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10453519-DS-23 | 10,453,519 | 27,843,199 | DS | 23 | 2192-11-28 00:00:00 | 2192-11-28 10:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins / Erythromycin Base / Levaquin
Attending: ___
Chief Complaint:
pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ s/p bilateral L4-5 microdiscectomies, L5-S1
laminectomies for Spondylolisthesis with spondylolysis L4-5 and
large disk herniation L4-5 causing cauda equina compression.
Symptoms were initially on the right. Immediately
post-operatively, symptoms began on the left. Presents now with
worsening L pain and weakness and paraesthesias. Pain is
"excruciating" ___. Has been off his medications x2 weeks
because he ran out. No bowel/bladder incontinence
Past Medical History:
- 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:
Mother obese.
Father, diabetes.
Grandmother, ___, bipolar.
No history of prostate, breast, or skin cancer. No MI.
Physical Exam:
O: T: 100.2 BP: 138/75 HR: 102 R 14 O2Sats 100
Gen: WD/WN, in moderate distress from ___ pain.
HEENT: Pupils: ___ EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Pt in TLSO brace
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. L ___ exam consistent with left foot drop.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally, except LLE. LLE: decreased sensation
over
medial/lateral thigh, medial/lateral calf. Significant pain to
touch over dorsum of right foot
Coordination: normal on finger-nose-finger, rapid alternating
movements,
Pertinent Results:
Lumbar MRI ___
1. Stable grade 1 retrolisthesis of L4 on L5 and Grade 1
anterolisthesis of L5 on S1. Patient is s/p L4-S1 bilateral
laminectomies with placement of bilateral pedicular screws at L4
and S1 and right side screws in L5, somewhat limiting evaluation
at the level of concern. Minimal change in borad based central
disc protrusion causing narrowing of the bilateral L5 neural
foramen.
2. Diffuse enhancement of soft tissue posterior to surgical site
with a 6.1 x 3.0 cm T1 hypointense T2 hyperintense peripherally
enhancing fluid collection extending from the superior aspect of
the left L3 lamina to the superior aspect of S2. Collection
abuts
but does not appear to be in continuity with the thecal sac.
Findings may reflect post-surgical change/seroma but cannot
exclude superimposed infectious process.
3. Thecal sac including a few select nerves of the cauda equina,
as well as the L4-S1 intrathecal nerves demonstrate enhancement.
___ reflect arachnoiditis, aseptic inflammation of nerve roots,
but cannot exclude infection.
4. Enhancement of the ventral epidural fat as well as abnormal
enhancement of the L4-L5 and L5-S1 disc. Again cannot
differentiate changes related to instrumentation vs disciits.
5.Though no dand within th minimal if any enhancement is evident
in the soft tissue posterior the the surgical site surrounded by
edematous non-ehancing soft tissue. Collection is not in
continuity with the thecal sac and likely reflects a
post-operative seroma.
___ LENIs - no dvt lle
Brief Hospital Course:
Pt was admitted to observation on ___ for pain management.
LENIs were obtained which showed no DVT. D/w PCP to increase
___ as indicated. Informed pt to d/c TLSO brace. F/u in
___ weeks with Dr. ___
___ on Admission:
Acid Control 150 mg tablet
Adderall 10 mg qAM and 20mg qNoon
lithium carbonate ER 300 mg Tab q AM
lithium carbonate ER 450 mg Tab q HS
mirtazapine 45 mg tablet q HS
omeprazole 40 mg capsule qD
rifampin 600 mg q D
gabapentin 200 mg TID
Seroquel 200 mg q HS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*100 Tablet Refills:*0
2. Adderall *NF* (amphetamine-dextroamphetamine) 10 mg Oral qAM
Reason for Ordering: Wish to maintain preadmission medication
while hospitalized, as there is no acceptable substitute drug
product available on formulary.
3. Adderall *NF* (amphetamine-dextroamphetamine) 20 mg ORAL QHS
Reason for Ordering: Wish to maintain preadmission medication
while hospitalized, as there is no acceptable substitute drug
product available on formulary.
4. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
5. Lithium Carbonate SR (Lithobid) 300 mg PO QAM
Lithobid SR
6. Lithium Carbonate SR (Lithobid) 450 mg PO QHS
Lithobid SR
7. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety
8. Mirtazapine 45 mg PO HS
9. Omeprazole 40 mg PO DAILY
10. Quetiapine Fumarate 200 mg PO HS
11. Rifampin 600 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
left leg pain
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
- You will not need your TLSO Brace anymore
- Increase your activity as tolerated
- Do not lift anything greater than 25lbs.
- Your gabapentin was increased to 300mg TID. You will f/u with
your PCP accordingly on ___ this week
Followup Instructions:
___
|
10453833-DS-14 | 10,453,833 | 29,854,942 | DS | 14 | 2163-01-18 00:00:00 | 2163-01-21 15:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
simvastatin
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Dual chamber ICD pacemaker ___ Inogen) placement
___
History of Present Illness:
___ with PMHx of CAD s/p CABG ___, aflutter, sCHF, atrial
flutter s/p recent ___ arrhythmia ablation, and
poorly controlled diabetes presenting to the ED as transfer from
OSH with weakness and bradycardia. Pt reports over the past 3
days he has generally been feeling weak with nausea/vomiting,
epigastric abdominal pain, and chest pain.
In the ED, initial vitals were: 96.0, 37, 106/36, 18, 98% RA
Labs: notable for white count of 19, lactate 4.9 down to 3.5, Cr
3.5, K 5.4, anion gap metabolic acidosis bicarb 15 w/ AG 21,
LFTs elevated to the 400s and T bili 1.6, lipase 75.
negative UA
Imaging:
RUQ US showed Contracted GB, thick walled GB. Mild L
hydronephrosis.
CT abd/p: Minimal fat stranding around porta hepatis, partially
contracted GB with high density material which may represent
sludge. Nodular liver with ascites.
Consults: ACS and Cardiology
Patient was given: unasyn, dopamine ggt, 2g Ca gluconate, Zofran
4mg
Decision was made to admit to CCU for bradycardia requiring
pressors
Vitals on transfer were: 98.9, 61, 158/91, 20, 100% RA
Upon arrival to the floor, patient reports that since his
discharge he has had a number of medication changes. His
metoprolol was increased to 150mg XL daily, his furosemide was
increased to 120 and 60 alternating every other day (from 60
daily), and his warfarin was increased to 7.5mg TTS and 5mg the
other days of the week. He was also started on amiodarone 200
BID and lisinopril 10mg daily. He cannot recall why he was
started on amiodarone but does state that his BP was elevated.
He says he started the amiodarone about 2 days prior to "being
sick". Per chart review he saw his PCP ___ ___ and was found to
be in ___ so he was referred to his cardiologist on ___ who
started amiodarone 200 BID with plan to decrease to 200 daily
after one week and metop was increased to 150.
When asked about his medications he says that he administers
them himself and upon review of the medications he was going to
take tonight there was 13.5 mg warfarin in the box. He states
that he usually doesn't make mistakes with his medications but
may have over the last 2 days. He gets his medications filled at
___.
Of note his BB was held intermittently on his last admission ___
to bradycardia and his ___ course was complicated by
junctional bradycardia, which resolved within 24 hours. On
arrival to the ICU his dopamine was weaned off and patient
remained stable.
REVIEW OF SYSTEMS:
(+) per HPI
Past Medical History:
Atrial Flutter s/p ablation ___
CAD s/p CABG ___
Moderate to severe MR
Moderate TR
CHF â grade 2 diastolic dysfunction with EF of 47%
Uncontrolled Type 2 DM
Chronic kidney disease Cr ___
Hyperlipidemia
Hypertension
GERD
Obesity
Social History:
___
Family History:
Father died age ___ from ___.
Mother died age ___ from MI.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
VS: 98.7, 51, 101/57, 18, 99% RA
Weight: 98.5 kg
Tele: bradycardic
GEN: elderly man sitting in bed, slow to answer questions but in
NAD. Alert and oriented x4.
HEENT: PERRL, EOMI, MMM without teeth, no lesions, sclera
anicteric
CV: heart sounds distant, bradycardic, regular, S1, S2 no S3, S4
or murmurs appreciated. JVP ___
LUNGS: CTAB
ABD: obese, distended, mild epigastric tenderness, normal BS
EXT: WWP, 1+ pitting edema bialterally
SKIN: no concerning rashes or lesions
NEURO: CN ___ grossly intact, strength ___ bilaterally.
DISCHARGE PHYSICAL EXAM:
VS: 98.7 120/77 75 18 95%RA
I/O: ___
GEN: elderly man sitting in bed, in NAD. Alert and oriented x4.
HEENT: PERRL, EOMI, MMM without teeth, no lesions, sclera
anicteric
CV: heart sounds distant, regular, S1, S2 no S3, S4 or murmurs
appreciated.
LUNGS: CTAB
ABD: obese, distended, mild epigastric tenderness, normal BS
EXT: WWP, 1+ pitting edema bialterally
SKIN: no concerning rashes or lesions
NEURO: CN ___ grossly intact, strength ___ bilaterally.
Pertinent Results:
ADMISSION / PERTINENT LABS:
___ 08:10PM BLOOD ___
___ Plt ___
___ 08:10PM BLOOD ___
___ Im ___
___
___ 08:10PM BLOOD ___ ___
___ 08:10PM BLOOD ___
___
___ 08:10PM BLOOD ___
___ 08:10PM BLOOD ___
___ 08:10PM BLOOD ___ 08:10PM BLOOD ___
___
___ 02:59AM BLOOD ___
___ 02:59AM BLOOD ___
___ IgM ___
___ 02:59AM BLOOD HCV ___
___ 08:23PM BLOOD ___
___ 12:17AM BLOOD ___
___ 08:46AM BLOOD ___
IMAGING / STUDIES:
EKG ___
Atrial fibrillation and a slow junctional rhythm with further
evolution of
anterolateral and inferior ischemic appearing ___ wave changes,
especially inferiorly with deepening of the T wave inversion and
new T wave inversion in leads III and aVF. Rule out myocardial
infarction. Followup and clinical correlation are suggested.
Intervals ___
Rate PR QRS QT QTc (___) QRS T
36 ___
CXR ___
FINDINGS:
Patient is status post median sternotomy and CABG. Moderate
enlargement of cardiac silhouette is re- demonstrated.
Mediastinal contour is unchanged. Diffuse atherosclerotic
calcifications of the aorta are noted. Hilar contours are
within normal limits. Pulmonary vasculature is not engorged.
Lungs are clear without focal consolidation. No large pleural
effusion or pneumothorax is detected, however the extreme lung
apices are obscured by the patient's chin and neck soft tissues
projecting over these regions. There are no acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
RUQ US ___
IMPRESSION:
1. Mild gallbladder wall thickening relates to underdistention.
No
gallstones. Not consistent with acute cholecystitis.
2. Coarsened and nodular hepatic echotexture without concerning
focal lesion.
3. Trace ascites. Patent portal vein. No splenomegaly.
ECHO (TTE) ___
The left atrium is elongated. The right atrium is moderately
dilated. Left ventricular wall thicknesses and cavity size are
normal. There is severe global left ventricular hypokinesis
(LVEF = ___ %). Overall left ventricular systolic function is
severely depressed. The right ventricular cavity is mildly
dilated The diameters of aorta at the sinus, ascending and arch
levels are normal. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate (___) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] The tricuspid valve
leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with severe global hypokinesis. Right ventricle is
dilated but function cannot be assessed. Moderate tricuspid
regurgitation. Mild to moderate mitral regurgitation.
ECG ___
Most likely atrial fibrillation with moderate ventricular
response. Compared to tracing #1 the patient is now in atrial
fibrillation. Otherwise, ___ wave abnormalities in the inferior
and anterolateral leads persist but appear less pronounced.
Clinical correlation is suggested.
Intervals ___
Rate PR QRS QT QTc (___) P QRS T
77 ___ 0 -57 144
CXR PA/LAT ___
IMPRESSION:
No previous images. There is enlargement of the cardiac
silhouette without vascular congestion, a discordance the raises
the possibility of
cardiomyopathy. ___ pacer via the left subclavian
approach has leads in the right atrium and apex of the right
ventricle. No evidence of post procedure pneumothorax.
There are small bilateral pleural effusions on the lateral view.
No evidence of acute focal
ECG ___
Sinus rhythm with ventricular bigeminy. Intraventricular
conduction delay.
Rate PR QRS QT QTc (___) P QRS T
80 ___ 435 61 -___ -179
ECG ___
Sinus rhythm with atrial ectopy. Intraventricular conduction
delay. Possible prior inferior myocardial infarction.
Rate PR QRS QT QTc (___) P QRS T
76 ___ -___
Brief Hospital Course:
Mr. ___ is a ___ year old man with a past medical history
of CAD s/p CABG ___, aflutter s/p ablation ___, sCHF, and
poorly controlled diabetes presented with cardiogenic shock
secondary to symptomatic junctional bradycardia now s/p
___ ICD.
# Bradycardia complicated by acute on chronic systolic heart
failure and cardiogenic shock
Patient presented with shortness of breath, nausea, and fatigue
and briefly required dopamine drip. Patient improved s/p ICD and
diuresis. He did develop drug rash towards the end of his stay
but had already completed 3 days of antibiotics
___.
#Patient had pacemaker associated tachycardia, which EP was able
to troubleshoot. PVARP increased and will continue to be managed
by EP
# Elevated LFTs
Most likely shock liver as liver enzymes were downtrending
during hospital stay.
# H/O ___:
Patient underwent ___ ablation on ___, with
___ course complicated by junctional bradycardia
which resolved within 24 hours. He was found to be in ___ with
RVR on ___ and started on amiodarone by his outpatient
cardiologist on ___. Patient discharged on warfarin and off
amiodarone. Continued metoprolol.
# Acute on Chronic Systolic heart failure: LVEF = ___ %.
Patient with known h/o CHF. Outpatient PO lasix recently
increased from 60 daily to 60/120 ALTERNATING. Restarted PO
lasix 60mg daily on discharge. Continued metoprolol.
# CAD s/p CABG ___. Continued atorvastatin, ASA, Ezetimibe and
lisinopril on discharge.
# T2DM
Continued home lantus.
# ___ on CKD
Patient with known CKD baseline ___. Presented with ___ to
3.3 most likely from combination of ATN (muddy brown casts) and
cardiorenal syndrome. Lisinopril held initially, and restarted
on discharge as ___ resolved.
# Elevated lactate: Resolved
Most likely was secondary to poor perfusion ___ bradycardia
TRANSITIONAL ISSUES
===================
-Diuresis: Discharged at 60mg PO Lasix
-sCHF: Lisinopril 10 mg daily, Metoprolol XL 150mg daily.
-Patient has device clinic follow up but will need to be set up
with a new ___ outpatient cardiologist
-Patient wishes to consolidate care, so switching to ___
Geriatrician for PCP, but should have his old PCP manage his
___ until he establishes with new providers. Please fax
INRs to number below.
-Patient switched PCP to BI ___. Old PCP is
___.
Location: ___ PRIMARY CARE ___
Address: ___
Phone: ___
Fax: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 60 mg PO EVERY OTHER DAY
2. Ezetimibe 10 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Warfarin 5 mg PO 4X/WEEK (___)
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. Metoprolol Succinate XL 150 mg PO DAILY
8. Glargine 68 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
9. Furosemide 120 mg PO EVERY OTHER DAY
10. Amiodarone 200 mg PO BID
11. Lisinopril 10 mg PO DAILY
12. Warfarin 7.5 mg PO 3X/WEEK (___)
13. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Ezetimibe 10 mg PO DAILY
3. Ondansetron 4 mg PO Q8H:PRN nausea
4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
5. Metoprolol Succinate XL 150 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Glargine 68 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
8. Furosemide 60 mg PO DAILY
Your furosemide dose was recently increased. Go back to your
60mg daily dose
9. Aspirin 81 mg PO DAILY
10. Warfarin 5 mg PO 4X/WEEK (___)
11. Warfarin 7.5 mg PO 3X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Acute on Chronic Systolic Heart Failure
Cardiogenic Shock
Symptomatic Bradycardia s/p ___ ICD
Diabetes Mellitus Type II
Afib/Aflutter
___ on CKD
Lactic Acidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for a slow heart rate that
caused fluid to back up in your heart and lungs.
WHAT WAS DONE?
==============
- A pacemaker was placed
- You received medications to help remove the extra fluid
WHAT SHOULD I DO NEXT?
======================
- Take all medications as prescribed
- Attend all follow up appointments as scheduled
- Ensure your Coumadin levels are still followed up on. We have
scheduled you an appointment with a new PCP
- ___ yourself every morning, call MD if weight goes up more
than 3 lbs.
- Seek medical attention if you develop worsening chest pain,
shortness of breath, fevers, or palpitations.
Wishing you the best of health moving forward,
YOUR ___ TEAM
Followup Instructions:
___
|
10453982-DS-4 | 10,453,982 | 23,651,686 | DS | 4 | 2147-08-17 00:00:00 | 2147-08-17 12:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending: ___.
Chief Complaint:
left sided rib pain
Major Surgical or Invasive Procedure:
left chest tube placed
left chest tube removed ___
History of Present Illness:
___ year old female with h/o anemia, HTN, anxiety, and
osteoporosis
presents to the ED as a transfer from ___
with left rib fractures. The patient reported that she was
walking without her walker when she lost her balance and
fell onto her left side. She acutely began to endorse left
wrist pain, left arm pain, and left rib pain. Her OSH chest
x-ray showed 4 left sided rib fractures. Her left arm and
wrist x-ray showed no evidence of fracures or dislocations.
She denied head strike, head pain, LOC, neck pain, back
pain, chest pain, dyspnea, abdominal pain, N/V/D, fevers,
chills, and dysuria.
Past Medical History:
-osteoporosis
-HTN
-anxiety
-arthritis
Social History:
___
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAMINATION: upon admission
Temp: 98.0 HR: 98 BP: 142/59 Resp: 18 O(2)Sat: 99 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Neck is supple
Chest: Clear to auscultation, left chest wall tenderness no
crepitice
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender, Nondistended
Extr/Back: Left wrist pain with deformity and swelling,
Moves all extremities equally, NVI
Skin: No rash, Warm and dry
Neuro: Speech fluent, MAE
Psych: Normal mood, Normal mentation
Discharge Physical Exam:
VS: 98.1, 124/68, 77, 18, 93 Ra
Gen: A&O x3, sitting in chair in NARD
Pulm: LS ctab
CV: HRR
Abd: soft NT/ND
Ext: No edema
Skin: left CT site CDI covered in occlusive dsg
Pertinent Results:
___ 06:55AM BLOOD WBC-8.4 RBC-2.55* Hgb-7.4* Hct-24.5*
MCV-96 MCH-29.0 MCHC-30.2* RDW-18.4* RDWSD-61.1* Plt ___
___ 07:40AM BLOOD WBC-8.5 RBC-2.55* Hgb-7.8* Hct-24.5*
MCV-96 MCH-30.6 MCHC-31.8* RDW-18.1* RDWSD-61.6* Plt ___
___ 06:55AM BLOOD Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:50AM BLOOD Glucose-117* UreaN-27* Creat-0.5 Na-139
K-3.9 Cl-99 HCO3-26 AnGap-14
___ 07:40AM BLOOD Glucose-101* UreaN-26* Creat-0.5 Na-140
K-4.5 Cl-101 HCO3-26 AnGap-13
___ 02:10AM BLOOD Glucose-126* UreaN-21* Creat-0.6 Na-139
K-4.3 Cl-99 HCO3-26 AnGap-14
___ 07:50AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.3
___: CT c-spine:
1. There is 4 mm C3-4 anterolisthesis; while there are
degenerative changes that can account for this degree of
spondylolisthesis, if there is clinical concern for cervical
spine injury this level, MRI could be obtained for further
evaluation.
2. Minimal C5-6 retrolisthesis, likely degenerative. No evidence
of fracture or pre-vertebral fluid.
3. Severe multilevel cervical spine degenerative change, with
multilevel
moderate spinal canal and severe neural foraminal narrowing, as
above.
___: ct head:
1. No acute intracranial process. No hemorrhage or fracture.
2. Chronic findings include global involutional change mild to
moderate
changes of chronic white matter micro-angiopathy, and vascular
calcifications.
___: cxr:
New opacity within the right lower lung zone may reflect a
pulmonary contusion given the history of trauma or pneumonia.
___: right wrist:
Osteoarthritis, most severe at the thumb carpometacarpal joint
and triscaphe joint. Chondrocalcinosis. No acute fracture or
dislocation.
___: cxr:
Suboptimal evaluation given low bilateral lung volumes however
there is a
persisting opacity in the right lower lung zone as well as a
left pleural
effusion.
___: CT chest:
. Moderate left pleural effusion with layering hyperdensity that
could
reflect a small amount of blood products in the setting of
recent trauma.
Anterior left fifth and sixth rib fractures appear the most
recent of the many
left-sided rib deformities.
2. Small right-sided non-hemorrhagic pleural effusion. No acute
rib fractures are seen on the right.
3. Near complete atelectasis of the left lower lobe.
4. Segmental atelectasis of the right lower lobe.
5. Multilevel chronic-appearing vertebral body height loss in
the thoracic
spine with vertebral augmentation changes at T9-T12.
6. 7 mm ground glass nodule at the right lung apex. 6 month CT
follow-up is recommended
___: CXR:
A left chest tube projects over the left lung base. There is
been interval decrease in size of the left pleural effusion
however small bilateral pleural effusions do persist with
subjacent atelectasis. There is no discrete pneumothorax
identified. Marked degenerative changes around both shoulders.
___: CXR:
Left chest tube is in place. Multiple left rib fractures are
re-demonstrated.
Left pleural effusion has decreased after placement of left
chest tube. Small right pleural effusion is noted. Bi-basal
areas of atelectasis are present.
No appreciable pneumothorax. No pulmonary edema.
___: CXR:
No pneumothorax post removal of the left chest tube. No
significant interval
change in appearance of the lungs when compared to prior.
___: CXR:
No evidence of pneumothorax.
No change in the left small pleural effusion and left lower lobe
atelectasis.
urine culture:
___ 2:17 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Brief Hospital Course:
___ year old female admitted to the hospital after a fall in
which she struck her left side. Upon admission, the patient
underwent imaging and was reported to have left sided ___ rib
fractures. Her pain was controlled with oral analgesia. During
her hospital stay she underwent serial chest x-rays. She
required one unit of packed red blood cells for a hematocrit of
20. Her hematocrit increased to 25 and she required no
additional blood products.
To further evaluate her pulmonary status, she underwent a cat
scan of the chest which showed a moderate left pleural effusion
with layering hyper-density. She was also noted to have a small
right-sided non-hemorrhagic pleural effusion. Her oxygen
saturations remained stable. Because of the extensive pleural
effusion a chest tube was placed on HD #7 into the left pleural
effusion which drained a large amount of sero-sanguinous fluid.
The chest tube was removed on HD #10. Follow-up x-rays have
showed no evidence of pneumothorax and no change in the left
small pleural effusion and left lower lobe atelectasis. During
her hospitalization, she completed 5 day course of ciprofloxacin
for a urinary tract infection.
The patient was evaluated by physical therapy in preparation for
discharge. She was discharged to a rehabilitation facility on
HD #12. Her vital signs were stable and she was afebrile. She
was tolerating a regular diet and voiding without difficulty.
Her hematocrit remained stable at 24.5 with a hemoglobin of 7.5.
Discharge instructions were reviewed. The Acute care clinic
was informed of her discharge and would inform the patient of
the date and time of her follow-up appointment. She will need a
chest x-ray prior to her visit. This information was reported
to the ___ clinic.
++++++++++++++++++++++++
of note: 7 mm ground glass nodule at the right lung apex. 6
month CT follow-up is
recommended.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 2.5 mg PO DAILY
2. LORazepam 0.5 mg PO BID
3. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Moderate
4. FoLIC Acid 1 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
2. Docusate Sodium 100 mg PO BID
3. Heparin 5000 UNIT SC BID
continue until patient ambulatory
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
hold for increased sedation, resp. rate <8
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 17.2 mg PO HS
8. amLODIPine 2.5 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. LORazepam 0.5 mg PO BID
11. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fall:
left ___ rib fractures
left hemothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after a fall resulting in left
sided fractured ribs and a collection of blood in your chest.
You had a chest tube placed for removal of the fluid. The chest
tube has been removed and your respiratory status has been
stable. You are being discharged with the following
instructions:
Your injury caused with left sided rib fractures which can
cause severe pain and subsequently cause you to take shallow
breaths because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Followup Instructions:
___
|
10454129-DS-14 | 10,454,129 | 28,957,213 | DS | 14 | 2194-05-15 00:00:00 | 2194-05-19 09:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / clindamycin / Coreg
Attending: ___
Chief Complaint:
Abdominal pain, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with a history of idiopathic chronic
pancreatitis, ___'s thyroiditis, diverticulitis s/p
colonic resection, s/p cholecystectomy, and asthma presents with
abdominal pain and fever.
Patient was just discharged yesterday from ___
___ pancreatitis with similar symptoms. Shortly after
arriving home she again developed fever to ___ and slight
worsening of her abdominal pain. She contacted her
gastroenterologist, Dr. ___ be on inpatient consults
this week), who recommended that she return for admission. She
has not had any fever today.
Imaging from ___:
___: CT abdomen - Acute pancreatitis with increase pancreatic
duct dilation.
___: ERCP - Cannulation of CBD. Intra/extra hepatic biliary
ductal dilation.
ED course:
Imaging: CXR - Small left pleural effusion.
Labs: Lipase 129, ALP 120, Hgb 9.7 (~13 on ___ at ___, but
~9.0 during ___ admission)
Meds: Morphine 4mg IV, unasyn 3g IV, ondansetron 4mg IV,
Dilaudid 1mg IV x 2, 1L NS
Past Medical History:
chronic pancreatitis
s/p celiac plexus block
HTN/HLD
Hashimotos thyroiditis
asthma
Diverticulitis s/p colonic resection
ovarian cyst
cholecystectomy
ongoing tobacco use (smoking)
Social History:
___
Family History:
Father w/colon cancer
No pancreatic disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.8, BP 116/60, P 64, RR 16, O2 98% RA
GEN: Well-appearing, sitting upright in bed, NAD
HEENT: EOMI, PERRL, MMM, OP clear, anicteric sclera
NECK: Supple, no LAD
PULM: Clear to auscultation bilaterally
CV: RRR, normal s1s2, no m/r/g, no JVD
ABD: Moderately tender to palpation in LUQ, otherwise
non-tender, non-distended, +BS, no hepatosplenomegaly
EXT: No c/c/e, 2+ distal pulses
NEURO: No focal deficits, A&Ox3
PSYCH: Appropriate mood and affect
SKIN: No rashes
On Discharge:
GEN: Thin appearing, sitting up, comfortable appearing
HEENT: EOMI, sclerae anicteric, MMM, OP clear
NECK: No LAD, no JVD
CARDIAC: RRR, no M/R/G
PULM: normal effort, no accessory muscle use, LCAB
GI: soft, mild tenderness in epigastrum/RUQ, ND, NABS
MSK: No visible joint effusions or deformities.
DERM: No visible rash. No jaundice.
NEURO: AAOx3. No facial droop, moving all extremities.
PSYCH: Full range of affect
EXTREMITIES: WWP, no edema
Pertinent Results:
ADMISSION LABS:
___ 04:15PM WBC-6.3 RBC-3.25* HGB-9.7*# HCT-30.2* MCV-93
MCH-29.8 MCHC-32.1 RDW-17.0* RDWSD-57.9*
___ 04:15PM NEUTS-72.7* LYMPHS-15.3* MONOS-7.6 EOS-3.2
BASOS-0.9 IM ___ AbsNeut-4.59 AbsLymp-0.97* AbsMono-0.48
AbsEos-0.20 AbsBaso-0.06
___ 04:15PM GLUCOSE-185* UREA N-7 CREAT-0.7 SODIUM-138
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-24 ANION GAP-15
___ 04:15PM ALT(SGPT)-10 AST(SGOT)-23 ALK PHOS-120* TOT
BILI-0.3
___ 04:46PM LACTATE-1.7
___ 04:15PM LIPASE-129*
___ 04:15PM ALBUMIN-3.5
IMAGING:
CXR (___):
Small left pleural effusion, perhaps slightly decreased in size
from the prior
study, with adjacent left lower lobe atelectasis.
MRCP (___):
1. MR findings consistent with chronic pancreatitis, stable in
appearance.
No mass lesion identified.
2. Interval increase in the dilation of the extrahepatic bile
duct.
3. Pneumobilia.
4. Stable left renal cyst and spinal hemangiomas.
5. New cycle area of enhancement in the left lower lung lobe
most likely presenting atelectasis.
6. Area of transient hepatic intensity difference in the right
lobe of liver.
** ___ ***
___: CT abdomen - Acute pancreatitis with increase pancreatic
duct dilation.
___: ERCP - Cannulation of CBD. Intra/extra hepatic biliary
ductal dilation.
___ CXR
Small left pleural effusion, perhaps slightly decreased in size
from the prior study, with adjacent left lower lobe atelectasis.
___ CT A/P
1. No evidence of intra-abdominal or intrapelvic abscess.
2. Interval decrease in peripancreatic stranding compared with
prior study
from ___. Unchanged main pancreatic ductal irregularity
with areas of
dilation and narrowing and scattered calculi, consistent with
sequelae of
chronic pancreatitis.
3. Pneumobilia is increased from prior exam and likely relates
to recent ERCP.
4. Unchanged chronic intra- and extrahepatic biliary ductal
dilation.
5. Mild splenomegaly is more pronounced than on the prior exam
from ___.
Brief Hospital Course:
___ year old female with a history of idiopathic chronic
pancreatitis, ___'s thyroiditis, diverticulitis s/p
colonic resection, s/p cholecystectomy, and asthma presents with
abdominal pain and fever.
# Fevers
# Klebsiella bacteremia: ___ had several days of fever prior
to admission. She spiked a fever to 101 during her hospital
stay. Blood cultures here notable for Klebsiella bacteremia.
Source unclear but presumed secondary to ERCP procedure at OSH
prior to her admission here. She underwent CT scan to evaluate
for evidence of intra-abdominal collection/abscess. CT scan was
without evidence of abscess. Klebsiella was pansensitive. Given
sulfa allergy, bactrim was avoided and she is discharged to
complete a 2 week course of cipro. Given concurrent zofran use,
QTc was checked and was 393. She will need repeat EKG for QTc
evaluation at her next scheduled PCP ___.
# Abdominal pain
# Chronic pancreatitis: Patient presented with acute on chronic
pancreatitis. No further intervention was pursued in house. She
met with her outpatient gastroenterologist this admission to
discuss potential nutritional options moving forward. The
patient elected to hold off on tube feeds or PPN and to await a
clinical trial to be available next month. She will follow up
with Dr. ___ month after discharge. Symptoms
ultimately resolved and she tolerated a regular diet with
minimal difficulty. She was continued on her home chronic pain
regimen.
# HTN
- Continued home lisinopril
# Asthma
- Continued home meds (Advair, Spiriva, Singulair)
# Hypothyroidism
- Continued home levothyroxine
# HLD
- Continued home atorvastatin, fenofibrate
# Anxiety
- On clonazepam and lamotrigine as outpatient, continued
in-house
Transitional:
- Patient to continue ciprofloxacin for two weeks through
___
- Patient has follow up with her PCP ___ ___ at which time
she should have an EKG for QTc monitoring
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
2. Spiriva Respimat (tiotropium bromide) 2.5 mcg/actuation
inhalation BID
3. Montelukast 10 mg PO QPM
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
5. Lisinopril 10 mg PO DAILY
6. Levothyroxine Sodium 137 mcg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Fenofibrate 134 mg PO QPM
9. Vitamin D ___ UNIT PO 1X/WEEK (MO)
10. ClonazePAM 0.25-0.5 mg PO QHS:PRN anxiety/insomnia
11. Omeprazole 20 mg PO BID
12. Ranitidine 150 mg PO QHS
13. Viokace (lipase-protease-amylase) 20,880-78,300- 78,300 unit
oral QAC
14. Fentanyl Patch 75 mcg/h TD Q72H
15. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN
BREAKTHROUGH PAIN
16. LamoTRIgine 250 mg PO BID
17. Ondansetron ODT 4 mg PO Q6H:PRN nausea
18. Senna 8.6 mg PO BID
19. Docusate Sodium 100 mg PO BID
20. Alive Womens Energy (multivit-calc-iron-FA-K-hb#244)
___ mg-mcg-mcg oral DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice daily
Disp #*23 Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
3. Alive Womens Energy (multivit-calc-iron-FA-K-hb#244)
___ mg-mcg-mcg oral DAILY
4. Atorvastatin 40 mg PO QPM
5. ClonazePAM 0.25-0.5 mg PO QHS:PRN anxiety/insomnia
6. Docusate Sodium 100 mg PO BID
7. Fenofibrate 134 mg PO QPM
8. Fentanyl Patch 75 mcg/h TD Q72H
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. LamoTRIgine 250 mg PO BID
11. Levothyroxine Sodium 137 mcg PO DAILY
12. Lisinopril 10 mg PO DAILY
13. Montelukast 10 mg PO QPM
14. Omeprazole 20 mg PO BID
15. Ondansetron ODT 4 mg PO Q6H:PRN nausea
16. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN
BREAKTHROUGH PAIN
17. Ranitidine 150 mg PO QHS
18. Senna 8.6 mg PO BID
19. Spiriva Respimat (tiotropium bromide) 2.5 mcg/actuation
inhalation BID
20. Viokace (lipase-protease-amylase) 20,880-78,300- 78,300
unit oral QAC
21. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute on chronic pancreatitis
Klebsiella bacteremia
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 fevers and abdominal
pain. The abdominal pain is likely related to your chronic
pancreatitis. You met with your outpatient gastroenterologist to
discuss alternative options like TPN or tube feeding. You
decided that you will await the camostat trial. You were able to
resume a regular diet and tolerated it quite well.
You had a fever while you were admitted. Your blood cultures are
growing a gram negative bacteria called "Klebsiella." This is
bacteria that often originates in the GI tract. You had a CT
scan to determine if you have an abscess in your abdomen and it
did NOT reveal the presence of an abscess. This is good news.
Please scheduled a follow up with Dr. ___ in one month.
Please follow up with your PCP as scheduled. You will continue
to take cipro through ___ but will need to have an EKG at
your next PCP ___.
Followup Instructions:
___
|
10454245-DS-8 | 10,454,245 | 28,792,921 | DS | 8 | 2181-06-25 00:00:00 | 2181-06-25 13:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ ___ year old right handed man with
multifactorial gait disorder who presents today with a fall.
He
has been seen by multiple neurologists in the past for his gait
disorder and continues to live alone with a life line. He had
significant bleeds back in ___ and in ___
resulting in a stay at ___. Of note these falls are
often in the morning and he always falls backwards. He again
fell yesterday and went to ___ ED and had a negative head CT.
Today he fell again while getting clothes off of his recliner
and
fell backward striking his head. He again went to ___ and was
found to have a right basal ganglia hemorrhage/carona radiata
and
a left parafalcine subdural. He has a history of labile blood
pressures and his BP was 187/72 at that time. He states that
his
falls his legs just don't do what they are supposed to. He
states he has been feeling very fatigued lately and depressed.
He denies snoring at night, but lives alone so he isn't sure.
Wakes up multiple times per evening to use the restroom with his
prostate difficulties.
Of note PRIMARY CARE PHYSICIAN: Dr. ___,
___.
CARDIOLOGIST: Dr. ___, ___.
NEUROLOGIST: Dr. ___, ___.
On neuro ROS, the pt has a very mild headache, no loss of
vision,
blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
.
On general review of systems, the pt 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. History of several falls, likely secondary to multifactorial
gait disorder.
2. History of intracranial hemorrhage ___ years ago improved
without surgery.
3. Chronic small vessel ischemic changes of the brain and
amyloid
angiopathy.
4. Coronary artery disease status post CABG in ___.
5. Status post right hernia repair in ___.
6. Lower GI bleed secondary to diverticulosis in ___.
7. Hypertension.
8. Hyperlipidemia.
9. Possible prior TIAs.
10. Possible ITP, baseline platelets around 100,000.
11. Status post cataract surgeries.
12. Benign prostatic hyperplasia."
Social History:
___
Family History:
Sister with strokes and passed away at ___ years of age
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals: T:98.4 P:80 R:18 BP:172/84 SaO2:97%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: in ___ J collar
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
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, but does have some difficulty through the exam and
beint tangential. 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. Calculation was intact (answers seven quarters in
$1.75)
.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation however
inattentive and difficult to formally assess
III, IV, VI: EOMI without end gaze nystagmus. Normal saccades.
No limitation of upgaze
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, mild increase in tone throughout but
difficulty relaxing in lower extremities with a paratonia. No
pronator drift bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 4+ 5 4+ ___ 5 5 5
R 5 ___ ___ 5 5 5 5 5
.
-Sensory: gradient to pinprick and vibration to mid shin.
propioception intact at toes but given difficulty relaxing tough
to accurately assess. No extinction to DSS.
.
-DTRs: difficult to assess given his inability to relax.
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
.
-Coordination: No dysmetria on FNF or HKS bilaterally.
.
-Gait: did not assess given his lack his c spine has yet to be
cleared.
Neurological Exam at Discharge: Increased tone in right greater
than left lower extremity. Mild b/l hip flexion and right knee
flexion weakness (4+/5-). Absent ankle jerks b/l. Extensor
plantar response b/l. Decreased vibration at both ankles.
Impaired proprioception in R-toe. Arises using both hands and
tends to retropulse easily on standing
Pertinent Results:
WBC 5.8 Hb 13.9 Hct 41.7 Plt 133
Na 141 K 3.9 Cl 103 CO2 30 BUN 16 Cr 0.8 Glu 89
DIAGNOSTIC STUDIES:
CT C-SPINE:
1. No acute fracture or subluxation.
2. Moderate degenerative changes throughout the cervical spine.
3. Heterogeneously nodular thyroid as previously seen. Can be
assessed with thyroid ultrasound in indicated.
CT HEAD:
1. Small left parafalcine subdural and right basal
ganglia/corona radiata intraparenchymal hemorrhage are stable
since yesterday.
2. Small occipital subdural hematoma is also stable. No
associated fracture.
MRI C-SPINE:
1. No acute cervical malalignment.
2. Moderate-to-severe multilevel cervical spondylosis. C5-6
moderate-to-severe spinal canal stenosis. Multilevel
moderate-to-severe neural foraminal narrowing as described
above.
3. Mild indentation of the cord from disc bulges/protrusions,
but no evidence of cord compression or cord signal
abnormalities.
Brief Hospital Course:
Mr. ___ is an ___ y/o man with multifactorial gait
disorder and amyloid angiopathy who presents after a fall. He
was found to have a right corona radiata hemorrhage, which is
likely due to his amyloid angiopathy. He was also found to have
a small left parafalcine subdural hematoma. which is likely
traumatic in nature. He had repeat head imaging in 24 hours,
which showed the hemorrhages were both stable. Given his history
of amyloid angiopathy and new hemorrhage, his daily Aspirin was
stopped.
Regarding his multifactorial gait disorder, this is likely due
to a combination of a frontal gait disorder, neuropathy and
cervical spondylosis with myelopathy. He had an MRI of his
C-spine, which showed moderate-to-severe multilevel cervical
spondylosis and neural foraminal narrowing. He was given a soft
cervical collar to wear for this. He was seen by ___, who
recommended that he needed rehab for his gait disorder.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes (pneumoboots, no Hep SQ
given hemorrhage) - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
Medications on Admission:
1. Finasteride 5 mg oral once a day
2. Flomax 0.4 mg once a day.
3. Lopressor 25 mg oral twice daily.
4. Simvastatin 20 mg oral once a day.
5. Aspirin 81 mg once a day.6
6. Lasix 20 mg daily
7. Multivitamin 1 tablet once daily.
8. Vitamin D 1 tablet once daily.
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Vitamin D 400 UNIT PO DAILY
7. Tamsulosin 0.4 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right intraparenchymal hemorrhage (likely due to amyloid
angiopathy)
left parafalcine subdural hemorrhage (likely traumatic)
cervical spondylosis with myelopathy
mutlifactorial gait disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neurological Exam at Discharge: Increased tone in right greater
than left lower extremity. Mild b/l hip flexion and right knee
flexion weakness (4+/5-). Absent ankle jerks b/l. Extensor
plantar response b/l. Decreased vibration at both ankles.
Impaired proprioception in R-toe. Arises using both hands and
tends to retropulse easily on standing
Discharge Instructions:
You were admitted to the hospital after a fall and was found
to have a small hemorrhage (bleed) on the right side of your
brain as well as a small subdural hemorrhage on the left side.
The right sided bleed is likely due to your known diagnosis of
amyloid angiopathy, which predisposes you to bleeds. The left
sided bleed is likely traumatic from your fall. Given your
history of amyloid angiopathy and your new hemorrhage, you
should stop taking Aspirin daily.
With regards to your walking difficulty, this is likely
multifactorial in nature, but a component coming from disc
disease in your neck. You should wear a soft cervical collar for
this.
Followup Instructions:
___
|
10454455-DS-18 | 10,454,455 | 21,265,329 | DS | 18 | 2133-12-05 00:00:00 | 2133-12-11 08:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Biaxin /
Levaquin / Augmentin / Zetonna
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Cardiac cath ___
Bronchoscopy with valve placement ___
Chest Tube Placement ___
Chest Tube Replacement ___
Bronchoscopy with valve placement ___
Chest Tube Removal ___
History of Present Illness:
___ female with a history of COPD (not on home O2),
hypertension, diabetes, who is here for evaluation of acute
onset shortness of breath.
History obtained from review of OMR / ED notes - limited
participation ___ interview due to nausea and pain. Patient
reports she was ___ her usual state of health, without fevers,
chills, increased cough, dyspnea, or chest pain. Upon returning
home from the store, she reports sudden onset shortness of
breath, mild chest discomfort approximately 20 minutes prior.
___ the ED, initial vitals: 138 22 100% RA
- She was found to have a moderate sized right pneumothorax,
which was decompressed with pigtail catheter, resulting ___
symptomatic relief. Chest x-ray revealed persistent apical
pneumothorax
- ED course also notable for rate-related infero-lateral ST
elevations on EKG. Troponin negative x1. ST changes resolved
with improvement ___ tachycardia.
- She was given azithromycin for COPD exacerbation but no
steroids given reported allergy to steroids.
- She was also given IV morphine 2mg x2, lorazepam 0.25 mg,
ondansetron 4mg x2.
- Immediately prior to transfer to the ICU, she triggered for
hypotension to ___, associated with nausea, dizziness, which
improved to the ___ a few minutes after starting IV fluid bolus
On transfer, vitals were: ___ 18 97% Nasal Cannula
On arrival to the MICU, patient reports nausea and pain ___ the
back of her chest especially around the insertion of her chest
tube.
Past Medical History:
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
DEPRESSION WITH ANXIETY
HYPERTENSION
HYPERLIPIDEMIA
DIABETES TYPE II
Social History:
___
Family History:
asthma, seasonal allergies, chronic bronchitis
Physical Exam:
ADMISSION EXAM:
Vitals- T: 97.9 BP: ___ P: 99 R: 18 O2: 95% 2L
GENERAL: Alert, uncomfortable appearing, somewhat agitated
HEENT: Sclera anicteric, MMM
NECK: supple, JVP non-elevated
LUNGS: Decreased breath sounds R compared to left, no wheezes or
rales
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No cyanosis or pallor
NEURO: Moving all 4 extremities symmetrically, appropriate
mentation
DISCHARGE EXAM:
Vitals- Afebrile, vital signs stable, satting high ___ on room
air
GENERAL: Alert, oriented, NAD
HEENT: Sclera anicteric, MMM
NECK: supple, JVP non-elevated
LUNGS: CTAB
CV: RRR, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, NT, ND
EXT: Warm, well perfused, 2+ pulses, no edema. Compression
stockings ___ place
SKIN: No cyanosis or pallor
NEURO: CN ___ intact, moving all extremities
Pertinent Results:
ADMISSION LABS
-----------------
___ 04:40PM BLOOD WBC-8.1 RBC-4.38 Hgb-14.0 Hct-41.3 MCV-94
MCH-31.9 MCHC-33.8 RDW-13.5 Plt ___
___ 04:40PM BLOOD ___ PTT-27.1 ___
___ 04:40PM BLOOD Glucose-328* UreaN-24* Creat-0.6 Na-129*
K-3.7 Cl-90* HCO3-25 AnGap-18
CARDIAC ENZYMES
------------------
___ 02:32AM BLOOD CK(CPK)-145
___ 04:40PM BLOOD proBNP-116
___ 04:40PM BLOOD cTropnT-<0.01
___ 02:32AM BLOOD CK-MB-15* MB Indx-10.3* cTropnT-0.72*
___ 07:58AM BLOOD CK-MB-15* MB Indx-9.9* cTropnT-0.64*
proBNP-2687*
___ 02:00PM BLOOD cTropnT-0.57*
___ 02:32AM BLOOD Calcium-8.4 Phos-4.1 Mg-1.6
PERTINENT LABS
-------------------
___ 07:40AM BLOOD %HbA1c-5.8 eAG-120
___ 07:58AM BLOOD TSH-2.4
___ 07:07AM URINE Color-Yellow Appear-Hazy Sp ___
___ 07:07AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-LG
___ 07:07AM URINE RBC-2 WBC->182* Bacteri-MANY Yeast-NONE
Epi-1 TransE-1
___ 07:07AM URINE CastHy-27*
___ 07:07AM URINE AmorphX-FEW
___ 07:07AM URINE WBC Clm-OCC Mucous-MANY
DISCHARGE LABS
-------------------
___ 07:30AM BLOOD WBC-5.6 RBC-3.63* Hgb-11.7* Hct-34.2*
MCV-94 MCH-32.2* MCHC-34.2 RDW-13.5 Plt ___
___ 06:15AM BLOOD Glucose-91 UreaN-8 Creat-0.5 Na-133 K-4.6
Cl-96 HCO3-30 AnGap-12
___ 06:15AM BLOOD Calcium-9.5 Phos-4.5 Mg-1.6
IMAGING
-------------------
___ CXR
A moderate size right pneumothorax is demonstrated with mild
atelectasis of the right lung. There is no substantial shift of
midline structures to the left. Cardiac silhouette size is
normal. Mediastinal and hilar contours are unremarkable. Lungs
are hyperinflated, unchanged. No large pleural effusion is
noted, though the left costophrenic angle is excluded from the
field of view. No acute osseous abnormality is seen.
Atherosclerotic calcifications are again noted ___ the regions of
both subclavian arteries.
IMPRESSION: Moderate size right pneumothorax.
___ CXR
Interval placement of a right-sided pigtail catheter.
Right-sided pneumothorax is now small.
___ ECHO
Limited views. The left atrium is normal ___ size. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. There is probably moderate regional left ventricular
systolic dysfunction with distal LV and apical akinesis . The
anterior wall, ___ and lateral wall appear hypokinetic
to akinetic ___ some views (limited). No masses or thrombi are
seen ___ the left ventricle. There is no ventricular septal
defect. with focal hypokinesis of the apical free wall. There is
no aortic valve stenosis. The mitral valve leaflets are mildly
thickened. Mild to moderate (___) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Regional LV systolic dysfunction suggestive of
CAD/MI.
___ CXR
A right apical pneumothorax is small and unchanged. Pigtail
catheter has been repositioned. There is no change ___ bibasal
opacities ___ cardiomediastinal silhouette.
___ CXR
IMPRESSION:
Right lower lobe is still Collapsed, and there has been a slight
increase ___ small right pleural effusion. Moderate right
pneumothorax is substantially smaller than at 17:09. Right
pleural pigtail drainage catheter essentially unchanged ___
position. Mediastinum is midline and right diaphragm position
is physiologic. Left lung is clear. Heart size is normal.
Subcutaneous emphysema ___ the right chest wall and neck is
unchanged.
___ CT CHEST wo/ con:
1. Interval increase ___ size of right pneumothorax with
unchanged position of
right pleural catheter, and improvement of subcutaneous gas ___
the right chest
wall. Pigtail catheter side holes are within the pleural space.
2. Mucus plugging of right middle and lower lobe bronchi,
resulting ___
complete right middle lobe collapse.
3. Bilateral pleural effusions have increased ___ volume, still
small.
4. Calcified right adrenal mass measuring at least 7.3 cm and
multiple
hyperdense bilateral renal lesions are not well evaluated on
this noncontrast
CT. CT or MRI is recommended for further evaluation of these
lesions.
CXR ___: As compared to ___ radiograph from 2 hr
earlier, a large right pneumothorax has substantially decreased
___ size, with residual moderate pneumothorax remaining, with
right pigtail pleural catheter ___ place. Along with partial
re-expansion of the right lung, atelectasis ___ the right mid and
lower lung have partially improved. Within the left lung, a
small left apical pneumothorax is again demonstrated, along with
improving left basilar atelectasis. No other relevant changes
since recent study.
CT Chest wo/con ___:
1. Interval decrease ___ size of a right pneumothorax with a
right pigtail
catheter seen ___ place.
2. Extensive subcutaneous gas involving the right chest wall is
increased from the prior examination.
3. Right middle lobe and right upper lobe bronchial pulmonary
valves have been placed. There is partial, minimal aeration of
the right middle lobe however it is mostly still collapsed. Near
complete collapse of the right upper lobe
is new from the prior examination.
4. Minimal bibasilar atelectasis and trace bilateral pleural
effusions.
5. Large calcified right adrenal mass and multiple hyperdense
bilateral renal lesions are stable.
CXR ___: As compared to the previous image, the right chest
tube is ___ unchanged position. The size of the pre-existing
right pneumothorax has substantially decreased. The right lung
is substantially better expanded than on the previous image.
Decrease ___ extent of the soft tissue air collection on the
right. Unchanged appearance of the left lung and of the cardiac
silhouette.
CXR ___: As compared to the previous image, the right chest
tube and the right soft tissue air collection is unchanged.
Better visualized than on the previous radiograph are small
apical air-fluid levels and a small apical pneumothorax. The
right endobronchial parts are unchanged. No change ___
appearance of the cardiac silhouette and of the left lung.
CXR ___: As compared to the previous radiograph, the right
chest tube is ___ unchanged position. Unchanged right lateral air
collections ___ the soft tissues. The right valve 's are also
unchanged. The extent of the known small apical fluid or
pneumothorax is constant. No evidence of tension. No acute
abnormalities ___ the left hemi thorax.
CXR ___: As compared to the prior study from earlier today, a
small to moderate right apical hydro pneumothorax has decreased
___ size. Subcutaneous emphysema ___ the adjacent right lateral
chest wall is minimally increased. No other relevant changes
since the recent exam.
Micro:
Blood cx ___: negative
___ 12:30 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
>100,000 ORGANISMS/ML. Commensal Respiratory Flora.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Time Taken Not Noted ___ Date/Time: ___ 2:29 pm
BRONCHOALVEOLAR LAVAGE RIGHT LWER LOB.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
RESPIRATORY CULTURE (Final ___:
>100,000 ORGANISMS/ML. Commensal Respiratory Flora.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
TEST CANCELLED, PATIENT CREDITED.
This is a low yield procedure based on our ___
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
Time Taken Not Noted ___ Date/Time: ___ 5:06 pm
BRONCHIAL BRUSH Site: MIDDLE LOBE RT MIDDLE LOBE.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
100 CFU/ML Commensal Respiratory Flora.
STAPH AUREUS COAG +. 100 CFU/ML.
SENSITIVITIES PERFORMED ON REQUEST..
Isolates are considered potential pathogens ___ amounts
>1000
cfu/ml.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
TEST CANCELLED, PATIENT CREDITED.
This is a low yield procedure based on our ___
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
___ 7:07 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ =>32 R <=2 S
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
VANCOMYCIN------------ <=0.5 S
Pathology:
Lung, right middle lobe bronchus, transbronchial biopsy ___:
- Fragments of alveolated lung parenchyma and airway tissue with
mild acute and chronic
inflammation.
- No malignancy or granulomatous inflammation identified;
multiple levels examined.
Brief Hospital Course:
___ female with a history of COPD (not on home O2),
hypertension, diabetes, sCHF (EF=35%), atrial fibrillation with
RVR, who presents with worsening shortness of breath ___
decompensated sCHF which later became stable through medical
management. New apical akinesis seen on echo concerning for
___'s cariomyopathy. Patient also with pneuomothorax and
persistent air leak managed by interventional pulm.
ACTIVE ISSUES
------------------
# Pneumothorax: Patient presented with a moderate right
pneumothorax which was thought to be due to a ruptured
emphysematous bleb. A right-sided chest tube was placed ___ the
ED with improvement ___ pneumothorax. However, patient had a
persistent air leak and subcutaneous emphysema prompting IP
consult. They performed a bronchoscopy ___ and placed a valve
that did not resolve the air leak. CT chest showed persistence
of the leak and more valves were placed ___ however ultimately
the entire RUL was sealed with surgicell to prevent further
leakage. Chest tube was changed to water seal ___, capped
___, removed ___. Vital signs stable, satting well on room
air, deemed safe for discharge home with IP follow-up within 1
week. Given course of PNA prophylaxis and cough suppresant
maintenance therapy.
# Atrial Fibrillation: Patient developed atrial fibrillation
with rate-related ST elevations and troponin elevation. She was
started on aspirin, heparin gtt, and statin. She was also
started on metoprolol and, later, esmolol gtt and digoxin. She
also developed hypotension. On ___, TEE with cardioversion
was recommended, which patient refused due to not wanting a tube
___ her throat. She quickly reverted back to normal sinus rhythm
and has remained ___ NSR throughout remainder of stay. However,
given brief run of A Fib and apical akinesis, patient should be
on anticoagulation for 1 month and then have a repeat ECHO.
Maintained on heparin gtt throughout course of IP procedures,
eventually transitioned to rivaroxaban prior to discharge. To be
taken for 1 month and reassessed at f/u cardiology appt.
# New Apical Akinesis seen on ECHO: Concerning for ischemia vs.
Takotsubo's cardiomyopathy. Associated with troponin elevation
to 0.72. Started on ASA, heparin gtt, statin. Cardiac
catheterization showed no CAD. Was initially briefly diuresed
but then quickly became euvolemic and no longer required
diuretics. Now on metoprolol 100mg XL and lisinopril 2.5mg
daily. Should have follow-up ECHO ___ 1 month and cardiology
follow-up appointment as well.
# Acute systolic heart failure: ___ what is believed to be
Takatsuobos. Started on ACEi and metoprolol XL. Maintained
euvolemia without daily diuresis.
#Utrinary Tract Infection
Started on nitrofurantoin ___ to complete 7 day course, later
changed to ceftriaxone and finished ___lso developed
urinary retention that improved with resolution of UTI.
CHRONIC ISSUES
------------------
# COPD: No signs/symptoms of exacerbation. Received a dose of
azithromycin ___ the ED which was stopped on admission.
- Patient reports taking Spiriva and not Dulera, but last pulm
note states she should be on Dulera. Spiriva continued ___ house
as dulera not formulary
- Weaned down to RA prior to discharge. ___'s ___ show FEV1 41%
predicted, FEV1/FVC ratio 74% predicted, actual value 56.
switched to and maintained on spiriva with ipratroprium nebs
prn.
# Hypertension: Amlodipine and HCTZ held ___ setting of
hypotension and hyponatremia.
# Diabetes mellitus: Received sliding scale insulin however
fingersticks were normal and patient stated she doesn't require
insulin at home so fingersticks held
# Anxiety: treated with scheduled and prn ativan. symptoms
improved as medical issues resolved.
TRANSITIONAL ISSUES
-needs repeat echo ___ 1 month
-needs rivaroxaban anti-coagulation for 1 month on discharge,
and cards will decide after 1 month.
-pt sent home with ipratroprium nebs prn sob per her request as
albuterol and/or steroids make her anxious
-continue pneumonia prophylaxis with cefpodoxime for 10 days.
Day 1: ___. Stop day ___
-f/u adrenal mass seen on CT - based on size >5cm and features
discuss surgical resection vs hormonal eval vs serial
imaging/monitoring. Per radiology report, differential
considerations of adrenal mass include benign and malignant
considerations, including old hemorrhage, cystic/hemorrhagic
adenoma, as well as adrenal cortical carcinoma. Multiple
hyperdense lesions within the left kidney were also noted,
incompletely characterized on the current exam. Further
evaluation with an adrenal/renal mass protocol CT is
recommended.
-outpatient urinary retention work-up if returns
-prescription provided for boost supplements to help nutritional
intake, f/u further PO intake and weight to ensure good PO
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 12.5 mg PO DAILY
2. Ipratropium-Albuterol Neb 1 NEB NEB Q12H:PRN shortness of
breath
3. Lorazepam 0.5 mg PO BID:PRN anxiety
4. Tiotropium Bromide 1 CAP IH DAILY
5. Vitamin D 50,000 UNIT PO 1X/MONTH
6. Doxycycline Hyclate 100 mg PO DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU BID nasal polyps
8. azelastine 2 sprays nasal BID
9. Diltiazem Extended-Release 180 mg PO DAILY
Discharge Medications:
1. Boost (food supplement, lactose-free) 1 bottle oral BID
RX *food supplement, lactose-free [Boost High Protein] 1 bottle
by mouth twice a day Disp #*7110 Milliliter Milliliter
Refills:*0
2. Ipratropium Bromide Neb 1 NEB IH Q4H:PRN SOB, wheeze
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 puff IH Q4H: PRN
SOB Disp #*1 Bottle Refills:*0
3. azelastine 2 sprays nasal BID
4. Fluticasone Propionate NASAL 2 SPRY NU BID nasal polyps
5. Vitamin D 50,000 UNIT PO 1X/MONTH
6. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
7. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*11 Tablet Refills:*0
9. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Guaifenesin-CODEINE Phosphate 5 mL PO Q6H
RX *codeine-guaifenesin 100 mg-10 mg/5 mL 5 mL by mouth every
six (6) hours Refills:*0
11. Tiotropium Bromide 1 CAP IH DAILY
12. Lorazepam 0.5 mg PO BID:PRN anxiety
13. Rivaroxaban 20 mg PO DINNER
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
14. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Systolic congestive heart failure
___'s Cardiomyopathy
Pneumothorax
Right lung air leak
Secondary Diagnoses:
Chronic Obstructive Pulmonary Disease
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted for fluid overload caused by uncontrolled
heart failure. This improved with diuresis, however you were
also found to have overall worsened cardiac function which
required medical management. After being stabilized from a
cardiac standpoint, you were transferred from the cardiac ICU to
the general medicine floor.
During your stay you were also found to have an air leak ___ your
right lung believed to be caused by a ruptured bleb due to COPD.
This was managed by the interventional pulmonology team who
placed multiple valves ___ your right lung to stop the leak. You
had a chest tube ___ place for many days that was eventually
removed. You will be contacted by the pulmonology team about a
follow-up appointment to be made within the week.
You were also noted to be retaining urine during your stay,
which required regular straight catheterizations and later foley
catheter placement. This was later removed and you urinated well
on your own.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Wishing you well,
Your ___ Medicine Team
Followup Instructions:
___
|
10454455-DS-20 | 10,454,455 | 24,797,722 | DS | 20 | 2135-07-24 00:00:00 | 2135-07-24 14:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Biaxin /
Levaquin / Augmentin / Zetonna / Xopenex / nitrofurantoin
macrocrystal
Attending: ___.
Chief Complaint:
s/p mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___, PMH severe COPD (not on home O2), HTN, Afib (on apixiban)
who presents after mechanical fall (tripped on rug) complaining
of right shoulder and hip pain. The patient was pan scanned in
the ER which is essentially negative besides Right Humerus and
Right Hip fractures. She had a baseline HR of 90-100s in the ER
which has since crept up to 120s and her SBP has gone down to
___ from 100s. She was also found to have a Hct drop from 37 to
30. FAST in ED and pan-scan was negative for bleeding. She has
two marked, stable hematomas at the hip and shoulder.
Past Medical History:
PMH
- CV: AF, HTN, HL
- Pulm: COPD (severe),
- Endo: Osteoporosis, T2DM
- Psych: depression, anxiety
PSH
R heart catheterization with coronary angiography ___
Bronchoscopy with valve placement ___
Chest Tube Placement ___
Chest Tube Replacement ___
Bronchoscopy with valve placement ___
Chest Tube Removal ___
Social History:
___
Family History:
asthma, seasonal allergies, chronic bronchitis
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS HR 105 BP 94/68 RR 16 SpO2 100%
General: Frail appearing, elderly female
HEENT: Pupils 2mm, symmetric, mucous membranes moist
Neck: Trachea midline, supple
CV: Irregularly irregular; extremities non-cyanotic
Lungs: Breath sounds faint; lungs clear
Abdomen: Softly distended, non-tender
GU: Deferred
Ext: DPs/radial pulses palpable, no pedal edema
Neuro: Motor/sensation grossly intact throughout
Skin: Stable ecchymoses over shoulder/hip fractures; hematoma
margins from ___ AM marked in ink
Discharge Physical Exam:
VS: 98.5, 121/87, 92, 18, 93%ra
Gen: A&O x3
HEENT: WNL
Neck: Trachea midline, supple
CV: Irregularly irregular
Lungs: Breath sounds faint; lungs clear
Abdomen: Nondistended, non-tender
GU: Foley
Ext: Resolving hematoma from right axillary to wrist with
extension into flank. Ace bandage in place for swelling. Left
forearm with bruising from PIV.
Neuro: no deficits
Pertinent Results:
___ 05:10AM BLOOD WBC-9.1 RBC-2.37* Hgb-7.6* Hct-22.8*
MCV-96 MCH-32.1* MCHC-33.3 RDW-14.2 RDWSD-49.1* Plt ___
___ 05:35AM BLOOD WBC-9.7 RBC-2.47* Hgb-7.8* Hct-23.0*
MCV-93 MCH-31.6 MCHC-33.9 RDW-14.5 RDWSD-49.1* Plt ___
___ 07:40AM BLOOD WBC-9.9 RBC-2.67* Hgb-8.3* Hct-25.6*
MCV-96 MCH-31.1 MCHC-32.4 RDW-15.5 RDWSD-54.2* Plt ___
___ 03:00PM BLOOD WBC-8.9 RBC-2.76*# Hgb-8.6*# Hct-26.6*#
MCV-96 MCH-31.2 MCHC-32.3 RDW-16.2* RDWSD-57.0* Plt ___
___ 01:32AM BLOOD WBC-7.8 RBC-1.91*# Hgb-6.1*# Hct-19.1*#
MCV-100* MCH-31.9 MCHC-31.9* RDW-13.3 RDWSD-48.3* Plt ___
___ 11:55AM BLOOD WBC-9.9 RBC-2.62* Hgb-8.4* Hct-27.5*
MCV-105* MCH-32.1* MCHC-30.5* RDW-13.3 RDWSD-51.1* Plt ___
___ 03:16AM BLOOD WBC-13.6* RBC-2.82* Hgb-8.9* Hct-28.2*
MCV-100* MCH-31.6 MCHC-31.6* RDW-13.0 RDWSD-47.9* Plt ___
___ 01:30AM BLOOD WBC-16.4* RBC-3.11* Hgb-9.9* Hct-30.2*
MCV-97 MCH-31.8 MCHC-32.8 RDW-13.2 RDWSD-47.0* Plt ___
IMAGING:
___ CT Chest:
Nondisplaced right greater trochanter fracture. Partially imaged
right humerus fractures are better delineated on the dedicated
shoulder radiographs.
___ Right hip plain film:
Suspected fracture through the right greater trochanter.
___ Right shoulder plain film:
Comminuted impacted fracture of the surgical and potentially
anatomic neck of the humerus.
___ CT C-spine:
No acute fracture or traumatic malalignment. Severe emphysema.
___ CT Head:
No acute intracranial process.
___ CT Torso:
1. Nondisplaced right greater trochanter fracture.
2. Partially imaged right humerus fracture is better delineated
on the dedicated shoulder radiographs.
3. Heterogeneous partially calcified 8.6 cm right adrenal lesion
was partially seen on multiple chest CTs dating back to ___ and
may reflect prior hemorrhage. Recommend further evaluation with
MRI.
4. Renal cysts of intermediate density, possibly hemorrhagic or
proteinaceous cyst. These can be evaluated on the adrenal MRI.
___ TTE:
Hyperdynamic left ventricle (EF 80%). 3+ tricuspid
regurgitation. Pulmonary artery pressure is increased. IVC
mass/thrombus.
___ CTA Chest:
1. There is no evidence of pulmonary embolism.
2. There is no CT evidence of inferior vena cava thrombosis.
3. There is a new solid 6 mm middle lobe spiculated nodule with
a smaller adjacent nodule, which in combination with a prominent
right hilar lymph node raises suspicion for malignancy. At this
point, a follow-up PET scan is recommended to better
characterize this lesion.
4. 8 x 6.5 cm heterogeneously dense right adrenal mass does have
mass effect on the surrounding tissue including the liver and
the hepatic portion of the IVC.
5. Hyperattenuating 1.2 cm left upper pole lesion does not
appear to enhance with contrast, and can be considered a Bosniak
II renal cyst.
6. Likely chronic posterior right ninth and tenth rib fractures
___ Bilateral LENIs:
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
Brief Hospital Course:
Ms. ___ is a ___ yo F admitted to the Acute Care Trauma
Surgery service on ___ after a fall. She has a past medical
history significant for afib on apixaban. She xray and CT
imaging that revealed a nondisplaced right greater trochanter
fracture, a right humerus fracture, and a right shoulder and
right flank hematoma. Orthopedic surgery was consulted and
recommended nonoperative management of the fractures, non-weight
bearing to right upper extremity and touchdown weight bearing to
right lower extremity. She was admitted to the TSICU due to
hemodynamic instability.
TSICU Course
___: 1.5L given in ED for tachycardia and hypotension. Admitted
to ICU; repeat labs stable. TTE: dilated RV and IVC clot. CTA
negative for PE or IVC clot. Bilateral LENIs negative for DVT.
The patient continued to be in A-fib with RVR (HR to 170s),
hemodynamic instability (SBP ___. The patient was started on
diltiazem gtt, she was denying chest pain or altered mental
status. A left radial arterial line placed. Conversion back to
sinus rhythm was noted in ___. On HD2, the Hct was 19.1, she was
given 2u pRBC, with a post transfusion hct 26. At that point the
patient was transferred to the floor in hemodynamically stable
condition.
HD3, Thoracic surgery was consulted for an incidental finding of
a 6mm RML nodule. They are recommending further outpatient
work-up, including PET scan and PFTs. The patient was seen and
evaluated by Physical therapy, who recommended rehab once
medically stable.
Diet was advanced as tolerated to a regular diet with good
tolerability. During this hospitalization, the patient ambulated
with ___ assistance, was adherent with respiratory toilet and
incentive spirometry, and actively participated in the plan of
care. The patient received subcutaneous heparin and venodyne
boots were used during this stay. The Apixiban was discontinued
and should not be restarted for 2 weeks post fall. Hematocrit
drifted to 23 in the days following transfusion but remained
stable there. On ___, the patient was unable to void so the
Foley catheter was replaced.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, out of bed to chair with assistance, voiding via the
Foley, and pain was well controlled. The patient was discharged
to rehab. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Rehab stay expected to be less than 30 days.
Medications on Admission:
Ipratropium Bromide Neb 1 NEB IH Q4H:PRN SOB, wheeze
Lorazepam 0.5 mg PO BID:PRN anxiety
Losartan Potassium 25 mg PO DAILY
Metoprolol Succinate XL 50 mg PO DAILY
Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -200 unit oral DAILY
Apixaban 5 mg PO BID
Tiotropium Bromide 1 CAP IH DAILY
Compazine 2.5mg
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Heparin 5000 UNIT SC BID
4. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN prn sob
5. Lidocaine 5% Patch 1 PTCH TD QAM prn pain
6. Prochlorperazine 5 mg PO Q6H:PRN nausea
7. TraMADol ___ mg PO Q4H:PRN Pain - Moderate
8. Apixaban 5 mg PO BID
Do not take this medication until ___ (two weeks after your
fall).
9. Albuterol Inhaler ___ PUFF IH Q6H:PRN prn sob
10. Artificial Tears ___ DROP BOTH EYES PRN dry eye
11. Ciprofloxacin 0.3% Ophth Soln ___ DROP RIGHT EYE Q4H
12. Famotidine 20 mg PO BID
13. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
14. LORazepam 0.5 mg PO TID:PRN anxiety
15. Losartan Potassium 25 mg PO DAILY
16. Metoprolol Succinate XL 25 mg PO DAILY
17. Montelukast 5 mg PO DAILY
18. Tiotropium Bromide 1 CAP IH DAILY
19. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right proximal humerus fracture
Right greater trochanteric hip fracture
Hematoma Right shoulder/right flank
Incidental Finding: new RML nodule measuring 6mm
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 ___ after a fall. You were found to have
a fractured right shoulder and right hip. The Orthopedic doctors
___ and determined the fractures will all heal with
nonoperative management. During your work-up, there was an
incidental finding of a lung nodule. Thoracics saw you for this
and are recommending outpatient work-up. You have your follow-up
appointments scheduled. You have worked with Physical Therapy,
and your are now medically cleared for discharge to rehab to
continue your recovery.
Your blood thinner apixaban is on hold. You can resume this
medication in 2 weeks.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10454455-DS-22 | 10,454,455 | 23,440,043 | DS | 22 | 2136-10-28 00:00:00 | 2136-10-28 15:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Biaxin /
Levaquin / Augmentin / Zetonna / Xopenex / nitrofurantoin
macrocrystal
Attending: ___.
Chief Complaint:
Alerted Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with the past medical
history noted below who presented with constipation and altered
mental status.
On arrival to the floor she is confused and unable to provide
much history. She says that she came to the ED because she was
losing weight at home. She also reported four weeks without a
bowel movement. She is wearing curlers in her hair and asking if
she can get her hair bleached in the hospital. She was also
asking if we were in ___.
Per ED records:
"Collateral from patient's son & neighbor: patient is off her
baseline cognitively and has visibly lost significant weight.
Also reports that she is not taking her meds. Neighbor reports
that 4 weeks w/o bowel movement is not accurate; she tells him
different things at different times."
CT was notable for large stool burden in rectal vault and
possible stercorcal colitis. She was seen by surgery who
recommended aggressive manual disimpaction followed by a bowel
regimen. She was disimpacted by the ED physician with ___ large
amount of stool reportedly removed.
In the ED she received lactulose, IV doxycycline, IV Ativan, and
IV morphine. She then developed atrial fibrillation to the 140s
and was given 500cc NS, 10mg IV diltiazem, and 30mg PO
diltiazem.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
HTN
HLD
COPD (severe)
Osteoporosis
T2DM
Depression/anxiety, possible eating disorder
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization. Father died of colon cancer at ___. Also had
afib. Mother died of a stroke at ___. Has 2 sisters (1 has a
pacemaker), 1 twin brother (heart disease), and ___ younger
brother.
