hours Total cumulative -625ml
IN: Total 0ml
OUT: Total 625ml, Urine Amt 625ml
Last 24 hours Total cumulative 460ml
IN: Total 2010ml, PO Amt 2010ml
OUT: Total 1550ml, Urine Amt 1550ml
GENERAL: Well developed, well nourished in NAD.
HEENT: PERRL. MMM. Neck veins flat.
CARDIAC: RRR. Normal S1S2. No murmurs, rubs or gallops
LUNGS: CTAB
ABDOMEN: soft, non-tender
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
24 HR Data (last updated ___ @ 805)
Temp: 98.0 (Tm 98.1), BP: 204/78 (126-222/61-97), HR: 67
(65-82), RR: 16 (___), O2 sat: 93% (93-96), O2 delivery: Ra,
Wt: 143.96 lb/65.3 kg
Fluid Balance (last updated ___ @ 739)
Last 8 hours Total cumulative -625ml
IN: Total 0ml
OUT: Total 625ml, Urine Amt 625ml
Last 24 hours Total cumulative 460ml
IN: Total 2010ml, PO Amt 2010ml
OUT: Total 1550ml, Urine Amt 1550ml
GENERAL: Well developed, well nourished in NAD.
HEENT: PERRL. MMM. Neck veins flat.
CARDIAC: RRR. Normal S1S2. No murmurs, rubs or gallops
LUNGS: CTAB
ABDOMEN: soft, non-tender
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS:
==============
___ 01:44PM GLUCOSE-104* UREA N-35* CREAT-2.1* SODIUM-137
POTASSIUM-4.0 CHLORIDE-95* TOTAL CO2-25 ANION GAP-17
___ 01:44PM ALT(SGPT)-24 AST(SGOT)-32 ALK PHOS-83 TOT
BILI-1.0
___ 01:44PM cTropnT-<0.01
___ 01:44PM TSH-7.3*
___ 01:44PM WBC-12.6* RBC-4.31 HGB-14.3 HCT-40.3 MCV-94
MCH-33.2* MCHC-35.5 RDW-12.8 RDWSD-43.5
___ 01:44PM NEUTS-80.5* LYMPHS-7.3* MONOS-10.9 EOS-0.2*
BASOS-0.4 IM ___ AbsNeut-10.13* AbsLymp-0.92*
AbsMono-1.37* AbsEos-0.03* AbsBaso-0.05
___ 01:44PM PLT COUNT-293
STUDIES:
=======
___ TTE:
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color
Doppler. There is normal left ventricular wall thickness with a
normal cavity size. There is normal
regional and global left ventricular systolic function.
Quantitative biplane left ventricular ejection
fraction is 66 %. Left ventricular cardiac index is low normal
(2.0-2.5 L/min/m2). There is no left
ventricular outflow tract gradient at rest or with Valsalva.
Tissue Doppler suggests an increased left
ventricular filling pressure (PCWP greater than 18 mmHg). Normal
right ventricular cavity size with
normal free wall motion. The aortic sinus diameter is normal for
gender with normal ascending aorta
diameter for gender. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis.
There is no aortic regurgitation. The mitral valve leaflets are
mildly thickened with no mitral valve
prolapse. There is moderate mitral annular calcification. No
valvular systolic anterior motion (___) is
present. There is trivial mitral regurgitation. Due to acoustic
shadowing, the severity of mitral
regurgitation could be UNDERestimated. The tricuspid valve
leaflets appear structurally normal. There
is mild [1+] tricuspid regurgitation. The estimated pulmonary
artery systolic pressure is borderline
elevated. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes and
regional/global biventricular systolic
function. No valvular pathology or pathologic flow identified.
Borderline elevated pulmonary
artery systolic pressure. No structural cardiac cause of syncope
identified.
___ CT Head
FINDINGS:
There is no evidence of infarction, hemorrhage, edema,or mass.
The
periventricular and sub cortical white matter hypodensities are
nonspecific,
but often related to microangiopathy. There is prominence of
the ventricles
and sulci suggestive of involutional changes.
There is no evidence of fracture. Layering secretions within
the maxillary
sinuses, mostly on the right, and sphenoidal sinuses. Patient
is status post
lens replacement. Mastoid air cells, and middle ear cavities
are clear.
Orbits are unremarkable
IMPRESSION:
1. No acute intracranial findings.
2. Chronic subcortical white matter changes from likely
microangiopathy.
___ CT C-Spine
FINDINGS:
Minimal anterolisthesis of C4 on C5 is likely degenerative given
facet joint
hypertrophic changes at this level. Elsewhere, alignment is
preserved. No
fractures are identified.There is no significant canal or
foraminal
narrowing.There is no prevertebral edema.
The thyroid and included lung apices are unremarkable.
Bilateral carotid
artery stents are noted. Surgical clips noted along the right
side of the
neck.
IMPRESSION:
No cervical spine fracture. Mild anterolisthesis of C4 on C5
most likely
degenerative.
___ CXR
IMPRESSION:
Focal opacity at the posterior costophrenic angle on the lateral
view, likely
localizing to the left. The exact etiology is uncertain based
on plain film.
Underlying parenchymal consolidation or mass lesion is possible.
Nonurgent
chest CT is suggested. This is less likely a Bochdalek's hernia
given
density.
DISCHARGE LABS:
===============
___ 07:52AM BLOOD Glucose-107* UreaN-19 Creat-1.3* Na-137
K-4.8 Cl-101 HCO3-22 AnGap-14
___ 07:52AM BLOOD Calcium-10.0 Phos-3.4 Mg-2.0
Brief Hospital Course:
TRANSITIONAL ISSUES:
===================
- Medication changes: furosemide discontinued. Nifedipine ER
decreased to 30 mg daily. Metoprolol-XL decreased to 100 mg
daily.
[] Focal opacity found on CXR in the L costophrenic angle.
Patient had a recent diagnosis of pneumonia, s/p antibiotic
regimen, and did not have infectious signs or symptoms during
hospitalization. Consider follow-up with chest CT.
[] Consider changing iron supplementation to every other day to
prevent constipation.
[] consider weaning off of fludricortisone if patient no longer
exhibits orthostasis
[] please continue to conservatively titrate blood pressures
medications as patient is very sensitive to medications changes
SUMMARY STATEMENT:
===================
___ year old female with pAF, HTN, HLD, and carotid disease who
presented following two pre-syncopal episodes at home, admitted
for autonomic instability. Orthostasis resolved after adjustment
of home antihypertensives and fluid bolus.
HOSPITAL COURSE:
================
# Autonomic instability
# Pre-syncope
Patient admitted due to presyncopal episodes, accompanied by
lightheadedness and shoulder/neck pain, most consistent with
orthostasis. Patient came in on furosemide 20 and nifediipine
90, which were discontinued. Metoprolol was reduced and
fractionated initially to 12.5 q 6. Echo normal. No acute
abnormalities on CT head. TSH and cortisol normal. Non-ischemic
EKG with negative troponins. Neurology was consulted. Captopril
3.125 TID was initiated and discontinued due to hypotension.
Metoprolol was uptitrated to 25 q 6 due to episode of Afib with
RVR. 1L NS bolus ___. Started fludricortisone on ___ and
orthostasis resolved. Nifedipine 30 was started for elevated
blood pressures. She was discharged on nifedipine 30 mg daily.
# pAF: CHADS2VASc2 of 5
Patient presented in NSR. Had episode of AFib w/ RVR w/ HRs 120s
on ___ AM, resolved with uptitrating metop to 25 q 6. Patient
maintained on apixaban 2.5mg BID. She was discharged on
metoprolol-XL 100 mg.
# HTN: recent med changes made including holding her home
nifedipine. Patient was persistently hypertensive with systolics
reaching greater than 200. Patient was asymptomatic at that
time. She was started on nifedipine 30mg daily on ___ with good
blood pressure effect and discharged on metoprolol-XL 100 and
nifedipine ER 30 mg.
# ___ on CKD:
Patient presented with Cr 2.1. Likely pre-renal in setting of
hypovolemia. Improved to 1.3 with fluids and holding Lasix.
# Dyslipidemia:
Continued home simvastatin 20mg.
# Fe deficiency anemia:
The patient was on ferrous sulfate 325mg BID as outpatient,
which was held during this hospitalization given lack of benefit
of BID iron supplementation. If patient is still iron deficient
as an outpatient, consider re-initiation of iron supplementation
every other day.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO BID
2. Vitamin D 1000 UNIT PO DAILY
3. Apixaban 2.5 mg PO BID
4. Magnesium Oxide 400 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Metoprolol Succinate XL 100 mg PO BID
7. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral DAILY
8. Simvastatin 20 mg PO QPM
9. Omeprazole 20 mg PO DAILY
10. albuterol sulfate 90 mcg/actuation inhalation QID:PRN
11. NIFEdipine (Extended Release) 30 mg PO DAILY
Discharge Medications:
1. Fludrocortisone Acetate 0.1 mg PO DAILY
2. Metoprolol Succinate XL 100 mg PO DAILY
3. NIFEdipine (Extended Release) 60 mg PO DAILY
4. albuterol sulfate 90 mcg/actuation inhalation QID:PRN
5. Apixaban 2.5 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral DAILY
8. Simvastatin 20 mg PO QPM
9. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Orthostatic hypotension
Autonomic instability
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because of a fall
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were evaluated for the fall and found to have no signs of
a stroke on a head image. You were also not found to have any
signs of a heart attack.
- You were found to have variable blood pressures. Your home
blood pressure medications were changed to help control your
blood pressures.
- An ultrasound of your heart was performed which showed normal
heart function and no problems with the heart valves.
- A neurologist evaluated you for your dizziness and variable
blood pressures.
- A physical therapist assessed and assisted you with walking
and returning to your previous functional ability.
- After giving you fluids and adjusting your medications, your
blood pressures and dizziness improved.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10450519-DS-11 | 10,450,519 | 23,770,476 | DS | 11 | 2158-04-05 00:00:00 | 2158-04-06 14:07:00 |
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:
none
History of Present Illness:
Mr. ___ is a ___ year old male with severe aortic stenosis
(valve area of 0.9 cm2; LVEF of 50-55%; peak velocity of 2.0 m/s
based on TTE on ___ and Gold III/IV COPD (FEV1 46% of
predicted on ___ PFTs), Coronary artery disease s/p NSTEMI
with peaked troponin of 0.23 in ___ and inferior wall motion
abnormality in TTE (___).
.
He presents to the ED with two day history of shortness of
breath. He reports having increased lower extremity swelling,
paroxysmal noctural dyspnea, two pillow orthopnea, whitish
productive sputum and abdominal distention over past two days.
He does not report fever, chills, pleuritic chest pain,
palpatations, dizziness, syncope or sick contacts. He reports he
has been using his inhaler more frequently yesterday without any
help. Of note they were at his son's house for ___
dinner. Patient and family do not report any sick contacts or
high salt intake. No history of eating outside.
.
In the ED, initial VS were: 98.2 97 131/61 30 96%. EKG showed
sinus rhythm at rate of ___elay and LBBB which
is similar to his previous EKG (___). No ST-T changes
compared to prior. CXR showed pulmonary vascular congestion with
cephalization of vessels. Labs significant for normal WBC,
creatinine at baseline of 2.3, troponin of 0.07, BNP of 2776, Mg
of 1.4 and lactate of 4.0
.
He was treated for COPD exacerbation with IV methylprednisolone
125 mg x 1; azithromycin 500 mg IV x 1; albuterol/ipratropium q1
nebs. He also received IV lasix 20 mg x 1 for acute on chronic
systolic heart failure though no urine output was noted. CPAP
with 4LNC was started to help with respiratory distress from
acute on chronic systolic heart failure and COPD exacerbation.
He was transferred for further evaluation and management of
hypoxemic respiratory distress. His vitals prior to transfer
were afebrile 87 127/72 24 99-100% CPAP 4LNC.
.
On arrival to the MICU, he reports feeling better after CPAP and
therapeutic regimen in the ED. Extensive discussion revealed he
would not like to be intubated or have cardiac resuscitation
which was confirmed with wife and HCP (___) at bedside. He is
ok with noninvasive positive pressure ventilation mask like CPAP
and BPAP. He reports having daily bowel movement. His baseline
shortness of breath is with walking to the bathroom which has
worsened to any activity over past two days.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
1. COPD Stage III (FEV1 46% expected ___
2. Severe aortic stenosis with valve area of 0.9 cm2 and mitral
reguritation (moderate)
3. coronary artery disease: Regional WMA on TTE
4. hypertension
5. hypercholesterolemia
6. chronic kidney disease with h/o uretral stones
7. benign prostatic hyperplasia
8. colonic adenomas (___)
Social History:
___
Family History:
Not relevant at this age.
Physical Exam:
Admission Physical Exam:
Vitals: T:97.9 BP:137-67 P:99 R:26 O2:96%6LNC
GENERAL: Elderly gentleman in moderate respiratory distress
whose speech is punctuated by brief, forceful inspirations.
NECK: No jugular venous distention appreciated though difficult
to ascertain with thick neck,
CARDIAC: Difficult to hear over audible wheezing but late
peaking systolic murmur with absent S2 noted over subxiphoid
process.
LUNGS: Using accessory muscles. Inspiratory and expiratory
wheezes with minimal air movement. Prolonged expiratory phase.
ABDOMEN: Soft and nontender. Distended. No hepatosplenomegaly
appreciated. No shifting dullness noted.
BACK: No concerning lesions, no CVA tenderness.
EXTREMITIES: 2+ pedal edema bilaterally. 1+ edema to knee
bilaterally. Appropriate temperature to touch at distal
extremities.
PULSES: 1+ femoral and PD pulses. Regular radial pulse
NEURO: Alert and oriented x 3. Did not ascertain muscle strength
due to shortness of breath.
98.6 129/77 (119-139) 92% 1L
189.6 --> 189 --> 186lbs
I/O: ___
GENERAL: Patient comfortable
NECK: No JVP appreciated ___ neck habitus.
CARDIAC: Distant heart sounds. II/VI systolic, late peaking
crescendo/decrescendo murmur heard best in L sternal and RUS
border. No appreciable radiation. Carotid pulse unremarkable.
LUNGS: Inspiratory and expiratory wheezes and rhonchi. Moderate
air movement.
ABDOMEN: Soft and nontender. Distended. No hepatosplenomegaly
appreciated. No shifting dullness noted.
EXTREMITIES: 1+ ___ edema bilaterally to ankle. Warm lower
extremities.
PULSES: Regular radial pulses. Distal pedal pulses present to
palpation.
NEURO: Alert and oriented x 3.
Pertinent Results:
ADMISSION LABS:
___ 07:40AM BLOOD WBC-7.7 RBC-3.31* Hgb-8.6* Hct-27.1*
MCV-82 MCH-26.0* MCHC-31.7 RDW-14.7 Plt ___
___ 07:40AM BLOOD Neuts-77.0* Lymphs-14.4* Monos-5.6
Eos-2.6 Baso-0.4
___ 07:40AM BLOOD Glucose-126* UreaN-43* Creat-2.3* Na-134
K-4.2 Cl-95* HCO3-27 AnGap-16
___ 07:40AM BLOOD ALT-27 AST-27 LD(LDH)-288* CK(CPK)-772*
AlkPhos-89 TotBili-0.2
___ 07:40AM BLOOD CK-MB-19* MB Indx-2.5 proBNP-2776*
___ 07:40AM BLOOD cTropnT-0.07*
___ 07:40AM BLOOD Albumin-4.2 Calcium-8.7 Phos-4.1 Mg-1.4*
___ 04:17AM BLOOD ___ Temp-36.7 pO2-62* pCO2-50*
pH-7.39 calTCO2-31* Base XS-3
___ 07:48AM BLOOD Lactate-4.0*
PERTINENT INTERVAL LABS:
___ 07:30AM BLOOD Glucose-88 UreaN-76* Creat-3.0* Na-138
K-3.7 Cl-93* HCO3-36* AnGap-13
___ 07:30AM BLOOD LD(LDH)-238 CK(CPK)-511*
___ 07:40AM BLOOD cTropnT-0.07*
___ 08:04PM BLOOD CK-MB-14* MB Indx-1.9 cTropnT-0.05*
___ 02:59PM BLOOD CK-MB-9 cTropnT-0.08*
___ 07:30AM BLOOD CK-MB-7 cTropnT-0.11*
___ 04:17AM BLOOD Lactate-1.0
___ 07:30AM BLOOD Ret Aut-1.9
___ 07:30AM BLOOD LD(LDH)-238 CK(CPK)-511*
___ 07:30AM BLOOD calTIBC-371 Hapto-292* Ferritn-14*
TRF-285
___ 07:30AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.2 Iron-23*
DISCHARGE LABS:
___ 07:35AM BLOOD WBC-7.7 RBC-3.27* Hgb-8.5* Hct-27.1*
MCV-83 MCH-26.0* MCHC-31.4 RDW-15.2 Plt ___
___ 07:35AM BLOOD Glucose-86 UreaN-85* Creat-3.0* Na-141
K-4.1 Cl-98 HCO3-34* AnGap-13
___ 07:35AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1
URINE
___ 02:22PM URINE Color-Straw Appear-Clear Sp ___
___ 02:22PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
MICRO:
Blood Cultures (___) x2: NGTD
Urine Culture (___): No growth
MRSA screen: negative
STUDIES:
ECG (___):
Moderate baseline artifact. Because of the baseline artifact, it
is difficult to identify atrial activity. The rhythm is regular
at a rate of 98 beats per minute. Probably normal sinus rhythm.
Complete left bundle-branch block. Possible prolonged A-V
conduction. Compared to the previous tracing of ___ no
diagnostic interval change.
CXR Portable (___):
FINDINGS: There is a focal area of hazy opacity in the left
lower lobe with loss of the left cardiac margin. This finding
appears unchanged when compared to prior radiographs on NCT.
There is prominent bronchopulmonary vascular markings with
possible interstitial edema in the peripheral interlobular
septa. There is no pleural effusion or pneumothorax. The imaged
osseous structures are intact. There is no free air below the
right hemidiaphragm.
IMPRESSION: Mild pulmonary vascular congestion and interstitial
edema
compatible with CHF.
ECHO (___):
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with basal to mid inferolateral hypokinesis.
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] The
right ventricular cavity is dilated with normal free wall
contractility. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets are moderately thickened with mild to moderate aortic
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate to severe (3+) mitral
regurgitation is seen. Severe [4+] tricuspid regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. Significant pulmonic regurgitation is seen. There is
no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the left ventricular wall motion abnormality is new and there is
now associated prominent mitral regurgitation that is likely
ischemic (post-infarction).
CXR (___):
FINDINGS: PA and lateral views of the chest. Mild cardiomegaly,
compared
with ___, the heart size has increased and the left atrium and
left ventricle are more prominent. Previously seen mild
interstitial pulmonary edema has decreased compared with
___. Aortic valve calcifications. No pleural effusion. No
pneumothorax. No infiltration. The mediastinal and hilar
contours are normal.
IMPRESSION:
1. Decrease in pulmonary edema compared with ___. No
infiltrate.
2. Mild cardiomegaly, compared with ___, the heart size has
increased and the left atrium and left ventricle are more
prominent.
Brief Hospital Course:
=======================
BRIEF HOSPITAL SUMMARY
=======================
Mr. ___ is a ___ year old male with severe aortic stenosis,
COPD, CAD s/p NSTEMI in ___ p/w shortness of breath, most
likely from COPD exacerbation.
=======================
ACTIVE ISSUES
=======================
# COPD excacerbation: Pt was treated with levalbuterol and
ipratropium nebs, azithromycin x 5 days and prednisone 40mg
daily x 5 days. He has 2 days remaining at time of discharge.
Lung symptoms improved. He was still wheezing at discharge, but
per patient and family, he was improved compared to his
baseline. Pt was sent home on ambulatory O2 of 1L when
ambulating.