Physical Exam:
ADMISSION EXAM
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress. Curlers in hair.
Very cachectic appearing
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly intact throughout
PSYCH: AAO X 3 but intermittently confused. Thought process
non-linear, perseverates on topics
DISCHARGE EXAM
Vitals: temp 97.3; BP 123/86; HR 84; RR 18; O2 97% RA
Gen: thin, elderly woman sitting comfortably in chair
HEENT: EOMI, sclera anicteric, MMM
Lungs: CTAB
Heart: RRR, S1 and S2
Abdomen: soft, NT, ND, +BS
Ext: warm and well perfused, no ___ edema
Psych: appears slightly anxious and hesistant to talk
Neuro: Alert and oriented x3, no focal deficits
Pertinent Results:
ADMISSION LABS
___ 02:25PM BLOOD WBC-9.7 RBC-4.52 Hgb-13.6 Hct-41.2 MCV-91
MCH-30.1 MCHC-33.0 RDW-13.6 RDWSD-45.1 Plt ___
___ 02:25PM BLOOD Neuts-79.6* Lymphs-14.3* Monos-5.3
Eos-0.1* Baso-0.3 Im ___ AbsNeut-7.74*# AbsLymp-1.39
AbsMono-0.52 AbsEos-0.01* AbsBaso-0.03
___ 02:25PM BLOOD ___ PTT-28.1 ___
___ 02:25PM BLOOD Glucose-79 UreaN-24* Creat-0.6 Na-140
K-3.2* Cl-92* HCO3-31 AnGap-17
___ 02:25PM BLOOD ALT-18 AST-26 AlkPhos-103 TotBili-0.9
___ 02:25PM BLOOD Lipase-31
___ 02:25PM BLOOD Albumin-4.3
___ 02:25PM BLOOD TSH-1.1
___ 02:48PM BLOOD Lactate-2.1*
___ 04:55PM URINE Color-Straw Appear-Hazy* Sp ___
___ 04:55PM URINE Blood-TR* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-MOD*
___ 04:55PM URINE RBC-2 WBC-10* Bacteri-FEW* Yeast-NONE
Epi-4 TransE-2
___ 04:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 04:00PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
MICROBIOLOGY
RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE.
IMAGING
CXR - IMPRESSION: Background COPD, with evidence for pulmonary
hypertension. No acute pulmonary process identified.
CT A/P - IMPRESSION:
1. Large amount of stool distending the rectum with equivocal
edema of the perirectal fat can be seen in ensuing stercoral
colitis. No bowel obstruction.
2. Quite distended urinary bladder; correlate with ability to
voluntarily urinate.
3. Unchanged 8.2 x 6.6 cm right adrenal mass with calcification,
likely a sequela of prior adrenal hemorrhage.
4. Stable 2.5 x 1.5 cm hypoattenuating lesion in the lower pole
of the left kidney with thin septation, consistent with a
Bosniak 2 cyst.
TTE - The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF = 65%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. 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
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of ___ the
left ventricle is no longer hyperdynamic. The tricuspid
regurgitation is reduced.
DISCHARGE LABS
___ 07:00AM BLOOD WBC-6.3 RBC-4.51 Hgb-13.4 Hct-40.7 MCV-90
MCH-29.7 MCHC-32.9 RDW-14.1 RDWSD-46.4* Plt ___
___ 07:00AM BLOOD Glucose-82 UreaN-31* Creat-0.6 Na-145
K-4.1 Cl-96 HC___ AnGap-23*
Brief Hospital Course:
___ y/o F with PMHx of HTN, HLD, COPD, DM2, who presented with
constipation and altered mental status. CT in the ED notable for
large stool burden in the rectal vault with possible stercoral
colitis. She was seen by surgery and underwent manual
disimpaction in the ED. ED course was also complicated by afib
with RVR, for which she was started on diltiazem. Of note, she
also has had a subacute decline in mental status and nutritional
status over the past month (with similar admit for same earlier
this year). There was concern for altered mental status and
possible neurocognitive disorder vs. pseudodementia.
#Atrial Fibrillation with RVR. Found to be in afib w/RVR. Rate
controlled on diltiazem. CHADS2-VASC score elevated so discussed
with patient and her brother who agreed to start anticoagulation
with Coumadin. She received first dose of Coumadin 5mg ___.
TSH was normal and Echo was unremarkable. Afib likely
contributed by poor nutrition and low BMI.
#History of anorexia, unclear if currently active
#Severe malnutrition, BMI 13- Seen by psychiatry who reported
previous history of anorexia nervosa. Psych believes here
current status does not meet the definitive criteria of anorexia
nervosa but note that her mood and concern for how her eating is
affecting her health is contributing to her poor diet. She
continued to report issues with swallowing and ___ abdominal
pain. Seen by S&S who did not appreciate any deficits. She also
noted concern that eating would make her constipated. She was
continually noted to have poor oral intake during this
hospitalization. Would monitor calorie counts following
discharge. Likely will difficulty eating is multifactorial
though probably mostly related to underlying mood/psychiatric
conditions.
#Delirium
#Possible neurocognitive disorder
#Depression, anxiety- Etiology of recent worsening mental status
was thought to be partially delirium in the setting of
constipation vs. pain.But her presentation was notable for a
more subacute decline in mental status with concurrent weight
loss and failure to thrive at home.DDx included neurocognitive
decline vs. eating disorder vs. depression. Neurology felt that
she likely had a fluctuating delirium due to poor nutritional
status and a possible pseudodementia due to depression, and they
did not find evidence of a clinically advanced neurodegenerative
process, but feel that she should have a full neurocognitive
assessment once her medical condition improves.
Psychiatry felt she may have a neurocognitive disorder, as well
as some delirium that may have resolved. They also think she may
have unspecified depressive and anxiety disorders. They do not
believe she has anorexia nervosa by definition but
her mood and concerns certainty negatively affect her eating
habits. She was resumed on remeron 7.5mg QHS. She should
continue to see psychiatry as an outpatient for further
titration of her medications.
She was evaluated by ___ and OT who both felt that she should be
discharged to rehab
-OT stated "Pt demonstrates difficulty with recall and
attention-based tasks today, as well as appropriately planning
out/executing hand placement of clock when given task. Given
pt's performance with these tasks today as well as previously
poor performance with medication management tasks with OT
evaluation in ___, recommend pt have assistance with IADL
tasks such as medication management and cooking at this time.
Anticipate pt will require 24 hour supervision and continued OT
services upon discharge. Should 24 hour supervision not be
available, recommend pt discharge to rehab. Pt will require
continued follow-up for mobility/OOB ADL." Discussed above
findings with patient, her family, and psychiatry who agreed
that rehab was the best option for the time being and would need
further assessment prior to discharge from rehab to assess
ability to safely return home to independent living.
#History of T2DM- 24 hours of fingerstick blood glucoses shows
no significant hyperglycemia that would require treatment, so
stopped fingersticks
#Prior constipation, stercoral colitis, with mild ongoing
abdominal discomfort
-She was seen by surgery and underwent manual disimpaction in
the ED. She was continued on a bowel regimen with the goal of
having a daily bowel movement, though she often refused her
bowel regimen medications. She did have BM day prior to
discharge. She should be encourage to take her medications on a
daily basis to prevent further constipation.
#Reported dysphasia- Given patient's report of food getting
stuck at her manubrium, she was seen by speech and swallow who
recommended a soft diet with thin liquids, but otherwise just
aspiration precautions. She has not been observed to have any
problems swallowing according to the nurses, nor have I seen any
issues
# HTN: Holding home losartan given initiation of dilt and
acceptable BP control
# COPD: on home tiotropium, advair, Flonase, albuterol prn
# GERD: on home omeprazole
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN prn sob
2. Docusate Sodium 100 mg PO BID
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. LORazepam 0.5 mg PO TID:PRN anxiety
6. Losartan Potassium 25 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. TraZODone 25 mg PO QHS:PRN insomnia
10. Omeprazole 20 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Mirtazapine 7.5 mg PO QHS
13. polyvinyl alcohol-povidone 0.5-0.6 % ophthalmic (eye)
QID:PRN dry eye
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
2. Diltiazem Extended-Release 180 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Lactulose 30 mL PO BID:PRN constipation
5. Polyethylene Glycol 17 g PO DAILY constipation
6. Senna 8.6 mg PO BID constipation
7. Warfarin 5 mg PO DAILY16
adjust dosage for goal INR of ___. Albuterol Inhaler ___ PUFF IH Q6H:PRN prn sob
9. Aspirin 81 mg PO DAILY
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
12. LORazepam 0.5 mg PO TID:PRN anxiety
13. Mirtazapine 7.5 mg PO QHS
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 20 mg PO DAILY
16. polyvinyl alcohol-povidone 0.5-0.6 % ophthalmic (eye)
QID:PRN dry eye
17. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#Constipation, Stercoral Colitis
#Failure to thrive, Weight loss, Severe malnutrition
#Atrial Fibrillation with rapid ventricular response
#Delirium, due to the above
#Depression
#History of anorexia nervosa
#Possible neurocognitive disorder vs. pseudodementia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You presented with recent weight loss as well severe
constipation. You were disimpacted in the ED and placed on
medications to help you have bowel movements. You also had an
irregular heart rhythm called atrial fibrillation. You were
placed on medications to help with your heart rate.
You were seen by the psychiatry, neurology, Occupational
Therapy, physical therapy, social work, and nutrition services
to help with your depression, memory, and ability to function
safely on a daily basis. Ultimately, after much discussion with
you and your brother you were sent to rehab for further
treatment.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10454455-DS-23 | 10,454,455 | 25,732,529 | DS | 23 | 2137-01-02 00:00:00 | 2137-01-02 18:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Biaxin /
Levaquin / Augmentin / Zetonna / Xopenex / nitrofurantoin
macrocrystal
Attending: ___.
Chief Complaint:
unresponsive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ w/ severe COPD, AF, HTN, HLD, T2DM,
depression & anxiety w/ a history of anorexia nervosa who
presents unresponsive.
The patient was unable to give a history given her mental state.
Her friend provided the history. Her friend states that the
patient was in her usual state of health ___. He then visited
her ___ and she was minimally responsive so EMS was called.
On arrival to the ___ ED, she remained minimally responsive &
was noted to be markedly tachypneic w/ poor air movement,
extensive secondary muscle use, & audible grunting & wheezing.
Her cardiac and abdominal exam was benign and she had bilateral
pulses. A VBG was concerning for CO2 retention so she was
placed on BiPAP w/ minimal improvement in VBG & work of
breathing. As such, she was intubated successfully w/
subsequent improvement in VBG.
In the ED, the patient was also noted to be markedly dry on
exam. She was hypotensive & briefly required pressors. She was
also given 3L NS.
Finally, a CXR was concerning for evolving right-sided PNA.
Her ED course is summarized below:
-Initial VS:
T 96.8 HR 56 BP 107/73 RR24 O295%4L NC
-Labs significant for:
VBG: 7.37/___/116/46 on arrival
Lactate: 1.4
Troponin: <0.01
\ 9.4 /
10.9 ------ 269
/ 31.0 \
145 | 97 | 55 /
--------------- 97
5.3 | 36 | 1.2 \
INR 3.8
-Patient was given:
albuterol
ipratropium
IV methylprednisolone
3L NS
azithromycin
CTX
vancomycin
norepinephrine drip
midazolam drip
-Imaging notable for:
CXR 940 ___:
1. Apparent new 2.1 cm nodule in the right mid hemithorax may be
artifactual. Consider oblique or lateral views for further
evaluation.
2. Hyperinflated lungs, consistent with known history of COPD.
3. Re-demonstration of coarse calcifications in right upper
quadrant, corresponding to patient's known right adrenal mass
and better characterized on CT from ___.
CXR 1015 ___:
1. Evolving right pneumonia.
2. Acute right posterolateral as well as an acute/subacute left
posterolateral ninth nondisplaced rib fractures.
3. Hyperinflated lungs consistent with history of COPD.
4. Re-demonstration of coarse calcifications right upper
quadrant,
corresponding to patient's known right adrenal mass and better
characterized on CT from ___.
-Consults: None.
On arrival to the MICU, the patient remained intubated & sedated
and was unable to provide further history.
Past Medical History:
HTN
HLD
COPD (severe)
Osteoporosis
T2DM
Depression/anxiety, possible eating disorder
Social History:
___
Family History:
Father died of colon cancer at ___. Also had afib. Mother died of
a stroke at ___. Has 2 sisters (1 has a pacemaker), 1 twin
brother (heart disease), and ___ younger brother.
Physical Exam:
ADMISSION:
==========
VITALS: Reviewed in MetaVision.
GENERAL: Cachectic appearing female, intubated, sedated.
HEAD: ETT in place.
CARDIAC: NSR on monitor.
RESPIRATORY: Trace wheezing anteriorly, breathing comfortable on
ventilator.
ABDOMEN: Soft, +BS.
EXTREMITIES: Thin, warm, pulses intact.
DISCHARGE:
==========
Temp: 98.0 (Tm 98.9), BP: 143/83 (138-143/74-83), HR: 88
(77-91),
RR: 32 (___), O2 sat: 93% (88-95), O2 delivery: 1L, Wt: 68.56
lb/31.1 kg
GENERAL: Cachectic female in NAD, flat affect
HEENT: AT/NC, EOMI, MMM,
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Clear to auscultation
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding,
EXTREMITIES: no cyanosis, clubbing or edema
NEURO: moving all four extremities with purpose. No facial
asymmetry
SKIN: Several right coccyx ulcerations, unstageable
ACCESS: PICC line
Pertinent Results:
ADMISSION:
==========
___ 04:55PM BLOOD WBC-10.5*# RBC-4.14 Hgb-12.0 Hct-40.8
MCV-99*# MCH-29.0 MCHC-29.4*# RDW-16.8* RDWSD-60.5* Plt ___
___ 04:55PM BLOOD Neuts-90.2* Lymphs-5.1* Monos-4.0*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-9.50* AbsLymp-0.54*
AbsMono-0.42 AbsEos-0.00* AbsBaso-0.01
___ 04:55PM BLOOD ___ PTT-50.0* ___
___ 04:55PM BLOOD Glucose-97 UreaN-55* Creat-1.2* Na-145
K-5.3* Cl-97 HCO3-36* AnGap-12
___ 04:55PM BLOOD proBNP-799*
___ 04:55PM BLOOD cTropnT-<0.01
___ 04:55PM BLOOD Calcium-9.3 Phos-6.9* Mg-2.5
___:04PM BLOOD ___ pO2-28* pCO2-116* pH-7.18*
calTCO2-46* Base XS-8
___ 05:04PM BLOOD Lactate-1.4 K-4.4
___ 05:04PM BLOOD O2 Sat-39 COHgb-6*
DISCHARGE:
==========
___ 05:08AM BLOOD WBC-9.1 RBC-2.72* Hgb-7.9* Hct-26.0*
MCV-96 MCH-29.0 MCHC-30.4* RDW-16.4* RDWSD-57.1* Plt ___
___ 04:35AM BLOOD ___
___ 04:35AM BLOOD Glucose-154* UreaN-13 Creat-0.6 Na-144
K-3.7 Cl-103 HCO3-34* AnGap-7*
___ 04:35AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.9
___ 05:51AM BLOOD calTIBC-209* Ferritn-229* TRF-161*
IMAGING:
========
CXR: ___. Evolving right pneumonia.
2. Acute right posterolateral as well as an acute/subacute left
poSterolateral ninth nondisplaced rib fractures.
3. Hyperinflated lungs consistent with history of COPD.
4. Re-demonstration of coarse calcifications right upper
quadrant,
corresponding to patient's known right adrenal mass and better
characterized on CT from ___.
Echocardiogram: ___ No specific echocardiographic evidence of endocarditis seen.
Echo imaging quality was very good.
2) Moderate to severe tricuspid regurgitation likely due to
annular dilation.
CT Chest: ___
M
u
l
t
i
f
o
c
a
l
p
n
e
umonia is more evident in the lower lobes and mildly worse since
___, likely due to aspirations.
CT Head: ___. No acute findings.
2. Moderate chronic small vessel ischemic changes.
RUQ US ___
No evidence of deep vein thrombosis in the right upper
extremity.
MICROBIOLGOY:
=============
Blood Culture, Routine (Final ___:
BETA STREPTOCOCCUS GROUP G.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CHAINS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CHAINS.
___ 5:11 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Preliminary):
BETA STREPTOCOCCUS GROUP G.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
___ 3:46 am SPUTUM Source: Endotracheal.
MODERATE GROWTH Commensal Respiratory Flora.
MORAXELLA CATARRHALIS. MODERATE GROWTH.
___ Blood culture: No growth
___ Urine culture: No growth
Brief Hospital Course:
___ year old lady with GOLD III COPD, atrial
fibrillation, hypertension, hyperlipidemia, diabetes,
depression/anxiety and history of anorexia nervosa who presented
unresponsive, found to have sepsis from multifocal pneumonia and
group G Strep bacteremia, acute respiratory failure requiring
intubation, and ___, was extubated and transferred to the floor
where she was stable for several days prior to discharge.
# Sepsis, due to
# Group G Strep Bacteremia
Patient initially presented unresponsive after being found down
at home. She was found to have high grade Group G Strep
bacteremia. A TTE was unrevealing of endocarditis. ID
recommended continuing IV antibiotics for a fourteen day course
from ___. A TEE was not recommended based on the virulence of
the organism. The patient was continued on ceftriaxone for end
date ___. A colonoscopy was suggested as a transitional issue
to further evaluate for a source of Group G strep.
# Multifocal pneumonia
Patient presented with multifocal pneumonia on CT chest and
improved on vancomycin + ceftriaxone + azithromycin with
downtrending leukocytosis. A respiratory culture was positive
for Moraxella and the patient completed a 5d course of
azithromycin and ceftriaxone. She was discharged to rehab with
stay anticipated to be less than 30 days.
# Acute on chronic anemia
The patient had chronic anemia likely in setting of
malnutrition. During her admission she had a downtrending H/H
and was found to have guiac positive stool likely from gastritis
vs. PUD from her initial critical illness. The patient refused
both a blood transfusion and IV iron despite considerable
discussion with her team. This was discussed with her health
care proxy who was agreeable to an emergent transfusion if she
became unstable, however he did not want a transfusion or IV
iron to be administered against her wishes. Neither transfusion
or IV iron were given during her admission and she was continued
on a BID PPI and iron supplementation at discharge. An
EGD/colonsocpy was recommended as a transitional issue.
# Urinary retention
During her hospitalization the patient failed multiple voiding
trials with at times ~1L retained. On review of records this had
happened in the past. A culture was negative for infection. The
patient was maintained on bladder scans q6h and straight cathed
for retention > 500cc.
# Anorexia nervosa/depression/anxiety:
From review of records has been consistently losing weight for
several months with BMI now 13.4. The team discussed NG tube for
enteral feeds with patient however she wished to continue taking
PO under close supervision. Psych was consulted and felt that
her weight loss was more due to neurocognitive decline and less
an underlying psychiatric problem. She was continued on her home
mirtazapine 6.5mg daily and her home lorazepam was held at
discharge. Patient's oral intake improved after proposal of NGT
placement as possible alternative.
# Acute hypoxic and hypercarbic respiratory failure
# COPD
Initially had respiratory failure due to multifocal pneumonia on
top of baseline severe COPD. She was intubated in ED and
extubated on ___. She had intermittent 1L O2 requirement for
comfort. She was discharged on home inhalers.
# Paroxysmal atrial fibrillation:
Patient was continued on home diltiazem during hospital course
and discharged on home dose of warfarin at 3 mg daily. INR was
2.6 at discharge within goal ___.
# ___
Patient presented with creatinine 1.4 on admission from baseline
< 1.0. This was likely from poor PO intake preceding admission
as creatinine responded w/ IVF and on discharge was .6
# Goals of Care:
Patient has evidence of cognitive decline, severe exacerbations
of anxiety when discussing medical issues (colonoscopy, blood
transfusion) and refusing these medically recommended
interventions. Discussed with health care proxy ___,
brother) who prefers to respect patients wishes unless she is
unstable and procedure is urgently necessary.
=======================
TRANSITIONAL ISSUES:
=======================
[ ] colonoscopy for further evaluation of Group G strep
bacteremia
[ ] EGD to evaluate for upper GI bleeding, close CBC monitoring
for anemia
[ ] bladder scan q6h, straight cath for >500cc
[ ] close monitoring of PO intake, low threshold for discussion
of NG tube
[ ] INR check on ___ for close monitoring of INR
MEDICATIONS:
- New Meds:
1) Ascorbic acid ___ daily
2) Calcium carbonate 500mg daily
3) Ceftriaxone 1g daily to end ___ Ferrous Sulfate 325 daily to end ___ Zinc Sulfate 220 mg daily to end ___ Pantoprazole 40 daily
- Stopped Meds:
1) Omeprazole 20mg daily
2) Ativan .5mg TID
- Changed Meds:
1) Warfarin 5mg to 3mg daily
FOLLOW-UP
- Follow up: Per rehab
- Tests required after discharge: INR, CBC check ___
- Incidental findings: none
OTHER ISSUES:
- Hemoglobin prior to discharge: 7.0
- Cr at discharge: .6
- INR 2.6
- Antibiotic course at discharge: Ceftriaxone 1g daily to end
___
# CONTACT: HCP: ___ (brother) ___
# CODE: Full
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN prn sob
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. LORazepam 0.5 mg PO TID:PRN anxiety
7. Mirtazapine 7.5 mg PO QHS
8. Omeprazole 20 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. polyvinyl alcohol-povidone 0.5-0.6 % ophthalmic (eye)
QID:PRN dry eye
11. Tiotropium Bromide 1 CAP IH DAILY
12. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
13. Lactulose 30 mL PO BID:PRN constipation
14. Polyethylene Glycol 17 g PO DAILY constipation
15. Senna 8.6 mg PO BID constipation
16. Diltiazem Extended-Release 180 mg PO DAILY
17. Warfarin 5 mg PO DAILY16
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY Duration: 10 Days
2. Calcium Carbonate 500 mg PO QID:PRN heartburn
3. CefTRIAXone 1 gm IV Q 24H
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Zinc Sulfate 220 mg PO DAILY Duration: 10 Days
8. Warfarin 3 mg PO DAILY16
9. Albuterol Inhaler ___ PUFF IH Q6H:PRN prn sob
10. Aspirin 81 mg PO DAILY
11. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
12. Diltiazem Extended-Release 180 mg PO DAILY
13. Fluticasone Propionate NASAL 1 SPRY NU DAILY
14. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
15. Lactulose 30 mL PO BID:PRN constipation
16. Mirtazapine 7.5 mg PO QHS
17. Multivitamins 1 TAB PO DAILY
18. Polyethylene Glycol 17 g PO DAILY constipation
19. polyvinyl alcohol-povidone 0.5-0.6 % ophthalmic (eye)
QID:PRN dry eye
20. Senna 8.6 mg PO BID constipation
21. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Sepsis due to Group G Strep Bacteremia
PNA
Acute hypoxic and hypercarbic respiratory failure
Acute on chronic COPD exacerbation
Paroxysmal atrial fibrillation
Severe protein calorie malnutrition
Anorexia nervosa/depression
___
Secondary diagnoses:
DM2
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your admission to ___.
Below you will find information regarding your stay.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted after you were found at home and were very
sick.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You had a breathing tube placed and had a machine helping you
breath while you were in the ICU.
- You also received medications to help your blood pressure
remain in the normal range.
- You were found to have a bacteria growing in your blood and
you were treated with intravenous antibiotics.
- You were transferred from the ICU to the regular floor where
we continued your antibiotics.
WHAT SHOULD I DO WHEN I GO HOME?
-Please continue to eat as much as possible and drink your
Ensure with every meal.
-Take your medications as prescribed
-Keep your follow up appointments with your team of doctors
Thank ___ for letting us be a part of your care!
Your ___ Care Team
Followup Instructions:
___
|
10454455-DS-24 | 10,454,455 | 23,663,548 | DS | 24 | 2137-02-04 00:00:00 | 2137-02-04 18:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Biaxin /
Levaquin / Augmentin / Zetonna / Xopenex / nitrofurantoin
macrocrystal / egg
Attending: ___.
Chief Complaint:
"wound eval"
Major Surgical or Invasive Procedure:
Sacral bone biopsy
Colonoscopy with biopsies
History of Present Illness:
Ms. ___ is a ___ yo woman with severe COPD, AF on
warfarin, HTN, HLD, depression & anxiety w/ a history of
anorexia
nervosa and chronic sacral ulcer presents from pheresis unit
after scheduled blood transfusion due to concern of worsening
ulcer. Pt reports increased pain for 2 weeks. She reports she
attempts not to sit on it all the time, but today she has been
sitting on it and the pain is worse. She denies fevers, chills,
loss of appetite.
She was recently admitted (___) with Strep G bacteremia and
respiratory failure (from COPD + pneumonia) requiring intubation
and ICU care. She was discharged to ___ and has been
receiving adjunct care through ___ Healthy Lives in
coordination with her PCP. She has gotten 2 recent blood
transfusions on ___ and ___.
To elaborate a bit more on her history, she has had several
admissions to ___ in the past year, and the central issue has
been failure to thrive, malnutrition, and concern for cognitive
decline and thus difficulty in adequately caring for herself.
She has refused help and certain aspects of care in the past,
which unfortunately led to her being found unresponsive in early
___ (when she was admitted to ICU). She was discharged to
___ SNF where she has been staying since. She
reports
it is going ok but she is eager to get home. Her brother ___
is her HCP and she has a close friend, ___, who is her neighbor
and looks in on her when she is at home.
In the ED, initial vitals:
99.7 101 124/77 17 100% Nasal Cannula
- Exam notable for:
"NAD, O2 via NC
RRR
Exp. rhonchi
Sacrum with deep wound, apparently extending to bone, with mild
ttp, purulent drainage, 1 cm of surrounding dark pink skin.
malodorous. "
- Labs notable for:
wbc 10.7-->11.1
h/h 9.5/30.2--> 8.7/28.1
plt ___
----------------- 85 AGap=11
3.7 41 0.5
___: 16.8 PTT: 29.9 INR: 1.6
Swab of sacral ulcer:
GRAM STAIN
1+ (<1 per 1000X FIELD): /POLYMORPHONUCLEAR LEUKOCYTES
4+ (>10 per 1000X FIELD): /GRAM NEGATIVE ROD(S)
2+ ___ per 1000X FIELD): /GRAM POSITIVE COCCI /IN PAIRS
- Imaging notable for:
CXR (to check PICC placement):
IMPRESSION:
PICC not visualized within the thorax. There is a line which
terminates in the left mid humerus.
- Surgery was consulted who recommended:
"Debrided at bedside. Exposed ___ need IV abx. Rec admit
to medicine for PICC placement and IV abx. Would also consult ID
and nutrition. Thanks! ~___ ___
- Pt given:
Acetaminophen
Vancomycin
Lorazepam
Acetaminophen
Morphine 1mg IV x2
Diltiazem 180mg ER
- Vitals prior to transfer:
100.0 95 139/85 13 100% RA
On the floor, the pt reports she is in ___ pain. She explains
that if she is careful and moves slowly she can get through the
pain. She states she is overwhelmed. Denies chills or pain in
other locations.
REVIEW OF SYSTEMS:
Complete ROS obtained and is otherwise negative.
Past Medical History:
HTN
HLD
COPD (severe)
Osteoporosis
T2DM
Depression/anxiety
Anorexia
Severely underweight
Social History:
___
Family History:
Father died of colon cancer at ___. Also had afib.
Mother died of a stroke at ___.
Has 2 sisters (1 has a pacemaker), 1 twin brother (heart
disease), and ___ younger brother.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=====================================
VITALS:
___ 1700 Temp: 98.7 PO BP: 120/73 R Lying HR: 110 RR: 18
O2
sat: 95% O2 delivery: 2L NC
GENERAL: Very thin, cachectic appearing elderly woman. Anxious
appearing. Oriented x3. Slowed speech.
HEENT: NCAT. Sclera anicteric. Conjunctiva pink.
NECK: Supple with no LAD or JVD.
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops.
LUNGS: Resp unlabored, no accessory muscle use. Lungs CTA
bilaterally. No crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: No c/c/e. Distal pulses palpable and symmetric.
SKIN: On the sacrum there is an approximately 5x5 ulcer with
visible underlying bone and necrotic material, gauze saturated
with blood, surrounding area indurated.
DISCHARGE PHYSICAL EXAM
=====================================
VITALS: 98.4 PO 160/82 R Lying 84 18 99 on 2L
GENERAL: Very thin, cachectic elderly woman. Lying in bed, NAD,
appears calm, asking when she will be able to go home later
today
HEENT: NCAT. Sclera anicteric.
NECK: Supple.
CARDIAC: irregularly irregular rhythm. No murmurs/rubs/gallops.
LUNGS: Distant/soft breath sounds, mild end-expiratory wheezes
on the right, crackles or rhonchi
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Very thin body habitus. Wearing TEDS stockings. 1+
edema in lower legs bilaterally
Pertinent Results:
ADMISSION LABORATORY STUDIES
=====================================
___ 06:52PM BLOOD WBC-10.7* RBC-3.39* Hgb-9.5* Hct-30.2*
MCV-89 MCH-28.0 MCHC-31.5* RDW-15.7* RDWSD-51.4* Plt ___
___ 06:52PM BLOOD Neuts-79.3* Lymphs-10.7* Monos-8.1
Eos-0.7* Baso-0.4 Im ___ AbsNeut-8.47* AbsLymp-1.14*
AbsMono-0.86* AbsEos-0.07 AbsBaso-0.04
___ 12:00AM BLOOD ___ PTT-29.9 ___
___ 06:52PM BLOOD Glucose-85 UreaN-15 Creat-0.5 Na-144
K-3.7 Cl-92* HCO3-41* AnGap-11
___ 07:20AM BLOOD Albumin-2.9* Calcium-8.7 Phos-2.7 Mg-1.9
___ 06:52PM BLOOD CRP-146.7*
___ 06:52PM BLOOD CRP-146.7*
DISCHARGE LABORATORY STUDIES
=====================================
___ 05:15AM BLOOD WBC-9.4 RBC-3.26* Hgb-9.1* Hct-30.6*
MCV-94 MCH-27.9 MCHC-29.7* RDW-16.1* RDWSD-55.3* Plt ___
___ 05:15AM BLOOD Glucose-96 UreaN-12 Creat-0.3* Na-145
K-4.2 Cl-102 HCO3-37* AnGap-6*
___ 05:15AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.1
IMAGING/REPORTS
=====================================
1. Colon, cecal mass, biopsy:
- Superficial fragments of adenomatous mucosa with high-grade
dysplasia; see note.
- Additional levels examined.
2. Colon, rectosigmoid polyp, biopsy:
- Tubular adenoma.
Note: Due to the superficial nature of the biopsy and the
presence of a mass-forming lesion, an unsampled invasive
carcinoma cannot be excluded. The initial findings were
discussed with Dr. ___ at 10AM on ___ by Dr. ___.
___.
MICROBIOLOGY
=====================================
___ 3:17 pm TISSUE SACRAL BONE BIOPSY #1.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
Reported to and read back by ___ MD (___)
___ @
11:26 ___.
___ REQUESTED WORKUP OF GRAM NEGATIVE RODS AND
POSITIVIE
COCCI.
PROTEUS MIRABILIS. RARE GROWTH.
MIXED BACTERIAL FLORA.
Due to mixed bacterial types [>=3] an abbreviated
workup is
performed; all organisms will be identified and
reported but only
select isolates will have sensitivities performed.
PROTEUS MIRABILIS. RARE GROWTH. ___ MORPHOLOGY.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
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.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SECOND MORPHOLOGY.
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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| PROTEUS MIRABILIS
| |
STAPHYLOCOCCUS, COAGULASE N
| | |
STAPHYLOCOCCUS,
| | | |
AMPICILLIN------------ <=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S <=2 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- 1 S 1 S
CLINDAMYCIN----------- R <=0.25 S
ERYTHROMYCIN---------- R =>8 R
GENTAMICIN------------ <=1 S <=1 S <=0.5 S <=0.5 S
LEVOFLOXACIN---------- 4 R
MEROPENEM-------------<=0.25 S <=0.25 S
OXACILLIN------------- =>4 R =>4 R
PIPERACILLIN/TAZO----- <=4 S <=4 S
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- <=1 S <=1 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
VANCOMYCIN------------ <=0.5 S 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
___ 3:19 pm TISSUE SACRALBONE BIOPSY #2.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STREPTOCOCCUS ANGINOSUS (___) GROUP. SPARSE GROWTH.
CLINDAMYCIN MIC >= 1.0 MCG/ML.
CEFTRIAXONE MIC = 2 MCG/ML = INTERMEDIATE.
CEFTRIAXONE test result performed by Etest.
ENTEROCOCCUS SP.. RARE GROWTH.
PROTEUS MIRABILIS. GROWING IN BROTH ONLY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (___)
GROUP
| ENTEROCOCCUS SP.
| | PROTEUS
MIRABILIS
| | |
AMPICILLIN------------ <=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- <=0.25 S
PENICILLIN G----------<=0.06 S 4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 0.5 S <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
Brief Hospital Course:
BRIEF SUMMARY
==============
___ with recurrent admissions over the last year for FTT,
anemia, cognitive decline, severe COPD, atrial fibrillation,
HTN, HLD, and recent admission for strep anginosis bacteremia
and respiratory failure, who presented with sacral ulcer leading
to associated osteomyelitis, developed melena during admission
and found to have fungaging cecal mass on colonoscopy with
biopsy-proven high-grade dysplasia, concerning for unsampled
invasive colon carcinoma.
ACTIVE ISSUES
============
#) OSTEOMYELITIS
Patient presented with a chronic sacral ulcer associated with
worsening pain and found to have exposed bone and pus at the
site. On admission, she underwent debridement and received one
dose of vancomycin, cefepime and metronidazole, although further
antibiotics were held while awaiting cultures. Underwent bone
biopsy on ___. Culture results showed polymicrobial growth,
including streptococcus anginosus. ID was consulted, and patient
was started on antibiotics with vancomycin and cefepime. Patient
was transitioned to vancomycin + cefepime + metronidazole with
an anticipated course of ___ weeks (day 1 ___, and a PICC
line was placed. The patient will continue on IV antibiotics
through her PICC for the remainder of the course. She will
follow up with ID, who will determine the final course of
antibiotics.
#) FUNGATING CECAL MASS with ___ dysplasia (c/f colonic
malignancy)
Patient was guaiac positive on prior admission in ___
___s during this admission, then developed frank melena.
Colonoscopy on ___ demonstrated large fungating, friable
mass in cecum as well as many polyps, including large polyps in
rectum and sigmoid colon. Biopsies demonstrated high-grade
dysplasia, but unsampled invasive carcinoma could not be ruled
out. Findings discussed with patient and her HCP (brother). The
patient clearly indicated that she would not want to pursue
surgical intervention, and she felt that she would likely not do
well with chemotherapy ("my body would not be able to take it").
She does not want to die in a nursing home and wants to spend
her time at home, working on her art (she restores old
sculptures). The patient will follow up with GI and palliative
care for further discussion of treatment options and prognosis.
#GI BLEED
Patient initally had guaiac positive stool followed by a short
bout of frank melena. Slow GI bleed secondary to the friable
cecal mass. EGD on ___ also demonstrated retained blood but no
obvious source of bleeding. Received 2 units of pRBCs for hgb <7
___s Vitamin K 2.5mg PO. Patient started on pantoprazole
40mg PO. Patient's warfarin was discontinued indefinitely given
risk of GI bleed from cecal mass/likely colonic malignancy
greatly outweighs risk of stroke from atrial fibrilliation.
Melena resolved and H&H stable by the time of discharge.
CHRONIC ISSUES
==============
#) Anxiety, depression, failure to thrive:
Patient has a long history of anxiety/depression and prior
eating disorder. Psychiatry has been involved in prior
hospitalizations and her HCP (brother) has needed to be invoked
previously. Patient was intermittently willing to engage in
conversations about her care during this hospitalization.
Psychiatry was consulted and deemed patient to have limited
capacity. HCP brother signed consent forms, per patient
preference. Patient was treated with thiamine (given potential
for wernicke's encephalopathy i/s/o severe malnutrition) as well
as folate and a multivitamin. Patient's home mirtazapine was
also increased from 7.5mg to 15mg qhs during this admission.
Nutrition was consulted, and patient was encouraged to eat 3
meals/day with snacks. Per MOLST, tube feeds not within GOC.
#) Atrial Fibrillation
Continued home diltiazem. Warfarin was discontinued indefinitely
given GI bleed/melena and finding of cecal mass c/f colonic
malignancy (risk of GI bleed higher than risk of stroke).
#) COPD:
Continued home inhalers (albuterol prn, fluticasone-salmeterol
(500/50), and tiotropium), although patient often refusing
inhalers as they make her feel shaky.
#) Lower extremity edema:
Likely secondary to poor nutritional status/cachexia. Gave
patient TEDs sockingas and started on Lasix 10mg daily, although
minimal improvement seen in ___ edema. Plan to discharge on this
low-dose Lasix, but may not help given ___ edema is likely
secondary to low oncotic pressure from low albumin/poor
nutritional status.
#Health care proxy/emergency contact: ___, brother,
___
Transitional issues:
1. Patient needs all of the following labs WEEKLY:
-Vancomycin monitoring: CBC with differential, BUN, Cr,
Vancomycin trough
-Ceftriaxone monitoring: CBC with differential, BUN, Cr, AST,
ALT, Total Bili, ALK PHOS
-Osteomyelitis monitoring: CRP
-ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
2. Patient will follow up with Infectious Disease on ___ and
___ to monitor her osteomyelitis and decide on exact length
of antibiotic treatment
3. Patient will follow up with Palliative Care on ___
4. Patient will follow up with GI. The patient will be called
with the appointment day and time. If the patient is not called
in 2 business days, she should call ___ to schedule an
appointment
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Diltiazem Extended-Release 180 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Mirtazapine 7.5 mg PO QHS
6. Senna 8.6 mg PO BID constipation
7. Tiotropium Bromide 1 CAP IH DAILY
8. Calcium Carbonate 500 mg PO QID:PRN heartburn
9. Albuterol Inhaler ___ PUFF IH Q6H:PRN prn sob
10. Multivitamins 1 TAB PO DAILY
11. polyvinyl alcohol-povidone 0.5-0.6 % ophthalmic (eye)
QID:PRN dry eye
12. Zinc Sulfate 220 mg PO DAILY
13. Pantoprazole 40 mg PO Q12H
14. Warfarin 3 mg PO DAILY16
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Ascorbic Acid ___ mg PO DAILY Duration: 14 Days
3. CefTRIAXone 2 gm IV Q24H
4. Collagenase Ointment 1 Appl TP DAILY
5. Docusate Sodium 100 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. MetroNIDAZOLE 500 mg PO Q8H
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Psyllium Powder 1 PKT PO DAILY
10. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
11. TraZODone 25 mg PO QHS:PRN insomnia
12. Vancomycin 1250 mg IV Q 24H
13. Mirtazapine 15 mg PO QHS
14. Pantoprazole 40 mg PO Q24H
15. Albuterol Inhaler ___ PUFF IH Q6H:PRN prn sob
16. Aspirin 81 mg PO DAILY
17. Calcium Carbonate 500 mg PO QID:PRN heartburn
18. Diltiazem Extended-Release 180 mg PO DAILY
19. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
20. polyvinyl alcohol-povidone 0.5-0.6 % ophthalmic (eye)
QID:PRN dry eye
21. Senna 8.6 mg PO BID constipation
22. Tiotropium Bromide 1 CAP IH DAILY
23. Zinc Sulfate 220 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Sacral osteomyelitis
Cecal mass, biopsy with atypical cells concerning for colon
cancer
COPD
Anxiety and Depression
Atrial Fibrillation
Lower extremity edema
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:
WHY YOU CAME TO THE HOSPITAL
-You came to the hospital because you had a wound on your bottom
that was infected
-While you were in the hospital, you began having blood in your
bowel movements
WHAT WE DID IN THE HOSPITAL
-We cleaned the wound on your bottom and gave you antibiotics to
treat the infection. You will continue getting these antibiotics
through your arm for ___ weeks.
-You had a colonoscopy to find out why you had blood in your
bowel movements. From the colonoscopy results, we are very
concerned that you may have colon cancer.
WHAT YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL
-You will continue getting antibiotics for ___ weeks total
-You will need to see the Infectious Disease doctors to make
sure your infection gets better. You will need to see the
Palliative Care doctors, who will talk to you about your colon
cancer. These appointments have already been scheduled for you
(see below).
-You will also need to see the Colon doctors (___).
You will be called at the ___ with the appointment
time. If you do not get a phone call in the next 2 days, please
call ___ to schedule an appointment with the colon
doctors.
Followup Instructions:
___
|
10454975-DS-3 | 10,454,975 | 20,840,102 | DS | 3 | 2158-02-14 00:00:00 | 2158-02-14 12:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
adhesive tape
Attending: ___.
Chief Complaint:
Headaches, confusion
Major Surgical or Invasive Procedure:
Right parietal craniotomy and resection of lesion on ___
History of Present Illness:
___ yr old female patient presented with hx of HTN, who presented
with c/o
confusion over the past week with intermittent right sided
headaches. She was unable to completed simple tasks that she had
done for years. For example, shuffling cards, doing a crossword
puzzle, and turning the TV on. Family brought her to ED where
they performed a CT scan and an MRI. Results showed a parietal
mass 3.6cm with edema. Pt was given Decadron 10mg and
transferred
to ___.
Past Medical History:
HTN, hypothyroidism, GERD, OA, HPL, ulcerative proctitis
Social History:
___
Family History:
non contributory
Physical Exam:
PHYSICAL EXAM:
AVSS
awake, alert, oriented x3
follows commands throughout
PERRL, EOMI, FSTM
no drift
MAE ___
sensation intact to light touch throughout
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
On Discharge:
awake, alert, oriented x3
follows commands throughout
PERRL, EOMI, FSTM
no drift
CN2-12 intact
strength ___ thoughout in ___ upper and Lower extremities
sensation intact to light touch throughout
wound clean dry and intact, no erythema or signs of infection
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Pertinent Results:
CT torso
1. No clear evidence of primary mass.
2. 1.7 cm right upper pole renal lesion demonstrates borderline
enhancement.
This may represent a complex cyst, however a low-grade neoplasm
cannot be
excluded. Recommend correlation with ultrasound.
3. Prominent pericolonic lymph node near the sigmoid colon is
nonspecific and could be related to inflammation, however
recommend correlation with
colonoscopy screening if not up to date.
4. Sigmoid diverticulosis.
5. Innumerable hepatic small hepatic hypodensities most likely
represent
biliary hamartomas, also known as on ___ complexes.
6. Right lower quadrant spigelian hernia containing loops of
small bowel
without CT evidence of incarceration.
MRI Brain ___ WAND
Re- demonstration of a 4 x 4 cm predominantly peripherally
enhancing parietal lobe mass
___ Non contrast head CT:
Expected postoperative changes after resection of right parietal
mass. No hemorrhage or mass effect
MRI head ___:
Postoperative changes in the right parietal lobe. Presence of
blood products limits evaluation for residual neoplasm.
Recommend followup imaging after resolution of acute blood
products to assess for residual tumor.
Brief Hospital Course:
Patient presented to the emergency department on ___ for
evaluation and was admitted for finding of right parietal brain
lesion. A CT of the torso to assess for any possible primary
malignancy was performed on ___. This did not show any signs of
primary malignancy that would suggest the intracranial lesion
was a metastasis. She was underwent a pre-op workup for surgery
planned for ___. A discussion was had with the patient and her
family regarding the planned procedure. Indications for the
procedure, risks, and benefits were all discussed at length with
the family. Following this informed consent was obtained for the
procedure. She was taken to the operating room on ___ for the
planned right sided craniotomy for resection of her right
parietal lesion. She toelrated the procedure well, was extubated
in the operating room, and brought to the SICU post-operatively
for monitoring and care. Post operative CT scan post operative
changes. On ___, patient was intact on examination. She reported
mild headache that was relieved with pain medication. Her MRI
was performed and she was transferred to the floor. ___ was
consulted for evaluation. on ___ the patients neuro exam was
unchanged and was intact. She had no complaints and this time
and was AO x3. She has been pain free and working with ___ and OT
which cleared her for home with services. She was medically
cleared for discharge on POD 3
Medications on Admission:
Lisinopril, canasa, prilosec, levoxyl
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Dexamethasone 2 MG PO BID Duration: ONGOING
3. Docusate Sodium 100 mg PO BID
4. LeVETiracetam 1000 mg PO BID
5. Levothyroxine Sodium 112 mcg PO DAILY
6. Lisinopril 2.5 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___.
Discharge Diagnosis:
Right parietal mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions:
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Your wound was closed with dissolvable sutures, you must keep
that area dry for 10 days.
You may shower before this time using a shower cap to cover
your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you may
safely resume taking this on ___.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101.5° F.
Followup Instructions:
___
|
10455067-DS-7 | 10,455,067 | 29,448,567 | DS | 7 | 2126-10-10 00:00:00 | 2126-10-10 13:42:00 |
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:
___ biopsy ___
___ biopsy ___
___ line placement ___
History of Present Illness:
Mr. ___ is a ___ w/ hx of Stage IIIb metastatic melanoma s/p
resection and chemo in remission, who presents with back pain.
Patient reports that around three months prior to admission he
injured his back while lifting a weight off of an outdoor pool
cover. Pain was located in the mid-back, radiating around to the
sides, feeling "tight". It is normally dull, but at times will
be
sharp and shooting. It did improve some with ___, especially the
pain around the sides, but otherwise has persisted. It is at
times so severe that it wakes him up from sleep. He reports no
fevers or chills, but did have some night sweats. He also
reported a 5lb weight loss and fatigue. Denies bowel
incontinence, denies urinary retention. Denies numbness,
tingling.
He reported this to his oncologist, who he follows with for
metastatic melanoma. His routine surveillance PET scan was moved
up, and was concerning for a possible spinal infection.
Following
this result, he was sent for an MRI, which was done at a clinic
affiliated with ___. This was concerning also for
infection,
and therefore he was referred to the ED.
On review of records, patient was first diagnosed with
metastatic
melanoma in ___ with an unknown primary. He underwent ___ year of
treatment with interferon. He has screening PET scans, but has
otherwise done well.
In the ED:
Initial vital signs were notable for: T 97.6, HR 86, BP 140/93,
RR 16, 99% RA
Exam notable for:
CN2-12 intact, intact sensation to light touch, ___ muscle
strength
point tenderness in mid/lower thoracic paraspinal
Labs were notable for:
- CBC: WBC 9.9, hgb 12.0, plt 227
- Lytes:
142 / 104 / 16 AGap=19
--------------- 90
4.1 \ 19 \ 0.8
- CRP: 28.5
- Lactate:0.9
Consults: Spine was consulted, and reviewed the MRI. They felt
that this appears to be T9-T10 discitis osteomyelitis vs
neoplastic changes. The patient is neuro intact with no
deficits,
afebrile and stable. Recommend ___ biopsy for definitive
diagnosis
and treatment accordingly.
Patient was given: no medications in the ED
Vitals on transfer: T 98, HR 82, BP 138/79, RR 16, 99% RA
Upon arrival to the floor, patient recounts history as above. He
currently has moderate pain.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Past Medical History:
1. Metastatic melanoma.
2. Hyperlipidemia.
3. Hearing loss.
4. Myopia.
5. Presbyopic.
6. Arthritis.
7. Impaired fasting glucose.
8. Plantar fasciitis.
9. Acquired deformity of the foot.
10. Depression/anxiety disorder.
Past Surgical History:
1. Herniorrhaphy in ___.
2. Vasectomy in ___.
Social History:
___
Family History:
- maternal grandfather - colon cancer
- maternal grandmother - melanoma
- paternal grandfather lung cancer (pt reports related to
___)
Physical Exam:
Admission Physical Exam
VITALS: T 98.0, HR 86, BP 144/71, RR 18, 99% RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, spinal tenderness about half-way down back.
Full strength in extremities
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, ___ strength in proximal and distal muscle groups
of upper and lower extremities
PSYCH: pleasant, appropriate affect
Discharge Physical Exam
Vitals: temp 98.5; BP 127/84; HR 81; RR 18; O2 94 % RA
Gen - well appearing, sitting up in bed, comfortable
HEENT - moist oral mucosa, no OP lesions
___ - rrr, s1/2, no murmurs
Pulm - CTA b/l, no w/r/r
Back - dressing site c/d/I, mild spinal TTP about mid way down
the back
GI - soft, non tender, non distended, +bowel sounds
Ext - no peripheral edema or cyanosis, Skin - warm and dry, no
rashes
Skin: no rashes appreciated. PICC Line in right arm
Psych - calm and cooperative
Neuro: AOx3, no focal deficits
Pertinent Results:
Admission Labs:
___ 09:30PM BLOOD WBC-9.9 RBC-4.34* Hgb-12.0* Hct-37.3*
MCV-86 MCH-27.6 MCHC-32.2 RDW-13.7 RDWSD-43.0 Plt ___
___ 09:30PM BLOOD Glucose-90 UreaN-16 Creat-0.8 Na-142
K-4.1 Cl-104 HCO3-19* AnGap-19*
___ 09:30PM BLOOD CRP-28.5*
___ 09:30PM BLOOD Calcium-9.1 Phos-2.9 Mg-2.0
___ 09:38PM BLOOD Lactate-0.9
Discharge Labs:
___ gram stain - leukocytes, no microorganisms seen, acid fast
negative
___ path - pending (prelim path negative for melanoma per
verbal discussion with pathology)
___ - MSSA
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ - path pending
___ - quant gold negative
___ - CRP 18.8 <- 28.5
___ PET scan -
1. Increased FDG uptake in the T9-10 level, measuring SUV max of
19.9, with prevertebral edema, stranding, and erosive changes
along the intervertebral disc space is concerning for
discitis/osteomyelitis. An adjacent focus of FDG uptake seen
along the right posterior pleura may represent a site of
contiguous spread. 2. Trace right pleural effusion with rounded
atelectasis.
3. Otherwise, no evidence of metastatic disease on today's exam.
___ MRI T-spine ___ read)
1. Discitis and osteomyelitis at T9-T10 with a 7 x 3 mm fluid
pocket in the ___ the T9-T10 disc.
2. Mild prevertebral phlegmon at T9-T10. 17 x 7 mm loculated
fluid collection in the right prevertebral space at T9-T10. 9 x
5 mm fluid pocket in the left prevertebral space at T9-T10.
3. Mild left anterior epidural phlegmon at T9-T10, mildly
indenting the ventral thecal sac without mass effect on the
spinal cord.
4. No evidence for spinal cord signal abnormalities.
CT guided biopsy ___
FINDINGS:
1. Again noted are features suggestive of spondylodiscitis at
the level of
T8/T9.
2. Soft tissue density along the T8/T9 right paravertebral are
also noted
unchanged.
3. Post aspiration and biopsies, no complications were noted
IMPRESSION:
Successful CT-guided aspiration and biopsies of a T8/9 right
paravertebral
collection and T8 vertebral body.
Brief Hospital Course:
Mr. ___ is a ___ w/ hx of Stage IIIb metastatic melanoma s/p
resection and chemo in remission, who presents with back pain
and concern for discitis/osteomyelitis on imaging.
# Back pain
# T9-T10 discitis/osteomyelitis
Patient presents with three months of back pain, with PET scan
and MRI t-spine both concerning for possible
discitis/osteomyelitis. Neoplastic disease is also on
differential. He had an ___ guided biopsy which was negative for
infection. ID was consulted and recommended repeat biopsy given
imaging findings, and cultures from this were positive. Source
of infection remains unclear, however he remained clinically
stable without fever or leukocytosis while hospitalized.
Preliminary path is negative for melanoma, and acid fast stain
is negative. Quant gold is negative. He was initially started on
daptomycin and ceftriaxone with a plan to continue these for ___
weeks total. Ultimately because of a delay in discharge due to
needing insurance auth of home antibiotics, he was able to stay
in house long enough for his final micro to return, and it
showed MSSA. As such, his daptomycin was discontinued and he was
kept on ceftriaxone 2g daily alone, via PICC line that was
placed ___. He will need weekly labs and this will be done
by his ___. ID will schedule him for a follow up. Plan to
complete at least 6 week course of abx through ___. CRP was
downtrending from 28.5 to 18.8 on discharge.
-Weekly labs to OPAT: CBC with differential, BUN, Cr, AST, ALT,
Total Bili, ALK PHOS
# Hyperlipidemia - Continued home atorvastatin 20mg daily
# OSA- Ccontinued CPAP
# History of melanoma- Continue outpatient follow up
# Anemia - noted slightly anemic, can have outpatient workup
Transitional Issues:
[] f/u weekly labs as noted above
[] f/u with ID to definitively decide on abx course
[] f/u final pathology report- pending on discharge
Greater than 30min spent on discharge planning
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tizanidine 2 mg PO TID
2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
3. Atorvastatin 20 mg PO QPM
Discharge Medications:
1. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g iv once a
day Disp #*39 Intravenous Bag Refills:*0
2. Atorvastatin 20 mg PO QPM
3. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
4. Tizanidine 2 mg PO TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Vertebral osteomyelitis/discitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with concern for a spinal
infection. You had fluid from your spine sampled twice and
ultimately it was felt you did indeed have infection in the bone
(called Vertebral Osteomyelitis). The treatment for this is
prolonged antibiotics and we have set you up with a line in your
arm called a PICC line, along with antibiotics to be given at
home with the help of a visiting nurse. Our infectious disease
team will follow your cultures and make adjustments to your
antibiotics if necessary. If you experience severe back pain or
high fevers, these might be signs of an infection and you should
call your doctor.
It has been a pleasure to care for you in the hospital. We wish
you the very best!
Sincerely,
Your care team at ___
Followup Instructions:
___
|
10455424-DS-3 | 10,455,424 | 20,346,232 | DS | 3 | 2180-03-28 00:00:00 | 2180-04-05 09:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Exercise stress echocardiogram ___
History of Present Illness:
Ms. ___ is a ___ year old female with a history of HTN, HLD
who presents with to ED with complaint of L sided chest
discomfort, which she describes as "lightening" that radiated to
her mouth/jaw, it was non-pleuritic, non-reproducible,
non-positional. The pain lasted 15 minutes and was associated
with nausea, flushing (but no clear diaphoresis), no vomiting.
She measured her BP which was elevated to the 190s and she took
2 amlodipine. The pain resolved with rest. She went to bed at 10
___, at 2:00 AM when she woke to use the bathroom, she felt
flushed and checked her BP which was in the 200s. She went back
to bed. This morning, after she ate breakfast, her blood
pressure remained high; she took 2 amlodipine, and took her
pulse, which was in the 110s. During these episodes, she denies
dyspnea, pleuritic chest pain. She reports mild nausea, but no
vomiting.
In the ED, initial vitals: T of 98.2, HR: 90, BP 153/89, 100% on
RA
Labs were significant for: Trop < 0.01, WBC: 5.6, H/H: 13.9/43.2
CXR showed 1) No pneumothorax or pneumonia; 2) Moderate hiatal
hernia, also seen on CT ___.
In the ED, she received aspirin 324 mg.
Vitals prior to transfer: T: 98.3, HR: 88, BP 134/77, R 17, 98%
on RA
Currently, on the floor, she complains of a dull occipital
headache, without photosensitivity, without any focal
weakness/numbness/paresthesias. She denies any fevers/chills and
denies cough. She denies any current palpitations.
Past Medical History:
Hyperlipidemia
Hypertension
Lumbar radiculopathy: MRI ___ showing L4-L5 disease s/p
epidural injection
Lytic skull lesion - likely hemangioma in left parietal bone
Depression
Osteoporosis
Social History:
___
Family History:
No history of sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T: 98.2 BP 150/81 HR: 74 RR: 18 99% RA
GEN: Alert, lying in bed, no acute distress, conversant
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD, no JVD appreciated
PULM: Generally CTA b/l without wheeze or rhonchi,
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, mild 1+ edema
NEURO: CN II-XII grossly intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
97.4, BP 145/93, HR: 84, 20, 100% O2
GEN: Alert, lying in bed, no acute distress, conversant
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD, no JVD appreciated
PULM: Generally CTA b/l without wheeze or rhonchi,
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, mild 1+ edema
NEURO: CN II-XII grossly intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 09:00PM BLOOD CK-MB-6 cTropnT-<0.01
___ 12:35PM BLOOD WBC-5.6 RBC-4.38 Hgb-13.9 Hct-43.2
MCV-99* MCH-31.7 MCHC-32.2 RDW-13.7 RDWSD-50.4* Plt ___
DIAGNOSTICS:
#CXR ___:
Rotated positioning. Allowing for this, the cardiomediastinal
silhouette is probably unchanged compared with ___,
though the aorta could be somewhat more tortuous, even allowing
for patient rotation. There is background hyperinflation,
compatible with COPD. No CHF, focal infiltrate or effusion is
identified. No pneumothorax is detected. A retrocardiac
density is consistent with a moderate hiatal hernia, in keeping
with findings on the ___ chest x-ray. There is
moderate kyphosis of the thoracic spine with multilevel loss of
vertebral body height. Incidental note made of probable healed
left proximal humeral fracture.
IMPRESSION: 1. No pneumothorax or pneumonia. 2. Moderate
hiatal hernia, also seen on CT ___.
#Exercise stress echo ___:
The patient exercised for 9 minutes and 30 seconds according to
a Gervino treadmill protocol ___ METS) reaching a peak heart rate
of 139 bpm and a peak blood pressure of 170/86 mmHg. The test
was stopped because of fatigue. This level of exercise
represents an average exercise tolerance for age and gender. In
response to stress, the ECG showed no diagnostic ST-T wave
changes (see exercise report for details). with normal blood
pressure and heart rate responses to stress.
Resting images were acquired at a heart rate of 76 bpm and a
blood pressure of 130/78 mmHg. These demonstrated normal
regional and global left ventricular systolic function. Doppler
demonstrated no aortic stenosis, aortic regurgitation or
significant mitral regurgitation or resting LVOT gradient. .
Echo images were acquired within 61 seconds after peak stress
at heart rates of 110-97 bpm. These demonstrated appropriate
augmentation of all left ventricular segments.
IMPRESSION: Fair to average functional exercise capacity. No 2D
echocardiographic evidence of inducible ischemia to achieved
workload. Normal hemodynamic response to exercise.
#Exercise stress test:
___ yo woman with HL and HTN was referred to evaluate
an atypical chest discomfort. The patient completed 9.5 minutes
of a
Gervino protocol representing an average exercise tolerance for
her age;
~ ___ METS. The exercise test was stopped due to fatigue. No
chest, back,
neck or arm discomforts were reported. No significant ST segment
changes
were noted. The rhythm was sinus with rare isolated VPBs and one
ventricular couplet. Occasional isolated APBs with short runs of
atrial
bigeminy were noted post-exercise. The heart rate and blood
pressure
response to exercise was appropriate.
IMPRESSION: Average exercise tolerance. No anginal symptoms or
ischemic
ST segment changes. Appropriate hemodynamic response to
exercise. Echo
report sent separately.
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-6.4 RBC-4.26 Hgb-13.3 Hct-41.0 MCV-96
MCH-31.2 MCHC-32.4 RDW-13.6 RDWSD-48.5* Plt ___
___ 06:30AM BLOOD Glucose-97 UreaN-16 Creat-0.7 Na-141
K-4.0 Cl-104 HCO3-26 AnGap-15
___ 09:00PM BLOOD CK(CPK)-206*
___ 09:00PM BLOOD CK-MB-6 cTropnT-<0.01
___ 12:35PM BLOOD cTropnT-<0.01
___ 06:30AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.4
Brief Hospital Course:
Ms. ___ is a ___ year old female with a history of
hypertension and hyperlipidemia who presented with transient
chest pain at rest that lasted for 15 minutes, with jaw
radiation. The pain was not positional, not pleuritic, and not
reproducible. Her initial EKG showed normal sinus rhythm and no
focal signs of ischemia, T-wave inversions, or Q waves. Two
troponins were < 0.01. Her chest x-ray did not show any acute
cardiopulmonary process. Her last stress-EKG was in ___, which did not show any ischemic events. Given the concern
for her risk factors (age, hypertension, hyperlipidemia), the
abnormal presentation of cardiac disease in women, she was
admitted for a planned stress echo.
During her stress test, she completed 9.5 minutes of a Gervino
protocol, representing average exercise tolerance of ___ METS,
stopped due to fatigue, without typical angina symptoms
reported, or significant ST segment changes. Stress echo showed
no evidence of inducible ischemia to achieved workload. There
was normal hemodynamic response to exercise.
She was monitored on telemetry and had no significant events.
She was ambulatory without symptoms and felt well after her
stress test, and so she was discharged with plan to follow-up
with cardiology as an outpatient.
#Hypertension: Patient reported hypertensive urgency at home.
Not noted to be hypertensive > 150s at ___.
-Amlodipine 5 mg once daily
-Valsartan 160 mg once daily
CHRONIC ISSUES:
===============
#Hyperlipidemia:
-Continued home atorvastatin 10 mg
#Dry eyes:
-Continued home eye drops
TRANSITIONAL ISSUES:
====================
-Cardiology follow-up arranged within one month
-Continued cardiac medications: amlodipine, aspirin,
atorvastatin, valsartan
-Code status: full
-CONTACT: ___ / ___ / Daughter (Health Care
Proxy)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 160 mg PO DAILY
2. Gabapentin 100 mg PO QHS
3. Desonide 0.05% Cream 1 Appl TP BID
4. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN rectal
itch
5. olopatadine 0.2 % ophthalmic DAILY
6. Docusate Sodium 200 mg PO DAILY
7. amLODIPine 5 mg PO DAILY
8. Cyclosporine 0.05% Ophth Emulsion 1 drop both eyes BID Other
DAILY
9. Atorvastatin 10 mg PO QPM
10. ciclopirox 0.77 % topical BID
11. TraMADol 50 mg PO BID:PRN Pain - Moderate
12. Aspirin 81 mg PO DAILY
13. Loratadine 10 mg PO DAILY:PRN allergies
14. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. ciclopirox 0.77 % topical BID
5. Cyclosporine 0.05% Ophth Emulsion 1 drop both eyes BID
Other DAILY
6. Desonide 0.05% Cream 1 Appl TP BID
7. Docusate Sodium 200 mg PO DAILY
8. Gabapentin 100 mg PO QHS
9. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN rectal
itch
10. Loratadine 10 mg PO DAILY:PRN allergies
11. olopatadine 0.2 % ophthalmic DAILY
12. TraMADol 50 mg PO BID:PRN Pain - Moderate
13. Valsartan 160 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
-Atypical chest pain
SECONDARY DIAGNOSES:
-Hypertension
-Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___:
You were admitted to the ___ on ___ for chest pressure
that radiated to the jaw, which was concerning for blocked
vessels in your heart. This happened while you were resting,
which increased our concern for clogged vessels to heart. During
your hospitalization, you did not have any additional symptoms
of chest pain or shortness of breath. We administered your home
medications.
On ___, we did a stress test of your heart, which
showed no evidence of coronary artery blockage in the heart.
This is good news, however it means that the exact cause of your
chest pain is not clear.
You did not have any chest pain or shortness of breath when you
were discharged from the hospital.
Please follow up with Dr. ___ on ___.
We hope you feel better. It was a pleasure to take care of you.
Your ___ Team
Followup Instructions:
___
|
10455482-DS-8 | 10,455,482 | 23,125,519 | DS | 8 | 2157-08-29 00:00:00 | 2157-08-31 20:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
clarithromycin
Attending: ___.
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Mechanical ventilation
Advanced vascular access
EGD ___
Paracentesis ___
History of Present Illness:
___ with EtOH cirrhosis c/b esophageal varices s/p banding ___,
thyroid CA s/p thyroidectomy, seizure d/o, depression
transferred via MedFlight after presenting with massive
hematemesis.
Per documentation, pt recently admitted to ___ on
___ with hematemesis secondary to esophageal varices
requiring banding x6 by Dr. ___ on ___. He was treated with a
five-day course of octreotide, was also treated for pneumonia
with Zosyn and vancomycin. He states that he was feeling fine
since discharge until he developed sudden onset vomiting bright
red blood just prior to arrival, filling the toilet twice. He
denies any recent alcohol. There was no associated fever, chest
pain, back pain, difficulty breathing, abdominal pain urinary
symptoms or black/bloody stools. He has had loose stools
however.
Patient reported to have continued hematemesis in OSH ED and was
intubated with concern for respiratory distress after
vecuronium. OSH H/H 8.1/24.5. 2 large bore PIVs then right
femoral line placed at OSH. Patient was bolused with octreotide,
protonix with gtt initiated, given zosyn, received 4 units
pRBCs. He received an additional 2 units pRBCs during med
flight.
In ED initial VS: 97.2 SBP 109/76, 92, 20, 100% on vent
ED Exam: notable with melena in bed
massive transfusion protocol initiated
Patient was initiated on fentanyl/midazolam for sedation.
Given 1 unit of FFP, 2g Calcium gluconate
Imaging notable for: CXR revealing ET tube at 3.8 cm
Hepatology was consulted, plan to consider endoscopy in MICU.
On arrival to the MICU, patient producing large clots in mouth
and into ET tube.
Past Medical History:
EtOH use disorder
Cirrhosis c/b variceal bleeding s/p banding ___
HTN
dyslipidemia,
thyroid CA (s/p thyroidectomy)
GERD
seizure disorder
depression
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION:
VITALS: 97.2 88 104/70 18 100%vent
GENERAL: intubated and sedated
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated
LUNGS: clear to anterior auscultation
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: 2+ pulses, no clubbing, cyanosis or edema
DISCHARGE:
VS: 98.1 PO 112/71 L Lying 50 18 95 RA
GENERAL: Thin middle-aged man, not in distress
HEENT: +Icterus. MMM.
NECK: JVP not elevated. RIJ ___ removed, dressing CDI.
HEART: RRR, no murmurs rubs or gallops.
LUNGS: Non-labored, CTAB.
ABDOMEN: Soft, non-distended, non-tender, .
EXTREMITIES: Warm, well-perfused, no edema.
SKIN: No rashes or lesions.
NEUROLOGIC: A&Ox3. No asterixis. EOMI, face symmetric,
repositions in bed without weakness or ataxia.
PSYCHIATRIC: Much improved with less anxiety
Pertinent Results:
ADMISSION LABS
==============
___ 01:58AM BLOOD WBC-21.0* RBC-3.61* Hgb-11.9* Hct-35.2*
MCV-98 MCH-33.0* MCHC-33.8 RDW-17.1* RDWSD-58.3* Plt ___
___ 01:58AM BLOOD Plt ___
___ 01:58AM BLOOD ___ PTT-33.1 ___
___ 01:58AM BLOOD Glucose-130* UreaN-13 Creat-1.4* Na-130*
K-5.7* Cl-99 HCO3-17* AnGap-20
___ 01:58AM BLOOD ALT-19 AST-65* AlkPhos-103 TotBili-2.9*
___ 01:58AM BLOOD Calcium-6.4* Phos-5.2* Mg-1.8
___ 01:58AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:55PM BLOOD Hapto-<10*
___ 02:04AM BLOOD ___ pO2-66* pCO2-51* pH-7.22*
calTCO2-22 Base XS--7 Comment-GREEN TOP
___ 02:04AM BLOOD Glucose-131* Lactate-2.5* Na-132* K-5.7*
Cl-104
___ 02:04AM BLOOD Hgb-12.2* calcHCT-37 O2 Sat-88 COHgb-4
MetHgb-0
___ 02:04AM BLOOD freeCa-0.83*
___ 09:10AM BLOOD freeCa-1.10*
___ 02:08AM URINE Color-Yellow Appear-Clear Sp ___
___ 02:08AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 02:08AM URINE RBC-<1 WBC-3 Bacteri-FEW Yeast-NONE
Epi-<1
___ 10:13AM URINE Mucous-RARE
___ 10:13AM URINE CastHy-8*
___ 12:51PM ASCITES TNC-66* RBC-225* Polys-24* Lymphs-24*
___ Mesothe-6* Macro-46* Other-0
___ 02:51PM ASCITES TNC-66* RBC-150* Polys-10* Lymphs-0
Monos-2* Mesothe-2* Macroph-86*
___ 02:51PM ASCITES TotPro-0.5 Glucose-110 Creat-1.2
LD(LDH)-36 TotBili-0.3 Albumin-0.4
DISCHARGE LABS
==============
___ 05:43AM BLOOD WBC-8.6 RBC-2.49* Hgb-7.9* Hct-24.0*
MCV-96 MCH-31.7 MCHC-32.9 RDW-18.4* RDWSD-61.7* Plt ___
___ 05:43AM BLOOD ___ PTT-33.9 ___
___ 05:43AM BLOOD Glucose-121* UreaN-12 Creat-1.2 Na-136
K-3.9 Cl-102 HCO3-21* AnGap-17
___ 05:43AM BLOOD ALT-21 AST-85* AlkPhos-119 TotBili-2.1*
___ 05:43AM BLOOD Albumin-3.6 Calcium-7.4* Phos-2.9 Mg-1.9
MICRO
==============
___ 2:51 pm PERITONEAL FLUID PERITONEAL FLUID.
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 (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 10:58 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 9:43 pm BLOOD CULTURE Source: Line-tlc.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:30 pm BLOOD CULTURE Source: Line-tlc.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 12:51 pm PERITONEAL FLUID
SITE VERIFIED BY: ___ (___) AT 15:11 ON ___.
**FINAL REPORT ___
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 (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 10:13 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 2:15 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:08 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING & STUDIES
==============
+ EGD ___
Findings:
There was a column of blood upon entering the esophagus. There
was a mix of newer and older blood in the stomach. This could
not be cleared and therefore the fundus was not visualized,
however his recent endoscopy did not reveal any gastric varices.
In the esophagus there were multiple cords of medium sized
varices. There were multiple (~4) areas of ulceration,
presumably from recent banding. There were multiple red ___
signs distal to this area. There was one varix with an overlying
clot. That varix was banded distal to the clot, decompressing
it. The varix then occupied the entire lumen of the esophagus
and at that point no other areas were amenable to banding. 1
band was successfully placed in the distal esophageal varix as
described.
Impression:
Blood in the esophagus and stomach. Multiple medium sized
varices, some with red ___ signs and some with ulcers from
prior banding. Clot overlying one varix, which was banded distal
to that clot. (ligation)
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
BRIEF SUMMARY
====================
___ with EtOH cirrhosis who was ___ transferred from
___ to ___ MICU for massive variceal re-bleed after
recent banding. He was intubated for airway protection and
resuscitated with massive transfusions and pressors, as well as
octreotide, PPI, and prophylactic ceftriaxone. EGD found
multiple esophageal varices with high risk features, one of
which was banded, as well as ulcers from prior banding. TIPS was
considered but ultimately not done since the patient's bleeding
stopped. He was monitored on the floor and restarted on
diuretics and nadolol and was discharged in stable condition
with close follow-up.