# Shortness of breath/acute on chronic systolic CHF: The
patient's shortness of breath most likely due to COPD
exacerbation. He also had a smaller component of pulmonary edema
from acute on chronic systolic heart failure. He was initialy
admitted to the MICU where the patient was intially started on
diueresis with Lasix bolus of 40 mg IV, but was soon started on
a Lasix drip with goal net negative output of 2 liter. He was
also given prednisone 40mg daily and azithromycin along with
levalbuterol and ipratropium nebs for COPD. The patient's O2
requirement improved with his diueresis and upon transfer to the
floor, he was breathing comfortably on nasal cannula. While
being diuresed, BID lytes were checked and repleted. His rate
control was also increased, as metoprolol was started at 25 mg
q8, with target heart rate in the ___ to ensure adequate time
for diastolic filling. This was then stopped as it seemed to
exacerbate his underlying lung disease.
# Severe aortic stenosis and diastolic dysfunction/CAD: Pt
declines any invasive procedures or surgical interventions.
Troponin were elevated, appropriate for his renal failure. MB
was flat. His echo showed some inferolateral hypokinesis which
likely reflects a prior MI within the last year ___ echo
negative). Pt does not want any cardiac catheterization
procedures. Continued on ASA 81. Pt declines to take his statin.
Stopped his metoprolol on this admission since it seemed to
exacerbate his COPD symptoms.
# Lactic acidosis: Lactate initialy 4.0, improved to 1.0.
Likely due to acute low perfusion state from acute on chronic
systolic heart failure and severe aortic stenosis.
Acute Renal Failure/ CKD: Baseline Cr 2.2-2.5. While in MICu, he
was started n lasix drip for pulmonary congestion. His symptoms
improved and lasix drip was stopped. While on drip, Cr
increased, bicarb increased, K decreased, suggesting
over-diuresis. Lasix was stoped and Cr stabalized at 3.0. He has
renal follow up.
# HTN: Stopped his home HCTZ on this admission since BP stable
on current medications. Also stopped his metoprolol since seemed
to exacerbate his COPD. Continued his amlodipine 10mg daily.
Lasix was held and may be resumed when Cr improves to baseline.
#Anemia: Pt found to have anemia that is likely combination of
Fe def anemia and from CKD. Recc pt start ferrous sulfate BID
and ___ with nephrologist to discuss if he would benefit
from Epo supplementation. Workup for iron deficiency can be
considered outpatient, although pt and family do not want any
invasive procedures.
==========================
INACTIVE ISSUES
==========================
7. HLD: Atoravastatin discontinued during last admission.
Appropriate considering age and comorbidity with risk/benefit.
Pt does not wish take his statin.
8. BPH: Continued tamsulosin 0.4 mg po qhs
=============================
TRANSITIONAL ISSUES
=============================
1. Fe Deficiency anemia: can discuss with pt whether or not to
work this up. Started Ferrous Sulfate
2. Acute Renal Failure: ___ checking Cr on post-discharge visit
to see if it trends down. Pt's ARF likely from over-diuresis.
3. MEDICATION CHANGES:
STOP: Metoprolol, this is likely making your wheezing and lung
COPD worse.
STOP: Hydrochlorothiazide, your blood pressures do well without
this medication. Your primary care doctor can consider
restarting this medication outpatient.
STOP: stop Lasix for now. You have no fluid in your lungs and
you do not need this at this time. However, your primary care
doctor may wish to resume this medication when your kidney
function returns to normal.
START: Iron supplentation: you have anemia from low iron and we
recommend you take iron supplements
START: Azithromycin- this is an antibiotic for your reason lung
infection. You will take this for 2 more days.
START: Prednisone 40mg daily. This is for your emphysema flair.
You will take this for 2 more days.
START: LevAbluterol nebulizer. You can take this instead of your
albuterol inhaler since it is easier to take and allows more of
the medicine to go to your lungs. You can take the ipratropium
nebulizer instead of your atrovent inhaler and instead of the
combivent inhaler.
Medications on Admission:
Albuterol sulfate 90 mcg HFA Aerosol inhaler ___ puff q4-6
Amlodipine 10 mg po qdaily
Lasix 20 mg po prn edema (patient reports not taking any)
HCTZ 25 mg po qdaily
Atrovent HFA 17 mcg/actuation HFA Aersol 2 puffs q6
Combivent 18 mcg-103 mcg (90 mcg) 2pff QID
Latanoprost 0.005% drops 1 drop both eyes at bedtime
Metoprolol 50 mg ER po qdaily
Omeprazole 40 mg po qdaily
Tamsulosin 0.4 mg ER po qhs
Aspirin 81 mg po qdaily
Fish oil-DHA-EPA 1,200 mg-144 mg-216 mg Capsule po BID
Discharge Medications:
1. Home oxygen Sig: One (1) When Ambulating only: ___ L when
ambulating only. Ambulatory O2 RA=85%. Ambulatory O2 with 1L NC:
89%. Dx: COPD.
Disp:*1 1* Refills:*0*
2. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q2H (every 2 hours) as needed for wheezing.
Disp:*300 ml* Refills:*3*
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. nebulizer & compressor Device Sig: One (1) Miscellaneous
every four (4) hours as needed for shortness of breath or
wheezing.
Disp:*1 u* Refills:*0*
5. nebulizer accessories Kit Sig: One (1) Miscellaneous
every four (4) hours as needed for nausea.
Disp:*1 unit* Refills:*0*
6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*300 ml* Refills:*2*
7. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puff Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
8. Combivent ___ mcg/Actuation Aerosol Sig: Two (2) puff
Inhalation four times a day.
9. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
15. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
16. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary diagnoses:
COPD exacerbation
Acute on chronic heart diastolic failure secondary to aortic
stenosis
Acute Kidney Injury
Iron Deficiency Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you.
You were admitted to the hospital for shortness of breath. We
treated you for both an exacerbation of COPD and also for an
acute on chronic episode of heart failure.
While in the hospital, you had an echocardiogram. We diuresed
you (removed fluid) and gave you nebulized breathing treatments
and azithromycin; and your breathing improved significantly.
You should weigh yourself every day, and call your doctor if you
gain more than 2 pounds in one day.
Your kidney function is a little worse then usual but is stable
these last 2 days of your hospitalization. We anticipate that it
will improve over the next few days now that you are no longer
on the lasix medication. Please make sure to follow with your
primary care doctor who will check your kidney function. We
scheduled an appointment for you to see a kidney doctor in the
next 2 weeks.
You should continue taking all of your medications as you had
prior to your hospitalization, except:
STOP: Metoprolol, this is likely making your wheezing and lung
COPD worse.
STOP: Hydrochlorothiazide, your blood pressures do well without
this medication. Your primary care doctor can consider
restarting this medication outpatient.
STOP: Lasix for now. You have no fluid in your lungs and you do
not need this at this time. However, your primary care doctor
may wish to resume this medication when your kidney function
returns to normal.
START: Iron supplentation: you have anemia from low iron and we
recommend you take iron supplements
START: Azithromycin- this is an antibiotic for your reason lung
infection. You will take this for 2 more days.
START: Prednisone 40mg daily. This is for your emphysema flair.
You will take this for 2 more days.
START: LevAbluterol nebulizer. You can take this instead of your
albuterol inhaler since it is easier to take and allows more of
the medicine to go to your lungs. You can take the ipratropium
nebulizer instead of your atrovent inhaler and instead of the
combivent inhaler.
Followup Instructions:
___
|
10450590-DS-6 | 10,450,590 | 22,541,137 | DS | 6 | 2161-05-28 00:00:00 | 2161-05-28 21:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain and fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of indeterminate colitis who presents with
fevers and increased abdominal pain. Patient is being followed
in GI (Dr. ___ clinic for indeterminate colitis, which began
___ years ago. He underwent colonoscopy and sigmoidoscopy in
___ which showed pancolitis. Pt was started on ___ on
___.
Admission ___ for indeterminate colitis flair and he was
started on prednisone 40mg daily, with plan to taper by 5mg per
week. He was also re-initiated on Asacol 2400mg BID. His
symptoms were resolved at discharge. Was seen by Dr. ___ on
___, who increased prednisone dose to 50mg daily,
with planned taper. This morning patient reports waking up at
3:30AM with severe ___ stabbing and burning lower abdominal
pain +fevers (102 at home), chills. Called into GI clinic who
recommended he present to the ED. Last vomited last Wendesday.
Pt denies change in his BMs, still baseline ___ episodes of
diarrhea per day. No relief of abd pain with BM, only
alleviating factor is prednisone of which pt took his daily 50
today plus an extra 20 this AM. No exacerbating factors other
than stress.
In the ED, initial vital signs were: 98.4 93 134/87 18 98 % ra.
Exam notable for generalized abd TTP worse in bilateral lower
quadrants, no epigastric or suprapubic tenderness. +voluntary
guarding. No rebound tenderness, -rosvings, -iliopsoas sign.
Hemoccult negative. Labs were notable for lipase 132, lactate
1.6. Patient was given morphine and ondansetron.
On Transfer Vitals were: 98.5 60 117/69 20 96% RA.
Pt states that this feels like his other colitis flares. Pt
denies N/V currently. Feels hungry. Last BM yesterday. No chest
pain, SOB, dysuria.
Past Medical History:
IBD
Hypothyroid
Depression
Social History:
___
Family History:
Sister with GI issues, diagnosis not known.
Physical Exam:
On admission:
Vitals- 98.4 117/86 67 16 97%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- +bs, non-distended, soft, non-tender to palpation
throughout, no rebound tenderness or guarding
GU- no foley
Ext- warm, well perfused, no clubbing, cyanosis or edema
On discharge:
Vitals- 98.4 128/87 60 16 97%RA
General- Alert, oriented, NAD
HEENT- Sclera anicteric, MMM, oropharynx clear
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- +bs, non-distended, mildly tender to deep palpation on
LLQ, no rebound or guarding
GU- no foley
Ext- warm, well perfused, no clubbing, cyanosis or edema
Labs: Reviewed, see below
Pertinent Results:
==================
Labs:
==================
___ 07:20AM BLOOD WBC-10.9 RBC-4.23* Hgb-12.9* Hct-38.7*
MCV-92 MCH-30.6 MCHC-33.4 RDW-13.3 Plt ___
___ 07:45AM BLOOD WBC-9.6 RBC-4.12* Hgb-12.6* Hct-38.7*
MCV-94 MCH-30.6 MCHC-32.5 RDW-13.1 Plt ___
___ 07:20AM BLOOD Neuts-90.2* Lymphs-3.9* Monos-5.4 Eos-0.3
Baso-0.2
___ 07:45AM BLOOD Glucose-92 UreaN-11 Creat-1.1 Na-143
K-3.5 Cl-103 HCO3-30 AnGap-14
___ 07:20AM BLOOD ALT-15 AST-11 AlkPhos-39* TotBili-0.7
___ 02:19AM BLOOD ALT-22 AST-16 AlkPhos-39* TotBili-0.3
___ 07:20AM BLOOD Lipase-132*
___ 02:19AM BLOOD Lipase-201*
___ 07:20AM BLOOD Albumin-3.8
___ 07:26AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.1
___ 07:45AM BLOOD Calcium-8.4 Phos-2.4* Mg-2.0
___ 08:15AM BLOOD Triglyc-73
___ 07:20AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 08:17AM BLOOD Lactate-1.6
___ 02:32AM BLOOD Lactate-1.6
___ 09:42AM URINE Color-Straw Appear-Clear Sp ___
___ 09:42AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
==================
Micro:
==================
___ 7:20 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 9:42 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 6:57 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
___ 8:00 am BLOOD CULTURE
Blood Culture, Routine (Pending):
CMV Viral Load (Final ___:
CMV DNA not detected.
___ C diff: Positive for toxigenic C. difficile by the
Illumigene DNA amplification.
==================
Imaging:
==================
CHEST (PA & LAT) Study Date of ___ 8:17 AM
IMPRESSION: No acute cardiopulmonary process.
PORTABLE ABDOMEN Study Date of ___ 8:11 AM
IMPRESSION:
Normal bowel gas pattern without obstruction. No free air.
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 11:58 AM
IMPRESSION:
1. Mild pancreatic edema and peripancreatic fat stranding
involving the
distal body and tail of the pancreas. These findings have
developed since the previous CT and are suggestive of mild acute
pancreatitis. No evidence of pancreatic necrosis. No abscess
or evidence of perforation. MRCP is recommended for further
evaluation.
2. No CT features suggestive of active colitis. Subtle loss
of the normal haustral pattern within the descending colon.
LIVER OR GALLBLADDER US (SINGLE ORGAN)
IMPRESSIO:
1. No cholelithiasis or secondary findings of acute
cholecystitis.
2. Mild splenomegaly, as above.
Brief Hospital Course:
___ with a history of indeterminate colitis who presents with
fevers and increased abdominal pain concerning for flare of
indeterminiate colitis, found to be c diff positive, with
pancreatitis on CT.
# Acute pancreatitis: Lipase elevated at 201. CT with evidence
of pancreatitis without abscess or necrosis. Etiology not known,
but suspected to be due to recent therapy with ___ for
indeterminate colitis. Pt denied heavy etoh use. RUQ u/s without
gallstones. ___ wnl. Pt was made npo and given IV fluids and
analgesics. Diet was advanced, and was tolerating low fat, low
residue diet prior to discharge.
#C diff: Pt with abdominal pain and fevers at home, consistent
with flare of indeterminate colitis - however, found to be c
diff positive. C diff infection helped elucidate why pt symptoms
were refractory to increased doses of prednisone. No evidence of
colitis on CT. CMV viral load negative. GI discussed starting
___ to treat indeterminate colitis, which was not started
during admission. Hepatitis serologies negative. PPD negative
during this admission, quantiferon gold also sent given pt could
be anergic due to prednisone therapy. C diff was treated with po
vancomycin (started ___ to be continued through ___ to
complete 14 day course. Was also treated with IV flagyl, which
was discontinued prior to discharge. For indeterminate colitis,
pt was initially treated with IV methylprednisolone x 1 day,
before continuing home prednisone 50mg daily, to be continued
until pt is started on ___. Was also continued on home
Asacol. Home ___ was discontinued due to pancreatitis. While on
prednisone, pt advised to avoid NSAIDs, and take calcium and
vitamin D supplementation. If he continued on prednisone,
Bactrim prophylaxis should be considered.
# Headache: Pt reported consistent with prior migraines, though
more severe, which may have been exacerbated by poor sleep. Was
treated with fioricet prn and resolved prior to discharge.
#Hypothyroid: Stable. Continued on home levothyroxine.
#Depression: Stable. Continued on home SSRI.
Transitional issues:
-Pt to complete 2 week course of oral vancomycin (end date
___ for treatment of c diff.
-Pt to follow up with GI for consideration of starting ___
for inderminate colitis. For now, remains on prednisone 50mg
daily. Pt advised to avoid NSAIDs and take calcium and vitamin D
supplementation. Please start on Bactrim prophylaxis as
appropriate if he remains on prednisone.
-Code: full
-Emergency Contact: wife ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluoxetine 40 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Mesalamine ___ 2400 mg PO BID
4. PredniSONE 50 mg PO DAILY
5. TraZODone 50 mg PO HS:PRN insomnia
6. Mercaptopurine 75 mg PO DAILY
Discharge Medications:
1. Fluoxetine 40 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Mesalamine ___ 2400 mg PO BID
4. PredniSONE 50 mg PO DAILY
5. TraZODone 50 mg PO HS:PRN insomnia
6. Vancomycin Oral Liquid ___ mg PO/NG Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp
#*44 Capsule Refills:*0
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
Do not take if sedated; no not drive or operate machinery while
using
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*10
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-C diff
-Pancreatitis
Secondary:
-Indermiinate colitis
-Hypothyroidism
-Depression
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. You were hospitalized due to
abdominal pain. You were found to have an infection of your
large intestine due to a bacteria called clostridium difficile
("c diff"). This infection was treated with antibiotics. You
were also found to have pancreatitis, which was treated with IV
fluids, pain medication, and careful reintroduction of eating.
In the absence of other identified causes, we suspect the
pancreatitis may be due to the mercaptopurine who were taking
for indeterminate colitis, which was discontinued. You should
follow up with your primary care provider, as well as with Dr.
___ consideration starting ___ for your inderterminate
colitis. While on prednisone, please avoid NSAIDs (including
Advil, ibuprofen, Aleve, naproxen). We recommend daily
supplementation of calcium and vitamin D while on prednisone. If
you will stay on the high dose of prednisone for a longer
period, please discuss with your physician about adding bactrim
as preventive antibiotic for a lung infection called "PCP".
Followup Instructions:
___
|
10450914-DS-5 | 10,450,914 | 27,558,167 | DS | 5 | 2183-06-15 00:00:00 | 2183-06-15 09:41:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
Abdominal pain, nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ yo F with PMH significant for asthma,
constipation, endometriosis, PID, head and neck cancer s/p
chemoradiation and g tube placement, and remote diagnostic
laparoscopy and open myomectomy who had acute onset of diffuse
sharp abdominal pain around 10PM last night after eating a
sandwich, and associated nausea and bloating. She did not take
any medication for the pain, and it increased in severity over
the next few hours, so she presented to the ED for evaluation.
Upon arrival to the ED, she began to have nonbloody emesis. Her
pain is now improved, s/p dilaudid. She has not passed flatus
since the pain began. Last bowel movement was 2 days ago, and
was normal. She has no shortness of breath or chest pain, no
fevers, chills, no urinary symptoms. She has never had pain like
this before, and no history of bowel obstructions.
Past Medical History:
endometriosis
fibroids
asthma
constipation
head and neck cancer s/p chemotherapy and radiation
Pelvic inflammatory disease following IVF treatment
hiatal hernia
Past Surgical History:
Diagnostic laparoscopy
Open myomectomy
G tube placement
Social History:
___
Family History:
Adopted. Son is healthy, ___ yo.
Physical Exam:
Admit PE:
Vitals: 98.0 80 121/79 16 97% 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, minimally distended, nontympanic, tender to palpation
in the LLQ, no rebound or guarding, hyperactive bowel sounds, no
palpable masses or hernias. Well healed infraumbilical scar.
Well-healed low transverse incision.
Ext: No ___ edema, ___ warm and well perfused
Discharge PE:
Vitals: 99.0 59 115/68 16 98% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/R/G, WWP
PULM: No W/R/C, normal WOB
ABD: Soft, non-distended, non-tender to palpation, no rebound or
guarding.
Ext: No CCE
Pertinent Results:
___ 03:21AM BLOOD WBC-8.5 RBC-4.50 Hgb-13.6 Hct-41.1 MCV-91
MCH-30.2 MCHC-33.1 RDW-13.4 RDWSD-44.2 Plt ___
___ 04:00AM BLOOD WBC-3.4* RBC-3.57* Hgb-10.6* Hct-33.4*
MCV-94 MCH-29.7 MCHC-31.7* RDW-13.3 RDWSD-45.7 Plt ___
___ 04:00AM BLOOD Neuts-59.3 ___ Monos-10.4
Eos-8.0* Baso-0.6 AbsNeut-1.99# AbsLymp-0.73* AbsMono-0.35
AbsEos-0.27 AbsBaso-0.02
Imaging:
Chest radiograph:
FINDINGS:
The lungs are well-expanded and clear. The cardiomediastinal
silhouette is unremarkable. The hilar pleural surfaces are
normal. There is no subdiaphragmatic free air.There is a small
hiatal hernia.
CT A/P ___ IMPRESSION:
1. Findings compatible with small bowel obstruction, with
transition point in the right lower quadrant.
2. Moderate volume abdominopelvic free fluid.
3. Extensive diverticulosis, with no evidence of diverticulitis.
4. Moderate hiatal hernia.
5. Fibroid uterus.
6. Prominent pancreatic duct, with no obstructing lesion
identified.