MICU COURSE
===================
#HEMORRHAGIC SHOCK: variceal bleed, initially resuscitated with
pRBCs/FFP/platelets and neo. GIB managed as below.
#GIB: found to have grade 3 varices with stigmata of recent
bleeding, requiring banding. He stabilized without further
episodes of hematemesis. ___ was consulted for possible TIPS but
wasn't necessary in the acute setting.
#ACUTE RESPIRATORY FAILURE: intubated in the setting of massive
GI bleed, successfully extubated once bleeding stabilized.
#ETOH CIRRHOSIS: MELD 25, followed by GI at ___.
Recently discharged from 2 week detox program. BB and diuretics
held in the setting of hemorrhagic shock.
FLOOR COURSE
====================
# VARICEAL HEMORRHAGE:
Patient remained stable after finishing a 5-day course of
octreotide, IV PPI, and prophylactic ceftriaxone. TIPS was
considered but ultimately not done since bleeding stopped.
Patient was restarted on diuretics and nadolol and was
discharged in stable condition with close follow-up.
# COAGULOPATHY
Likely due to both cirrhosis and losses from hemorrhage. INR
remained stable without need for Vitamin K or FFP.
# ASCITES
Unclear whether patient is truly diuretic refractory since he
was actively drinking before admission and diuretics were held
in the setting of variceal bleeding. After resolution of
bleeding and ___, he underwent therapeutic paracentesis with
7.5L removed with good relief of symptoms. His previous diuretic
regimen was then resumed (furosemide 40 / spironolactone 100).
# DECOMPENSATED ETOH CIRRHOSIS:
MELD in high ___. Decompensated by variceal bleeding and
ascites. No h/o SBP or HE. Followed by GI at ___.
Recently discharged from 2 week detox program. Nadolol and
diuretics were held in the setting of hemorrhagic shock and then
restarted. Patient was discharged with a limited course of cipro
prophylaxis in the setting of GI bleeding. (No hard indications
for long-term ppx but could consider since ascites protein 0.5,
deferred to outpatient providers.)
# ___:
Cr peaked at 1.7, unknown baseline. Likely prerenal in the
setting of hemorrhagic shock. Urine output and Cr improved with
resuscitation.
# ALCOHOL USE DISORDER
Patient reportedly recently completed a 2-week abstinence
program. Social work was consulted while inpatient. Patient was
treated empirically with IV thiamine 500 q8h x 3 days, folate,
and multivitamin.
CHRONIC ISSUES
====================
#THYROID CANCER S/P THYROIDECTOMY
Maintained on home levothyroxine dose.
#DEPRESSION:
Home venlafaxine and quetiapine were initially held in the
setting of acute GIB, then restarted prior to discharge.
TRANSITIONAL ISSUES
====================
- Discharge weight: 73.76 kg
- Discharge diuretics: furosemide 40mg, spironolactone 100mg
daily
- Encourage patient to enroll in structured alcohol abstinence
program.
- Recommend continued social work support
- Nadolol was increased from 20 to 40 mg daily with HR at target
(___).
- Patient was discharged on pantoprazole daily and sucralfate
QID for ___ week course. Reevaluate in ___ weeks whether to
continue.
- Needs follow-up with his outpatient GI Dr. ___
consideration of repeat EGD. Can discuss TIPS if warranted.
- Will continue PO antibiotics for an additional 2 days upon
discharge (last day ___. No hard indications for long-term
prophylaxis but could consider since ascites protein was 0.5.
- Evaluate need for keppra, unclear why he was on medication
before.
# CODE: Full (confirmed)
# CONTACTS:
Healthcare Proxy: ___ ___
Alternate Contacts: ___ (sister) ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Potassium Chloride 20 mEq PO DAILY
3. Venlafaxine 25 mg PO DAILY
4. Acamprosate 333 mg PO BID
5. Levothyroxine Sodium 200 mcg PO DAILY
6. Gabapentin 300 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Lactulose 30 mL PO QID
9. Magnesium Oxide 400 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Nadolol 20 mg PO DAILY
12. Simethicone 80 mg PO DAILY
13. Furosemide 40 mg PO DAILY
14. LevETIRAcetam 500 mg PO BID
15. Nicotine Patch 7 mg TD DAILY
16. QUEtiapine Fumarate 25 mg PO BID
17. QUEtiapine Fumarate 25 mg PO QHS
18. Spironolactone 100 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q24H
Please take for an additional 2 days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth Daily Disp #*2
Tablet Refills:*0
2. Miconazole 2% Cream 1 Appl TP BID:PRN Groin Rash
RX *miconazole nitrate 2 % apply to rash twice daily Refills:*0
3. Pantoprazole 40 mg PO Q24H Duration: 8 Weeks
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*56
Tablet Refills:*0
4. Sucralfate 1 gm PO QID Duration: 8 Weeks
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*224 Tablet Refills:*0
5. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days
RX *zinc sulfate 220 mg (50 mg zinc) 1 capsule(s) by mouth daily
Disp #*14 Capsule Refills:*0
6. Nadolol 40 mg PO DAILY
RX *nadolol 40 mg 1 tablet(s) by mouth Daily Disp #*60 Tablet
Refills:*0
7. Acamprosate 333 mg PO BID
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
9. FoLIC Acid 1 mg PO DAILY
10. Furosemide 40 mg PO DAILY
11. Gabapentin 300 mg PO BID
12. Lactulose 30 mL PO QID
13. LevETIRAcetam 500 mg PO BID
14. Levothyroxine Sodium 200 mcg PO DAILY
15. Magnesium Oxide 400 mg PO BID
16. Multivitamins 1 TAB PO DAILY
17. Nicotine Patch 7 mg TD DAILY
18. Potassium Chloride 20 mEq PO DAILY
19. QUEtiapine Fumarate 25 mg PO BID
20. QUEtiapine Fumarate 25 mg PO QHS
21. Simethicone 80 mg PO DAILY
22. Spironolactone 100 mg PO DAILY
23. Venlafaxine 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=====================
Esophageal varices with hemorrhage
SECONDARY DIAGNOSES
=====================
Hemorrhagic shock
Acute respiratory failure
Decompensated alcoholic cirrhosis with ascites
Coagulopathy due to cirrhosis
Acute renal failure
Alcohol use disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why you were admitted:
- Bleeding from your esophagus and stomach
What we did while you were here:
- You were admitted to the Intensive Care Unit
- You needed to be placed on a breathing machine temporarily
- We gave you blood transfusions and medicines to save your life
- We did an EGD where we looked inside your esophagus with a
camera and placed bands to stop the bleeding
- Fortunately the bleeding stopped and you got better
Instructions for when you leave the hospital:
- Take all of your medications as prescribed to lower your risk
of having another bleed.
- We highly recommend you join a structured program to help you
stay sober. This is the most important thing you can do for your
health.
- Follow up with your primary care and liver doctors. ___ below
- ___ to the hospital immediately if you have any bleeding,
fever, confusion, or other symptoms that worry you.
We wish you all the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10455683-DS-13 | 10,455,683 | 24,031,399 | DS | 13 | 2158-09-30 00:00:00 | 2158-09-30 09:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Mental status changes s/p falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o gentleman transferred from an OSH with a
diagnosis of L frontal SAH, SDH, and intraparenchymal bleeds on
CT scan. Patient presented to OSH with father who reported falls
in the last week. ___ father brought
him to OSH for slurred speech and sleepiness. Patient reports
headache. Denies numbness, weakness, tingling, blurred vision,
double vision, nausea or vomiting. Patient also denies falling
but it is clear from the history he is not fully oriented. Pt
was not loaded with AED at OSH. Upon arrival patient is slightly
lethargic, but interacts readily and is appropriate.
Neurosurgery was consulted to evaluate him in the setting of his
intracranial bleeding.
Past Medical History:
Hypertension
Hyperlipidemia
Social History:
___
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
O: T: 98.4 HR: 66 BP: 134/80 RR: 14 Sat: 99% 2L
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nystagmus
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to self, ___, and ___
Language: Speech slightly slowed but fluent with good
comprehension and repetition. Naming intact. No dysarthria or
paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2mm to
1.5mm bilaterally and slightly sluggish. 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, proprioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
On discharge:
A&Ox2
Full motor
Pertinent Results:
___ NCHCT:
Stable left frontal subdural hematoma, hemorrhagic contusions
and small focus of right parafalcine subarachnoid hemorrhage as
well as subdural hematoma along the right tentorium cerebelli,
follow-up head CT is recommended to evalute evolution.
Brief Hospital Course:
Mr. ___ was admitted to the Neurosurgery service on ___
after being transferred from an outside hospital with a
diagnosis of left subdural hematoma, hemorrhagic contusions, and
subarachnoid hemorrhage. He was loaded with Dilantin in the ED
and transferred to the floor for further observation and
management. A repeat Head CT performed on the morning of ___
was stable from the previous CT scan. The patient had presented
on ___ with a creatinine of 2.2 and was started on IV fluids;
the creatinine had decreased to 1.9 by the morning of ___ and
1.7 on ___. Sodium levels were decreased at 131 on admission
and slowly normalized. On ___, patient was cleared by ___ to be
discharged home. He was ambulating and eating appropriately.
Medications on Admission:
Lisinopril, Atenolol, Percocet
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
3. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left frontal SDH, hemorrhagic contusions, and SAH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to ___.
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
10455694-DS-10 | 10,455,694 | 29,811,294 | DS | 10 | 2162-06-16 00:00:00 | 2162-07-02 13:44:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Motor Vehicle Collision with ejection
Major Surgical or Invasive Procedure:
___:
PROCEDURES PERFORMED:
1. Open treatment cervical fracture dislocation.
2. Anterior cervical discectomy with interbody arthrodesis,
C6-C7.
3. Interbody reconstruction with biomedical device.
4. Anterior plate reconstruction, C6-C7.
5. Autograft, same incision.
___:
Open tracheostomy
___
___ procedure: 18 ___ G-tube placement
History of Present Illness:
___ (aka ___ unrestrained driver - car vs car.
Reportedly +starred windshield, unresponsive at the scense - he
was reportedly "blue and hanging out the passenger side window".
He was ambu bagged to OSH where he was intubated and transferred
to ___ for further care.
Trauma activation was declared. A NCHCT was obtained, a small L
sided tSAH was noted.
Past Medical History:
Past Medical History:
Lumbrosacral back pain
Decreased right grip strength
?bipolar disorder
?depression
ADHD
anxiety
Past Surgical History:
Left Rotator Cuff Repair
Social History:
___
Family History:
FAMILY PSYCHIATRIC HISTORY:
-History of psychiatric disorders: anxiety and depression in
pt sons
-History of suicide attempts: denies
-History of substance use: denies
Physical Exam:
Discharge Physical Exam:
VS: T: 97.3 PO BP: BP: 102/63 R Sitting HR: 64 RR: 18 O2: 98% Ra
GEN: A+Ox3, NAD
HEENT: MMM. Previous tracheostomy site healed with no s/s
infection.
CV: RRR
PULM: No respiratory distress, breathing comfortably on room
air.
ABD: prior G-tube site scabbed with no s/s infection. Soft,
non-distended, non-tender to palpation
EXT: wwp, no edema b/l
Pertinent Results:
IMAGING:
___: CT C-spine:
1. Acute fracture of the left occipital condyle with left alar
ligament
avulsion.
2. Acute fracture at the left C6 transverse process, for which
CTA is needed to exclude injury to the vertebral artery.
3. Left C7 superior facet fracture.
4. Asymmetric widening of the right C6-7 facet joint, likely
acute.
RECOMMENDATION(S): CTA neck
___: CT Head:
Isolated focus of subarachnoid hemorrhage in a left
temporoparietal region
sulcus.
___: CT Chest:
1. Small to moderate right pneumothorax with small right
hemothorax and no
signs of active bleeding.
2. Multiple right-sided rib fractures detailed above with
greater than 4
segmental rib fractures concerning for flail chest.
3. Adjacent to the right eighth lateral rib fracture which is
markedly
displaced, there is a small traumatic lung herniation.
4. Significant atelectasis of the right lower lobe.
5. Right chest wall emphysema tracks into the right neck likely
related to
right pneumothorax.
___: MRI C-spine:
1. Previously identified cervical spine fractures are better
visualized on CT examination. Unchanged widening of the right
C6-C7 facet joint with associated injury to the interspinous
ligament and disruption of the right posterior aspect of the
disc at this level. The posterior longitudinal ligament is
intact.
2. Widening of the C6-C7 anterior interspace with injury to the
anterior
longitudinal ligament and disruption of disc.
3. To a lesser degree, widening of the C5-C6 anterior interspace
with possible injury to the anterior margin to ligament and swab
than of the anterior aspect of the disc.
4. No additional acute fracture or traumatic malalignment of the
thoracic or cervical spine is identified.
5. Diffuse muscle edema predominantly along the right neck
contrast lesser
degree along the left neck is consistent with ligamentous
injury.
6. Multilevel degenerative changes of the cervical spine as
detailed above are most pronounced at C4-C5 where there is a
disc extrusion resulting in
remodeling of the ventral cord but without cord signal
abnormality.
7. Multilevel degenerative changes of the lumbar spine as
detailed above with congenital lumbar spine canal stenosis are
most pronounced at L2-L3 and L3-L4 with there is moderate spinal
canal stenosis and L3-L4 severe left and moderate right neural
foraminal narrowing.
8. Small right pleural effusion with associated atelectasis.
___: CTA Head & Neck:
1. Small amount of subarachnoid hemorrhage in the
bilateraltemporoparietal
lobes is unchanged. New subarachnoid hemorrhage in the right
aspect of the quadrigeminal cistern likely represents
redistribution.
2. No evidence of cervical or intracranial vessel injury.
3. Unchanged cervical spine fractures, better depicted on the
dedicated CT of the cervical spine.
4. Redemonstration of subcutaneous soft tissues along the right
lateral neck, extending anteriorly and superiorly to the right
carotid space as well as inferiorly to the level of the chest.
5. Stable small right apical pneumothorax
6. An endotracheal tube and orogastric tube are present. Small
amount of
fluid in the nasopharynx.
___: CTA Chest:
1. Pulmonary emboli extending from the right upper lobar
bifurcation to
segmental and subsegmental branches.
2. No central pulmonary embolism through the lobar level on the
left.
Segmental and subsegmental branches cannot be assessed secondary
to
heterogeneous opacification and motion artifact. Questionable
segmental
pulmonary emboli in the left upper lobe.
3. Complete collapse of the right middle and lower lobes.
Heterogeneous
enhancement suggests a superimposed pneumonia. ___ and
ground-glass opacities in the bilateral apices likely represent
aspiration.
4. Right basilar chest tube. Right pneumothorax seen on prior
CT from ___ has resolved.
5. Redemonstration of displaced fractures of the right fourth
through
eleventh ribs. The right seventh and eighth ribs are displaced
by greater
than one shaft width.
___: CT C-spine:
1. Status post spinal fusion at C6-7 level since the previous
MRI study.
2. No evidence of intraspinal hematoma.
3. Mild spinal cord deformity at C4-5 level due to central
protrusion is
unchanged from the previous study.
4. No abnormal signal seen within the spinal cord.
___: MRI Head:
Punctate diffusion and susceptibility abnormalities suggestive
of diffuse
axonal injury. Small right frontal subdural effusion. No
hydrocephalus,
midline shift or side and soft herniation.
___: ___ G-tube Placement:
Successful placement of a MIC 18 ___ gastrostomy tube. The
catheter should not be used for 24 hours.
LABS:
___ 06:39PM GLUCOSE-135* UREA N-11 CREAT-0.7 SODIUM-142
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-23 ANION GAP-14
___ 06:39PM ALT(SGPT)-80* AST(SGOT)-141* ALK PHOS-71 TOT
BILI-0.4
___ 06:39PM ALBUMIN-4.3 CALCIUM-8.1* PHOSPHATE-2.9
MAGNESIUM-1.9
___ 06:39PM WBC-12.5* RBC-4.32* HGB-14.2 HCT-42.1 MCV-98
MCH-32.9* MCHC-33.7 RDW-14.6 RDWSD-52.5*
___ 06:39PM ___ PTT-24.6* ___
___ 03:29PM GLUCOSE-91 LACTATE-1.7 NA+-144 K+-3.4
CL--111* TCO2-22
___ 03:29PM HGB-14.1 calcHCT-42
___ 03:23PM estGFR-Using this
___ 03:23PM ASA-NEG ___ ACETMNPHN-NEG
tricyclic-NEG
___ 03:23PM PLT COUNT-240
___ 03:23PM ___ PTT-24.1* ___
Brief Hospital Course:
Mr. ___ is a ___ year old male who was transferred to ___
___ on ___ after a MVC with R
___ rib fx, flail chest, L SAH, right hemo-pneumothorax,
C6-C7,T1 fractures, and alar ligament avulsion. He was intubated
and sedated on arrival. A right pleural pigtail was placed.
Plastics was consulted for a right ear lac, neurosurgery was
consulted for the trace L SAH, and ortho spine was consulted for
the spine fractures. Patient was admitted to the trauma ICU for
management of polytrauma.
In the ICU, APS was consulted for placement of an epidural in
the setting of his multiple rib fractures. ___ requested repeat
NCHCT, which was stable, and recommended no keppra and to hold
SQH. The patient was taken to the operating room with spine
surgery on ___ underwent a C6-C7 anterior
discectomy with anterior plate fusion. The patient tolerated the
procedure well without complications and returned to the ICU
intubated. Remainder of his hospital course will be discussed by
systems below.
Neuro: The patient's pain was initially controlled with an
epidural. This was discontinued after 5 days and then he was
transitioned to oral pain medication with IV breakthrough.
Regarding the patient's small subarachnoid hemorrhage, evaluated
by neurosurgery and they signed out shortly thereafter when his
hemorrhage was deemed to be stable. He did not require Keppra.
After the patient was extubated, he was slow to arouse but was
following commands appropriately. Patient's mental status did
not improve and again worsened when he was reintubated.
Cardiovascular: Patient was hemodynamically stable throughout
his admission and never required sustained pressor support. He
is actually found to be hypertensive and transferred to the
floor and was started on low-dose of lisinopril for blood
pressure control.
Pulmonary: The patient suffered multiple right-sided rib
fractures complicated by right hemopneumothorax at the time of a
motor vehicle crash. A right sided pigtail was placed in the ED
and was removed on ___. He suffered multiple pulmonary
complications and issues with his respiratory status throughout
his admission. During his initial ICU stay, the patient
underwent bronchoscopy was found to have a Haemophilus
pneumonia. He was treated with ceftriaxone for this. He was
extubated to high flow nasal cannula, eventually weaned to
regular nasal cannula, and transferred to the surgical floor on
___. Next day, the patient was treated for increased work
of breathing and hypoxia and was transferred back to the ICU.
He was found to have pulmonary embolisms and was started on a
heparin drip after clearance with neurosurgery. He also
underwent repeat bronchoscopy which demonstrated a new or
worsening pneumonia in the right middle and lower lobes. His
antibiotics were broadened at this time. The patient was soon
weaned to minimal vent settings and passed his spontaneous
breathing trial on ___. He was extubated a second time,
however he desatted only 2 hours after extubation and required
reintubation. Bronchoscopy was performed which demonstrated
substantial blood clots worse on the right, which were suctioned
out of the lungs. On ___ he was taken to the operating room
and underwent open tracheostomy.
GI: The patient was initially kept n.p.o. on IV fluids. After
he was extubated, the patient was unable to pass a speech and
swallow assessment given his prolonged altered mental status.
So, a Dobbhoff tube was placed for enteral access, and tube
feeds were initiated.
GU: The patient's renal function and urine output were monitored
closely throughout his ICU course. His kidney function remained
normal. His diuresis is appropriate based on clinical
assessment of his volume status.
Heme: The patient's prophylactic subcu heparin was held for 3
days on admission due to his subarachnoid hemorrhage.
Subsequently developed pulmonary embolism and was initiated on a
heparin drip on ___.
Infectious disease: The patient underwent treatment for
right-sided pneumonia. He was initially treated with
ceftriaxone for a Haemophilus pneumonia. However, his
antibiotics were broadened after he continued to spike fevers
and repeat bronchoscopy demonstrated worsening infection in the
right middle and lower lobes.
Musculoskeletal: Patient suffered C6-C7 fractures with pallor
ligament avulsion, was taken to the operating room with ortho
spine for anterior discectomy and anterior plate fusion on
___. He remained in a c-collar postoperatively per
orthospine.
Floor course: ___
Neuro:
The patient had periods of agitation that waxed and waned.
Psychiatry was consulted for delirium and agitation. They
started him on Depakote and PRN olanzapine. Over the course of
his floor stay, he became increasingly more awake and
interactive, but did exhibit sundowning with acute agitation. He
received PO and IV Haldol as needed when patient was a danger to
himself and others. The psychiatry team was actively involved in
medical management of the patients delirium and agitation. Both
pharmacologic and non-pharmacologic interventions were
instituted.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. He had a few
episodes of hypotension which resolved once anti-hypertensives
were discontinued.
Pulmonary: The patient was treated with Vancomycin for presumed
MRSA pneumonia due to rising WBC and increased secretions. Good
pulmonary toilet and early mobilization were encouraged
throughout hospitalization.
GI: The patient was initially kept NPO with PEG tube in place.
He tolerated tube feeds at goal rate. The patient was followed
by speech language pathology team who continued to monitor
ability to swallow. He had multiple PO trials and was eventually
transitioned to a soft regular diet and thin liquids with 1:1
supervision. His tube feeds were cycled, decreased, and then
ultimately discontinued once he was tolerating a regular diet.
His PEG tube was removed on ___ as it was no longer needed.
Ultimately, upon discharge he was cleared for a regular diet
with thin liquids.
GU/FEN:
Patient's intake and output were closely monitored. He was
initially incontinent of urine and condom catheter was applied
to maintain skin integrity and monitor urine output. He
eventually regained continence and voided without issue.
ID: The patient's fever curves were closely watched for signs of
infection. As noted above, he was treated with vancomycin for
presumed hospital acquired pneumonia based on rising WBC and
increased sputum production.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none. Given the patients
stability, daily labs were not continued.
Prophylaxis: Given the above mentioned pulmonary embolisms seen
on imaging, Eliquis was initiated. It was determined that he
would require a 3 (three) month course of Eliquis and this
medication was initiated on ___. ___ dyne boots were used
during this stay and was encouraged to get up and ambulate as
early as possible.
MSK: Hard cervical collar was maintained for s/p C6-7 ACDF and
eventually removed on ___ once cleared by orthopedic spine
surgery.
The patient was noted to have decreased mobility in the right
arm that was difficult to assess due to his mental status.
Initially Neurology recommended an MRI with of the brachial
plexus was considered but the patient's mental status would not
allow for an accurate study do to inability to lie flat/still.
Collateral information was obtained from the patient's parents
who reported history of right sided rotator cuff and elbow
injury. Therefore further imaging and diagnostic testing was not
done during this hospitalization.
He also developed hand pain, for which a radiograph was obtained
showing no fracture.
Multiple interdisciplinary family meetings were held to work on
a safe discharge plan for the patient. He was ultimately cleared
to be discharged to a skilled nursing facility.
-----
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Apixaban 5 mg PO BID
3. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
4. Divalproex Sod. Sprinkles 500 mg PO DAILY BETWEEN 1400-1500
5. Divalproex Sod. Sprinkles 750 mg PO QHS
6. Divalproex Sod. Sprinkles 500 mg PO DAILY
7. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
8. FoLIC Acid 1 mg PO DAILY
9. Haloperidol 4 mg PO BID
10. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
11. Lidocaine 5% Patch 2 PTCH TD QAM:PRN pain
12. Nicotine Patch 7 mg/day TD DAILY
13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
14. Propranolol 60 mg PO BID
15. Ramelteon 8 mg PO QHS for sleep
Should be given 30 minutes before bedtime
16. Senna 8.6 mg PO BID:PRN Constipation - Second Line
17. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
[] Displaced fractures of the right fourth through eleventh ribs
with right hemopneumothorax
[] Left SAH in temperoparietal sulcus
[] Left C6 transverse process fracture
[] Right C6-7 facet joint widening
[] Left occipital condyle fracture, alar ligament avulsion
[] Right ear laceration to concha
[] L3 TP fracture
[] Diffuse axonal injury, moderate encephalopathy
[] Respiratory failure secondary to aspiration pneumonia
(HAP/VAP)
[] Pulmonary emboli extending from the right upper lobar
bifurcation to segmental and subsegmental branches
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after a motor vehicle
collision. You suffered a traumatic brain injury, cervical spine
injury, right sided rib fractures with an associated lung
injury. You underwent surgery to stabilize your neck and the
hard collar was later cleared to be removed by the Spine team as
it was no longer needed. You had a chest tube placed to drain
blood from your lung cavity and to help re-inflate the lung.
This was later removed. Due to your severe head injury, you were
unable to safely handle respiratory secretions or eat food on
your own, so a tracheostomy tube and gastrostomy tube (G-tube)
were place; you received your nutrition and medications through
the G-tube. Once your breathing improved the tracheostomy was
removed. You were also treated for pneumonia, and started
anticoagulation for a pulmonary embolism (blood clot in your
lung). The G-tube was also removed as you were eating and
drinking adequately. You are now medically stable and ready to
continue your recovery at a skilled nursing facility.
Please note the following discharge instructions:
Return to the Emergency Department or see your own doctor right
away if any problems develop, including the following:
Persistent nausea or vomiting.
Increasing confusion, drowsiness or any change in alertness.
Loss of memory.
Dizziness or fainting.
Trouble walking or staggering.
Worsening of headache or headache feels different.
Trouble speaking or slurred speech.
Convulsions or seizures. These are twitching or jerking
movements of the eyes, arms, legs or body.
A change in the size of one pupil (black part of your eye) as
compared to the other eye.
Weakness or numbness of an arm or leg.
Stiff neck or fever.
Blurry vision, double vision or other problems with your
eyesight.
Bleeding or clear liquid drainage from your ears or nose.
Very sleepy (more than expected) or hard to wake up.
Unusual sounds in the ear.
Any new or increased symptoms
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10455855-DS-24 | 10,455,855 | 28,197,045 | DS | 24 | 2172-07-23 00:00:00 | 2172-07-26 08:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___omplete heart block s/p pacer
___, CKD, and CAD presents who presents with dizziness resulting
in a near fall. Patient woke up in at 3am this morning to use
the toilet and suddenly felt dizzy while walking. She fell
against her chair and caught herself. She denied any loss of
consciousness or head trauma, however she could not make it to
the toilet in time and had an episode of bowel incontinence. She
describes the dizziness as the room spinning when turning her
head or after she stands up. Patient reports having dizziness
for the past ___ years with episodes about ___ per week. She
notices that her dizziness severity is increasing. Patient
reports her right ear feels like "there is water in it" fo the
past 3 months. She denies any ear pain, tinnitus or headaches.
Patient's last fall was a few months ago. She has had previous
hospitalizations for dizziness. She reports bloody bowel
movements twice per day for the past 3 months. Patient describes
bright red blood in the toilet with clots. She says she had a
known history of hemorrhoids. Patient believes her last
colonoscopy was within ___ years and she was supposed to follow up
with another after ___ years. Patient denies any recent illness,
fever, chest pain, palpitations or shortness of breath.
In ED found to have:
Prominent nystagmus, equivocal ___, ___ SEM.
EKG: Unchanged from prior: Apaced, LAD, extensive qwaves, LVH,
TWI I and avl
500cc bolus
Chem7, CBC, CXR - Final read pending
UA - dirty, few whites, given Bactrim x1
Past Medical History:
2. CARDIAC HISTORY:
- PERCUTANEOUS CORONARY INTERVENTIONS: ___ in ___ RCA
stent placed
- PACING/ICD: ___ in ___ DDDR pacer placed for
bradycardia, last check ___: DDDR mode with a base rate of
65, a rest rate of 60, a maximum track rate of 110 and an upper
sensor rate of 105 beats per minute. The mode switch function
is ON for atrial rates greater than 180 beats per minute.
3. OTHER PAST MEDICAL HISTORY:
- T2DM
- arthritis
- cholelithiasis
- chronic abdominal pain
- complete heart block
- CAD
- diverticulitis
- hypertension
- hyperlipidemia
- osteomalacia
- peripheral edema
- peripheral neuropathy
- peripheral vascular disease
- PPD positive ___
- acute kidney injury
- spinal stenosis
- dysphagia
- chronic kidney disease (baseline Cr 1.6-1.8)
- Recurrent UTIs
- Chronic oral pain ___ poor-fitting dentures
Social History:
___
Family History:
Mother died of stroke; father died of MI at ___ yo. One brother
died from lung cancer. Her daugther has colon cancer.
Physical Exam:
On Admission:
VS - AF 98.0 182/90 HR 60 sat 98% on RA
Orthostatics: standing --> 138/80 HR 60
GENERAL - NAD, lyingD comfortably in bed
HEENT - dry oral mucosa, patient itching nose repeatedly
LUNGS - CTAB, no whezes
HEART - NR, RR, systolic ejection murmur ___ heard throughout
ABDOMEN - NT, ND, soft
EXTREMITIES - no lower ext edema
SKIN - no rash or skin lesions
NEURO - nystagmus with gaze in any direction, CN's otherwise
wnl; Pupils were 1mm bilaterally
RECTAL- no masses or fissures, guaiac was negative
On Discharge:
AF 99.1 130-190/70-80s HR 60's sat 98-100% on RA
GENERAL - NAD, lying comfortably in bed
HEENT - dry oral mucosa, patient itching nose repeatedly
LUNGS - CTAB, no whezes
HEART - NR, RR, systolic ejection murmur ___ heard throughout
ABDOMEN - NT, ND, soft
EXTREMITIES - no lower ext edema
SKIN - no rash or skin lesions
NEURO - nystagmus with gaze in any direction, CN's otherwise
wnl; Pupils were 1mm bilaterally; Patient stood up this morning
and did not feel dizzy which was improved. She also was able
turn her head side to side without becoming dizzy this morning
which was also improved.
Pertinent Results:
___ 06:00AM BLOOD WBC-7.6 RBC-3.88* Hgb-12.2 Hct-37.4
MCV-96 MCH-31.4 MCHC-32.5 RDW-13.5 Plt ___
___ 08:30AM BLOOD Hct-37.7
___ 06:00AM BLOOD Glucose-158* UreaN-32* Creat-1.8* Na-136
K-6.1* Cl-99 HCO3-28 AnGap-15
___ 08:30AM BLOOD UreaN-24* Creat-1.7* Na-141 K-4.7 Cl-106
HCO3-28 AnGap-12
Cardiovascular Report ECG Study Date of ___ 5:10:08 AM
A-V sequentially paced rhythm at 65 beats per minute. Compared
to the previous tracing of ___ findings are similar.
Brief Hospital Course:
Ms. ___ is a ___omplete heart block s/p pacer
___, CKD and CAD presents who presented with positional
dizziness and orthostasis resulting in a near fall orthostatic
hypotension.
# Orthostasis: Patient found to be markedly orthostatic in
setting of diuretic use and doxazosin. She also likely has
diabetic autonomic dysfunction. Patient's orthostasis improved
with giving fluids, holding doxazosin, HCTZ and codeine. Her
orthostasis is likely contributing to her dizziness. Cardiac
etiology is possible, although less likely based on symptoms. EP
interrogated pacer and found no events.
- Discontinued doxazosin
- Discontinued codeine cough syrup
- Restart home HCTZ
# Dizziness: Likely primarily due to orthostasis as resolved
with management. Patient could have vestibular system
dysfunction. Since her vertigo is positional, she could have
Benign Positional Vertigo. Patient likely also symptomatic from
codeine based on her pinned pupils, itchy nose, and slow
movements on admission. The differential diagnosis also includes
labyrinthitis, menieres, vestibular schwannoma, multiple
sclerosis, and cerebellar tumor. Her ear fullness was mildly
concerning for some anatomical issue with her vestibular system.
Patient could not keep eyes open long enough for ___ as
appeared to be sedated with pinned pupils from home codeine.
There is no concern for seizure. Considered imaging test of
head, however dizziness improving and was only positional before
making need for imaging less likely.
- avoid sedating medications
- Looked in ears with otoscope on ___ and had no external signs
of anatomic defect
- ___ consulted: home services
# Hematochezia: Likely due to known hemorrhoids. Patient is
hemodynamically stable with Hgb 12.2. Guaiac negative on
admission. Last colonoscopy was ___ and found to have
Grade I internal hemorrhoids.
- no colonoscopy required at this time, may consider if
continued bleeding
# Diabetes Mellitus Type II:
- restart home Glipizide (patient found to not be on repaglinide
per ___ & ___)
- continued home glargine 10units qHS
# Hypertension: Ran on high side up to low 190's one time.
- stopped doxazosin due to orthostasis
- decreased atenolol from 100mg to 50mg po daily for renal
function
- held HCTZ, restart on discharge
- continue amlodipine 5mg po BID
- will follow up with PCP, ___, next week to eval blood
pressure
# CKD: creatinine at baseline 1.8
- renally dosed meds
# CAD
- continued home aspirin 325mg po daily
# CODE STATUS: FULL- confirmed
# CONSULTS: EP, ___
# CONTACT: ___ (___) ___
# DISPO: Medicine to home
# PCP: ___
# Transitional Issues:
- home ___
- family informed of need to use her walker at home
- patient instructed to stop codeine syrup and doxazosin
- will have BP recheck and post d/c follow up with PCP ___
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Doxazosin 1 mg PO HS
2. Fluocinonide 0.05% Cream 1 Appl TP BID
3. Hydrocortisone Acetate Suppository ___ID
4. Hydrocortisone (Rectal) 2.5% Cream ___ID
5. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H
6. Atenolol 100 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
hold for loose stools
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. Amlodipine 5 mg PO BID
10. Atorvastatin 40 mg PO HS
11. Glargine 10 Units Bedtime
12. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO QD PRN pain
13. Omeprazole 20 mg PO DAILY
14. Aspirin 325 mg PO DAILY
15. Duloxetine 30 mg PO BID
16. GlipiZIDE 5 mg PO DAILY
17. Hydrochlorothiazide 12.5 mg PO DAILY
18. Vitamin D 1000 UNIT PO DAILY
19. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO BID
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 40 mg PO HS
4. Docusate Sodium 100 mg PO BID
hold for loose stools
5. Duloxetine 30 mg PO BID
6. Fluocinonide 0.05% Cream 1 Appl TP BID
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. Hydrocortisone (Rectal) 2.5% Cream ___ID
9. Hydrocortisone Acetate Suppository ___ID
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Omeprazole 20 mg PO DAILY
13. GlipiZIDE 5 mg PO DAILY
14. Hydrochlorothiazide 12.5 mg PO DAILY
15. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO QD PRN pain
16. Atenolol 50 mg PO DAILY
RX *atenolol 50 mg 1 tablet(s) by mouth once per day Disp #*30
Tablet Refills:*0
17. Glargine 10 Units Bedtime
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Orthostatic Hypotension
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 ___
___ for dizziness. While you were here, we gave you
some intravenous fluids to help rehydrate you. We stopped one of
your blood pressure medications, doxazosin. That medication was
likely contributing to your dizziness. You no longer felt dizzy
on your second day in the hospital. You were also seen by your
primary care provider, Dr. ___, while you were here.
We discussed our plan with him. It is important that you follow
up with him as listed below.
Followup Instructions:
___
|
10455855-DS-26 | 10,455,855 | 20,785,281 | DS | 26 | 2173-02-13 00:00:00 | 2173-03-05 20:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Valsartan / doxazosin
Attending: ___.
Chief Complaint:
hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with history of DM2 (A1C 6.9), CKD, presented to
the ED for unresponsiveness with FSBS of 40.
Pt stated that recently her appetite has not been as strong as
before, and she had been experiencing more episodes of
hypoglycemia. She typically self treats with orange juice. The
day prior to admission, pt had insulin at 11pm, went to bed, and
woke up at 2:30 feeling fatigue and jittery, concerning for
hypoglycemia. She ran out of orange juice and called her
daughter. When her daughter checked on her, pt was found
nonresponsive. EMS was called, and pt was found to have FSBS of
40. Pt was given 1 amp of dextrose with some improvement.
Typically, pt takes glipizide 5 mg in AM and NPH 12 units at bed
time. She otherwise denies F/C, chest pain, SOB, N/V/D, dysuria.
She does have constipation and hemorrhoids issues.
In the ED, initial VS were: 97.1 67 168/77 15 94% on RA. Labs
were notable for fs of 40 and a creatinine of 2.9, up from a
baseline of 2.1. CXR noted new interstitial opacities most
consistent with edema. UA was concerning for infection so she
was given ceftriaxone. Gave 500cc of NS, then started on D5NS @
75ml/hr. Admission was requested given unwell appearance and
diabetic regimen. Most recent vitals prior to admission were
98.4 60 167/70 18 98% on RA.
Past Medical History:
- PERCUTANEOUS CORONARY INTERVENTIONS: ___ in ___ RCA
stent placed
- PACING/ICD: ___ in ___ DDDR pacer placed for
bradycardia, last check ___: DDDR mode with a base rate of
65, a rest rate of 60, a maximum track rate of 110 and an upper
sensor rate of 105 beats per minute. The mode switch function
is ON for atrial rates greater than 180 beats per minute.
- T2DM
- arthritis
- cholelithiasis
- chronic abdominal pain
- diverticulitis
- hypertension
- hyperlipidemia
- osteomalacia
- peripheral edema
- peripheral neuropathy
- peripheral vascular disease
- PPD positive ___
- acute kidney injury
- spinal stenosis
- dysphagia
- chronic kidney disease (baseline Cr 1.6-1.8)
- Recurrent UTIs
- Chronic oral pain ___ poor-fitting dentures
Social History:
___
Family History:
Mother died of stroke; father died of MI at ___ yo. One brother
died from lung cancer. Her daugther has colon cancer.
Physical Exam:
ADMISSION:
VS - 98.0 65 182/80 18 96% on RA
GENERAL - elderly female in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVD ~ 8 cm, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, nl S1-S2, ___ systolic ejection
murmur @ LUSB, +S2, radiating to carotids
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3
DISCHARGE:
VS: 98.4 160/71 18 97%RA
GENERAL - elderly female in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVD ~ 8 cm, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, nl S1-S2, ___ systolic ejection
murmur @ LUSB, +S2, radiating to carotids
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3
Pertinent Results:
LABS:
___ 06:05AM BLOOD WBC-5.5 RBC-3.16* Hgb-9.7* Hct-29.7*
MCV-94 MCH-30.6 MCHC-32.6 RDW-14.2 Plt ___
___ 03:15PM BLOOD Glucose-141* UreaN-37* Creat-2.6* Na-138
K-5.0 Cl-106 HCO3-25 AnGap-12
___ 04:25PM BLOOD Glucose-80 UreaN-41* Creat-2.9* Na-140
K-5.0 Cl-107 HCO3-23 AnGap-15
___ 04:25PM BLOOD cTropnT-0.02*
___ 03:15PM BLOOD Calcium-8.4 Phos-3.3 Mg-2.6
___ 04:25PM BLOOD Lactate-1.3
==========================================================
IMAGING/OTHER STUDIES:
CXR ___: FINDINGS: There is cardiomegaly as well as a
pacemaker with leads terminating in appropriate position. There
are new interstitial opacities consistent with edema. No focal
opacities concerning for infection. No pleural effusion or
pneumothorax.
Brief Hospital Course:
___ yo female with history of DM2 (A1C 6.9), CKD, HTN, HL and
multiple prior UTI's who presented to the emergency department
after an episode of unresponsiveness at home, found to have
hypoglycemia and acute on chronic renal failure.
# Hypoglycemia: Likely secondary to poor oral intake and insulin
combined with a sulfonylurea. Given patient's recurrent episodes
of hypoglycemia, her glyburide was stopped during this
admission. She was continued on her previous regimen of 12u
glargine qHS. She will have close followup with the ___
___.
# Acute on chronic renal failure: This was almost certainly
prerenal azotemia in the setting of decreased PO intake. Cr
returned to baseline with IV fluids.
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TRANSITIONAL ISSUES:
#Hypoglycemia: Glyburide was discontinued during this admission.
Given recurrent episodes of symptomatic hypoglycemia, patient
may benefit from slightly looser glucose control goals. She was
discharged on home dose of 12u glargine qHS which may need to be
adjusted.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO BID
2. Aspirin 325 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Atorvastatin 40 mg PO HS
5. Docusate Sodium 100 mg PO BID
hold for loose stools
6. Duloxetine 30 mg PO BID
7. Fluocinonide 0.05% Cream 1 Appl TP BID
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Hydrocortisone (Rectal) 2.5% Cream ___ID
11. Hydrocortisone Acetate Suppository ___ID
12. Glargine 12 Units Bedtime
13. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO QD PRN pain
16. Vitamin D 1000 UNIT PO DAILY
17. GlipiZIDE 5 mg PO DAILY
18. Maalox/Diphenhydramine/Lidocaine 5 mL PO Q2H:PRN mouth pain
swish and spit
19. Nitroglycerin SL 0.3 mg SL PRN chest pain
Discharge Medications:
1. Amlodipine 5 mg PO BID
2. Aspirin 325 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Atorvastatin 40 mg PO HS
5. Docusate Sodium 100 mg PO BID
6. Duloxetine 30 mg PO BID
7. Fluocinonide 0.05% Cream 1 Appl TP BID
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. Hydrocortisone (Rectal) 2.5% Cream ___ID
10. Hydrocortisone Acetate Suppository ___ID
11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Hydrochlorothiazide 12.5 mg PO DAILY
15. Maalox/Diphenhydramine/Lidocaine 5 mL PO Q2H:PRN mouth pain
16. Nitroglycerin SL 0.3 mg SL PRN chest pain
17. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO QD PRN pain
18. Glargine 12 Units Bedtime
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hypoglycemia
Acute on chronic renal failure
Secondary:
Type 2 Diabetes Mellitus
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 low blood sugars (hypoglycemia)
and worsening kidney function. You were given sugar through the
IV and you began eating and your sugars came back to normal. We
will stop your diabetes medication, glipizide, to help prevent
episodes of hypoglycemia in the future. It is important that you
have juice or other sugar containing snacks around in case you
begin to feel that your sugar is dropping.
Your worsening kidney function was likely caused by dehydration
and improved back to your baseline with IV fluids. You should be
sure to keep well hydrated at home to help protect your kidneys.
It was a pleasure taking part in your care and we wish you a
speedy recovery!
Followup Instructions:
___
|
10455855-DS-28 | 10,455,855 | 25,557,960 | DS | 28 | 2173-04-23 00:00:00 | 2173-04-23 16:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Valsartan / doxazosin / lisinopril
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a ___ year-old with PMH significant for coronary artery
disease, permanent pacemaker, diabetes mellitus, chronic kidney
disease, hypertension, hyperlipidemia, peripheral vascular
disease who presents with shortness of breath.
The patient was recently admitted to ___ on ___ with
similar symptoms and was found to have acute diatolic congestive
heart failure responsive to IV diuretics. A superimposed
pneumonia was another concern and she completed 5-days of oral
levofloxacin. She was discharged feeling improved on ___.
She saw Dr. ___ in clinic on ___ and he reduced her home
Lasix dosing from 40 to 20 mg daily given concerns regarding her
renal function. Over the last few days she was also noted to
have elevated blood pressure readings at home and it was
recommended that she increase her Isosorbide mononitrate dosing
to 30 mg twice daily.
Since decreasing the dose she has noted some worsening shortness
of breath mostly with exertion and worsening leg swelling for
___ days. She also notes some associated chest discomfort that
radiates from her epigastrum up to her throat area, which she
says 'she gets when she has too much fluid'. She also reports an
associated productive cough with frothy, whitish sputum. Denies
sick contacts or recent URI symptoms. No fevers or chills.
In the ED, initial VS 99.5 65 198/78 18 96% RA. Labs notable for
WBC 4.5, HCT 30%, PLT 199. INR 0.9. Troponin-T 0.04. Creatinine
3.1. A CXR was obtained. Ceftriaxone 1 gram IV was dosed in the
ED.
On arrival to the floor, she appears comfortable but is
hypertensive.
Past Medical History:
- PERCUTANEOUS CORONARY INTERVENTIONS: ___ in ___ RCA
stent placed
- PACING/ICD: ___ in ___ DDDR pacer placed for
bradycardia, last check ___: DDDR mode with a base rate of
65, a rest rate of 60, a maximum track rate of 110 and an upper
sensor rate of 105 beats per minute. The mode switch function
is ON for atrial rates greater than 180 beats per minute.
- T2DM
- arthritis
- cholelithiasis
- chronic abdominal pain
- diverticulitis
- hypertension
- hyperlipidemia
- osteomalacia
- peripheral edema
- peripheral neuropathy
- peripheral vascular disease
- PPD positive ___
- acute kidney injury
- spinal stenosis
- dysphagia
- chronic kidney disease (baseline Cr 1.6-1.8)
- Recurrent UTIs
- Chronic oral pain ___ poor-fitting dentures
Social History:
___
Family History:
Mother died of stroke; father died of MI at ___ yo. One brother
died from lung cancer. Her daugther has colon cancer.
Physical Exam:
ADMISSION EXAM:
VITALS: 98.3 ___ 2L NC
GENERAL: Appears in no acute distress. Alert and interactive.
Well nourished appearing.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes dry with some whitish plaques and ulcers at
denture line.
NECK: supple. JVP 3-cm above the clavicle at 30-degrees.
___: AV-paced. Regular rate, III/VI SEM at RUSB with radiation
to neck, no rubs or gallops. S1 and S2.
RESP: Decreased breath sounds at bases bilaterally with diffuse
crackles at bases. No wheezing, rhonchi. Stable inspiratory
effort without labored breathing.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing, 2+ peripheral pulses; 1+ pitting
edema to ankles bilaterally.
NEURO: Alert and oriented x 3. Sensation grossly intact. Gait
deferred.
DISCHARGE EXAM:
VITALS: 98.9 98.1 159/62 65 20 99% RA
GENERAL: Sitting up comfortably in bed, appears in no acute
distress. Alert and interactive. Well nourished appearing.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes less dry, still with some whitish plaques and
ulcers at denture line.
NECK: supple. JVP 3 cm above the clavicle at 30-degrees.
___: AV-paced. Regular rate, III/VI systolic ejection murmur at
RUSB with radiation to neck, no rubs or gallops. S1 and S2
normal.
RESP: Decreased breath sounds at bases bilaterally, otherwise
clear to auscultation bilaterally. No wheezing, rales, rhonchi.
Stable inspiratory effort without labored breathing.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs. Tender to
palpation over right ribs (from fall night before)
EXTR: no cyanosis, clubbing, 2+ peripheral pulses; 1+ pitting
edema to shins bilaterally.
NEURO: Alert and oriented x 3. Sensation grossly intact. Gait
deferred.
Pertinent Results:
PERTINENT LABS:
___ 01:05PM BLOOD WBC-4.5 RBC-3.22* Hgb-9.4* Hct-30.0*
MCV-93 MCH-29.0 MCHC-31.2 RDW-14.4 Plt ___
___ 07:32AM BLOOD WBC-3.7* RBC-3.06* Hgb-8.8* Hct-28.7*
MCV-94 MCH-28.7 MCHC-30.5* RDW-14.5 Plt ___
___ 08:00AM BLOOD WBC-4.0 RBC-2.86* Hgb-8.7* Hct-26.5*
MCV-93 MCH-30.5 MCHC-32.9 RDW-14.8 Plt ___
___ 01:05PM BLOOD Glucose-192* UreaN-38* Creat-3.1* Na-142
K-4.7 Cl-107 HCO3-24 AnGap-16
___ 08:00AM BLOOD Glucose-55* UreaN-38* Creat-3.0* Na-144
K-3.7 Cl-107 HCO3-27 AnGap-14
___ 01:05PM BLOOD CK-MB-2 cTropnT-0.04* ___
___ 09:10PM BLOOD CK-MB-2 cTropnT-0.03*
___ 01:05PM BLOOD Calcium-8.9 Phos-4.0 Mg-2.2
___ 08:00AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.3
___ 07:44PM URINE Color-Straw Appear-Clear Sp ___
___ 07:44PM URINE Blood-NEG Nitrite-NEG Protein-300
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
___ 07:44PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-3
PERTINENT IMAGING:
CHEST PA & LAT (___) - Persistent bibasilar opacities may
represent combination of pleural effusions and atelectasis,
underlying consolidation not entirely excluded. Enlargement of
the cardiac silhouette. Pulmonary edema, somewhat improved from
the prior study.
EKG (___) - AV-paced. LAD. LBBB morphology. Non-specific ST
changes particularly in V3-4 (stable compared to prior). V2
appears misplaced.
TTE ___ - Normal biventricular size and systolic function.
Moderate AR. ___ central MR. ___ pulmonary
hypertension.
PERTINENT MICRO:
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION:
___ with a PMH significant for coronary artery disease,
permanent pacemaker, diabetes mellitus, chronic kidney disease,
hypertension, hyperlipidemia, and peripheral vascular disease
who presented with shortness of breath attributed to worsening
diastolic heart failure due to uncontrolled hypertension found
to have worsening valvular dysfuction on TTE.
ACTIVE PROBLEMS:
Acute dyspnea - Likely due to diastolic biventricular heart
failure in the setting of uncontrolled blood pressures and fluid
overload after reducing her dose of diuretic. She denied any
recent dietary indiscretions, remained afebrile without
leukocytosis to suggest ongoing or new infection, and there was
no strong clinical suspicion for ACS/MI- her EKGs were without
ischemia and cardiac biomarkers were reassuring. She was
diuresed and switched from metoprolol to carvedilol. TTE
performed inhouse found ___ MR.
___ pain - Symptoms were most likely related to reflux
esophagitis given her description of its radiation from
epigastrium to esophagus and worsening with reclining, ACS/MI
was excluded as above. Chest pain improved with increasing PPI
to BID dosing.
Hypertension - Home regimen includes CCB, beta-blocker, diuretic
and long-acting nitrates. BP elevated on admission in the
setting of volume overload, continued to be elevated during
stay; was better controlled with increase in Imdur from 60 to
90, switching from metoprolol to carvedilol 12.5 BID, and
diuresing with lasix. Home amlodipine was continued. PO
hydralazine was also used as needed. An ACEi was considered but
held off in the setting of her renal disease.
Chronic kidney disease - Attribtued to hypertensive and diabetic
nephropathy. Baseline creatinine has slowly been increasing from
1.8 to 2.8 over the last several months. Evidence of acute
kidney injury on admission with clinical evidence of volume
overload suggesting poor forward perfusion in the setting of
diastolic dysfunction, improved with diuresis. Appears new
baseline creatitine near 3.0.
Hyperlipidemia - continued statin dosing.
Diabetes mellitus - HbA1c 6.9% in ___. Evidence of
nephropathy. Was on insulin sliding scale while in house.
TRANSITIONAL ISSUES:
- Monitor weights daily and adjust lasix dosing as needed
- Monitor electrolytes and creatinine periodically given
increase in lasix dosing
- Titrate carvedilol as needed for appropriate BP control
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO BID
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 40 mg PO HS
4. Docusate Sodium 100 mg PO BID
5. Duloxetine 30 mg PO BID
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. Glargine 8 Units Bedtime
8. Isosorbide Mononitrate (Extended Release) 30 mg PO BID
9. Omeprazole 20 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Fluocinonide 0.05% Cream 1 Appl TP BID
12. Hydrocortisone (Rectal) 2.5% Cream ___ID
13. Hydrocortisone Acetate Suppository ___ID
14. Maalox/Diphenhydramine/Lidocaine 5 mL PO Q2H:PRN mouth pain
15. Nitroglycerin SL 0.3 mg SL PRN chest pain
16. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO DAILY:PRN
pain
17. linagliptin *NF* 5 mg Oral DAILY
18. Metoprolol Succinate XL 25 mg PO DAILY
19. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO BID
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 40 mg PO HS
4. Docusate Sodium 100 mg PO BID
5. Duloxetine 30 mg PO BID
6. Fluocinonide 0.05% Cream 1 Appl TP BID
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. Furosemide 40 mg PO DAILY
9. Hydrocortisone (Rectal) 2.5% Cream ___ID
10. Hydrocortisone Acetate Suppository ___ID
11. Glargine 8 Units Bedtime
12. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
13. Maalox/Diphenhydramine/Lidocaine 5 mL PO Q2H:PRN mouth pain
14. Omeprazole 20 mg PO BID
15. Vitamin D 1000 UNIT PO DAILY
16. Carvedilol 12.5 mg PO BID
17. Nitroglycerin SL 0.3 mg SL PRN chest pain
18. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO DAILY:PRN
pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Principal Diagnosis
1.Diastolic biventricular congestive heart failure
Secondary Diagnosis
1. Hypertension
2. Coronary artery disease
3. Permanent Pacemaker
4. Diabetes mellitus
5. Chronic kidney disease
6. Hyperlipidemia
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 Internal Medicine service at ___
___ on ___ regarding management
of your difficulty breathing. We believe it was due to having
excess fluid in your lungs causes by very high blood pressures.
Here we gave you lasix to decrease the fluid in your body and
help you breathe, added a new medicine to control your blood
pressure, and increased the dose of your medicine for GERD which
had been causing you pain in your belly that traveled up your
throat.
It is important to take all of your medications as prescribed.
Weigh yourself every morning, call your doctor if your weight
goes up more than 3 lbs. In addition, please make every attempt
to attend your follow-up appointments, as scheduled.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If 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 an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10455855-DS-32 | 10,455,855 | 29,742,982 | DS | 32 | 2173-11-13 00:00:00 | 2173-11-13 16:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Valsartan / doxazosin / lisinopril
Attending: ___.
Chief Complaint:
fall/? syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ F with history of HFpEF, bradyarrhytmia s/p pacemaker, DM2,
HTN, CKD IV (baseline Cr 3) who presents transferred from
___ after an unwitnessed fall. History is obtained
from patient and granddaughter.
Per rehab documentation, "Pt was found unresponsive at 2:40pm.
Couldn't get BP. 911 called. NP called."
Patient denies knowledge of falling and denies bowel/bladder
incontinence. She denies an LOC, chest pain, headache, numbness,
tingling, weakness, dyspnea.
There was some question of chest pain in the ED, but the patient
clarifies that she did not experience any chest pain, but
instead experienced left shoulder pain after her fall.
She endorses displeasure with her rehab facility and would like
to go to a different facility when she is discharged.
Of note, she was recently admitted for a R hip fracture from
___ and underwent R hip surgery.
In the ED initial vitals were: pain 6 T 96.2 HR 65 BP 133/64 RR
16 SaO2 98% on RA
- Labs were significant for Cr 3.5 (baseline ~ 3), trop 0.07
- ECG showed paced rhythm without Sgarbossa changes
- Patient was given ASA 325mg
Vitals prior to transfer were: pain 0 T 98.1 HR 60 BP 169/48 RR
14 SaO2 100% RA
On the floor, she reports feeling comfortable but is thirsty.
She denies any current chest/shoulder pain. Her right leg also
hurts but she denies any numbess, tingling.
Past Medical History:
1. Type 2 diabetes.
2. DDDR pacemaker for bradycardia.
3. Mild aortic stenosis.
4. Diastolic heart failure.
5. Moderate-to-severe mitral regurgitation, moderate tricuspid
regurgitation, and mild aortic regurgitation.
6. Coronary artery disease: s/p RCA stent in ___ in ___
7. Hypertension.
8. PVD.
9. Chronic kidney disease with baseline creatinines in the 2.5-3
range (stage IV-V, not a candidate for HD given age per
nephrology)
10. Arthritis.
11. Neuropathy.
12. Spinal stenosis.
13. Recurrent UTIs.
14. Hyperlipidemia.
Social History:
___
Family History:
Mother died of stroke; father died of MI at ___ yo. One brother
died from lung cancer. Her daugther has colon cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
PHYSICAL EXAM:
Vitals- T 98.2 BP 181/77 HR 71 RR 16 SaO2 100% on RA
Orthostatics
Supine: 185/77 HR 78
Sitting: 179/69 HR 63
Standing: unable due to injured hip
General- Chronically ill appearing elderly female
HEENT- Dry mucous membranes, EOMI
Neck- JVP ~ 6cmH2O
Lungs- CTAB
CV- III/VI systolic ejection murmur heard best at RSB
Abdomen- Soft, nontender, nondistended
GU- No foley
Ext- Nonedematous, warm
Back- pressure ulcer (stage 2) on sacrum and left hip
Neuro- Alert, oriented to self, person, location. Moving all
four extremities. Intact sensation in bilateral lower
extrmities. Surgical scar present in R hip.
DISCHARGE PHYSICAL EXAM:
VS - 98.4 167/78 (148-170/54-78) 70 18 100% RA
General: chronically ill appearing, no acute distress, alert to
hospital, year and circumstance
HEENT: PERRL, EOMI, sclera anicteric. mucous membranes dry
Neck: no JVD
CV: regular rhythm and rate, III/VI mid systolic ejection murmur
appreciated best at ___ without radiation, no diastolic murmur,
no rub or gallop
Lungs: CTAB without adventitious sounds
Abdomen: nondistended, NABS, nontender to palpation without
organomegaly
Ext: warm and well perfused, no evidence of edema, 1+ DP pulses
bilaterally
Neuro: no new focal deficits appreciated
Pertinent Results:
PERTINENT LABS:
___ 04:40PM BLOOD WBC-5.1 RBC-3.18* Hgb-9.7* Hct-31.1*
MCV-98 MCH-30.3 MCHC-31.1 RDW-15.4 Plt ___
___ 06:30AM BLOOD WBC-4.7 RBC-3.09* Hgb-9.4* Hct-30.0*
MCV-97 MCH-30.3 MCHC-31.2 RDW-15.2 Plt ___
___ 04:40PM BLOOD ___ PTT-39.6* ___
___ 04:40PM BLOOD Glucose-112* UreaN-55* Creat-3.5* Na-135
K-5.0 Cl-98 HCO3-27 AnGap-15
___ 06:00AM BLOOD Glucose-84 UreaN-52* Creat-3.0* Na-139
K-4.4 Cl-101 HCO3-30 AnGap-12
___ 04:40PM BLOOD CK-MB-2 cTropnT-0.07*
___ 01:45AM BLOOD CK-MB-2 cTropnT-0.07*
___ 06:30AM BLOOD Calcium-8.7 Phos-5.2* Mg-2.1
___ 08:04PM BLOOD Lactate-0.9
MICROBIOLOGY:
___ 02:00PM URINE Color-Yellow Appear-Hazy Sp ___
___ 02:00PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ urine culture pending
___ blood cultures x 2 pending - no growth to date
IMAGING:
___ Hip 2-view
Status post ORIF of a right intertrochanteric femoral neck
fracture without evidence of hardware complications. No acute
fracture or dislocation identified. Diffuse demineralization of
the osseous structures.
___ Femur 2-view
Status post ORIF of a right intertrochanteric femoral neck
fracture without evidence of hardware complications. No acute
fracture or dislocation identified. Diffuse demineralization of
the osseous structures.
___ Chest x-ray
No acute cardiopulmonary process.
ECG:
A-V paced rhythm. Since the previous tracing of ___ no
significant change.
PACEMAKER INTERROGATION:
Generator Brand: ___
___ Name: ___ Number: ___ ___
Presenting rhythm: AP-VP
Intrinsic Rhythm: sinus with complete heart block
Programmed Mode: DDD, base rate 65 bpm, rest rate 60 bpm, max
tracking rate 110 bpm, max sensor rate 105 bpm
Battery Voltage: 2.68 V
Remaining Longevity: ___ years
RA lead
Intrinsic amplitude: 0.2-0.4 mV
Pacing impedance: 294 ohms
Pacing threshold: 0.5 V @ 0.6 ms
% Pacing: 37%
RV lead
Intrinsic amplitude: no intrinsic ventricular activity
Pacing impedance: 537 ohms
Pacing threshold: 0.75 V @ 0.6 ms
%pacing: >99%
Diagnostic information: High rate, Mode switch:
- ___: High Atrial Rate episode @10:57 AM, peak HR 183, 28
secs
- ___: High Atrial Rate episode @7:19 AM, peak HR 183, 10
secs
- ___: High Atrial Rate episode @3:32 AM, likely atrial
tachycardia, 6 secs
- ___: High Atrial Rate episode @10:55 ___, likely atrial
tachycardia, 7 secs
Programming changes (details):
Changed atrial sensitivity to 0.2mV from 0.3mV to increase
tracking.
Summary (normal / abnormal device function):
Normal device function. Stable thresholds and impedances. No
evidence of pacemaker malfunction to explain cause of syncope.
Brief Hospital Course:
___ with DDD pacemaker, advanced CKD, Type II diabetes and
recent fall in ___ with hip fracture presents after recent
fall at ___ rehab concerning for syncope
# Fall/? syncope
Most likely cause is hypotension in setting of uptitration of
carvedilol. Carvedilol back at 6.25 mg BID dose. Cardiac source
unlikely given negative cardiac enzymes and no arrythmia on
pacemaker interrogation. She was continued on low dose of
carvedilol, with no uptitration as SBP remained less than 180.
# Hypertension
This was a stable issue while inpatient. Her carvedilol was
titrated as above, and she was also continued on her home
amlodipine and imdur.
# Hip fracture
No evidence of acute fracture or dislocation after this most
recent fall. She was placed on prn 1 tablet vicodin every ___
hrs for pain management. She has follow-up scheduled in
orthopedics clinic for staple removal and re-imaging on ___.
# chronic CHF with preserved EF
No evidence of decompensated heart failure on clinical exam.
# chronic kidney disease
Her creatinine was stable from her baseline while inpatient. No
further intervention was necessary, as patient has previously
refused dialysis.
CHRONIC ISSUES: dyslipidemia, depression, GERD, Type II DM,
anemia.
Ms. ___ was continued on her atorvastatin, duloxetine,
omeprazole, iron supplementation, and insulin sliding scale with
no complications. She did not require insulin while inpatient,
and was having her blood glucose checked twice a day at ___
___.
TRANSITIONAL ISSUES
- orthopedics follow-up for staple removal, reassessment
- carvedilol to be continued at 6.25 mg BID, resume all other
previous medications
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Carvedilol 37.5 mg PO BID
4. Docusate Sodium 200 mg PO BID
5. Duloxetine 30 mg PO BID
6. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN congestion
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Omeprazole 20 mg PO BID
9. Vitamin D 1000 UNIT PO DAILY
10. Acetaminophen 1000 mg PO Q8H Pain
11. Calcium Carbonate 500 mg PO TID
12. Heparin 5000 UNIT SC TID
13. Multivitamins 1 TAB PO DAILY
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Senna 2 TAB PO BID
16. Amlodipine 5 mg PO BID
17. Maalox/Diphenhydramine/Lidocaine 30 mL PO BID:PRN mouth pain
18. Nitroglycerin SL 0.4 mg SL PRN chest pain
19. Ferrous Sulfate 325 mg PO DAILY
20. Torsemide 50 mg PO DAILY
21. OxycoDONE (Immediate Release) 5 mg PO QID
22. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain
23. Guaifenesin 10 mL PO Q6H:PRN cough
24. Fleet Enema ___AILY:PRN constipation
25. Bisacodyl 10 mg PR HS:PRN constipation
26. Milk of Magnesia 30 mL PO HS:PRN constipation
Discharge Medications:
1. Amlodipine 5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Calcium Carbonate 500 mg PO TID
5. Carvedilol 6.25 mg PO BID
6. Docusate Sodium 200 mg PO BID
7. Duloxetine 30 mg PO BID
8. Ferrous Sulfate 325 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN congestion
10. Guaifenesin 10 mL PO Q6H:PRN cough
11. Heparin 5000 UNIT SC TID
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 20 mg PO BID
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Senna 2 TAB PO BID
17. Vitamin D 1000 UNIT PO DAILY
18. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN hip
pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
Q6H:PRN Disp #*15 Tablet Refills:*0
19. Bisacodyl 10 mg PR HS:PRN constipation
20. Fleet Enema ___AILY:PRN constipation
21. Maalox/Diphenhydramine/Lidocaine 30 mL PO BID:PRN mouth pain
22. Milk of Magnesia 30 mL PO HS:PRN constipation
23. Nitroglycerin SL 0.4 mg SL PRN chest pain
24. Torsemide 50 mg PO DAILY
25. Acetaminophen 325 mg PO Q8H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
possible syncope likely due to hypotension
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 ___ after being found on the ground at
___. We made sure that you did not have a heart
attack or abnormal heart beats, and that your pacemaker was
working properly. Both of these things were normal. We believe
you fell probably because of low blood pressure because of an
increased dose in carvedilol. You should resume the lower dose
of 6.25 mg twice a day for this medication.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10455855-DS-34 | 10,455,855 | 21,004,902 | DS | 34 | 2174-02-16 00:00:00 | 2174-02-17 13:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Valsartan / doxazosin / lisinopril
Attending: ___.
Chief Complaint:
Leg swelling, difficulty walking
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy (___)
History of Present Illness:
Ms. ___ is an ___ year old woman with a history of HFpEF CHF,
bradyarrhytmia s/p pacemaker, DM2, HTN, CKD IV (baseline Cr 3),
anemia (recent admit for BRBPR) who presents with increasing
lower extremity edema, inability to ambulate. Her legs are
painful with blisters that have ruptured, and she notes
increasing DOE and weight gain. Denies f/c/n/v/d/abd pain. Per
note in OMR by ___ ___ "Spoke with ___ nurse,
___ (___). Patient's weight up 5 lbs from ___,
now ___ lbs (was 122-125 lbs 2 weeks ago). Eating hot dogs and
___. Grand daughter, ___ told nurse
patient going to emergency room today, can only get out of the
house by ambulance. Extra Torsemide not effective" (increased
from 40 to 60 on ___.
In the ED intial vitals were: + Triage 17:46 8 99.1 59 150/56 18
100% RA. Lungs with bibasilar crackles. Labs significant for Cr
3.8 (from baseline 2.8), Hgb 6.9 (from 7.8), BNP 11k from 7k.
CXR showed mild vascular congestion and pleural effusions.
Patient was given 40mg IV lasix and foley placed.
Vitals on transfer: Today 00:13 98.1 60 149/60 16 100% RA
On the floor she has no acute complaints, is able to lie flat,
has chronic pain in her neck. Last BM yesterday, small and soft.
Unable to verify her medications.
ROS: negative except as per HPI.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CAD: ___ cath in ___ w/4VD, RCA stent placed. ___
imaging stress w/ fixed inferior wall defect, LVEF 59%. mild mr.
___ p-MIBI showed no defects, EF 62%
- PACING/ICD: ___, model 2210 dual-chamber pacemaker
s/p pacemaker change ___. For bradycardia.
-Moderate-to-severe mitral regurgitation, moderate tricuspid
regurgitation, and mild aortic regurgitation.
3. OTHER PAST MEDICAL HISTORY:
CKD stage IV-V
PVD
arthritis
neuropathy
recurrent UTI's
recent hip fracture repaired ___
spinal stenosis
chronic abdomominal pain
diverticulitis
hemorrhoids
Social History:
___
Family History:
Mother-stroke
Father-MI at ___ yo
No hx of DM
Physical Exam:
ADMISSION EXAM:
VS: 98.0, 61, 159/50, 20, 100%RA
Admit weight: 63.8 (bed)
GENERAL: WDWN elderly woman in NAD. Alert. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
Dry mucous membranes.
NECK: Supple with JVP of 12 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. ___ systolic murmur best heard at apex.
No /r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, but crackles in
bilateral bases, wheezes or rhonchi.
ABDOMEN: Soft, ND, mild epigastric TTP. No HSM or tenderness.
Abd aorta not enlarged by palpation. No abdominal bruits.
EXTREMITIES: No clubbing cyanosis. ___ pitting edema of
bilateral lower extremities, L>R. L leg with mild erythema and
resolved bullae. Dystrophic toenails.
DISCHARGE EXAM - Unchanged from above, except as below:
___ weight: 56.8 (stand)
NECK: JVP of 6-7cm
LUNGS: No crackles
EXTREMITIES: Trace ankle edema
Pertinent Results:
ADMISSION LABS
___ 09:25PM BLOOD WBC-5.5 RBC-2.20* Hgb-6.9* Hct-22.6*
MCV-103* MCH-31.3 MCHC-30.5* RDW-15.7* Plt ___
___ 09:25PM BLOOD Neuts-66.4 ___ Monos-4.5 Eos-4.6*
Baso-0.9
___ 09:25PM BLOOD Glucose-111* UreaN-70* Creat-3.8* Na-139
K-4.8 Cl-104 HCO3-23 AnGap-17
___ 09:25PM BLOOD ___
___ 09:25PM BLOOD Calcium-9.1 Phos-5.9* Mg-2.5
___ 09:34PM BLOOD Lactate-1.0
DISCHARGE LABS:
___ 06:52AM BLOOD WBC-3.7* RBC-2.25* Hgb-7.4* Hct-23.2*
MCV-103* MCH-33.1* MCHC-32.1 RDW-15.4 Plt ___
___ 06:52AM BLOOD Glucose-101* UreaN-54* Creat-3.2* Na-142
K-4.0 Cl-106 HCO3-26 AnGap-14
___ 06:52AM BLOOD Calcium-8.9 Phos-4.6* Mg-2.2
IMAGING
___ CXR
Small bilateral pleural effusions with overlying atelectasis,
enlarged cardiac silhouette. Mild vascular congestion.
___ Unilateral Lower Extremity Venous Study
No left lower extremity DVT
___ Transthoracic Echo
he left atrium is moderately dilated. The estimated right atrial
pressure is ___ mmHg. Mild symmetric left ventricular
hypertrophy with normal wall thickness, cavity size, and global
systolic function (biplane LVEF = 60 %). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The number of aortic valve leaflets
cannot be determined. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. Mild to moderate
(___) aortic regurgitation is seen. The mitral valve leaflets
are moderately thickened. Moderate (2+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] Moderate to
severe [3+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. There is a small
pericardial effusion located predominantly along the right
atrium and lateral left ventricular wall. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of ___,
pulmonary pressures are higher. There is more mitral and
tricuspid regurgitation. Other findings are probably similar.
___ Flex Sig
The procedure, indications, preparation and potential
complications were explained to the patient, who indicated her
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
moderate sedation. Supplemental oxygen was used. The patient was
placed in the left lateral decubitus position.The digital exam
was normal. The colonoscope was introduced through the rectum
and advanced under direct visualization until the splenic
flexure was reached. The colonoscope was retroflexed within the
rectum. Careful visualization was performed as the instrument
was withdrawn. The procedure was not difficult. The quality of
the preparation was good. The patient tolerated the procedure
well. There were no complications.
Brief Hospital Course:
Ms. ___ is an ___ with a history of CAD s/p stenting, dCHF,
CKD, and anemia who presents with weight gain, increased ___
edema and inability to ambulate.