Brief Hospital Course:
The patient presented to Emergency Department on ___. Pt was
evaluated by ACS upon arrival to ED. Given findings on history,
exam, and imaging suggestive of SBO, the patient was admitted to
___ for observation and monitoring. She was managed
conservatively with bowel rest and IV fluids. She responded
well and had return of bowel function HD 1. By HD 2 she was
tolerating a regular diet.
Neuro: The patient was alert and oriented throughout
hospitalization.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO on IV fluids. On
HD 1, the diet was advanced sequentially to a Regular diet,
which was well tolerated. Patient's intake and output were
closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: ___ dyne boots were used during this stay and was
encouraged to get up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
On CT patient has a prominent pancreatic duct, measuring up to 5
mm in diameter, no evidence of focal lesion identified and no
peripancreatic stranding. She should follow-up with a
gastroenterologist for possible MRCP and/or ERCP to rule-out
neoplastic process. Her PCP's office, ___. at
___, was contacted with this information on ___ at
10:58am.
Medications on Admission:
Colace
senna
occasional claritin, zyrtec
asthmanex qd
albuterol prn
Allergies:
amoxicillin- rash
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
2. Docusate Sodium 100 mg PO BID
do not take if you are having diarrhea or nausea/vomiting
3. Senna 8.6 mg PO BID:PRN constipation
do not take if you are having diarrhea or nausea/vomiting
Discharge Disposition:
Home
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with a
small bowel obstruction. You were managed conservatively with
bowel rest and IV fluids. You are recovering well and are now
ready for discharge. Please follow the instructions below to
continue your recovery:
Re-introduces foods slowly into your diet. Eat small, frequent
meals.
Please follow-up with your primary care physician and ___
gastroenterologist about the finding on CT of a prominent
pancreatic duct which needs further investigation.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Followup Instructions:
___
|
10450918-DS-13 | 10,450,918 | 27,762,502 | DS | 13 | 2181-01-26 00:00:00 | 2181-01-27 07:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Recurrent falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with a past medical history of
CAD s/p CABG in ___ (LIMA-LAD, SVG-Diag, SVG-PDA), aortic
stenosis s/p AVR (___. ___ tissue) in ___, mild
dementia, BPH, rheumatoid arthritis, hypertension, who presents
with recurrent falls.
His family reports that when he attempts to stand, his legs
appear to give out and he falls to the floor. The patient does
not have a recollection of the falls. The patient has no
headache, he has mild neck pain. He states he walks around the
house without a walker but it appears he was told to use a
walker/cane in the past.
Past Medical History:
Aortic Stenosis
Benign Prostatic Hyperplasia
Coronary Artery Disease
Cervical Spine Injury (Fractured C2 due to MVA)
Hyperlipidemia
Hypertension
Mitral stenosis
Rheumatoid arthritis
Past Surgical History:
Bilateral hip replacements
Neck surgery
Bilateral cataract surgery
Social History:
___
Family History:
Father died of a myocardial infarction at age ___.
Brother had ___, died of a myocardial infarction
in early ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
T 97.9 BP 192/97 HR 74 RR 18 SaO2 96%Ra
General: Alert. No acute distress. Sitting in bed in J-collar.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper extremities to
flexion, grip, shoulder abduction. Lower extremity with ___
plantar flexion bilateral, ___ plantar and hip flexion in left,
4+/5 of these in right limited by pain in the right femur,
grossly normal sensation. Oriented to place, hospital, city,
thinks year is ___.
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: Temp 97.8 BP 156/79 HR 69 RR 18 O2 97 on RA
General: NAD, alert and oriented to person, place but not year
(thinks ___
Lungs: CTAB
CV: RRR, no MRG.
GI: Soft, nondistended, nontender diffusely.
Ext: No edema, erythema, or TTP of calves
Neuro: ___ strength bilaterally of the UE; ___ strength of foot
plantar flexion, hip flexion, toe extensor/flexors bilaterally;
___ strength on L knee flexion; neg Babinski; no pronator drift;
equal sensation to light touch bilaterally; no postural
instability; no cogwheel rigidity or pill-rolling tremors;
PERRL, EOMI
Pertinent Results:
ADMISSION LABS
================
___ 11:30AM BLOOD WBC-8.0 RBC-4.29* Hgb-13.5* Hct-41.7
MCV-97 MCH-31.5 MCHC-32.4 RDW-14.5 RDWSD-51.3* Plt ___
___ 11:30AM BLOOD Glucose-91 UreaN-15 Creat-0.9 Na-142
K-4.6 Cl-106 HCO3-25 AnGap-11
DISCHARGE LABS
===============
___ 07:09AM BLOOD WBC-6.5 RBC-3.93* Hgb-12.4* Hct-38.2*
MCV-97 MCH-31.6 MCHC-32.5 RDW-14.3 RDWSD-50.3* Plt ___
___ 07:09AM BLOOD Glucose-89 UreaN-13 Creat-0.9 Na-141
K-4.5 Cl-107 HCO3-26 AnGap-8*
___ 07:09AM BLOOD ALT-7 AST-12 AlkPhos-68 TotBili-0.4
MICROBIOLOGY
===============
___ 4:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING/STUDIES
==================
CT C-SPINE IMPRESSION:
1. No evidence of fracture or subluxation.
2. Status post resection of the left posterior arch of C1 with
apparent
embolic material adjacent to the surgical site.
CT HEAD IMPRESSION:
No evidence acute intracranial abnormalities.
X-RAY LEFT FEMUR/PELVIS IMPRESSION:
No evidence of fracture or dislocation.
LUMBAR SPINE X-RAY IMPRESSION:
No radiographic evidence of acute fracture is identified.
Findings suggest with polyethylene liner wear in the left hip
arthroplasty.
Brief Hospital Course:
___ w/ hx of CAD s/p CABG ___, aortic stenosis s/p AVR ___,
mild dementia, BPH, rheumatoid arthritis, HTN, presenting for
recurrent falls.
#Recurrent Falls, Deconditioning: Patient's family brought Mr.
___ to the ___ for recurrent falls, increasing in frequency
over the past ___ months. Patient was noted to be neurologically
intact without evidence of stroke. An detailed work up for falls
was performed. No evidence of infection or UTI. NCHCT without
evidence of ventriculomegaly and non-magnetic gait dispelled NPH
from the ddx. No bleed or infarct on CT head. Orthostatics were
positive and we provided IV fluids. Afterwards, repeat
orthostatics were negative. Imaging was negative beyond
degenerative changes to the C and L spine; no fractures.
Overall, it appeared that the patient's recurrent falls were a
multifactorial result of deconditioning, fear of falling, and
orthostatic hypotension. Falls likely worsened due to ETOH use
as well in the setting of dementia and deconditioning. ___
recommended rehab and this was discussed with patient and
family. Patient agreed to rehab is being transferred to a rehab
facility with instructions to always use a walker until he can
build up his strength to talk without it. Further instructions
provided on avoiding alcohol as much as possible due to ability
to further impair his balance.
#ETOH Use: Patient had reported daily ETOH use, unclear amount.
Per patient, occasionally drinks shots of whiskey and glasses of
wine. Patient was monitored for ETOH withdrawal with no
signs/symptoms of withdrawal displayed. Recommend abstinence of
ETOH given increased risk of fall.
#Left thigh pain: Patient complained of intermittent left
anterior thigh pain without associated weakness, radiation,
numbness, or tingling. We obtained a XR of the left femur and
hip and L-spine to r/o potential fractures from falls given his
age and reassure patient. We did not find any fractures on XR.
Pain controlled with PRN Tylenol.
#HTN: Continued on home metoprolol and HCTZ.
#Degenerative change in C-spine: Chronic per patient. s/p
C-spine surgery in 1980s. No compression or acute findings.
Recommend outpatient follow up.
#AS s/p AVR: No new murmurs s/p AVR denoting that patient likely
has not re-stenosed his AV.
#CAD s/p CABG: Continued on home meds including metoprolol,
lisinopril, simvastatin and ASA.
#Mild dementia: continued home donepezil. A&Ox2 at baseline.
Oriented to self, hospital but does not know date.
#Rheumatoid arthritis: Continued hydrochloroquine.
#BPH: Continued tamsulosin. UA negative for hematuria.
TRANSITIONAL ISSUES
============================================
[ ] Recommend ETOH abstinence.
[ ] Due to repeat screening colonoscopy s/p polypectomy.
[ ] Consider changing metoprolol tartrate to Toprol XL for CHF.
[ ] Consider changing simvastatin to high-intensity statin eg
atorvastatin for CAD.
[ ] Aspirin dose lowered to 81mg QD for secondary prevention.
(Was taking aspirin 325mg PO QD at home)
EMERGENCY CONTACT/HCP: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Metoprolol Tartrate 100 mg PO BID
3. Simvastatin 40 mg PO QPM
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Hydroxychloroquine Sulfate 200 mg PO BID
6. Tamsulosin 0.4 mg PO QHS
7. Donepezil 10 mg PO QHS
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
9. Omeprazole 20 mg PO DAILY
10. Aspirin 325 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Aspirin 81 mg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. Donepezil 10 mg PO QHS
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Hydroxychloroquine Sulfate 200 mg PO BID
8. Lisinopril 40 mg PO DAILY
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Omeprazole 20 mg PO DAILY
11. Simvastatin 40 mg PO QPM
12. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Recurrent falls
Dementia
Deconditioning
Orthostatic hypotension
Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were seen in the hospital for ongoing falls.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were evaluated with a thorough physical, labs, and imaging
all of which were normal with regards to causing your fall. You
received IV fluids to treat low blood pressures.
- You had a CT scan of your head and neck that did not show
broken bones or new strokes.
- Physical therapy helped walk with you and you performed well
using your walker. Please ensure that you continue to walk with
your walker at all times.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- You are being discharged to a rehab to help make you stronger.
- ALWAYS USE YOUR WALKER
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10450953-DS-18 | 10,450,953 | 25,190,122 | DS | 18 | 2150-10-26 00:00:00 | 2150-10-26 19:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: ___ with approximately 12 hours of intense, diffuse
abdominal pain. Pain reportedly awakened him from sleep this
morning and has progressively gotten worse over the course of
the
day. Pain is described as sharp, and nonradiating. Pt denies
nausea, vomiting, CP, SOB, hematemesis. Does endorse small
amount
of blood with BM this morning. Upon arrival at ___ ED, pt
noted to be markedly hypertensive to 170s but otherwise afebrile
and hemodynamically normal. Pt was treated with 20mg IV
labetolol
with only moderate effect.
Past Medical History:
Peripheral vascular disease
Smoking
Hyperlipidemia
Hypertension
Chronic renal insufficiency
Pericarditis
left lower extremity DVT on Coumadin
Social History:
___
Family History:
Noncontributory
Physical Exam:
Physical examination upon admission: ___
PE: 97.4 66 178/73 20 97% ra
GEN: Aox3 NAD
HEENT: NC/AT
COR: S1S2
RES: Normal respiratory effort
ABD: Soft, nondistended, mild periumbilical TTP, no rebound or
guarding
NEU:Without focal deficit
PSY: Normal mood, pleasan affect
Physical examination upon discharge: ___:
General: NAD
CV: ns1, s2, -s3, -s4
LUNGS: clear
ABDOMEN: soft, non-tender, hypoactive BS
EXT: no pedal edema bil., no calf tenderness bil
MENTATION: alert and oriented x 3, speech clear, no tremors
Pertinent Results:
___ 10:30PM BLOOD WBC-5.9 RBC-5.64 Hgb-15.8# Hct-48.8#
MCV-87 MCH-28.0 MCHC-32.4 RDW-14.7 Plt ___
___ 09:45AM BLOOD Plt ___
___ 09:45AM BLOOD ___ PTT-36.0 ___
___ 11:00PM BLOOD ___ PTT-26.2 ___
___ 10:30PM BLOOD Glucose-104* UreaN-19 Creat-1.6* Na-135
K-5.5* Cl-101 HCO3-22 AnGap-18
___ 10:30PM BLOOD ALT-20 AST-39 AlkPhos-67 TotBili-0.7
___ 10:30PM BLOOD Albumin-4.4 Calcium-9.8 Phos-3.9 Mg-1.5*
___ 10:40PM BLOOD Lactate-1.6 K-4.9
___: CTA of abdomen:
IMPRESSION:
1. Multifocal areas of bowel dilatation with intervening areas
of bowel with either bowel wall thickening or adjacent fat
stranding. The overall picture is not one of mechanical
obstruction, rather there appeared to be areas with inflamed
bowel leading to pre stenotic dilatation. The differential for
the etiologies of the inflammation would be infectious or
ischemic; given the patient's vascular history a low perfusion
state could have caused the multiple areas of inflammatory
changes.
2. Patent SMA, celiac, ___. Occluded fem-fem bypass since ___.
Occluded bilateral external iliacs and occluded common iliac on
the left. All the vascular changes appear stable since ___
___: x-ray of the abdomen:
Wet Read: ___ SUN ___ 6:05 ___
Persistent dilated loops of small bowel better assessed in prior
CT. No
contrast seen in the colon more than 7 hours after
administration.
Brief Hospital Course:
The patient is a ___ year old gentleman who was admitted to the
hospital with diffuse abdominal pain. Upon admission, he was
made NPO, given intravenous fluids, and underwent imaging. He
was reported to have an elevated blood pressure treated with
labetalol. On CTA of the abdomen he was reported to have
multiple dilated loops of small bowel with multiple transition
point at relatively the same level (coronal slice 15). This was
concerning for small bowel obstruction due to an internal
hernia. A small amount of mesenteric fluid was noted in the
left lower quadrant. The vascular service was consulted because
of his prior vascular history. After reviewing his films, they
determined that his findings were not indicative of mesenteric
ischemia and that the findings on CTA were stable from a prior
study in ___ and that no vascular intervention was needed. As
the patient's abdominal pain resolved, he resumed clear liquids
and was advanced to a regular diet. His vital signs remained
stable and he was afebrile. His hematocrit normalized. His INR
was 1.9 and he resumed his daily coumadin 3.5 mg dose. On HD
#2, he was discharged home with instructions to follow-up with
his primary care provider and with the ___ clinic.
Medications on Admission:
___:
1. Crestor 40 mg Tab Daily
2. Cholecalciferol (vitamin D3) 1,000 unit Cap Daily
3. cilostazol 100 mg tablet BID
4. Enalapril maleate 20 mg Tab BID
5. hydrochlorothiazide 50 mg Tab Daily
6. Warfarin 1 mg Tab as directed
Discharge Medications:
1. Enalapril Maleate 20 mg PO BID
2. Rosuvastatin Calcium 40 mg PO DAILY
3. Warfarin 3.5 mg PO DAILY16
4. Hydrochlorothiazide 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with diffuse abdominal pain.
Imaging of your abdomen was done and you were found to have
dilated loops of bowel. Because of your extensive vascular
history, you were seen by vascular surgery. No surgery was
indicated. Your abdominal pain has resolved and you are
preparing for discharge home with the following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* Return of your abdominal pain
* Rectal bleeding
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in 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.
Please take your coumadin as directed and f/u in ___ clinic
for repeat ___
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered
Followup Instructions:
___
|
10450953-DS-20 | 10,450,953 | 22,649,702 | DS | 20 | 2151-11-25 00:00:00 | 2151-11-27 14:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bilateral lower extremity claudication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with a history of peripheral
arterial disease admitted for management of disabling
claudication secondary to aorto-iliac disease. Having undergone
multiple bypasses as well as catheter-based interventions to
improve the circulation to his feet which have unfortunately
have all failed.
Admitted on ___ from clinic for concerns of wound cellulitis
and disabling claudication and his risk vs benefit of undergoing
surgery were evaluated and patient was discharge to home ___
with a follow up appointment in a month. Patient was discharge
on coumadin for LLE DVT.
Today, he presents with worsening pain which has kept him awake
at night. Worse on the right>left as well has complains of
worsening bilateral toe ulcers.
Past Medical History:
1. Peripheral vascular disease
2. Hyperlipidemia
3. Hypertension
4. Chronic renal insufficiency
5. Pericarditis
6. left lower extremity DVT on Coumadin
7. right common iliac stenosis
8. right SFA occlusion
9. left CIA, EIA, CFA and SFA occlusion
10. Hemorrhoids
11. History of colitis from indeterminate etiology
Past Surgical History:
1. failed left fem-pop bypass with saphenous vein graft at ___
around ___
2. right to left common fem-fem bypass as well as right external
iliac angioplasty and stent ___ ___
3. Angioplasty and re-stenting of occluded right external iliac
stent, angioplasty and stenting of occlusion of proximal
profunda
femoris artery ___ ___ angioplasty and stent
of right proximal profunda artery ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission,
VS: Temp: 98.6 HR: 126 BP: 190/110 Resp: 20 O(2)Sat: 99 Normal
AOx3 NAD
RRR S1S2
No respiratory distress
Abdomen is soft, non tender
Bilateral extremities have well healed scars from prior
interventions. R hallux nail, thickened, yellowed, dystrophic
with lifted free edge. No ingrown borders. No drainage, redness,
malodor, edema or fluctuance noted
Doppler Signals:
R Femoral/pop/pt/dp monophasic
L Femoral biphasic / pop/pt/dp monophasic
On discharge,
General: AVSS, well-appearing, in no acute distress
Cardiopulmonary: RRR, normal S1 and S2 with no murmurs, rubs or
gallops. CTAB
Abdomen: Soft, non-tender, non-distended
Neurologic: Grossly intact, AAOx3
Extremities: Right hallux nail is absent, nail bed appears to be
healing nicely, tender to palpation and some dry blood is
present. Rest is unchanged from admission. Femoral, popliteal,
___ and DP with dopplearable signals.
Pertinent Results:
___ 10:09AM BLOOD WBC-4.3 RBC-4.69 Hgb-12.7* Hct-41.6
MCV-89 MCH-27.2 MCHC-30.6* RDW-13.7 Plt ___
___ 10:09AM BLOOD Neuts-57.2 ___ Monos-9.8 Eos-5.8*
Baso-1.5
___ 10:09AM BLOOD ___ PTT-41.6* ___
___ 10:09AM BLOOD Glucose-83 UreaN-24* Creat-1.7* Na-138
K-4.2 Cl-102 HCO3-24 AnGap-16
___ 05:15PM BLOOD cTropnT-<0.01
___ 10:09AM BLOOD cTropnT-<0.01
___ 07:00AM BLOOD Calcium-9.5 Phos-3.9 Mg-1.5*
___ 10:30AM BLOOD Lactate-1.7
___ 08:35AM BLOOD WBC-4.2 RBC-4.04* Hgb-11.2* Hct-35.2*
MCV-87 MCH-27.7 MCHC-31.8 RDW-13.7 Plt ___
___ 08:35AM BLOOD ___ PTT-82.8* ___
___ 08:35AM BLOOD Glucose-105* UreaN-24* Creat-2.1* Na-138
K-4.6 Cl-103 HCO3-27 AnGap-13
___ 08:35AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.1
FOOT AP,LAT & OBL RIGHT (___)
No convincing radiographic evidence of osteomyelitis
ECG (___)
Baseline artifact. Sinus rhythm. Early R wave progression.
Prominent precordial voltage but does not meet criteria for left
ventricular hypertrophy. Anterolateral T wave abnormalities.
Since the previous tracing of ___ the rate is now faster.
ST-T wave abnormalities are more prominent. The QTc interval is
shorter
ECG (___)
Sinus rhythm. Diffuse T wave changes suggestive of myocardial
ischemia.
Compared to the previous tracing of ___
wave
abnormalities are unchanged
Brief Hospital Course:
Patient was admitted to the vascular surgery service for
worsening bilateral lower extremity claudication and non-healing
right hallux ulcer. He was started on intravenous broad-spectrum
antibiotics and pain control was instituted. A podiatry consult
was requested for management of his toe lesion. Affected nail
was removed at bedside and an x-ray ruled out compromise to the
underlying bone. Given poor pain control, the chronic pain
service was consulted for recommendations. Oxycontin was added
to the regimen with good results, as pain remained controlled
throughout the rest of his hospital stay (albeit severe
claudication on ambulation of short distances). Patient received
all his home medications, however coumadin was held on admission
given supratherapeutic INR levels, and later anticipating a
possible intervention. For this latter reason, he was started on
a heparin drip and dosed appropriately depending on repeatedly
monitored PTT levels.