# Acute on chronic diastolic CHF. Weight up to 63.8kg (140lb) on
admission from 122-125lb 2 weeks ago, increased ___ edema, mild
vascular congestion on CXR with crackles on exam, BNP elevated
above baseline ___ (previously ___) all suggest CHF
exacerbation. Trigger seems to be dietary indiscretion, no
evidence of infection or ischemia. ___ negative for DVT. Echo
shows increased pulm htn and worsened mitral and tricuspid
regurg. She was diuresed with Lasix 80mg IV boluses with good
UOP. Shortness of breath and lower extremity swelling had
greatly improved by day of discharge, she was satting well on
room air at discharge. She was placed on torsemide 40mg at
discharge. DISCHARGE WEIGHT = 56.8kg.
# ___ on CKD. Baseline Cr 2.8-3.0. Cr was elevated to 3.8 on
admission, likely venous congestion from CHF exacerbation.
Patient is not a candidate for HD given age per nephrology at
last admit. Renal function improved with aggressive diuresis. At
discharge, Cr had improved to 3.2, which is close to her
baseline.
# Anemia. Likely secondary to anemia of chronic disease and
hemorrhoids. Recent admission with BRBPR thought ___ hemorrhoids
which was seen on flex sig in ___. Ferritin high, so iron
stopped. This admission there was no evidence of active bleeding
and patient was asymptomatic. She notes some hematochezia/melena
with diarrhea ___ laxatives) over the last month concerning for
possible occult GIB. Rectal exam grossly negative for blood
(___). Patient underwent flex sigmoidoscopy this admission
which was consistent with int/ext hemorrhoid but no evidence of
active bleeding. She did not require blood transfusion. Ferritin
was high-normal (177). She has been non-compliant with Aranesp
injections for the past 6 months which is likely contributing to
her anemia as she has advanced CKD. Follow-up was arranged with
nephrology after discharge to consider reinitiating Aranesp
injections.
# Epigastric pain: Likely in the setting of CHF and vascular
congestion. ___ also be consistent with GERD symptoms. Improved
with hot pack and aggressive diuresis.
--CHRONIC ISSUES--
#CORONARIES: CAD s/p stenting. Continued home statin, isosorbide
mononitrate, ASA 81mg, carvedilol
#HTN: Continued home amlodipine and other meds as above
#T2DM: No episodes of hypoglycemia. continued on ISS.
TRANSITIONAL ISSUES
-Arranged for follow-up with nephrology to discuss Aranesp
injections and anemia
-Importance of diet adherence amphasized during admission, will
need reinforcement as an outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO Q8H:PRN pain
2. Atorvastatin 40 mg PO DAILY
3. Docusate Sodium 200 mg PO DAILY
4. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN congestion
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Lidocaine 5% Patch 1 PTCH TD QAM R hip pain
7. Omeprazole 20 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Torsemide 40 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Aspirin 81 mg PO DAILY
12. Maalox/Diphenhydramine/Lidocaine 30 mL PO BID:PRN mouth pain
13. Milk of Magnesia 30 mL PO HS:PRN constipation
14. Nitroglycerin SL 0.4 mg SL PRN chest pain
15. Carvedilol 25 mg PO BID
16. Amlodipine 5 mg PO DAILY
17. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO DAILY:PRN
pain
18. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID
Discharge Medications:
1. Maalox/Diphenhydramine/Lidocaine 30 mL PO BID:PRN mouth pain
2. Nitroglycerin SL 0.4 mg SL PRN chest pain
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Carvedilol 25 mg PO BID
6. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN congestion
7. Milk of Magnesia 30 mL PO HS:PRN constipation
8. Vitamin D 1000 UNIT PO DAILY
9. Acetaminophen 325 mg PO Q8H:PRN pain
10. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*1
11. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
RX *isosorbide mononitrate [Imdur] 60 mg 1 tablet extended
release 24 hr(s) by mouth Daily Disp #*30 Tablet Refills:*1
12. Lidocaine 5% Patch 1 PTCH TD QAM R hip pain
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Torsemide 40 mg PO DAILY
15. Pantoprazole 20 mg PO Q12H
RX *pantoprazole 20 mg 1 tablet,delayed release (___) by
mouth Twice daily Disp #*60 Tablet Refills:*1
16. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID
17. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO DAILY:PRN
pain
18. Docusate Sodium 200 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
ACUTE on CHRONIC diastolic CHF
Secondary diagnoses:
Chronic kidney disease
Type 2 diabetes
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
You were admitted for your symptoms of increased weight, leg
swelling, and difficulty walking. It was determined that your
symptoms were a worsening of your congestive heart failure.
An echocardiogram was performed to identify any new problems
with your heart. We saw a small amount of increased leakage from
your valves. While you were in the hospital, we also saw that
your blood count was low and we were concerned about bleeding
from your intestines. You had a procedure in which a camera
looking into your intestines to look for bleeding, but none was
seen. Please start taking your Aranesp injections again to help
keep your blood counts up.
Ultimately, you were given diuretics to remove the extra fluid
that had collected in your legs. Your swelling decreased and
your symptoms improved. You were discharged to home on
torsemide 40mg, which you were taking at home. Your discharge
weight was 56.8 kg (125 lbs).
Please weigh yourself every morning, and call your doctor if
your weight goes up more than 3 lbs.
Thank you,
-___ Team
Followup Instructions:
___
|
10456409-DS-18 | 10,456,409 | 28,793,424 | DS | 18 | 2146-07-08 00:00:00 | 2146-07-12 13:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Percocet / Stadol
Attending: ___
Chief Complaint:
right neck pulsation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year-old right-handed female with
history of
breast granulomatous mastitis and migraines (with episode of 1
minute of vision loss in ___ who presents from OSH with 10
days
of R neck pain with visible pulsations seen in the right neck
above the clavicle. In retrospect, she has seen this before,
but only when she was angry or very upset. Never before she had
this when calm and at rest. The very first time this happened
10 days ago, she took a dose of baby aspirin and shortly
thereafter the symptoms went away. However, happening in the
next day for each of the following 10 days. She reports that
the neck pain fluctuates seemingly without provocation. Since
this started, she has felt a little bit of difficulty
swallowing, as the food moves down into her throat. This
happened twice and was associated with coughing prompting her to
spit out the food. Last night she felt that the pulsations were
getting bigger and that the mass was expanding so she presented
to the ___ emergency department in ___. There, she was
hypertensive with SBP is in the 170s. CTA there with intimal
tear in the R ICA. She was given a labetalol bolus and started
on a heparin gtt prior to transfer to the ___ ED for further
management.
No clear trauma or trigger for the dissection although she is a
nurse at ___ and reports that she frequently lifts heavy
patients and boost them. No recent chiropractic manipulation,
massage, heavy lifting/CrossFit. She notes that her purse is
heavy but she always carries this on the left.
No new headaches, no vision changes. Chronic paresthesias in the
left digits 2 3 and 4, but this has been going on for several
months. She also notes that her legs have been swollen over the
last several months, for which she is being worked up by her
PCP.
On neuro ROS, she notes for remote episodes of brief vision loss
that occurred in the setting of lasting loudly; these have not
happened for quite some time. She denies headache, recent
vision changes, blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness or
numbness. No bowel or bladder incontinence or retention. Denies
difficulty with gait.
On general review of systems, she 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:
MASTITIS
?Granulomatous Mastitis
Migraines
Miscarriage ×1 at approximately 3 months gestation, which she
notes came after heavy lifting at work
Social History:
___
Family History:
Mom with hypertension
Son with autism
No known family history of blood clots, DVT/PE, connective
tissue disease, or any other neurological conditions.
Physical Exam:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, full ROM
Pulmonary: breathing comfortably on RA
Cardiac: warm and well-perfused with brisk capillary refill
Abdomen: soft, NT/ND
Extremities: Mild nonpitting lower extremity edema symmetrically
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. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
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, pin, and temperature.
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, or cold
sensation throughout. Minimal length dependent reduction of
vibration sense in the bilateral lower extremities. No
extinction to DSS.
-DTRs:
Bi ___ Pat Ach
L 2 2 2 1
R 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. She self reports feeling
"clumsy" with the left hand, but has no objective
dysdiadochokinesia or dysmetria.
-Gait: Deferred
Pertinent Results:
___ 03:00AM BLOOD WBC-4.1 RBC-4.54 Hgb-12.4 Hct-39.5 MCV-87
MCH-27.3 MCHC-31.4* RDW-13.0 RDWSD-41.5 Plt ___
___ 07:37AM BLOOD WBC-4.2 RBC-4.52 Hgb-12.4 Hct-39.7 MCV-88
MCH-27.4 MCHC-31.2* RDW-13.0 RDWSD-41.7 Plt ___
___ 07:37AM BLOOD Neuts-50.9 ___ Monos-6.2 Eos-2.6
Baso-0.2 Im ___ AbsNeut-2.12 AbsLymp-1.65 AbsMono-0.26
AbsEos-0.11 AbsBaso-0.01
___ 09:26AM BLOOD PTT-42.4*
___ 03:00AM BLOOD Glucose-103* UreaN-18 Creat-0.8 Na-144
K-4.0 Cl-105 HCO3-25 AnGap-14
___ 07:37AM BLOOD Glucose-100 UreaN-18 Creat-0.7 Na-142
K-4.0 Cl-106 HCO3-23 AnGap-13
___ 03:00AM BLOOD CK(CPK)-199
___ 03:00AM BLOOD TotProt-6.6 Calcium-9.3 Phos-4.7* Mg-1.9
MRI brain:
1. Study is mildly degraded by motion.
2. No acute intracranial hemorrhage or infarction.
3. Mild global volume loss and probable microangiopathic
changes, as
described.
Brief Hospital Course:
___ y/o woman with history of migraines, who presented to an
outside hospital with right-sided neck pain, pulsations, and
intermittent dysphagia, transferred to ___ for evaluation
after CTA findings concerning for a proximal right ICA
dissection.
Neurologic examination remained intact throughout her stay.
Based on history, reassuring neurologic exam, review of the OSH
CTA, and discussion with radiology team we determined findings
likely benign anatomical variant which does not correlate to her
presenting symptoms. NCHCT and MRI without evidence of
hemorrhage, infarct or large mass lesion. Etiology of her
presentation likely in the setting of hypertension, given
consistently elevated systolic blood pressures.
At this time she would benefit from close blood pressure
monitoring, and antihypertensive management for which she was
started on amlodipine 2.5mg PO daily on discharge. We recommend
PCP follow up within a week from discharge and have provided her
with the neurology clinic number to schedule a follow up
appointment (to discuss the utility of MRA with fat suppression
sequences).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Ferrous Sulfate Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. amLODIPine 2.5 mg PO DAILY
RX *amlodipine 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Ferrous Sulfate unknown PO DAILY
3. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertension
Benign variant of right internal carotid artery
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were hospitalized due to symptoms of right neck pain and
bulging concerning for a tear in the vessels of your neck.
Imaging of your vessels showed no tear but a benign variant
which does not account for your symptoms. ___ had imaging of
your brain with a CT and an MRI, which did not show evidence of
strokes or bleed. While admitted we monitored your blood
pressures which were elevated and started a medication called
amlodipine at a low dose of 2.5 mg daily, which ___ can discuss
with your primary care doctor. ___ will need to follow up with
your primary care doctor within one week of discharge. Please
call to schedule an appointment. Please take your other
medications as prescribed. If ___ experience any of the symptoms
below, please seek emergency medical attention by calling
Emergency Medical Services (dialing 911). In particular, since
stroke can recur, please pay attention to the sudden onset and
persistence of these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
___
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10456576-DS-7 | 10,456,576 | 20,793,528 | DS | 7 | 2185-04-27 00:00:00 | 2185-04-27 19:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Gadolinium-Containing Contrast Media
Attending: ___.
Chief Complaint:
Headache, photophobia, and neck stiffness for 5 days.
Major Surgical or Invasive Procedure:
___ - ___ Lumbar Puncture: Opening Pressure 26cm
H20; Protein 45; Glucose 77 mg/dL; Tube#1: 254WBC, 5RBC,
96%lymphocytes, 2%PMNs, 2%monocytes
History of Present Illness:
___ PMHx genital herpes (on lifelong acyclovir suppression) and
chronic lower back pain s/p lumbar spine steroid injection in
___ complicated by neutrophilic-predominant meningitis
presents with headache, neckstiffness, and photophobia due to
HSV-2 (Mollaret's) meningitis.
The patient was at her daughter's home on ___ when she
began having symptoms of malaise, fevers, chills 5 days prior to
presentation. She returned home to ___ but her symptoms
worsened and her sister took her to ___.
She does not note GI symptoms before her admission but did have
a headache, chills and neck pain. She has not had any recent
travel.
Past Medical History:
GERD
Genital Herpes (manifests on L buttock)
Anxiety
HTN
HLD
Hypothyroidism
Pneumonia ___, complicated by intubation and ICU admission)
Hepatitis B (Not on any medications)
Chronic lower back pain
Social History:
___
Family History:
Brother (deceased, aged ___: MI
Mother (deceased, aged ___ : MI
Physical Exam:
---------------
ADMISSION EXAM:
General- Alert, orientedx3, in no acute distress. Lying in bed
flat on back in dark room, crying in pain
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- UNABLE to flex, extend, and rotate neck. JVP not elevated,
no LAD
Lungs-Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Fast. Normal S1, S2, no murmurs, rubs, gallops
Abdomen- obese soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Back - Paraspinal pain with palpation at L4/5.
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, Strength ___ bilaterally in upper and
lower extremities. Sensation intact bilaterally. Bruzinski+,
Kernig+.
----------------
DISCHARGE EXAM:
VS:98.0 141/79 82 18 96/RA,
General- OVERALL INTERVAL IMPROVEMENT Alert, orientedx3, in no
acute distress. Ambulatory.
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- Able to flex, extend, and rotate neck without pain. JVP
not elevated, no LAD
Lungs-Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Fast. Normal S1, S2, no murmurs, rubs, gallops
Abdomen- obese soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Back - Paraspinal pain with palpation at L4/5.
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, Strength ___ bilaterally in upper and
lower extremities. Sensation intact bilaterally. ___-,
Kernig-.
GU- 5mm purple macule on left buttock without vesiculation. No
vesicles noted on the labia or perineum.
Pertinent Results:
-----------
ADMISSION LABS:
___ 10:56PM BLOOD WBC-7.2 RBC-3.83* Hgb-12.0 Hct-36.4
MCV-95 MCH-31.3 MCHC-32.9 RDW-13.7 Plt ___
___ 10:56PM BLOOD Neuts-75.7* ___ Monos-3.4 Eos-0.5
Baso-0.5
___ 10:56PM BLOOD Glucose-137* UreaN-10 Creat-0.6 Na-140
K-4.2 Cl-107 HCO3-26 AnGap-11
___ 01:49AM BLOOD HIV Ab-NEGATIVE
___ 10:56PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:05PM BLOOD Lactate-1.2
___ 02:59PM CEREBROSPINAL FLUID (CSF) ARBOVIRUS CULTURE AND
PCR-PND
___ 02:59PM CEREBROSPINAL FLUID (CSF) BORRELIA BURGDORFERI
ANTIBODY INDEX FOR CNS INFECTION-PND
___ 02:00PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR- POSITIVE HSV2, NEGATIVE HSV1.
___ LP:
Opening Pressure 26cm H20; Protein 45; Glucose 77 mg/dL
Tube#1: 254WBC, 5RBC, 96%lymphocytes, 2%PMNs, 2%monocytes
Tube#4: 409WBC, 3RBC, 95%lymphocytes, 2%PMNs, 3%monocytes
___ LP (___):
Protein 246; Glucose 39mg/dL
Tube #1: 8117WBC, 712RBC, 93%PMNs, 3%lymphs, 1%eos
Tube #4: 8617WBC, 861RBC, 94%PMNs, 2%lymphs,
Fungal Cx: No growth; CSF gram stain: Many PMNs, few GPCs, rare
GPR
Bacterial Cx: No growth.
___ 2:00 pm CSF;SPINAL FLUID Source: LP.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method, please
refer to hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO GROWTH.
---------
IMAGING:
___ MRI OF CERVICAL, THORACIC, AND LUMBAR SPINE
IMPRESSION:
1. Multilevel degenerative changes throughout the cervical
spine as described above with no evidence of focal or diffuse
lesions throughout the cervical spinal cord.
2. Disc degenerative changes are also identified at the
thoracic spine, more significant at T11/T12, causing mild
anterior thecal sac deformity with no evidence of neural
foraminal narrowing or spinal canal stenosis. No focal or
diffuse lesions are noted throughout the thoracic spinal cord.
3. Multilevel degenerative changes throughout the lumbar spine,
more
significant at L3/L4 and L4/L5 levels, consistent with mild
posterior disc bulge and articular joint facet hypertrophy,
there is also articular joint facet hypertrophy at L5/S1 and
mild epidural lipomatosis as described above.
There is no evidence of abnormal enhancement throughout the
cervical,
thoracic, or lumbar spine to indicate leptomeningeal disease.
Brief Hospital Course:
___ PMHx genital herpes (on lifelong acyclovir suppression) and
chronic lower back pain s/p lumbar spine steroid injection in
___ complicated by neutrophilic-predominant meningitis
presents with headache, neckstiffness, and photophobia due to
HSV-2 (Mollaret's) meningitis.
--------
ACTIVE ISSUES:
# ASEPTIC MENINGITIS: MARKED CLINICAL IMPROVEMENT. The patient
presented to ___ with headache, neck stiffness, and
photophobia where CT Head did not show acute process.
Transferred to ___ for ___ LP in the setting prior
providers' inability to perform unguided LP. CSF at ___ showed
opening Pressure 26cm H20; Protein 45; Glucose 77 mg/dL Tube#1:
254WBC, 5RBC, 96%lymphocytes, 2%PMNs, 2%monocytes. Covered
intially with ceftriaxone and acyclovir. Positive PCR result for
HSV-2. Discharged on PO valacyclovir 1g tid for total 14 days,
through ___, for Mollaret's syndrome. Ceftriaxone discontinued
after above results, negative CSF gram stain, negative CSF
(bacterial and fungal)culture, and clinical improvement. Lyme
serology negative. MRI C-, T-, L-spine was unrevealing for
infectious nidi or structural abnormality leading to repeat
meningitis given her episode of bacterial meningitis 3 months
prior. At discharge, Lyme CSF and Arboviridae PCR at State Lab
pending at time of discharge. Pain control effected with
acetaminophen, naproxen, and oxycodone. Discharged with 21
tablets PO 5mg oxycodone q8:PRN for 7 days with encouragement to
use acetaminophen and naproxen alone.
#GENITAL HERPES (on L buttock): ___ ID recommendation included
urging the patient to present to her PCP at next outbreak while
on her suppressive therapy at which time one of the vesicles
should be unroofed and swabs sent for DFA confirmation and
acyclovir resistance testiting. Please consider switching the
patient to valacyclovir for chronic suppression, as her
acyclovir has been stopped in the setting of high-dose
valacyclovir.
------------
CHRONIC ISSUES:
# Chronic Back Pain: STABLE. Continue on home gabapentin.
# GERD: STABLE. Continued home omeprazole 40mg qd.
# HLD: STABLE. Continued home simvastatin
# HYPOTHYROIDISM: STABLE. Continue home levothyroxine.
# INSOMNIA: STABLE. Continued home zolpidem.
------------
TRANSITIONAL ISSUES:
# CONSTIPATION: PERSISTENT. Iatrogenic, due to narcotic use.
Started on docusate and senna; however, patient may require
bowel regimen escalation on followup.
# ANXIETY: SEVERE. The patient clearly demonstrated significant,
nearly debilitating anxiety during her hospital course that was
treated in the short term with 1mg lorazepam q6:PRN; however,
longer term combination treatment with appropriate
pharmacotherapy and behavioral therapy is recommended.
# HEPATITIS B: Patient is not on any medications at present.
# GENITAL HERPES: See above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Lorazepam 0.5 mg PO BID
3. Gabapentin 1200 mg PO TID
4. Zolpidem Tartrate 5 mg PO HS
5. Simvastatin 20 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Acyclovir 400 mg PO Q12H
Discharge Medications:
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Lorazepam 0.5 mg PO BID
3. Simvastatin 20 mg PO DAILY
4. Zolpidem Tartrate 5 mg PO HS
5. Acetaminophen 1000 mg PO Q6H
6. Docusate Sodium 100 mg PO BID Stop when constipation
resolves.
7. Naproxen 375 mg PO Q8H:PRN pain (Stop IMMEDIATELY if
worsening stomach upset, blood in stool, or vomiting blood.)
8. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN PAIN
(Dispensed 21 tablets)
This is a TEMPORARY medication.
9. Senna 1 TAB PO DAILY Stop when constipation resolves.
10. Gabapentin 1200 mg PO TID
11. Omeprazole 40 mg PO DAILY
12. ValACYclovir 1000 mg PO Q8H ___, total 14 days through
___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
HSV-2 meningitis (Mollaret's meningitis)
Genital Herpes (on left buttock)
Secondary diagnoses:
Anxiety
Chronic lower back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was our pleasure to care for you while you were admitted to
___. You were transferred to ___ from ___ where
you presented with neck stiffness, headache, and tremendous pain
with expsoure to light. You undewent CT scan of your head at
___ then were transferred to ___ where you underwent guided
lumbar puncture whose results were compatible with viral
meningitis. You were initially started on antibiotics and
acyclovir; however, the antibiotics were stopped once the
results of the lumbar puncture demonstrated herpes simplex virus
type 2 in your cerebrospinal fluid.
It appears this episode of viral meningitis is unrelated to the
bacterial meningitis you had 3 months ago. You underwent MRI
imaging of the cervical, thoracic, and lumbar spine which did
not reveal evidence that would support an occult infection or a
cause for a second episode of meningitis. You had an MRI of your
spine which did not show structural evidence for why you had two
episodes of meningitis.
Followup Instructions:
___
|
10456718-DS-6 | 10,456,718 | 24,295,192 | DS | 6 | 2130-06-08 00:00:00 | 2130-06-08 21:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
___: left and right side cardiac cath.
___: attempted TEE, but unable to complete due to
esophageal diverticula.
History of Present Illness:
Mr. ___ is a ___ w/ non-ischemic cardiomyopathy and CHF
(EF = 10% on ___ and AF on warfarin and amiodarone who was
sent to the ED by his PCP for worsening SOB on exertion and
orthopnea. He was recently admitted to ___ from ___
with AF w/ RVR and was found to have a new decrease in his EF to
10% (previously 25% in ___. During that admission he
underwent DCCV and was trialed on Dofetilide; however, this was
discontinued due to QTc prolongation. He was loaded with
amiodarone and discharged home. He was doing well after
discharge until the last week, and he began experiencing severe
orthopnea 2d ago, after which he presented to ___ Urgent
Care. There he noted a 10 pound weight gain over his baseline
and was given 10 mg IV Lasix and IV Metoprolol for HR in the
120s. He felt better and was sent home on an increased dose of
lasix (changed from 20 mg PO QOD to 40 mg PO QD), and increased
metoprolol succinate from 50 mg daily to 100 mg daily. After
discharge patient fell well, but his symptoms recurred
yesterday, so his PCP advised him to go to the ED. There he
also noted abdominal discomfort and bilateral leg swelling, but
no fever/chills, chest pain, palpitations, diarrhea or
constipation.
Was previously on Warfarin ___ years ago; was diagnosed with
Atrial fibrillation at that time. But in ___ was all
medications for atrial fibrillation were discontinued. Warfarin
was restarted in ___- and patient reports that has
been therapeutic on Warfarin since.
In the ED, initial vitals were: Temp. 97.3, HR 94, BP 108/88, RR
18, 96% RA. Weight was 188 lbs in the ED (190 at ___ dry
weight reported to be 180 lbs). Labs were notable for CBC WNL,
lytes WNL w/ exception of BUN/Cr 34/1.7 (baseline Cr 0.9-1.0),
BNP 7550 (no baseline), INR 2.4. UA w/ 28 WBCs and few
bacteria. CXR showed cardiomegaly & mild pulmonary edema. EKG
showed an irregularly irregular rhythm at a rate of 103
consistent with AF, low voltage, Q waves in lead III and V1
through V3 (new Q wave in V3), poor R wave progression, diffuse
ST segment changes similar to prior with pseudo-normalization of
T wave in V1 through V3. He received Lasix 20 mg IV x1,
Ceftriaxone 1g, and Metoprolol succinate 50 mg. VS prior to
transfer were 96.8 89 ___ 98% RA.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS:neg Diabetes, neg Dyslipidemia,
positive for Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
-___
3. OTHER PAST MEDICAL HISTORY:
-left knee replacement
-hx of prostatitis
Atrial fibrillation
Systolic Congestive Heart Failure
Social History:
___
Family History:
Dad had ___ VSD s/p repair died of leukemia ___. Mom had
"early aging"
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
============================
Exam: VS: 97.8 ___ 82 18 96% RA wt 84.4 kg
Gen: In no acute distress, sitting comfortably in bed
HEENT: Moist mucous membranes
Neck: JVP elevated (pulsation visible at earlobe with the
patient seated upright)
Heart: Distant heart sounds, but irregularly irregular rhythm,
no discernible murmurs
Lungs: Coarse crackles at the bilateral bases
Abdomen: Soft, nondistended, no suprapubic tenderness
Extremities: 2+ pitting edema to the knees bilaterally
Skin: No rash
GU: Deferred
Neuro: Moving all extremities, AOx3
Right: +2 Radial pulse.
Left: +2 Radial Pulse.
PHYSICAL EXAM ON DISCHARGE
==========================
VS: T= 97.6 BP= 93/68 HR= 101 RR= 14 O2 sat= 93%
Wt: 80.4 kg
tele: HR: 116-101. A. fib. Rare PVCs.
GENERAL: in NAD. Oriented x4. Mood, affect appropriate.
cooperative
HEENT: Dry mucous membranes. NCAT. Sclera anicteric. PERRL,
EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa. No xanthelasma.
NECK: Supple with JVP of 9cm
CARDIAC: Tachycardic. irregular irregular.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No suprapubic
tenderness.
EXTREMITIES: Bilateral pitting edema up to mid shin. Less
edematous compared to yesterday.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: +2 Radial pulse
Left: +2 Radial Pulse.
Pertinent Results:
LABS ON ADMISSION:
=====================
___ 11:05AM BLOOD WBC-6.6 RBC-4.73 Hgb-15.3 Hct-46.8
MCV-99* MCH-32.3* MCHC-32.7 RDW-17.0* RDWSD-60.8* Plt ___
___ 11:05AM BLOOD ___ PTT-36.2 ___
___ 11:05AM BLOOD Glucose-105* UreaN-34* Creat-1.7* Na-140
K-5.1 Cl-101 HCO3-25 AnGap-19
___ 11:53PM BLOOD ALT-27 AST-26 AlkPhos-74 TotBili-1.5
___ 09:00PM BLOOD cTropnT-<0.01
___ 11:05AM BLOOD cTropnT-<0.01 proBNP-7550*
___ 05:40AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.0
LABS ON DISCHARGE:
=========================
___ 07:26AM BLOOD WBC-6.6 RBC-4.42* Hgb-14.2 Hct-43.6
MCV-99* MCH-32.1* MCHC-32.6 RDW-16.9* RDWSD-60.2* Plt ___
___ 07:26AM BLOOD Plt ___
___ 07:26AM BLOOD Glucose-98 UreaN-24* Creat-1.2 Na-138
K-3.9 Cl-102 HCO3-23 AnGap-17
___ 11:05AM BLOOD cTropnT-<0.01 proBNP-7550*
___ 09:00PM BLOOD cTropnT-<0.01
___ 07:26AM BLOOD Calcium-8.9 Phos-2.4* Mg-1.8
___ 10:30AM BLOOD calTIBC-213* Ferritn-448* TRF-164*
___ 10:30AM BLOOD TSH-2.8
___ 10:30AM BLOOD PEP-AWAITING
___ 10:30AM BLOOD HIV Ab-Negative
MICRO:
==========
Urine culture: ___ NO GROWTH
___ 11:15 6* 6* FEW NONE 0
IMAGING:
==========
___ ECHO:
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. There is severe global left ventricular hypokinesis
(LVEF = 20%). The right ventricular cavity is moderately dilated
with moderate global free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. Moderate [2+] tricuspid regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Symmetric LVH with severe global left ventricular
systolic dysfunction. Moderate right ventricular systolic
dysfunction. Mild mitral regurgitation. Moderate tricuspid
regurgitation.
Compared with the prior study (images reviewed) of ___, the
findings are similar.
___: Left and Right Side Catheterization:
Co-dominance
C.I: 2.66
LAD: 30% stenosis Circumflex: 30 % proximal stenosis Ramus:
Moderate size vessel with 60% stenosis. Circumflex with 30%
stenosis proximally. No discordance between LVEDP and RVEPD.
Brief Hospital Course:
Mr. ___ is a ___ w/ non-ischemic cardiomyopathy and CHF
(EF = 10% on ___ and AF on warfarin and amiodarone who is
admitted with DOE and orthopnea concerning for acute
decompensated systolic congestive heart failure.
# Acute on chronic systolic heart failure (EF 20%):
Patient presented with dyspnea on exertion and orthopnea and was
found to have a systolic heart failure exacerbation. The
etiology was unclear however ischemia was ruled out with
negative troponins, absence of ischemic ECG changes, and left
heart cath showing only 30% stenosis of the LAD. Also concern
for alcohol cardiomyopathy given alcohol history, but
catheterization did not show a dialated pathology.
Patient underwent right and left heart cath on ___ that
showed 30% stenosis on LAD . Patient diuresed with 40 mg IV
Lasix BID. Also concern for rate control contributing given
atrial fibrillation. Cardiomyopathy work up included TSH,
ferritin, serum iron, SPEP/UPEP, and HIV that showed normal TSH,
elevated Ferritin, normal serum Iron, low TIBC and Transferrin,
and negative HIV. SPEP and UPEP were pending at time of
discharge. Metoprolol was initially held but restarted prior to
discharge. Losartan was initially held but restarted prior to
discharge. Lasix 40 mg daily also continued at time of
discharge. Weight on discharge was 80.4 kg.
# Atrial Fibrillation:
Patient recently admitted to ___ from ___ with AF w/
RVR and was found to have a new decrease in his EF to 10%
(previously 25% in ___. During that admission he underwent
DCCV and was trialed on Dofetilide; however, this was
discontinued due to QTc prolongation. He was loaded with
amiodarone and discharged home. He was doing well after
discharge until the week prior to this ___ admission, and he
began experiencing severe orthopnea on ___ after which he
presented to ___ Urgent Care where he was found to have
atrial fibrillation with RVR.
On arrival patient continued on amiodarone, beta blocker held in
setting of severely depressed EF. Warfarin 7.5 mg daily held on
___ given cardiac catheterization as above and heparin drip
initiated. Had a left and right sided catheterization without
intervention on ___. Plan was for TEE and cardioversion post R.
and left heart cath on ___ per EP; however could not
proceed with TEE because patient had esophageal diverticula. Was
bridged with Lovenox on ___ s/p cath and Warfarin 7.5 mg was
restarted on ___. Patient will have INR check on ___ and
lovenox can be discontinued when INR > 2
#Hypotension
Patient noted to have transient hypotension on ___ to 70/40.
At that time patient was asymptomatic. 250 cc bolus given and
blood pressure improved to 90-100 range. This was felt to likely
be secondary to underlying systolic EF.
# Urinary Retention/UTI
Patient noted to have urinary retention on ___ at which
time UA/Culture was obtained. Given severity of urinary
retention foley placed. Patient started on IV ceftriaxone from
___. On ___ was started on a 4-day course of Bactrim.
Urine culture showed -no growth. Patient also with history of
prostatitis though did not feel that this was consistent with
prior episodes. On ___ foley was removed and patient was able
to urinate on his own. The patient will likely benefit from
outpatient urology follow up.
#Acute Kidney Injury:
Creatinine elevated to 1.9 on admission from baseline 1.0. This
was likely secondary to post-renal etiology as patient had
obstruction that improved after foley placement. Creatinine
improved to 1.2 on day of discharge. Creatine should be checked
at time of follow up.
# EtOH Abuse:
History of EtOH abuse also with reported use of Ativan at home
0.5 mg BID. This was continued while in house. Did not appear
to have signs or symptoms of withdrawl.
TRANSITIONAL ISSUES:
========================
- Lovenox started to bridge to therapeutic warfarin. INR at
discharge was 1.8.
- INR should be checked on ___ and sent to ___
Anticoagulation Program ___ clinic, ___ RN.
Lovenox can be stopped when INR > 2.
- Please check INR at PCP appointment on ___.
- Please check chem-7 to ensure renal function is stable
(creatinine on discharge 1.2)
- Lasix was continued at 40 mg daily. Please continue to monitor
weight and volume status.
- Bactrim DS BID was continued until ___ to complete 7 day
course.
- Patient needs barium swallow as TEE unsuccessful given
esophageal diverticuli
- Patient should have evaluation for BPH and consider initiation
of flomax as had urinary retention this hospitalization.
- Please follow-up pending blood cultures from ___, and
___.
-please follow up SPEP and UPEP pending at time of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.5 mg PO Q4H:PRN anxiety
2. Losartan Potassium 25 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Warfarin 7.5 mg PO DAILY16
6. Amiodarone 300 mg PO DAILY
Discharge Medications:
1. Warfarin 7.5 mg PO DAILY16
2. Losartan Potassium 25 mg PO DAILY
3. Sulfameth/Trimethoprim DS 1 TAB PO BID
Plan for 7-day course, to be completed ___.
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*8 Tablet Refills:*0
4. Enoxaparin Sodium 80 mg SC BID
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 80 mg subcutaneous twice a day Disp
#*20 Syringe Refills:*0
5. Lorazepam 0.5 mg PO BID anxiety
6. Outpatient Lab Work
ICD-10 I48.2
Please check INR on ___.
Please fax results to ___. Patient is followed by
___ Anticoagulation Program (___).
7. Amiodarone 200 mg PO DAILY
RX *amiodarone 200 mg Take 1 tablet by mouth daily Disp #*30
Tablet Refills:*0
8. Furosemide 40 mg PO DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Biventricular Heart Failure
Atrial Fibrillation
Urinary Tract Infection
Secondary:
Alcohol use
Hypertension
Anxiety
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 with shortness of breath and were found
to have a condition called "heart failure." We treated you with
medications to get the extra fluid off. We started a medication
called lovenox that you will take until your "INR" is in the ___
range along with warfarin. Once it is in this range the lovenox
can be stopped and warfarin alone continued. The ___
___ clinic will follow your INR level and tell you
when to stop the lovenox. Please Weigh yourself every morning,
call MD if weight goes up more than 3 lbs.
Please go to the ___ clinic on ___ to have your
INR level checked.
It was a pleasure being involved in your care,
Your ___ Team
Followup Instructions:
___
|
10456768-DS-13 | 10,456,768 | 27,361,807 | DS | 13 | 2110-04-25 00:00:00 | 2110-04-26 16:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Major Surgical or Invasive Procedure:
Permanent Pacemaker Placement (___)
Percutaneous Nephrostomy Placement (___)
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 04:10PM BLOOD WBC-4.2 RBC-3.53* Hgb-9.2* Hct-29.3*
MCV-83 MCH-26.1 MCHC-31.4* RDW-14.0 RDWSD-42.8 Plt ___
___ 04:10PM BLOOD Neuts-76.7* Lymphs-7.9* Monos-11.4
Eos-2.1 Baso-0.7 Im ___ AbsNeut-3.22 AbsLymp-0.33*
AbsMono-0.48 AbsEos-0.09 AbsBaso-0.03
___ 05:47AM BLOOD ___ PTT-30.5 ___
___ 04:10PM BLOOD Glucose-102* UreaN-45* Creat-2.4* Na-132*
K-5.1 Cl-97 HCO3-19* AnGap-16
___ 04:10PM BLOOD ALT-25 AST-58* LD(LDH)-786* AlkPhos-65
TotBili-0.5
___ 04:10PM BLOOD CK-MB-5 ___ 04:10PM BLOOD cTropnT-0.06*
___ 04:10PM BLOOD Calcium-10.3 Phos-4.2 Mg-1.9
___ 04:10PM BLOOD Albumin-2.6* UricAcd-12.7*
___ 04:10PM BLOOD Ferritn-1352*
___ 05:47AM BLOOD Hapto-217*
___ 05:47AM BLOOD Osmolal-298
___ 04:10PM BLOOD TSH-1.4
___ 04:10PM BLOOD Free T4-1.3
___ 05:47AM BLOOD FreeKap-123.9* FreeLam-33.4* Fr K/L-3.71*
___ 06:02AM BLOOD freeCa-1.42*
MICRO
======
___- Blood Cx:
NGTD
___ Urine Cx: Coag-neg staph sensitive to nitrofurantoin,
tetracycline, vanc
Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI
IN PAIRS AND CLUSTERS. COAGULASE (-)
___ blood cx: NGTD
PERTINENT IMAGING:
===================
___ TTE
CONCLUSION:
The left atrial volume index is mildly increased. There is no
evidence for an atrial septal defect by 2D/color
Doppler. There is mild symmetric left ventricular hypertrophy
with a normal cavity size. Overall left ventricular
systolic function is normal. However, the inferior and posterior
walls are hypokinetic. Quantitative biplane
left ventricular ejection fraction is 64 % (normal 54-73%).
There is no resting left ventricular outflow
tract gradient. Normal right ventricular cavity size with normal
free wall motion. Tricuspid annular plane
systolic excursion (TAPSE) is normal. The aortic sinus diameter
is normal for gender with a normal ascending
aorta diameter for gender. The aortic arch is mildly dilated.
There is no evidence for an aortic arch coarctation.
The aortic valve leaflets are moderately thickened. There is
SEVERE aortic valve stenosis (valve area 1.0 cm2
or less). 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 trivial mitral regurgitation. Due to acoustic
shadowing, the severity of mitral regurgitation could be
UNDERestimated. The pulmonic valve leaflets are
normal. The tricuspid valve leaflets appear structurally normal.
There is tricuspid regurgitation present (could
not be qualified). Due to acoustic shadowing, the severity of
tricuspid regurgitation may be UNDERestimated.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Severe aortic stenosis.
Inferior posterior hypokinesis.
___ CXR
IMPRESSION:
Right PICC line tip is at the level of mid SVC.
Right atrial and right ventricular pacemaker leads appear to be
in expected
positions.
Heart size and mediastinum are stable. Right basal
consolidation has
substantially improved in the interim. There is no pulmonary
edema. There is no interval increase in pleural effusion or
development of pneumothorax
___ CT Abd/Pelvis with Contrast
IMPRESSION:
1. Severe lymphadenopathy within the abdomen/pelvis as described
above,
including infiltrative mass involving the retroperitoneum, which
obstructs the ureter, consistent with lymphoma. Largest portion
is a conglomerate of lymph nodes measuring up to 8.3 cm in
diameter within the right pelvis.
2. There is involvement of lymphatic disease within the right
perirenal fat with soft tissue thickening along Gerota's and
Zuckerkandl's fascia. There is associated severe right
hydronephrosis and severe right hydroureter.
3. Large left inguinal hernia containing nonobstructed sigmoid
colon.
4. Nonspecific hypoattenuating lesion within the spleen could
represent
malignancy.
5. Prostatomegaly.
6. Bilateral pleural effusions with associated atelectasis,
right greater than left.
7. Further evaluation of abdominal soft tissues and vessels is
limited due to lack of contrast.
___ Renal US
IMPRESSION:
1. No visualized renal stones or hydronephrosis.
2. Redemonstration of large right rectus sheath hematoma.
___ CXR Portable
IMPRESSION:
Lungs are low volume with prominence of the interstitium.
Cardiomediastinal silhouette is enlarged but unchanged. Right
pleural effusion has decreased in volume. Left-sided pacemaker
is unchanged. Right-sided central line has been placed with its
tip in the SVC. Previously visualized right-sided PICC line is
unchanged in position. No pneumothorax. A small left pleural
effusion
___ CT Abd/Pelvis w/o contrast
IMPRESSION:
1. Interval removal of the double-J catheter with new moderate
right
hydronephrosis likely secondary to the right pelvic adenopathy
and rectus
sheath hematoma. No left hydronephrosis.
2. Interval decrease in size of the pelvic lymphadenopathy.
3. Large right inferior rectus sheath hematoma, minimally
increased in size since prior.
4. Interval decrease in volume of ascites.
5. Increased size of the pleural effusions bilaterally, now
moderate in
volume.
___ CT HEAD
no acute intracranial process
___ Bilateral ___ Non-invasives
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins or upper extremity veins
___ RUQUS
IMPRESSION:
1. No intrahepatic or extrahepatic dilation. Gallbladder
sludge. No
cholecystitis
2. Trace perihepatic, perisplenic ascites and right pleural
effusion, similar to prior CT.
3. 11 cm rectus sheath hematoma, similar in size compared to the
CT from ___ when accounting for difference in technique.
___ TTE
EF 35%. Suboptimal image quality. Inferoposterolateral
hypokinesis with moderate-to severe mitral regurgitation.
___ Unilat UE US
IMPRESSION:
1. Nonocclusive deep venous thrombosis in 1 of the right
brachial veins.
2. Evaluation of the right subclavian vein is extremely limited
secondary to overlying bandages. Within this limitation, the
visualized portion of this vessel appears patent.
___ CT ABD/PELVIS W/O CONTRAST
IMPRESSION:
1. Interval resolution of the previously noted right-sided mild
to moderate
hydronephrosis with percutaneous nephrostomy tube in unchanged
position.
Unchanged appearance of right perinephric stranding and soft
tissue
thickening.
2. Mild decrease in size (few mm) in the known retroperitoneal
and right
pelvic lymphadenopathy with increased calcifications, reflecting
response to
treatment. No new or enlarging lymph nodes.
3. No significant interval change in size of the inferior right
rectus sheath
hematoma measuring up to 10.7 cm, currently predominantly
containing
low-attenuation fluid, indicating chronicity.
4. Persistent moderate-sized bilateral pleural effusions.
DISCHARGE LABS
===============
___ 12:00AM BLOOD WBC-19.5* RBC-2.67* Hgb-7.8* Hct-24.9*
MCV-93 MCH-29.2 MCHC-31.3* RDW-16.4* RDWSD-55.2* Plt Ct-91*
___ 12:00AM BLOOD Neuts-82* Bands-4 Lymphs-4* Monos-5
Eos-0* ___ Metas-3* Myelos-2* AbsNeut-16.77* AbsLymp-0.78*
AbsMono-0.98* AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD Plt Smr-LOW* Plt Ct-91*
___ 12:00AM BLOOD ___ PTT-37.9* ___
___ 12:00AM BLOOD Glucose-114* UreaN-32* Creat-2.7* Na-140
K-4.2 Cl-102 HCO3-25 AnGap-13
___ 12:00AM BLOOD ALT-20 AST-34 LD(LDH)-375* AlkPhos-218*
TotBili-0.6
___ 12:00AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.0 UricAcd-4.2
___ 12:11PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 05:47AM BLOOD FreeKap-123.9* FreeLam-33.4* Fr K/L-3.71*
Brief Hospital Course:
=================
PATIENT SUMMARY
=================
Primary Onc: Dr. ___
Mr. ___ is a ___ M with a PMH notable for paroxysmal atrial
fibrillation/atrial flutter on apixaban, CKD, and CVA who
presented to the ___ after ___ transferred to
___. He had a PPM placed and CTAP/lymph node biopsy showed
CD5+ DLBCL. He was started on DA-EPOCH which was complicated by
TLS and then transitioned to CHOEP. Hospital course was
complicated by upper extremity DVT, ___ on CKD due to
obstructive uropathy with PCN placement and initiation of HD,
and NSVT s/p amio loading with resultant hepatotoxicity.
TRANSITIONAL ISSUES
====================
[ ] Pt has PCN still in place, please readdress weekly if he can
have it taken out. Had several discussion with urology about
taking it out as his UOP increased, PCN output decreased and had
interval improvement in obstruction on CT scan. Urology felt
that he is still at risk for re-obstruction causing permanent
kidney damage. They felt that PCN should be in place until chemo
finished. Given that the tube is not actively needed at this
time, carries a risk of infection and that he finds much
discomfort from it, it should be readdressed weekly weighing the
risks/benefits of keeping it in.
Discharge weight: 91.2 kg (201.06 lb)
Discharge Cr: 2.7
Discharge Hgb: 7.8
Discharge ANC: ___
Discharge Platelets: 91
ACUTE ISSUES:
=============
# DLBCL
# TLS
Initially presented with lethargy, hypercalcemia and anemia.
Received bisphosphonate at outside hospital. CTAP showing (___)
diffuse lymphadenopathy. Noted to have TLS ___ despite
prophylaxis and hydration/diuresis. DA-EPOCH (___) with
rituximab as outpatient was originally planned however iso
profound renal injury due to TLS (s/p rasburicase ___ and
___ and obstructive ___ last cyclophosphamide dose was held
and rituximab held with prolonged hospital stay. Renal injury
and electrolyte abnormalities worsened iso of new VT and
pulmonary edema requiring two ICU transfers; when back on the
floor poor urine output was noted with volume overload and iHD
was ultimately started. Rituximab was given once he was stable
on dialysis. Got port and tunneled HD lines placed by ___ on
___. Started on CHOEP on ___.
- Outpatient Oncologist: Dr. ___
- ___ regimen: CHOEP C1D16 (___)
#Right upper extremity DVT
#DVT associated with PICC line
#Bleeding - resolved
On ___ the patient developed unilateral right upper extremity
swelling and underwent noninvasive ultrasound and was found to
have right axillary nonocclusive DVT around the PICC line. The
patient was started on heparin drip on ___ and switched to SQH
20,000 units twice daily (250units/kg) so the patient would not
have to be on continuous heparin drip for an extended period of
time. Plan was to continue anticoagulation for 3 months after
PICC line exchanged to single-lumen port and temp HD IJ line
changed to tunneled HD line ___. He had persistent bleeding
from PCN and IV access he was reversed with protamine with
significant improvement of bleeding. He required 2 u PRBC
___ with no evidence of active bleeding since. Restarted on
prophylactic AC with no further bleeding.
# ___, ATN iso hypotension
# Obstructive ureterohydronephrosis
# BPH
# intermittent dialysis
Cr 2.4 (admission) but steadily rose in setting of new diagnosis
of abdominal DLBCL measuring up to 8.3cm in R pelvis with
associated right ureterohydronephrosis. Renal US (___) with
moderate right ureterohydronephrosis. CTAP (___) notable for
severe right hydronephrosis and severe right hydroureter. s/p
PCN ___, PCN changed on ___ with adequate drainage. Cr
continued to increase ___ despite adequate hydration, output
w/diuretics, and management of obstruction concerning for
worsening renal insult ___ TLS and possible left ureteral
obstruction not seen on imaging. Patient was briefly transferred
to MICU twice iso VT and pulmonary edema, both accompanied by
hypotension which may have caused further kidney damage. ___
exchanged PCNU ___ after decreasing output was noted with no
significant improvement in urine output and worsening volume
overload. Dialysis started ___, mentation much improved and
less fatigue with subsequent sessions. Patient spontaneous urine
output continued to improve. PCN output clear after reversal of
anticoagulation. PCN output decreased and UOP increased closer
to discharge. Repeat imaging showed improvement in
lymphadenopathy however urology recommended keeping PCN in until
completion of chemotherapy as a preventative measure to decrease
risk of repeat obstruction causing permanent kidney damage. Did
not appear that patient needed PCN at discharge especially since
he found much discomfort from it. ___ be able to remove as an
outpatient earlier than was originally planned.
# A-fib with sinus pauses, likely paroxysmal
# Tachy-brady syndrome (pacemaker: DDD 60-130, ___
ACCOLADE MRI ___
# Arrhythmogenic syncope
# NSVT
New a-fib since ___ c/b hemodynamically significant
conversion pauses lasting ___ seconds, now s/p dual lead PPM
(___). Hospital course notable for runs of NSVT, intermittently
symptomatic with palpitations. Atrial fibrillation with
aberrancy noted on tele throughout. On ___, transferred to ICU
for wide complex tachycardia thought to be AFib w/ aberrancy
though episodes of VT also identified on device interrogation.
Received IV amiodarone bolus, was continued on PO
amiodarone/Metoprolol afterward and HR remained within target
range <110. Pt repleted to higher calcium goal given cardiac
irritability. Patient returned to ___ on ___ after flash Pulm
edema iso Afib rvr with hypotension and respiratory distress. In
the ICU, episode resolved without CRT, with BPs returning to
normal. Continued in Afib with rates in 90-110s with frequent
PVCs at times. Patient had 4min run of asymptomatic VT in ICU,
with eventual resolution. Returned to the floor on ___ in
atrial paced rhythm at 60bpm with intermittent PVCs. Metop was
increased in frequency and amio was made BID with dose increase
to 400mg. On ___, amio discontinued due to obstructive pattern
liver injury. Had AFib episode ___ during HD which lasted 3.5h
and reverted spontaneously after blood product administration,
stopping of dialysis, and standing metoprolol dosing. Metoprolol
up-titrated to metoprolol tartrate 50mg q6hr.
#Hypocalcemia
Thought to be ___ exaggerated response to prior bisphosphonate
administration iso of renal injury. Per Endocrine
recommendation, patient was started on calcitriol 0.5 mcg, and
calcium carb solution po 1250 BID.
# Obstructive biliary pattern transaminitis
On ___ slight increases in alk phos was noted which worsened in
the following days with dramatic increases in direct bilirubin
along with uptrending transaminases. All hepatotoxic medications
were stopped including micafungin, atorvastatin, and amiodarone
to rule out drug effect. Imaging including RUQUS ___ and CTAP
___ were without noted obstruction within biliary tree or
abnormalities in the hepatic parenchyma. Less likely viral
insult iso negative hepatitis serologies and predominantly
elevated markers of obstruction vs parenchymal injury.
Infiltrative disease unlikely ilo acuity of rise. Medication
effect most likely as bilirubin markedly decreased iso stopping
hepatotoxic drugs and MRCP was not pursued.
# Severe malnutrition
# Oropharyngeal lesions
Patient reports that he had not been able to eat partly due to
to his mouth hurting. On examination large oropharyngeal
erosions were present that are about 3 to 4 mm in diameter. The
patient also complained of pain underneath his tongue. In
setting of his recent neutropenia these lesions were concerning
for both either viral or fungal infections. Lesions noted to be
significantly improved ___. Micafungin stopped.
#Neutropenia
#Hypotension
#Concern for infection
Patient hypotensive ___ with concern for infection given
neutropenia so he was started on cefepime and vancomycin. UA was
polymicrobial but urine culture <100K of coag negative staph.
___ BCx NGTD. Remained afebrile but was immunocompromised.
#Severe AS
Bilateral lower extremity edema. TTE (___) demonstrated severe
AS ___ 0.9). Prominent murmur on exam. TTE on ___ w/EF 35%
and peak gradient of 55mmHg, VAI 0.4cm2/m2. EF decreased since
last TTE on ___. Currently deferring structural treatment
until treatment of lymphoma.
CHRONIC ISSUES:
===============
# History of CVA:
Pts aspirin and Plavix were stopped at ___ after he was
started on apixaban.
# BPH:
He was continued on home Tamsulosin 0.4 mg QHS
# HLD:
He was initially continued on home atorvastatin 80 mg QHS, held
due to hepatoxicity
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Metoprolol Tartrate 25 mg PO BID
2. Apixaban 2.5 mg PO BID
3. Tamsulosin 0.4 mg PO QHS
4. Atorvastatin 80 mg PO QPM
5. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO DAILY
2. Atovaquone Suspension 1500 mg PO DAILY
3. Calcitriol 0.5 mcg PO DAILY
4. Calcium Carbonate Suspension 1250 mg PO BID
5. Heparin 5000 UNIT SC BID
6. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Sob/wheezing
7. Maalox/Diphenhydramine/Lidocaine ___ mL PO TID:PRN
GERD/Mucocystits
8. Nephrocaps 1 CAP PO DAILY
9. Omeprazole 20 mg PO BID
10. Psyllium Powder 2 PKT PO TID:PRN constipation
11. Ramelteon 8 mg PO QPM:PRN insomnia
12. Senna 8.6 mg PO BID
13. Metoprolol Tartrate 50 mg PO Q6H
14. Polyethylene Glycol 17 g PO DAILY
15. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
===================
# Abdominal diffuse large B cell lymphoma
# Atrial fibrillation with superimposed ventricular tachycardia
s/p PPM placement
SECONDARY DIAGNOSIS
=====================
# Acute kidney injury
# Obstructive Uropathy
# Tumor lysis syndrome
# Tachy-Brady Syndrome
# Peripherally inserted central catheter associated deep vein
thrombosis
# Severe Aortic Stenosis
# Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I IN THE HOSPITAL?
- one of the valves in your heart (aortic valve) was excessively
tight and caused you to lose consciousness
- you were found to have an irregular rhythm
- you were found to have a large pelvic mass that was biopsied
and identified as a type of lymphoma called diffuse large B-cell
lymphoma
- the large pelvic mass was obstructing your right kidney and
caused a kidney injury
also contributing to your kidney injury was a syndrome called
tumor lysis syndrome in which the dead lymphoma cells released
toxins into your blood also hurt your kidneys
WHAT HAPPENED TO ME IN THE HOSPITAL?
- For your irregular heart rhythm a permanent pacemaker was
placed by the cardiologists
- A tube to drain your obstructed kidney was placed
- you were started on chemotherapy for your lymphoma
- You developed a clot due to the IV access for which you
received blood thinner which unfortunately made you bleed
- You were started on dialysis
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:
___
|
10456776-DS-21 | 10,456,776 | 25,132,454 | DS | 21 | 2123-08-14 00:00:00 | 2123-08-14 16:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Tegretol / Dilantin / Trileptal
Attending: ___
Chief Complaint:
Right Facial Pain consistent with previous trigeminal neuralgia
flares
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ y.o. right handed gentleman with a history
of hypertension, asbestosis, diet controlled DM, bilateral
hearing loss, trigeminal neuralgia on the left s/p surgical
ablation in the ___ and no recurrent symptoms, trigeminal
neuralgia on the right since ___, presenting with a 10 day
history of right sided facial pain consistent with his
trigeminal neuralgia symptoms.
He has had on and off symptoms on the right side of his face
since ___, was tried on multiple medications some of which
caused adverse reactions: dilangin (unknown), oxcarbazepine
(hyponatremia), carbamazepine (encephalopathy?). In ___, he
underwent gamma knife procedure to his right trigeminal nerve
and did not have any pain for the following ___ years, until
___ when he had severe pain again. He presented to
___ at that time and was admitted for 2 weeks, received
multiple agents and ended up on a combination of prednisone,
neurontin and dilaudid and advil which were subsequently weaned
off as his pain resolved. He recived carbamazepine then but had
a reaction concerning for encephalopathy. He had been symptom
free since then.
His pain started about 10 days ago and he immediately presented
to the emergency room at ___, given that he expected it was
going to be worse. He was started on Dilaudid 2mg q6hrs, which
was later increased to 2mg q5 then q4 as his symptoms did not
improve. He contacted his neurologist yesterday who started him
on prednisone 10mg TID. As his pain did not improve, he
presented to ___ again today, received a dose of
IV morphine with some improvement, and was sent to our emergency
room to be evaluated by neurology for a possible admission.
His pain is in a trigeminal distribution on the right and he
has, at baseline, a feeling of pins and needles, with a
superimposed severe and sharp pain lasting from seconds to 1
minute, every 30mn to 1 hour.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia,lightheadedness, vertigo,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:
- hypertension
- asbestosis
- diet controlled DM
- bilateral hearing loss
- trigeminal neuralgia on the left s/p surgical ablation in the
___ and no recurrent symptoms
- trigeminal neuralgia on the right since ___ s/p gamma knife
in ___.
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
***************
Vitals: T: 98 P: 88 R: 18 BP: 137/66 SaO2: 98%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
- Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. 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. 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. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation decreased on the left (s/p surgical
manipulation of trigeminal nerve)
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.
Motor:
Normal bulk and tone, no rigidity or bradykinesia.
Left:
Delt ___, ___ ___, Tri ___, Grip ___, Spread ___, IP ___, Quad
___, Ham ___, TA ___, ___ ___, Gastroc ___
Right:
Delt ___, ___ ___, Tri ___, Grip ___, Spread ___, IP ___, Quad
___, Ham ___, TA ___, ___ ___, Gastroc ___
-Sensory: No deficits to light touch, pinprick
Reflexes:
DTRs
Right: ___ 1 Tri 1 ___ 1 Patellar 1 Achilles 1
Left: ___ 1 Tri 1 ___ 1 Patellar 1 Achilles 1
Plantar response was flexor bilaterally.
-Coordination: he has intention tremor bilaterally. No dysmetria
on FNF.
-Gait: Not performed.
DISCHARGE EXAM: Facial pain has somewhat resolved on medical
regimen, and no changes to other components of examination. On
evaluation with attending, decreased corneal reflex was noted on
the right eye in the upper distribution. Also bilateral V2
decreased sensation was noted to pinprick with intact C3.
***************
Pertinent Results:
___ 04:50AM GLUCOSE-122* UREA N-17 CREAT-0.8 SODIUM-136
POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-31 ANION GAP-11
___ 04:50AM WBC-11.7* RBC-4.57* HGB-14.9 HCT-43.4 MCV-95
MCH-32.6* MCHC-34.3 RDW-12.7
___ 04:50AM PLT COUNT-289
___ 08:15PM GLUCOSE-166* UREA N-14 CREAT-0.8 SODIUM-135
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-30 ANION GAP-12
___ 08:15PM estGFR-Using this
___ 08:15PM ALT(SGPT)-29 AST(SGOT)-21 ALK PHOS-86 TOT
BILI-0.5
___ 08:15PM ALBUMIN-4.5
___ 08:15PM WBC-13.9* RBC-4.85 HGB-15.6 HCT-45.5 MCV-94
MCH-32.1* MCHC-34.2 RDW-12.6
___ 08:15PM NEUTS-77.0* LYMPHS-16.6* MONOS-5.6 EOS-0.5
BASOS-0.4
___ 08:15PM PLT COUNT-270
CHEST PA/LAT FINDINGS: In comparison with the study of ___,
the patient has taken a much better inspiration. Bilateral
pleural calcification is again consistent with asbestos-related
disease. No evidence of acute focal pneumonia.
MRI IMPRESSION:
1. 3 x 3 x 2 mm focus of enhancement in the retrogasserian
portion of the right trigeminal nerve, new since ___, which may
be related to a breakdown of blood/brain barrier following gamma
knife therapy. However, a nerve sheath tumor may have a similar
appearance. Comparison with any recent prior studies would be
helpful.
2. Extensive signal abnormalities in the supratentorial white
matter, nonspecific but most likely related to sequela of
chronic small vessel ischemic disease in a patient of this age.
Brief Hospital Course:
# NEUROLOGIC:
The patient was given Morphine IV in the ED, with some
responsiveness; however, he experienced significant improvement
when neurontin and baclofen was added to his theraputic regimen.
Mr. ___ was noted to have some decreased V1 distribution
sensory change with a reduced corneal reflex on the right upper
distribution. As a result of this finding which could have been
secondary to ___ Gamma Knife surgery for intractable trigeminal
neuralgia, an MRI head was obtained which showed only
post-surgical changes on the left, post-gamma knife changes on
the right, and was unremarkable for any mass effect. His
neurologist had originally prescribed Prednisone therapy, which
we continued throughout his stay.
Of note, the patient experienced some decrease in analgesia in
the regimen. As such alternative medications like Depakote were
added without any significant effect. Chronic pain management
was consulted with recommendation to use long acting opiates,
specifically MS ___ ___ BID. We also added Lamictal 50mg
BID which provided better relief for the patient. Neurosurgery
was also consulted for consideration of additional intervention
to the previous site of gamma knife therapy. Their suggestion
was continued follow-up with the Neurosurgeons at ___
___ possible second ablation with gamma knife versus
surgical intervention.
# PULMONARY:
Mr. ___ was noted to have rhonchorous breathing in the
setting of known asbestosis disease. He was evaluated for this
with a chest X-ray which showed no new process, and
redemonstration of the asbestosis-related disease. His oxygen
saturations were maintained with as necessary nasal cannula
oxygen.
# CV:
The patient was maintained on Enalapril while inpatient with
good BP control.
# WOUND CARE:
The patient is followed by a Dr. ___
from ___ for left-sided "half dollar sized" wound that did
not heal earlier in the ___ and a another
blister/wound was discovered on his right lateral malleolus
treated with antibiotics, dressings and compression wraps to his
lower extremities. On presentation, completely intact skin on
both ankles were present with dressings
impregnated with calamine lotion that later hardens into a soft
cast-like material. Wound care was consulted and adaptic
dressings to the two previously impaired areas were applied and
covered with dry 4x4 gauze, then wrapped with Kling, ACE
bandages, and covered by tubular net dressings. He will follow
up with his vascular physician after discharge.
# TRANSITIONS OF CARE:
Mr. ___ was scheduled with our clinic for follow up in 6
weeks. He was noted to be on Prednisone therapy as prescribed
by his Neurologist which we would consider using a wean as
outpatient. Analgesics given for maintainance of his facial
pain included Neurontin, Lamictal, and Oxycodone. We have
scheduled an appointment at ___ for further evaluation of the
patient as well by Neurosurgery.
Medications on Admission:
- Enalapril 20mg am, 10mg pm
- ASA 81 mg
- Multivitamins
- Prednisone 10mg q8
Discharge Medications:
1. Enalapril Maleate 10 mg PO DAILY every evening.
2. Aspirin 81 mg PO DAILY
3. Enalapril Maleate 20 mg PO DAILY every morning
4. Multivitamins 1 TAB PO DAILY
5. PredniSONE 10 mg PO TID
6. Gabapentin 600 mg PO TID
RX *gabapentin 300 mg 2 capsule(s) by mouth three times a day
Disp #*180 Capsule Refills:*3
7. Morphine SR (MS ___ 15 mg PO Q12H
Please hold if RR < 12, if pt sedated, or if pt refuses
RX *morphine [MS ___ 15 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
8. LaMOTrigine 50 mg PO BID
RX *lamotrigine [Lamictal] 25 mg 2 tablet(s) by mouth twice a
day Disp #*120 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Trigeminal Neuralgia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were evaluated at ___ for
your complaint of right sided facial pain which is consistent in
character and location with your past flares of trigeminal
neuralgia. We started you on a regimen of two medications to
control the pain you have experienced, Neurontin and Baclofen,
which had good effect in controlling your pain.
In order to thoroughly evaluate the pain that you have
experienced, we ordered an MRI of the head which was
unremarkable. As your pain became worse, we consulted our
chronic pain service physicians who recommended a course of MS
___ at a low dosage twice a day, and started you on Lamictal
twice a day which gave you good control.
We also contacted our neurosurgeons who evaluated you for
additional surgical workup; however, they recommended that you
follow up with the physicians who performed your original gamma
knife surgery, Drs. ___ and ___ at ___. As
such we scheduled an appointment with them for evaluation for
further intervention.
Please follow up with the appointments which have been
scheduled, and continue on the medications which have been
recommended for your pain relief regardless of whether you are
experiencing pain or not.
Followup Instructions:
___
|
10456837-DS-10 | 10,456,837 | 28,030,839 | DS | 10 | 2177-06-04 00:00:00 | 2177-06-04 12:23:00 |
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 foot ischemia - referred by PCP
___ or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with multiple prior
failed right leg bypasses with status post bypass from a prior
external iliac to profunda bypass to the peroneal via lateral
approach and fibulectomy presenting with worsening foot
ischemia.
The patient reports that he was initially doing well after
surgery. However for the past 2 weeks he has noticed worsening
blackening of his right first through third toes. He reports
that there has been more pain and intermittent discharge. The
patient was seen today at his PCPs office, and given the
appearance of his toes and recommended that he come to the
emergency room for further evaluation.
ROS: positive as per HPI, otherwise complete review of systems
is
negative
Past Medical History:
Past Medical History:
-recent mild CVA with slight speech deficit (speech therapy
treatment)
-pyloric channel ulcer and gastritis (___)
-colon CA s/p chemo
-HTN
-vit D deficiency
-dyspnea on exertion
-Vit D deficiency
-plantar fascial fibromatosis
-GERD
Past Surgical History:
-right leg vascular procedure x2, including fem-pop bypass with
stent, all done at ___ Medical History:
-recent mild CVA with slight speech deficit (speech therapy
treatment)
-pyloric channel ulcer and gastritis (___)
-colon CA s/p chemo
-HTN
-vit D deficiency
-dyspnea on exertion
-Vit D deficiency
-plantar fascial fibromatosis
-GERD
Past Surgical History:
-right leg vascular procedure x2, including fem-pop bypass with
stent, all done at ___
___ History:
___
Family History:
Noncontributory
Physical Exam:
Admission Physical Exam:
VS: 97.6 99 141/67 16 100% RA
General: overall well-appearing in NAD
HEENT: NC/AT, EOMI, no scleral icterus
Resp: breathing comfortably on room air
CV: mildly tachycardic, regular
Abd: soft, NT/ND
Ext: right foot with dry gangrene of the first-third toes - some
areas of bogginess without active drainage
Pulses: RLE w/ palpable right femoral pulse, monophasic Doppler
signal in DP, no signal over graft or in peroneal artery
Discharge:
Objective
Vitals: 24 HR Data (last updated ___ @ 1142)
Temp: 97.7 (Tm 98.2), BP: 131/75 (108-154/57-79), HR: 93
(81-100), RR: 18 (___), O2 sat: 100% (98-100), O2 delivery: Ra
GENERAL: []NAD [x]A/O x 3 []intubated/sedated []abnormal
PULM: []CTA b/l [x]no respiratory distress []abnormal
EXTREMITIES: []no CCE [x]abnormal [x]abnormal right foot with
dry gangrene
of the ___ toes.
PULSES:RLE w/ palpable right femoral pulse, monophasic Doppler
signal in DP, no signal over graft or in peroneal artery
Fluid Balance (last updated ___ @ 915)
Last 8 hours Total cumulative -721.3ml
IN: Total 78.7ml, IV Amt Infused 78.7ml
OUT: Total 800ml, Urine Amt 800ml
Last 24 hours Total cumulative -612.8ml
IN: Total 1487.2ml, PO Amt 360ml, IV Amt Infused 1127.2ml
OUT: Total 2100ml, Urine Amt 2100ml
Pertinent Results:
___ 07:34PM GLUCOSE-92 UREA N-16 CREAT-1.3* SODIUM-136
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-18* ANION GAP-15
___ 07:34PM estGFR-Using this
___ 07:34PM WBC-8.2 RBC-4.75 HGB-9.3* HCT-32.3* MCV-68*
MCH-19.6* MCHC-28.8* RDW-22.0* RDWSD-50.5*
___ 07:34PM NEUTS-60.5 ___ MONOS-6.5 EOS-5.1
BASOS-0.2 IM ___ AbsNeut-4.97 AbsLymp-2.23 AbsMono-0.53
AbsEos-0.42 AbsBaso-0.02
___ 07:34PM PLT COUNT-389
___ 07:34PM ___ PTT-31.2 ___
Brief Hospital Course:
The patient was admitted to ___ on ___ due to referral from
PCP for increased ___ from right ___ toe and concerns for
increasing gangrene and necrosis and concerns for peroneal graft
occlusion. Noninvasive arterial studies were performed on
___, which demonstrated complete occlusion of the peroneal
graft. We discussed options and need for BKA in the future. He
understands the plan and would like time to think through plan
alongside family. He was discharged with 1 week of antibiotics
and close follow up.
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. He will reach out with
questions and if worsening of toe wounds.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 25 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Gabapentin 300 mg PO TID
5. Sulfameth/Trimethoprim DS 2 TAB PO BID
6. Apixaban 5 mg PO BID
7. Pregabalin 50 mg PO BID
8. Sucralfate 1 gm PO BID
9. Cilostazol 50 mg PO BID
10. Omeprazole 20 mg PO BID
11. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
12. Docusate Sodium 100 mg PO BID
13. Senna 8.6 mg PO BID:PRN Constipation - First Line
14. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth twice a day Disp #*28 Tablet Refills:*0
3. Amitriptyline 25 mg PO BID
4. Apixaban 5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Cilostazol 50 mg PO BID
8. Docusate Sodium 100 mg PO BID
9. Gabapentin 300 mg PO TID
10. Omeprazole 20 mg PO BID
11. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
13. Pregabalin 50 mg PO BID
14. Senna 8.6 mg PO BID:PRN Constipation - First Line
15. Sucralfate 1 gm PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Dry gangrene of Right lower extremity
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 ___
___. You were admitted to the hospital due to
concerns that your gangrenous foot was worsening due your new
graft failing. We found that there was no immediate concern our
your disease acutely worsening. However you will likely need
further surgical intervention to manage your right lower
extremity gangrene. Please follow up with Dr. ___ to
discuss the results of your arterial studies and what further
interventions are needed.
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 leg or the
ability to feel your leg
Temperature greater than 100.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
___
|
10456861-DS-12 | 10,456,861 | 22,707,684 | DS | 12 | 2181-12-22 00:00:00 | 2181-12-22 16:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
___ 11:15AM BLOOD WBC-5.5 RBC-3.55* Hgb-11.4* Hct-33.7*
MCV-95 MCH-32.1* MCHC-33.8 RDW-13.4 RDWSD-46.8* Plt ___
___ 11:15AM BLOOD Neuts-73.6* Lymphs-13.6* Monos-9.4
Eos-2.4 Baso-0.5 Im ___ AbsNeut-4.06 AbsLymp-0.75*
AbsMono-0.52 AbsEos-0.13 AbsBaso-0.03
___ 11:15AM BLOOD Glucose-96 UreaN-16 Creat-1.3* Na-138
K-6.4* Cl-104 HCO3-21* AnGap-13
___ 11:15AM BLOOD calTIBC-202* VitB12-364 Folate->20
Ferritn-308 TRF-155*
___ 06:25AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.1
___ 11:15AM BLOOD CRP-52.0*
___ 11:29AM BLOOD Lactate-1.1 K-5.3
MICRO:
__________________________________________________________
___ 11:15 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 11:10 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 11:06 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING:
___ Imaging ELBOW (AP, LAT & OBLIQU
Moderate degenerative changes of the radiocapitellar and ulnar
trochlear joint with joint space narrowing and bony spurring.
Well corticated rounded ossific fragments along the medial and
lateral epicondyle, may be secondary to prior trauma and/or
degenerative changes. Diffuse soft tissue swelling at the
imaged portions of the elbow. Small joint effusion. Tiny
olecranon enthesophytes. No evidence of bony erosions to
suggest osteomyelitis. Soft tissue prominence along the
posterior aspect of the elbow joint.