Symptoms improved and right hallux nail bed continued to heal
nicely. For this reason, no intervention was deemed necessary at
this point and patient's coumadin was restarted. Plan for right
axillary-to-profunda femoris bypass graft was discussed with the
patient as a possibility for revascularization in the near
future. He was agreeable after going through risks and benefits
of the procedure and consent was obtained. He would come back in
a couple of weeks for surgery. Anticipating discharge, patient
was evaluated by our physical therapists who recommended him to
go home with ___, which was properly arranged. Upon return of INR
to therapeutic levels, patient was ready to be discharged to
home.
At the time of discharge, patient's rest pain was under control
(still exhibiting claudication symptoms). He was tolerating a
regular diet and voiding without assistance. Discharge teaching
and follow-up instructions were discussed with verbalized
agreement and understanding of the plan.
Medications on Admission:
1. Hydrochlorothiazide 50 mg PO DAILY
2. Rosuvastatin Calcium 40 mg PO DAILY
3. Warfarin 3.5 mg PO DAYS (___)
4. Warfarin 4 mg PO DAYS (___)
5. Acetaminophen 325-650 mg PO Q6H:PRN pain
6. Docusate Sodium 100 mg PO BID
7. Enoxaparin Sodium 60 mg SC Q12H
8. Gabapentin 300 mg PO Q12H
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
10. PleTAL (cilostazol) 100 mg ORAL BID
11. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Warfarin 4 mg PO ONCE Duration: 1 Dose
2. Senna 17.2 mg PO BID:PRN constipation
3. Rosuvastatin Calcium 40 mg PO DAILY
4. PleTAL (cilostazol) 150 mg ORAL BID
5. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
RX *oxycodone [OxyContin] 10 mg 1 tablet extended release 12
hr(s) by mouth twice daily Disp #*60 Tablet Refills:*0
6. OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN breakthrough
pain
RX *oxycodone 10 mg 1 tablet(s) by mouth every 3 hours as needed
for breakthrough pain, Disp #*60 Tablet Refills:*0
7. Gabapentin 400 mg PO TID
8. Hydrochlorothiazide 50 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Acetaminophen 650 mg PO Q6H
11. Bisacodyl 10 mg PO/PR BID:PRN constipation
12. Sulfameth/Trimethoprim SS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1
tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0
13. ___ MD to order daily dose PO DAILY16
RX *warfarin [Coumadin] 1 mg ___ tablet(s) by mouth daily at
16:00 Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bilateral lower extremity claudication
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 ___ with increase pain
and infection in your right great toe. We started you on IV
antibiotics and had the podiatry team remove your right great
toenail and the infection improved. We have transition you to
oral antibiotic to take until your surgery.
We also had the pain team evaluate you for the increased leg
pain you have been experiencing. They have started you on new
short acting and long acting pain medications. Please remember
that narcotic pain medication can be very constipating. Please
add over the counter laxatives such as colace, senna or milk of
magnesia as needed to keep your bowels moving regularly.
We have arranged for you to return for bypass surgery on ___.
Please call the office at ___ to confirm the time and
place to report. PLEASE STOP COUMADIN PRIOR TO SURGERY . THE
LAST DOSE WILL BE ON ___.
Followup Instructions:
___
|
10450953-DS-23 | 10,450,953 | 24,577,747 | DS | 23 | 2152-03-13 00:00:00 | 2152-03-13 14:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right Upper Extremity Swelling
Major Surgical or Invasive Procedure:
Exploration of right axilla with repair of axillary artery and 6
mm polytetrafluoroethylene (PTFE) interposition graft to
existing axillofemoral thrombectomy of graft
Exploration off right axillofemoral bypass graft in the axilla
with thrombectomy as well as angiography of the bypass graft
Past Medical History:
Past Medical History:
1. Peripheral vascular disease
2. Hyperlipidemia
3. Hypertension
4. Chronic renal insufficiency
5. Pericarditis
6. left lower extremity DVT on Coumadin
7. right common iliac stenosis
8. right SFA occlusion
9. left CIA, EIA, CFA and SFA occlusion
10. Hemorrhoids
11. History of colitis from indeterminate etiology
Past Surgical History:
1. failed left fem-pop bypass with saphenous vein graft at ___
around ___
2. right to left common fem-fem bypass as well as right external
iliac angioplasty and stent ___ ___
3. Angioplasty and re-stenting of occluded right external iliac
stent, angioplasty and stenting of occlusion of proximal
profunda femoris artery ___ ___ angioplasty
and stent of right proximal profunda artery ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Exam:
Alert and oriented x 3
VS: Tc: 98.1 BP: 122/60 HR: 104 RR: 20 SpO2: 99 on RA
Carotids: 2+, no bruits or JVD
Resp: Lungs clear
Abd: Soft, non tender, non distended
Ext: Pulses: Left Femoral (+)Doppler, DP (-)Doppler, ___
(-)Doppler
Right Femoral (+)Doppler, DP (-)Doppler, ___
(-)Doppler
(+) Right leg edema 1+, Feet warm, well perfused. No open
areas.
(+)Doppler Right ax-profunda BPG
Strength: Right leg weakness: 1(-) hip flexion; otherwise
sensi-neuro
Incisions Dressing clean dry and intact. Soft, no hematoma or
ecchymosis
Pertinent Results:
Complete Blood Count:
___ 08:32AM BLOOD WBC-5.2 RBC-3.09* Hgb-8.5* Hct-27.9*
MCV-90 MCH-27.5 MCHC-30.5* RDW-14.2 Plt ___
___ 06:00AM BLOOD WBC-6.2 RBC-2.98* Hgb-8.5* Hct-26.6*
MCV-89 MCH-28.7 MCHC-32.1 RDW-14.3 Plt ___
___ 07:00AM BLOOD WBC-7.3 RBC-3.24* Hgb-9.1* Hct-28.6*
MCV-88 MCH-28.0 MCHC-31.7 RDW-14.1 Plt ___
___ 04:54AM BLOOD WBC-7.0 RBC-3.07* Hgb-8.7* Hct-27.6*
MCV-90 MCH-28.5 MCHC-31.7 RDW-14.4 Plt ___
___ 04:19AM BLOOD WBC-12.0*# RBC-3.78* Hgb-10.5* Hct-32.9*
MCV-87 MCH-27.9 MCHC-32.1 RDW-14.2 Plt ___
___ 03:07PM BLOOD WBC-3.3* RBC-3.58* Hgb-10.3* Hct-31.5*
MCV-88 MCH-28.8 MCHC-32.7 RDW-14.0 Plt ___
___ 07:45AM BLOOD WBC-3.7* RBC-4.53* Hgb-12.2* Hct-40.1
MCV-89 MCH-26.9* MCHC-30.4* RDW-13.7 Plt ___
BASIC COAGULATION:
___ 08:32AM BLOOD Plt ___
___ 08:32AM BLOOD ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD ___ PTT-29.7 ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD ___ PTT-79.6* ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD ___
Brief Hospital Course:
Mr. ___ presented to the emergency room on ___ for
an apparent right shoulder swelling. Upon examination and CT
scan it was confirmed that Mr. ___ had a large hematoma from a
disruption of the proximal anastomosis of recently placed right
axillofemoral bypass graft. He was emergently taken to the
operating room for repair and an interposition graft was sewn to
the old bypass graft. There were no adverse events in the
operating room; please see the operative note for details. He
was intubated overnight in the critical care unite, and
extubated in AM. A heparin drip was started and he was then
transferred to the ward for observation. He was doing well for 2
days until the morning of postop day 2, when we noted that the
graft was down after a CT scan. After further evaluation, he was
taken back for thrombectomy with possible angioplasty and
stenting. There were no adverse events in the operating room;
please see the operative note for details. Mr. ___ was
extubated, taken to the PACU until stable, then transferred to
the ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a IV Dilaudid,
IV Acetaminophen, and oral Oxycodone, and then transitioned to
oral OxyContin, oral Oxycodone, and oral Acetaminophen. A
chronic pain consult was ordered and his home Neurontin was
increased from 2 times a day to 3 times a day.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, and incentive spirometry were encouraged throughout
hospitalization.
GI/GU/FEN: The patient was initially kept NPO then transition to
a regular diet, which was well tolerated. Patient's intake and
output were closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none. He was put on his home
Warfarin and his INR was closely monitored while he was on his
heparin drip. Once his INR became therapeutic, the heparin drip
was discontinued and the Warfarin amount was adjusted
accordingly.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay.
EXT: Mr. ___ was examined neurovascularly for return to
baseline function. He had an improved ax-profunda graft doppler,
however, both lower extremity DPs and PTs were not dopplerable.
He also had some right leg weakness.
At the time of discharge, Mr. ___ was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with a walker, voiding without assistance, and
pain was well controlled. The patient received discharge
teaching about his warfarin and the activity level concerning
his arm range of motion and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
We also explicitly discussed that further intervention for his
left and right grafts are very unlikely. Mr. ___ was
discharged to rehab for further care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Gabapentin 300 mg PO Q12H
3. Hydrochlorothiazide 25 mg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
6. Rosuvastatin Calcium 40 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Gabapentin 300 mg PO TID
3. Hydrochlorothiazide 25 mg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 - 2 tablet(s) by mouth every six (6) hours
Disp #*80 Tablet Refills:*0
6. Rosuvastatin Calcium 40 mg PO DAILY
7. PleTAL (cilostazol) 100 mg oral BID
8. Warfarin 4 mg PO ONCE Duration: 1 Dose
Please check INR to remain therapeutic
9. OxyCODONE SR (OxyconTIN) 10 mg PO QHS pain
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth at bedtime
Disp #*14 Tablet Refills:*0
10. Acetaminophen 650 mg PO Q6H pain
11. Bisacodyl 10 mg PO DAILY
12. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Disruption of proximal right axillofemoral bypass graft
Occluded right axillofemoral bypass graft
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). DO NOT RAISE RIGHT ARM ABOVE HEART; DO NOT EXTEND
RIGHT ARM BACKWARDS
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Upper to Lower Extremity Bypass Surgery Discharge Instructions
WHAT TO EXPECT:
1. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the arm and leg you were
operated on:
DO NOT elevate your arm above the level of your heart: This may
cause damage to your graft.
DO NOT bring your arm past your rear end (backward extension):
This may cause damage to your graft.
Elevate your leg above the level of your heart (use ___ pillows
or a recliner) every ___ hours throughout the day and at night
Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
Take aspirin as instructed
Follow your discharge medication instructions
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
Unless you were told not to bear any weight on operative foot:
You should get up every day, get dressed and walk
You should gradually increase your activity
You may up and down stairs, go outside and/or ride in a
car
Increase your activities as you can tolerate- do not do
too much right away!
No heavy lifting, pushing or pulling (greater than 5
pounds) until your post op visit
You may shower (unless you have stitches or foot
incisions) no direct spray on incision, let the soapy water run
over incision, rinse and pat dry
Your incision may be left uncovered, unless you have
small amounts of drainage from the wound, then place a dry
dressing over the area that is draining, as needed
CALL THE OFFICE FOR: ___
Redness that extends away from your incision
A sudden increase in pain that is not controlled with pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your leg
Temperature greater than 100.5F for 24 hours
Bleeding, new or increased drainage from incision or ___,
yellow or green drainage from incisions
Followup Instructions:
___
|
10450953-DS-25 | 10,450,953 | 24,558,069 | DS | 25 | 2152-07-02 00:00:00 | 2152-07-23 16:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Worsening right lower leg pain
Major Surgical or Invasive Procedure:
___ Left ___ placement
___ Right above-knee amputation
History of Present Illness:
Mr. ___ is a ___ M w/ severe peripheral arterial disease with
multiple failed bypass grafts and chronic rest pain. Mr. ___
vascular history includes right axilla to profunda bypass graft
with PTFE on ___. Unfortunately, that graft is no longer
patent. He presented to the ED today with increased rest pain,
predominantly in his Right great toe and Right second toe. He
has had a chronic eschar on his Right second toe. However now,
he presents with infection of his great toe with erythema
extending up his calf as well as dry gangrene of his Right
second toe. Pt reports that the pain is ___, sharp and
burning, unbearable in nature. He states that while he was
previously resistant to the idea of an amputation, he now
understands that he does not have any revascularization options
and is willing to undergo and amputation. His pain has not been
adequately controlled with oxycodone and oxycontin at home.
ROS: (+) Per HPI
(-) No SOB, CP, fevers, chills, lightheaded, dizzy, HA, N/V,
Sore
Throat, cough, abd pain
Past Medical History:
Past Medical History:
1. Peripheral vascular disease
2. Hyperlipidemia
3. Hypertension
4. Chronic renal insufficiency
5. Pericarditis
6. left lower extremity DVT on Coumadin
7. right common iliac stenosis
8. right SFA occlusion
9. left CIA, EIA, CFA and SFA occlusion
10. Hemorrhoids
11. History of colitis from indeterminate etiology
Past Surgical History:
1. failed left fem-pop bypass with saphenous vein graft at ___
around ___
2. right to left common fem-fem bypass as well as right external
iliac angioplasty and stent ___ St ___
3. Angioplasty and re-stenting of occluded right external iliac
stent, angioplasty and stenting of occlusion of proximal
profunda femoris artery ___ Saint ___ angioplasty
and stent of right proximal profunda artery ___
4. Right axillary-to-profunda bypass (___)
Social History:
___
Family History:
Non-contributory family history.
Physical Exam:
ADMISSION PHYSICAL EXAM ___
VS: 98.2 88 134/64 18 96%
General: Lethargic, falls asleep without stimulation.
HEENT:MMM
CV: RRR
Lungs: CTABL anteriorly
Abdomen: soft, nontender, no guarding
Ext: Black Necrotic Right Second Toe, Fluctuance of Right great
toe, warmth and erythema extending to mid calf of right leg.
Vascular: Palp radial pulses bilaterally. Dop Signals in Groin
bilaterally. No dop signals appreciated bilaterally in pop, DP
or ___.
DISCHARGE PHYSICAL EXAM ___
VS: 98.7 86 130/67 16 99%RA
General: NAD, AOx2
CV: regular rate rhythm
Lungs: No respiratory distress
Abdomen: soft, nontender, nondistended, no rebound/guarding
Wound: R above-knee amputation stump staple line intact without
erythema or drainage
Vascular: LLE: femoral dopplerable, ___ not dopplerable. RLE:
femoral dopplerable, AKA.
Pertinent Results:
ADMISSION LABS:
___ 10:05AM BLOOD WBC-6.7 RBC-4.33* Hgb-11.5* Hct-37.0*#
MCV-86 MCH-26.5* MCHC-31.1 RDW-14.2 Plt ___
___ 10:05AM BLOOD Plt ___
___ 10:05AM BLOOD Neuts-73.5* Lymphs-16.6* Monos-8.5
Eos-0.9 Baso-0.5
___ 10:05AM BLOOD ___ PTT-31.8 ___
___ 10:05AM BLOOD Glucose-112* UreaN-42* Creat-1.8* Na-135
K-3.9 Cl-98 HCO3-27 AnGap-14
___ 08:05AM BLOOD Calcium-9.6 Phos-2.7 Mg-1.4*
___ 10:16AM BLOOD ___ Comment-GREEN TOP
___ 10:16AM BLOOD Lactate-1.0
DISCHARGE LABS:
___ 04:33AM BLOOD WBC-10.4 RBC-3.45* Hgb-9.2* Hct-29.6*
MCV-86 MCH-26.6* MCHC-31.0 RDW-14.0 Plt ___
___ 05:57AM BLOOD Hct-29.8*#
___ 05:57AM BLOOD ___
___ 06:19AM BLOOD Glucose-100 UreaN-27* Creat-1.4* Na-136
K-4.1 Cl-97 HCO3-31 AnGap-12
Brief Hospital Course:
Mr. ___ is a ___ year-old male with severe peripheral arterial
disease with multiple failed bypass grafts and chronic rest pain
who presented on ___ with unremitting right lower leg pain
exhibiting dry gangrene of his ___ right toe and erythema
extending up his calf. He was admitted and started on empiric IV
antibiotics (vancomycin, ciprofloxacin, and metronidazole). A
PICC was placed in anticipation of long-term antibiotic therapy.
However, it was decided that he would most benefit from an
amputation. On ___, he underwent a right above the knee
amputation, which he tolerated well. He did have sinus
tachycardia to the 140s on POD1 but EKG was normal and he had no
additional episodes. He continued on IV antibiotics, which were
discontinued on POD5. He also resumed Coumadin post-operatively.
However, this was discontinued on POD3 as there was no longer
any indication for it (history of DVT is remote, has no
functioning bypass grafts). He continued on aspirin (which he
will continue on discharge). His primary post-operative issue
was pain control. Adjustments were made to his oral pain
regimen, consisting of Tylenol, his home oxycodone switched to
Dilaudid, and tramadol was started. He continued on his home MS
___ as well. The patient refused his narcotics at times
(saying that they caused hallucinations) but eventually did do
well on this regimen.
Mr. ___ remained afebrile and hemodynamically stable
throughout his hospital course. His electrolytes were within
normal limits and were repleted PRN. He tolerated a diet and
voided without difficulty. He worked with physical therapy as
well. His PICC was removed prior to discharge. He is being
discharged in stable but improving condition and will require
on-going physical therapy and rehabilitation services to restore
ambulatory function with eventual prostethics. He will follow up
in Vascular Surgery Clinic with Dr. ___ his
___ will be removed then.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Gabapentin 300 mg PO TID
3. Acetaminophen 650 mg PO Q6H:PRN Pain
4. Hydrochlorothiazide 25 mg PO DAILY
5. Losartan Potassium 50 mg PO DAILY
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
7. OxyCODONE SR (OxyconTIN) 10 mg PO QHS
8. Rosuvastatin Calcium 40 mg PO DAILY
9. Warfarin 3 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 300 mg PO TID
5. Hydrochlorothiazide 25 mg PO DAILY
6. Losartan Potassium 50 mg PO DAILY
7. OxyCODONE SR (OxyconTIN) 10 mg PO QHS
8. Rosuvastatin Calcium 40 mg PO DAILY
9. TraMADOL (Ultram) ___ mg PO Q6H:PRN pain
10. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Gangrene and pain, right foot
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:
Postoperative Care:
Do not expose recipient site to prolonged sunlight
Follow instructions given for bandaging your wound to provide it
with appropriate support during the healing process, and to
prevent contractures even after healing is complete
Inspect site for healing and good circulation, as shown by
healthy pink coloration.
Keep the recipient site clean and dry.
Call Your Doctor ___ Any of the Following Occurs
Cough, shortness of breath, chest pain, or severe nausea or
vomiting
Headache, muscle aches, dizziness, or general ill feeling
Redness, swelling, increasing pain, excessive bleeding, or
discharge from the incision site
Signs of infection, including fever and chills
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10451189-DS-9 | 10,451,189 | 20,984,870 | DS | 9 | 2159-05-08 00:00:00 | 2159-05-08 19:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
bee stings / Rocephin / NSAIDS (Non-Steroidal Anti-Inflammatory
Drug)
Attending: ___
___ Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Intubation, right IJ central line placement
History of Present Illness:
This is a ___ year old male with reported bee sting
hypersensitivity, recently intubated last week for bee sting,
presenting from home after being stung by bees twice today. He
did not give himself eipinephrine.
On arrival to the ED, his initial vitals were not recorded as he
was taken immediately to the treatment room. The resident
reports he was normotensive, short of breath and wheezing. He
was given epinephrine IM x2, solumedrol and benadryl with no
change in symptoms, blood pressure rose to 200/110. He then
became hypoxic to the 80's with a good pleth and he was prepped
for intubation. Prior to intubation, he stated that he was
difficult to obtain access on and offered that he did not want
an intraosseous line.