DISCHARGE LABS:
___ 06:27AM BLOOD WBC-4.2 RBC-3.38* Hgb-11.0* Hct-32.4*
MCV-96 MCH-32.5* MCHC-34.0 RDW-12.9 RDWSD-44.9 Plt ___
___ 06:27AM BLOOD Plt ___
___ 11:15AM BLOOD Neuts-73.6* Lymphs-13.6* Monos-9.4
Eos-2.4 Baso-0.5 Im ___ AbsNeut-4.06 AbsLymp-0.75*
AbsMono-0.52 AbsEos-0.13 AbsBaso-0.03
___ 06:27AM BLOOD Glucose-157* UreaN-16 Creat-1.0 Na-141
K-4.2 Cl-106 HCO3-21* AnGap-14
___ 06:27AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.2
Brief Hospital Course:
Mr. ___ is a ___ with history of CAD s/p PCI, follicular
lymphoma, and recently diagnosed left olecranon bursitits with
surround cellulitis who presents to the ED with acute worsening
of his left elbow swelling, found to have significantly elevated
CRP.
ACTIVE ISSUES:
==============
# Left olecranon bursitis
# Left elbow non-purulent cellulitis
Patient failed outpatient treatment for his olecranon bursitis
with Bactrim/Keflex. His CRP was elevated this admission and was
started on vancomycin and ceftriaxone. Orthopedics saw him and
did not think his exam was consistent with septic arthritis so
no arthrocentesis was completed as can lead to worsening
healing. Infectious disease saw him as an inpatient and
transitioned him to linezolid for a likely two week course. If
fails treatment again, ID recommended arthrocentesis to r/o gout
given strength of linezolid.
# ___
Cr 1.3 on admission, from baseline 1.0-1.1. Likely pre-renal in
the setting of decreased PO intake as improved with IVF.
Discharge creatinine was 1.0.
# Acute on chronic normocytic anemia
Likely due to acute infection. Stable.
CHRONIC ISSUES:
===============
# CAD s/p PCI
- Continued home ASA 81mg, metoprolol succinate 25mg,
rosuvastatin 40mg daily
# GERD
- Continued home esomeprazole 40mg BID
- ranitidine held given that recalled
# Follicular lymphoma
Diagnosed in ___ at ___. Followed by ___
Oncology, Dr. ___. Noted to have mild lymphadenopathy on
most recent imaging, but per ___ Heme-onc note, likely not
significant enough to cause symptoms.
# Prostate cancer
Diagnosed in ___, treated locally with XRT.
- Continued home Tamsulosin 0.4mg daily
#HTN:
Irbesartan NF so held while inpatient
TRANSITIONAL ISSUES:
=====================
[ ] Ensure follow up with infectious disease and orthopedics
[ ] continue linezolid ___ PO BID until ___
[ ] recheck creatinine within 1 week to ensure stable
[ ] ranitidine held given recall, please assess GERD symptoms
off this medication
#CONTACT: ___
Relationship: WIFE
Phone: ___
Other Phone: ___
##############
>30 minutes spent on discharge planning and care coordination on
the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sulfameth/Trimethoprim DS 1 TAB PO BID
2. Cephalexin 500 mg PO Q8H
3. Ranitidine 150 mg PO DAILY
4. Rosuvastatin Calcium 40 mg PO QPM
5. Tamsulosin 0.4 mg PO QHS
6. irbesartan 300 mg oral DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Esomeprazole 40 mg Other BID
9. Aspirin 81 mg PO DAILY
10. Docusate Sodium 100 mg PO DAILY
11. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral BID
12. Naproxen 500 mg PO DAILY:PRN Pain - Mild
13. Multivitamins 1 TAB PO DAILY
14. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
15. Artificial Tears Preserv. Free ___ DROP BOTH EYES DAILY:PRN
dry eyes
16. Psyllium Powder 1 PKT PO DAILY
Discharge Medications:
1. Linezolid ___ mg PO BID
2. Artificial Tears Preserv. Free ___ DROP BOTH EYES DAILY:PRN
dry eyes
3. Aspirin 81 mg PO DAILY
4. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral BID
5. Docusate Sodium 100 mg PO DAILY
6. Esomeprazole 40 mg Other BID
7. irbesartan 300 mg oral DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Psyllium Powder 1 PKT PO DAILY
11. Rosuvastatin Calcium 40 mg PO QPM
12. Tamsulosin 0.4 mg PO QHS
13. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Left olecranon bursitis
Left elbow non-purulent cellulitis
SECONDARY DIANGOSES:
CAD s/p PCI
GERD
Follicular lymphoma
Prostate cancer
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WAS I ADMITTED?
You were admitted because your elbow was swollen and red.
WHAT WAS DONE WHILE I AS HERE?
We placed you on IV antibiotics. You were seen by the orthopedic
doctors and ___ disease doctors and ___ were transitioned
to oral antibiotics.
WHAT SHOULD I DO NOW?
You should take your medications as instructed.
You should go to your doctors ___ as below.
We wish you the best!
-Your ___ Care Team
Followup Instructions:
___
|
10456934-DS-9 | 10,456,934 | 23,162,159 | DS | 9 | 2152-03-05 00:00:00 | 2152-03-06 17:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
___ presents to the ___ ER with a 3 day history of left
lower abdominal pain. Patient states the pain began as a dull
pain and progressive became more sharp and severe. The greatest
change in severity occured yesterday morning after waking up
with
a more intense pain. Patient also report subjective fevers,
anorexia and feeling of constipation, although his last bowel
movement was today and was described as loose. He denies nausea
or vomiting. He states he has had mild episodes of left lower
abdominal pain over the past year with attacks approximately
every month, however has never been severe enough to seek
medical
attention.
Past Medical History:
GERD, gout (podagra), L knee arthroscopy & partial medial
meniscectomy
Social History:
___
Family History:
noncontributory
Physical Exam:
Physical Exam:
Vitals: T 98.3 P 78 BP 145/93 RR 16 O2 98%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, tenderness to mild palpation in the LLQ
with associated rebound and guarding, normoactive bowel sounds,
reducible umbilical hernia
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ WBC-8.4 RBC-5.38 HGB-15.8 HCT-45.7 MCV-85 MCH-29.3
MCHC-34.6 RDW-13.7
___ ALT(SGPT)-44* AST(SGOT)-30 ALK PHOS-58 TOT BILI-0.7
___ GLUCOSE-93 UREA N-13 CREAT-0.9 SODIUM-138
POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-31 ANION GAP-12
CT A/P ___:
Perforated sigmoid diverticulitis with an adjacent locule of
free air in the mesentery. No evidence of abscess formation.
Brief Hospital Course:
The patient was admitted to the ACS service on ___ for acute
complicated (perforated) diverticulitis identified on the
admission CT abdomen/pelvis. He was made NPO and maintainence
IVFs were started. He was also started on IV cipro and flagyl.
He remained afebrile throughout his hospital course and
exhibited no leukocytosis. He LLQ abdominal pain improved and
he was advanced to clears on HD2, which he tolerated well. On
HD3, he was advanced to a regular diet, but had one episode of
nausea and emesis, so he was put back on clears.
His abdominal pain continued to improve and he no longer
complained of any nausea/vomiting, so he was again advanced to a
regular diet on HD4. He tolerated this well. On the day of
discharge, the patient was passing flatus and having BMs. He
was sent home with 14 more days of PO cipro and flagyl with
instructions to follow-up in the ___ clinic in ___ weeks. He
was also instructed to follow-up with his PCP to arrange for an
outpatient colonoscopy.
Medications on Admission:
none
Discharge Medications:
1. Ciprofloxacin HCl 750 mg PO Q12H
RX *Cipro 750 mg one Tablet(s) by mouth every twelve (12) hours
Disp #*28 Tablet Refills:*0
2. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *Flagyl 500 mg 1 (One) Tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
acute complicated diverticulitis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the acute care surgery service for acute
complicated diverticulitis. You were started on IV antibiotics
and put on bowel rest. You improved with this treatment and
began tolerating food again on the day of discharge.
You will be sent home on two antibiotics, Cipro and Flagyl. You
will take these for 14 more days. You need to follow-up with
your primary care physician to have an outpatient colonoscopy
done.
Followup Instructions:
___
|
10457366-DS-10 | 10,457,366 | 25,106,845 | DS | 10 | 2200-06-23 00:00:00 | 2200-06-23 15:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left elbow pain s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with left elbow pain s/p mechanical fall. Patient reports
she was stepping out of the shower when she slipped, she put out
her left arm to break her fall but had immediate pain in left
elbow. No head strike or LOC. Patient evaluated at ___
___ where she was found to have displaced,
angulated left distal humeral fracture. Per report she had some
ulnar nerve distribution numbness at that time, but now reports
no numbness or weakness. Pain in distal humerus and elbow.
Past Medical History:
IDDM, HTN
Social History:
___
Family History:
non contributory
Physical Exam:
Vitals: AVSS
___: Comfortable
LUE: Strong radial pulse, SILT in ulnar/median/radial
distributions. +DIO/FPL/EPL. ROM elbow limited by pain, pain and
deformity of distal shaft humerus with ecchymosis but no
laceration or abrasion.
+long posterior splint
Pertinent Results:
___ 12:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 09:10PM WBC-12.0* RBC-4.63 HGB-13.2 HCT-39.7 MCV-86
MCH-28.6 MCHC-33.4 RDW-13.4
___ 09:10PM NEUTS-77.5* LYMPHS-15.9* MONOS-5.2 EOS-1.3
BASOS-0.1
Brief Hospital Course:
Ms. ___ presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a displaced L distal ___ humeral shaft fracture and was
admitted to the orthopedic surgery service. She can be treated
in a closed manner without manipulation. She also has a radial
head fracture as well that can be similarly treated. The patient
worked with OT and was given a long posterior orthoplast brace
with a cuff and collar and ___ determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, and the patient was
voiding/moving bowels spontaneously. The patient is NWB in the
right upper extremity. She will follow up in two weeks per
routine and covert her to a
___ brace in clinic. A thorough discussion was had with
the patient regarding the diagnosis and expected post-discharge
course, and all questions were answered prior to discharge.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Citalopram 20 mg PO DAILY
3. ClonazePAM 0.5 mg PO QHS:PRN anxiety
RX *clonazepam 0.5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
4. Labetalol 300 mg PO BID
5. Lisinopril 5 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q3H:PRN pain
RX *oxycodone 5 mg 0.5 - 1 tablet(s) by mouth q3H Disp #*70
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L distal ___ humeral shaft fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
-RUE - NWB, No ROM
-Cuff and collar
Followup Instructions:
___
|
10457366-DS-13 | 10,457,366 | 28,463,250 | DS | 13 | 2204-05-19 00:00:00 | 2204-05-19 16:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Discharge from wound
Major Surgical or Invasive Procedure:
Serial wound debridement (___) by orthopedic oncology
History of Present Illness:
Ms. ___ is an ___ with past medical history of
dedifferentiated liposarcoma of the right thigh s/p wide
resection and prophylactic IMN R femur on ___ by orthopedics
who
presents with purulent discharge from the distal aspect of her
incision.
After her resection on ___, she was discharged to rehab at
___ ___ ___. She reports chronic leg
pain
and yesterday, the rehab facility noticed purulent drainage from
incision with mild erythema surrounding the area. Patient denies
fevers, chills, nausea, vomiting or diarrhea. Additionally, she
was found to have an abscess ___ the left upper chest which was
I&D and packed this morning. She denies any chest pain, dyspnea,
back pain, abdominal pain, urinary symptoms, paresthesias, and
has been walking with rehab at her baseline.
___ the ED, initial VS were: T 98.7 HR 76 BP 128/46 RR 18 O2 92%
RA
Exam notable for:
- RLE thigh has a healing 15cm incision. The distal 2cm is
mildly
erythematous with initially serous fluid and then purulent
material; not tender and not warm
- Chest wall: right upper chest has packed area with no TTP
2cmx2cm
Labs showed:
- WBC 9.7, Hgb 9.4, Plt 576
- INR 1.2
- CRP 116.5
- BUN 14, Cr 0.7
- UA 7 WBCs, mod bacteria, mod leuks, 11 epi
Consults:
- Orthopedics: Likely post-op infected seroma/hematoma.
- Please send off two wound cultures (collected)
- Recommend admit to medicine given medical complexity
- Please keep NPOpMN for possible washout tomorrow.
- Please send pre-op labs including T&S/coags
- ___ start IV abx, recommend Vanc/CTX to start.
Patient received:
- IV ceftriaxone 1gm, IV vancomycin 1500mg, PO fluconazole 150mg
Transfer VS were: T 98.36 HR 78 BP 146/52 RR 16 O2 96% RA
On arrival to the floor, patient is with her daughter. Patient
endorses the above history and adds that her leg has been
hurting
for the past week. She thinks this is due to being given smaller
amounts of pain medication at the rehab facility. For the past
two days, her daughter has noticed clear drainage that became
yellow today. Regarding her "chronic heart failure", her
daughter
reports that this was diagnosed at ___ during an
admission for pneumonia. She follows with Dr. ___ at ___.
Past Medical History:
ANXIETY/DEPRESSION
DM II (not on any medications), HTN, HLD, OBESITY, OSA
ONYCHOMYCOSIS
PERIPHERAL NEUROPATHY
RIGHT BUNDLE BRANCH BLOCK
DISTAL HUMERUS FRACTURE
Chronic heart failure (details unknown)
Social History:
___
Family History:
Mother with breast CA. No other family history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 98.4 149/77 7820 94% RA
GENERAL: Obese, well-appearing, ___ NAD
HEENT: NC/AT, EOMI, anisocoria L>R with left surgical pupil, MMM
NECK: Supple, no appreciable JVD at ___cmX2cm incision on L chest wall with several mm of
surrounding induration and minimal erythema, packed with
dressing
that is saturated with yellow drainage, non-TTP
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: Obese, soft, nondistended, non-tender to palpation, active
bowel sounds
EXTREMITIES: R leg firm and edematous compared to L leg. Large
surgical insicion on R thigh that is well healed proximally and
draining copious amounts of serious fluid distally; small amount
of surrounding erythema distally with mild TTP
NEURO: Alert, oriented, L facial droop with somewhat garbled
speech (c/w known Bell's palsy), CN V intact, moving all 4
extremities with purpose
DISCHARGE PHYSICAL EXAM:
========================
PHYSICAL EXAM:
Vitals: ___ 1137 Temp: 98.4 PO BP: 134/71 L Sitting HR: 73
RR: 18 O2 sat: 92% O2 delivery: 2L
General: alert, oriented, no acute distress
Eyes: Sclera anicteric
HEENT: MMM, oropharynx clear
Neck: supple, no LAD
Resp: clear to auscultation anteriorly
CV: regular rate and rhythm, exam limited by habitus and
reluctance to reposition.
GI: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
MSK: warm, well perfused. Medial thigh drain, surgical site
c/d/I. Covered with gauze and tegaderm dressing. R lower leg
with mild non-pitting edema.
Neuro: Alert and oriented, diminished left sided facial
movements.
Pertinent Results:
LABS ON ADMISSION
=================
___ 05:39PM PLT COUNT-576*
___ 05:39PM ___ PTT-28.8 ___
___ 05:39PM NEUTS-76.6* LYMPHS-11.5* MONOS-8.1 EOS-2.8
BASOS-0.2 IM ___ AbsNeut-7.45* AbsLymp-1.12* AbsMono-0.79
AbsEos-0.27 AbsBaso-0.02
___ 05:39PM WBC-9.7 RBC-3.70* HGB-9.4* HCT-30.1* MCV-81*
MCH-25.4* MCHC-31.2* RDW-15.3 RDWSD-45.1
___ 05:39PM CRP-116.5*
___ 05:39PM CALCIUM-9.3 PHOSPHATE-4.7* MAGNESIUM-1.7
___ 05:39PM GLUCOSE-238* UREA N-14 CREAT-0.7 SODIUM-135
POTASSIUM-5.0 CHLORIDE-91* TOTAL CO2-30 ANION GAP-14
___ 08:30PM URINE MUCOUS-OCC*
___ 08:30PM URINE HYALINE-12*
___ 08:30PM URINE RBC-1 WBC-7* BACTERIA-MOD* YEAST-NONE
EPI-11
___ 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD*
___ 08:30PM URINE COLOR-Straw APPEAR-Hazy* SP ___
PERTINENT INTERVAL LABS:
========================
___ 06:46AM BLOOD %HbA1c-10.8* eAG-263*
___ 05:39PM BLOOD CRP-116.5*
Test Result Reference
Range/Units
SED RATE BY MODIFIED 97 H < OR = 30 mm/h
WESTERGREN
LABS ON DISCHARGE
=================
___ 02:42AM BLOOD WBC-8.7 RBC-2.96* Hgb-7.3* Hct-24.5*
MCV-83 MCH-24.7* MCHC-29.8* RDW-15.2 RDWSD-46.0 Plt ___
___ 02:42AM BLOOD Glucose-64* UreaN-9 Creat-0.6 Na-141
K-3.8 Cl-99 HCO3-33* AnGap-9*
___ 02:42AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.7
MICRO
=====
___ 5:39 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
___ 8:30 pm SWAB Source: R thigh.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
ENTEROCOCCUS SP.. SPARSE GROWTH.
Susceptibility testing performed on culture # ___
___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 8:15 pm SWAB Source: R thigh.
**FINAL REPORT ___
WOUND CULTURE (Final ___:
ENTEROCOCCUS SP.. SPARSE GROWTH.
Identification and susceptibility testing performed on
culture #
___ ___.
___ 11:45 am TISSUE DEEP CULTURE RIGHT THIGH WOUND.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
Reported to and read back by ___ (___) @ 1608 ON
___.
TISSUE (Preliminary):
ENTEROCOCCUS SP.. MODERATE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
PENICILLIN G---------- 4 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
___ 11:45 am SWAB RIGHT THIGH WOUND CULTURE #1.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
ENTEROCOCCUS SP.. SPARSE GROWTH.
Identification and susceptibility testing performed on
culture #
___ ___.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(___).
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 11:45 am SWAB RIGHT THIGH WOUND CULTURE #2.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
ENTEROCOCCUS SP.. SPARSE GROWTH.
Identification and susceptibility testing performed on
culture #
___ ___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(___).
IMAGING
=======
CXR (___):
IMPRESSION:
Unchanged cardiomegaly without associated pulmonary vascular
congestion,
pulmonary edema, or pleural effusions. No radiographic evidence
of pneumonia.
RUQ U/S (___):
IMPRESSION:
Gallbladder contains sludge without evidence of cholecystitis.
CXR (___):
IMPRESSION:
Right-sided PICC terminates ___ the mid-distal SVC. No
pneumothorax.
Brief Hospital Course:
SUMMARY
=======
Ms. ___ is an ___ year old female with past medical history
of dedifferentiated liposarcoma of the right thigh s/p wide
resection and prophylactic IMN R femur ___ ___ who
presented from rehab with purulent discharge from wound site
concerning for skin/soft tissue infection. She underwent wash
out by Orthopedics ___ the OR on ___ and ___. She was treated
with IV vancomycin and ceftriaxone, narrowed to IV ampicillin
after her wound culture grew Enterococcus per susceptibilities.
She received a PICC and was discharged home with right thigh
drain.
ACTIVE ISSUES
===========
# Infected surgical site infection:
The patient presented with 1 day of purulent discharge from R
thigh incision and was found to have significantly elevated CRP.
She was treated with IV vancomycin/ceftriaxone, and underwent
wash-out by Orthopedic surgery on ___ and ___. She remained
hemodynamically stable without fever or leukocytosis. Her wound
culture grew Enterococcus and she was narrowed to IV Ampicillin
with plan for 6 week course. Her pain was controlled with
Tylenol 1g TID:PRN with home hydropmorphone ___ q4hr:PRN. She
was followed by orthopedic surgery and infectious disease during
her admission. Will need weekly lab draws (CBC with
differential, BUN, Cr, CRP) to be faxed to ___ CLINIC -
FAX: ___ while on IV antibiotics.
# T2DM:
The patients T2DM is poorly controlled per her daughter and
likely contributes to poor wound healing. Per daughter, had been
receiving glargine 60U qAM and 30U qPM at rehab. Her glargine
was increased to 70U qAM and 30U qPM. She received sliding scale
insulin while inpatient. Home metformin was held during
admission and re-started prior to discharge.
# Chest wall abscess:
The patient presented with a left upper chest wall abscess that
had undergone I&D at rehab facility followed by 10 day course of
Keflex. Seen by wound care who expressed white cheesy discharge
from the wound and packed it. Possibly epidermoid cyst,
treatment for which is I&D. Ultimately further drainage did not
appear to be necessary per orthopedics. She received IV
antibiotics as above. Will need follow up with ID as well as PCP
for continued monitoring.
#?Diastolic heart failure:
The patient reportedly has a history of "chronic heart failure"
___ chart. Last Echo (as part of stress test) ___ ___ showed EF
of 60-65%. Per daughter, was admitted to ___ with
pneumonia and was diagnosed with heart failure at this time. She
follows with Dr. ___ ___ ___. CXR shows
cardiomegaly without associated edema/effusions. No signs of
volume overload on exam. Home furosemide, amlodipine, and
losartan were continued. Home labetalol was continued but
changed from 200mg TID to ___ BID on ___ for convenience of
dosing. Would recommend follow up with outpatient cardiologist.
# Elevated alkaline phosphatase:
The patients alkaline phosphatase level was 137 on ___,
elevated compared to ___. GGT was 164, so the elevation
was not accounted for by intramedullary nailing procedure. A RUQ
US was obtained which showed gallbladder with sludge and no
cholecystitis.
# Vulvovaginal candidiasis:
# Dysuria:
Per daughter, patient was told ___ the ED that she had a yeast
infection and endorsed several days of dysuria and vaginal
pruritis. She was treated with PO fluconazole 150mg x1. UA was
negative for yeast but shows moderate bacteria/leukocytes. ___
urine culture grew mixed flora consistent with contamination.
#Pressure ulcer:
The patient presented with bilateral gluteal and unstageable
pressure injuries. She was followed by wound care. She received
low airloss mattress for moisture control management, gentle
skin cleansing with foam cleansing and disposable wash cloths.
Also per wound care recommendations, she received a treatment
with Critic Aid antifungal barrier ointment daily and q3d
cleaning, with plan to cover unstageable pressure injuries with
Sacral Border Mepilex once yeast dermatitis had completely
resolved.
CHRONIC ISSUES
=============
#Hypertension:
SBP's were 120-140s on arrival. Home furosemide 40mg, amlodipine
5mg daily, and losartan were continued. Home labetalol was
continued but changed from 200mg TID to ___ BID on ___ for
convenience of dosing.
# HLD:
Home atorvastatin 40mg daily was continued.
# Anxiety:
# Depression:
Home alprazolam 0.5mg TID:PRN and home escitalopram 10mg daily
were continued.
# Bell's palsy:
Per daughter, facial droop prompted initial admission where
patient was diagnosed with liposarcoma. Believes that patient
was treated with steroids. Currently has significant L sided
facial droop with normal facial sensation, unchanged from prior.
# Primary prevention:
Home ASA 81mg daily was continued.
TRANSITIONAL ISSUES
===================
[] Will be discharged on IV Ampicillin 2g IC q4 (through
___ as below, with ID follow up.
[] Will need weekly lab draws (CBC with differential, BUN, Cr,
CRP) to be faxed to ___ CLINIC - FAX: ___ while
on IV antibiotics.
[] Please ensure follow up with orthopedics for further
evaluation of right thigh wound as scheduled ___.
[] Activity as tolerated, no ROM or WB restrictions. Encourage
___ and mobility.
[] Dressing change PRN, recommend Q48h
[] Suture and drain to stay ___ until follow-up appt. Please
record drain output daily.
[] Continue Lovenox ppx as an outpatient per ortho recs
[] Insulin increased to 70U qAM and 30U qPM given poorly
controlled DM, HBA1c 10%. Will need ongoing titration of insulin
at rehab with repeat HBA1c ___ 3months.
[] Would recommend follow up with outpatient cardiologist re:
history of diastolic heart failure, current appears euvolemic on
exam.
OPAT Antimicrobial Regimen and Projected Duration:
Agent & Dose: Ampicillin 2g IV q4 hours
Start Date: ___ (last washout)
Projected End Date: ___ will be 6 weeks
LAB MONITORING RECOMMENDATIONS: NOTE: For lab work to be drawn
after discharge, a specific standing order for Outpatient Lab
Work is required to be placed ___ the Discharge Worksheet -
Post-Discharge Orders. Please place an order for Outpatient Labs
based on the MEDICATION SPECIFIC GUIDELINE listed below:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
WEEKLY: CBC with differential, BUN, Cr
WEEKLY: CRP
FOLLOW UP APPOINTMENTS: The ___ will schedule follow up
and
contact the patient or discharge facility. All questions
regarding outpatient parenteral antibiotics after discharge
should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
#CODE: Full (confirmed)
#CONTACT: ___: Daughter Cell phone:
___
>30 minutes spent coordinating discharge home
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO QHS:PRN Anxiety
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Escitalopram Oxalate 10 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Labetalol 200 mg PO TID
8. Lactulose 30 mL PO DAILY
9. Losartan Potassium 50 mg PO BID
10. Timolol Maleate 0.25% 1 DROP BOTH EYES DAILY
11. TraZODone 100 mg PO QHS
12. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
13. Docusate Sodium 100 mg PO BID
14. Enoxaparin Sodium 40 mg SC QHS
15. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
16. Senna 8.6 mg PO BID
17. Glargine 60 Units Breakfast
Glargine 30 Units Bedtime
18. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line
19. Clotrimazole Cream 1 Appl TP PRN skin irritation
20. melatonin 3 mg oral QPM
21. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
22. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Medications:
1. Ampicillin 2 g IV Q4H
2. Glargine 70 Units Breakfast
Glargine 30 Units Bedtime
Humalog 2 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Labetalol 300 mg PO BID
4. TraZODone 50 mg PO QHS:PRN insomnia
5. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
6. ALPRAZolam 0.5 mg PO QHS:PRN Anxiety
7. amLODIPine 5 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 40 mg PO QPM
10. Clotrimazole Cream 1 Appl TP PRN skin irritation
11. Docusate Sodium 100 mg PO BID
12. Enoxaparin Sodium 40 mg SC QHS
13. Escitalopram Oxalate 10 mg PO DAILY
14. Furosemide 40 mg PO DAILY
15. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
16. Lactulose 30 mL PO DAILY
17. Losartan Potassium 50 mg PO BID
18. melatonin 3 mg oral QPM
19. MetFORMIN (Glucophage) 500 mg PO BID
20. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - First Line
21. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
22. Senna 8.6 mg PO BID
23. Timolol Maleate 0.25% 1 DROP BOTH EYES DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#R thigh osteomyelitis
#Insulin dependent diabetes mellitus, poorly controlled
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why was I admitted to the hospital?
===================================
You were admitted to the hospital with increased discharge from
your right thigh wound. We think this was caused by a bacterial
infection of the wound site.
What happened while I was admitted?
====================================
- To treat the right thigh wound infection, you had two
surgeries on the wound site to clean it. After the surgery, a
wound vac was applied to help with healing. You also received
antibiotics.
- You also had a collection on your chest, which we think is
either an abscess or a cyst. We treated it with the same
antibiotics that we used to treat your thigh wound, and you
should follow up with your primary care provider and orthopedic
surgeons regarding any further drainage needed
What should I do when I leave the hospital?
============================================
Please take your medications as listed ___ discharge summary and
follow up at the listed appointments.
Thank you for allowing us to be involved ___ your care, we wish
you all the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10457524-DS-20 | 10,457,524 | 25,794,695 | DS | 20 | 2130-03-13 00:00:00 | 2130-03-13 19:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Atrial Flutter
Major Surgical or Invasive Procedure:
Atrial flutter ablation - ___
History of Present Illness:
___ with PMH of HL, HTN, T2DM, Depression, who is being
transferred from ___ for evaluation by EP for
aflutter ablation.
The patient was in his usual state of good health until the
beginning of ___, when he returned home from a trip to ___,
and felt acutely short of breath, unable to take several steps.
He was evaluated at ___ and was noted to have be in
CHF with aflutter, tachycardia induced cardiomyopathy (EF 40%
with global hypokinesis), ___ (Cr 1.7) and transaminitis
(AST/ALT both >2800). He was admitted to the MICU and rate
control was attempted with Lopressor, nitro, and Cardizem. He
received Lasix for agressive diuresis. He was initially treated
with Amiodarone, which was dc'd given his LFTs. He was also
treated with a heparin gtt. He was discharged on ___ on Aspirin
325mg, Lopressor 50 mg BID and Lisinopril 5 mg daily. At a later
visit with his cardiologist, his Lisinopril was increased to 10
mg daily. He was ordered for holter monitoring and a stress test
was scheduled for the morning of ___.
On arrival for his stress test on ___, his heart rate was
found to be in the 150-160s with an EKG showing 2:1 aflutter. He
was transferred to ___ where he was given 5mg of IV
Metoprolol, 50mg po Metoprolol, 7.5mg of IV Verapamil and he was
started on a heparin gtt. He was transferred to ___ for EP
eval.
In the ___, initial vitals were T 98.1, HR 108, BP 108/72, RR 18,
98% on RA. He was continued on a heparin drip and admitted for
evaluation by EP for possible ablation.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (+) Diabetes, (+) Dyslipidemia, (+)
Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
- Aflutter with variable block
3. OTHER PAST MEDICAL HISTORY:
-T2DM
-Depression
-Erectile disorder
-OSA
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T98 HR 92 and irregular BP 115/79 RR 14 96% on RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: irregularly irregular rhythm, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: obese, soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
DISCHARGE PHYSICAL EXAM:
98.2 ___ 120/86 77-120 81 ___ 98-99%RA
Weight 116.9kg
General: no acute distress
HEENT: NCAT
Neck: supple, no JVD appreciated
CV: RRR, no m/r/g
Lungs: clear to ascultation bilaterally
Abdomen: obese, soft, NT/ND
Ext: WWP, no c/c/e, distal pulses 1+ DP
Pertinent Results:
ADMISSION LABS:
___ 02:37PM BLOOD WBC-14.0* RBC-5.55 Hgb-15.3 Hct-45.7
MCV-82 MCH-27.6 MCHC-33.5 RDW-15.6* Plt ___
___ 02:37PM BLOOD Neuts-76.1* ___ Monos-3.4 Eos-1.1
Baso-0.5
___ 02:37PM BLOOD ___ PTT-137.1* ___
___ 02:37PM BLOOD Glucose-103* UreaN-17 Creat-1.4* Na-139
K-4.3 Cl-103 HCO3-25 AnGap-15
___ 02:37PM BLOOD ALT-112* AST-42* LD(LDH)-216 AlkPhos-78
TotBili-0.9
___ 06:49AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.3
OTHER RELEVANT LABS:
___ 02:37PM BLOOD ALT-112* AST-42* LD(LDH)-216 AlkPhos-78
TotBili-0.9
___ 06:20PM BLOOD ALT-89* AST-31 CK(CPK)-64 AlkPhos-73
TotBili-1.2
___ 04:23AM BLOOD ALT-83* AST-29 CK(CPK)-75 AlkPhos-71
TotBili-1.7*
___ 06:20PM BLOOD CK-MB-2 cTropnT-0.09*
___ 08:45PM BLOOD CK-MB-2 cTropnT-0.15*
___ 04:23AM BLOOD CK-MB-3 cTropnT-0.25*
___ 08:45PM BLOOD calTIBC-359 Ferritn-564* TRF-276
___ 06:49AM BLOOD TSH-6.3*
___ 06:49AM BLOOD Free T4-1.4
___ 08:45PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
___ 08:45PM BLOOD HCV Ab-NEGATIVE
___ 05:43PM BLOOD Glucose-208* Lactate-6.5* Na-138 K-5.0
Cl-99
___ 09:02PM BLOOD Lactate-4.0*
___ 12:19AM BLOOD Lactate-2.2*
___ 04:43AM BLOOD Lactate-1.6
___ 06:18PM URINE Color-Straw Appear-Clear Sp ___
___ 06:18PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 06:18PM URINE RBC-9* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
DISCHARGE LABS:
___ 06:20AM BLOOD WBC-8.6 RBC-5.90 Hgb-16.4 Hct-49.1 MCV-83
MCH-27.8 MCHC-33.4 RDW-15.9* Plt ___
___ 06:20AM BLOOD ___
___ 06:20AM BLOOD Glucose-130* UreaN-20 Creat-1.3* Na-139
K-4.1 Cl-97 HCO3-33* AnGap-13
___ 06:20AM BLOOD Calcium-9.4 Phos-3.6# Mg-2.3
MICRO:
BLOOD CULTURES ___: PND
URINE CULTURE ___: NEGATIVE
IMAGING:
TEE ___:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium or left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). The right atrium is dilated. No atrial
septal defect is seen by 2D or color Doppler. Overall left
ventricular systolic function is severely depressed (LVEF=
___. The right ventricle is also dilated with severe global
free wall hypokinesis. There are simple atheroma in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen. Moderate to
severe [3+] tricuspid regurgitation is seen. The tricuspid
regurgitation jet is eccentric and may be underestimated. The
pulmonary artery systolic pressure could not be determined. A
TEE procedure related complication occurred (see comments for
details).
IMPRESSION: Suboptimal image quality, limited gastric views. No
left atrial or left atrial appendage thrombus. Global severe
bi-ventricular hypokinesis (LVEF ___. Mild mitral
regurgitation. Moderate-severe tricuspid regurgitation.
TTE ___:
The left ventricular cavity size is normal. Overall left
ventricular systolic function is mildly depressed (LVEF=
40-45%). Right ventricular chamber size is normal. with
borderline normal free wall function. The estimated pulmonary
artery systolic pressure is normal.
Compared with the prior study (images reviewed) of ___,
biventricular systolic function has improved.
CXR ___:
FINDINGS: Lung volumes are low. Moderate-to-severe enlargement
of the
cardiac silhouette with signs of mild pulmonary edema. No
pleural effusions. No pneumothorax. No pneumonia.
RUQ US ___:
IMPRESSION:
Unremarkable right upper quadrant ultrasound.
CXR ___:
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Moderate cardiomegaly, mild fluid overload. Minimal
atelectasis at the right and left lung bases. No pleural
effusions. No pneumothorax.
CXR ___
IMPRESSION: Mild pulmonary edema and cardiomegaly.
Brief Hospital Course:
Mr. ___ is a ___ man with PMHx of HLD, HTN, T2DM, and
Depression, who was recently admitted to ___ for atrial
flutter with (presumed) tachycardia-induced cardiomyopathy (EF
40%) who was again noted to be in aflutter during outpatient
stress test and treated with IV and PO Metoprolol as well as
Verapamil. He was transferred to ___ for evaluation by EP for
aflutter ablation. On exam, he initially did not appear volume
overloaded. His labs were significant for Cr 1.4, downtrending
LFTs (from prior admission to ___ and downtrending
leukocytosis.
# Atrial flutter:
Pt was admitted with recurrence of atrial flutter with variable
block. EKG showed aflutter with alternating 2:1 and 3:1 block.
Pt underwent atrial flutter ablation on ___. Post-procedure,
pt became hypotensive and required pressors for hypotension to
SBP ___ (please see below). He was started on heparin gtt, and
transitioned to coumadin temporarily due to varying renal
function, before being switched to ribaroxiban on day prior to
discharge. He was noted to be in afib with RVR with rate to
150s on day prior to discharge, but returned spontaneously to
NSR. He was discharged on metoprolol to XL 100mg daily,
furosemide 50 daily and lisinopril 10 daily.
# Acute Decompensated sCHF and cardiogenic shock: TTE on OSH
showed EF of 40% with global hypokinesis, thought to be ___
tachycardia induced cardiomyopathy. TEE during ablation showed
LVEF of ___ which improved with pressors intra-procedure.
Repeat TTE showed EF 40-45% but patient had significant
pulmonary edema on CXR with crackles in bilateral lung fields,
requiring diuresis. He initially had poor UOP with IV lasix, was
transitioned to gtt with improved UOP. He also initially
developed hypotension (SBP in the ___, first during the
ablation, requiring phenylephrine and epinephrine with
improvement of SBP to 120s. On transfer to the CCU, he likely
had a vagal episode, became nauseated, diaphoretic and
hypotensive with SBPs to ___, which improved with dopamine that
was quickly weaned off with improvement of his blood pressure.
EKG had no concerning ST-T segment changes, troponin only mildly
elevated, CKMB normal. He was euvolemic at discharge, and
discharged on lasix 40mg po daily.
# Transaminitis:
At OSH, pt was recorded to have had transaminitis (1000 range),
which trended down to mild transaminitis during this admission
(ALT 112, AST 42 on admission). This was thought to be ___
transient hypoperfusion in the setting of Aflutter with RVR. Pt
underwent RUQ US (unremarkable), hepatitis serologies (noted for
positive HAV Ab, otherwise negative).
# Elevated lactate:
On transfer to CCU on ___, lactate was 6.5 and trended down to
normal on discharge. This was thought to be ___ hypoperfusion in
the setting of cardiogenic shock.
# Leukocytosis: Downtrended and thought elevated secondary to
stress of ablation; no localizing symptoms for infection.
# T2DM: Pt received ISS and nighly lantus 10.
# Depression: Continued Cymbalta
TRANSITIONAL ISSUES:
-Pt to f/u with EP, to schedule appt with Dr. ___ (given
phone number).
-Started on ribaroxiban ___
-Discharged on metop 100mg XL daily, lisinopril 10mg daily and
furosemide 40mg po daily.
-Blood cx ___ pending at discharge, negative to date
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. AndroGel (testosterone) 1 % (25 mg/2.5 g) Transdermal daily
2. Lisinopril 10 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO BID
4. Aspirin 325 mg PO DAILY
5. TraZODone 25 mg PO HS:PRN insomnia
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet,delayed
release (___) by mouth Daily Disp #*30 Tablet Refills:*0
2. Lisinopril 10 mg PO DAILY
3. TraZODone 25 mg PO HS:PRN insomnia
4. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
5. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet extended release 24
hr(s) by mouth Daily Disp #*30 Tablet Refills:*0
6. AndroGel (testosterone) 1 % (25 mg/2.5 g) Transdermal daily
7. Rivaroxaban 20 mg PO DAILY
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
8. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [Blood Glucose Test] Test Blood
Blucose QACHS Disp #*4 Container Refills:*0
RX *insulin glargine [Lantus] 100 unit/mL 10 units QHS 10 Units
before BED Disp #*1 Vial Refills:*0
RX *blood-glucose meter [Blood Glucose Monitoring] Dispense 1
Blood Glucose Monitor and Kit Once Disp #*1 Kit Refills:*0
RX *insulin lispro [Humalog] 100 unit/mL ___ Units Subcutaneous
Up to 10 Units QID per sliding scale Disp #*1 Vial Refills:*0
9. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial flutter
Acute Systolic Congestive Heart Failure
Diabetes
Hypertension
Hyperlipidemia
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
___. You were admitted with an irregular heart rhythm called
atrial flutter. You underwent a procedure to ablate the part of
your heart causing the flutter. You required transfer to the
intensive care unit because of low blood pressure after the
procedure. Your symptoms improved and you are being discharged.
You are being discharged on a blood thinner called rivaroxaban
and a medication to control your heart rate called metoprolol.
We wish you well.
Best Regards,
Your ___ Medicine Team
Followup Instructions:
___
|
10457788-DS-18 | 10,457,788 | 21,155,299 | DS | 18 | 2136-12-16 00:00:00 | 2136-12-16 15:51:00 |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
___ Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
C2 fracture s/p seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH seizure disorder who had 2 seizures on ___ afternoon
while sitting on his bed and hit his head against thewall. He
presented to an OSH this am because his fiancé brought him. The
OSH got a CT neck which showed odontoid type 2 fracture; he was
placed in a C-collar and transferred to ___. He denies
neck pain. Denies parethesias in his extremities or change in
motor function. Denies headache. Of note, patient is a poor
historian. ___ family present to supplement HPI.
Past Medical History:
-Seizure disorder
-TBI
-Anxiety
Social History:
___
Family History:
Denies family history of seizures
Physical Exam:
Gen: WD/WN, comfortable, NAD. ___ J collar in place.
HEENT: PERRLA
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, strange
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
Sensation: Intact to light touch
EXAM ON DISCHARGE:
General:
[x]AVSS T:98 BP:153/91 HR:80 RR:18 O2sats:97% RA
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Speech Fluent: [x]Yes [ ___
Comprehension intact [x]Yes [ ___
Motor:
TrapDeltoidBicepTricepGrip
IPQuadHamATEHLGast
[x]Sensation intact to light touch
Pertinent Results:
Please refer to ___ for important imaging and lab results.
Brief Hospital Course:
Mr. ___ presented from an OSH in a C-collar after CT
C-spine showed odontoid type 2 fracture. He was seen by the
neurosurgery service in the ED and admitted to the floor. He was
neurovascularly intact.
#C2 fracture
Patient was placed in a hard cervical collar. Neurologic
examination reassuring. Imaging was reviewed.On ___, MRI C-spine
showed some associated ligamentous injuries It was determined
fracture would be managed conservatively with hard cervical
collar at all times and follow up with repeat imaging in 1
month.
#Seizures
Patient was admitted after unwitnessed seizure. Known history
seizures takes oxycarbmazipine, risperidone and Ativan at home
for his seizures. Neurology was consulted for his seizures.
Levels of home AED were sent and are still pending at time of
discharge. MRI was done to r/o any source of seizure which was
unrevealing. Investigation was done to determine frequency of
patients seizures as this may impact whether or not he is a good
surgical candidate. However, the patient is very unreliable and
cannot provide details regarding his AEDs raising suspicion for
AED noncompliance even though he strongly denies this. Also per
his PCP, he has history of alcohol and cocaine abuse which can
also provoke seizures. Patient did not have any further seizures
while admitted. He was discharged on his home AEDs with follow
up with Neurology.
#SVT
On the morning on ___, he had supraventricular tachycardia to
the 160s. Medicine was consulted. He required adenosine x2.
Repeat EKG showed ___ ST changes. Medicine recommended continue
to monitor on telemetry and discharge with Holter monitor and
close PCP follow ___ further episodes of SVT were noted
during this hospitalization. At time of discharge Holter monitor
was ordered however patient does not have access to a landline
telephone so he was unable to receive the monitor. He was
scheduled for the next available Cardiology appointment to
continue to monitor.
#?Horner Syndrome
Neurologic examination was positive for a L horner's syndrome.
Given recent fall there was concern for possible dissection. A
CTA head was obtained on ___ to further evaluate vascular injury
___ left ptosis, which was read as preliminarily having ___
abnormalities, negative for dissection.
Dispo:
On ___ the patient continued to remain neurologically intact,
with ___ more episodes of SVT or evidence of seizures during this
admission. After further discussion with medicine and neurology
it was determined that the patient was able to be discharged
home with home services for home safety eval. The patient has
been instructed to follow up with his PCP, ___, and
Neurology for further evaluation and management. He will follow
up with Neurosurgery in 1 month with CT of c-spine.
Medications on Admission:
- Hydroxyzine 50mg
- Risperidone 0.5 BID
- Oxcarbazepine 900mg QHS
- Lorazepam 1mg BID
- Omeprazole 20mg
- Pantoprazole 40mg BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6H PRN pain Disp
#*84 Tablet Refills:*0
3. HydrOXYzine 50 mg PO DAILY
4. LORazepam 1 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. OXcarbazepine 900 mg PO QHS
7. RisperiDONE 0.5 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
C2 fracture
Seizure
SVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Activity
You must wear your cervical collar at all times. The collar
helps with healing and alignment of your fracture. You must wear
this collar at all times until you are seen in follow up in 1
month with Dr. ___.
You must wear your cervical collar while showering.
You may remove your collar briefly for skin care (be sure not
to twist or bend your neck too much while the collar is off). It
is important to look at your skin and be sure there are ___
wounds of the skin forming.
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You may take leisurely walks and slowly increase your activity
at your own pace. ___ try to do too much all at once.
___ driving while taking any narcotic or sedating medication.
___ contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing.
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.
*Please remember to take your anti-seizure medications as
prescribed.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs.
You had an irregular heart rhythm while you were admitted:
Supraventricular Tachycardia. You were evaluated by the Medicine
team who recommended you follow up with a Cardiologist.
Contact your PCP or seek medical attention in the ER if you
experience
Pain in chest, arm, back, or jaw
Shortness of breath
Palpitations
Dizziness or lightheadedness
Followup Instructions:
___
|
10457963-DS-15 | 10,457,963 | 26,243,248 | DS | 15 | 2124-08-30 00:00:00 | 2124-09-01 20:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
nadolol
Attending: ___
Chief Complaint:
confusion, diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hepatitis B cirrhosis (eAg- positive) on tenofovir, RLE
DVT on coumadin, and h/o grade III varacies on EGD ___ who
presents with increased confusion, weakness/fatigue. The
patients wife reports that she first noted confusion 5 days
prior to presentation and it has been worsening. The patient was
seen in liver clinic yesterday with Dr. ___ was started
on rifaxamin and lactulose.
The patient also reports ___ weeks of watery diarrhea. He
reports as many as ___ episodes of diarrhea per day, however he
only reports one episode of diarrhea yesterday. C. Diff
negative on ___. He denies sick contacts and recent travel.
Just started on lactulose yesterday. No abdominal pain, N/V.
Patient notes chills at home, but temperature not taken. Patient
denies cough, URI symptoms, and urinary symptoms. Denies CP,
SOB. Denies blood or black stools.
In the ED, initial vital signs were 97.8 108 141/79 18 95%
Labs significant for lactate of 3.0, INR 3.7, tbili 5.9.
UA with few bacteria, mod blood but nitrates and leuks negative.
CXR with R. pleural effusion. No ascites to tap.
Received 1L IVF.
He was admitted to ET for further management
Vitals prior to transfer 97.7 79 124/74 16 100% RA
ROS: per HPI, denies fever, 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:
-HBV cirrhosis - eAg-positive HBV, genotype D. Clinically
cirrhotic - He has never had a liver biopsy, but he had an
elevated FibroScan 75 kPA (IQR 0.0) and Hepascore 1.00 (from
___.
-Grade III esophageal varices (___)
-H/o RLE DVT - ___
-Left inguinal hernia
-S/p right inguinal hernia repair
-HTN
-T2DM - diet controlled
Social History:
___
Family History:
no hx of cancer, heart disease, liver disease
Physical Exam:
admission exam
VS: 97.5 127/70 98 18 100% RA
General: comfortable in NAD
HEENT: supple, mildly icteric sclera
Neck: supple. no LAD
CV: RRR
Lungs: diminished breath sounds at right base
Abdomen: +BS. soft. nontender, nondistended. no fluid wave
GU: no foley
Ext: 2+ pitting edema on right side. 2+ DP pulses
Neuro: A&Ox3. +asterixis. moving all extremities. strength ___
in upper and lower extremities
Skin: no rash
discharge exam
VS: 98.6 98/60 (90s-120s/60s-70s) 57 (50s-80s) 17 97% RA
General: comfortable in NAD
HEENT: supple, mildly icteric sclera
Neck: supple. no LAD
CV: RRR
Lungs: diminished breath sounds at right base
Abdomen: +BS. soft. nontender, nondistended. no fluid wave
GU: no foley
Ext: 2+ pitting edema on right side. 2+ DP pulses
Neuro: A&Ox3. NO asterixis. moving all extremities. strength ___
in upper and lower extremities
Skin: no rash
Pertinent Results:
admission labs
___ 10:30AM BLOOD WBC-5.9 RBC-3.55* Hgb-13.7* Hct-38.1*
MCV-107* MCH-38.7* MCHC-36.0* RDW-16.2* Plt Ct-81*
___ 10:30AM BLOOD Neuts-82* Bands-1 Lymphs-2* Monos-9
Eos-5* Baso-0 ___ Metas-1* Myelos-0
___ 10:30AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+
___ 10:30AM BLOOD ___
___ 10:30AM BLOOD UreaN-15 Creat-0.9 Na-136 K-4.2 Cl-104
HCO3-22 AnGap-14
___ 10:30AM BLOOD ALT-66* AST-93* AlkPhos-153* TotBili-5.0*
DirBili-1.2* IndBili-3.8
___ 10:30AM BLOOD Albumin-2.3*
discharge labs
___ 04:55AM BLOOD WBC-3.2* RBC-2.64* Hgb-9.9* Hct-28.7*
MCV-109* MCH-37.5* MCHC-34.4 RDW-16.6* Plt Ct-59*
___ 04:55AM BLOOD Glucose-191* UreaN-18 Creat-0.8 Na-136
K-4.0 Cl-109* HCO3-22 AnGap-9
___ 04:55AM BLOOD ALT-47* AST-63* AlkPhos-80 TotBili-3.7*
___ 04:55AM BLOOD Calcium-7.5* Phos-2.7 Mg-1.9
urine
___ 01:50PM URINE Color-Amber Appear-Clear Sp ___
___ 01:50PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-SM Urobiln->12 pH-6.0 Leuks-NEG
___ 01:50PM URINE RBC-10* WBC-7* Bacteri-FEW Yeast-NONE
Epi-<1
___ 01:50PM URINE CastHy-7*
micro
___ 5:18 pm STOOL CONSISTENCY: FORMED 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 VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
HBV Viral Load (Final ___:
133 IU/mL.
Performed using the Cobas Ampliprep / Cobas Taqman HBV
Test v2.0.
Linear range of quantification: 20 IU/mL - 170 million
IU/mL.
Limit of detection: 20 IU/mL.
___ 10:45 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
CLOSTRIDIUM SPECIES NOT C. PERFRINGENS OR C. SEPTICUM.
Isolated from only one set in the previous five days.
studies:
RUQ U/S ___
IMPRESSION:
1. Hepatic cirrhosis with portal hypertension including
splenomegaly and
recanulized paraumbilical vein. No evidence of abdominal
ascites.
2. Patent portal vein with hepatopetal flow.
3. Right pleural effusion.
Chest X-Ray PA and Lateral ___
IMPRESSION: Large right-sided pleural effusion and right lower
lobe
atelectasis.
CTA ABD w/ and w/out contrast ___
IMPRESSION:
1. Cirrhosis with evidence of portal hypertension. No focal
hepatic lesions
identified.
2. Chronic appearing nonocclusive thrombus involving a short
segment of the
portal vein and SMV as discussed in detail above.
3. Moderate right-sided pleural effusion.
TTE ___
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal
(LVEF=70%). The estimated cardiac index is high (>4.0L/min/m2).
The left ventricular outflow tract velocity is increased in the
absence of anatomic obstruction due to high cardiac output.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. There is no valvular aortic
stenosis. The increased transaortic velocity is likely related
to high cardiac output. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. No mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Normal biventricular cavity size and global/regional
systolic function. High cardiac output.
Chest X-Ray PA and Lateral ___
IMPRESSION:
Decrease in right pleural effusion with improved aeration of the
right lung
Brief Hospital Course:
___ yo M with hx of eAg-positive hepatitis B on tenofovir who
presents with hepatic encephalopathy and diarrhea.
ACUTE ISSUES:
==============
# Hepatic encephalopathy - Pt presented with confusion and
asterixis consistent with hepatic encephalopathy. Pt had been
started on lactulose and rifaximin two days prior to admission.
On admission, pt was started on lactulose Q2hrs and rifaximin.
Pt's encephalopathy cleared, and lactulose was able to be spaced
to QID dosing on discharge. Pt was discharged on lactulose and
rifaximin. Pt was scheduled for follow up with the ___ liver
center at discharge.
# Diarrhea: Pt presented with a reported history of watery
diarrhea for the past 4 weeks with ___ BMs daily. Stool
cultures, ova and parasites, and C. diff toxin were negative.
In addition, ant-ttg and IgA were inconsistent with celiac. Pt
will follow up with the ___ as an outpatient, and
otupatient colonoscopy will be considered if diarrhea is
persistent.
# Right pleural effusion: Pt was found to have a right sided
pleural effusion on chest -X-ray. Pt's effusion was thought to
be represent hepatohydrothorax. Pt was diuresed with
improvement in the effusion. At discharge, pt was continued on
his home lasix 20mg daily and spironolactone 50mg daily.
# Hepatitis B cirrhosis - Pt presented with HBV cirrhosis on
tenofovir complicated by ascites, encephalopathy, and varices.
Pt presented decompensated with MELD 27 from baseline 15. Pt
was managed with lactulose, rifaximin, and diuretics as
described above. Pt was continued on his home tenofovir.
Notably, pt's HBV VL was found to be 133 IU/mL during his
course. Pt was continued on nadolol for known varices. Pt was
not treated with SBP prophylaxis given no history of SBP.
During his course, transplant workup was started as an
inpatient. Pt will follow up with the ___ liver transplant
center as an outpatient.
# Clostridium positive blood culture: Pt's blood culture from
the ED grew C. perfringens consistent with skin flora
contamination. Pt did not demonstrate evidence of sepsis, and
antibiotics were held.
CHRONIC ISSUES:
================
# History of DVT - Pt presented with history of DVT on coumadin
and supratherapeutic INR to 3.6. Pt's INR was held, and a small
amount of vitamin K was administered. At discharge, pt's INR
was 2.3, and coumadin was held with plans for follow up labs as
outpatient. In addition, thrombophilia workup should be
performed as outpatient given pt's history of DVT.
TRANSITIONAL ISSUES:
===================
# patient will need dental evaluation, infectious disease
consultation, PFTs
# given recurrent clots, patient should have outpatient
thrombophilia workup
# INR elevated during admission. Warfarin held at time of
discharge. INR should be checked on ___ and if <2.5,
restart 1 mg warfarin (reduced dose).
# Patient should have CBC, Chem 10, LFTs, INR checked on ___
___
# diuretic dosing may need further adjustment
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Spironolactone 50 mg PO DAILY
3. Nadolol 10 mg PO QHS
4. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
5. Warfarin 2 mg PO DAILY16
6. Lactulose 30 mL PO TID
7. Rifaximin 550 mg PO BID
Discharge Medications:
1. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Lactulose 30 mL PO QID
titrate to ___ BMs daily and mental status
RX *lactulose 10 gram/15 mL 30 mL by mouth four times a day
Refills:*0
3. Nadolol 10 mg PO QHS
RX *nadolol 20 mg 0.5 (One half) tablet(s) by mouth daily Disp
#*15 Tablet Refills:*0
4. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
5. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
7. Vitamin D 50,000 UNIT PO 1X/WEEK (___) Duration: 3 Months
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth QWEEK Disp #*12 Capsule Refills:*0
8. Outpatient Lab Work
ICD-9: Cirrhosis 571.0
Please check CBC, Chem 10, LFTs (AST, ALT, Alk Phos, Tbili), INR
Fax results to Dr. ___ Dr. ___ at ___
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: hepatic encephalopathy
secondary diagnosis: hepatitis B cirrhosis, deep venous
thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you while you were admitted to
___. You were admitted because you were more confused, which
is likely related to worsening of your liver function. You were
treated with lactulose and rifaxamin and your confusion
resolved. You also had an infectious workup that was negative,
and we did some initial evaluation for your diarrhea which was
also negative. During admission, a liver transplant evaluation
was also started, but there are still a few pending tests and
evaluations you must complete.
Please have your blood drawn on ___.
-If your INR is less than 2.5, please restart warfarin at 1 mg
(reduced dose).
For your liver transplant workup:
-Please follow up with your providers as scheduled
-You will need to have pulmonary function testing, dental
evaluation, and likely an infectious disease evaluation.
Given your history of recurrent blood clots, you should also
talk with your doctor about having some additional testing
(thrombophilia workup).
Your vitamin D level was noted to be low. Please start taking
vitamin D 50,000 units once weekly for 3 months.
Please take the rest of your medications as prescribed and
follow up with your doctors as ___.
Followup Instructions:
___
|
10458324-DS-11 | 10,458,324 | 21,744,342 | DS | 11 | 2178-07-26 00:00:00 | 2178-07-26 19:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Compazine / Thorazine / Haldol
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Pigtail placement
History of Present Illness:
___ with PMH of IVDU and PTSD who presents to the ED after a
mechanical fall now with right sided ___ rib fractures. Pt
states he was ___ the shower and was stepping into the bathtub
when he slipped and hit his right lateral chest against the
bathtub. Denied LOC/head strike. He walked down to the first
floor of his apartment building and was called an ambulance by
the concierge. On arrival to the ED, he was hypoxic satting 96%
on 4L and evaluated by trauma surgery. CXR and CT chest revealed
right ___ rib fractures, small right PTX, and subcutaneous
emphysema. APS consulted for possible epidural.
Past Medical History:
PAST PSYCHIATRIC HISTORY:
Diagnoses: PTSD (Dx ___ ___, nightmares of being left alone and
mistreated; Bipolar disorder; Polysubstance use; Opiate
dependence
Hospitalizations: ___ hospitalizations from ___ years old - at
that time diagnosed with bipolar disorder. ___ ___, dual
diagnosis admission at ___ with SI.
Suicide attempts: At ___ years old, attempted to hang himself ___
the setting of sexual abuse. At ___, attempted to overdose
with barbiturates and alcohol, never told anyone.
Current treaters: ___ (counselor at ___ ___
___.
Medications: Prozac (made him depressed), Thorazine (dystonia),
Haldol (felt like a clown)
Harm to others: Denies
Access to weapons: Guns through other substance users
Trauma: Sexual abuse as child. Physical abuse.
PAST MEDICAL HISTORY:
Denies.
Social History:
___
Family History:
No known formal diagnoses.
However, a maternal cousin had narcotic addiction and there is
concern that he committed suicide.
Physical Exam:
ADMISSION PHYSICAL
==================
VITALS: afebrile, 78HR , 119/82 BP , 24RR , 96% on 4L O2sat
GENERAL: NAD, A&Ox3
HEENT: AT, MMM
HEART: no pedal edema
LUNGS: non-labored breathing, on MC
BACK: tenderness on right posterior back and along the right
lateral chest. areas of subcutaneous emphysema along the right
posterior back
ABD: ND
MSK/EXT: moving all 4 extremities equally and symmetrically
DISCHARGE PHYSICAL:
===================
VS: 98.4 118/76 62 17 96 Ra
GENERAL: Cachectic male, standing up ___ room on nasal cannula,
mildy tachypnic.
Neck: JVP to midneck sitting straight up, improved from jawline
___
CV: s1/s2 RRR
Resp: inspiratory crackles b/l lower lobes, otherwise CTAB
Extremities: TEDS on, pedal edema bilaterally, 2+ DP pulses
Neuro: Normal Gait
Pertinent Results:
ADMISSION LABS
==============
___ 10:30AM BLOOD WBC-10.5* RBC-4.48* Hgb-13.6* Hct-39.3*
MCV-88 MCH-30.4 MCHC-34.6 RDW-12.6 RDWSD-40.1 Plt ___
___ 10:30AM BLOOD Neuts-70.3 Lymphs-16.4* Monos-10.6
Eos-1.4 Baso-0.7 Im ___ AbsNeut-7.41* AbsLymp-1.73
AbsMono-1.12* AbsEos-0.15 AbsBaso-0.07
___ 10:30AM BLOOD Glucose-98 UreaN-13 Creat-1.0 Na-136
K-4.4 Cl-97 HCO3-26 AnGap-13
___ 07:10AM BLOOD CK(CPK)-555*
___ 07:10AM BLOOD Calcium-8.9 Phos-2.5* Mg-2.2
___ 10:43AM BLOOD ___ pO2-52* pCO2-41 pH-7.42
calTCO2-28 Base XS-1 Intubat-NOT INTUBA
DISCHARGE LABS:
===============
___ 06:15AM BLOOD WBC-6.6 RBC-3.72* Hgb-10.9* Hct-33.3*
MCV-90 MCH-29.3 MCHC-32.7 RDW-13.4 RDWSD-43.5 Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD Glucose-85 UreaN-15 Creat-0.8 Na-137
K-5.2* Cl-100 HCO3-26 AnGap-11
___ 06:15AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.1
MICRO
=====
___ 2:23 pm SPUTUM Site: EXPECTORATED
Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE. HEAVY
GROWTH.
BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN.
___ 9:04 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 9:04 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING
=======
___ CXR AP
IMPRESSION:
1. Acute displaced fractures likely involving at least the right
lateral ___ and likely 9th ribs, with associated
subcutaneous emphysema.
2. Probable small right apical pneumothorax.
3. Right lung base atelectasis versus contusion.
___ L spine
1. No fracture or traumatic malalignment.
2. Bilateral L5 spondylolysis with grade 2 anterolisthesis of L5
on S1.
___ C spine
Degenerative changes without fracture or malalignment.
___ CT CHest
1. Multiple consecutive acute fractures involving the ___
through 11th ribs,
all of which are displaced except for the eleventh rib.
2. Small right pneumothorax. Small nonhemorrhagic right pleural
effusion.
3. Areas of airway mucous plugging with multifocal ___
and nodular
parenchymal opacities as described above, suspicious for
aspiration or
pneumonia.
4. Prominent mediastinal lymph nodes are likely reactive.
5. 3mm non-obstruction left renal stone.
___ CXR
The right-sided pigtail catheter is unchanged. The right
hydropneumothorax is unchanged. Subcutaneous emphysema ___ the
right lateral chest wall is also unchanged. There is
subsegmental atelectasis ___ the left lung base. There is also
subsegmental atelectasis ___ the right lower lobe.
Cardiomediastinal silhouette is stable.
___ CXR
IMPRESSION:
Tiny to small residual right apical pneumothorax.
___ CXR
IMPRESSION:
Tip of ET tube 2 cm above bifurcation of the trachea
___ CXR
IMPRESSION:
Bilateral effusions right greater than left are stable. Patchy
parenchymal opacities bilaterally right greater than left are
also unchanged. There are multiple displaced right-sided rib
fractures, unchanged. Cardiomediastinal silhouette is stable.
No pneumothorax is seen.
___ ECHO
The left atrium is normal ___ size. Left ventricular wall
thicknesses are normal. 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 = 65%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
(___) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
Brief Hospital Course:
___ with PMH of IVDU and PTSD who presents to the ED after a
mechanical fall now with right sided ___ rib fractures and
small right PTX (now s/p pigtail catheter removal). Sent to unit
for afib with RVR, course c/b resp distress requiring
___ now self extubated. Also spiked fever ___
the unit and was treated with 2 days of broad spectrum abx but
subsequently stopped. He was transferred to medicine for ongoing
management of hypoxemia with new O2 requirement and paroxysmal
atrial fibrillation.
#Rib Fracture
R ___ rib fx, small PTX on chest imaging, had pigtail placed to
clear the PTX. His pain was managed with oxycodone and encourage
to use incentive spirometer. He was txfr'ed to the TSICU.
#Paroxysmal atrial fibrillation
Patient was transferred to ___ due to afib with RVR and
increasing O2 requirement. Likely triggered ___ the setting of
recent trauma/pain vs infectious cause (aspiration PNA). Was
requiring IV metop and dilt, transitioned to PO Metoprolol 25 mg
Q6H with better control and was back ___ NSR on ___ through his
discharge. Chads2Vasc=0, not started on anticoagulation. He was
then having rates ___ the ___ w/ some isolated readings ___ the
___ on this dose of metop so was started on metop succinate at a
slightly lower dose of 75 mg daily. He had no episodes of RVR
during the several days after transfer to the medicine service.
#Hypoxemia:
#Cough:
Patient transferred to ___ i/s/o afib with RVR and hypoxia.
Initial CT chest with evidence of aspiration PNA. Was intubated
due to worsening hypoxia, fever and hypotension, required
pressors briefly ___ the unit. Also had H flu growing ___ sputum.
On transfer to medicine, patient still on O2 requirement of 2L.
Was started on Augmentin for PNA for ___lso noted to
be volume up, given Lasix 20 mg IV for 2 days with good output.
TTE obtained which showed MR but no systolic or diastolic
dysfunction. He was noted to be splinting ___ the setting of his
rib pain. Wheezes ___ the lungs suggest possible asthma or COPD
given smoking history. Was initial concern for TB given reported
4 week history of productive cough with very thin body habitus,
but patient then denied any history of cough/fevers/night
sweats/weight loss. He was able to have his O2 weaned. He will
finish a 5 day course of Augmentin for PNA on ___.
___ edema
New finding this admission. Not significantly fluid resuscitated
during admission. CV exam normal and lungs clear other than RLL
near site of fracture, CXR no significant edema and normal
cardiac silhouette. He was diuresed intermittently with IV Lasix
w/ improvement ___ his edema. He was not discharged on a
diuretic.
CHRONIC/STABLE ISSUES:
===============================
#PTSD
-Continued home gabapentin
-Psych had seen patient. He is interested ___ outpatient psych
f/u
#History of IVDU
-Continued methadone 70mg PO daily, confirmed with clinic
TRANSITIONAL ISSUES:
=====================
DISCHARGE WEIGHT: 62.1 mg
MEDICATIONS STARTED: Amoxicillin-Clavulanic Acid ___ mg PO/NG
Q12H (last day ___, Lidocaine 5% Patch 1 PTCH TD QAM,
Metoprolol Succinate XL 75 mg PO DAILY, Acetaminophen 1000 mg PO
Q8H:PRN
-Patient to finish 5 day course of Augmentin for PNA on ___
-Patient continued on methadone 70 mg daily. Last dose ___ at
0600. He was discharged with a last dose letter
-Patient discharged without diuretic. Would consider maintenance
diuretic if persistent ___ edema
-Discharged on 75 mg metop succinate. F/u HR to determine
whether to adjust his dose of BB
-Patient wishes to establish care w/ PCP at ___. Unable to book
this appointment at the time of discharge due to it being the
weekend. The patient was told we would make an appointment and
left several contact numbers for us to get ___ touch with him.
-Consider psych referral as an outpatient as patient
#Contact: ___ (sister) - ___
___ (friends) - ___
Patient's cell (not currently working but he's getting it fixed
upon discharge) - ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO TID
2. Methadone 70 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg 2 tablet(s) by mouth Q8H:PRN Disp #*84
Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*5 Tablet Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % Apply one patch to affected area QAM Disp #*15
Patch Refills:*0
4. Metoprolol Succinate XL 75 mg PO DAILY
RX *metoprolol succinate 25 mg 3 tablet(s) by mouth QAM Disp
#*48 Tablet Refills:*0
5. Gabapentin 300 mg PO TID
6. Methadone 70 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
=======
Rib fracture
Paroxsysmal Atrial Fibrillation
Secondary
=========
Pneumonia
Mitral Regurgitation
Discharge Condition:
Mental Status: Clear and coherent.
Mental Status: Confused - sometimes.
Mental Status: Confused - always.
Discharge Instructions:
Mr. ___,
It was a pleasure to take care of you at ___.
WHY WAS I HERE?
You were admitted to the hospital because you fell and broke
your ribs.
WHAT WAS DONE WHILE YOU WERE ___ THE HOSPITAL
- While you were ___ the hospital you were treated for your pain
- You had problems breathing and needed to be intubated
- You had an abnormal heart ryhtym and were started on a new
medication
- You were treated for a pneumonia
- You were given medicine to help remove fluid from your body
that was accumulating ___ your legs
WHAT SHOULD I DO WHEN I GET HOME?
1) Folow up with your new PCP
2) Finish your course of antibiotics
All our best,
Your ___ Care Team
Followup Instructions:
___
|
10458345-DS-14 | 10,458,345 | 27,209,416 | DS | 14 | 2207-06-29 00:00:00 | 2207-07-12 16:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
laparoscopic cholecystectomy
History of Present Illness:
___ with history of HLD/HTN presents with acute onset abdominal
pain. Patient reports being in his usual state of health until
___. He had nausea and poor PO intake and went to bed early.
He was awakened with sudden onset, severe RUQ pain. The pain was
severe and sharp, associated with nausea and three episodes of
emesis overnight. When the pain didn't subside he presented to
the ED for evaluation.
He denies fevers, chills, chest pain, shortness of breath or
recent weight loss, or recent change in diet or bowel habits.
Past Medical History:
Narcolepsy, hypothyroidism, hyperlipidemia, ankle operations
Social History:
___
Family History:
non-contributory
Physical Exam:
Physical Exam at Admission:
Vitals: T97.9 BP171/95 HR93 RR18 94%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, non-distended, tender to palpation in RUQ/RLQ,
___ sign
Ext: No ___ edema, ___ warm and well perfused
Physical Exam at discharge:
General Awake, Alert, No Acute Distress
Vitals: 98.3, 132/82, 80, 18 96%RA
HR: Regular rate and rhythm (not in afib at time of discharge),
no murmur
Pulm: CTAB, no wheeze
Abd: Soft, non-distended, non-tender to palpation
Wound:RUQ drain serous, no erythema at drain site. otherwise
C/D/I
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 11:44PM BLOOD WBC-7.8 RBC-4.40* Hgb-13.3* Hct-39.2*
MCV-89 MCH-30.2 MCHC-33.9 RDW-14.3 RDWSD-47.0* Plt ___
___ 11:44PM BLOOD Glucose-111* UreaN-20 Creat-0.8 Na-139
K-3.5 Cl-106 HCO3-20* AnGap-17
___ 02:43AM BLOOD ALT-180* AST-136* LD(LDH)-430*
AlkPhos-136* TotBili-0.7
___ 11:44PM BLOOD Calcium-9.4 Phos-4.4 Mg-2.0
ECHO ___:
Conclusion:
The left atrial volume index is mildly increased. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Atrial fibrillation. Hypertensive heart disease.
Hyperdynamic left ventricular systolic function. No pathologic
valvular flow.
Liver/Gallbladder US ___:
IMPRESSION: Findings suggestive of acute cholecystitis.
CT Abd/Pelvis ___:
IMPRESSION:
1. Distended gallbladder with stones and mild pericholecystic
fluid and trace perihepatic ascites is concerning for early
cholecystitis.
2. Mild sigmoid diverticulosis is seen without acute
diverticulitis.
3. The kidneys are of normal and symmetric size with normal
nephrogram.
A large simple cyst in the interpolar region of the left kidney
measuring 7.2 x 8.6 cm. There is no evidence of focal renal
lesions or hydronephrosis. There is no perinephric abnormality
Brief Hospital Course:
Mr. ___ is a ___ year old male with history of HLD/HTN
presented to ___ with acute onset of abdominal
pain and was admitted for an emergent laparoscopic
cholecystectomy on ___. He was found to have a gangrenous
cholecystitis during the operation. Post operatively he
developed atrial fibrillation with rapid ventricular rate which
could not be broken with metoprolol or diltiazem PO on the floor
so he was transferred to Neuro ICU for diltiazem drip. He was
transitioned from IV diltiazam to PO diltiazem. His home
amlodipine was discontinued due to dual calcium channel
blockade. He was evaluated for underlying hyperthyroid which was
negative. He was transitioned from diltiazem PO to metoprolol PO
at ___ time he spontaneously converted back to normal sinus
rhythm. He was transferred back to the floor. His rate remained
controlled with metoprolol and he was maintained on telemetry
which continued to demonstrate normal sinus rhythm. He was
started on apixiban 5mg BID anticoagulation at discharge. He was
very eager to discharge for a family vacation on ___, and
was recommended close follow-up with the Acute Care
Surgery-Trauma team as well as recommended to follow-up with
cardiology in the next 2 weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Celecoxib 100 mg oral BID
3. amLODIPine 10 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN Pain
- Moderate
6. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral BID
7. Methadone ___ mg PO QHS:PRN as neded
8. Aspirin 81 mg PO DAILY
9. Levothyroxine Sodium 88 mcg PO DAILY
10. Modafinil 400 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
Do not exceed 4000mg in 24 hours.
2. Apixaban 5 mg PO BID non valve afib
RX *apixaban [Eliquis] 5 mg 5 mg by mouth twice a day Disp #*60
Tablet Refills:*0
3. Metoprolol Tartrate 25 mg PO Q6H
RX *metoprolol tartrate 25 mg 1 tablet by mouth every 6 hours
everday Disp #*120 Tablet Refills:*0
4. Omeprazole 20 mg PO BID
5. Senna 8.6 mg PO BID:PRN constipation
6. amLODIPine 10 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral BID
10. Docusate Sodium 100 mg PO BID
11. Levothyroxine Sodium 88 mcg PO DAILY
12. Methadone ___ mg PO QHS:PRN as neded
13. Modafinil 400 mg PO DAILY
14. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN
Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for
with acute onset abdominal pain and determined to have acute
cholecystitis. You were admitted to the hospital with acute
cholecystitis. You were taken to the operating room and had your
gallbladder removed laparoscopically. You tolerated the
procedure well. After the surgery you developed atrial
fibrillation which required a visit to the ICU to get control of
your high heart rate. You are now managed with anticoagulation
and rate controlling medications. Yoare now being discharged
home to continue your recovery with the following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming. This means no swimming on your
trip to the ___!
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
You are also taking a few new medications including Metoprolol
and Abixapan. Please continue taking your Aspirin as recommended
by your cardiologist. Please stop taking the Celecoxib and do
not take NSAIDS (advil, motrin, ibuprofen etc.) as they can
cause increased risk of bleeding when taking the abixapan.
Followup Instructions:
___
|
10458345-DS-15 | 10,458,345 | 22,678,576 | DS | 15 | 2209-05-25 00:00:00 | 2209-05-27 18:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old man with a history of popliteal
artery aneurysm s/p surgical repair (___), afib on eliquis,
narcolepsy, HTN, HLD and s/p thyroid removal, who is presenting
with two days of chills, L shoulder pain, and RLE redness and
pain/difficulty with walking.
For a few days, pt attests to difficulty and pain with walking
and redness in his R lower leg. Also has had some pain in his
knees. Had N/V yesterday. Also complains of some L shoulder pain
with abduction. Has had chills and is currently feeling cold.
Of note, patient had an episode of cellulitis in the same area
as
he is currently experiencing pain and redness ___ years ago. He
was seen in ___ ED, held in observation over night, and
discharged the next day on clindamycin.
Denies subjective fevers, CP, SOB, diarrhea. No recent surgeries
or travel.
In the ED, initial vitals: T 100.1, HR 87, BP 139/69, RR 18
- Exam notable for:
Febrile to 101.5
Large, well-demarcated erythematous area on anterior R calf,
extending around medial leg to posteromedial surface of RLE
below
knee. TTP in some areas.
Full ROM of ankle and foot. Sensory, motor functions intact
distally with 2+ DP pulses bilaterally. Trace ___ edema b/l.
- Labs notable for: WBC 17.0, Hgb 13.1, Cr 1.0, lactate 1.7
- Imaging notable for: R LENIs-No evidence of deep venous
thrombosis in the right lower extremity veins.
- Patient was given:
Acetaminophen 650 mg
IV Vancomycin 1000 mg
IV CefTRIAXone 1g
- Consults: None
- Vitals prior to transfer: T 98.6, HR 89, BP 119/75, RR 16, O2
sat 97% RA
On arrival to the floor, the patient confirms the above history.
Endorses significant pain when walking on his right leg. He says
he has not had any trauma to his right leg or insect bites. Says
his left shoulder pain is not present currently (occurred when
he
reached over his head yesterday), thinks he may have slept on it
wrong, no pain with ranging or palpation currently. Endorses
bilateral lumps on his knees. Denies fevers, but says he has had
chills earlier today. No nausea or vomiting today.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative less otherwise noted in the HPI.
Past Medical History:
BENIGN PROSTATIC HYPERTROPHY
HYPERLIPIDEMIA
HYPOTHYROIDISM
POPLITEAL ANEURYSM
PROSTATE CANCER
SLEEP APNEA
THYROID DISORDER
THYROID NODULE
MGUS
POPLITEAL ARTERY ANEURYSM
ATRIAL FIBRILLATION
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
VS: T 98.6, HR 89, BP 119/75, RR 16, 97% RA
GENERAL: Pleasant, lying in bed comfortably
HEENT: anicteric sclerae
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Right leg w/ anteromedial erythema outlined. No warmth or
erythema or tenderness of left shoulder. Right knee with mild
effusion.
PULSES: 2+ DP pulses
NEURO: Alert, oriented, motor and sensory function grossly
intact
DISCHARGE PHYSICAL EXAM
===========================
VS: 24 HR Data (last updated ___ @ 2348)
Temp: 98.2 (Tm 98.2), BP: 138/81 (121-153/75-87), HR: 59
(59-73), RR: 16 (___), O2 sat: 97% (95-97), O2 delivery: Ra
GENERAL: Pleasant, lying in bed comfortably
HEENT: anicteric sclerae
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Right leg w/ anteromedial erythema from bottom of knee to
top of ankle outlined, warm to palpation, TTP. Improved from
prior along the superior and lateral edge.
PULSES: 2+ DP pulses
NEURO: Alert, oriented, motor and sensory function grossly
intact
Pertinent Results:
ADMISSION LABS
===================
___ 11:04AM BLOOD WBC-17.0* RBC-4.35* Hgb-13.1* Hct-39.6*
MCV-91 MCH-30.1 MCHC-33.1 RDW-13.8 RDWSD-46.3 Plt ___
___ 11:04AM BLOOD Neuts-91.5* Lymphs-3.5* Monos-4.2*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-15.58* AbsLymp-0.60*
AbsMono-0.72 AbsEos-0.00* AbsBaso-0.03
___ 11:04AM BLOOD Plt ___
___ 11:04AM BLOOD Glucose-106* UreaN-22* Creat-1.0 Na-135
K-3.9 Cl-101 HCO3-22 AnGap-12
___ 11:09AM BLOOD Lactate-1.7
___ 7:12 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
DISCHARGE LABS
===================
___ 04:52AM BLOOD WBC-4.7 RBC-4.14* Hgb-12.6* Hct-36.7*
MCV-89 MCH-30.4 MCHC-34.3 RDW-13.8 RDWSD-45.2 Plt ___
___ 04:52AM BLOOD Glucose-91 UreaN-16 Creat-0.8 Na-138
K-3.7 Cl-105 HCO3-23 AnGap-10
IMAGING
====================
R Knee XR ___
IMPRESSION:
Trace knee joint effusion. Moderate tricompartmental
degenerative changes as
well as evidence of CPPD.
R ___ ___
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
Brief Hospital Course:
SUMMARY
==============
Mr. ___ is a ___ year-old man with a history of popliteal
artery aneurysm s/p surgical repair (___), afib on eliquis,
narcolepsy, HTN, HLD and s/p thyroid removal, who presented with
two days of chills, L shoulder pain, and RLE redness and
pain/difficulty with walking, with exam consistent with RLE
cellulitis. He received 4 days of IV ceftriaxone with
improvement in his cellulitis. He was subsequently discharged on
cefpodoxime for a total 10 day course.
TRANSITIONAL ISSUES
======================
[] Patient provided with prescription for rolling walker ___
pain from cellulitis.
[] Will complete cefpodoxime on ___ for a 10 day course of
antibiotics for his cellulitis.
ACUTE ISSUES:
=============
# RLE Cellulitis
# Chills
Presented with RLE redness, chills, pain w/ ambulation and
elevated WBC with neutrophil predominance consistent with
cellulitis. Initially the leg was noted to be very erythematous
and warm, TTP, but he did not have any skin breaks or pus
expression. No c/f R knee involvement given XR findings and exam
w/ normal ROM. Received vanc/CTX in ED. He was de-escalated to
ceftriaxone only which he received for 4 days prior to discharge
at which time he was discharged on cefpodoxime for a total 10
day course.
# Left shoulder pain
Initially reported L shoulder pain that could not be reproduced
on exam. Pain resolved without intervention.
CHRONIC ISSUES:
===============
# Afib
- continued apixaban 5 mg BID
# Narcolepsy
- continued Modafinil
- continued methylphenidate prn
# HTN
- continued amlodipine
# HLD
- continued atorvastatin
# s/p Thyroidectomy
# Hypothyroidism
- continued levothyroxine
# h/o Depression
- continued citalopram
# CODE: full (confirmed with patient)
# CONTACT: ___, wife.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
2. Endocet (oxyCODONE-acetaminophen) ___ mg oral Q6H:PRN
3. Omeprazole 20 mg PO DAILY
4. amLODIPine 10 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Citalopram 20 mg PO DAILY
7. MethylPHENIDATE (Ritalin) ___ mg PO DAILY:PRN narcolepsy
8. Modafinil 200 mg PO QAM
9. Apixaban 5 mg PO BID
10. Levothyroxine Sodium 88 mcg PO DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 6 Days
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp
#*11 Tablet Refills:*0
2. amLODIPine 10 mg PO DAILY
3. Apixaban 5 mg PO BID
4. Atorvastatin 40 mg PO QPM
5. Citalopram 20 mg PO DAILY
6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
7. Endocet (oxyCODONE-acetaminophen) ___ mg oral Q6H:PRN
8. Levothyroxine Sodium 88 mcg PO DAILY
9. MethylPHENIDATE (Ritalin) ___ mg PO DAILY:PRN narcolepsy
10. Modafinil 200 mg PO QAM
11. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
====================
Non-purulent cellulitis
SECONDAY DIAGNOSIS
====================
Atrial fibrillation
Narcolepsy
Hypertension
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 taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for cellulitis (skin infection).
What was done for me while I was in the hospital?
- You were given IV antibiotics to improve your infection.
What should I do when I leave the hospital?
- You should take your medications as prescribed.
- You should call your doctor if you develop fevers or chills.
- Please go to all of your appointments listed below.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10458533-DS-15 | 10,458,533 | 26,643,421 | DS | 15 | 2189-03-01 00:00:00 | 2189-03-01 21:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodinated Contrast Media - Oral and IV Dye
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Endoscopy - ___
History of Present Illness:
Mr. ___ is a ___ with T2DM, splenectomy, HBV cirrhosis and
HCC(MRI ___ with 4.8cm seg VII, 0.9cm medial seg VII, and
1.3cm seg II/III) s/p TACE to seg VII ___, found to have
locally metastatic disease making him not a candidate for liver
transplant, who presents with right upper quadrant pain and
elevated bilirubin.
In review of OMR, it appears that in ___ (1 month post
TACE) MRI showed residual tumor at the TACE treatment zone (1.4
cm nodule at the superior of segment as well as smaller OPTN 5
lesions. Also noted to have tumor thrombus within the branch of
the right posterior portal veins and enlarged retroperitoneal
and porta hepatis lymph nodes. Incidental 5 mm cystic lesion in
the uncinate process of the pancreas. Chest CT, ___
and bone scan, ___ without metastatic disease. He
last saw his oncologist in ___ and they discussed SOC
___ and on trial with folfox + ___ but he wanted to
think about treatment. However, it appears that he missed
several follow-up appointments and has not been seen since that
time.
He presented to ___ with complaint of RUQ
abdominal pain. Symptoms started ___ days ago and have
progressively worsened. Nausea/vomiting started 1 day prior to
admission and he has been unable to tolerate PO. He presented to
___ where he was found to have elevated LFTs and CT
abd/pelvis with concern for ?cholecystitis. Denies diarrhea,
blood stools, shortness of breath, fevers chills. At ___, he
received Morphine 4mg, Dilaudid 2mg, Zofran 8mg. He was
transferred to ___ for further evaluation.
Past Medical History:
Per OMR:
1. HBV cirrhosis.
2. Possible alcohol excess.
3. Type 2 diabetes mellitus.
4. Hypertension.
5. Benign prostate hypertrophy.
6. History of inguinal hernia.
7. Status post motor vehicle accident with multiple surgeries.
8. Anxiety.
9. Status post splenectomy in ___.
10. Status post inguinal hernia repair x 3, most recently
___.
11. Status post bilateral ankle fracture surgery.
12. Status post bilateral elbow surgery
___. Status post small intestinal surgery in ___.
14. Status post partial gastrectomy in ___.
15. Status post L1, L2, L3 discectomy.
16. Status post TURP ___.
Social History:
___
Family History:
The patient's father was diagnosed with colon cancer in his ___
and died in his ___. A maternal grandfather was treated for
lung
cancer at ___ years. A brother died of lymphoma at ___ years. A
sister was treated for brain cancer in her ___. His other
sister
and two children are without health concerns.
Physical Exam:
ADMISSION EXAM
==============
VS: 98.5 155/87 65 18 92 RA
GENERAL: Lying in bed, frustrated, NAD
HEENT: Mucus membranes moist, no scleral icterus, EOMI. Neck
supple no LAD
CARDIAC: Normal S1/S2, no m/r/g
PULMONARY: CTAB, normal respiratory effort
ABDOMEN: Distended liver. Absent spleen. Midline surgical scar
noted. Tender to palpation diffusely but more prominent in RUQ.
No rebound.
GENITOURINARY: No Foley
EXTREMITIES: No c/c/e
SKIN: No rashes noted
NEUROLOGIC: No asterixis. A/O x3.
DISCHARGE EXAM
==============
VS: T 97.9, BP 95-108/56-66, HR 82-89, RR 18, SpO2 95/RA
GENERAL: Lying in bed, NAD
ARDIAC: RRR, S1+S2, no M/R/G
PULMONARY: CTAB, no W/R/C
ABDOMEN: Non-distended, soft. Midline surgical scar noted. TTP
in RUQ. No rebound.
EXTREMITIES: WWP, no edema
NEUROLOGIC: No asterixis. A/O x3.
Pertinent Results:
ADMISSION LABS
==============
___ 12:34PM cTropnT-<0.01
___ 08:57AM WBC-8.6 RBC-6.26* HGB-18.8* HCT-52.2* MCV-83
MCH-30.0 MCHC-36.0 RDW-23.1* RDWSD-62.9*
___ 08:57AM NEUTS-56.4 ___ MONOS-17.1* EOS-3.5
BASOS-0.8 NUC RBCS-0.6* IM ___ AbsNeut-4.85 AbsLymp-1.87
AbsMono-1.47* AbsEos-0.30 AbsBaso-0.07
___ 08:57AM PLT COUNT-154
___ 08:56AM K+-4.4
___ 06:21AM K+-5.7*
___ 04:35AM GLUCOSE-76 UREA N-13 CREAT-0.8 SODIUM-135
POTASSIUM-5.4* CHLORIDE-100 TOTAL CO2-23 ANION GAP-17
___ 04:35AM ALT(SGPT)-66* AST(SGOT)-125* ALK PHOS-190*
TOT BILI-2.1*
___ 04:35AM LIPASE-90*
___ 04:35AM cTropnT-<0.01
___ 04:35AM ALBUMIN-3.0*
___ 04:35AM bnzodzpn-NEG barbitrt-NEG
___ 04:35AM WBC-10.2* RBC-6.61*# HGB-19.1* HCT-57.0*
MCV-86# MCH-28.9# MCHC-33.5 RDW-21.6* RDWSD-60.9*
___ 04:35AM NEUTS-47.9 ___ MONOS-13.7* EOS-2.3
BASOS-0.9 NUC RBCS-0.2* IM ___ AbsNeut-4.89 AbsLymp-3.53
AbsMono-1.40* AbsEos-0.23 AbsBaso-0.09*
___ 04:35AM PLT COUNT-148*
MICRO
=====
__________________________________________________________
___ 4:25 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 4:35 am BLOOD CULTURE
Blood Culture, Routine (Pending___:
___ 05:45AM BLOOD HBV VL-PND
DISCHARGE LABS
==============
___ 05:28AM BLOOD WBC-9.5 RBC-6.94* Hgb-19.8* Hct-58.7*
MCV-85 MCH-28.5 MCHC-33.7 RDW-21.2* RDWSD-58.8* Plt ___
___ 05:28AM BLOOD Plt ___
___ 05:28AM BLOOD ___ PTT-39.9* ___
___ 05:28AM BLOOD Glucose-70 UreaN-18 Creat-0.8 Na-134
K-4.4 Cl-99 HCO3-25 AnGap-14
___ 05:28AM BLOOD ALT-71* AST-112* AlkPhos-214*
TotBili-2.6*
___ 05:28AM BLOOD Albumin-3.0* Calcium-8.8 Phos-3.3 Mg-1.7
IMAGING/STUDIES
===============
___ DOP ABD/PEL LIMI
1. The hepatic parenchyma appears heterogeneous with multiple
echogenic foci concerning for malignancy.
2. The main portal vein demonstrates no flow consistent with
occlusion. The left portal vein demonstrates limited flow
consistent with partial occlusion.
3. No evidence of cholecystitis.
___ (PA & LAT)
Mild bibasilar atelectasis without focal consolidation to
suggest pneumonia.
___ 1:00:00 ___ - EGD report
Varices at the lower esophagus
Mosaic appearance in the body, antrum compatible with portal
gastropathy
Varices at the fundus
Otherwise normal EGD to third part of the duodenum
___ ABD & PELVIS WITH CO
1. Interval progression of portal venous thrombosis in the right
portal vein now extending into the left and main portal veins
which are expanded.
Evaluation is limited on this single phase exam, however this
thrombosis was demonstrated to be enhancing on prior studies and
is compatible with tumor thrombus.
2. Cirrhosis with post treatment cavities with high density in
segments VI and VII. This single arterial phase study is not
sufficient to evaluate for recurrent or residual HCC, however an
enhancing 1.2 x 1.1 cm lesion in the dome of the liver was not
seen on the prior MRI and is suspicious. The 1.1 cm lesion
meeting OPTN 5A criteria medial to the segment VII treatment
cavity seen on the prior MRI is not seen on today's study.
Additionally, a 1.4 cm suspicious focus for residual tumor just
superior to this treatment cavity is also not seen on today's
study. A 1.0 x 0.9 cm enhancing lesion at the junction of
segments V and VIII is slightly increased in size and correlates
to an arterially enhancing lesion with washout and pseudo
capsule seen on the prior MRI which measured up to 0.7 cm at
that time.
3. Stable left adrenal adenoma
Brief Hospital Course:
Mr. ___ is a ___ with T2DM, splenectomy, HBV cirrhosis and
HCC(MRI ___ with 4.8cm seg VII, 0.9cm medial seg VII, and
1.3cm seg II/III) s/p TACE to seg VII ___, found to have
locally metastatic disease making him not a candidate for liver
transplant, who presents with right upper quadrant pain and
elevated bilirubin.
#EXTENSION OF PORTAL VEIN THROMBUS: CT abd/pel (though
monophasic and not preferred triphasic) showing extension of
clot into main portal vein, concerning for spread of tumor
thrombus. Per radiology, this is almost certainly cancer
progression. No role for anticoagulation. This (spread of
disease) was felt to be the cause of RUQ pain and elevated
bilirubin on presentation. Should have MRI as outpatient for
cancer staging. AFP during admission of 194,500; most recently
630 in ___. Will follow-up with oncology as an outpatient
regarding systemic chemotherapy.
#HBV CIRRHOSIS: MELD-Na 19 on admission. No evidence of
ascites, hepatic encephalopathy on admission. Continued on home
entecavir. f/u HBV VL pending at the time of discharge.
#VARICES: four cords of medium-sized varices seen in lower
esophagus on EGD ___. Started on nadolol 20mg daily;
tolerated well. BP 55-65. Conside uptitrating as outpatient if
HR can tolerate.
#HCC s/p TACE: AFB 630 in ___. Ruled out for transplant by
___ criteria. Was referred to oncology for systemic
chemotherapy, but patient never followed up. AFP very high
suggests progression of disease.
- f/u with oncology as outpatient
#ERYTHROCYTOSIS: Concerning for ___ producing EPO, given EPO
level 44.5 (ULN 18.5). ___ also be component of
hemoconcentration in setting of nausea/vomiting. Can be
contributing to his hypercoagulability as well.
#GERD: continued home omeprazole 20mg daily
#T2DM: Insulin sliding scale while admitted.
#BPH: Continued home finasteride
#HYPERTENSION: Continued home lisinopril and metoprolol.
TRANSITIONAL ISSUES
===================
[ ] EGD on ___ with esophageal and gastric varices (4 cords
of medium sized varices). Started on nadolol 20mg daily. ___ be
uptitrated to 40mg as outpatient.
[ ] ___ consider referral to palliative care pending patient's
goals of care. Of note, patient was discharged with 2 days
supply of dilaudid for pain
[ ] Patient and family may benefit from referral to
psychiatry/social work for coping with illness
[ ] AFP on discharge: 194,500
[ ] HBV viral load pending at time of discharge
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Entecavir 0.5 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID
6. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four hours Disp #*10 Tablet Refills:*0
3. Nadolol 20 mg PO DAILY
RX *nadolol 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Polyethylene Glycol 17 g PO DAILY constipation
it is very important that you take this medicine if you take the
dilaudid
RX *polyethylene glycol 3350 17 gram/dose 17 g by mouth daily
Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [Senexon] 8.6 mg 1 capsule by mouth twice a day
Disp #*60 Tablet Refills:*0
6. Entecavir 0.5 mg PO DAILY
7. Finasteride 5 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Lisinopril 10 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
hepatocellular carcinoma with progression of tumor thrombus
hepatitis B cirrhosis
esophageal varices
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Why were you here?
- You had belly pain and some of your lab tests were high.
What was done while you were here?
- You had a CT scan that showed a mass in the blood vessels near
the liver, blocking blood flow. We think this might be the cause
of your pain. You should talk to your oncologist about how to
treat this, as we think the mass is an extension of your liver
cancer.
- You had an endoscopy that showed large blood vessels in the
esophagus. You were started on a new medicine to help prevent a
bleed.
What should you do when you get home?
- Please follow-up with your oncologist and your liver doctor.
- Please continue to take this new medicine called nadolol.
Followup Instructions:
___
|
10458567-DS-18 | 10,458,567 | 25,977,570 | DS | 18 | 2164-02-12 00:00:00 | 2164-02-14 15:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left knee pain
Major Surgical or Invasive Procedure:
Open reduction internal fixation of left medial tibial plateau
fracture
History of Present Illness:
Mr. ___ is a healthy ___ s/p fall off a trampoline
transferred from ___ for management of a L tibial plateau
fracture. He was jumping on a trampoline when he landed onto a
foam block on to his LLE. No headstrike or loss of
consciousness. Some paresthesias to L ___ toe, otherwise no
sensory changes. No pain elsewhere.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAMINATION AT ADMISSION:
General: NAD
Vitals: 98.4 104 120/85 18 100%
Left lower extremity:
- Left knee effusion
- Mild soft tissue swelling including calf, compressible
compartments
- No pain with passive ROM
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
PHYSICAL EXAMINATION AT DISCHARGE
General: NAD. A&Ox3
Vital signs were stable. Patient was afebrile.
Left lower extremity:
Incision clean, dry, intact
Moderate amount of swelling, ecchymosis.
Compartments soft and compressible.
No pain with passive range of motion
Patient SGILT in SPN/TPN/DPN/TN/saphenous/sural distributions
Fires ___
2+ ___ pulses. Foot WWP
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left tibial plateau fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation of left tibial plateau 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
touch down weightbearing in the left lower extremity extremity,
and will be discharged on aspirin 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 650 mg PO Q6H:PRN pain, fever
2. Aspirin (Buffered) 325 mg PO DAILY
RX *aspirin, buffered 325 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
5. tall axillary crutches x 2
Diagnosis: left tibial plateau fracture
Prognosis: good
Duration: 13 months
Discharge Disposition:
Home
Discharge Diagnosis:
Left medial tibial plateau fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery of your left
tibial plateau fracture. It is normal to feel tired or "washed
out" after surgery, and this feeling should improve over the
first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- touch-down weightbearing 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 Aspirin x 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
Touch-down weightbearing of left lower extremity.
Range of motion as tolerated in left lower extremity
Treatments Frequency:
Patient will have sutures/staples removed at 2 week follow-up.
Elevate left lower extremity when not ambulating
Followup Instructions:
___
|
10459005-DS-22 | 10,459,005 | 27,652,873 | DS | 22 | 2141-04-08 00:00:00 | 2141-04-13 13:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Motrin / Iodine-Iodine Containing / Naprosyn / Lisinopril /
Flomax
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
cardioversion
transesophageal echocardiogram
History of Present Illness:
___ male with a past medical history of coronary artery
disease status post CABG ___, chronic systolic and diastolic
heart failure (EF ___, hypertension, hyperlipidemia, V. tach
s/p ICD who presents with dyspnea and fatigue. The patient
states he has been feeling unusually short of breath with
minimal exertion (walking across a room) for the last ___ weeks.
He is also waking up at night more frequently short of breath
___ times per night). He endorses left-sided chest pressure
when episodes of dyspnea occur. Per PCP note, the patient has a
history of chronic low level nonexertional left precordial chest
pain. Pt had his ICD device interrogated on ___ because of
symptoms of dyspnea and fatigue. Interrogation showed: AP:60%,
VP:0.3%, Events:1 episode in VT monitor zone on ___ 7
seconds. 1:1 conduction rate=98bpm, 2 AF/AFL episodes on
___ with A rate 273 Vent response up to 135, duration > 10
hours. Patient was called to make an appointment with Dr.
___ cancelled it.
Pt denies fevers/chills, cough, dysuria, or N/V/D. Weight has
been stable. He notes some chronic b/l ankle edema.
In the ED intial vitals were: Pain 0, T 98.6, HR 140, BP 128/88,
RR 18, O2 97%. Labs were notable for an initial troponin of 0.04
which was rechecked 6 hrs later and found to be 0.05. Patient
also had mild anemia (hgb 12.3) which is his baseline. U/A was
unremarkable.
Patient was given: 5mg IV metop and 50mg PO metop tartrate 20
min later. HR came down to 110s. 90 min from initial IV metop
dose, he was given an additional 5mg IV metoprolol. He was given
an additional 25mg PO metoprolol at 15:45. At 21:54 he was given
his home dose sotalol 40mg. He was admitted to cardiology
service for afib with RVR and complex cardiac hx and for serial
trops.
Overnight patient had HRs in the 130s. BP remained stable.
Initially when interviewed, patient denied chest pain, shortness
of breath, palpitations. Shortly afterwards, he developed chest
pain on right and left anterior chest and Triggered.
Reproducible with palpation. Chest pain resolved. EKG remained
stable with Afib with RVR in the 130s, with ST depressions in V5
and V6, likely related to rate. Given 5mg IV metop, and BP
dropped slightly to 70-90s/50s. REturned to ___ in the 100s.
Past Medical History:
PAST MEDICAL HISTORY:
1. Coronary artery disease status post CABG in ___ with SVG to
his PDA, SVG to his OM and composite LIMA and SVG to LAD with
known total occlusion of all his venous grafts and PCI to his
LCx-OM, RCA and most recently to his right PDA in ___.
2. Chronic systolic and diastolic heart failure with class II
___ Heart Association symptoms with a left ventricular
ejection fraction of ___ and inferior akinesis due to a prior
inferior MI.
3. Hypertension.
4. Hyperlipidemia.
5. Obstructive sleep apnea, on home CPAP.
6. History of syncope with inducible VT on EP study, status post
ICD with recent generator change in ___.
Social History:
___
Family History:
Brother also has a history of coronary artery disease
Physical Exam:
=========================
ON ADMISSION:
=========================
VS: T=98.0 BP=110/85 HR=111 RR=20 O2 sat=100% RA
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP to angle of mandible.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Tachycardic, IRIR. Soft systolic murmur loudest at apex.
No r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c. Trace pitting edema on b/l ankles.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ radial and DP b/l.
==========================
ON DISCHARGE:
==========================
VS: T=97.8 BP= 126/78 (Post cardioversion: 100-120s/70s) HR=70s,
RR=18 O2 sat=100% RA
GENERAL: Pleasant man, sitting up in bed. Oriented x3. No
apparent distress.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva pink, no
oropharynx clear. No xanthelasma.
NECK: Supple with JVP to angle of mandible.
CARDIAC: regular rate and rhythm. Soft systolic murmur loudest
at apex. No r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominal bruits.
EXTREMITIES: No c/c. Trace pitting edema on b/l ankles. No point
tenderness, erythema at left knee or ankle.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ radial and DP b/l.
Pertinent Results:
==================
ADMISSION LABS:
==================
___ 01:00PM BLOOD WBC-5.5 RBC-4.47* Hgb-12.3* Hct-38.1*
MCV-85 MCH-27.4 MCHC-32.2 RDW-14.5 Plt ___
___ 01:00PM BLOOD Neuts-63.1 ___ Monos-8.1 Eos-2.0
Baso-0.5
___ 01:00PM BLOOD ___ PTT-29.3 ___
___ 01:00PM BLOOD Glucose-91 UreaN-22* Creat-0.9 Na-139
K-4.6 Cl-105 HCO3-23 AnGap-16
___ 01:00PM BLOOD cTropnT-0.04*
___ 07:21AM BLOOD Albumin-3.7 Calcium-6.3* Phos-4.0 Mg-2.0
==================
PERTINENT LABS:
==================
___ 01:00PM BLOOD cTropnT-0.04*
___ 07:10PM BLOOD cTropnT-0.05*
___ 04:20AM BLOOD CK-MB-8 cTropnT-0.04*
___ 07:21AM BLOOD CK-MB-9 cTropnT-0.06*
___ 05:18PM BLOOD CK-MB-9 cTropnT-0.09*
___ 07:28AM BLOOD TSH-2.7
___ 07:28AM BLOOD Free T4-1.1
___ 07:38AM BLOOD freeCa-1.22
==================
DISCHARGE LABS:
==================
___ 07:28AM BLOOD WBC-5.8 RBC-4.60 Hgb-12.5* Hct-39.1*
MCV-85 MCH-27.3 MCHC-32.1 RDW-14.3 Plt ___
___ 07:28AM BLOOD Glucose-91 UreaN-27* Creat-1.0 Na-138
K-4.7 Cl-105 HCO3-24 AnGap-14
___ 07:28AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.0
==================
STUDIES:
==================
TEE ___: No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. Overall left ventricular
systolic function is severely depressed. Right ventricular
chamber size is normal, with severe global free wall
hypokinesis. There are simple atheroma in the aortic arch. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. No masses or vegetations are seen on the aortic
valve. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mass or vegetation is seen on
the mitral valve. Moderate (2+) mitral regurgitation is seen.
Pulmonary artery systolic pressure is undetermined. There is no
pericardial effusion.
CXR: Unchanged moderate cardiomegaly with mild pulmonary
vascular congestion but no overt pulmonary edema
EKG: Atrial fibrillation with a rapid ventricular response.
Possible prior anterior infarction, age undetermined. Diffuse
ST-T wave changes. Cannot exclude ischemia. Compared to the
previous tracing the rate is increased. Findings are otherwise
similar
Brief Hospital Course:
Mr. ___ is a ___ male with a past medical history of
CAD status post CABG with multiple stents, chronic systolic and
diastolic heart failure, hypertension, hyperlipidemia, V. tach
s/p ICD who presents with dyspnea and fatigue found to be in
Afib with RVR.
# Afib with RVR: etiology thought to be due to previous ischemic
heart disease. Started on a heparin drip. Unable to control
tachycardia with oral and IV metoprolol, and had intermittent
episodes of hypotension with SBP 70-80s. Went for TEE and
cardioverison. Converted into sinus rhythm, HR ___, SBP
100-120s. Heparin stopped and started on rivaroxaban 20mg with
dinner. Amiodarone loaded for concurrent rate and rhythm
control. 400mg twice a day for 1 week (start ___, 200mg
twice a day for 1 week (start ___, 200mg once a day
indefinitely (start ___. Stopped sotalol and plavix.
Changed aspirin to 81mg daily.
# CAD s/p CABG and stenting: Pt has chronic chest pain. Troponin
elevated to 0.09 after cardioversion. EKG changes with rapid
ventricular rate, thought to be demand ischemia. Plavix stopped
since anticoagulation initiated. Switched to aspirin 81mg.
Continued on rosuvastatin 40mg daily. Chest pain free.
# Chronic systolic and diastolic heart failure (EF ___: JVD
elevated but otherwise appears euvolemic on exam without
crackles ___ edema. Does not appear to be volume overloaded.
Held home antihypertensives while hypotensive in setting of Afib
w/RVR. Hemodynamically stable post cardioversion. Restarted on
spironolactone and torsemide.
CHRONIC ISSUES:
# Hypertension: home meds held when hypotensive. Restarted post
cardioversion. Home medications: isosorbide mononitrate,
losartan, spiriolactone, torsemide.
# OSA: Uses CPAP at home. Pt unsure of settings. CPAP ordered
with respiratory consult.
# HLD: continue Ezetimibe 10 mg PO DAILY and rosuvastatin 40mg
qhs
# GERD: continue Ranitidine 300 mg PO QHS
# Depression: continue Fluoxetine 40 mg PO DAILY
========================
TRANSITIONAL ISSUES:
========================
- NEW MEDICATION: amiodarone 400mg twice a day (start ___,
then 200mg twice a day for one week (start ___, and change
to 200mg once a day on ___.
- NEW MEDICATION: rivaroxaban 20mg daily, take with dinner
- CHANGE: Aspirin 81mg daily (changed from 325mg daily)
- STOP: Sotalol and plavix
- Pt instructred that if SBP <90, he can hold his losartan
- All CHF medications remained the same
- Will have follow up appointment with Dr. ___ 2 weeks
after discharge. Will follow up with Dr. ___ ___ weeks after
discharge.
- Pending labs: TSH, Free T4
- FULL CODE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH QID
2. ammonium lactate 12 % topical BID
3. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
4. Clopidogrel 75 mg PO DAILY
5. Ezetimibe 10 mg PO DAILY
6. Fluoxetine 40 mg PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. FoLIC Acid 1 mg PO DAILY
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Losartan Potassium 25 mg PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Nitrolingual (nitroglycerin) 400 mcg/spray translingual
Q1H:PRN chest pain
13. Ranitidine 300 mg PO QHS
14. Rosuvastatin Calcium 40 mg PO QPM
15. Sotalol 40 mg PO BID
16. Spironolactone 25 mg PO DAILY
17. Torsemide 20 mg PO DAILY
18. TraMADOL (Ultram) 50-100 mg PO TID:PRN pain
19. Acetaminophen 1000 mg PO Q8H:PRN pain
20. Aspirin 325 mg PO DAILY
21. Docusate Sodium 100 mg PO BID:PRN constipation
22. Loratadine 10 mg PO DAILY:PRN allergies
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Albuterol Inhaler 2 PUFF IH QID
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Ezetimibe 10 mg PO DAILY
6. Fluoxetine 40 mg PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. FoLIC Acid 1 mg PO DAILY
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Losartan Potassium 25 mg PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Ranitidine 300 mg PO QHS
13. Rosuvastatin Calcium 40 mg PO QPM
14. Spironolactone 25 mg PO DAILY
15. Torsemide 20 mg PO DAILY
16. Amiodarone 400 mg PO BID Duration: 14 Doses
400mg twice a day x 1 week (start date ___
200mg twice a day x 1 week
200mg daily thereafter
RX *amiodarone 200 mg ___ tablet(s) by mouth twice a day, then
once a day Disp #*56 Tablet Refills:*0
17. Rivaroxaban 20 mg PO DINNER
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
18. ammonium lactate 12 % topical BID
19. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
20. Loratadine 10 mg PO DAILY:PRN allergies
21. Nitrolingual (nitroglycerin) 400 mcg/spray translingual
Q1H:PRN chest pain
22. TraMADOL (Ultram) 50-100 mg PO TID:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Atrial fibrillation
SECONDARY DIAGNOSIS:
chronic systolic and diastolic congestive heart failure
coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of ___ at ___.
___ came to the hospital because ___ were short of breath. ___
were found to have a fast and irregular heart rhythm called
atrial fibrillation. Oral medication was unable to control your
heart rate, so ___ underwent a cardioversion. The cardioversion
was a success and your heart rate returned to normal.
___ were started on a new medication called amiodarone. ___ will
take 400mg twice a day for one week (through ___, start
taking 200mg twice a day on ___ for one week, and start
taking 200mg once a day on ___. ___ will take 200mg once a
day until ___ are told by your cardiolgoist. ___ were also
started on rivaroxaban, which is a blood thinner. ___ should
take this every day with dinner.
___ should stop taking your sotalol and plavix.
Take your blood pressure every day. If the top number of your
blood pressure is less than 90, do not take your losartan.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Sincerely,
Your medical team at ___
Followup Instructions:
___
|
10459005-DS-23 | 10,459,005 | 20,810,174 | DS | 23 | 2141-08-08 00:00:00 | 2141-08-12 11:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Motrin / Iodine-Iodine Containing / Naprosyn / Lisinopril /
Flomax / spironolactone
Attending: ___
Chief Complaint:
Tachycardia, chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old gentleman with history of CAD s/p
CABG in ___ (SVG to PDA, SVG to OM and composite LIMA and SVG
to LAD with known total occlusion of all his venous grafts and
PCI to his
LCx-OM, RCA and most recently to his right PDA in ___,
chronic systolic heart failure (EF ___, HTN, HLD, Vtach s/p
ICD, afib on rivaroxaban presenting with chest pain, found to be
in ventricular tachycardia.
Patient was at his daughter's graduation, developed shortness of
breath and associated chest pain. When he returned home he had
an episode of emesis, subsequently called ___. On arrival EMS
found patient to be in wide complex tachycardia. Pressure was
90/palp. Patient received 2.5mg ativan for sedation,
cardioversion with 1 shock and 150mg amiodarone. Patient then
converted to sinus rhythm after shock with improvement in blood
pressures and resolution of chest pain. Patient then became
somnolent after ativan, arousable to sternal rub.
On arrival to the ___ ED patient denies any chest pain,
shortness of breath, abdominal pain.
In the ED, initial vitals were: 82 110/66 16 97% RA
-Exam notable for: No JVD, leg swelling
-EKG - sinus, normal axis, LBBB, no sgarbossa
- Labs were significant for H/H 10.6/34.0; INR 1.1, Cr 1.1, K
4.0, trop <0.01, proBNP 1118, Mg 2.2, lactate 1.6
- CXR showed mild interstitial pulmonary edema
- The patient was given 1L IVF
- EP was consulted, fellow recommended no amiodarone gtt as on
PO at home. Continue PO amiodarone, can consider lidocaine if
continued VT.
Patient was then admitted to ___ for further management.
Vitals prior to transfer were: 75 101/62 14 98% RA
Upon arrival to the floor patient is feeling well without
further chest pain, palpitations, shortness of breath. He
reports his regular weight is 215lbs.
Past Medical History:
PAST MEDICAL HISTORY:
1. Coronary artery disease status post CABG in ___ with SVG to
his PDA, SVG to his OM and composite LIMA and SVG to LAD with
known total occlusion of all his venous grafts and PCI to his
LCx-OM, RCA and most recently to his right PDA in ___.
2. Chronic systolic and diastolic heart failure with class II
___ Heart Association symptoms with a left ventricular
ejection fraction of ___ and inferior akinesis due to a prior
inferior MI.
3. Hypertension.
4. Hyperlipidemia.
5. Obstructive sleep apnea, on home CPAP.
6. History of syncope with inducible VT on EP study, status post
ICD with recent generator change in ___.
Social History:
___
Family History:
Brother also has a history of coronary artery disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.3 134/79 76 16 97% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP elevated at 9CM , no LAD
CV: Regular rate and rhythm, systolic murmur best appreciated at
apex no 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 , no cva tenderness
Ext: Warm, well perfused, 2+ pulses, chronic venous stasis
changes with hair loss lower legs, 1+ pitting edema to mid shins
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
DISCHARGE PHYSICAL EXAM:
VS: T=98.2 BP=103/71 HR=77 RR=16 O2 sat= 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP elevated at 9CM , no LAD
CV: Regular rate and rhythm, systolic murmur best appreciated at
apex no 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 , no cva tenderness
Ext: Warm, well perfused, 2+ pulses, chronic venous stasis
changes with hair loss lower legs, 1+ pitting edema to mid shins
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
Pertinent Results:
ADMISSION LABS:
___ 10:45PM WBC-4.9 RBC-3.82* HGB-10.6* HCT-34.0* MCV-89
MCH-27.7 MCHC-31.2* RDW-14.6 RDWSD-47.6*
___ 10:45PM ___ PTT-27.9 ___
___ 10:45PM GLUCOSE-157* UREA N-28* CREAT-1.1 SODIUM-139
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15
___ 10:45PM CALCIUM-9.0 PHOSPHATE-2.9 MAGNESIUM-2.2
___ 10:45PM cTropnT-<0.01 proBNP-1118*
___ 10:56PM BLOOD Lactate-1.6
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-5.2 RBC-3.78* Hgb-10.4* Hct-33.7*
MCV-89 MCH-27.5 MCHC-30.9* RDW-14.7 RDWSD-47.7* Plt ___
___ 06:25AM BLOOD Glucose-85 UreaN-32* Creat-1.4* Na-139
K-4.5 Cl-100 HCO3-29 AnGap-15
___ 08:55AM BLOOD ALT-36 AST-41* LD(LDH)-272* AlkPhos-74
TotBili-0.2
MICROIOLOGY: none
IMAGING/STUDIES:
Pacemaker Interrogation ___:
-1 episode of VT, monitored, at 21:17 lasting 1:06:33 with an
average ventricular rate of 167bpm.
-no device therapies (ATP/shock)
-time in AT/AF: 0.0%
-OptiVol fluid index is below threshold in ___
-functional activity 4hr/day
CXR ___: mild interstitial pulmonary edema.
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with history of CAD s/p
CABG in ___ (SVG to PDA, SVG to OM and composite LIMA and SVG
to LAD with known total occlusion of all his venous grafts and
PCI to his LCx-OM, RCA and most recently to his right PDA in
___, chronic systolic heart failure (EF ___, HTN,
HLD, Vtach s/p ICD, afib on rivaroxaban presenting with chest
pain, found to be in ventricular tachycardia.
#Ventricular Tachycardia: The patient has a known history of VT
with ICD in place. He came in with an episode of VT, likely
precipitated by volume overload from his CHF. His ICD did not
fire. He was cardioverted into sinus rhythm in the ER. The
patient's pacemaker was interrogated. It was found to be
functioning normally, recognized the VT event, but did not shock
as average VT rate was 167 BPM and threshold to shock was
188BPM. This occurred in the setting of starting amiodarone
___. It is likely that amiodarone reduced resting and VT
rates, so VT did not reach rate threshold to shock. The ICD's
settings were adjusted by EP and they lowered the rate threshold
to shock so future events should be treated. We continued the
patient's home amiodarone and he had no further episodes of VT
during this admission.
#Hyperkalemia: The patient's K was 4.0 initially, 5.7 morning of
___. He was given 10U insulin and amp of D50, with follow-up
K 4.8. We held his spironolactone and losartan. Gave Lasix for
CHF as below. We restarted losartan on discharge but continued
to hold the spironolactone. Patient was discharged with
instructions to have outpatient electrolytes drawn.
#Systolic Heart Failure with acute exacerbation: On admission,
the patient was up 3lbs from dry weight (215 lbs) with evidence
of volume overload on exam and CXR. This was likely the
precipitant of his VT. BNP 1118 on admission, was 1508 in ___. The patient was given aggressive IV diuresis with
improvement of his physical exam. He was discharged on his home
torsemide. We continued his home metoprolol throughout the
admission.
#HTN: chronic. We continued the patient's home losartan, beta
blocker, and isosorbide mononitrate.
#HLD: Chronic. We continued the patient's home rosuvastatin and
aspirin.
#Afib: Chronic. We continued the patient's home rivaroxaban and
metoprolol.
***Transitional Issues***
[ ] Pt was hyperkalemic to 5.7 during this admission, treated
with insulin and dextrose. Stopped home spironolactone and
continued losartan. Pt is also on torsemide 20 at home. Needs
outpatient electrolytes checked. Pt given script for bloodwork
on ___ and lab instructed to send to cardiologist.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Albuterol Inhaler 2 PUFF IH QID
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Ezetimibe 10 mg PO DAILY
6. Fluoxetine 40 mg PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. FoLIC Acid 1 mg PO DAILY
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Losartan Potassium 25 mg PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Ranitidine 300 mg PO QHS
13. Rosuvastatin Calcium 40 mg PO QPM
14. Spironolactone 25 mg PO DAILY
15. Torsemide 20 mg PO DAILY
16. Amiodarone 200 mg PO DAILY
17. Rivaroxaban 20 mg PO DINNER
18. ammonium lactate 12 % topical BID
19. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
20. Loratadine 10 mg PO DAILY:PRN allergies
21. Nitrolingual (nitroglycerin) 400 mcg/spray translingual
Q1H:PRN chest pain
22. TraMADOL (Ultram) 50-100 mg PO TID:PRN pain
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Albuterol Inhaler 2 PUFF IH QID
3. Amiodarone 200 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Ezetimibe 10 mg PO DAILY
8. Fluoxetine 40 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. FoLIC Acid 1 mg PO DAILY
11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
12. Loratadine 10 mg PO DAILY:PRN allergies
13. Losartan Potassium 25 mg PO DAILY
14. Metoprolol Succinate XL 25 mg PO DAILY
15. Ranitidine 300 mg PO QHS
16. Rivaroxaban 20 mg PO DINNER
17. Rosuvastatin Calcium 40 mg PO QPM
18. TraMADOL (Ultram) 50-100 mg PO TID:PRN pain
19. ammonium lactate 12 % topical BID
20. Nitrolingual (nitroglycerin) 400 mcg/spray translingual
Q1H:PRN chest pain
RX *nitroglycerin 400 mcg/spray 1 spray every 5 minutes as
needed for chest pain, may repeat twice ( 3 sprays) 1 spray
every 5 minutes PRN Disp #*1 Bottle Refills:*0
21. Torsemide 20 mg PO DAILY
22. Outpatient Lab Work
ICD-9 427.1 Ventricular Tachycardia.
Please draw Chem-10 and fax results to:
___, ___, ___
Phone: ___
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular tachycardia.
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 because you had an episode of
ventricular tachycardia that was not treateed by your internal
defibrillator. We treated the irregular heart rhythm with
medication. We checked the defibrillator and discovered that it
is functioning normally, but the settings were too high for it
to deliver a shock. We changed the settings of the defibrillator
so it will deliver a shock in case you have another episode of
ventricular tachycardia.
We would like you to follow up with Dr. ___ in clinic. An
appointment has been made for you and is listed below.
You had an episode of high potassium while you were here, which
we treated. We stopped your spironolactone because that
medication can cause high potassium. We made no other changes to
your medications. A complete list of medications is attached.
We would also like to to have bloodwork drawn on ___.
We are giving you a prescription for bloodwork.
On behalf of your cardiology team, take care and be well.
-___ medical team.
Followup Instructions:
___
|
10459005-DS-24 | 10,459,005 | 24,587,598 | DS | 24 | 2141-12-18 00:00:00 | 2141-12-21 20:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Motrin / Iodine-Iodine Containing / Naprosyn / Lisinopril /
Flomax / spironolactone
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male, with past history of ___
(EF<= 30%), atrial fibrillation on rivaroxaban, hypertension
presenting with increased dyspnea. Patient is being admitted to
the ___ service for management of suspected heart failure
exacerbation.
Patient reports that over the past 2 weeks, he has been having
increased dyspnea with exertion. Patient reports that he has had
increased shortness of breath and cannot walk more than ___
feet without having to stop to catch his breath. He also has
been having increased chest tightness but has not taken any prn
nitroglycerin. He denies any fevers, chills, sputum, additional
complaints. Patient reports a stable 2 pillow orthopnea but
positive PND. He also been having increased lower extremity
edema since ___, and since then, he has been having
increased dyspnea and lower extremity edema. Notes high sodium
diet with high soup intake. He has a history of hypothyroidism
with TSH 100 recently started on replacement. He was uptitrated
to a dose of synthroid of 75mcg daily but was only able to
tolerate 50mcg due to nausea.
Upon presentation to the ED, patient was ill appearing, with
short labored breathing. Patient did have pitting edema in lower
extremity edema, and increased dyspnea with chest pain.
Of note, patient was recently admitted on ___, and was
found to be in ventricular tachycardia. Patient at that time was
having increased dyspnea, and then found to be in wide complex
tachycardia, with SBPs 90 / palp, and underwent cardioversion
with 1 shock and 150 mg of amiodarone with conversion of rhythm.
At that time, thought to be ___ CHF exacerbation. Patient also
found to be hyperkalemic, systolic heart failure, hypertension,
atrial fibrillation and placed on rivaroxaban. At that time,
patient's weight was recorded to be 215 lbs. Patient was also
admitted in ___, and found to have increased dyspnea on
exertion, and endorsed left sided chest pressure with episodes
of dyspnea, and was found to be in atrial fibrillation with RVR.
ED COURSE
In the ED initial vitals were: 96.9 98 119/88 20 96% RA
EKG: 82, a-paced, Sgarbossa negative.
Labs/studies notable for: Sodium 141, Potassium 4.9, Chloride
103, Bicarb 21, BUN 59, Creatinine 2.4. Trop-T 0.02, proBNP
6510. WBC 6.3, Hgb 10.2, Hct 34.3, Platelet 265, With 68% PMN.
Urinalysis done with negative nitrite, protein 30, few bacteria,
WBC 8, negative ketone, negative glucose. Spec ___ 1015. Cast
Gr 67, Cast Hy 28.
Patient was given:
___ 10:31 IV Furosemide 40 mg
Upon transfer, patient's vitals were: 88 117/80 23 97% RA
On the floor, he reports significantly improved symptoms
following diuresis with IV Lasix. Breathing comfortably on room
air in full sentences.
Past Medical History:
PAST MEDICAL HISTORY:
1. Coronary artery disease status post CABG in ___ with SVG to
his PDA, SVG to his OM and composite LIMA and SVG to LAD with
known total occlusion of all his venous grafts and PCI to his
LCx-OM, RCA and most recently to his right PDA in ___.
2. Chronic systolic and diastolic heart failure with class II
___ Heart Association symptoms with a left ventricular
ejection fraction of ___ and inferior akinesis due to a prior
inferior MI.
3. Hypertension.
4. Hyperlipidemia.
5. Obstructive sleep apnea, on home CPAP.
6. History of syncope with inducible VT on EP study, status post
ICD with recent generator change in ___.
Social History:
___
Family History:
Brother also has a history of coronary artery disease
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 97.6 104/64 77 18 98% on RA
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
Appears comfortable.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM. No xanthelasma.
+sublingual jaundice.
NECK: Supple with JVP to earlobe seated upright.
CARDIAC: RRR, normal S1, S2. heart sounds distant. No
murmurs/rubs/gallops. No thrills, lifts.
LUNGS: crackles ___ up thorax, decreased breath sounds
bilaterally, no wheezes or rhonchi. normal work of breathing on
room air.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ edema to knees
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM
=======================
VS: 98.0, 107/70, 70, 18, 97% on RA
weight 98.9 kgs
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
Appears comfortable. Very pleasant and appreciative.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM. No xanthelasma.
+sublingual jaundice. diffuse hair loss with no particular patch
of alopecia. eyebrows normal. thyroid normal and size,
nontender, no appreciable nodules.
NECK: Supple with JVP 10cm seated upright.
CARDIAC: RRR, normal S1, S2. heart sounds distant. No
murmurs/rubs/gallops. No thrills, lifts.
LUNGS: trace BB crackles, decreased breath sounds bilaterally,
no wheezes or rhonchi. normal work of breathing on 1L NC.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: trace edema to mid shins
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS
==============
___ 08:10AM BLOOD WBC-6.3 RBC-3.80* Hgb-10.2* Hct-34.3*
MCV-90 MCH-26.8 MCHC-29.7* RDW-15.6* RDWSD-50.4* Plt ___
___ 08:10AM BLOOD Neuts-68.7 Lymphs-16.7* Monos-10.2
Eos-3.3 Baso-0.8 Im ___ AbsNeut-4.31 AbsLymp-1.05*
AbsMono-0.64 AbsEos-0.21 AbsBaso-0.05
___ 07:00PM BLOOD ___ PTT-39.8* ___
___ 08:10AM BLOOD Glucose-80 UreaN-59* Creat-2.4* Na-141
K-4.9 Cl-103 HCO3-21* AnGap-22*
___ 07:00PM BLOOD ALT-81* AST-67* LD(LDH)-370* AlkPhos-170*
TotBili-0.5
___ 08:10AM BLOOD cTropnT-0.02* proBNP-6510*
___ 07:00PM BLOOD CK-MB-7 cTropnT-0.02*
___ 06:45AM BLOOD CK-MB-5 cTropnT-0.02*
___ 07:00PM BLOOD Calcium-9.5 Phos-3.4 Mg-2.1
___ 07:05PM BLOOD Lactate-1.2
NOTABLE LABS
==============
___ 07:30AM BLOOD Cortsol-19.0
___ 07:00PM BLOOD Free T4-0.43*
___ 07:00PM BLOOD TSH-104*
___ 07:10AM BLOOD Free T4-1.2
___ 06:50AM BLOOD T4-3.4*
DISCHARGE LABS
==============
___ 07:10AM BLOOD WBC-4.7 RBC-3.60* Hgb-9.7* Hct-32.1*
MCV-89 MCH-26.9 MCHC-30.2* RDW-15.4 RDWSD-49.1* Plt ___
___ 07:10AM BLOOD Glucose-81 UreaN-33* Creat-1.6* Na-138
K-4.7 Cl-99 HCO3-33* AnGap-11
___ 07:10AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.8*
___ 07:10AM BLOOD ALT-52* AST-47* LD(LDH)-299* AlkPhos-116
TotBili-0.4
IMAGING/STUDIES
==============
___ EKG
Sinus rhythm. Intraventricular conduction delay of left
bundle-branch block type. Compared to the previous tracing of
___ the ventricular rate is faster.
___ Chest Xray
FINDINGS: Mild prominence of the central pulmonary vasculature
suggests a underlying mild pulmonary vascular congestion. No
overt pulmonary edema is identified. There is no, pneumothorax,
or consolidation. Trace right pleural effusion. Severe
cardiomegaly is unchanged. The patient is status post median
sternotomy and CABG. A left-sided pectoral pacemaker is
unchanged in position.
IMPRESSION: Stable, severe cardiomegaly and mild central
pulmonary vascular congestion. Trace right pleural effusion.
Brief Hospital Course:
Mr. ___ is a ___ year old male with past history atrial
fibrillation with RVR, Ventricular tachycardia with ICD
placement, and CHF (EF < 30%), presenting with increased dyspnea
and lower extremity edema admitted for acute systolic CHF
exacerbation.
# Acute decompensated congestive heart failure: EF<30%. Patient
presented with elevated BNP (6510), ___ edema, dyspnea with
baseline BNP 1000-1500. Patient previously with arrhythmias
precipitating heart failure exacerbation, however ___ ICD
evaluation without significant burden of changes, similar on
interrogation by EP on ___. He also admitted to indulging in a
high sodium diet was found to be severely hypothyroid with TSH
on 105 on admission. He was diuresed daily with IV lasix 40 mg
twice daily for ___ net negative goal and then transitioned to
20mg torsemide daily. Thyroid replacement detailed below.
Continued on metoprolol XL 25 mg daily along with aspirin and
rosuvastain. Transaminitis and ___ both improved with diuresis
suggesting likely congestion. Significantly improved
symptomatically after volume removal. Held losartan for ___ and
soft SBPs in 90-100s, but otherwise blood pressures
well-controlled during admission with no signs of inadequate
afterload reduction. Discharge weight 98.9kg
# Hypothyroidism: started on amiodarone for atrial fibrillation
in ___ with subsequent rise of TSH to 105. Started on thyroid
replacement as an outpatient with gradual uptitration but was
unable to tolerated full scheduled dose of 75mcg and has been
taking 50mcg at home. TSH 100s on this admission which was a
likely contributor to his overall clinical heart failure
picture. Endocrine consulted and attributed to iodine myxedema
given rapidity of onset after started amiodarone. Per Endocrine
recommendations, he was started on IV and then oral replacement
of thyroxine at weight based dosing. After discussion with
Endocrine team, it was deemed appropriate to restart amiodarone
upon discharge as the patient will be continued on Synthroid
___ daily for thyroid replacement.
# Atrial Fibrillation: Patient's CHADS2Vasc=5 (age, sex, CHF,
HTN, vascular disease). In sinus rhythm on admission EKG.
Initially held amiodarone due to concern for toxicity but after
discussing with Endocrine, he was restarted. Reduced dose of
rivaroxaban for CrCl on admission to 15mg but when creatinine
improved, it was put back at his home dose of 20mg.
# Ventricular Tachycardia: Of note, on the day prior to
discharge, the patient had an episode of ventricular tachycardia
lasting 10 minutes which was terminated by AVP pacing. His ICD
did not fire and the patient mentated well throughout the event.
EP adjusted his device to increase the sensitivity to these
events and the patient will ___ in ___ clinic for further
management. He was continued on metoprolol and amiodarone.
# ___ on CKD: presented with ___ with creatinine of 2.4, with
baseline of 1.2-1.4. Suspect cardiorenal given improvement with
diuresis. Losartan held and creatinine trended with continually
improvement with diuresis.
# Normocytic Anemia: baseline hemoglobin ___, on presentation in
___. Previous anemia work-ups showed iron-deficiency but also
likely component of anemia of chronic disease from thyroid
disease. No signs of external loss. Trended CBC during admission
without significant findings. Added finding to transitional
issues for PCP ___.
# Coronary Artery Disease s/p CABG: continued metoprolol XL
25mg, rosuvastatin, imdur and Nitrolingual (nitroglycerin). No
chest pain while admitted.
# Hyperlipidemia: continued rosuvastatin and ezetimibe.
# Depression: continued ___ Fluoxetine 40 mg PO DAILY
# Sleep Apnea: continued home CPAP while admitted
# Fibromyalgia: continued tramadol 50 mg q8 hours as needed
with a bowel regimen
# Dermatitis: continued ammonium lactate 12 % topical BID
# Allergies: continued home Albuterol Inhaler and Loratadine .
Stopped Fluticasone Propionate nasal spray due to epistaxis
# GERD: continued home ranitidine 300 mg qhs
TRANSITIONAL ISSUES
==================
# Acute decompensated congestive heart failure:
[ ] f/u weight and blood pressure control
[ ] Held losartan in setting of soft BPs, consider restarting as
out-pt
[ ] f/u electrolytes in ___ days
[ ] f/u LFTs in ___ days
# Severe hypothyroidism:
[ ] started on 150mcg of levothyroxine
[ ] Endocrine ___
[ ] f/u TSH/free T4 within ___ weeks of discharge.
# Atrial fibrillation
[ ] f/u rate control, per endocrine, okay to restart amiodarone
as patient will be on Synthroid for amiodarone-induced
thyrotoxicity
[ ] PFTs while on amiodarone
# ___ on CKD: secondary to cardiorenal syndrome, improving with
diuresis but not at baseline
[ ] f/u creatinine and electrolytes at next visit
# Anemia:
[ ] ensure up-to-date on colonoscopy
[ ] f/u CBC
Discharge hemoglobin: 9.7
Discharge weight: 98.9kg
Discharge Cr: 1.6
Code: Full
Contact: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Albuterol Inhaler 2 PUFF IH QID
3. Amiodarone 200 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Ezetimibe 10 mg PO DAILY
8. Fluoxetine 40 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. FoLIC Acid 1 mg PO DAILY
11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
12. Loratadine 10 mg PO DAILY:PRN allergies
13. Losartan Potassium 25 mg PO DAILY
14. Metoprolol Succinate XL 25 mg PO DAILY
15. Ranitidine 300 mg PO QHS
16. Rivaroxaban 20 mg PO DINNER
17. Rosuvastatin Calcium 40 mg PO QPM
18. TraMADOL (Ultram) 50-100 mg PO TID:PRN pain
19. ammonium lactate 12 % topical BID
20. Nitrolingual (nitroglycerin) 400 mcg/spray translingual
Q1H:PRN chest pain
21. Torsemide 20 mg PO DAILY
22. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Albuterol Inhaler 2 PUFF IH QID
3. ammonium lactate 12 % topical BID
4. Aspirin 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
6. Ezetimibe 10 mg PO DAILY
7. Fluoxetine 40 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Loratadine 10 mg PO DAILY:PRN allergies
11. Ranitidine 300 mg PO QHS
12. Rivaroxaban 20 mg PO DINNER
13. Rosuvastatin Calcium 40 mg PO QPM
14. TraMADOL (Ultram) 50-100 mg PO TID:PRN pain
15. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
16. Fluticasone Propionate NASAL 1 SPRY NU BID
17. Metoprolol Succinate XL 25 mg PO DAILY
18. Nitrolingual (nitroglycerin) 400 mcg/spray translingual
Q1H:PRN chest pain
19. Torsemide 20 mg PO DAILY
20. Levothyroxine Sodium 150 mcg PO DAILY
RX *levothyroxine 150 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
21. Amiodarone 200 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Acute decompensated systolic congestive heart failure
Hypothyroidism
Ventricular tachycardia
Acute kidney injury on chronic kidney disease
Hypertension
Secondary Diagnoses:
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Mr. ___,
You were admitted to ___ for evaluation of your shortness of
breath. We determined that you were having an exacerbation of
your heart failure. You were given diuretics to help you pee out
the extra water that you had on your body. We also noticed that
your thyroid gland was not producing any natural hormone. Our
Endocrine specialists were consulted and helped determine the
correct replacement method.
Please continue to take all your medications as prescribed,
adhere to a low salt diet and attend your ___
appointments.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
It was a pleasure taking care of you during your stay- we wish
you all the best!
- Your ___ Cardiology Tean
Followup Instructions:
___
|
10459005-DS-25 | 10,459,005 | 20,351,055 | DS | 25 | 2142-01-01 00:00:00 | 2142-01-02 19:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Motrin / Iodine-Iodine Containing / Naprosyn / Lisinopril /
Flomax / spironolactone
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ - VT ablation
History of Present Illness:
Mr. ___ is a ___ year old male, with past history of sCHF
(LVEF= ___ % in ___, atrial fibrillation on rivaroxaban,
hypertension, s/p ICD presented with chest pain. Patient
complained of substernal pressure for 3 hours, denies SOB,
reported some neck pain. Per EMS report, he was pale with a BP
of 92/60, with a 12 lead EKG at the time showing sinus rhythm at
76 with a left bundle branch block.
Of note, patient was recently hospitalized ___ for acute
decompensated heart failure. At that time, patient presented
with dyspnea, signs of volume overload including BNP>6500.
Trigger felt to be due to dietary indiscretion with contribution
for acutely worsened hypothyroidism. He was diuresed daily with
IV lasix 40 mg twice daily for ___ net negative goal and then
transitioned to 20mg torsemide daily. Discharged at 98.9 kg.
Also discharged on 150 mcg levothyroxine up from 75 mcg.
In the ED:
Got EKG showing monomorphic VT around 120-130 bpm, BP soft to
systolics in ___.
Labs notable for Na 131, BUN 66/creatinine 2, Trop T 0.02, ALT
140, AST 141, ProBNP 7630, no leukocytosis, INR 2.4, Lactate 2.0
Cardiology and EP consulted.
Patient was given 325 mg ASA once, given IV Amiodarone 300 mg x1
Cardiology attempted to restore sinus with rhythm with ATP,
eventually successfully restoring sinus rhythm in HR=70s with
LBBB after ___ attempt of ATP.
Decision was made to admit to the CCU. Upon arrival to the CCU
patient was still in sinus rhythm with much improved BP in
100s/70s-80s. He was comfortable and with no acute complaints,
stated he was feeling much better.
Past Medical History:
PAST MEDICAL HISTORY:
1. Coronary artery disease status post CABG in ___ with SVG to
his PDA, SVG to his OM and composite LIMA and SVG to LAD with
known total occlusion of all his venous grafts and PCI to his
LCx-OM, RCA and most recently to his right PDA in ___.
2. Chronic systolic and diastolic heart failure with class II
___ Heart Association symptoms with a left ventricular
ejection fraction of ___ and inferior akinesis due to a prior
inferior MI.
3. Hypertension.
4. Hyperlipidemia.
5. Obstructive sleep apnea, on home CPAP.
6. History of syncope with inducible VT on EP study, status post
ICD with recent generator change in ___.
Social History:
___
Family History:
Brother also has a history of coronary artery disease
Physical Exam:
ADMISSION EXAM:
===============
VS: Tm/Tc 97.6 | BP 88/61-107/80 | HR ___ | RR ___ | O2 98%
RA
Discharge weight: 98.9 kgs
Admission weight: 100.2 kg
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Pleasantly
interactive.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM. No xanthelasma.
Diffuse hair loss with no particular patch of alopecia.
NECK: Supple with no appreciable JVP at 30 degrees.
CARDIAC: RRR, normal S1, S2. heart sounds distant. No
murmurs/rubs/gallops. No thrills, lifts.
LUNGS: Trace basilar crackles. Decreased breath sounds
bilaterally,
no wheezes or rhonchi. Normal work of breathing on 1L NC.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace edema to mid shins.
PULSES: Distal pulses palpable and symmetric
DISCHARGE EXAM:
===============
VS: 98.4 90-120/60-70's 95%RA
General: In no acute distress
Heart: RRR
Lung: Minimally decreased air entry in bases, no crackles
Extremities: +1 pitting edema
Pertinent Results:
ADMIT LABS
==========
___ 07:40PM BLOOD WBC-5.9 RBC-3.62* Hgb-10.0* Hct-31.8*
MCV-88 MCH-27.6 MCHC-31.4* RDW-15.5 RDWSD-49.4* Plt ___
___ 07:40PM BLOOD Neuts-64.7 ___ Monos-11.4 Eos-2.0
Baso-0.7 Im ___ AbsNeut-3.84 AbsLymp-1.25 AbsMono-0.68
AbsEos-0.12 AbsBaso-0.04
___ 07:40PM BLOOD ___ PTT-38.3* ___
___ 07:40PM BLOOD Glucose-126* UreaN-66* Creat-2.0* Na-131*
K-5.1 Cl-95* HCO3-26 AnGap-15
___ 07:40PM BLOOD ALT-140* AST-141* AlkPhos-141*
TotBili-0.5
___ 07:40PM BLOOD Lipase-50
___ 07:40PM BLOOD proBNP-7630*
___ 07:40PM BLOOD cTropnT-0.02*
___ 07:40PM BLOOD Albumin-4.2 Mg-2.5
___ 07:48PM BLOOD Lactate-2.0
DISCHARGE LABS
==============
___ 06:00AM BLOOD WBC-5.3 RBC-3.12* Hgb-8.3* Hct-27.8*
MCV-89 MCH-26.6 MCHC-29.9* RDW-15.8* RDWSD-50.4* Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD ___ PTT-33.3 ___
___ 06:00AM BLOOD Glucose-88 UreaN-50* Creat-1.5* Na-139
K-3.9 Cl-95* HCO3-35* AnGap-13
___ 06:00AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.3
PERTINENT TESTS
===============
___ CHEST X-RAY:
Right the atrial lead appears to have moved in position as
compared to the
prior study, now pointing more to the right, and setting
superiorly.
Persistent marked enlargement of the cardiac silhouette.
Moderate central pulmonary vascular congestion.
___ CXR:
In comparison with the study of ___, there are improved
lung volumes. Again there is huge enlargement of the cardiac
silhouette in a patient with intact midline sternal wires.
There is minimal vascular congestion, producing a discordance
that raises the possibility of cardiomyopathy or possibly even
pericardial effusion. Blunting of the right costophrenic angle
suggests small pleural effusion. Dual-channel pacer remains in
place. The tip of the right atrial lead has been change since
the previous study.
___ ECG:
Atrially paced rhythm. Extensive intraventricular conduction
delay of the left bundle-branch block type. Possible extensive
myocardial infarction in the anterior territory. Compared to
tracing #1 atrially paced rhyhtm has replaced ventricular
tachycardia.
___ ECG:
Likely ventricular tachycardia. Morphology of ventricular
tachycardia suggests left ventricular epicardial origin.
Compared to the previous tracing of ___ the rate of
ventricular tachycardia is slightly slower.
___ ECG:
Regular atrial pacing with native ventricular conduction. Left
bundle-branch block. Compared to the previous tracing of
___ there is no significant change.
Brief Hospital Course:
___ male with history of CAD s/p CABG, chronic systolic heart
failure, recurrent ventricular tachycardia with ICD in place,
a-fib on rivaroxaban presented with several hours of chest
discomfort and feeling off of his baseline, found to be
hypotensive and in monomorphic VT in the ED, which was converted
to sinus via ATP, s/p VT ablation on ___.
# CORONARIES: s/p CABG SVG to PDA, SVG to OM and composite LIMA
and SVG to LAD with known total occlusion of all his venous
grafts and PCI to his LCx-OM, RCA and most recently to his right
PDA in ___.
# PUMP: ___ as of ___
# RHYTHM: A-paced V-sensed, HR=70-80, LBBB
# Ventricular Tachycardia: Patient was found to have monomorphic
VT with Right Bundle Branch morphology and ___ axis noted
in ED. He got 300mg amiodarone x1 in ED and converted after four
attempts of ATP. Etiology is not certain but he has signs of
volume overload on exam so most likely trigger is acute
decompensated heart failure. He has had multiple episodes of VT
in past, noted as recently as his last hospitalization. He had
ICD in place but not firing due to relative slow rate of his VT,
120s-130s. During last hospitalization, EP adjusted his device
to increase the sensitivity to these events and he was continued
on metoprolol and amiodarone. He is s/p EP ablation on ___.
His final medical regimen includes Amiodarone 200 mg PO/NG and
metoprolol succinate 25 XL.
# ACUTE DECOMPENSATED HEART FAILURE ___ as of last TTE
in ___: Patient was recently hospitalized with decompensated
heart failure and had signs of volume overload during this
admission (elevated JVP, crackles on lungs, trace pitting
edema). He was electively intubated at beginning of EP ablation,
however PEEP was higher than anticipated which was attributed to
volume overload. Volume overload improved with diuresis with
furosemide 80 mg IV on top of home torsemide. He was discharged
on home Torsemide 20 mg daily.
#Urinary retention: Patient was found to have urinary retention
on ___ requiring multiple straight cath. We started tamsulosin
on ___ and his symptoms improved.