He was intubated with succinylcholine and ketamine with no
difficulty obtaining airway and no significant airway edema. He
was noted to have no significant resistance on the ventilator.
Initial ABG was 7.33/56/397 on Vt 450 PEEP 5 RR 12 FiO2 1. He
was very difficult to sedate with fentanyl and versed,
eventually settling out on propofol and fentanyl. A right IJ was
obtained for access, CVP was 13 with 1 liter NS.
Labs were then drawn which were notable for WBC 11.6, H/H
12.2/38.0, lactate 2.6. He is transferred to the FICU.
Review of systems:
Unable to obtain.
Past Medical History:
-Anaphylaxis to bees with recent intuabtion 1 week prior at ___
per patient
-Bipolar
-HTN
-L Shoulder ligament repair 2 months ago
Social History:
___
Family History:
Unable to obtain.
Physical Exam:
On Admission:
Vitals: T 98.7 HR 72 BP 118/76 RR 16 O2 98% FiO2 40%
General: intubated, sedated
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley with clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
On Discharge:
Vitals: T 98.3 HR 70 BP RR SaO2
General: lying comfortably in bed, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
On Admission:
___ 07:15PM BLOOD WBC-11.6* RBC-4.22* Hgb-12.2* Hct-38.0*
MCV-90 MCH-28.8 MCHC-31.9 RDW-14.4 Plt ___
___ 07:15PM BLOOD Neuts-90.6* Lymphs-5.0* Monos-4.1 Eos-0.3
Baso-0.1
___ 07:15PM BLOOD ___ PTT-51.3* ___
___ 07:15PM BLOOD Glucose-138* UreaN-21* Creat-0.7 Na-144
K-4.6 Cl-110* HCO3-28 AnGap-11
___ 07:15PM BLOOD ALT-32 AST-28 AlkPhos-40 TotBili-0.2
___ 07:15PM BLOOD Albumin-3.6 Calcium-8.2* Phos-3.0 Mg-2.1
___ 04:47PM BLOOD Type-ART pO2-397* pCO2-56* pH-7.33*
calTCO2-31* Base XS-2
___ 10:04PM URINE bnzodzp-POS barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
.
On Discharge:
___ 06:25AM BLOOD WBC-8.7 RBC-4.21* Hgb-11.8* Hct-37.5*
MCV-89 MCH-28.1 MCHC-31.6 RDW-14.7 Plt ___
___ 06:25AM BLOOD Glucose-121* UreaN-17 Creat-0.7 Na-138
K-3.9 Cl-102 HCO3-33* AnGap-7*
.
Microbiology:
___ Blood Culture - pending at time of discharge
.
Imaging/Studies:
___ Portable CXR
Single portable view of the chest. There has been interval
placement of right-sided central venous catheter with tip
projecting over the region of the mid-to-lower SVC. Low lung
volumes are seen. There is novisualized pneumothorax based on
the supine film. ET and enteric tube are again noted.
Retrocardiac opacity now seen silhouetting the descending
thoracic aorta and potentially atelectasis.
Brief Hospital Course:
___ year old male with history of bee sting anaphylaxis who
presented with with dyspnea, wheeze and hypoxia after bee sting.
He was intubated but quickly extubated and had no other systemic
signs/symptoms of anaphylaxis.
.
# Hypoxemic respiratory distress
Initially felt to be anaphylaxis in the setting of known
anaphylaxis, reported bee sting, and hypoxia on arrival.
However, he had no resistance measured on the ventilator, no
other systemic symptoms or signs of anaphylaxis (no rash or
angioedema), and was extubated within hours. He may have
responded in a delayed manner to initial H2 blockade and
epinephrine, but unlikely. Other possibility is anxiety-induced
hyperventilation and hypoxia. ___ have inhaled a drug/medication
that caused acute bronchospasm or pneumonitis. His respiratory
status remained stable on room air after extubation.
.
# Left shoulder pain
After extubation he complained of acute on chronic left shoulder
pain. He has history of left shoulder surgery, but potentially
could have fallen prior to arrival in the setting of respiratory
distress. He declined shoulder x-ray. His pain was treated
initially with oxycodone but discharged on tramadol.
.
# Bipolar Disorder
He is on depakote at home. After extubation he reported feeling
that his mood was unstable and that he was becoming manic.
Psychiatry evaluated him and recommended a short-term crisis
center which he voluntarily decided to attend.
.
# Medication Reconciliation
Patient reports being on atenolol, labetalol, Lisinopril. He had
been mildly hypertensive while hospitalized, but we were unable
to confirm these medications and did not start them. He was told
to continue his preadmission medications at discharge and to
___ with a PCP.
.
## Transitional Issues
- Needs to establish care with a PCP for ___
- Continue to emphasize the importance of carrying his EpiPen at
all times
- Medication reconciliation
# Communication: mother ___
# Code: Presumed full
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atenolol 25 mg PO DAILY
2. Labetalol 50 mg PO BID
3. Lisinopril 20 mg PO DAILY
4. Divalproex (EXTended Release) 1500 mg PO DAILY
5. Citalopram 20 mg PO DAILY
6. ALPRAZolam 1 mg PO DAILY:PRN anxiety
7. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL (1:1,000) injection PRN
allergic reaction
Discharge Medications:
1. ALPRAZolam 1 mg PO DAILY:PRN anxiety
2. Citalopram 20 mg PO DAILY
3. Divalproex (EXTended Release) 1500 mg PO DAILY
4. Atenolol 25 mg PO DAILY
5. Labetalol 50 mg PO BID
6. Lisinopril 20 mg PO DAILY
7. EpiPen (EPINEPHrine) 0.3 (1:1,000) INJECTION PRN allergic
reaction
RX *epinephrine 0.3 mg/0.3 mL (1:1,000) 0.3 mg/ml infection
once Disp #*2 Each Refills:*0
8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Monitor for tremor, agitation, muscle rigidity as a sign of
serotonin syndrome
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*15
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: hypoxemic respiratory distress
Secondary: Bipolar disorder, shoulder pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were admitted to ___ because of difficulty breathing. You
felt that you were having an allergic reaction to a bee sting.
Your oxygen levels were low and you had to be intubated (a
breathing tube was placed) to help you breathe. Your breathing
quickly improved and we were able to take the breathing tube
out. You had no other signs or symptoms of allergic reaction.
You had shoulder pain that we treated with pain medications. You
are safe to be discharged from the hospital.
It is important that you carry your EpiPen with you at all times
and if you feel that you are having an allergic reaction, use it
and call ___ immediately.
After discharge you are going to an acute crisis ___
management of your bipolar disorder.
Followup Instructions:
___
|
10451372-DS-16 | 10,451,372 | 25,216,949 | DS | 16 | 2137-09-17 00:00:00 | 2137-09-17 20:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Norvasc
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is an ___ with a PMHx of dementia and HTN brought in
by daughter for generalized weakness and was found to have a
UTI.
Patient lives in assisted living ___. She had a
choking episode several days ago and required the Heimlich
manuever. She was lethargic today per daughter and needed
assistance to get up. Mental status currently at baseline but
daughter has noticed a gradual decline. Pt also reports cough
and, per daughter, had diarrhea.
In the ED intial vitals were: 100.8 80 155/54 20 95%
- Labs were significant for positive UA. CXR was negative. EKG
showed NSR at 76bpm, LAD, PRWP.
- Patient was given CTX for UTI
Vitals prior to transfer were:
On the floor, pt reports feeling "lousy" and "tired" but is
unable to clarify further. She is A+Ox3.
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,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Alzheimer's disease
- Hypertension
- Hyperlipidemia
- Osteoporosis
- LBP ___ spinal stenosis and compression fractures of T6 (sp
kyphoplasty)
- Glaucoma
- MVP per record
- Anxiety.
- Left pelvic fracture in ___.
- Chronic lower extremity edema.
- Gait instability with falls.
- HZV x 2.
- SP inguinal hernia repair
- SP cataract extraction with lens implants
- SP tonsillectomy
- SP D + C
Social History:
___
Family History:
Mother - CAD
Father - HTN
Sister - DM
Physical ___:
ADMISSION PHYSICAL EXAM:
==================
Vitals - T: 98.3 BP: 158/62 HR: 69 RR: 20 02 sat: 97%RA
GENERAL: Elderly female in NAD, sleeping; A+Ox3 (with
redirection)
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, 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: moving all extremities well, no cyanosis or
clubbing.
Trace pitting edema bl.
PULSES: 1+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in ___.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
==================
Vitals - T: 99.8 78 154/57 18 96% RA
GENERAL: NAD; A+Ox3 (with redirection)
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, 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: moving all extremities well, no cyanosis or
clubbing.
Trace pitting edema bl.
PULSES: 1+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in ___.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===========
___ 05:52PM BLOOD WBC-7.8 RBC-4.47 Hgb-13.8 Hct-42.3 MCV-95
MCH-30.8 MCHC-32.6 RDW-12.9 Plt ___
___ 05:52PM BLOOD Neuts-85.3* Lymphs-9.7* Monos-3.9 Eos-0.8
Baso-0.3
___ 05:52PM BLOOD Glucose-94 UreaN-22* Creat-0.7 Na-134
K-4.4 Cl-98 HCO3-22 AnGap-18
___ 05:52PM BLOOD CK(CPK)-29
___ 05:52PM BLOOD TSH-0.44
___ 05:52PM BLOOD Free T4-1.4
___ 07:50PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:50PM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 07:50PM URINE RBC-<1 WBC-6* Bacteri-MANY Yeast-NONE
Epi-0 TransE-<1
PERTINENT IMAGING:
=============
CXR ___:
FINDINGS: AP and lateral views of the chest. Lungs are
essentially clear.
Minimal persistent opacity at the left lateral costophrenic
angle is most
likely due to atelectasis. There is no evidence of effusion or
pulmonary
vascular congestion. Cardiomediastinal silhouette is within
normal limits.
Atherosclerotic calcifications noted at the aortic arch.
Vertebroplasty
changes seen in the mid thoracic spine. Known compression
deformities are not
as clearly identified on the current exam due to technique.
IMPRESSION: No acute cardiopulmonary process.
PERTINENT MICRO:
============
UCx: Pending
BCx: Pending
DISCHARGE LABS:
===========
___ 07:50AM BLOOD WBC-4.8 RBC-3.98* Hgb-12.0 Hct-37.3
MCV-94 MCH-30.2 MCHC-32.3 RDW-12.6 Plt ___
___ 07:50AM BLOOD Glucose-91 UreaN-19 Creat-0.7 Na-135
K-4.1 Cl-102 HCO3-23 AnGap-14
Brief Hospital Course:
Ms. ___ is an ___ with a PMHx of dementia and HTN brought in
by daughter for generalized weakness and was found to have a
UTI.
ACTIVE ISSUES:
==========
# UTI:
Pt presented with fatigue/weakness/AMS, UA with bacteria,
nitrites,and WBCs and neutrophilic predominance on CBC. No
dysuria, hematuria, frequency, urgency, or hesitancy. She
received a dose of Ceftriaxone and was transitioned to PO
Cefpodoxime to complete the remaineder of a 7-day course. The
morning after admission, she felt back to her usual self.
Physical therapy evaluated her, and she was discharged back to
her assisted living facility.
CHRONIC ISSUES:
===========
# HTN:
The patient was continued on her home Atenolol, Hydralazine, and
Lisinopril (doses and frequency verified with her pharmacy)
# Hyperlipidemia:
The patient was continues on her home atorvastatin.
# Glaucoma:
The patient's eye drops were held on this admission and were
resumed at discharge.
TRANSITIONAL ISSUES:
==============
- Patient with diagnosis of osteoporosis but is not on Calcium,
or a Bisphosphonate. Consider starting these medications as an
outpatient.
- Patient with prior medication list containing Ambien 5 mg PO
QHS - given that this medication was not on record with her
pharmacy, it was removed from her medication list.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO BID
2. Atorvastatin 10 mg PO DAILY
3. HydrALAzine 25 mg PO TID
4. Lisinopril 20 mg PO BID
5. Memantine 10 mg PO DAILY
6. Timolol Maleate 0.25% 1 DROP LEFT EYE BID
7. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Atenolol 25 mg PO BID
2. Atorvastatin 10 mg PO DAILY
3. HydrALAzine 25 mg PO TID
4. Lisinopril 20 mg PO BID
5. Memantine 10 mg PO DAILY
6. Timolol Maleate 0.25% 1 DROP LEFT EYE BID
7. Vitamin D 1000 UNIT PO DAILY
8. Cefpodoxime Proxetil 100 mg PO Q12H
RX *cefpodoxime 100 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*13 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Urinary tract infection
Secondary: Alzheimer's dementia, hypertension, hyperlipidemia,
osteoporosis, glaucoma.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was our pleasure caring for you at ___
___. You were admitted to the hospital because of
altered mental status and weakness. You were found to have a
urinary tract infection, for which we are prescribing you a
course of antibiotics. You were discharged home.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
10451372-DS-18 | 10,451,372 | 22,927,356 | DS | 18 | 2138-03-09 00:00:00 | 2138-03-09 13:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics) / Norvasc
Attending: ___.
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
Left hip hemiarthroplasty
History of Present Illness:
Ms. ___ is an ___ year old woman with a history of Alzheimer's
dementia who presented after fall from sitting on the toilet,
found to have a left femoral neck fracture, s/p repair on
___. She lives in assisted living facility. The patient
herself does not recall anything from the fall including
lightheadedness, dizziness, or chest pain. Per report, the
patient ambulates with assistance of a walker and has multiple
falls in the past including a recent fall in ___ when she
suffered a right sided pelvic fracture which was treated
conservatively without surgery. Of note, the patient was also
recently admitted for CHF exacerbation in ___.
Past Medical History:
- Alzheimer's disease
- Hypertension
- Hyperlipidemia
- Osteoporosis
- LBP ___ spinal stenosis and compression fractures of T6 (sp
kyphoplasty)
- Glaucoma
- MVP per record
- Anxiety.
- Left pelvic fracture in ___.
- Chronic lower extremity edema.
- Gait instability with falls.
- HZV x 2.
PSH:
- SP inguinal hernia repair
- SP cataract extraction with lens implants
- SP tonsillectomy
- SP D + C
Social History:
___
Family History:
Mother - CAD
Father - HTN
Sister - DM
Physical ___:
DISCHARGE PHYSICAL EXAM:
Gen: alert, able to be oriented with re-direction, no acute
distress
Cardio: RRR
Resp: breathing unlabored
MSK:
LLE: Dressing taken down and incision visualized, C/D/I with
staples in place, no excessive erythema, swelling, or drainage,
foot WWP, good cap refill in toes, SILT saph/sural/tibial/sp/dp
distributions, wiggles toes, dorsi/plantar flexes foot
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 femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left hip hemiarthroplasty, 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#2. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient 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 weight bearing as tolerated in the
left lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine.
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Atenolol 25 mg PO BID
3. Atorvastatin 10 mg PO HS
4. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 6 Days
RX *cefpodoxime 100 mg 1 tablet(s) by mouth twice a day Disp
#*10 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
6. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg/0.4mL SC QPM Disp #*14 Syringe
Refills:*0
7. Famotidine 20 mg PO Q24H
8. Lidocaine 5% Patch 1 PTCH TD QPM
9. Losartan Potassium 50 mg PO DAILY
10. HydrALAzine 25 mg PO Q8H
11. Milk of Magnesia 30 ml PO BID:PRN Dyspepsia
12. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 to 1 tablet(s) by mouth every four (4)
hours Disp #*50 Tablet Refills:*0
13. Senna 8.6 mg PO DAILY
14. TraZODone 25 mg PO HS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left femoral neck fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
CHF Monitoring:
- Weigh yourself every morning, call your PCP if weight goes up
more than 3 lbs.
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:
- Activity as tolerated
- Left lower extremity: Weight bearing as tolerated
Physical Therapy:
- Activity as tolerated
- Right lower extremity: Full weight bearing
- Left lower extremity: Full weight bearing
Treatments Frequency:
Site: Incision
Type: Surgical
Dressing: Gauze - dry
Comment: Please change dressing daily or as needed to keep it
clean and dry. If wound remains non-draining, OK to leave it
open to air.
Wound Care:
Site: R shin
Description: Skin tear x2 from fall.
Care: Adaptic applied w/ kerlix. Change dsg PRN
Wound Care:
Site: L great toe
Description: Toe nail missing from L great toe.
Care: Adaptic applied, wrapped w/ kerlix. Change PRN
Followup Instructions:
___
|
10451611-DS-3 | 10,451,611 | 28,956,958 | DS | 3 | 2121-10-12 00:00:00 | 2121-10-12 14:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Traumatic SAH, Motor Vehicle Collision
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ female passenger in rollover ___ where
driver swerved to miss ___ deer. Speed unknown. Patient got
herself out of vehicle. Per EMS, she was initially a GCS of 11
but later "collapsed" and had a GCS of 4 where she was then
intubated and flown here. There is almost no information about
the patient and it is thought that she is ___ speaking
only. The driver of the car had reportedly only met her today.
Past Medical History:
Unknown
Social History:
___
Family History:
Unknown
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Intubated, off sedation
HEENT: Pupils: 3-2mm ___
Neuro:
Mental status: Awake on vent, eyes open spontaneously and track
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3-2mm ___
III, IV, VI: Extraocular movements not formally tested but
grossly intact when patient tracks
Motor: Very purposeful x4 with good strength, no commands
*****
PHYSICAL EXAM ON DISCHARGE:
___ Speaking.
MS: AOx3. NAD
Neuro: CN ___ Intact. PERRLA. MotorL: Moves all 4 ext.
Grossly full strength throughout. Reflexes: symmetric.
Sensation: Intact to light touch.
Ambulates with assistance of nursing or walker.
Left foot with well healing wound.
Pertinent Results:
___:
CXR & Pelvis XR (Trauma Protocol):
1. Bilateral lower lobe heterogeneous opacities as well as
linear plate like opacity in the right lower lobe is most
consistent with atelectasis with or without coexisting
aspiration or contusion.
2. Support lines and tubes as described above.
3. Nonobstructive bowel gas pattern.
4. No displaced rib fracture or obvious pelvic fracture, but
recommend
correlation with outside CT of the same date for more complete
evaluation.
5. Partially visualized radiopacity projecting over the right
upper quadrant could represent a structure external to the
patient for may reflect intravenous contrast within the right
renal collecting system. Repeat radiograph following removal or
repositioning of external structures may be helpful for initial
further evaluation if warranted clinically.
___:
CT Head:
1. Stable subtle subarachnoid hemorrhage primarily near vertex
in right
frontal lobe along right frontotemporal lobe, left frontal lobe
and
interpeduncular cistern.
2. No new hemorrhage.
3. No fracture.
4. 4.3 cm right frontal subgaleal hematoma.
SECOND OPINION CT OF T/L SPINE: ___
IMPRESSION:
1. No evidence of traumatic intrathoracic or intra-abdominal
injury.
2. Slight irregularity of the anterior aspect of the T11
vertebral body with a mild compression deformity. This is age
indeterminate. There is no surrounding stranding or hematoma,
suggesting it is likely chronic. Given the clinical history, if
further evaluation is needed, an MRI is recommended.
3. Moderate bilateral atelectasis.
CT HEAD: ___
IMPRESSION:
Near-complete resolution of previously seen subarachnoid
hemorrhage. No new hemorrhage.
LEFT FOOT XRAY: FINDINGS: ___
Left foot:
There are mild degenerative changes at the first
metatarsophalangeal joint. No fracture or dislocation seen. No
destructive lytic or sclerotic bone lesions. There is extensive
soft tissue swelling over the dorsum of the forefoot. No cause
for this is identified on the current study. There is a
moderate-sized plantar calcaneal spur. There is a large os
navicularis.