# ___ on CKD: He presented with ___ with creatinine of 2.0, with
baseline of 1.2-1.4. The ___ is likely cardiorenal given signs
of volume overload. ___ improved considerably with diuresis.
# Transaminitis: LFTs were found to be elevated above baseline
at admission. This is likely due to volume overload causing
hepatic congestion. This was present on prior admission and
resolved with diuresis. Of note, INR newly elevated to 2.0-2.4
in the past 4 months.
===============
CHRONIC ISSUES:
===============
# Hypothyroidism: He was started on amiodarone for atrial
fibrillation in ___ with subsequent rise of TSH to 105.
TSH=100s on previous admission, which was felt to be a likely
contributor to his overall clinical heart failure
decompensation. Endocrine consulted and attributed to iodine
myxedema given rapidity of onset after started amiodarone. Per
Endocrine recommendations, he was started on IV and then oral
replacement of thyroxine at weight based dosing. He has
continued on his discharge dose of 150 mcg daily.
# Atrial Fibrillation: Patient's CHADS2Vasc=5 (age, sex, CHF,
HTN, vascular disease). Not in fib on most recent EKG or
telemetry in unit. Has been on rivaroxaban home dose of 20mg
daily, but we held it on admission given ___ and elevated INR.
Rivaroxaban was restarted on ___.
# Coronary Artery Disease s/p CABG: No chest pain since coming
to unit.
- Continued Rosuvastatin 40 mg PO QPM
- Held ezetimibe
# Hyperlipidemia:
- Continued rosuvastatin
- Held ezetimibe
# Depression: we continued home Fluoxetine 40 mg PO DAILY
# Sleep Apnea: we continued home CPAP while admitted
# Fibromyalgia: We held tramadol 50 mg q8 hours as needed
# Dermatitis: We held ammonium lactate 12 % topical BID
# Allergies: We held home Albuterol Inhaler, Loratadine, and
Fluticasone Propionate nasal spray
# GERD: Continued home ranitidine 300 mg qhs
***TRANSITIONAL ISSUES:***
- Please monitor for recurrent urinary retention. Evaluate for
BPH as a contributor.
- Given normotension, home isosorbide mononitrate was held at
discharge.
- Patient will follow-up with EP after discharge.
- Full Code
- Contact: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Albuterol Inhaler 2 PUFF IH QID
3. ammonium lactate 12 % topical BID
4. Aspirin 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Ezetimibe 10 mg PO DAILY
7. Fluoxetine 40 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Loratadine 10 mg PO DAILY:PRN allergies
11. Ranitidine 300 mg PO QHS
12. Rivaroxaban 20 mg PO DINNER
13. Rosuvastatin Calcium 40 mg PO QPM
14. TraMADOL (Ultram) 50-100 mg PO TID:PRN pain
15. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
16. Fluticasone Propionate NASAL 1 SPRY NU BID
17. Metoprolol Succinate XL 25 mg PO DAILY
18. Nitrolingual (nitroglycerin) 400 mcg/spray translingual
Q1H:PRN chest pain
19. Torsemide 20 mg PO DAILY
20. Levothyroxine Sodium 150 mcg PO DAILY
21. Amiodarone 200 mg PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Fluoxetine 40 mg PO DAILY
5. Levothyroxine Sodium 150 mcg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Rivaroxaban 20 mg PO DINNER
8. Rosuvastatin Calcium 40 mg PO QPM
9. Torsemide 20 mg PO DAILY
10. Ezetimibe 10 mg PO DAILY
11. Acetaminophen 1000 mg PO Q8H:PRN pain
12. Albuterol Inhaler 2 PUFF IH QID
13. ammonium lactate 12 % topical BID
14. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
15. Fluticasone Propionate NASAL 1 SPRY NU BID
16. FoLIC Acid 1 mg PO DAILY
17. Loratadine 10 mg PO DAILY:PRN allergies
18. Nitrolingual (nitroglycerin) 400 mcg/spray translingual
Q1H:PRN chest pain
19. Ranitidine 300 mg PO QHS
20. TraMADOL (Ultram) 50-100 mg PO TID:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Ventricular Tachycardia
Secondary:
Systolic heart failure, acute on chronic, decompensated
Atrial fibrillation
Acute urinary retention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted because of chest pain and an abnormal heart
rhythm called ventricular tachycardia. You underwent a procedure
called a VT ablation during which the electrophysiology team
found the site in your heart causing this abnormal rhythm and
ablated it. You were stable thereafter. You also developed
urinary retention after this procedure, likely related to
anesthesia, but possibly because of an enlarged prostate. After
24 hours you were able to urinate on your own. Please follow-up
with your primary care physician regarding the need to assess
for an enlarged prostate.
You also have follow-up with the electrophysiology doctors.
___ weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10459005-DS-26 | 10,459,005 | 20,144,923 | DS | 26 | 2142-01-17 00:00:00 | 2142-01-23 14:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Motrin / Iodine-Iodine Containing / Naprosyn / Lisinopril /
Flomax / spironolactone
Attending: ___
Chief Complaint:
Chest Pain/Dyspnea/Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man with history of CAD, CHF, VT s/p ablation on
___, and atrial fibrillation, who is referred to the ED
from ___'s office with chest pain and shortness of breath. The
pain is left flank and substernal, and radiates to the left
forearm. It is worse with coughing. It is a dull pain, not
pleuritic, and somewhat reproducible with palpation. He's had
the cough since his EP ablation, and it is dry/non-productive.
He also has dyspnea on exertion which has worsened over the last
5 days to the point that he becomes short of breath walking
across the room. His orthopnea is at baseline. No fevers/chills,
no N/V, no diarrhea. No sick contacts. Of note, he weights
himself daily and since his discharge his weight has been stable
at 214 lbs.
In the ED:
- initial vitals were 97, HR 82, BP 117/72, RR 18, 100% on RA.
- labs were notable for: H/H 9.0/28.9, alk phos 135, ___
10626, BUN/Cr 46/2.2 (baseline creatinine 1.5-1.7), troponin x 2
negative.
- physical exam was notable for mild dullness at bases of lungs,
1+ pitting edema to knees.
- CXR was performed which showed possible trace right pleural
effusion. Persistent cardiomegaly. No pulmonary edema.
- EKG: LBBB, no ST changes, similar to prior
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Past Medical History:
1. Coronary artery disease: status post CABG in ___ with SVG to
his PDA, SVG to his OM and composite LIMA and SVG to LAD with
known total occlusion of all his venous grafts and PCI to his
LCx-OM, RCA and most recently to his right PDA in ___.
2. Chronic systolic and diastolic heart failure with class II
___ Heart Association symptoms with a left ventricular
ejection fraction of ___ and inferior akinesis due to a prior
inferior MI.
3. Hypertension.
4. Hyperlipidemia.
5. Obstructive sleep apnea, on home CPAP.
6. History of syncope with inducible VT on EP study, status post
ICD with recent generator change in ___.
Social History:
___
Family History:
Brother also has a history of coronary artery disease
Physical Exam:
ADMISSION EXAM:
===============
Vitals: 98.4 97/68 80 20 93% RA
Wt: 97.4 kg
General: Sitting up in bed, NAD, chatty
HEENT: atraumatic
Neck: supple, no JVP
CV: RRR, no murmurs
Lungs: CTAB- no wheezes, no crackles
Abdomen: soft, non-distended, + BS. Tender to palpation below
ribcage on left side. No rebound, no guarding.
Extr: WWP, 1+ edema to mid-shin
Neuro: symmetrical facial features, clear speech, normal gait
Skin: no rashes
DISCHARGE EXAM:
===============
Vitals: AF, 109/61, 74, 20, 98% on RA
Wt: 97.4 kg -> 97 kg->97.5 kg
I/O: 96/600; ___
General: Sitting up in bed, NAD, chatty
HEENT: atraumatic
Neck: supple, JVD to clavicle at 90 degrees. JVP 10 cm.
CV: RRR, no murmurs
Lungs: crackles at lower left base. otherwise CTA.
Abdomen: soft, non-distended, + BS. Tender to palpation below
ribcage on left side. No rebound, no guarding.
Extr: WWP, trace to 1+ edema to mid-shin
Neuro: symmetrical facial features, clear speech, normal gait
Skin: no rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 08:15PM cTropnT-0.01
___ 02:15PM GLUCOSE-99 UREA N-46* CREAT-2.2* SODIUM-141
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-27 ANION GAP-17
___ 02:15PM estGFR-Using this
___ 02:15PM ALT(SGPT)-32 AST(SGOT)-33 ALK PHOS-135* TOT
BILI-0.5
___ 02:15PM cTropnT-0.01
___ 02:15PM ___
___ 02:15PM ALBUMIN-3.8
___ 02:15PM URINE HOURS-RANDOM
___ 02:15PM URINE UHOLD-HOLD
___ 02:15PM WBC-6.2 RBC-3.38* HGB-9.0* HCT-28.9* MCV-86
MCH-26.6 MCHC-31.1* RDW-15.1 RDWSD-46.8*
___ 02:15PM NEUTS-71.4* LYMPHS-12.7* MONOS-12.2 EOS-2.8
BASOS-0.7 IM ___ AbsNeut-4.40 AbsLymp-0.78* AbsMono-0.75
AbsEos-0.17 AbsBaso-0.04
___ 02:15PM PLT COUNT-271
___ 02:15PM ___ PTT-39.8* ___
___ 02:15PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:15PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 02:15PM URINE RBC-2 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-<1 TRANS EPI-<1
___ 02:15PM URINE HYALINE-7*
___ 02:15PM URINE MUCOUS-RARE
DISCHARGE LABS:
===============
___ 10:00AM BLOOD WBC-6.4 RBC-3.37* Hgb-8.9* Hct-29.0*
MCV-86 MCH-26.4 MCHC-30.7* RDW-14.9 RDWSD-46.5* Plt ___
___ 10:00AM BLOOD ___ PTT-35.1 ___
___ 10:00AM BLOOD Glucose-95 UreaN-44* Creat-1.4* Na-137
K-4.4 Cl-99 HCO3-30 AnGap-12
___ 10:00AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.3
IMAGING/STUDIES:
================
+ CHEST X-RAY ___:
IMPRESSION:
Possible trace right pleural effusion. Persistent cardiomegaly.
No pulmonary edema.
+ ECG: a-paced, left bundle-branch block, no ST changes, similar
to prior EKGs
TTE ___: The left atrium is moderately dilated. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is at
least 15 mmHg. The left ventricular cavity is severely dilated.
There is severe regional left ventricular systolic dysfunction
with akinesis of the inferolateral segments and hypokinesis of
all remaining walls. The right ventricular cavity is mildly
dilated with moderate global free wall hypokinesis. The
diameters of aorta at the sinus, ascending and arch levels are
normal. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet. The
mitral valve leaflets are mildly thickened. Severe (4+) mitral
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Dilated left ventricle with severely depressed
systolic function. Dilated, depressed right ventricular systolic
function. Severe mitral regurgitation. Severe pulmonary artery
systolic hypertension. EF 20%.
Brief Hospital Course:
___ man with CAD s/p CABG, chronic systolic heart
failure, recurrent ventricular tachycardia with ICD in place and
recent ablation, and a-fib on rivaroxaban, admitted with
left-sided chest pain, cough, and SOB. Chest pain occurred only
with cough and was unrelated to exertion.
# CORONARIES: s/p CABG SVG to PDA, SVG to OM and composite LIMA
and SVG to LAD with known total occlusion of all his venous
grafts and PCI to his LCx-OM, RCA and most recently to his right
PDA in ___.
# PUMP: ___ as of ___
# RHYTHM: A-paced V-sensed, HR=70-80, LBBB
# SOB/systolic CHF exacerbation: Patient presented with SOB and
non-productive cough. Felt to be due to CHF exacerbation, as
patient had elevated JVP, though he did not have crackles on
lung exam or increase in weight from prior discharge. EKG was
unchanged and trop was negative x 2. Patient was diuresed with
80 mg IV Lasix BID and then transitioned to 40 mg PO torsemide.
TTE showed LVEF 20%. Inpatient stress test could not be obtained
due to the long week-end and recommendations were made to
undergo nuclear stress test as outpatient to rule out ischemia
as the trigger of CHF.
He was also started on 10 mg Isordil and 10 mg Hydralazine TID
for afterload reduction. He was sent home with 30 mg Imdur daily
and Hydralazine was held at discharge due to soft blood
pressures (SBPs ___, asymptomatic).
# ___ on CKD: 2.2, baseline 1.7-1.9: likely
pre-renal/overdiuresis as it improved to 1.4 with diuresis prior
to discharge.
# Coronary Artery Disease s/p CABG: chest discomfort not
consistent with ACS, EKG was unchanged, trop negative x2.
Ezetimide was held.
# hypothyroidism: amiodarone-induced
- continued home Levothyroxine 150 mcg daily
# Atrial Fibrillation: CHADS2Vasc = 5 (age, sex, CHF,
HTN, vascular disease).
- continued home rivaroxaban 15 mg daily
# Depression:
- continued home Fluoxetine 40 mg PO DAILY
# Sleep apnea:
- continued home CPAP while admitted
# Fibromyalgia:
- continued home tramadol 50 mg q8 hours as needed
# GERD:
- continued home ranitidine 300 mg qhs
TRANSITIONAL ISSUES:
-- Patient started on 40 mg PO torsemide daily. Follow up
weights and adjust torsemide as needed.
-- Patient started on Imdur 30 mg. Held hydralazine 10 mg TID
due to soft BPs at discharge (SBPs 80-90s, asymptomatic). Please
monitor BPs as outpatient and adjust meds for afterload
reduction as needed.
-- Patient will need ischemic evaluation (nuclear stress test)
as outpatient. New heart failure exacerbation could be due to
change in ischemic disease.
Full Code
Weight on Discharge: 94.9 kg
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Levothyroxine Sodium 150 mcg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
4. Amiodarone 200 mg PO DAILY
5. ammonium lactate 5 % topical PRN
6. Betamethasone Dipro 0.05% Oint 1 Appl TP BID:PRN itchiness
7. diclofenac sodium 1 % topical TID:PRN knee pain
8. Ezetimibe 10 mg PO DAILY
9. Fluoxetine 40 mg PO DAILY
10. Fluticasone Propionate NASAL 2 SPRY NU BID
11. FoLIC Acid 1 mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Ranitidine 300 mg PO QHS
15. Rivaroxaban 20 mg PO DAILY
16. Rosuvastatin Calcium 40 mg PO QPM
17. Torsemide 20 mg PO DAILY
18. TraMADOL (Ultram) 50 mg PO TID:PRN pain
19. Docusate Sodium 100 mg PO BID:PRN constipation
20. Loratadine 10 mg PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Fluoxetine 40 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU BID
6. FoLIC Acid 1 mg PO DAILY
7. Levothyroxine Sodium 150 mcg PO DAILY
8. Loratadine 10 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Ranitidine 300 mg PO QHS
11. Rosuvastatin Calcium 40 mg PO QPM
12. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
13. TraMADOL (Ultram) 50 mg PO TID:PRN pain
14. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
15. ammonium lactate 5 % topical PRN
16. Betamethasone Dipro 0.05% Oint 1 Appl TP BID:PRN itchiness
17. diclofenac sodium 1 % TOPICAL TID:PRN knee pain
18. Ezetimibe 10 mg PO DAILY
19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
20. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Hold this medication if your blood pressure is less than 90/60.
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
21. Rivaroxaban 15 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Acute on chronic systolic heart failure
Coronary artery disease s/p coronary artery bypass graft surgery
Chest pain, pleuritic - most likely due to VT ablation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ due to concern that you had fluid
overload in your body. The extra fluid was removed with IV
Lasix. We then transitioned you to oral medication called
Torsemide. You were also started on some medications to help
lower your blood pressure and make it easier for your heart to
pump blood to your body. You will need to take 1 of these
medications when you leave the hospital. This new medication is
called Imdur (isosorbide mononitrate).
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. If you feel lightheaded, please have the ___ check
your blood pressure and call your doctor if your blood pressure
is too low.
It has been a pleasure taking care of you.
Sincerely,
Your ___ Cardiology Team
Followup Instructions:
___
|
10459005-DS-27 | 10,459,005 | 25,329,648 | DS | 27 | 2142-02-06 00:00:00 | 2142-02-08 10:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Motrin / Iodine-Iodine Containing / Naprosyn / Lisinopril /
Flomax / spironolactone
Attending: ___.
Chief Complaint:
Dyspnea, orthopnea
Major Surgical or Invasive Procedure:
Right heart catheterization
History of Present Illness:
___ y/o male with past medical history of systolic CHF (ECHO
___ EF 20% with global hypokinesis), CAD, VT (s/p ablation
on ___, and atrial fibrillation who presents with weight
gain and dyspnea.
Patient states that he has been having increasing dyspnea on
exertion and orthopnea since discharge from the ___ on ___.
He sleeps with two pillows, but this has been stable for at
least ___ year. He also notes a dry cough. He thinks he has gained
about 10-pounds since his discharge.
Patient reports adherence to his medications and adherence to a
low-salt diet
He denies fevers/chills, chest pain, abdominal pain, nausea,
vomiting, diarrhea.
Of note he was recently ___ thru ___ admitted to ___ for
CHF exacerbation. During that hospitalization he was diuresed
with IV furosemide 80mg BID in house and then discharged on 40mg
PO torsemide. He was also started isosorbide mononitrate ER 30mg
daily. Recommendation was for outpatient stress testing to
evaluate for potential ischemic cause of his heart failure
exacerbation.
In the ED, initial vitals were 96.8 84 98/66 24 100% on NC
(unclear how much oxygen).
Labs with:
WBC 5.9 Hbg 8.9 Hct 28.9 Plt 212
PTT 42.6 INR 3.0
136 95 69
------------<97
4.2 29 2.5
Ca 9.1 Mg 2.3 Phos 4.7
Troponin <0.01 proBNP ___
Lactate 1.6
CXR with mild pulmonary vascular congestion.
Upon arrival to the floor, he has continued complaint of
dyspnea, worse with exertion, but also mildly at rest.
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 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:
- Coronary artery disease (status post CABG in ___ with SVG to
his PDA, SVG to his OM and composite LIMA and SVG to LAD with
known total occlusion of all his venous grafts and PCI to his
LCx-OM, RCA and most recently to his right PDA in ___
- Chronic systolic and diastolic heart failure (ECHO ___
EF 20% with global hypokinesis)
- Hypertension
- Hyperlipidemia
- Obstructive sleep apnea, on home CPAP
- History of syncope with inducible VT on EP study, status post
ICD with recent generator change in ___
- Chronic kidney disease
Social History:
___
Family History:
Brother also has a history of coronary artery disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.9 77 94/67 (right arm) 114/65 (left arm) 19 96% on
room air.
Weight: 213.6 pounds
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, no LAD. The JVP is at the jawline when lying 45
degrees.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes or
crackles.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Somewhat cool. There is 1+ pitting edema bilaterally to
just below the knee.
Neuro: AOx3. CNII-XII intact, no focal deficits.
DISCHARGE EXAM
VS: 98.5 ___ 87-97/55-63 18 98-100% RA
I/O: ___
Wt: 93.1 kg ___ yesterday)
GENERAL: NAD, A&Ox3, mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP midway up neck
CARDIAC: RR, normal rate, normal S1, S2. No
murmurs/rubs/gallops.
LUNGS: CTAB, No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: trace-1+ pitting edema BLE
Pertinent Results:
ADMISSION LABS:
___ 05:50PM BLOOD WBC-5.9 RBC-3.40* Hgb-8.9* Hct-28.9*
MCV-85 MCH-26.2 MCHC-30.8* RDW-15.4 RDWSD-46.8* Plt ___
___ 05:50PM BLOOD Neuts-68.1 Lymphs-16.0* Monos-11.8
Eos-3.2 Baso-0.7 Im ___ AbsNeut-4.00 AbsLymp-0.94*
AbsMono-0.69 AbsEos-0.19 AbsBaso-0.04
___ 05:54PM BLOOD ___ PTT-42.6* ___
___ 05:50PM BLOOD Glucose-97 UreaN-69* Creat-2.5*# Na-136
K-4.2 Cl-95* HCO3-29 AnGap-16
___ 05:50PM BLOOD Albumin-3.9 Calcium-9.1 Phos-4.7*# Mg-2.3
___ 05:50PM BLOOD ALT-29 AST-38 AlkPhos-118 TotBili-0.4
___ 05:50PM BLOOD proBNP-8987*
___ 05:48PM BLOOD Lactate-1.6
PERTINENT LABS:
___ 05:50PM BLOOD cTropnT-<0.01
___ 05:55AM BLOOD cTropnT-<0.01
___ 05:55AM BLOOD TSH-0.52
___ 05:55AM BLOOD T4-3.9* T3-44*
DISCHARGE LABS:
___ 09:15AM BLOOD WBC-5.2 RBC-3.80* Hgb-9.6* Hct-32.3*
MCV-85 MCH-25.3* MCHC-29.7* RDW-15.5 RDWSD-47.8* Plt ___
___ 09:15AM BLOOD Neuts-64.5 Lymphs-16.0* Monos-12.0
Eos-6.7 Baso-0.6 Im ___ AbsNeut-3.38 AbsLymp-0.84*
AbsMono-0.63 AbsEos-0.35 AbsBaso-0.03
___ 09:15AM BLOOD ___ PTT-38.2* ___
___ 09:15AM BLOOD ___
___ 09:15AM BLOOD Ret Aut-0.9 Abs Ret-0.03
___ 09:15AM BLOOD Glucose-118* UreaN-56* Creat-1.7* Na-140
K-5.1 Cl-98 HCO3-33* AnGap-14
___ 09:15AM BLOOD ALT-23 AST-29 LD(LDH)-261* CK(CPK)-75
AlkPhos-98 Amylase-74 TotBili-0.3
___ 09:15AM BLOOD TotProt-6.7 Albumin-3.7 Globuln-3.0
Calcium-9.5 Phos-3.6 Mg-2.3 UricAcd-7.4* Iron-PND Cholest-PND
IMAGING:
___HEST W/O CONTRAST
IMPRESSION:
No acute intrathoracic process.
=
___ Cardiovascular STRESS
IMPRESSION: Very poor exercise tolerance (Weber Class D) with a
very
low ventilatory threshold. Mildly elevated VE/VCO2 slow
(Ventilatory
Class I) with an mildly abnormal PET CO2 response to exercise.
EOV was
noted during the procedure. Relative hypotension at baseline
(patient
asymptomatic throughout) with no change in blood pressure noted
with
exercise. The ECG was uninterpretable for ischemia.
=
___ Cardiovascular Cath Physician ___ ___
___ Impressions:
1. Elevated right and left sided filling pressures.
2. Mild pulmonary venous hypertension.
3. Low normal cardiac output.
___ Imaging CARDIAC PERFUSION PHARM
IMPRESSION: 1. No significant interval change in the fixed
severe anterior and moderate lateral wall defect. 2. Increased
left ventricular size with apical akinesis, suggestive of
interval decompensation. 3. Low EF at 18%
=
___ Cardiovascular STRESS
=
___ CHEST X RAY: Moderate cardiomegaly with mild pulmonary
vascular congestion.
MICROBIOLOGY
============
___ Blood (Toxo) TOXOPLASMA IgG
ANTIBODY-PENDING; TOXOPLASMA IgM ANTIBODY-PENDING INPATIENT
___ Blood (EBV) ___ VIRUS VCA-IgG
AB-PENDING; ___ VIRUS EBNA IgG AB-PENDING; ___
VIRUS VCA-IgM AB-PENDING INPATIENT
___ Blood (CMV AB) CMV IgG ANTIBODY-PENDING
INPATIENT
___ SEROLOGY/BLOOD VARICELLA-ZOSTER IgG
SEROLOGY-PENDING INPATIENT
___ SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-PENDING INPATIENT
___ URINE URINE CULTURE-FINAL
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
BRIEF SUMMARY
=============
Mr. ___ is a ___ yo male with a PMH of ischemic cardiomyopathy
with EF of 20% by TTE in ___, CAD s/p CABG and PCI, VT with
ICD s/p ablation in ___, atrial fibrillation on rivaroxaban
who presented with shortness of breath and ___ edema.
He was found to have an acute exacerabation of his systolic
heart failure, and was diuresed aggressively with improvement in
his symptoms. A PMIBI scan showed fixed severe anterior and
moderate lateral wall defect, but did now show evidence of any
new defects. A CPET scan showed a decreased VO2max. A right
heart cath was performed which showed elevated PCWP and PA
pressures. The patient may be a candidate for a heart
transplant, so pre-treatment labs were ordered but were not back
prior to discharge.
The patient has had a series of recent CHF exacerbations, which
may be related to excessive levothyroxine administration versus
insufficient diuresis during previous admissions. His free T4
was low so his levothyroxine dose was reduced to 100 mg daily
from 150 mg daily.
During his admission he also experienced an elevated creatinine,
which improved with diuresis.
ACUTE ISSUES
============
# Acute systolic congestive heart failure: recent ___ with
LVEF of 20% and global hypokinesis), presented with worsening
dyspnea and ___ edema. Weight was equal to discharge on ___ BNP
___ on admission (was 10k at prior admission on ___. He is on
torsemide 40 mg at home. No clear cause for decompensation, or
for his many recent decompensations, however free T4 was
elevated so may be due to iatrogenic hyperthyroidism in the
setting of levothyroxine administration. A PMIBI scan was
performed on ___ which showed unchanged anterior and lateral
wall defects and increased LV size suggesting interval
decompensation in CHF. EP consulted on ___ for evaluation for
Bi-V pacer, felt that he was not a good candidate at this time
due to inadequate QRS prolongation. RHC and CPET performed on
___, which showed elevated left and right filling pressures and
poor exercise tolerance and low VO2 peak. The patient is likely
a candidate for heart transplant and was ordered for
pre-transplant labs, but these were not back prior to discharge.
He was diuresed aggressively with resolution of his SOB and ___
edema. His isosorbide was replaced with Losartan 25 mg po daily.
Once he achieved euvolemia, he was restarted on his home
torsemide 40 mg po daily and discharged to follow up with his
PCP, ___, and the advanced heart failure team.
#) Hypothyroidism: Patient with severe hypothyroidism in
___ (___ 104). During this admission, his TSH was
0.52, T4 3.9, T3 44, and free T4 was 4.5. Endocrinology was
consulted, who recommended decreasing his levothyroxine to 100
mg daily from 150 mg daily with instructions to have repeat TSH
and free ___ weeks post-discharge. After the patient was
discharged, endocrinology recommended that his dose be increased
to 125 mg.
#) Acute on chronic kidney disease: Baseline creatinine ~ 1.6.
Likely secondary to vascular congestion in the setting of his
heart failure exacerbation. Creatinine on admission was 2.5,
discharge 1.7.
CHRONIC ISSUES
#) HTN: Continued losartan 25 mg daily and metoprolol 12.5 mg
BID
#) Atrial fibrillation:
- continued home amiodarone 200mg daily
- Continued rivaroxaban 15 mg qpm
- Continued ASA 81mg daily
#) Coronary artery disease: status post CABG in ___ with SVG to
PDA, SVG to OM and composite LIMA and SVG to LAD with known
total occlusion of all his venous grafts and PCI to his LCx-OM,
RCA and most recently to his right PDA in ___.
- Continued metoprolol tartrate 12.5 mg BID as above
- continued rosuvastatin 40mg daily
- continued ezetimibe 10mg daily
- continued ASA 81mg daily
#) Anemia: Hbg on admission is 8.9. Baseline is around 9.
Stable.
# Depression:
- continued home fluoxetine 40mg daily
# Sleep apnea:
- continued home CPAP
# Fibromyalgia:
- continued home tramadol 50mg q8hrs as needed
# GERD:
- continued home ranitidine 300mg qHS
TRANSITIONAL ISSUES
===================
-The patient was found to have an elevated free T4 of 6.1 and
then 4.5 two days later. His levothyroxine dose was reduced from
150 mcg to 100 mcg daily. Post-discharge, endocrinology updated
their recommendations, suggesting a dose of levothyroxine 125
mcg daily. He will need a TSH and free T4 rechecked within ___
weeks of discharge, and may need his levothyroxine dose adjusted
-Pt was evaluated by EP for a Bi-V pacemaker, but was not a
candidate due to insufficient prolongation of QRS interval. He
may benefit from CRT in the future if this changes
-The patient has a documented allergy to spironolactone due to
hyperkalemia, so was not discharged on this medication due to a
d/c potassium of 5.1 (a rise of K from 3.8 to 5.1 after one day
of spironolactone)
-F/u ___ ___ and CHF NP 7 days from discharge.
Would order RUQ US and 24 hr urine collection at next NP
appointment for transplant evaluation.
-Following labs (for heart transplant eval) pending at d/c:
Iron: Pnd
Ferritn: Pnd
TRF: Pnd
Triglyc: Pnd
HDL: Pnd
HBsAg: Pnd
HBs-Ab: Pnd
HBc-Ab: Pnd
HAV-Ab: Pnd
HCV-Ab: Pnd
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Rosuvastatin Calcium 40 mg PO QPM
3. Betamethasone Dipro 0.05% Augmented Gel 1 Appl TP BID
4. Nitrolingual (nitroglycerin) 400 mcg/spray translingual up to
3x for chest pain
5. Ezetimibe 10 mg PO DAILY
6. Acetaminophen 1000 mg PO Q8H:PRN pain
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
8. Amiodarone 200 mg PO DAILY
9. ammonium lactate ___ % topical BID
10. Aspirin 81 mg PO DAILY
11. Fluoxetine 40 mg PO DAILY
12. Fluticasone Propionate NASAL 1 SPRY NU BID
13. FoLIC Acid 1 mg PO DAILY
14. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
15. Levothyroxine Sodium 150 mcg PO DAILY
16. Loratadine 10 mg PO DAILY
17. Metoprolol Succinate XL 25 mg PO DAILY
18. Ranitidine 300 mg PO QHS
19. Torsemide 40 mg PO DAILY
20. TraMADOL (Ultram) 50-100 mg PO TID:PRN pain
21. Rivaroxaban 15 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
3. Amiodarone 200 mg PO DAILY
RX *amiodarone 200 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
6. Ezetimibe 10 mg PO DAILY
7. Fluoxetine 40 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. FoLIC Acid 1 mg PO DAILY
10. Ranitidine 300 mg PO QHS
RX *ranitidine HCl 300 mg 1 tablet(s) by mouth daily at night
Disp #*30 Tablet Refills:*0
11. Rivaroxaban 15 mg PO DINNER
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
12. Rosuvastatin Calcium 40 mg PO QPM
RX *rosuvastatin [Crestor] 40 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
13. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
14. TraMADOL (Ultram) 50-100 mg PO TID:PRN pain
15. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
16. ammonium lactate ___ % topical BID
17. Betamethasone Dipro 0.05% Augmented Gel 1 Appl TP BID
18. Loratadine 10 mg PO DAILY
19. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
20. Nitrolingual (nitroglycerin) 400 mcg/spray translingual up
to 3x for chest pain
21. Levothyroxine Sodium 100 mcg PO DAILY
RX *levothyroxine 100 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
#acute-on-chronic systolic heart failure
#acute-on-chronic kidney disease
SECONDARY DIAGNOSES
===================
#hypertension
#atrial fibrillation
#iatrogenic hyperthyroidism
#coronary artery disease
#Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with worsening shortness of
breath, especially while lying on your back. You were found to
have a worsening of your heart failure, and were treated with
medicines to take fluid off your body. We performed a heart
catheterization to determine the pressures in your heart to help
us better diagnose your condition. We pulled fluid off of your
body with medicines and your symptoms improved.
You may be a candidate for a heart transplant so it is important
that you follow up with our heart failure doctors.
Weigh yourself every morning, call your doctor if your weight
goes up more than 3 lbs.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
10459005-DS-30 | 10,459,005 | 27,223,723 | DS | 30 | 2142-07-14 00:00:00 | 2142-07-14 21:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Motrin / Iodine-Iodine Containing / Naprosyn / Lisinopril /
Flomax / spironolactone
Attending: ___.
Chief Complaint:
Abdominal pain, weight gain
Major Surgical or Invasive Procedure:
PICC line placement ___
Right Heart Cath ___
History of Present Illness:
This is a ___ gentleman with a history of coronary
artery disease status post coronary artery bypass graft,
hypertension, systolic heart failure, chronic kidney disease who
presents today with RUQ pain and weight gain. This pain has been
present for the last 3 days constantly and is RUQ/epigastric
pain. It is an aching pain and since yesterday patient has been
feeling dizzy. He has eaten almost nothing yesterday. No N/V/D.
No fever/chills. Got 324mg ASA en route and 200cc IVF while
being transferred to the ED.
In the ED initial vitals were: 8 96.0 93 87/63 100%. EKG was
consistent with prior EKGs showing his paced rhythm.
Labs/studies notable for ___ to 2.5 from a baseline of 1.5.
The patient also had an elevation in his transaminases. The
patient had a Liver Or Gallbladder US 1. Normal biliary tree.
Post cholecystectomy. 2. Trace perihepatic ascites. CT Abd &
Pelvis W/O Contrast was Limited examination without IV contrast.
There is nonspecific stranding in
the abdomen, centered in the region of the second and third
portion of the duodenum, findings are nonspecific but can be
seen in duodenitis. Remainder of the bowel is unremarkable. CXR
showed No significant interval change in the appearance of the
chest with mild
vascular congestion but no frank pulmonary edema. The patient
was noted to have a lactate on 2.2 on arrival which decreased to
1.7 on recheck without intervention. The patient was given 160mg
of IV Lasix and admitted to the ___ service.
On the floor the patient's vitals were 97.4 86/65 77 18 97 on
RA. The patient was resting comfortably lying flat in bed. The
patient reported that his abdominal pain was significantly
improved. He had no active complaints on arrival.
ROS:
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope. Denies exertional buttock or calf pain.
On further review of systems, denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. Denies recent fevers,
chills or rigors. All of the other review of systems were
negative.
Past Medical History:
. Coronary artery disease status post CABG in ___ with SVG to
PDA, SVG to OM, and SVG to LAD with a known total occlusion of
all his venous graft and a PCI to the circumflex OM, RCA and
most
recently to his right PDA in ___.
2. Heart failure with reduced ejection fraction, chronic
systolic echo in ___, EF of 20% with global hypokinesis.
3. Hypertension.
4. Hyperlipidemia.
5. Obstructive sleep apnea, on CPAP.
6. History of syncope with inducible VT on EP study status post
ICD with a generator.
7. Chronic kidney disease.
8. Atrial fibrillation on anticoagulation
Social History:
___
Family History:
His brother had a history of coronary artery disease. No history
of early cardiomyopathy, sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 97.4 86/65 77 18 97 on RA
GENERAL: resting comfortably NAD. Oriented x3. Mood, affect
appropriate; cool extremities, however pulses were strong in all
four extremities distally
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 10 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. minimal crackles
bilaterally; no wheezes or rhonchi.
ABDOMEN: Soft, mildly TTP. No HSM or tenderness.
EXTREMITIES: +2 pitting edema bilaterally up to the knees
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
========================
VS: T 98.6 BP 103-128/65-78 HR ___ RR ___ O2 94-100% RA
I/O: 245.6/800 (8h), 1385/2175 + 1BM (24hr)
Wt: 96.7 < 97.2 < 97.3 < 97.1 < 95.5 < 93.8 < 94.7
GENERAL: resting comfortably NAD. Oriented x3. Mood, affect
appropriate
HEENT: NCAT. Sclera anicteric.
NECK: Supple with JVP 9.
CARDIAC: RR, normal S1, S2. ___ holosytolic murmur. No
rubs/gallops. No thrills, lifts.
LUNGS: CTAB. No chest wall deformities, scoliosis or kyphosis.
Resp unlabored on room air, no accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Nontender to palpation. Nondistended.
EXTREMITIES: 1+ edema bilaterally over the shins, warm
extremities, Distal pulses palpable and symmetric. Cath site to
left AC with no hematoma, dressing clean, dry, intact.
PICC: line in place with no surrounding erythema or swelling.
Pertinent Results:
Admission labs:
===============
___ 09:45PM BLOOD WBC-5.8 RBC-3.92* Hgb-10.8* Hct-34.2*
MCV-87 MCH-27.6 MCHC-31.6* RDW-17.8* RDWSD-55.8* Plt ___
___ 09:45PM BLOOD Neuts-65.1 ___ Monos-11.4 Eos-2.6
Baso-0.5 Im ___ AbsNeut-3.78 AbsLymp-1.17* AbsMono-0.66
AbsEos-0.15 AbsBaso-0.03
___ 09:45PM BLOOD ___ PTT-32.5 ___
___ 09:45PM BLOOD Glucose-98 UreaN-74* Creat-2.5* Na-138
K-4.9 Cl-100 HCO3-23 AnGap-20
___ 09:45PM BLOOD ALT-111* AST-130* CK(CPK)-134
AlkPhos-140* TotBili-0.4
___ 09:45PM BLOOD CK-MB-4
___ 09:45PM BLOOD cTropnT-0.01
___ 09:45PM BLOOD Albumin-4.1 Calcium-8.9 Phos-5.0* Mg-2.7*
___ 10:11PM BLOOD Lactate-2.2*
Other labs:
___ 05:31PM URINE Color-Straw Appear-Clear Sp ___
___ 05:31PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:31PM URINE Hours-RANDOM Creat-51 TotProt-5
Prot/Cr-0.1
___:00AM BLOOD ALT-41* AST-34 AlkPhos-102 TotBili-0.2
___ 09:45PM BLOOD Lipase-31
Improvement of kidney function on milrinone:
___ 06:30AM BLOOD Glucose-75 UreaN-55* Creat-1.8* Na-143
K-5.1 Cl-99 HCO3-36* AnGap-13
___ 03:05PM BLOOD Glucose-81 UreaN-46* Creat-1.6* Na-140
K-4.4 Cl-98 HCO3-34* AnGap-12
___ 05:45AM BLOOD Glucose-79 UreaN-36* Creat-1.4* Na-140
K-4.3 Cl-99 HCO3-34* AnGap-11
___ 05:05PM BLOOD Glucose-83 UreaN-30* Creat-1.2 Na-136
K-4.6 Cl-97 HCO3-31 AnGap-13
___ 07:00AM BLOOD Glucose-91 UreaN-36* Creat-1.3*# Na-137
K-3.6 Cl-96 HCO3-32 AnGap-13
___ 03:00PM BLOOD Glucose-90 UreaN-40* Creat-1.4* Na-137
K-5.3* Cl-96 HCO3-32 AnGap-14
CARDIAC STUDIES:
================
CATH PHYSICIAN ___ ___
Impressions:
Elevated filling pressures, and large V waves consistent with
mitral regurgitation. Low cardiac index.
Recommendations
Med mgt on floor.
Other studies:
==============
Abd US ___
IMPRESSION:
1. Normal biliary tree. Post cholecystectomy.
2. Trace perihepatic ascites.
CT abdomen and pelvis ___
IMPRESSION:
1. Retroperitoneal fluid centered along the second and third
portion of the
duodenum may reflect duodenitis. Please correlate clinically.
2. Enlarged prostate.
Discharge labs:
================
___ 06:17AM BLOOD WBC-7.1 RBC-3.73* Hgb-10.2* Hct-33.1*
MCV-89 MCH-27.3 MCHC-30.8* RDW-17.0* RDWSD-54.2* Plt ___
___ 06:17AM BLOOD Glucose-77 UreaN-38* Creat-1.4* Na-137
K-4.8 Cl-100 HCO3-29 AnGap-13
___ 06:17AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.4
Brief Hospital Course:
Mr. ___ is a ___ gentleman with a history of CAD s/p
CABG, HTN, systolic heart failure, and CKD who presented with
RUQ pain and weight gain, consistent with heart failure
exacerbation.
# Acute decompensated Heart failure with reduced ejection
fraction, systolic:
He was found to be in acute decompensated heart failure with a
reduced ejection fraction, systolic: ___ class IV Stage D.
Patient is on the transplant list, status 1B. He has had 7
admissions in the past 8 months for fluid overload and
decompensated heart failure. On admission he was found to have
cool extremities and elevated lactate of 2.2, as well as an
elevated Cr of 2.5. He responded well to Lasix drip at 20mg/hr.
His lactate improved to 1.7 after being on the Lasix drip. After
significant diuresis, he was started on a milrinone drip at
0.25mcg/kg/min on ___ with a milrinone dosing weight of
94.7kg. This was started in order to determine whether his
kidney dysfunction was related to a chronic cardiorenal state.
He did well on the milrinone drip with improvement in his
creatinine to 1.2. He continued to autodiurese well on the
milrinone drip. He went for Right Heart Catheterization on
___ which revealed elevated filling pressures. Given the
result of his RHC his milrinone drip rate was increased to a
rate of 0.375mcg/kg/min for a weight of 94.7 kg and his
torsemide was continued at 40mg PO daily. For afterload
reduction he was continued on losartan 25mg. For contractility
he was continued on his home Metoprolol Succinate XL 12.5 mg in
addition to the milrinone. Before discharge a PICC line was
placed and patient was sent home on a milrinone drip. Patient
is functionally limited by his heart disease and will require
hospital bed at home for severe PND and orthopnea.
# Abdominal Pain | Transaminitis:
Patient also presented with abdominal pain, and his labs
revealed transaminitis. In the context of HF exacerbation,
likely reflects congestive hepatopathy. In the ED he was started
on ciprofloxacin and flagyl, however these were discontinued
given no other signs of infection. His LFTs improved over time,
and his abdominal pain resolved with diuresis, as above.
# Acute Renal Failure:
Patient with Cr on admission of 2.5, up from baseline of 1.5.
Given that he responded well to diuresis with improvement in his
creatinine, this is most likely cardiorenal. Milrinone was
started and continued as above. Cr 1.4 on day of discharge.
# Atrial Fibrillation
Patient with a history of atrial fibrillation. He had been
anticoagulated on warfarin, however his INR was subtherapeutic
on arrival. Patient was not bridged given his low stroke risk.
His warfarin was continued at 6mg daily, and was titrated daily
for an INR goal of ___. His INR on day of discharge was
subtherapeutic at 1.9. During his hospitalization he was placed
on a dose of 6mg daily, which was increased to 7mg daily (from
___, on the day of discharge his was sent home on 7.5
daily. Recommend follow up of his INR as an outpatient and dose
adjustment as necessary. For rate control his home Metoprolol
Succinate XL 12.5 mg was continued.
# Positive blood culture:
Blood cultures drawn in the ED were positive for gram positive
cocci in pairs and chains, and were later speciated to coag
negative staph. This likely reflected a contaminant, as patient
displayed no clinical signs of infection, however he did receive
vancomycin x2 (___).
# Coronary artery disease:
cardiac catheterization ___ showed he was right dominant
and LMCA was patent. LAD had an 80% lesion that was occluded
distally. LCX with a 50-60% ISRS stent stenosis. RCA, patent
stents. The ISRS LCX lesion was negative FFR. Known occluded
grafts, status post CABG. Continued on home Ezetimibe 10 mg PO,
home Aspirin 81 mg PO and home Rosuvastatin 40
#Anemia:
Patient found to have anemia that was microcytic and iron
deficient. He had a colonoscopy back in ___ upon which polyps
were removed. During his hospitalization, he was continued on
his home oral iron repletion.
#OSA:
Patient carries a diagnosis of OSA. He has a home CPAP. During
this hospitalization he was encouraged to use his CPAP every
time he slept.
TRANSITIONAL ISSUES:
-Discharge weight: 96.7kg (213.2lbs)
-Discharge diuretic regimen: 40mg PO torsemide daily, milrinone
drip at 0.375mcg/kg/min with drip dosed to weight of 94.7kg
-Sent home with PICC line on milrinone drip, with ___ infusion
services. Recommend ongoing medication management teaching and
close follow up.
-Weekly CBC, CMP and INR while on milrinone, labs will be drawn
by ___ and faxed to Dr. ___.
-Transplant status 1B, NYHA class IV Stage D. Currently listed
for transplant.
-Sent home on warfarin 7.5mg daily, subtherapeutic on admission,
next INR check on ___. Continue regular INR checks.
-Elevated PSA: s/p prostate biopsy ___ samples with concern for
malignancy. Standard of care per urology, repeat biopsy in one
year and follow up PSA q6 months
- Patient received pneumococcal 23 vaccine and HepB vaccine on
___. Scheduled for accelerated Hep B vaccine series (day 0 =
___, doses should be on days 0,7,21 and ___, next dose due
on ___.
- Patient discharge Cr is 1.4, please continue to monitor,
lowest Cr while on milrinone normal at 1.2.
# CODE: FULL
# CONTACT: Name of health care proxy: ___
Relationship: wife
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Losartan Potassium 25 mg PO DAILY
3. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
4. ammonium lactate 12 % topical BID
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Ezetimibe 10 mg PO DAILY
8. Amiodarone 200 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. Warfarin 2.5 mg PO DAILY16
11. Ranitidine 300 mg PO DAILY
12. Rosuvastatin Calcium 40 mg PO QPM
13. Ferrous Sulfate 325 mg PO BID
14. Torsemide 80 mg PO DAILY
15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
16. TraMADol 50-100 mg PO Q8H:PRN Pain - Moderate
17. Aspirin 81 mg PO DAILY
18. Loratadine 10 mg PO DAILY
19. albuterol sulfate 90 mcg/actuation inhalation Q6H
20. FLUoxetine 40 mg PO DAILY
21. Levothyroxine Sodium 112 mcg PO DAILY
22. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Milrinone 0.375 mcg/kg/min IV DRIP INFUSION
RX *milrinone in 5 % dextrose 20 mg/100 mL (200 mcg/mL) 0.375
mcg/kg/min IV CONTINUOUS Disp #*30 Intravenous Bag Refills:*12
RX *milrinone 1 mg/mL 0.375 mcg/kg/min IV CONTINUOUS Disp #*30
Vial Refills:*12
2. Torsemide 40 mg PO DAILY
3. Warfarin 7.5 mg PO DAILY16
Please follow up with ___ ACMS for INR checks and dosing
instructions for your warfarin
RX *warfarin [Coumadin] 7.5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
5. albuterol sulfate 90 mcg/actuation inhalation Q6H
6. Amiodarone 200 mg PO DAILY
7. ammonium lactate 12 % topical BID
8. Aspirin 81 mg PO DAILY
9. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
10. Docusate Sodium 100 mg PO BID
11. Ezetimibe 10 mg PO DAILY
12. Ferrous Sulfate 325 mg PO BID
13. FLUoxetine 40 mg PO DAILY
14. Fluticasone Propionate NASAL 1 SPRY NU BID
15. FoLIC Acid 1 mg PO DAILY
16. Levothyroxine Sodium 112 mcg PO DAILY
17. Loratadine 10 mg PO DAILY
18. Losartan Potassium 25 mg PO DAILY
19. Metoprolol Succinate XL 25 mg PO DAILY
Hold if HR less than 50 beats per minute
20. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
21. Ranitidine 300 mg PO DAILY
22. Rosuvastatin Calcium 40 mg PO QPM
23. TraMADol 50-100 mg PO Q8H:PRN Pain - Moderate
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Congestive Heart Failure Exacerbation
Acute on chronic kidney failure
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care here at ___
___.
WHY YOU WERE HERE:
You came to us with an exacerbation of your heart failure.
WHAT WAS DONE FOR YOU:
- We gave you a medication called Lasix (furosemide) through
your IV and got a lot of extra fluid out of your body.
- We started you on a continuous IV medication called Milrinone,
which makes your heart pump stronger. We followed your kidney
function, and found that your kidney function improved with
milrinone.
- We placed a PICC line, a more permanent IV, in your arm so
that we could send you home on the milrinone drip. This medicine
worked really well for you and we hope that by continuing this
drip, you won't have to return to the hospital as freqently.
WHAT YOU SHOULD DO AT HOME:
- Please attend the follow up appointment with cardiology to
continue management of your heart failure.
- Please follow up with your primary care doctor for ongoing
management of your other medical conditions.
- Please continue to take your medications as prescribed
- Please weigh yourself every morning, and call your
cardiologist if your weight goes up more than 3 lbs.
- Please take care of your PICC line and milrinone drip medicine
as instructed.
YOUR WEIGHT AT THE TIME OF DISCHARGE: 96.7kg (213.2lbs)
Thank you for choosing ___ for your healthcare needs.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10459203-DS-6 | 10,459,203 | 24,563,368 | DS | 6 | 2150-09-06 00:00:00 | 2150-09-06 12:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Latex / Codeine / Morphine /
Vicodin / Shellfish Derived / Epinephrine
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ year old female with a history of ___
Disease. Her history is variable in accuracy, but she is
accompanied by her son, who has flown in from ___.
Ms ___ currently lives at an assisted living facility (she
has been there about 4 weeks) where she fell last night,
apparently from a standing position, striking her head on the
floor. Ordinarily, she has a personal care assistant who helped
her with a shower just before she fell, but the PCA was not in
the room when she fell. Apparently, she was on the ground
until the morning, when she was discovered. It is unclear if
she lost consciousness.
She endorses some reduction in fluid intake over the last few
denies but denies any obvious fevers, chills, headaches,
dizziness, lightheadedness, nausea, vomiting, diarrhea, or
abdominal pain.
In terms of her ___ Disease, she was diagnosed in ___,
and has had tremors, akinesia, bradykinesia, rigidity, and
hallucinations. She and her son deny that falls have been a
problem. She recently had a decrease in her Sinemet dose.
She is followed by neurology at ___. She denies worsening of
her tremor, hallucinations, or bradykinesia in the past month.
However, the son states that her dementia and other parkinsonian
symptoms have considerably worsened over the past six months.
In the ED, a head CT was performed which revealed no acute
process. Her laboratory work revealed a CK of 1400.
12 pt ROS except as described above, is otherwise negative.
___ female who presents status post unwitnessed fall.
Patient has ___ disease. She was at her assisted-living
last night when she fell. She did hit her head in the process.
No loss of consciousness. Per report, patient has been
increasingly weak over the past several days. She denies chest
pain or shortness of breath. Denies dizziness or
lightheadedness. She does state she was able to really after the
fall, but required assistance.
PLAN:
- ct head and neck
- infectious w/u
Per family, patient has had increasing but steady decline in her
neuro-cognitive status over the past month. Unclear if this is
due to her underlying ___ or another etiology. Patient
also reportedly left odd "sentimental" voicemails with her
physical therapists yesterday. Denies SI/HI. Patient only able
to provide very limited history, unsafe to return to living
facility. Will need admission for further evaluation / workup
and likely new placement.
NS for elevated CK
Fall Pathway Assessment:
[ ] Traumatic injuries identified (if any):
[ ] Contributing medications:
[ ] Other Contributing factors:
[ ] Orthostatics (positional change in VS and/or symptoms):
[ ] Get Up and Go Test results
[ ] ADL capabilities (specify limitations, if any, and if new or
old):
[ ] Disposition plan: admit to medicine
Past Medical History:
PMH: HTN, depression, anxiety.
PSH: Two C-sections, one lumpectomy, and spine surgery.
Social History:
___
Family History:
Noncontributory.
Physical Exam:
VS: temp 98, BP 130/80 HR 80 RR 12 O2 sat 98% RA
Neuro:
Cognitively, Ms ___ is a poor historian and difficult to
redirect with significant tangentiality. She speaks with
monotone and has latency of speech. No paraphasic errors. She
demonstrates masked facies. Rigidity is apparent in upper
extremities bilaterally. No visible tremor.
Cardiac:
Nl s1/s2 RRR no murmurs appreciable
Pulm:
Clear bilaterlaly
Abd:
soft and nontender with normoactive bowel sounds
Ext: warm and well perfused
Pertinent Results:
Negative head CT and CXR
___ 09:43AM CK(CPK)-___*
Brief Hospital Course:
___ year old female with a history of ___ disease
presenting with fall from assisted living facility. We obtained
a CT scan of her head which was normal. Her CK was initially
elevated which improved with IVFs. We consulted neurology
given that appeared that her cognitive deficits had worsened.
They recommended intiation of aricept. We did not increase her
sinemet dosing as it appeared that sinemet at higher doses was
causing her hallucinations. She did endorse intermittent
hallucinations during her hospital stay. Given progression of
disease, we met with her outpatient neurologists and family and
decided that she would require a higher demand of care and a
plan was made for her to go to a SNF rather than an ALF.
Following discharge to a SNF, she will be transferred to a SNF
in ___, near her son.
Transitional issue:
Please recheck serum postassium ___. If low, would consider
stopping HCTZ and starting Amlodipine 5mg daily and uptitrating
for BP control.
Discharge Medications:
1. BuPROPion 75 mg PO QAM
2. Carbidopa-Levodopa (___) 1 TAB PO TID
3. Duloxetine 90 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
6. Donepezil 5 mg PO QAM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
(1) ___ Disease
(2) Recent fall
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms ___,
You were admitted for worsening ___ disease and
worsengin cognitive decline. After consultation with
neurology, you were started on a new medication, called Aricept,
which may help with some of your memory difficulties. Because
of your fall, we also got x-rays and did not see any fractures.
Given your risk of falling again, we planned you to go to a
___ nursing facility rather than ___ (your prior
assisted living facility). From there, your family will be
helping you to get to a skilled nursing facility in ___,
near your son's apartment.
Followup Instructions:
___
|
10459382-DS-20 | 10,459,382 | 24,881,450 | DS | 20 | 2134-05-09 00:00:00 | 2134-05-11 07:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amitriptyline / Celebrex / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Abdominal pain, fever
Major Surgical or Invasive Procedure:
Upper endoscopy ___
History of Present Illness:
___ w/ PMH of lupus, AVN s/p left THR, recent hospitalization
for
meningitis and sepsis resulting in CKD V on HD and bilateral
foot
gangrene presents with abdominal pain, nausea, vomiting and poor
PO intake.
Patient was discharged form rehab on ___ after prolonged
hospitalization for meningitis at ___. Since then, she reports
that has been having abdominal pain which has progressed to the
point that she is unable to tolerate p.o. for the last 3 days.
When it started in ___, it felt like she had gas in her
intestines and her symptoms did resolve after burping. However
if she did not burp, she would vomit. The pain would usually
start in the epigastric area/RUQ and would move to the RLQ. As
the pain progressed, she started feeling it as a sharp pain as
soon as she ate or drank anything. She also reports that she
now
vomits with every meal. Patient also reports fever since she
left
rehab as high as 102.5. She had an episode of diarrhea night
prior to admission that was nonbloody but has not had other
episodes. She has some intermittent night sweats that she thinks
are related to fevers and chronic bilateral foot/shoulder pain.
She denies headache but reports has photophobia because the
lighting in the hallway was extremely bright. Denies neck pain,
cough, SOB, weight loss, hip pain or new lower extremity wounds.
As mentioned above, patient had hospitalization at ___ in
___
for meningitis requiring intubation and trach. The hospital
course was complicated by sepsis, bilateral ___ gangrene, acute
kidney injury requiring dialysis, and C. difficile infection.
Trach has since been decannulated. She was discharged to rehab
and then discharged home on ___. Since hospitalization she
has also been on HD (MWF). She only had 1 hour session on ___
as
she was unable to tolerate.
On arrival to the floor, patient reports she has photophobia due
to the bright lights and lower extremity pain. Also reports that
had not taken PO for the last 3 days prior to this admission.
Past Medical History:
SLE
fibromyalgia
asthma
CKD on HD ___ hospitalization for meningitis from ___ for meningitis
requiring intubation and trach (now decannulated)
C. diff infection
Avascular necrosis s/p hip replacement
Gangrenous feet
Social History:
___
Family History:
Sister with lupus which has manifested with shrinking
lung syndrome. She also has a cousin with lupus; however, she
is
uncertain of her disease activity.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 92 BP 124/88 RR 18 O2 sat 95% on RA
GENERAL: Alert and interactive. Appears umcomfortable and
speaking with her eyes closed
HEENT: Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Unable to exam as patient did not want to get up in the
hallway but frontal fields CTAB
ABDOMEN: Normal bowels sounds, non-distended, voluntary guarding
and TTP in the epigastric area, RLQ and LLQ. No organomegaly.
EXTREMITIES: bilateral toe gangrene and heel gangrene on the R,
no increased swelling or erythema, no purulence
NEUROLOGIC: AOx3
DISCHARGE PHYSICAL EXAM
======================
Temp: 98.1 PO BP: 114/80 HR: 77 RR: 18 O2 sat: 97%
O2 delivery: ra
GENERAL: Alert and interactive. Speaking with eyes open.
HEENT: Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: RRR. Audible S1 and S2. No murmurs, rubs or gallops
appreciated.
LUNGS: CTAB bilaterally
ABDOMEN: Tender to light palpation in RUQ, RLQ, and epigastric
region.
EXTREMITIES: Bilateral toe gangrene and heel gangrene on the R,
no increased swelling or erythema, no purulence
NEUROLOGIC: AOx3
Pertinent Results:
ADMISSION LABS
==============
___ 11:13PM BLOOD WBC-8.1 RBC-2.34* Hgb-6.5* Hct-21.9*
MCV-94 MCH-27.8 MCHC-29.7* RDW-19.8* RDWSD-66.6* Plt Ct-98*
___ 11:13PM BLOOD Neuts-89* Lymphs-6* Monos-4* Eos-1 Baso-0
AbsNeut-7.21* AbsLymp-0.49* AbsMono-0.32 AbsEos-0.08
AbsBaso-0.00*
___ 11:13PM BLOOD Hypochr-2+* Anisocy-2+* Poiklo-1+*
Macrocy-2+* Polychr-2+* Tear Dr-1+* RBC Mor-SLIDE REVI
___ 11:13PM BLOOD Plt Smr-LOW* Plt Ct-98*
___ 11:55PM BLOOD ___ PTT-20.3* ___
___ 08:40AM BLOOD ___
___ 11:13PM BLOOD Ret Aut-3.1* Abs Ret-0.07
___ 08:10PM BLOOD Glucose-50* UreaN-14 Creat-5.1* Na-138
K-4.6 Cl-95* HCO3-20* AnGap-23*
___ 08:10PM BLOOD ALT-<5 AST-19 CK(CPK)-61 AlkPhos-57
TotBili-0.5
___ 08:10PM BLOOD Lipase-77*
___ 08:10PM BLOOD cTropnT-0.15*
___ 11:13PM BLOOD CK-MB-1 cTropnT-0.15*
___ 08:10PM BLOOD Albumin-3.5 Calcium-8.7 Phos-4.4 Mg-1.9
___ 11:13PM BLOOD Hapto-161
___ 08:40AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-NEG
___ 07:39AM BLOOD CRP-33.0*
___ 08:40AM BLOOD ___ Titer-1:640* dsDNA-POSITIVE
A
___ 02:30PM BLOOD b2micro-36.5*
___ 08:40AM BLOOD C3-49* C4-11
___ 08:40AM BLOOD HCV Ab-NEG
___ 08:26PM BLOOD Glucose-48* Lactate-1.6 Creat-4.8* Na-139
K-4.4 Cl-99 calHCO3-22
DISCHARGE LABS
==============
___ 07:10AM BLOOD WBC-7.0 RBC-2.61* Hgb-7.5* Hct-24.4*
MCV-94 MCH-28.7 MCHC-30.7* RDW-19.3* RDWSD-64.5* Plt Ct-92*
MICRO
=====
C. difficile PCR (Final ___: NEGATIVE.
Urine culture ___: Skin flora
Urine culture ___: No growth
Blood cultures ___: No growth
IMAGING REPORTS
===============
___ ENDOSCOPY
IMPRESSION: normal mucosa of the esophagus, stomach, duodenum.
Biopsies taken. See path report.
___ TTE
IMPRESSION: Small-moderate circumferential pericardial effusion
without echocardiographic evidence for tamponade physiology.
Mild
symmetric left ventricular hypertrophy with normal cavity size
and mild global hypokinesis. Mild mitral regurgitation with
normal valve morphology.
___ CT AB & PELVIS
1. Large pericardial effusion. Correlate clinically for
possible pericarditis.
2. Small volume pelvic ascites and numerous but not enlarged
retroperitoneal and pelvic lymph nodes which can be seen in the
setting of lupus.
3. No evidence of colitis.
___ CXR
Left lower lobe consolidation is better seen on the CT from the
same day. Mild enlargement of the cardiac silhouette, presumably
related to
pericardial effusion, better seen on the CT from the same day.
Brief Hospital Course:
SUMMARY ASSESSMENT
==============================
Mrs. ___ is a ___ year old woman with a hx of lupus,
fibromyalgia, AVN (s/p left THR), recent hospitalization for
meningitis and sepsis resulting in CKD V on HD and bilateral
foot gangrene who presented with abdominal pain, nausea,
vomiting and fever to 103. She was initially treated with broad
spectrum antibiotics and IV methylprednisolone. Broad
infectious, autoimmune and gastrointestinal workup was
unrevealing. After starting IV methylprednisolone, she remained
afebrile throughout hospitalization. Her abdominal pain
gradually improved through hospitalization and she was able to
stop IV Dilaudid and eat meals by time of discharge. She was
discharged on ___ to home.
TRANSITIONAL ISSUES
==============================
[ ] F/u abdominal imaging for enlarged retroperitoneal and
pelvic lymph nodes
[ ] Will need cardiology referral and repeat cardiac TTE as
patient had EF of 44% of presentation as well as a pericardial
effusion on TTE
[ ] Patient had spot urine protein of 2.2. Consider 24 hour
urine protein.
ACTIVE ISSUES
==============================
# Fever
On presentation, patient reported intermittent fevers for the
last month with fever in the ED to 103. She also reported
nausea, vomiting and abdominal pain. She was started on broad
spectrum antibiotics (vancomycin, ceftazadime and flagyl).
Broad infectious workup, including blood cx, urine cx,
norovirus, C diff, influenza was negative. Rheumatology was
consulted, who provided recommendations and followed her
throughout admission. She was started on IV methylprednisolone
for possible autoimmune cause of fevers. Autoimmune workup was
notable for positive ___ at 1:640, positive dsDNA, positive
anti-SSA, positive B2 glycoprotein I, and positive B2
microglobulin. Antibiotics were stopped as fevers were judged to
be most likely autoimmune in origin. At discharge, patient had
been afebrile for six days. Patient was discharged on 20 mg of
prednisone with atovaquone PCP ___.
#Nausea/Vomiting/Diarrhea/Abdominal pain:
Patient presented with 8 out of 10 abdominal pain that was
constant. Patient vomited when eating food because of the pain.
Pain was present at rest without eating food. In addition to
nausea and vomiting, patient reported one episode of diarrhea.
Differential included PUD, gastric outlet obstruction,
gastritis. Mesenteric ischemia less likely given constant pain.
Infxn workup unremarkable. CT A/P did not reveal colitis,
abdominal source of infection or signs of mesenteric ischemia.
Hep B immune, Hep A neg, HCV neg, Norovirus negative, C diff
neg. EGD ___ showed no pathology. We deferred CTA as symptoms
are not consistent with mesenteric ischemia or vasculitis. Her
pain was initially treated with Dilaudid IV ___ mg q4h. This was
transitioned to dilaudid 6 mg PO q4h, her home pain regimen. She
was discharged on dilaudid 6 mg PO q4h.
#Lupus
Patient was recently on hydroxychloroquine 200 mg twice daily
and prednisone 10 mg daily prior to her ___ hospitalization.
She was treated with IV methylprednisolone 16 mg during
hospitalization. This was transitioned to 20 mg prednisone PO
for discharge. She was discharged on atovaquone for PCP
___.
#Proteinuria
Patient was observed elevated protein in urine (2.8).
Differential
includes podocyte damage from critical illness, lupus nephritis,
FSGS. 24 hour urine protein collection was ordered but not
collected at time of discharge.
# Anemia:
# Thrombocytopenia
Anemia and thrombocytopenia are chronic issues. Pt presented
with Hb of 6.5 and bumped appropriately after transfusion. Hb
ranged from 6.5 to 8.4 throughout hospitalization. Plt ranged
from 98 to 56 throughout hospitalization. Hem-onc reviewed
peripheral smear, and there was low concern for TTP. Time course
was not consistent with HIT. Patient was discharged with Hb of
7.5 and Plt of 92.
# Newly reduced EF
Patient underwent TTE in ED. EF was observed to be 44%. Of note,
she had a TTE during the prolonged hospitalization at ___ that
was 25% while she was ill and recovered to 69%. Repeat echo is
warranted to confirm recovery of ejection fraction.
# QTc prolongation
Patient was observed to have prolonged QTc at 520s. Patient
received IV Mg in the ED. QTc prolonging medications, including
Zofran, were avoided throughout hospitalization.
# CKD: Patient presented with Cr 5 on arrival and reported this
to be her baseline. She received HD on ___ schedule through
admission.
# Elevated pt-INR
INR elevated at 1.3. Likely secondary to poor PO intake. Patient
received Vitamin K 2.5 mg. No evidence of bleeding throughout
admission.
# Pericardial effusion:
Mild to moderate pericardial effusion was observed on TTE on
presentation. Differential includes lupus flare or infection.
Patient was hemodynamically stable throughout hospitalization.
Pulsus was monitored throughout hospitalization and was
consistently 8 mm Hg. Would repeat TTE as outpatient.
CHRONIC/STABLE ISSUES:
======================
# Gangrenous feet:
Patient presented with gangrenous toes, a chronic issue since
critical illness. No skin tears or open wounds were observed on
exam. Patient's feet were kept dry throughout hospitalization.
Patient was provided with podiatry referral.
# Avascular necrosis:
Patient takes PO dilaudid 6 mg q4h at home for chronic pain.
Patient was continued on dilaudid during hospitalization.
# Enlarged Retroperitonial lymph nodes
Numerous but not enlarged retroperitoneal and pelvic lymph nodes
which can be seen in the setting of lupus. Interval f/u with
abdominal imaging to make sure not enlarging.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. HYDROmorphone (Dilaudid) 6 mg PO Q4H:PRN Pain - Moderate
3. PredniSONE 5 mg PO DAILY
Discharge Medications:
1. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 10 ml by mouth once a day Refills:*0
2. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
3. PredniSONE 20 mg PO DAILY
RX *prednisone 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. FoLIC Acid 1 mg PO DAILY
5. HYDROmorphone (Dilaudid) 6 mg PO Q4H:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Functional abdominal pain
Fever
Lupus
End stage renal disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you had fever and abdominal
pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a scan of your abdomen performed, which did not show
anything concerning.
- You also had a scope of your stomach performed, which also did
not show anything concerning.
- You were initially treated with antibiotics, but these were
stopped and you were started on steroids.
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:
___
|
10459458-DS-17 | 10,459,458 | 22,326,572 | DS | 17 | 2172-08-13 00:00:00 | 2172-08-12 20:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Morphine
Attending: ___.
Chief Complaint:
right upper quadrant pain
Major Surgical or Invasive Procedure:
___ laparoscopic cholecystectomy
History of Present Illness:
This patient is a ___ year old female who complains of Abd
pain. ___ yo F who presents with abdominal pain starting this
evening at the RUQ. The pain is not associated with food. No
fevers or chills. Nonbloodly nonbilious emesis. No diarrhea.
No chest pain, feels shrot of breathing with pain only. Had
similar episodes several months ago. No urianry symptoms.
Post partum x 3 months not currently menstruating normally
yet. No rashes.
Past Medical History:
PGYNHX:
- LMP: ___
- Paps: denies abnl
- STIs: denies
- contraception: condoms
PMH/PSH: denies
Social History:
___
Family History:
unknown
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Temp: 97.5 HR: 75 BP: 117/73 Resp: 18 O(2)Sat: 100
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Nondistended, Soft
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent
Physical Examination on Discharge: ___
Temp: 98.0, HR: 62, BP: 97/63, RR: 18, O2: 98% RA
General: A+Ox3, MAE
HEENT: Normocephalic, atraumatic
Cardiovascular: RRR, no extra heart sounds auscultated
Respiratory: CTA b/l
Abdomen: slightly distended, soft, moderate tenderness to
palpation
Skin: Lap sites c/d/i. No erythema or induration
Extremeties: no edema
Abdomen:
Pertinent Results:
___ 11:30PM BLOOD Neuts-74.5* ___ Monos-3.9 Eos-1.6
Baso-0.5
___ 05:43AM BLOOD ___ PTT-29.4 ___
___ 11:30PM BLOOD Glucose-95 UreaN-14 Creat-0.8 Na-141
K-4.4 Cl-102 HCO3-24 AnGap-19
___ 11:30PM BLOOD ALT-34 AST-51* AlkPhos-120* TotBili-0.2
___ 11:30PM BLOOD Lipase-33
___ 11:30PM BLOOD Albumin-4.3
Report not finalized.
Logged in only.
PATHOLOGY # ___
GALLBLADDER
___: liver/gallbladder US:
Nondistended gallbladder containing multiple gallstones and
top-normal wall thickness measurements of 2-3 mm. However, given
the negative sonographic ___ sign and lack of pericholecystic
fluid/ascites, acute cholecystitis is felt to be unlikely.
Brief Hospital Course:
The patient was admitted to the hospital with right upper
quadrant pain. Upon admission, the patient was made NPO, given
intravenous fluids, and underwent imaging. An ultra-sound of
the abdomen was done which showed a nondistended gallbladder
containing multiple gallstones and top-normal wall
thickness. Because the patient continued to have abdominal
pain, she was taken to the operating room where she underwent a
laparoscopic cholecystectomy. Her operative course was stable
with minimal blood loss. The patient was extubated after the
procedure and monitored in the recovery room.
Her post-operative course has been stable. The patient resumed
clear liquids and advanced to a regular diet. Initially
reportedly voiding in small amounts. Her incisional pain was
controlled with oral analgesia. The patient was discharged home
in stable condition on POD #1 in stable condition. A follow-up
appointment was made with Dr. ___ in the acute care clinic.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain
do not drive while on this medication
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
5. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
cholelithiasis
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 right upper quadrant
pain. You underwent an ultra-sound which showed gallstones.
You were taken to the operating room to have your gallbladder
removed. You are recovering from your surgery and you are
preparing for discharge home with the following instructions:
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
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 4 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for a couple of 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:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
10459488-DS-14 | 10,459,488 | 25,820,075 | DS | 14 | 2144-04-20 00:00:00 | 2144-04-20 19:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Asacol / Trazodone / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Bright Red Blood Per Rectum
Major Surgical or Invasive Procedure:
Endoscopy ___
Colonoscopy ___
History of Present Illness:
Mrs ___ is a ___ year old female with a history of Crohn's
s/p partial colectomy and gastritis who presents with BRBPR.
Mrs ___ underwent at stent placement in ___ for an
NSTEMI and started on aspirin/plavix. In ___ she
experienced two days of epigastric abdominal pain. While
hospitalized, she was noted to have a short episode of afib and
was started on warfarin. Some hours later she developed melanic
stools, so warfarin stopped. Subsequently underwent EGD in early
___ which was unrevealing.
In the past week, she endorses a vague sensation of abdominal
and vaginal fullness. She was otherwise in her usual state of
health after the EGD until the evening of ___ when she noted
BRBPR, first on her tissue paper. She also noted the passage of
several large stringy clots. This relieved her fullness
sensation. Since that time she has had 5 large bloody bowel
movements.