Left ankle:
No fracture, dislocation or degenerative change seen. No
destructive lytic or sclerotic bone lesions. No radiopaque
foreign body or soft tissue calcification.
XRAY TIB/FIB: ___
IMPRESSION:
No acute bony injury seen.
Radiology Report CHEST (PORTABLE AP) Study Date of ___
3:54 ___
IMPRESSION: No evidence of pneumonia, effusion or pneumothorax
Brief Hospital Course:
Ms. ___ was admitted to the ICU for close neurological
monitoring. Repeat imaging showed the small amount of traumatic
SAH to have remained stable. She was extubated the morning after
admission without complication. With an interpreter, she was
following commands but remained intermittently confused per her
daughter. Her ___ was cleared in the absence of neck pain
with negative CT C-Spine at the OSH. On ACS Tertiary survey, she
reported thoracic tenderness; imaging from the OSH was
unavailable for review, and CT T/L Spine was ordered for further
evaluation. Her daughter reports no additional medical problems
and no history of anticoagulant use.
On ___, the second opinion CT of the torso read chronic T-11
fracture. Bedrest and log roll orders were lifted. The patient
seemed slightly lethargic and confused this morning, a stat head
CT was obtained and showed almost complete resolution of the
tSAH.
On ___, the patient remained confused but stable on exam.
Physical therapy evaluated the patient. Transfer orders were
written to the floor.
Over the weekend of ___ the patient remained
neurologically stable. She continued to mobilize however, the
patient is refusing to participate in ADLs and refusing to take
po intake.
On ___, the patient remained stable and continued refusing to
mobilize and take po intake. The patient complained of
dizziness, a one time dose of Ativan 1mg was given po with good
effect. Awaiting for physical therapy recommendations. At this
time the patient does not have rehab benefits.
On ___, the patient remained stable. Over night the patient was
unable to void and was bladder scanned for 300cc, she was
straight cathed and IVFs were started in the setting of poor po
intake. In the morning the patient was tolerating good po intake
and the IVFs were turned off. ___ RN noted foul order from
urine, a urine analysis and culture was obtained. The patient
continued to complain of dizziness and she was started on
Meclizine prn with good effect.
On ___, the patient remained neurologically stable. Occupational
therapy evaluated the patient and recommended rehab. While
working with ___ the patient complained of left foot pain and
unable to bear weight. An xray of her left foot and leg was
obtained and did not show any fractures. Her UA was positive and
she was started on Cipro po.
On ___, the patient remained stable, and rehabing in house. The
sutures to her head lac were removed, incision cd&i.
On ___, the patient was neurologically stable. a chest xray was
perfromed and was consistent with No evidence of pneumonia,
effusion or pneumothorax.
Patient remained inpatient for ___ needs and lack of insurance
with rehab coverage. Chest pain continued and was incited by
palpation.
___: pt c/o left chest pain, w/ interpreter she said it was the
same type of pain experienced ___, EKG normal, ordered tums
because pain was low possibly gastric, also noted to be TTP on
exam this AM, ?MSK
___: L foot remains tender, XR on ___ negative for fx or
dislocation, wound consult ordered
___: Foot contusion reportedly stable. Wound Nursing concerned
for Compartment syndrome. Ortho consulted. Lanced hematoma on
dorasal foot. Wrapped in gauze. Recommended keflex ___ QID x 5
days, change dressing in two days, then change daily thereafter.
___ bear weight as tolerated.
___: Stable exam, dispo planning. ___ working toward w/c
level for home. On ___, ___ and Case Management met with family
to discuss discharge goals. The family informed them that both
daughters live in second-story apartments and ___ still needs to
work with the patient going up/down stairs. During this time,
the patient wasn't always participating with the exam or ___, so
motivation has been difficult.
___: the patient was stable and there were no acute
events. She worked with ___ to do well enough with stairs so
that she could go home with her daughter.
___: the patient was stable and there were no events
over night. She worked with ___ and did much better. She also
was found to have insurance with a rehab benefit and was
screened for rehab. She was felt to be safe for discharge.
Medications on Admission:
Unknown
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Calcium Carbonate 500 mg PO QID:PRN GERD
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC TID
6. Ibuprofen 400 mg PO Q8H:PRN pain
7. Meclizine 12.5 mg PO Q8H:PRN dizziness
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Polyethylene Glycol 17 g PO DAILY
10. Sarna Lotion 1 Appl TP BID:PRN itching
11. Senna 8.6 mg PO DAILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Traumatic Subarachnoid Hemorrhage, Motor Vehicle Collision
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were hospitalized at ___ following a motor
vehicle accident that resulted in a Subarachnoid Hemorrhage.
You did well, though continued to require symptomatic medication
for dizziness and pain at the time of discharge.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You 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, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10451766-DS-5 | 10,451,766 | 24,775,712 | DS | 5 | 2159-09-16 00:00:00 | 2159-09-17 18:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / baclofen
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with bulbar ALS presenting with shortness of breath. The
patient has had progressive shortness of breath over the past 6
months. Initially it was only at night, now it is at both during
the day and at nighttime. She can only sleep for ___ hours
before waking up feeling short of breath. She states this is
likely due to chest muscle weakness. She is followed by
interventional pulmonary for this. She denies chest pain, cough,
fevers, abdominal pain. She uses CPAP at home and is on the
maximum settings at this time. She called IP and then
recommended for her to present to the ED for further evaluation.
Of note, patient was recently evaluated by IP on ___. She
reported increased weakness and dyspnea over the last 6 months
and feels more short of breath and unable to do actitivies due
to dyspnea. She has started to have dry mouth related to BIPAP
use and is refractory to humidified oxygen. They discussed the
possibility of placing a tracheostomy but the patient preferred
to defer at that time.
In the ED, initial VS were 98.6 89 116/40 18 96% ra
Exam significant for NIF: -10
Labs significant for normal WBC and lactate. UA with WBC, no
bacteria.
ECG: SR @82, NANI, no ST changes
CXR showed no acute process.
Received 1L NS
Transfer VS were 97.9 80 128/69 17 98% RA
On arrival to the floor, patient and husband report that patient
acutely became SOB which did not resolve even after increasing
her CPAP "to its max." Patient ultimately removed CPAP and took
ativan and fell asleep. However,when she awoke in the morning
felt short of breath and anxious. Husband reports that she
looked dishelved and pale. Patient also reports that yesterday
she was seen at her pulmonologist office where she and
pulmonologist had a detailed discussion about goals of care,
which made her anxious and she thinks may have contributed to
her difficult evening. She reports that tonight she is back to
her baseline.
Past Medical History:
amyotrophic lateral sclerosis
carpal tunnel syndrome
cervical spondylosis
dysarthria
dysphagia
sleep apnea
Social History:
___
Family History:
Mother: ___ Body dementia
Physical Exam:
Admission Exam:
Tc 98 Tmax 98 HR ___ BP 102/98 ___ RA
GENERAL: less anxious appearing woman, no acute distress
HEENT: quiet voice
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: clear to auscultation though patient appears to have some
difficulty taking deep breaths
ABDOMEN: PEG in place, gauze in place around entrance of tube,
nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
NEURO: alert and orientated
Discharge Exam:
Tc 98 Tmax 98 HR ___ BP 102/98 ___ RA
GENERAL: less anxious appearing woman, no acute distress
HEENT: quiet voice
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: clear to auscultation though patient appears to have some
difficulty taking deep breaths
ABDOMEN: PEG in place, gauze in place around entrance of tube,
nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
NEURO: alert and orientated
Pertinent Results:
Admission Labs:
___ 03:22PM BLOOD Lactate-0.9
___ 03:01PM BLOOD LtGrnHD-HOLD
___ 03:01PM BLOOD HoldBLu-HOLD
___ 03:01PM BLOOD Glucose-82 UreaN-24* Creat-0.4 Na-140
K-4.6 Cl-98 HCO3-36* AnGap-11
Discharge Labs
___ 07:40AM BLOOD WBC-3.4* RBC-4.45 Hgb-13.2 Hct-41.1
MCV-92 MCH-29.8 MCHC-32.2 RDW-14.0 Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-83 UreaN-17 Creat-0.4 Na-138
K-4.5 Cl-101 HCO3-31 AnGap-11
CXR ___
FINDINGS: The cardiac, mediastinal and hilar contours appear
stable. The aortic arch is partly calcified. There is no
pleural effusion or
pneumothorax. The lungs appear clear.
IMPRESSION: No evidence of acute cardiopulmonary disease.
Brief Hospital Course:
___ yo F with hx of bulbar ALS presenting with worsening
shortness of breasth vs. anxiety.
# SOB: Patient satted well overnight on continous oxygen
monitoring. She was given ativan PRN for anxiety and used CPAP
at night. Interventional Pulmonolgy physician was in room and
stated no emergent need for trach. If patient decides she would
like a trach placed at later date they would be willing to place
it. On morning of discharge interventional Pulmonolgy physician
stated no emergent need for trach. If patient decides she would
like a trach placed at later date they would be willing to place
it.
# ALS: continued home riluzole
# sleep apnea: cpap.
# hypothyroidism: home levothyroxine
# depression: home citalopram
Transitional Issues:
[] consider GOC discussion with patient and further discussion
on trach placement
[] palliative care consult
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.5 mg PO/NG Q8H:PRN anxiety/insomnia
2. Citalopram 40 mg PO DAILY
3. Levothyroxine Sodium 88 mcg PO/NG DAILY
4. Rilutek (riluzole) 50 mg oral BID
Discharge Medications:
1. Levothyroxine Sodium 88 mcg PO DAILY
2. Lorazepam 0.5 mg PO Q8H:PRN anxiety/insomnia
3. Rilutek (riluzole) 50 mg oral BID
4. Citalopram 40 mg PO DAILY
10 mg/5 mL solution 20 mL by mouth daily
Discharge Disposition:
Home
Discharge Diagnosis:
shortness of breath
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You came into the hospital for shortness of
breath. You did not have any evidence of infection or fluid in
your lungs that would cause your shortness of breath. We
monitored your oxygen level during your stay and it remained
stable. You were seen by interventional pulmonology who
recommended possible tracheostomy. You should call and schedule
an appointment with your pulmonologist if you would like to
pursue this option. We think that your shortness of breath is
likely related to your ALS and a component of anxiety.
Please take your medications as prescribed and follow up with
your doctors as ___.
Followup Instructions:
___
|
10452422-DS-7 | 10,452,422 | 29,320,280 | DS | 7 | 2186-11-30 00:00:00 | 2186-12-06 12:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / Sulfa (Sulfonamide Antibiotics) / lisinopril
Attending: ___.
Chief Complaint:
L leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ a h/o metastatic peritoneal ovarian vs cervical carcinoma
and DVT (___) who p/w left leg pain. Pt states that she woke
up this AM w/ pain in her left calf, which was worse w/ weight
bearing. She had a DVT ___ years ago which p/w similar pain. Pt
has been on xarelto since her DVT but this was held for the past
3 days for paracentesis at ___ yesterday. Pt is also s/p removal
of an IVC filter 2 weeks ago, which was placed after debulking
surgery in ___. She requires paracentesis every 4 months.
She is able to ambulate independently but has been resting in
bed for the past 2 weeks due to her ascites and abdominal pain,
which is baseline for her due to her cancer. She denies chest
pain, lightheadedness, fever, diarrhea, dysuria, and bloody
stools.
In the ED, initial vitals were 97.6 86 150/81 16 96% RA. Exam
was notable for tenderness over the L medial calf, WWP
extremities, w/ 2+ ___ and DP pulses. Labs were significant for
Hgb 8.7, trop <0.01. Imaging was notable for normal LUE
ultrasound but CTA positive for PE w/o e/o R heart strain. Pt
was started on heparin ggt and received PO oxycodone for pain.
On arrival to the floor, pt denies SOB and states that the pain
in her L calf is much improved.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ Presented with 3 month history of abdominal pain.
___ Endovaginal ultrasound: Uterus was slightly enlarged
at 7.6 x 4.2 x 3.5 cm. She appeared to have a right fundal
subserosal fibroid. The endometrial thickness was 4 mm, the
upper limit for this menopausal lady, and the uterus was
somewhat
distended by fluid with a 1 cm echogenic nodule. The left ovary
was of normal size and appearance and the right ovary was not
seen. The patient was referred to Dr. ___.
___ Hysteroscopy: The endometrial cavity appeared
unremarkable, although there were 4 small "pellets."
Endometrial
biopsy did not reveal any pathology. Only scant inactive
endometrium was seen and the biopsy itself did not reveal
tissue.
That biopsy may represent the small "pellets." There was no
evident mass or polyp.
___ Returned to Dr. ___ of more pelvic pain
and
dysuria. Urinalysis was unremarkable and she was referred to
Dr.
___ urogynecology. He did not find local pathology and
planned a cystoscopy. He did not feel that the more general
abdominal pain was related to her dysuria.
___ CT scan of the torso shows multiple sites of thickened
peritoneum and greater omentum, new since the CT of ___.
There is also some ascites and mesenteric thickening. Again,
the
endometrial cavity is distended with fluid and there appears to
be a right-sided mass associated with it,
measuring 3.6 x 4.6 cm with some calcifications.
___, MRI pelvis perhaps showed an increase in free
fluid in the abdomen, otherwise confirmed the previous findings.
___ Colonoscopy Negative.
___ Laparoscopy, Dr ___:
FINDINGS: On exploratory laparoscopy, all peritoneal surfaces
were involved and peritoneal irregularities which had an
appearance consistent with widely metastatic disease.
These included the mesentery of the small and large bowel. Also
identified were plaques of disease in the serosal surface of the
small and large bowel. The disease was particularly dense in the
posterior cul-de-sac, and extending onto the uterus, the bladder
and where the left adnexal region should have been.
We were unable to identify a clear left tube and ovary. The
right
tube and ovary, interestingly, were normal.
An omental cake was identified in multiple segments. No visible
intestinal irregularity was seen beyond the abnormalities noted
above. Biopsies were obtained from the left lower quadrant.
Pathology:
___- Final PATHOLOGIC DIAGNOSIS:
1. Peritoneum, biopsy #1: - Fibroadipose tissue with scattered
mucinous glands and mucin. See note.
2. Peritoneum, biopsy #2: - Fibroadipose tissue with scattered
mucinous glands and mucin. See note.
Note: Scattered mucinous glands with low grade histology and
mucin, consistent with a mucinous neoplasm are seen. On
immunostains tumor cells show strong positivity for CK7,
highlighting the glandular epithelium. Focal positivity for
PAX-8
(both blocks), estrogen receptors (few nuclei) and only rare
cells positive with CK20 is seen. Tumor cells are negative for
CDX2. Findings are suggestive of a mullerian primary. However
this is a limited sample, and clinical work up/correlation to
completely rule out other primary sites is recommended. This
case
was discussed and reviewed with Dr. ___.
Cytology: (Peritoneal Washings)
___ CYTOLOGY REPORT - Final
PERITONEAL WASHINGS
DIAGNOSIS: Peritoneal washings: POSITIVE FOR MALIGNANT CELLS.
Consistent with metastatic adenocarcinomas, see note.
Note: Tumor cells are immunoreactive for CK7, B72.3, CD20
(focally), PAX-8. They are negative for CDX-2 ER, WT-1.
Mucicarmine stain is positive. There findings favor a GYN
origin.
EGD unremarkable.
Diagnosis therefore mucinous ovarian cancer. These do not
respond
well to carboplatin/taxol, used for usual serous ovarian cancer,
plan FOLFOX, used for GI malignancies.
___ Port-a-Cath placed
___ Start FOLFOX:
___ Peroneal vein thrombosis, anticoagulated
___ Cycle ___ FOLFOX
___ Cycle #3
___ Cycle #4
___ CT ABDOMEN AND PELVIS WITH CONTRAST
IMPRESSION:
1. Extensive peritoneal disease with diffuse omental caking,
ascites, and tethering of small bowel loops, in keeping with
reported history of metastatic mucinous peritoneal cancer. A
normal left ovary is not identified, which raises the
possibility
of ovarian primary. No evidence of bowel obstruction currently.
2. Markedly tortuous abdominal aorta with focal stenosis just
below the renal artery origin. The major abdominal branches of
the aorta are patent but also quite tortuous. The overall
appearance suggests a congenital or a longstanding abnormality,
possibly congenital coarctation.
3. Fluid-filled endometrial cavity and probable 5 cm uterine
leiomyoma.
___ Start abraxane/gemcitabine
___ Admitted ___ with increased ascites, pain and
fever/spontaneous peritonitis. 2.5 L drained, exudative, 710
polys. Treated with antibiotics, initially with ceftriaxone and
then changed to oral ciprofloaxacin. She will take cipro for a
total of 4 more days. Abdominal pain required a PCA but she was
ultimately able to tolerate oral medications and was discharged
home on oxycontin 120 mg tid with prn oxycodone 20 mg every 4 hr
as needed. She was followed during her hospital stay by the
palliative care team. She elected to be DNR/DNI.
In addition to the oxcycontin 120 mg tid, oxycodone 20 mg prn,
lovenox and coumadin, she was discharged on gabapentin 300 mg
tid, atorvastatin 40 mg a day, lorazpam 0.5 mg as needed for
nausea, vitamin B complex, colace 200 mg bid, senna 8.6 mg bid,
miralax 17 gm bid prn
___ Day 8 gemcitabine
___ Cycle 2 Day 1 ___
MEDICAL & SURGICAL HISTORY:
Metastatic peritoneal ovarian cancer
DVT
HTN
HLD
Carpal tunnel syndrome
S/p cholecystectomy
S/p appendectomy
Social History:
___
Family History:
Mother had ovarian versus uterine cancer
Physical Exam:
ADMISSION EXAM:
================
VS: 98.4 150/84 64 18 93%RA
General: Alert, NAD, speaking in full sentences
HEENT: PERRL, EOMI, MMM, anicteric sclerae, OP clear
Neck: Supple, no JVD, no LAD
Lungs: CTAB, no W/R/R
Cardiac: RRR, S1/S2 normal, no M/R/G
Abdomen: Soft, lower abdomen mildly TTP, slightly distended,
+bowel sounds, no rebound tenderness or guarding
Extremities: WWP, no pedal edema, mildly tender to palpation
over L medial calf
Neuro: CNs ___ grossly intact, ___ BUE/BLE
DISCHARGE EXAM:
=================
Vitals: Tmax 98.4 BP 114/61 HR 64 RR 18 O2sat 95% RA
General: Alert, NAD, speaking in full sentences
HEENT: PERRL, EOMI, MMM, anicteric sclerae, OP clear
Neck: Supple, no JVD, no LAD
Lungs: CTAB, no W/R/R
Cardiac: RRR, S1/S2 normal, no M/R/G
Abdomen: Soft, lower abdomen mildly TTP, slightly distended,
+bowel sounds, no rebound tenderness or guarding
Extremities: WWP, no pedal edema, mildly tender to palpation
over L medial calf
Neuro: CNs ___ grossly intact, ___ BUE/BLE
Pertinent Results:
ADMISSION LABS:
===============
___ 11:23AM BLOOD Neuts-58.6 ___ Monos-10.5 Eos-2.6
Baso-1.1* Im ___ AbsNeut-3.35 AbsLymp-1.53 AbsMono-0.60
AbsEos-0.15 AbsBaso-0.06
___ 11:23AM BLOOD ___ PTT-34.1 ___
___ 11:23AM BLOOD Glucose-115* UreaN-7 Creat-0.6 Na-133
K-3.4 Cl-97 HCO3-25 AnGap-14
___ 11:23AM BLOOD proBNP-160
___ 11:23AM BLOOD cTropnT-<0.01
___ 05:45PM BLOOD cTropnT-<0.01
DISCHARGE LABS:
================
___ 06:05AM BLOOD WBC-6.5 RBC-3.08* Hgb-8.6* Hct-26.1*
MCV-85 MCH-27.9 MCHC-33.0 RDW-29.8* RDWSD-89.8* Plt ___
___ 06:05AM BLOOD ___ PTT-90.0* ___
___ 06:05AM BLOOD Glucose-92 UreaN-7 Creat-0.6 Na-132*
K-3.5 Cl-97 HCO3-28 AnGap-11
___ 06:05AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.5*
IMAGING/STUDIES:
=================
Lower Extremity Ultrasound (___): No evidence of deep venous
thrombosis in the left lower extremity veins.
CTA Chest (___):
1. Pulmonary embolus of the distal right main pulmonary artery
extending to the upper, middle, and lower lobar arteries with
scattered segmental pulmonary artery emboli. No finding to
suggest right heart strain.
2. New small left pleural effusion with adjacent atelectasis.
3. Multiple loculated fluid collections in the upper abdomen,
though overall size of fluid in the upper abdomen has decreased
from prior studies.
4. New 6 mm right upper lobe pulmonary nodule for which
follow-up imaging is recommended.
Brief Hospital Course:
Ms. ___ is a ___ w/ a h/o metastatic peritoneal ovarian vs
cervical carcinoma and DVT, on home rivaroxaban which was held
for paracentesis, who p/w left calf pain, found to have a right
main pulmonary artery pulmonary embolism.
ACTIVE ISSUES:
===============
# Pulmonary Embolism: The patient initially presented to the ED
with mild left calf pain. She had reported some shortness of
breath on ambulation felt to be secondary to deconditioning. A
CTA was obtained which demonstrated a pulmonary embolus of the
distal right main pulmonary artery extending to the upper,
middle, and lower lobar arteries with scattered segmental
pulmonary artery emboli without findings of right heart strain.
Lower extremity ultrasound without evidence of DVT. Troponins
were <0.01 x 2, and BNP was normal. ECG with TWI in
anteriolateral leads, stable from prior ECG from ___. She
remained hemodynamically stable throughout her admission. Felt
that have had a PE in the setting of holding her anticoagulation
on two separate occasions for paracentesis and for IVC filter
removal. Did not feel that this was failure of treatment, so
restarted the patient on Rivaroxaban 15mg po BID to treat for 21
days, and then transition to 20mg po daily.
CHRONIC ISSUES:
================
# Metastatic peritoneal ovarian cancer: Continued on home
oxycodone, prochlorperazine, lorazepam, and senna/docusate
# Hypertension: Stable throughout admission. Initially
fractionated home metoprolol in the setting of PE. Continued
home amlodipine and hydrochlorothiazide. On discharge resumed
home metoprolol succinate 25mg po daily.
***TRANSITIONAL ISSUES***
==========================
# Pt is discharged on rivaroxaban 15 mg PO BID for 21 days,
which should then be followed by 20mg po daily for her acute PE.
Patient declined enoxaparin.
# Pt will require outpatient follow-up with her oncologist, Dr.
___, for further evaluation and management of her
anticoagulation therapy.
# On CTA found to have a new 6 mm right upper lobe pulmonary
nodule. Outpatient for which follow-up imaging is recommended.
# CODE STATUS: Full (confirmed)
# CONTACT: ___ (daughter/HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. LORazepam 0.5 mg PO Q8H:PRN Nausea, anxiety, insomnia
5. OxyCODONE (Immediate Release) 20 mg PO Q4H:PRN Pain -
Moderate
6. Prochlorperazine 10 mg PO Q6H:PRN Nausea
7. Pyridoxine 100 mg PO DAILY
8. Senna 8.6 mg PO QHS
9. Docusate Sodium 50 mg PO QHS
10. Cyanocobalamin 100 mcg PO DAILY
11. Rivaroxaban 15 mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Gabapentin 300 mg PO BID
Discharge Medications:
1. Rivaroxaban 15 mg PO BID
RX *rivaroxaban [___] 15 mg (42)- 20 mg (9) 1 tablets(s) by
mouth as directed Disp #*1 Dose Pack Refills:*0
2. amLODIPine 5 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Cyanocobalamin 100 mcg PO DAILY
5. Docusate Sodium 50 mg PO QHS
6. Gabapentin 300 mg PO BID
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. LORazepam 0.5 mg PO Q8H:PRN Nausea, anxiety, insomnia
9. Metoprolol Succinate XL 25 mg PO DAILY
10. OxyCODONE (Immediate Release) 20 mg PO Q4H:PRN Pain -
Moderate
11. Prochlorperazine 10 mg PO Q6H:PRN Nausea
12. Pyridoxine 100 mg PO DAILY
13. Senna 8.6 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Pulmonary embolism
SECONDARY: Metastatic peritoneal carcinoma
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 a blood clot in your right lung. We monitored your
vital signs and the electrical activity of your heart.
Fortunately, you remained clinically stable.
Please continue to take Xarelto at a higher dose of 15 mg twice
a day with food for 21 days, and then continue 20 mg daily with
food.
Thank you for allowing us to be involved in your care!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10452634-DS-20 | 10,452,634 | 21,702,101 | DS | 20 | 2122-12-18 00:00:00 | 2122-12-18 19:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Stab Wound to Chest
Major Surgical or Invasive Procedure:
1. Endotracheal intubation
2. Chest Tube x3
3. Left video-assisted thoracic surgery for evacuation of left
hemothorax
History of Present Illness:
___ Y/o M who presents to the ED today for evaluation s/p
stab wound this evening. Pt was stabbed with a 6 inch
"reported" butcher knife in his left upper supraclavicular
chest. Medics report that when the knife was removed, there
was about 1.5 inches of blood on the blade. Pt was AO at
scene and informed medics that he had been using alcohol
this evening. He had reportedly 2 episodes of vomiting while
en route and a prehospital BP od SBP in 80___. The patient
appears lethargic on arrival in the ED and only little
history was provided by medics. Pt intubated shortly after
arrival, making history limited.
Past Medical History:
NC
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION
Temp: AF HR: 113 BP: 120/90 Resp: 24 O(2)Sat: 94
Constitutional: Pt is lethargic on arrival.
HEENT: Normocephalic, atraumatic
Blood foam in mouth, no blood visualized in posterior
oropharnyx. Pt intubated wit 8.0 endotracheal tube, 20 cm at
the lips.
Chest: Left breath sounds diminished. Crepitus left upper
chest wall. Post intubation: equal breath sounds
bilaterally.
Cardiovascular: Normal first and second heart sounds.
Strong peripheral pulses. Regular Rate and Rhythm
Abdominal: Nondistended, Soft
GU/Flank: No costovertebral angle tenderness
Extr/Back: Extremities atraumatic. Pt moving all four
extremities. periph pulses including LUE +/symmetric
Skin: Warm and dry, No rash
Neuro: pt responding to commands on arrival. Pt sedated and
intubated.
Psych: lethargic
___: No petechiae
PHYSICAL EXAM ON DISCHARGE
Gen: A/Ox3, NAD
HEENT: PERRLA, EOMI
Chest: stab wound covered with dry sterile dressing, old chest
tube site with dsg, chest tube site x2 with occlusive dressing
Lungs: CTAB
CV: RRR
GI: Abd soft, NTND
Pertinent Results:
___ 05:55AM BLOOD WBC-6.4 RBC-3.38* Hgb-9.8* Hct-30.1*
MCV-89 MCH-29.0 MCHC-32.6 RDW-12.1 Plt ___
___ 05:40AM BLOOD WBC-6.2 RBC-3.13* Hgb-9.3* Hct-27.9*
MCV-89 MCH-29.8 MCHC-33.5 RDW-12.4 Plt ___
___ 01:53AM BLOOD WBC-6.7 RBC-3.32* Hgb-9.5* Hct-29.9*
MCV-90 MCH-28.5 MCHC-31.7 RDW-13.1 Plt ___
___ 07:28AM BLOOD WBC-9.0 RBC-3.71* Hgb-10.6* Hct-33.2*
MCV-89 MCH-28.6 MCHC-32.0 RDW-13.1 Plt ___
___ 03:15AM BLOOD WBC-9.8 RBC-3.76* Hgb-10.8* Hct-33.9*#
MCV-90 MCH-28.8 MCHC-31.9 RDW-12.9 Plt ___
___ 01:10AM BLOOD Hct-26.5*#
___ 05:40AM BLOOD Glucose-101* UreaN-10 Creat-0.9 Na-135
K-4.0 Cl-102 HCO3-26 AnGap-11
___ 01:53AM BLOOD Glucose-121* UreaN-11 Creat-1.1 Na-132*
K-3.9 Cl-103 HCO3-27 AnGap-6*
___ 03:15AM BLOOD Glucose-111* UreaN-10 Creat-0.9 Na-136
K-4.0 Cl-108 HCO3-18* AnGap-14
___ 12:14AM BLOOD Glucose-104* UreaN-12 Creat-1.2 Na-138
K-5.0 Cl-110* HCO3-10* AnGap-23*
___ 05:40AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.9
___ 01:53AM BLOOD Calcium-8.0* Phos-2.4* Mg-2.0
___ 03:15AM BLOOD Calcium-6.9* Phos-3.9 Mg-1.4*
___ 10:25PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
CTA chest ___: showed that the major vessels were intact
without hematoma. There was a moderate left hemorrhagic pleural
effusion, and fracture of the left anterior third rib. Left lung
opacities were consistent with likely pulmonary hemorrhage, and
bibasilar opacities were consistent with likely aspiration.
CXR ___: In comparison with the earlier study of
this date, the left chest tube has been removed. No evidence
of pneumothorax. Pulmonary contusion and possible fluid in
the pleural space persist. Right lung is clear.
CXR ___
The 2 left-sided chest tubes has been removed. Again seen is a
small left
apical lateral pneumothorax. , this is similar in size compared
to the study
from earlier the same day. There continues to be fluid loculated
anteriorly on
the left. There is also small left effusion. There is volume
loss at the left
base.
IMPRESSION:
Small left apical lateral pneumothorax.
DISCHARGE LABS:
___ 05:15AM BLOOD WBC-9.8 RBC-2.63* Hgb-7.4* Hct-23.3*
MCV-89 MCH-28.1 MCHC-31.6 RDW-13.5 Plt ___
___ 05:15AM BLOOD Glucose-117* UreaN-9 Creat-0.8 Na-138
K-4.2 Cl-101 HCO3-26 AnGap-15
___ 05:15AM BLOOD Calcium-7.7* Phos-2.9 Mg-2.4
Brief Hospital Course:
Mr. ___ is a ___ y.o. man with unknown past medical history
who was admitted to ___ on ___ with complaints of a stab
wound to left upper anterior chest. He was hemodynamically
stable on arrival but was intubated for agitation/emesis and
concern for aspiration. A left sided chest tube was placed with
return of 500cc of bloody fluid initially, and another 340cc
overnight. The patient was monitored closely in the ICU. On HD1
he had a drop in his blood pressure responded to administration
of 2 units pRBCs and fluids. His vital signs stabilized and his
labs normalized. He was extubated on HD2 without difficulty and
transferred to the floor. His chest tube remained in for the
next 3 days due to a persistent air leak. The chest tube was
pulled on HD 5 and a post pull CXR showed no evidence of
pneumothorax but was notable for a left lower lobe
consolidation. On HD5 the patient spiked a fever to 103 with
tachycardia. He was pan cultured and started on Levaquin IV.
Chest X-Ray at this time revealed a left lower lobe
consolidation. Over the next ___ hours he continued to spike
fevers up to 101 with persistant tachycardia while afebrile to
110's. He remained hemodynamically stable with an oxygen
requirement of ___. His antibiotics were broadened at this
time to Vancomycin and Cefepime and ___ were negative. The
patient continued to spike fevers. A CTA of the chest was
completed, which was negative for PE but revealed left lower
lobe opacities most likely retained hemothorax bibasilar
opacities consistent with aspiration. At this time Thoracic
surgery was consulted and the patient underwent a Left VATS
decortication and hematoma evacuation on ___. He had two
chest tubes that were initially to suction. Pain was controlled
and diet was advanced as appropriate. Chest tubes were placed to
water seal and serial chest xrays were obtained that showed
persistent, small, left apical pneumothorax. The patient was
weaned off oxygen on POD1 and remained stable on room air. His
chest tubes were discontinued on day of discharge and he was
given instructions on how to care for the dressings. He will
follow up with both thoracic surgery and general acute care
surgery.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
do not exceed 3000mg/day
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*50 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
hold for loose stools
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. left 3rd rib fracture
2. left hemorrhagic pleural effusion
3. pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your admission to
___. You were brought in to the hospital after sustaining
injuries from a stab wound to your left chest. You suffered from
a fractured rib and a lung injury. You required a chest tube be
placed to drain the blood from your lung and to help reinflate
the lung. You were also briefly intubated and monitored in the
ICU due to your injury. Your chest xrays have shown your lung
injury is clinically improving and re-expanded. You are now
ready to return home to continue your recovery. Please follow up
in the ___ clinic appointment listed below. Please also note the
following discharge instructions:
*You have 4 wounds that need dressings. The bottom two from your
chest tube sites should continue the plastic covered bandages
for 72hours. You may shower with these bandages on. You can then
remove the plastic part and keep the area covered by dry,
sterile guaze. The wound under your armpit from your old chest
tube and the stab wound should also be covered by dry, sterile
guaze changed as needed and after showering. You may shower. Let
the water run over the area and pat dry. Do not soak or swim
until you talk with your surgeons.
* Your injury caused a rib fracture 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).
All the Best,
The ___ Surgery Team
Followup Instructions:
___
|
10452911-DS-11 | 10,452,911 | 28,578,904 | DS | 11 | 2178-04-09 00:00:00 | 2178-04-09 16:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right bimalleolar ankle fracture
Major Surgical or Invasive Procedure:
Open reduction and internal fixation of right ankle on 112 ___
___ of Present Illness:
HPI: ___ female history of hypertension presents with the above
fracture s/p mechanical fall. Fell down 4 stairs. Was first
seen at ___. There, she was reduced and
splinted. Transferred to main campus for further treatment.
Past Medical History:
PMH/PSH:
Hypertension
Social History:
___
Family History:
Noncontributory
Physical Exam:
Exam:
General: Well-appearing, breathing comfortably
MSK right lower extremity short leg splint over right lower
extremity is s clean, dry and intact. Patient is firing extensor
hallucis longus, flexor hallucis longus, tibialis anterior and
gastrocnemius. Sensation is intact to light touch in the deep
peroneal, superficial peroneal, tibial, saphenous and sural
nerve
distributions. Foot is warm and well-perfused. Drains with
serosanguinous output.
Pertinent Results:
___ 09:05PM BLOOD WBC-14.1* RBC-4.05 Hgb-12.3 Hct-37.4
MCV-92 MCH-30.4 MCHC-32.9 RDW-13.4 RDWSD-45.9 Plt ___
___ 09:05PM BLOOD Neuts-82.0* Lymphs-12.4* Monos-4.6*
Eos-0.1* Baso-0.3 Im ___ AbsNeut-11.57* AbsLymp-1.75
AbsMono-0.65 AbsEos-0.01* AbsBaso-0.04
___ 09:05PM BLOOD ___ PTT-27.7 ___
___ 09:05PM BLOOD Glucose-111* UreaN-14 Creat-0.6 Na-140
K-4.3 Cl-101 HCO3-___ AnGap-14
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right bimalleolar ankle fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ open reduction internal face
fixation of right bimalleolar fracture, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications 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
splinted in the right lower extremity , and will be discharged
on aspirin 325 for 4 weeks for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 20 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
2. Aspirin 325 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*40 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
7. Escitalopram Oxalate 20 mg PO DAILY
8. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right bimalleolar ankle fracture dislocation status post ORIF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Nonweightbearing right lower extremity.
No showering until splint removal.
Avoid liquid or water soaking of the splint.
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add ___ mg of 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:
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 ___ regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take aspirin 325 mg daily for 4 weeks
WOUND CARE:
- No water on the splint at any time.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
Physical Therapy:
Nonweightbearing right lower extremity:
See physical therapy notes for treatment
Treatments Frequency:
Physical therapy ___ times per week
Followup Instructions:
___
|
10453488-DS-30 | 10,453,488 | 24,212,931 | DS | 30 | 2151-11-19 00:00:00 | 2151-11-19 14:54:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Feldene / Codeine / Sulfadiazine
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Percutaneous Drain Placement ___ Gall Bladder
History of Present Illness:
___ from home with fever to 101 and severe abdominal pain x 4
days. She states that the pain is constant but does state that
she has noted intermittent abdominal pain over the past couple
of years ___ the similar R sided location. She is unsure if this
pain was related to food intake. She states that she had a
bowel moment yesterday and that it was normal. No reports of
diarrhea. She has noted nausea.
___ the ED, initial vs were: 116 109/54 20 96%. Alk phos was
168. Other LFTs nl. INR was 3.4. RUQ US showed distended
gallbladder with marked mural thickening and positive
sonographic ___ sign. UA showed mod blood and leuk est
with 12 wbcs. However pt states that she is asymptomatic. ___
the ED she received Acetaminophen 500mg Tablet. MetRONIDAZOLE
(FLagyl) 500mg, Ciprofloxacin IV 400mg, and
Piperacillin-Tazobactam 4.5 g. Surgery was consulted who
recommended NPO wiwth zosyn. Then perfom HIDA with perc tube
placement if positive.
ROS was otherwise negative.
Past Medical History:
-Chronic venous stasis/lymphedema bilaterally; followed by Dr.
___ vascular
-PUD s/p "probable ___ II surgery" ___ ___ per GI note
-Afib
-CVD
-DVT (> ___ years ago ___ the context of ovarian CA)
-Ovarian cancer s/p TAH/BSO and XRT (per ___ GI note ___ OMR)
-Osteoporosis
-Hiatal hernia
-Spinal stenosis -> decompression laminectomy ___
-Knee arthroscopy, synovectomy, meniscectomy ___
-Cataract OS
-Diarrhea thought ___ to bacterial overgrowth intermittently
treated w/ augmentin (BID ___ 5 days of each month)
-Ectopic pregnancy
-Appendectomy
-Tonsillectomy
-Chronic venous stasis/lymphedema bilaterally; followed by Dr.
___ vascular
-PUD s/p "probable ___ II surgery" ___ ___ per GI note
-Afib
-CVD
-DVT (> ___ years ago ___ the context of ovarian CA)
-Ovarian cancer s/p TAH/BSO and XRT (per ___ GI note ___ OMR)
-Osteoporosis
-Hiatal hernia
-Spinal stenosis -> decompression laminectomy ___
-Knee arthroscopy, synovectomy, meniscectomy ___
-Cataract OS
-Diarrhea thought ___ to bacterial overgrowth intermittently
treated w/ augmentin (BID ___ 5 days of each month)
-Ectopic pregnancy
-Appendectomy
-Tonsillectomy
Social History:
___
Family History:
Venous disease, lymphedema
Physical Exam:
ADMISSION:
8.1 108/64 24 80 99% RA
General: A&O
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bibasilay crackles present b/l, no wheezes
CV: Regular rate and rhythm, normal S1 + S2, ___ systeolic
murmur at RUSB
Abdomen: soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, + ___ sign with ttp ___ the RUQ
Ext: Warm, well perfused, 2+ pulses, chronic venous stasis
changes present with trace pretibial edema
Skin: no rash
Neuro: grossly non focal
DISCHARGE:
97.5 115/61 96 18 96%
General: A&O
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bibasilay crackles present b/l R>L, no wheezes
CV: RRR, normal S1 + S2, ___ systeolic murmur at RUSB
Abdomen: soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, diffuse ttp ___ RUQ but improved greatly
since perc drain placement, drain present and draining bloody
thick drainage
Ext: Warm, well perfused, 2+ pulses, chronic venous stasis
changes present with trace pretibial edema
Skin: no rash
Neuro: grossly non focal
Pertinent Results:
ADMISSION
___ 10:10AM BLOOD WBC-11.0# RBC-3.14* Hgb-10.5* Hct-31.1*
MCV-99* MCH-33.6* MCHC-33.9 RDW-14.8 Plt ___
___ 10:10AM BLOOD Neuts-87.6* Lymphs-6.6* Monos-5.3 Eos-0.5
Baso-0.1
___ 01:49PM BLOOD ___ PTT-40.7* ___
___ 10:10AM BLOOD Glucose-102* UreaN-24* Creat-0.6 Na-138
K-3.4 Cl-98 HCO3-29 AnGap-14
___ 10:10AM BLOOD ALT-15 AST-22 AlkPhos-168* TotBili-1.0
___ 05:30AM BLOOD Albumin-2.5* Calcium-7.9* Phos-2.9 Mg-2.0
___ 09:50AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 09:50AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-MOD
___ 09:50AM URINE RBC-0 WBC-16* BACTERIA-MANY YEAST-NONE
EPI-0
___ 09:50AM URINE HYALINE-21*
___ 09:50AM URINE MUCOUS-MANY
DISCHARGE
___ 06:12AM BLOOD WBC-7.9 RBC-2.92* Hgb-9.4* Hct-29.2*
MCV-100* MCH-32.3* MCHC-32.3 RDW-14.6 Plt ___
___ 06:12AM BLOOD Glucose-93 UreaN-17 Creat-0.5 Na-140
K-4.2 Cl-103 HCO3-32 AnGap-9
___ 05:50AM BLOOD ALT-16 AST-20 AlkPhos-113*
___ 06:12AM BLOOD Calcium-8.3* Phos-2.2* Mg-1.8
RUQ US
Distended gallbladder with marked mural thickening and positive
sonographic ___ sign, most consistent with acute
cholecystitis.
Intraluminal debris may reflect sloughed membranes raising
suspicion for
gangrenous cholecystitis.
CXR
AP and lateral views of the chest. Aortic calcifications are
again
seen. No focal consolidation is seen. There is no pneumothorax.
The
cardiomediastinal contours are stable.
BILIARY FLUID CYTOLOGY
NEGATIVE FOR MALIGNANT CELLS.
Numerous neutrophils and histiocytes.
DRAIN PLACEMENT
Informed consent was obtained via the son. ___
timeout
was performed to confirm patient identity and indication for
examination. Under direct sonographic visualization, an
___ ___ catheter was inserted into the gallbladder via
transhepatic trocar mounted route. After confirmation of
purulent return, the catheter was deployed over the metal
stylus. Post-procedural imaging showed that the catheter to be
___ good position. The pigtail was locked and the catheter was
secured. 150 cc of purulent fluid was aspirated and samples
were sent for cytology and microbiology as per clinical request.
A final post-procedural image showed a decompressed
gallbladder. The patient tolerated the procedure well and there
were no immediate complications. The patient reported reduced
pain
immediately post-procedure.
PICC Placement:
BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___. CEFEPIME sensitivity testing confirmed by ___
___.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- 8 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Anaerobic Bottle Gram Stain (Final ___:
URINE CULTURE (Preliminary):
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
GRAM NEGATIVE ROD #2. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 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-------- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 9:25 pm FLUID,OTHER Site: GALLBLADDER
GRAM STAIN (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0105.
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Preliminary): RESULTS PENDING.
Brief Hospital Course:
___ yo female with hx of afib, htn, chronic venous stasis present
with 4 days of acute on chronic abdominal pain and RUQ US c/w
cholecystitis.
.
ACUTE
# Abdominal pain - Patient presented with RUQ tenderness and US
c/w cholecystitis. ACS was consulted ___ the ED, at which time
they recommended placement of percutaneous drain. The pts INR
on admission was 3.5. She was made NPO, supported with IVF, and
started on zosyn. Her coumadin was discontinued and she was
given vitamin K and FFP. Her INR decreased to 1.4, at which
time ___ placed a percutaneous drain. Fluid from the gall
bladder grew GPCs ___ chains and clusters. Speciation and
sensitivites are pending. The patient was started on vancomycin
although did not receive 1st dose of vancomycin until today
because of lack of IV access. She is due for her 4th dose
tonight (___). A trough should be drawn prior to this and
sent to Dr. ___. This may be discontinued pending
speciation and sensitivities. However, we will follow-up this
data and let you know within the next couple of days.
Otherwise, the vanco should be continued till ___.
Additionally, there remains the possibility that this could be
VRE as it is an enterococcus species. However, she looks well,
and this seems less likely. As mentioned above, we will
follow-up these cultures and relay them to the necessary
individuals. She should follow-up with general surgery ___ 2
weeks to discuss surgical options. At this time, she should
present a log of the daily output of her percutaneous drain.
.
# GNR Bacteremia - Initial blood cultures grew E Coli. She was
continued continued on her zosyn, which was started on
presentation because of the cholecystitis. Repeat surveillance
cultures have been negative. She should complete a 2 - wk
course of zosyn to management of this issue. Last day is
___.
.
# Atrial Fibrillation - Her INR was supratherapeutic on
presentation. As such, her coumadin was held and she was
reversed with vitamin K and FFP. She was started on rivaroxaban
per Dr. ___. This was done ___ large part because of the
likelihood of her going to surgery ___ the next month given that
anticoagulation can be undone ___ ~2 days of held doses. She was
continued on her home dose of metoprolol.
.
# Dirty UA - Pt denied frequency or dysuria on presentation.
Therefore, we did not specifically treat based on her UA. Cx
grew out 10,000 - 100,000 K. pneumonia. Zosyn is likely
sufficient to cover this, although sensitivities to zosyn were
not specifically performed.
.
CHRONIC
# dCHF - she denied SOB, orthopnea, or pnd on presentation.
She had trace ___ edema, but her lasix was held given concern for
developing sepsis. Her lasix was then restarted at her home
dose after clinical improvement and placement of the
percutaneous drain. She has remained hemodynamically stable.
.
TRANSITIONAL
# f/u with gen surg ___ 2 weeks
# f/u with Dr. ___
# record daily log of output from gall bladder drain
# check electrolytes on ___
# f/u vanc level trough tonight (___) and relay info to Dr.
___ dosage adjustment:
Name: ___
Location: ___ - ___
___: ___
Phone: ___
Fax: ___
Email: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 25 mg PO BID
hold for rr<12 or sbp < 100
2. Furosemide 40 mg PO BID
hold for sbp <100
3. Omeprazole 20 mg PO DAILY
4. Warfarin 2 mg PO 2 MG ON MON, WED, SAT; 4MG ON SUN, TUES,
THURS, FRI
5. Cholestyramine 4 gm PO DAILY abdominal pain
Discharge Medications:
1. Furosemide 40 mg PO BID
hold for sbp <100
2. Metoprolol Tartrate 25 mg PO BID
hold for rr<12 or sbp < 100
3. Omeprazole 20 mg PO DAILY
4. Piperacillin-Tazobactam 4.5 g IV Q8H
Last day ___
5. Vancomycin 1000 mg IV Q 12H
Last day ___ or until notified that they may be stopped by
provider at ___
6. Rivaroxaban 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Cholecystitis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure caring for you during your recent admission to
___. You were admitted because of cholecystitis. You were
treated with IV antibiotics and then taken to interventional
radiology to have a drain placed ___ your gall bladder. A more
permanent IV was placed ___ your arm and you were discharged to
rehab with a prescription for IV antibiotics. You will need to
follow-up with your PCP and with general surgery ___ 2 weeks. At
this appointment, you will need to present a daily log of the
output from your gall bladder drain. The following changes were
made to your medications:
STOP
warfarin
START
zosyn
vancomycin
rivaroxaban
*** You will need a vancomycin trough drawn before your 4th dose
of vancomycin tonight (___). This should then be faxed to
Dr. ___ further instructions on vancomycin dosing.
Name: ___
Location: ___ - ___
___: ___
Phone: ___
Fax: ___
Email: ___
Followup Instructions:
___
|
10453511-DS-22 | 10,453,511 | 23,810,988 | DS | 22 | 2134-04-04 00:00:00 | 2134-04-08 18:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dehydration
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with history of AS, B12 deficiency,
hypothyroidism, recent admission in ___nd UTI, who presents to the ED with abdominal pain that started
yesterday. She is a poor historian and refused to give the full
history as she is angry about the care she's received. She tells
me that she was "very sick" yesterday with abdominal pain
(crampy), chest pain, n/v/d, back pain. She reports a
temperature of 99 at that time. She reports that since coming to
the ED her abdominal pain is better, but she is very upset
because someone threw a shoe at her in the ED. Unfortunately she
won't tell me much beyond this.
.
In the ED, VS 97.6 56 149/50 18 95 RA . She was noted to have a
WBC of 11.8 with a BUN/Cr ratio of 40/0.7 and lipase 64. Hct was
also low at 34.4. CT abd/pelvis was considered but deferred
given benign abdominal exam, and concern re: IV dye load.
.
On the floor, pt reports her abodminal pain is better. VS were
declined by the patient.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
-cervical myelopathy
-aortic valve disease
-B12 deficiency
-s/p cataract surgery
Social History:
___
Family History:
mother-asthma deceased in ___
father- deceased of unclear causes in his ___
only child and never had children
Physical Exam:
FEX ON ADMISSION
VS - Pt declining
GENERAL - Agitated, tangentel. Knows she is in BI, but doesnt
know date. Oriented to self
HEENT - sclerae anicteric, dry MM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - RRR, nl S1-S2, ___ systolic murmur at RUSB
LUNGS - CTAB,
ABDOMEN - BS+, soft/NT/ND, no masses or HSM. Abdominal bruit
appreciated
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, agitated not cooperating with exam
FEX ON DISCHARGE
VS - T 97.7, 97.0, 138/49, 59, 18, 98%RA
GENERAL - Elderly woman laying flat in bed, in NAD. Calmer this
morning. Not oriented to place (I'm at home, I own this bed) or
time ___ ___, ___. On reexamination later in the
morning, she is well appearing elderly woman, sitting up in her
chair. She is now oriented to 'hospital' (but thinks she is in
___ and ___. She notes she recently had a birthday.
HEENT - sclerae anicteric, dry MM, OP clear
NECK - Supple, no JVD, no carotid bruits
HEART - RRR, nl S1, ___ systolic murmur at RUSB, loud S2
LUNGS - Nonlabored, CTAB
ABDOMEN - BS+, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, oriented as above. Somewhat circumstantial
thought process. cooperative. CNII-XII intact. strength ___ and
symetric throughout. Cerebellar fxn intact to FTN. Gait
deferred.
Pertinent Results:
ADMISSION LABS:
___ 07:27PM BLOOD WBC-11.8*# RBC-3.35* Hgb-10.9* Hct-34.4*#
MCV-103* MCH-32.6* MCHC-31.7 RDW-13.7 Plt ___
___ 07:27PM BLOOD Neuts-89.1* Lymphs-6.6* Monos-3.9 Eos-0.2
Baso-0.2
___ 07:27PM BLOOD Glucose-129* UreaN-40* Creat-0.7 Na-140
K-4.4 Cl-103 HCO3-29 AnGap-12
___ 07:27PM BLOOD ALT-15 AST-22 AlkPhos-49 TotBili-0.6
___ 07:27PM BLOOD Lipase-64*
___ 07:27PM BLOOD Albumin-4.4 Calcium-9.6 Phos-4.1 Mg-2.5
DISCHARGE LABS:
___ 09:04AM BLOOD ___ Folate-GREATER TH
___ 09:04AM BLOOD TSH-0.63
___ 09:04AM BLOOD WBC-7.5 RBC-3.00* Hgb-9.7* Hct-30.5*
MCV-102* MCH-32.3* MCHC-31.8 RDW-14.0 Plt ___
___ 09:04AM BLOOD Glucose-89 UreaN-26* Creat-0.6 Na-141
K-4.0 Cl-108 HCO3-28 AnGap-9
___ 09:04AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.1
URINE:
___ 12:14PM URINE Color-Yellow Appear-Clear Sp ___
___ 12:14PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
___ 12:14PM URINE RBC-<1 WBC-4 Bacteri-NONE Yeast-NONE
Epi-2 TransE-<1
MICROBIOLOGY:
___ URINE URINE CULTURE-FINAL <10,000 CFU
REPORTS:
___ Radiology CHEST (PA & LAT)
In comparison with the study of ___, there is little
change.
Continued low lung volumes may be accentuating the mild
enlargement of the
cardiac silhouette. No evidence of vascular congestion, pleural
effusion, or acute focal pneumonia.
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION:
___ woman with history of aortic valve disease, past admission
for mechanical falls and UTI, presented to ED with abdominal
pain, n/v/d and dehydration for the past 2 days.
ACTIVE PROBLEMS:
# Abdominal pain, N/V/D: Given time course and symptoms, appears
to have been a self-limited gastroenteritis. She was started on
cipro/flagyl empirically in the ED. Symptoms had resolved by
admission to medicine floor and abx were discontinued. She was
clinically dehydrated on presentation to the ED with elevated
BUN/Cr ratio. She received IVF's overnight with improvement in
labs and complete resolution of symptoms. Pt was advanced a
regular diet without any difficulty and was eager to return
home.
# Agitation: Patient appeared to have sundowned in the setting
of being dehydrated from gastroenteritis. The morning after
admission, her mental status had cleared markedly and she was
back to her baseline mental status per her family/primary
caregivers. ___ workup with UA and CXR was negative. Her
abdominal exam was benign and she advanced a regular diet
without any difficulty. B12 and folate were wnl. After
discussion with patient, family and PCP, it was felt that she
was at her functional baseline and declined evaluation for
placement into ECF. She was discharged home with home services
per patient and family wishes.
CHRONIC PROBLEMS
# Aortic stenosis: Per history, and patient noted to have murmur
on exam. No echo in our system. Did not have s/s of failure at
this time. Notably, continues to have clear S2 on auscultation.
.
# Hypothyroid: Continued home levothyroxine.
MEDICATION CHANGES:
None
TRANSITIONAL ISSUES:
-Continued close outpatient follow up with PCP
___ on ___:
1. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID ().
6. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*0*
7. Pedialyte Solution Sig: ___ cups PO once a day as needed
for dehydration.
Disp:*2 bottles* Refills:*2*
Discharge Medications:
1. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 (one
half) Tablet PO once a day.
5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO three times a day.
6. Pedialyte 10.6-4.7 mEq/8.5 gram Powder in Packet Sig: ___
cups PO once a day as needed for dehydration.
7. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO three
times a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Gastroenteritis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It has been a pleasure taking care of you at ___
___. You were admitted to the hospital
because you were having bad abdominal pain and vomiting and
required IV fluids. We gave you fluids and you began to feel
better. We think your symptoms were secondary to
gastroenteritis. You were evaluated by physical therapy who felt
it was safe for you to return home with 24 hour care, which you
currently have in place.
We made no changes to your medications.
Your primary care physician ___ contact you regarding follow
up.
Followup Instructions:
___
|
10453519-DS-21 | 10,453,519 | 20,778,491 | DS | 21 | 2192-08-17 00:00:00 | 2192-08-17 13:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins / Erythromycin Base / Levaquin
Attending: ___.
Chief Complaint:
back ___ and numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old man with ___ years if intermittent and
recurrent back and RLE ___ with radiation behind the knee. He
has has some bilateral thigh numbness, right greater than left.
He has worked with a ___ in the past. He has not had
any ___ or ESI, nor has he seen a ___ management specialist. He
admits to going to the ED for reills of Dilaiudid which he has
been taking for years. He denies bowel and bladder incontinence
and ED. He has back ___ primarily when he elevates his legs and
it is worsened when he is seated.
Past Medical History:
PMHx:
- Hep C
- Esophagitis.
- Depression/anxiety.
- Bipolar disorder.
- History of positive PPD (per records was started on INH, but
stopped due
to side effects).
- hx Cocaine abuse
- History of alcohol abuse, sober for several years and is in
AA.
- History of incarceration ___ and a portion of ___ and ___
-TBI ___
-sinus disease
-chronic
-headaches and hypersomnia, followed by BI Neurology
All:Erythromycin base, Levaquin, penicillin.
Social History:
___
Family History:
FAMILY HISTORY:
Mother obese.
Father, diabetes.
Grandmother, ___, bipolar.
No history of prostate, breast, or skin cancer. No MI.
Physical Exam:
At Admission:
PHYSICAL EXAM:
O: HR: 66 BP: 109/63 rr: 20 Sat: 99%
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic, atraumatic
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
IP Q H AT ___ G
R 5 5 5 5 5 5
L 5 5 5 5 5 5
Sensation: Decrease over mid buttock bilaterally, decreased on
bilat circumferential thighs to knees.
Reflexes: B Pa Ac
Right 1+ 1+ 1+
Left 1+ 1+ 1+
Toes downgoing bilaterally
Rectal exam normal sphincter control
No clonus
At Discharge:
Palpable back ___ midline. ___: 4+/5 right IP due to ___. No
sign of weakness otherwise. Reports slight numbness at the
lateral calf and anterior thigh and well as the medical left
foot, no toe involvement. SLR -. No clonus. Reflexes ___ at the
patella and ___ tendon.
Pertinent Results:
MRI Lumbar Spine ___:
Large central posterior disc protrusion at L4/5 and bulge at
L5/S1 with
impingement on the traversing and exiting L5 nerve roots
bilaterally (R>L), respectively
Brief Hospital Course:
Mr. ___ was evaluated in the emergency room, underwent a
lumbar MRI and was subsequently admitted to the neurosurgery
service for ___ control and further evaluation. He had no
significant ___ weakness. His images were reviewed by Dr. ___
___ Dr. ___. He had dynamic Lspine imaging to eval for
spondylolisthesis. He will have ___ and follow up with Dr.
___ possible epidural steroid
injections. If he fails conservative treatment, he may require a
lumbar fusion. He was discharged to home on the afternoon of ___
with instructions for followup.
Medications on Admission:
Medications:
Adderall 10 mg Tab, 1 Tablet(s) by mouth every morning then two
tablets at noon
quetiapine 200 mg Tab, 1 Tablet(s) by mouth in morning and at
bedtime and one half tablet at noon
levetiracetam 750 mg Tab, 2 Tablet(s) by mouth Twice per day
Take
1 per day; after one week increase to 1 twice each day.
nortriptyline 25 mg Cap, 1 Capsule(s) by mouth at bedtime
omeprazole 20 mg Cap, Delayed Release, 1 Capsule(s) by mouth
twice daily
lithium carbonate ER 450 mg Tab, 1 Tablet(s) by mouth at bedtime
lithium carbonate ER 300 mg Tab, 1 Tablet(s) by mouth QAM
tramadol 50 mg Tab, 2 Tablet(s) by mouth four times a day as
needed for headache
sumatriptan 50 mg Tab, 1 Tablet(s) by mouth take 1 with headache
onset ___ repeat 1 x 1 hour later
Dilaudid -- Unknown # of dose(s) Patient reports taking dilaudid
every ___ hours as needed for ___
Discharge Medications:
1. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
2. nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. lithium carbonate 300 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
6. quetiapine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): at noon.
7. sumatriptan succinate 50 mg Tablet Sig: One (1) Tablet PO X1
PRN as needed for Headache.
8. quetiapine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. amphetamine-dextroamphetamine 5 mg Tablet Sig: Two (2) Tablet
PO QAM (once a day (in the morning)).
10. amphetamine-dextroamphetamine 5 mg Tablet Sig: Four (4)
Tablet PO at noon ().
11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
12. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for ___: pre-hospital medication.
13. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for spasm.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Central disc herniation at L4/5
Spondylolisthesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
Increase your intake of fluids and fiber, as ___ medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic ___ medication.
___ Medication: We only prescribe a small amoutn of ___
medication after discharge as you have not had surgery. You
should refer to your PCP for ___ medication needs in the
future.
You should not drive while taking narcotic ___ medications.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
___ that is continually increasing or not relieved by ___
medicine.
Any weakness, numbness, tingling in your extremities.
Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
___
|
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