She denies any change in bowel frequency or pain, although she
claims she might have been more constipated recently. No
lightheaded or dizziness. No melena.
Transferred from ___ to ___ where she was
given IVF, 2 large bore IVs, and IV pantoprazole.
In the ED initial vitals were: 96.6 77 99/56 16 98% RA. Labs
were significant for WBC 13.1, H/H 8.6/27.7, normal caogs,
normal Chem 7. Baseline Hb appears to be 10.5 to 11. Vitals
prior to transfer were: 98.3 68 105/60 18 99% RA
Past Medical History:
Crohns Disease s/p left colectomy,
pAF
NSTEMI
CAD
Cholelithiasis
Gastritis
HLD
Osteoporosis
Rectal abscesses
C-section x 2
Social History:
___
Family History:
Anemia
Father had leukemia; diverticulosis
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 99.5 BP: 116/77 HR: 82 RR: 16 02 sat: 98/RA
GENERAL: awake, alert, NAD, pleasant
HEENT: NCAT, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD
CARDIAC: RRR, nl S1/S2 II/VI SEM. no r/g. No JVD
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, normoactive BS, mild ttp in RUQ, ___
sign negative. no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: dry and WWP, no cyanosis, clubbing or edema,
PULSES: 2+ DP pulses bilaterally
NEURO: moving all 4 extremities with purpose. facial movements
symmetrical. CN II-XII intact
SKIN: no excoriations or lesions, no rashes
DISCHARGE PHYSICAL EXAM:
Vitals: 98.1 106/48 71 16 97/RA
GENERAL: awake, alert, NAD, pleasant
HEENT: NCAT, EOMI MMM
CARDIAC: RRR, nl S1/S2 II/VI SEM. no r/g.
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft nt/nd normoactive BS
EXTREMITIES: dry and WWP, no cyanosis, clubbing or edema,
PULSES: 2+ DP pulses bilaterally
NEURO: moving all 4 extremities with purpose. facial movements
symmetrical. CN II-XII intact
SKIN: no excoriations or lesions, no rashes
Pertinent Results:
ADMISSION LABS:
___ 03:05AM BLOOD WBC-13.1* RBC-3.08* Hgb-8.6* Hct-27.7*
MCV-90 MCH-27.9 MCHC-31.0 RDW-14.8 Plt ___
___ 03:05AM BLOOD ___ PTT-24.9* ___
___ 03:05AM BLOOD Glucose-108* UreaN-19 Creat-0.9 Na-142
K-3.9 Cl-106 HCO3-24 AnGap-16
___ 12:50PM BLOOD ALT-16 AST-18 LD(LDH)-136 AlkPhos-61
Amylase-70 TotBili-0.9
___ 03:05AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.0
___ 12:50PM BLOOD calTIBC-277 Ferritn-27 TRF-213
NOTABLE LABS:
___ 03:05AM BLOOD WBC-13.1* RBC-3.08* Hgb-8.6* Hct-27.7*
MCV-90 MCH-27.9 MCHC-31.0 RDW-14.8 Plt ___
___ 12:50PM BLOOD WBC-8.5 RBC-2.82* Hgb-7.7* Hct-25.1*
MCV-89 MCH-27.4 MCHC-30.9* RDW-14.9 Plt ___
___ 05:00PM BLOOD WBC-7.5 RBC-3.25* Hgb-9.1* Hct-28.7*
MCV-88 MCH-28.1 MCHC-31.9 RDW-14.5 Plt ___
___ 08:45PM BLOOD WBC-7.9 RBC-3.41* Hgb-9.7* Hct-30.2*
MCV-89 MCH-28.6 MCHC-32.3 RDW-14.9 Plt ___
___ 08:35AM BLOOD WBC-8.7 RBC-3.03* Hgb-8.7* Hct-26.5*
MCV-87 MCH-28.6 MCHC-32.8 RDW-15.3 Plt ___
___ 03:00PM BLOOD WBC-7.7 RBC-3.14* Hgb-8.9* Hct-27.6*
MCV-88 MCH-28.5 MCHC-32.5 RDW-15.7* Plt ___
DISCHARGE LABS:
___ 03:00PM BLOOD WBC-7.7 RBC-3.14* Hgb-8.9* Hct-27.6*
MCV-88 MCH-28.5 MCHC-32.5 RDW-15.7* Plt ___
___ 03:00PM BLOOD Plt ___
___ 08:35AM BLOOD Glucose-77 UreaN-7 Creat-0.8 Na-142 K-3.3
Cl-108 HCO3-25 AnGap-12
___ 08:35AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.8
___ MRI OF THE PELVIS WITH AND WITHOUT IV CONTRAST:
The bladder is normal. The uterus and adnexa are normal.
Atherosclerosis of the infrarenal abdominal aorta is present
with wall irregularity, without aneurysmal dilatation or
significant stenosis. There is no free fluid in the abdomen and
pelvis. There is no concerning mesenteric, retroperitoneal or
pelvic lymphadenopathy. The bone marrow signal is normal.
IMPRESSION: Two short segments of active inflammation in the
distal ileum. The overall appearance is better compared to
___. No evidence of fistula or abdominal collections.
No masses.
___ EGD:
Impression:
Mildly irregular z-line was seen at the GE junction. (biopsy)
Normal mucosa in the stomach
Normal mucosa in the duodenum
No fresh or old blood was seen.
Otherwise normal EGD to third part of the duodenum
___ Colonoscopy:
Finding:
Maroon-red appearing liquid compatible with blood was found but
no active bleeding was identified. Post-surgical anatomy was
appreciated in setting of previous left colectomy. Terminal
ileum was grossly normal up to 10 cm and no gross or fresh blood
was seen. Pathy ulceration was seen through sigmoid colon
compatible with known Crohn's disease. 1 cm clean based
non-bleeding ulcer with 3 mm smaller adjacent ulcer was seen in
the rectum near the anal verge on retroflexion. Cold forceps
biopsies were performed for histology at the distal rectum
ulcers near anal verge.
Impression: Maroon-red appearing liquid compatible with blood
was found but no active bleeding was identified. Post-surgical
anatomy was appreciated in setting of previous left colectomy.
Terminal ileum was grossly normal up to 10 cm and no gross or
fresh blood was seen. Pathy ulceration was seen through sigmoid
colon compatible with known Crohn's disease. 1 cm clean based
non-bleeding ulcer with 3 mm smaller adjacent ulcer was seen in
the rectum near the anal verge on retroflexion. (biopsy)
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
PATIENT:
___ with history of Crohn's disease, gastritis and CAD s/p DES
on aspirin/plavix who presented with 1 day of BRBPR consistent
with lower GI bleed.
ACUTE ISSUES
# BRBPR: Likely Lower GI given history of symptoms. ASA/Plavix
continued despite bleed given recent stent placement. Hemoglobin
trended while inpatient. Transfused 1 unit PRBCs for worsening
anemia. Patient underwent endoscopy and colonoscopy which did
not identify culprit source lesion. Pill cam planned but MRE
demonstrated Crohn's inflammation in terminal illeum concerning
for strictures so further imaging not pursued. Bleeding self
terminated and hemoglobin remained stable for remainder of
hospitalization.
# Chest Pain: Patient had several episodes of chest pain while
hospitalized. Non-exertional and not similar to outpatient
anginal symptoms. EKGs were unchanged during these episodes
which self resolved or diminished after nitroglycerin
administration. Home ASA continued inpatient, and metoprolol
restarted at time of discharge.
CHRONIC ISSUES
# CAD/NSTEMI s/p DES: home ASA and Plavix continued while
inpatient
# paroxysmal AFIB: Patient in nsr for duration of
hospitalization
# HLD: continued home statin
# Crohn's Disease: continued home prednisone
TRANSITIONAL ISSUES
# MRE demonstrated stricture's likely Crohn's related: pill cam
not performed as an inpatient
# Medical team was not able to identify cause of bleeding during
this hospitalization
# PCP/Gastroenterologist to continue to Crohn's optimal
medication management
# Patient was experiencing chest pain while inpatient, deemed
not cardiac related. However, patient reported symptoms occuring
at home that are suggestive of stable angina
# No medications started during this admission
# Questionable history of afib, but was NSR while inpatient.
Question need for Holter monitoring.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Wheezing
2. Clopidogrel 75 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest Pain
5. Pantoprazole 40 mg PO Q24H
6. PredniSONE 4 mg PO DAILY
7. Rosuvastatin Calcium 40 mg PO DAILY
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Wheezing
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest Pain
5. PredniSONE 4 mg PO DAILY
6. Rosuvastatin Calcium 40 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Lower GI Bleed
Secondary Diagnosis:
Crohn's Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to the hospital because ___ had bleeding from
the rectum. Because ___ had lost a significant amount of blood,
___ were given extra blood by a transfusion. ___ underwent a a
colonoscopy and an endoscopy to evaluate the source of your
bleeding. While we were unfortunately not able to identify a
source from our tests, your bleeding stopped. ___ will be
discharged home and ___ should follow up with your PCP and
gastroenterologist.
Please take all medications as prescribed and keep all scheduled
appointments. If ___ have a recurrence of your symptoms or any
other signs that affect ___ please seek medical attention.
It was a pleasure taking care of ___!
Your ___ Care Team
Followup Instructions:
___
|
10459488-DS-16 | 10,459,488 | 28,992,536 | DS | 16 | 2144-09-18 00:00:00 | 2144-09-18 17:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Asacol / Trazodone / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy with biopsy ___
History of Present Illness:
___ with newly diagnosed metastatic small bowel
adenocarcinoma, Crohn's and CAD s/p stent presenting with melena
since ___. She was recently hospitalized for Crohn's
related
small bowel obstruction from ___ which resolved
medically. During that admission she was found to have
metastatic
liver lesions from tubular GI malignancy likely small bowel
adenocarcinoma. Since being at home she has been doing well as
has
appointments to see oncology (Dr. ___ next ___ as well
as
undergo port placement for chemotherapy. Patient reports she was
in USOH until yesterday morning when she noticed dark red bloody
stools. She had a total of 7 episodes but attempted to wait for
resolution. When she had another episode this morning, she
contacted her gastroentrologist, who recommended visiting the
ED. The patient proceeded to work, but felt dizzy/lightheaded,
diaphoretic, and weak following another dark red BM while there
and her co-workers called an ambulance.
In the ED, initial vital signs were: T P BP R O2 sat.
- Exam notable for: maroon stool. abd soft nt/nd, hd stable
- Labs were notable for stable H+H relative to prior discharge,
leukocytosis, lactate wnl, BUN/creat ___, negative trop x1.
Has had episodes of brbpr in both ___ and ___
requiring transfusion. Was on plavix and ASA (for PCI), they d/c
ASA in ___. No brbpr since ___ but has been hemoccult
positive since.
Reportedly went into A-fib in ambulance per pt but NSR on
arrival. Pt reports history of Afib during admission in ___ to
___ and was switched from brillinta to plavix with
hope of transition to coumadin but experienced bleed while on
heparin bridge so it was d/c'd.
Upon arrival to the floor, the patient reports feeling mildly
lightheaded but otherwise well. No HA, CP, SOB, abdominal pain,
or n/v/d. No fevers.
Past Medical History:
Crohn's disease with known TI stricture
Rectal abscesses
Osteoporosis
Asthma
Hyperlipidemia
Herpes zoster
Recurrent right upper quadrant discomfort
Osteopenia
CAD with history of NSTEMI, cardiac cath, and drug eluting stent
placement
Biliary colic and cholelithiasis
Chronic anemia (thought to be secondary to GI bleeding)
requiring multiple outpatient transfusions and chronic oral iron
therapy
Social History:
___
Family History:
No family history of colon CA. Cousin with UC. Father had
leukemia, prostate CA. Mother died of MI @ ___.
Physical Exam:
ADMISSION:
Vitals: 98.3 115/56 76 16 97%RA
General: WDWN woman laying comfortably in hospital bed
HEENT: NCAT EOMI MMM mild conjunctival pallor
Neck: Supple, full rom, no cervical LAD
CV: S1/S2, RRR no m/r/g
Lungs: CTAB w/o w/r/r
Abdomen: +BS soft NT/ND
GU: No CVA tenderness
Ext: No c/c/e
Neuro: AAOx3
Skin: Warm, dry intact
DISCHARGE:
Vitals: 98.3 126/56 64 18 97%RA
General: WDWN woman laying comfortably in hospital bed
HEENT: NCAT EOMI MMM mild conjunctival pallor
Neck: Supple, full rom, no cervical LAD
CV: S1/S2, RRR no m/r/g
Lungs: CTAB w/o w/r/r
Abdomen: +BS soft NT/ND
GU: No CVA tenderness
Ext: No c/c/e
Neuro: AAOx3
Skin: Warm, dry intact
Pertinent Results:
ADMISSION:
___ 11:30AM BLOOD WBC-15.3*# RBC-3.39* Hgb-9.2* Hct-29.1*
MCV-86 MCH-27.3 MCHC-31.7 RDW-19.8* Plt ___
___ 11:30AM BLOOD Neuts-74.8* ___ Monos-5.4 Eos-1.1
Baso-0.8
___ 11:30AM BLOOD ___ PTT-24.6* ___
___ 11:30AM BLOOD Plt ___
___ 11:30AM BLOOD Glucose-105* UreaN-19 Creat-0.9 Na-142
K-3.7 Cl-101 HCO3-27 AnGap-18
___ 11:30AM BLOOD cTropnT-<0.01
___ 07:25PM BLOOD cTropnT-<0.01
___ 05:30AM BLOOD Calcium-8.2* Phos-4.5 Mg-2.0
___ 11:41AM BLOOD Lactate-1.7
DISCHARGE:
___ 05:48AM BLOOD WBC-10.9 RBC-3.11* Hgb-8.9* Hct-26.5*
MCV-85 MCH-28.6 MCHC-33.7 RDW-19.4* Plt ___
___ 05:48AM BLOOD Plt ___
___ 05:30AM BLOOD Glucose-74 UreaN-12 Creat-0.7 Na-141
K-3.9 Cl-105 HCO3-25 AnGap-15
___ 05:30AM BLOOD CK-MB-5 cTropnT-0.06*
___ 03:50PM BLOOD CK-MB-4 cTropnT-0.05*
___ 05:30AM BLOOD Calcium-8.2* Phos-4.5 Mg-2.0
IMAGING:
___ GI Tissue Biopsy PATHOLOGIC DIAGNOSIS:
Terminal ileum, mucosal biopsies:
Adenocarcinoma, low grade, in this biopsy sample.
Note: A morphologic comparison to the liver mass lesion biopsy
(___) demonstrates a similar
cytomorphology. Preliminary findings were conveyed to Dr. ___
___ telephone at 14:27 on
___.
___ CXR IMPRESSION:
No evidence of pneumonia.
Brief Hospital Course:
___ with newly diagnosed metastatic small bowel adenocarcinoma,
Crohn's and CAD s/p stent presented with a day of melena. She
was recently hospitalized for Crohn's related small bowel
obstruction from ___ which resolved medically but was
found to have metastatic liver lesions from tubular GI
malignancy likely small bowel adenocarcinoma. She now presented
with melena and colonoscopy on ___ showed friable ulcerated
area in terminal ileum, pathology consistent with adenocarcinoma
similar to liver mets (this just came back ___ evening). Re
her CAD, she is <12 mo out from stenting and plavix on hold so
we started 81mg aspirin daily.
#GIB--
Given history, initial concern for lower GI bleed ___ malignancy
vs. Crohn's dx. Given recent liver pathology reports suggestive
of tubular GI tract adenocarcinoma likely small bowel and lesion
in TI, thought to represent bleed from malignant lesion. Patient
reports sx previously well controlled on prednisone with recent
switch to budesonide but prior to yesterday limited to ___ well
formed non-bloody BMs/day. Reports no change in recent diet.
Patient appeared hemodynamically stable with stable H+H relative
to discharge earlier in month on admission to the floor with
negative orthostatics. 2 PIVs placed, maintained active type and
screen with cross match. Patient transfused 1 unit pRBCs on
hospital day 2 and subsequently had stable H+H through rest of
admission. Follow-up colonoscopy with biopsy confirmed
adenocarcinoma of GI tract. Patient set up with outpatient
follow-up with Dr. ___ further evaluation and
management.
#Crohn's disease
Previously well managed on prednisone 4 mg PO daily, recently
switched to budesnoide after episodes of BRPBR. Continued
budensonide 9 mg PO daily through admission.
#Leukocytosis
Found to initially have leukocytosis, which likely represented
stress reaction in setting of illness. No recent signs of
infection, afebrile, colitis likely represents malignancy vs.
IBD. CXR w/o PNA. Resolved on hospital day #2.
#CAD
Expedition drug-eluting stent placed in LCx in ___. Off aspirin
since ___. Off plavix for past 2 days given previous plan
for port placement planned for ___. Initially held then
restarted metoprolol XL and imdur once hemodynamic stability
assured.
#?Afib
Not on anticoagulation reportly ___ to prior major bleed.
Initially held metop XL 25 mg PO in setting acute bleed, then
restarted the day prior to discharge. Monitored on telemetry
during admission without significant irregularity or noted Afib.
#HLD
Continued rosuvastatin 40 mg PO daily
TRANSITIONAL ISSUES
- Aspirin restarted
- Patient had mild troponemia with no ECG changes while
inpatient. Will follow-up with ___ in Cardiology to
establish care and re-address as needed.
- Terminal ileum adenocarcinoma diagnosed
- GI bleed requiring 1 unit pRBC transfusion
- Plavix held for PORT placement as well as GI bleed as
recommended by surgery team
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
2. Ferrous Sulfate 325 mg PO BID
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergies
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Rosuvastatin Calcium 40 mg PO QPM
6. Vitamin D 50,000 UNIT PO EVERY 2 WEEKS
7. Cyanocobalamin 1000 mcg IM/SC MONTHLY
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Budesonide 9 mg PO DAILY
11. Clopidogrel 75 mg PO DAILY
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
13. anise miscellaneous DAILY
14. Tylenol Extra Strength (acetaminophen) 1000 mg oral at least
BID x2 weeks for pain
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
2. Budesonide 9 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergies
4. Pantoprazole 40 mg PO Q24H
5. Rosuvastatin Calcium 40 mg PO QPM
6. Aspirin 81 mg PO DAILY
7. anise 0 MISCELLANEOUS DAILY
8. Cyanocobalamin 1000 mcg IM/SC MONTHLY
9. Ferrous Sulfate 325 mg PO BID
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
13. Tylenol Extra Strength (acetaminophen) 1000 mg oral at least
BID x2 weeks for pain
14. Vitamin D 50,000 UNIT PO EVERY 2 WEEKS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: metastatic adenocarcinoma of the small bowel,
gastrointestinal bleed, anemia
Secondary: coronary artery disease, angina
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 at ___
___. You were admitted for a gastrointestinal bleed
and had a colonoscopy which showed an ulcerated area of the last
part of your small intestine. The biopsy from this area showed
cancer that is likely the source of the cancer in your liver.
You were treated with a transfusion and your blood counts
stabilized.
You will need to follow up with your outpatient providers as
scheduled.
Thank you,
Your ___ Care Team
Followup Instructions:
___
|
10459538-DS-9 | 10,459,538 | 22,566,429 | DS | 9 | 2188-11-23 00:00:00 | 2188-11-23 17:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
s/p unhelmeted fall from scooter
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ male who presents to ___ on
___ with a severe TBI. The patient was riding his scooter
un-helmeted this morning going approximately twenty miles per
hour when he fell off and hit his head with positive loss of
consciousness. He was taken to an OSH where a ___ demonstrated
multiple right sided epidural hematomas.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory
Physical Exam:
ON ADMISSION:
**************
Physical Exam:
GCS at the scene: 15_
GCS upon Neurosurgery Evaluation:15 Time of evaluation:
Airway: [ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[x]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
Exam:
Gen: WD/WN, comfortable, NAD.
HEENT:
Neck:
Extrem: warm and well perfused
Neuro:
Mental Status: Awake, alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech is fluent with good comprehension.
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
AT DISCHARGE:
**************
VS Tmax 98.9; HR37-69; BP 85-113/45-63; RR ___ 98-100% SpO2
RA
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No
Comprehension intact [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
IPQuadHamATEHLGast
[x]Sensation intact to light touch
Pertinent Results:
Please refer to OMR for relevant imaging and lab results.
Brief Hospital Course:
#Epidural Hematoma
Patient was admitted to the Neuro ICU on ___ following an
unhelmeted fall from scooter for close surveillance and
conservative management. On ___, the patient remained
neurologically stable on examination and it was determined she
would be transferred out of the neuro ICU to the ___ for close
monitoring. On ___, he underwent a repeat non-contrast head CT
that was stable. He remained neurologically intact throughout
his admission. On ___ he was discharged home and told to
follow-up with Dr. ___ with repeat imaging in 4 weeks.
#ST Elevations on Telemetry
On ___, the patient was noted to have ST elevations on
telemetry. An EKG was obtained which showed ST elevations and
was reviewed by Cardiology. It was determined no further
intervention or tests were needed.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Pain -
Moderate
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth Q6 hours prn Disp #*30 Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. LevETIRAcetam 750 mg PO BID
RX *levetiracetam [Keppra] 750 mg 1 tablet(s) by mouth twice a
day Disp #*7 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN Constipation
Discharge Disposition:
Home
Discharge Diagnosis:
epidural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. 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 have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10459551-DS-15 | 10,459,551 | 20,934,317 | DS | 15 | 2159-05-21 00:00:00 | 2159-05-21 22:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L.leg pain and epigastric pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a ___ y.o man with h.o COPD, HL, HTN, pancreatitis, COPD
with recent dx of PNA and COPD supposed to be taking prednisone
and levofloxacin who presented to the ED with 2 issues. First
issue is epigastric "irritation" ___ that developed acutely
last night at 9pm and was ___. He reports feeling "bile" with
this. He denies n/v/d/c/melena/brbpr/dysuria, fever or chills.
In addition, he reports ___ l.thigh pain that is "shifting"
that started sat night. He reports chronic unchanged swelling in
the b/l ___. He denies paresthesias or weakness.
In addition, he denies CP, sob, palpitations, cough, headache,
dizziness. OTher 10pt ROS reviewed and otherwise negative.
In the ED, he was given IV heparin for DVT and IV
ctx/azithromycin.
Past Medical History:
HTN
"arthritis"
pulmonary nodules
"fatty liver"
COPD
Social History:
___
Family History:
Mother-emphysema, PE (died ___
GM-stroke
Cousin - stroke
HTN
Cancer
Physical Exam:
GEN: NAD, speaking in full sentences, no coughing
vitals:
97.7
PO 141 / 79 56 18 95 RA
HEENT:ncat eomi anicteric MMM
chest: b/l ae no w/c/r
heart: s1s2 rr no m/r/g/
abd: +bs, soft, NT, ND, no guarding or rebound
ext: 3+ ___ edema, L>R with dry skin noted
neuro: face symmetric, speech fluent
psych: calm, cooperative
Pertinent Results:
___ 05:17AM LACTATE-1.3
___ 03:33AM ___ PTT-24.1* ___
___ 03:33AM ___ PTT-24.1* ___
___ 02:39AM ALT(SGPT)-24 AST(SGOT)-14 ALK PHOS-68 TOT
BILI-0.2
___ 02:39AM LIPASE-158*
___ 02:39AM cTropnT-<0.01
___ 02:39AM ALBUMIN-3.7
___ 02:39AM URINE HOURS-RANDOM
___ 02:39AM URINE UHOLD-HOLD
___ 02:39AM WBC-8.3 RBC-4.25* HGB-13.0* HCT-38.2* MCV-90
MCH-30.6 MCHC-34.0 RDW-14.8 RDWSD-47.8*
___ 02:39AM NEUTS-69.6 ___ MONOS-8.1 EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-5.78# AbsLymp-1.77 AbsMono-0.67
AbsEos-0.01* AbsBaso-0.02
___ 02:39AM PLT COUNT-143*
___ 02:39AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:39AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
Discharge labs
___ 07:47AM BLOOD WBC-5.8 RBC-5.15 Hgb-15.3 Hct-45.2 MCV-88
MCH-29.7 MCHC-33.8 RDW-14.6 RDWSD-46.8* Plt ___
___ 07:16AM BLOOD Glucose-154* UreaN-16 Creat-1.0 Na-139
K-3.7 Cl-99 HCO___ AnGap-15
___ 08:44AM BLOOD Lipase-127*
___ 02:39AM BLOOD Lipase-158*
___:
IMPRESSION:
Focal non-occlusive thrombus within the deep femoral vein at the
level of the confluence with the superficial femoral vein. Clot
extends into the deep femoral vein.
CXR ___:
IMPRESSION:
Right base opacity concerning for pneumonia
EKG:
reviewed, has some TWI V4-v6 that appear new
Brief Hospital Course:
___ y.o man with h.o COPD, HTN, HL, prior pancreatitis, recent dx
of PNA/COPD treated with levoflox/prednisone who presented with
epigastric pain, LLE pain found to have DVT, continued PNA,
concern for pancreatitis.
#acute DVT LLE-pt reports chronic ___ edema. Possibly provoked
with long train rides. U/s with new DVT. Pt put IV heparin
given need for monitoring with reports of guaiac + brown stool.
No melena seen during hospitalization and hematocrit remained
stable; however guaiac was positive initially and negative on
subsequent checks. Patient was counseled at length regarding
use of coumadin or NOAC and decision made to use coumadin, so he
was bridged with heparin gtt as he continued coumadin. We
offered a lovenox bridge but Mr. ___ refused needles at home
so was bridged in house until INR therapeutic. He was
discharged on coumadin 8 mg daily and will f/u with ___
clinic on ___ for INR check.
#pneumonia, bacterial
#COPD, chronic
-pt recently presented to the ED ___ and was dx with PNA rx
levoflox x 5 days. He also appears to have a prednisone
prescription for 40mg x 5 days starting on ___. CXR here with
continued evidence of PNA but clinically no fever, SOB, cough
and likely pt improving. Unclear if pt taking his prescribed
medication correctly given pills in bottles. Course of
prednisone and levaquin completed this admission.
He still had occasional wheezing, discharged on albuterol,
should discuss with his PCP obtaining ___, use of combivent,
spiriva.
#epigastric pain, possible gastritis/duodenitis
#guaiac positive brown stool -
#h.o pancreatitis, concern for current pancreatitis
Etiologies possibly due to epigastric pain due to pancreatitis
or possible duodenitis/gastritis given NSAID use and prednisone
use. Elevated lipase but pt denied any current abdominal pain or
nausea and refuses any diet other than regular diet. He would
eat large portions of food during admission. PPI started
empirically but was discontinued after 1 week course. He did
have one guaiac positive stool in the hospital. He should have
EGD as an outpatient, and should have GI f/u arranged through
his PCP to discuss his chronic symptoms of intermittent
n/v/epigastric pain. Of note, pt declined anything but a regular
diet.
Despite one reported guiaic positive stool, he was not anemic
despite being anti coagulated and hit was 45 on day of
discharge.
#HTN-continued home HCTZ. Occasional SBP less than 100; PCP can
consider reducing dose or stopping medicine altogether.
#arthritis/pain-Tylenol. Held NSAIDS given above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levofloxacin 750 mg PO Q24H
2. PredniSONE 40 mg PO DAILY
3. Naproxen 500 mg PO Q12H:PRN Pain - Mild
4. Baclofen 10 mg PO TID
5. Hydrochlorothiazide 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
DVT
Abdominal pain
pneumonia - treated
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for evaluation of leg pain and an abdominal
pain and found to have a blood clot in your leg and continued
pneumonia and possible pancreatitis. You were started on a blood
thinner which you will need to take for at least 3 to six months
time. You will need to have your "INR"/blood test checked every
few days by your ___ clinic until things are stable.
In regards to your abdominal pain with occasional nausea and
vomiting, we recommend that your PCP order an endoscopy and
consider gastroenterology referral, especially since you had a
trace amount of blood in your stool. Your PCP can also consider
a gastric emptying study if deemed appropriate.
While you are on a blood thinner please DO NOT use alcohol and
do NOT take medicines such as ibuprofen or aspirin as these
things will dramatically increase your risk of bleeding.
Please be sure to elevate your legs to help with swelling and to
continue to discuss with your PCP leg swelling and management
and work up strategies as appropriate.
Your doctor's office has a ___ clinic from 830-415 on
___. You can walk in without an appointment. They are
expecting you.
I have faxed a prescription for your Coumadin and for your
albuterol inhaler to the ___ in ___ Corner. Please use
your albuterol for your wheezing, and talk to your PCP regarding
other medicines that you may need for your COPD
Followup Instructions:
___
|
10459551-DS-17 | 10,459,551 | 24,278,480 | DS | 17 | 2159-12-09 00:00:00 | 2159-12-09 17:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
leg tightness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male with a history of
COPD, LLE DVT previously on warfarin, HTN, HLD, a reported
history of CHF (LVEF unknown) and recurrent ED visits (for
various complaints, mostly dyspnea recently), who presents with
complaints of bilateral lower extremity edema.
Patient reports that he has had bilateral lower extremity
swelling for years, but recently he feels an increased tightness
in his bilateral legs. He reports that his legs feel stiff when
he climbs stairs. He denies any pain in either leg. He notes
that
he recently complete 6 months of warfarin for left lower
extremity DVT. He denies any fevers or chills. He denies any
sores or ulcers on his lower extremities. He reports that he has
only been able to wear sandals for several months because his
shoes do not fit.
He reports shortness of breath with exertion, which has been
ongoing for years (since he was in his ___. He states that this
is unchanged. He cannot climb more than ___ steps without
getting
winded. He denies any chest pain or palpitations either at rest
or with exertion. He denies orthopnea or PND.
In the ED, initial vital signs were: 97.8 67 151/78 20 98% RA
- Exam notable for: Obese malodorous male with marketed
bilateral
lower extremity edema extending above the knees bilaterally with
chronic stasis dermatitis. No open wounds, no tenderness to
palpation, both legs appear relatively equal bilaterally.
Remainder of exam is unremarkable
Past Medical History:
COPD
HTN
Congestive heart failure
HLD
DVT, previously on warfarin
History of pancreatitis
History of recurrent pneumonia
Pulmonary nodules
Arthritis
Fatty liver
Sleep apnea
Social History:
___
Family History:
Mother-emphysema, PE (died ___
GM-stroke
Cousin - stroke
HTN
Cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.2 61 179/100 18 95% RA
GENERAL: AOx3, in no acute distress
EYES: PERRL, EOMI
ENT: Moist mucous membranes, missing many teeth, poor dentition
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
PULM: CTAB, no wheezes, rales, rhonchi. Intermittent dry cough
during exam.
GI: Obese, soft, nontender, nondistended
MSK: Bilateral lower extremity lymphedema. 2+ pitting edema in
feet bilaterally. ___ palpable but faint. Negative ___.
SKIN: Bilateral venous stasis changes of lower extremities. Skin
intact without ulceration.
NEUROLOGIC: Aox3, no focal deficits, steady gait.
DISCHARGE PHYSICAL EXAM:
Vitals: 97.3 PO 160 / 84 HR: 76 RR:20 O2: 97% RA
GENERAL: AOx3, elderly man sitting up on bed
EYES: PERRL, EOMI
ENT: Moist mucous membranes, missing many teeth, poor dentition
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
PULM: Inspiratory and expiratory wheezes noted on exam
bilaterally
GI: Obese, soft, nontender
MSK: Bilateral lower extremity lymphedema. Nonpitting edema
SKIN: Bilateral venous stasis changes of lower extremities. Skin
intact without ulceration.
NEUROLOGIC: Aox3, no focal deficits
Pertinent Results:
ADMISSION LABS:
___ 06:10AM BLOOD WBC-4.2 RBC-4.68 Hgb-13.9 Hct-41.7 MCV-89
MCH-29.7 MCHC-33.3 RDW-14.7 RDWSD-47.2* Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD Glucose-106* UreaN-16 Creat-1.0 Na-145
K-4.0 Cl-106 HCO3-26 AnGap-13
___ 06:10AM BLOOD ALT-14 AST-13 LD(LDH)-208 AlkPhos-69
TotBili-0.2
DISCHARGE LABS:
___ 07:10AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.0
___ 07:10AM BLOOD WBC-5.6 RBC-4.86 Hgb-14.0 Hct-42.5 MCV-87
MCH-28.8 MCHC-32.9 RDW-14.5 RDWSD-46.5* Plt ___
___ 07:10AM BLOOD Glucose-101* UreaN-18 Creat-1.1 Na-145
K-4.0 Cl-103 HCO3-29 AnGap-13
___ ultrasound ___
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
CXR ___
Possible mild pulmonary vascular congestion.
Brief Hospital Course:
___ man with a history of COPD, LLE DVT previously on
warfarin, HTN, HLD, a reported history of CHF (LVEF unknown),
sleep apnea, and multiple recurrent ED visits (for various
complaints, dyspnea recently), who presents with bilateral lower
extremity tightness and difficulty walking.
#Lymphedema
Patient states he has had leg swelling for "at least ___ years".
Tried compression stockings previously but they "hurt too much"
and he refuses to try them again. He was advised to use
pneumatic compression devices in the past but states they were
too expensive. Denies leg pain. He has extensive bilateral
nonpitting edema; says his legs feel "tight" and it was
difficult for him to climb the stairs. He reports a recent
episode of DVT which was treated with warfarin; repeat U/S here
was negative for DVT. The patient was advised to call the
lymphedema center at ___ to schedule an appointment
(appointment could not be made for him)
#Congestive heart failure
Patient with reported history of heart failure (LVEF) unknown,
and patient reports that he has not been taking his furosemide
recently. States he often misses appointments with his primary
care doctor and cardiologist because he forgets about them. His
BNP was normal in the ED and his leg swelling was nonpitting,
likely due to his chronic lymphedema rather than a heart failure
exacerbation. CXR showed only mild pulmonary vascular
congestion. He was treated with two doses of iv Lasix and then
transitioned to his home po Lasix. We emphasized the importance
of going to his doctor's appointments and taking his medications
as prescribed.
#HTN
Patient with SBPs in 150s-170s, previously took
hydrochlorothiazide but stopped this when his primary care
doctor started him on furosemide. He was started on amlodipine
5mg daily in the hospital. Please titrate as appropriate.
#COPD
Wheezing on exam. Continued home albuterol inhaler. Ambulatory
O2 sat 96%.
#HLD
Continued home pravastatin.
#Sleep apnea
Chronic issue for patient but he refuses CPAP, stating that it
is too loud.
TRANSITIONAL ISSUES:
[ ] Patient was restarted on home furosemide 40 mg BID and will
need to have his electrolytes checked within 1 week of leaving
the hospital.
[ ] Patient was started on amlodipine 5mg in the hospital for
hypertension. Please titrate as appropriate.
[ ] He has follow up appointments scheduled with his primary
care doctor and cardiologist.
[ ] He was advised to call the ___ lymphedema center to
schedule an appointment. Please ensure follow-up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO BID
2. Pravastatin 20 mg PO QPM
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheeze
4. Potassium Chloride 20 mEq PO DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheeze
3. Furosemide 40 mg PO BID
4. Potassium Chloride 20 mEq PO DAILY
5. Pravastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
lymphedema
congestive heart failure
hypertension
Secondary:
chronic obstructive pulmonary disease
hyperlipidemia
arthritis
sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent but with difficulty
Discharge Instructions:
Dear Mr. ___,
You presented to ___ because you were having
leg tightness and it was difficult for you to walk. The medicine
team explained to you that this is a chronic condition called
lymphedema. This condition is best treated with medication
management. Thus, it is important for you to take your
medications as prescribed (see below) and follow up with your
primary care provider and cardiologist.
Your appointments with your primary care doctor and cardiologist
have already been scheduled for your convenience (see below).
You also need to follow up with a lymphedema specialist. Your
primary care doctor can refer you to the ___ clinic at
___ of ___. If you wish to see a specialist at ___, please
call ___ to schedule an appointment.
We started you on a new blood pressure medication, amlodipine
5mg daily. Please take this every day and follow-up with your
primary care doctor.
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
10459883-DS-18 | 10,459,883 | 23,109,176 | DS | 18 | 2199-03-05 00:00:00 | 2199-03-06 18:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
___ PPM lead replacement
History of Present Illness:
Mr. ___ is a ___ with a history
of mitral valve and aortic valve replacement, CHB s/p PPM,
a-fib,
who presents with worsening dyspnea over the several months and
found to have worsening AI on TTE.
He initially arrived at ___ in respiratory distress with
oxygen saturation in the 80. Started on BiPAP. Had pulmonary
vascular congestion so he was given antibiotics and Lasix 20mg
IV
with minimal output.
Formal cardiology TTE there showed worsening aortic
regurgitation. Spoke to cardiology at ___ and was transferred
here for further evaluation by cardiac surgery. Troponin 0.07
and
BNP elevated.
In the ED initial vitals were: 97.8 112 136/64 28 98% RA
Labs/studies notable for: Leukocytosis, BNP 1670, trop 0.06, vbg
7.46/29, INR 4.8
Imaging notable for:
___ CXR
IMPRESSION: Stable examination. No evidence of pneumonia or
acute
cardiopulmonary abnormality.
Vitals on transfer: 96 ___ 95% 4L NC
On the floor, patient reports a chronic worsening of his
dyspnea.
States that it has been bad for years but worse since ___,
worse with exertion, limits him to one flight of stairs. No
chest
pain, palpitations, PND, edema.
At time of interview feels relatively well, not in respiratory
distress.
REVIEW OF SYSTEMS: 10 point ROS negative except as above
Past Medical History:
Aortic Insufficiency
Atrial fibrillation
Diabetes
Dyslipidemia
Hypertension
Complete heart block- pacemaker, s/p RV lead revision ___
Endocarditis
AVR and MVR (mechanical)
Left MCA stroke in ___ with residual seizures (none x ___ yr)
Renal insufficiency
GERD
Gastritis
OCD
Social History:
___
Family History:
Mom with depression; dad diabetes, prostate cancer, pacemaker;
sister with cancer currently in remission; children in good
health.
Physical Exam:
ADMISSION EXAM:
===============
GENERAL: WDWN in NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple, JVP not elevated
CARDIAC: RRR, mechanical S1 and S2, no murmurs/rubs/gallops. No
water hammer pulse or head ___.
LUNGS: Slightly increased WOB but speaking full sentences.
Slight
rales in bases, no wheeze.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE EXAM:
===============
___ 0827 Temp: 98.1 PO BP: 122/77 R Sitting HR: 91 RR: 15
O2
sat: 99% O2 delivery: Ra FSBG: 108
GENERAL: NAD
HEENT: NC/AT, anicteric sclera, MMM
NECK: Supple, no JVD
CARDIAC: RRR, mechanical S1/S2 with II/VI systolic murmur
LUNGS: CTABL, no wheezes/rhonci/rales
ABDOMEN: Soft, non-tender to palpation without rebound/guarding,
non-distended
EXTREMITIES: Fading erythema on L leg/thigh within delineated
margins, echymosses extending into left flank, continually
interval improvement. Ecchymoses in the L popliteal fossa
SKIN: Warm and well-perfused, no rashes
NEURO: Alert, oriented, moving all extremities with purpose
Pertinent Results:
ADMISSION LABS:
==============
___ 01:23PM BLOOD WBC-16.7* RBC-4.44* Hgb-13.5* Hct-42.8
MCV-96 MCH-30.4 MCHC-31.5* RDW-15.7* RDWSD-55.9* Plt ___
___ 01:23PM BLOOD Neuts-78.3* Lymphs-6.9* Monos-8.9 Eos-4.9
Baso-0.5 Im ___ AbsNeut-13.09* AbsLymp-1.15* AbsMono-1.48*
AbsEos-0.82* AbsBaso-0.09*
___ 02:01PM BLOOD ___ PTT-46.0* ___
___ 01:23PM BLOOD Glucose-96 UreaN-35* Creat-2.1* Na-142
K-5.1 Cl-103 HCO3-22 AnGap-17
___ 07:30AM BLOOD ALT-20 AST-34 LD(LDH)-568* AlkPhos-82
TotBili-0.5
___ 01:23PM BLOOD proBNP-1670*
___ 07:30AM BLOOD Albumin-3.4* Calcium-10.0 Phos-4.0 Mg-2.1
___ 07:30AM BLOOD %HbA1c-6.1* eAG-128*
___ 01:18PM BLOOD ___ pO2-20* pCO2-43 pH-7.38
calTCO2-26 Base XS--1
PERTINENT STUDIES:
==================
CAROTID SERIES COMPLETE ___
IMPRESSION:
Mild heterogeneous plaque within both carotid arteries, with
less than 40%
stenosis of each carotid artery.
TEE ___
IMPRESSION: Good image quality. Well seated bileaflet mitral
valve prosthesis with normal disc motion
and gradient with mild paravalvular valvular regurgitation. Well
seated mechanical aortic valve
prosthesis with normal disc motion, normal gradient, and
moderate paravalvular aortic regurgitation.
CARDIAC CATH ___
Dominance: Co-dominant
* Left Main Coronary Artery
The LMCA is without significant disease.
* Left Anterior Descending
The LAD is without significant disease.
* Circumflex
The Circumflex is without significant disease.
The ___ Marginal is with mid focal 70%.
* Right Coronary Artery
The RCA is without significant disease.
CT LOW EXT W/O CONTRAST ___
IMPRESSION:
Expansion and edema within the left vastus lateralis muscle with
intramuscular collections consistent with intramuscular
hematomas given hematocrit level. associated subcutaneous edema
and stranding within the anterior soft tissues of the left lower
thigh. Small left knee joint effusion.
CT A/P W/O CONTRAST
CT LOW EXT W/O CONTRAST ___
1. No change in left thigh hematoma. No evidence of
retroperitoneal
hemorrhage
2. Very mild acute sigmoid diverticulitis.
3. Left lower lobe pneumonia.
CT HEAD W/O CONTRAST ___
1. No acute infarcts, hemorrhage, edema or mass effect. Please
note MRI of the brain is more sensitive for the detection of
acute infarct.
2. Chronic left MCA territory infarct.
3. Atrophy, probable small vessel ischemic changes, and
atherosclerotic
vascular disease as described.
EP PROCEDURE REPORT ___
Successful addition of new RV pacing lead.
Capping of old RV pacing lead.
Reuse of existing pacemaker generator.
There were no complications.
CXR ___
Left-sided pacemaker is unchanged. Moderate cardiomegaly is
stable. There is stable elevation of the right hemidiaphragm.
No pneumothorax is seen. There are no pleural effusions
DISCHARGE LABS:
===============
___ 12:00PM BLOOD WBC-15.7* RBC-3.35* Hgb-9.6* Hct-30.7*
MCV-92 MCH-28.7 MCHC-31.3* RDW-17.6* RDWSD-57.1* Plt ___
___:00PM BLOOD ___ PTT-33.4 ___
___ 12:00PM BLOOD Glucose-145* UreaN-37* Creat-1.4* Na-139
K-4.5 Cl-102 HCO3-24 AnGap-13
___ 03:45AM BLOOD CK(CPK)-409*
___ 12:00PM BLOOD Calcium-9.4 Phos-3.7 Mg-2.1
___ 07:38AM BLOOD calTIBC-228* ___ Ferritn-282
TRF-175*
___ 07:30AM BLOOD %HbA1c-6.1* eAG-128*
Brief Hospital Course:
Mr. ___ is a ___ with a history of mitral valve and aortic
valve replacement who presented with worsening dyspnea over
months and was found to have worsening AI on TTE due to valvular
leak and planned for outpatient plugging. His hospital course
was complicated by development of left thigh intramuscular
hematoma. He was observed and bridged to warfarin. Additionally,
he was found to have elevated RV impedance and underwent lead
replacement.
ACTIVE ISSUES
=============
# Acute aortic insufficiency
# Mechanical mitral and aortic vales
# Acute heart failure
Presented with dyspnea requiring BiPap in ED. TTE at OSH showed
severe 3+ aortic regurgitation. Cardiac surgery and structural
cardiology were consulted and TEE performed which showed
moderate aortic regurgitation paravalvularly. Plan was made for
outpatient percutaneous plugging of paravalvular leak, though
after discussion with outpatient cardiologist will continue with
medical optimization for now and defer procedure. Restarted on
warfarin with heparin bridge while subtherapeutic. D/c INR 2.3,
D/c Warfarin 5mg, though will require close monitoring.
# Left Thigh Intramuscular Hematoma
Developed acute-onset left thigh pain ___ while walking while
on heparin gtt bridge awaiting therapeutic INRs. ___ negative
for DVT. CT with intramuscular hematoma and subcutaneous edema.
ACS consulted and recommended wrapping leg and holding heparin
drip. No evidence of compartment syndrome. Heparin initially
held, then restarted as a bridge to warfarin. INR reached
therapeutic level and heparin gtt discontinued. Hgb fell,
transfused for <8, s/p total of 5U pRBC. ACS signed off.
Hematoma improved substantially prior to discharge.
# AV block s/p PPM
Patient underwent PPM interrogation and was found to have
elevated RV lead impedance. He underwent successful lead
replacement and his PPM was interrogated the next day. Will have
outpatient device clinic follow=up
# Hyperkalemia
Persistent hyperkalemia throughout admission, requiring
intermittent treatment with calcium gluconate and
insulin/dextrose. Etiology felt to be in the setting of
hemolysis from left thigh hematoma. K was 4.5 on day of DC.
# Leukocytosis
Pt with persistent leukocytosis throughout his admission,
thought to be stress response ___ hematoma. Infectious w/u was
negative, though found to have clinically non-significant LLL
PNA and mild sigmoid diverticulitis incidentally on CT A/P. Had
brief episode of hypotension and AMS on ___ and was briefly on
ABx, though BCx were negative and ABx were quickly DC'd
CHRONIC/STABLE ISSUES
=====================
# CAD
The patient was continued on Aspirin 81 mg PO/NG DAILY and
Rosuvastatin Calcium 20 mg PO QPM
# Epilepsy
The patient was continued on Lamotrigine 150 mg PO/NG DAILY
# Anxiety/depression
The patient was continued on Sertraline 100 mg PO/NG DAILY
# DMII
The patient takes Lantus 50u BID at home, and was reduced to 30
units BID + HISS while in the hospital.
# CKD
Pt with baseline Cr 1.6-2.0, pt's Cr on DC improved to 1.4
TRANSITIONAL ISSUES:
====================
# DC INR: 2.3
# DC Cr: 1.4
# DC Hb: 9.6
[] INR goal 2.5-3.5 as patient with mechanical AV/MVs, also with
CVA hx. If INR persistently <2.5, may require heparin gtt. Was
on IV Vancomycin from ___ for post-PPM prophylaxis, which
may affect INR
[] Please check electrolytes in next ___ to ensure stable K and
Cr
[] Please check CBC in next ___ to ensure stable Hb
[] Per discussion with outpatient Cardiologist, will plan for
medical management of AI and defer any procedures for now
[] Please monitor Lt thigh hematoma to ensure resolution
#DC WEIGHT: 91.31kg (201.3 lbs)
#CODE: Full
#CONTACT: Sister, ___ (___)
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Aspirin 81 mg PO DAILY
4. Warfarin 8 mg PO 3X/WEEK (___)
5. Warfarin 6 mg PO 4X/WEEK (___)
6. Rosuvastatin Calcium 20 mg PO QPM
7. Lisinopril 5 mg PO DAILY
8. LORazepam 1 mg PO QHS:PRN anxiety
9. Zolpidem Tartrate 5 mg PO QHS
10. LamoTRIgine 150 mg PO DAILY
11. Sertraline 100 mg PO DAILY
12. Vitamin D Dose is Unknown PO DAILY
13. Glargine 50 Units Breakfast
Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Lidocaine 5% Patch 1 PTCH TD QPM
3. Metoprolol Tartrate 6.25 mg PO BID
please hold for HR<60, sBP<100
4. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
5. Ramelteon 8 mg PO QHS
Should be given 30 minutes before bedtime
6. TraZODone 25 mg PO QHS:PRN insomnia
7. Glargine 30 Units Breakfast
Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Vitamin D 1000 UNIT PO DAILY
9. ___ MD to order daily dose PO DAILY16
10. Aspirin 81 mg PO DAILY
11. LamoTRIgine 150 mg PO DAILY
12. LORazepam 1 mg PO QHS:PRN anxiety
13. Multivitamins 1 TAB PO DAILY
14. Rosuvastatin Calcium 20 mg PO QPM
15. Sertraline 100 mg PO DAILY
16. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until you talk with your Cardiologist
17. HELD- Metoprolol Succinate XL 25 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until you talk with your PCP or cardiologist
18. HELD- Zolpidem Tartrate 5 mg PO QHS This medication was
held. Do not restart Zolpidem Tartrate until you talk with your
PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
- Acute on chronic aortic regurgitation
- Left lateralis thigh hematoma
- PPM Elevated RV Lead impedance
SECONDARY DIAGNOSIS:
====================
- Mechanical mitral and aortic valve
- Hyperkalemia
- DM2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
WHY WAS I ADMITTED TO THE HOSPITAL?
- You developed shortness of breath.
- You had an echocardiogram which showed that one of your
mechanical valves was not working properly.
- You needed an evaluation by the cardiac surgeons.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were seen by our cardiac surgery team and then our
interventional cardiology team.
- They recommended that you work on medical management of your
valve, and if you need a procedure, it will be done outpatient.
- After restarting your blood thinner, you developed a hematoma
in your thigh.
- We monitored your hematoma and watched as your INR came back
to an appropriate level.
- Because of the blood you lost into the hematoma in your thigh,
we gave you blood transfusions.
- While you were here, your pacemaker was evaluated and it was
found that the lead needed to be replaced. You had a procedure
done to replace the lead. After this procedure, you were given
antibiotics to help prevent an infection from developing.
WHAT SHOULD I DO WHEN LEAVE?
- Please take all of your medications as prescribed.
- Please attend all of your follow up appointments as arranged
for you.
- Please check your weight daily and call your Cardiologist if
your weight increases by more than ___ lbs
It was a pleasure taking care of you and we wish you the best!
Sincerely,
Your ___ Cardiology Team
Followup Instructions:
___
|
10459906-DS-5 | 10,459,906 | 23,849,609 | DS | 5 | 2173-08-31 00:00:00 | 2173-08-31 18:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Hypertensive emergency/aortic dissection
Major Surgical or Invasive Procedure:
___ - ___
History of Present Illness:
This is a ___ yo Male with an unremarkable PMH who presented to
___ in ___ of ___ with severe bilateral
upper back pain, radiating to his left arm and diaphoresis.
There was no inciting event and no prior similar episodes. He
reported pain ___ and at ___ waiting room, had
subsided to ___ but then escalated again with diaphoresis. He
was taken to ___ and this showed a type B aortic dissection
originating distal to the left subclavian artery to the level of
the infrarenal abdominal aorta. He also noted to have two
infrarenal aneurysms measuring 3.3cm and 2.5cm, as well as a
left common iliac artery measuring 1.8cm.
His BP on presentation was 192/86. He has never been on blood
pressure medication. Was previously hypertensive and quit
alcohol consumption ___ years ago and since then BP has been
normal. Was seen by his PCP 3 weeks ago with a reportedly normal
BP per patient.
At ___, he was treated with Dilaudid, Ativan, Zofran for
symptoms, and started on an esmolol gtt for BP control. He was
subsequently transferred to ___.
In the ED, initial vitals:
7 98.8 78 151/78 16 98% RA
EKG: NSR, HR 76, NA, NI, TWI and STD in III
Chem 7 was unremarkable
CBC showed WBC of 17 with H/H of 13.7/40.7
Trop <0.01
He was started on nicardipine gtt as well with BP improvement,
then admitted to the MICU. He was evaluated by the vascular
surgery team, with no plans for OR.
On transfer, his systolics were in the 130's.
On arrival to the MICU, his chest pain is at ___
Past Medical History:
DEPRESSION H/O
HYPERLIPIDEMIA
HYPERTENSION
ALCOHOL ABUSE H/O-No alcohol x ___ years
Social History:
___
Family History:
Mother: ___.
Patient also reports there is a significant, but not diagnosed,
family history of ETOH problems.
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM:
=======================
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRLA
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+ symmetric pulses, no clubbing,
cyanosis or edema
SKIN: No rashes or erythema
NEURO: CN II-XII intact bilaterally, strength/sensation intact,
no focal deficits
=======================
DISCHARGE PHYSICAL EXAM:
=======================
Afebrile, VSS
General: well appearing, NAD
HEENT: normocephalic, atraumatic, no scleral icterus
Resp: breathing comfortably on room air
CV: regular rate and rhythm on monitor
Abdomen: soft, NT, ND
Extremities: bilateral upper extremities warm, groins soft, no
evidence of hematoma, feet warm, DP & ___ pulses palpable
bilaterally.
Pertinent Results:
LABS:
___ 03:25AM GLUCOSE-119* UREA N-19 CREAT-0.8 SODIUM-140
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15
___ 03:25AM PLT COUNT-198
___ 03:25AM ___ PTT-33.0 ___
___ 03:25AM WBC-17.4*# RBC-4.38* HGB-13.7 HCT-40.7 MCV-93
MCH-31.3 MCHC-33.7 RDW-12.2 RDWSD-41.5
IMAGING:
CTA Torso ___:
1. There is a type B aortic dissection originating distal to the
left subclavian artery to the level of the infrarenal abdominal
aorta. A small amount of fluid is seen around the aortic arch.
There is no intramural hematoma on the noncontrast phase. The
dissection flap does not involve the origins of the great
vessels including the left subclavian artery. Dissection flap
extends into the origin of the celiac axis. The superior and
inferior mesenteric arteries and left renal artery originate
from the true lumen. The right renal artery originates from the
false lumen. The celiac axis, superior and inferior mesenteric,
and renal arteries are patent.
Two infrarenal abdominal aortic aneurisms measuring 3.3cm and
2.5cm. The left common iliac artery is aneurismal measuring
1.8cm.
2. Trace emphysema with biapical predominance. Bilateral
dependent atelectasis. Otherwise, clear lungs. No pleural or
pericardial effusions. No axillary, hilar, or mediastinal
lymphadenopathy.
3. Abdomen and pelvis: Fatty liver. Thickening of the adrenal
glands bilaterally with no discrete nodules. No free air or free
fluid. Abdominal and pelvic viscera, and unopacified bowel are
unremarkable.
Brief Hospital Course:
Mr ___ presented to ___ with tearing back and chest pain
and severe hypertension. He was transferred to the ICU for
management of hypertension. Blood pressure was kept in tight
control with SBP less than 140s. The patient required high doses
of antihypertensive medications. Cardiology was consulted to aid
in transition to PO medications. The patient was briefly able to
be weaned from IV medications, but unfortunately had recurrence
of his back pain on ___, thus repeat CTA was performed which
showed stable appearance of his dissection, but in the setting
of recurrent pain the decision was made to take the patient to
the OR for TEVAR repair of aortic dissection. CTA of the head
and neck was performed to ensure intact circle of ___ and
vertebral arteries ___ involvement of the left subclavian artery
in preparation for the OR. The procedure was tolerated without
complication, for more information about the procedure please
refer to the operative report. The patient was initially managed
in the CVICU in the immediate post operative period, and
required IV antihypertensives to control his blood pressure. He
was eventually weaned of all drips and blood pressure was
managed on >4 PO antihypertensives. Lumbar drain was placed
during case, clamp trialed, and removed on POD 2. The patient
denied any neurologic deficits and none were noted on serial
neurologic exams. The patient was advanced to a regular diet
which he tolerated. Of note, Left arm blood pressure was checked
and noted to be 51/31, which is expected after surgery. He was
started on cilostazol for left upper extremity claudication
symptoms. On POD 4, the patient complained of dizziness with
standing and visual changes. His blood pressure was noted to be
___. Thus, his antihypertensive regimen was de-escalated
to amlodipine 10mg QD and labetalol 400 mg daily, and blood
pressures were controlled with this regimen. Patient had a
rising creatinine noted on POD 5, which peaked at 3.4. This
improved with IV rehydration and de-escalation of blood pressure
regimen. He underwent a renal duplex ultrasound which showed
normal flow to bilateral kidneys. ___ evaluated him and deemed
him appropriate for discharge to rehab. Of note, the patient was
found to have an adrenal incidentaloma which was noted on CTA.
He was worked up for pheochromocytoma, and all tests came back
negative. He was discharged home on POD 7. At the time of
discharge, he was urinating and stooling normally, pain was
controlled on oral pain medication, and he was out of bed to
ambulate with minimal assistance. He was discharged with plan to
follow up with endocrinology for refractory hypertension,
cardiology for refractory hypertension, and vascular surgery
with repeat CTA.
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
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
2. Labetalol 400 mg PO TID
RX *labetalol 200 mg 2 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*3
3. Acetaminophen 1000 mg PO Q8H
do not exceed > 3gm Tylenol a day
4. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
5. Calcium Carbonate 500 mg PO QID:PRN indigestion
6. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*100 Capsule Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth
daily Disp #*48 Packet Refills:*0
8. Cilostazol 100 mg PO BID
RX *cilostazol 100 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Symptomatic Type B Dissection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
MEDICATIONS:
Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT AT HOME:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart (use ___
pillows or a recliner) every ___ hours throughout the day and at
night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and go up and down stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call ___ for
transfer to closest Emergency Room.
Followup Instructions:
___
|
10459962-DS-4 | 10,459,962 | 24,336,030 | DS | 4 | 2115-09-18 00:00:00 | 2115-09-18 15:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
assault
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ gentleman who was brought to an outside
hospital after an assault. He had injuries to his face and was
extubated for extreme agitation.
Past Medical History:
None
Social History:
___
Family History:
noncontributory
Physical Exam:
Discharge Physical Exam:
Gen: alert and oriented x3 NAD
HEENT: lip laceration with sutures in place, some continued
oozing from site; echcymoses over left face
CV: RRR
Pulm: CTAB
Abd: Soft NT ND
Ext: WWP
Pertinent Results:
___ 04:43AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
CT Face
IMPRESSION:
1. Nondisplaced fracture of the alveolar process of the maxilla
to the left of midline, surrounding ___ teeth #9 and 10. There
may be loosening of these teeth, however, the teeth appear
intact.
2. Opacification of the right maxillary sinus likely a large
mucosal
retention cyst as no definite maxillary wall fracture is
identified.
CT Head
IMPRESSION:
1. No evidence of acute intracranial process.
2. Right maxillary sinus opacification with no definite
fracture visualized. The density is lower than what would be
expected for acute hemorrhage; however, maxillofacial CT is
recommended.
Brief Hospital Course:
Mr. ___ was initially taken to an outside hospital. He was
intubated for agitation and underwent CT of head and face. A
nondisplaced maxillary fracture was noted but no other acute
injuries. He was transfered to ___ for further care, and
admitted to the ___ given his ventilator-dependance on
transfer. Plastic surgery was consulted and sutured the
laceration on his lip. On HD 1 he was weaned off the vent and
extubated. He remained neurologically intact and reported only
mild left sided facial pain. His ___ tooth did become loose
after extubation and was kept in saline pending dental
evaluation. As his tertiary survey revealed no new injuries and
he was otherwise well, tolerating diet, voiding, and
hemodynamically stable, he was discharged home on HD 1. He will
follow up with his dentist on day of discharge and with ACS in
clinic as needed. He will also follow up in clinic with plastic
surgery.
Medications on Admission:
none
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4 Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
maxillary fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the Acute Care Surgery service for
management of your injuries after an assault. You were found to
have a small fracture to your maxilla and a laceration to your
lip. You were seen by plastic surgery in the emergency
department and the laceration was repaired.
Please make an appointment to see your dentist in the next day.
You will have a small amount of narcotic pain medication to take
for the pain. Please take this only as directed. You can also
take tylenol or motrin for pain, but only as directed on the
bottle.
Followup Instructions:
___
|
10460364-DS-9 | 10,460,364 | 27,638,967 | DS | 9 | 2146-03-01 00:00:00 | 2146-03-01 15:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ line
dialysis catheter
History of Present Illness:
Mr. ___ is a ___ year old man with a past medical history of
nephrolithiasis and morbid obesity s/p gastric bypass who
regained all weight who presents as a transfer from ___
___ for elevated bili ~20.
He was in his usual state of health until about 5 days ago when
he began developing RUQ pain. He noted that his stools were
becoming gray and greasy and his urine became more dark with
decreased UOP despite normal fluid intake (He last urinated on
AM
of ___. About 3 days ago he had extensive vomiting. He also
felt feverish over the past few days and so went to his PCP who
drew labs and then called him at home and told him to go to the
ED. He presented at ___ where work up was significant for
WBC
14.2 with bandemia, Sodium 128, Calcium 6.4, Cr 5.1 (unknown
baseline), T bili 17.9, Dbili >10, AST 63, ALT 88, ALP 202,
Lipase 193. He was given Zosyn and 1LNS and transferred to ___
given c/f pancreatitis and acute cholangitis.
In the ED,
- Initial Vitals: T 98.2, HR 90, BP 113/68, RR 22, SpO2 95% on
RA
- Exam showed obese, jaundiced, icteric sclera, diffuse abd
tenderness worst in LUQ, trace edema.
- Labs:
VBG ___
Lactate 2.5 --> 2.6 after total 2L IVF (one at OSH, one in ED)
___ 18, INR 1.7
WBC 14.1
Hgb 12.7
T bili 21
Na 131, BUN 66, Cr 5.9, AG 21
Ca 6.0
Blood cultures pending
- Imaging:
RUQUS: enlarged common hepatic duct at 10mm. cholelithiasis
without definite gallbladder thickening.
CT:
1. Extremely limited exam given patient's body habitus and lack
of intravenous contrast.
2. The pancreas is not well visualized; however, there is
peripancreatic stranding and edema, suggestive of acute
pancreatitis.
3. Cholelithiasis.
In the ___ ED he was given Zosyn, 2L LR, Calcium gluconate
4gm.
Despite fluid resuscitation he continued to have pH 7.2 and
elevated lactate so was admitted to the FICU given concern for
possible decompensation. Said his abdominal pain is worst in the
LUQ. Has
not had any UOP since yesterday AM.
Past Medical History:
Morbid Obesity s/p gastric bypass about ___ years ago
Nephrolithiasis
Hypertension
Shoulder surgery
Social History:
___
Family History:
Mom died of cancer unknown
Dad has T2DM
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
GENERAL: Morbidly obese man, alert and interactive.
HEENT: NCAT. PERRL, EOMI. Icteric sclera.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. JVD unable to assess given body
habitus.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: Unable to assess given patient cannot sit up due to pain.
ABDOMEN: Normal bowels sounds, non distended, no organomegaly.
Positive ___ sign. Also TTP in LUQ. Well healed midline
surgical scar from gastric bypass.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash. Venous stasis
hyperpigmentation of b/l lower legs.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. AOx3.
Pertinent Results:
Labs:
___
WBC-14.1* RBC-4.74 Hgb-12.7* Hct-40.5 MCV-85 MCH-26.8 MCHC-31.4*
RDW-19.0* RDWSD-58.9* Plt ___
___
WBC-10.2* RBC-2.04* Hgb-5.4* Hct-18.4* MCV-90 MCH-26.5
MCHC-29.3* RDW-16.3* RDWSD-53.3* Plt ___
___
WBC-6.9 RBC-2.57* Hgb-6.8* Hct-22.2* MCV-86 MCH-26.5 MCHC-30.6*
RDW-16.4* RDWSD-51.2* Plt ___
___
___ PTT-26.6 ___
___
Glucose-120* UreaN-66* Creat-5.9* Na-131* K-4.7 Cl-91* HCO3-19*
AnGap-21*
___
Glucose-111* UreaN-90* Creat-9.0* Na-125* K-5.0 Cl-86* HCO3-16*
AnGap-23*
___
Glucose-143* UreaN-92* Creat-4.7*# Na-133* K-3.7 Cl-88* HCO3-25
AnGap-20*
___
ALT-98* AST-114* AlkPhos-235* TotBili-21.0*
___
ALT-98* AST-114* AlkPhos-235* TotBili-21.0*
___
ALT-25 AST-32 AlkPhos-160* TotBili-1.3
___
Lipase-131*
___
Lipase-40
___
CK-MB-4 cTropnT-<0.01
___
Calcium-8.0* Phos-7.1* Mg-2.1
___
VitB12-1435* Folate-3
___
calTIBC-179* Ferritn-1365* TRF-138*
___
%HbA1c-5.6 eAG-114
___
Triglyc-225* HDL-13* CHOL/HD-9.7 LDLcalc-68
___
25VitD-<5*
___
HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG IgM HAV-NEG
___
AMA-NEGATIVE Smooth-NEGATIVE
___
___
___
IgG-584* IgA-285 IgM-26*
___
ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG
___
HCV Ab-NEG
___
Blood-SM* Nitrite-NEG Protein-100* Glucose-TR* Ketone-NEG
Bilirub-LG* Urobiln-NEG pH-5.5 Leuks-SM*
___
RBC-16* WBC-36* Bacteri-FEW* Yeast-NONE Epi-27 TransE-2
IMAGING
DUPLEX DOP ABD/PEL ___
IMPRESSION:
1. As before, the exam is significantly limited due to the
patient's body
habitus.
2. Patent hepatic vasculature.
3. CBD measures 0.8 cm, decreased from 1.0 cm. No intrahepatic
biliary ductal dilatation.
4. Cholelithiasis without definite sonographic evidence of acute
cholecystitis.
5. Splenomegaly.
CXR ___
IMPRESSION:
Moderate cardiomegaly has probably developed in the interim.
Mediastinal and pulmonary vascular engorgement suggest volume
overload. No pulmonary edema. No appreciable pleural effusion.
No pneumothorax.
CT A/P ___
IMPRESSION:
1. Extremely limited exam given patient's body habitus and lack
of intravenous
contrast.
2. Poorly visualized pancreas appears edematous with mild amount
of
peripancreatic fluid and fat straining, possibly representing
pancreatitis.
No drainable fluid collection. Recommend correlation with
symptoms and lipase level.
3. Right lateral abdominal wall nonobstructive colon containing
hernia.
4. Cholelithiasis.
RUQUS ___
IMPRESSION:
1. Significantly limited exam due to patient's body habitus.
2. There is no definite intrahepatic biliary dilatation. The
common hepatic
duct is enlarged, measuring up to 10 mm.
3. Cholelithiasis without other findings to suggest acute
cholecystitis.
MICROBIOLOGY
==============
___ 7:16 pm BLOOD CULTURE Source: Line-aline.
Blood Culture, Routine (Pending): No growth to date.
___ 7:00 am URINE Source: Catheter.
**FINAL REPORT ___
REFLEX URINE CULTURE (Final ___: NO GROWTH.
___ 10:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
SUMMARY:
============
Mr. ___ is a ___ year old man with a past medical history of
morbid obesity s/p gastric bypass who was transferred from
___ and admitted to the ___ for pancreatitis and
concern for cholangitis complicated by hyperbilirubinemia and
renal failure.
FICU COURSE ___ to ___:
=============================
#) GI:
On presentation to the FICU he had abdominal pain and was
jaundiced (Tbili 21) with a transaminitis, leukocytosis, and
mildly elevated lipase (131) with CT findings with
peripancreatic stranding and cholelithiasis concerning for acute
cholangitis and pancreatitis ___ gallstones and he was started
on zosyn ___ to ___. ___, GI, and Hepatology were consulted
and ultimately agreed that he most likely has biliary
obstruction due to gallstones but unable to do ERCP given
patient's body habitus and history of Roux-en-Y gastric bypass.
#) Renal
Of note, he also had ___ of unclear etiology with SCr 5.9,
uremeia, hypocalcemia, and hyponatremia. He developed worsening
renal failure and was started on CRRT from ___ to ___ and
transitioned to iHD on ___.
#) ID
He developed increasing leukocytosis (WBC 33) on ___ and was
started on IV vanc ___ to ___. He also had diarrhea and C.
diff was PCR+ toxin negative but given clinical symptoms and
increasing leukocytosis he was treated with a course of PO vanc
___ to ___. His Bcx, ucx, and CXR were negative and the IV
zosyn and vanc were stopped on ___. He remained hemodynamically
stable off pressors and on RA and was transferred to a regular
nursing floor for further management.
Floor course:
#) Transaminitis and hyperbilirubinemia
Patient presented with concern for cholangitis.
Given his BMI he was unable to receive standard of care
including MRCP, ERCP, PTBD and was at high risk for CCY per
surgery.
Fortunately his LFTs all improved with time and he did not
require any interventions other than antibiotics early in the
hospital course as above.
Hepatology felt based on his BMI that a part of this may have
been chronic from underlying undiagnosed NASH cirrhosis.
Plan is for him to follow up with hepatology and bariatric
surgery for consideration of CCY as an outpatient.
He was given first dose of hep A and hep B vaccine on ___.
#) Acute renal failure
Patient presented with ___ likely ___ ATN in the setting of
sepsis.
As above he received CRRT and iHD in the ICU. His last day of
iHD was ___. Since then he was continued on lasix 80 IV tid for
goal net negative 1 L per day and then transitioned to torsemide
60 BID on ___. I suspect that with resolution of his ___, he
will need less diuretics. At the same time, I think that his
appetite and PO intake will increase when he gets home which may
result in less negative net balance.
He should follow up with renal as an outpatient.
#) C diff
C diff PCR was positive and patient was empirically started on
PO vanc in the ICU for diarrhea. C diff toxin came back negative
but patient was already on the regular floor 7 days into course.
He completed 10 days of PO vanc.
He continued to have loose stools on and off which he says is
not new. Given hx of gastric bypass recommended he reduce simple
sugars and eat smaller more frequent meals.
#) pAfib
Patient was noted to have a run of afib while septic in the ICU.
He had no other events on tele. He has no history of afib. He
was continued on lopressor for rate control.
His Chadsvasc is 0. Anticoagulation was not started but should
continue to be reassessed if risk factors changed.
He said he has OSA but does not use CPAP because it is
uncomfortable. Finding a way to improve his adherence as an
outpatient may help with long term afib control.
#) Chronic lower back pain
Patient was on home tramadol.
Pain was worsened here likely from immobility and was given
oxycodone as needed.
#) HX of gastric bypass
Started on thiamine, folate and Vit D.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
2. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Metoprolol Tartrate 100 mg PO BID
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Hepatitis A Vaccine 1 mL IM ONCE Duration: 1 Dose
3. Lidocaine 5% Patch 1 PTCH TD QPM back pain
RX *lidocaine 5 % 1 patch once a day Disp #*10 Patch Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet by mouth once a day Disp #*7 Tablet
Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
RX *polyethylene glycol 3350 17 gram 1 dose by mouth once a day
Disp #*7 Packet Refills:*0
6. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
7. Torsemide 60 mg PO BID
RX *torsemide 20 mg 3 tablet(s) by mouth twice a day Disp #*180
Tablet Refills:*0
8. Vitamin D ___ UNIT PO 1X/WEEK (MO)
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth every ___ Disp #*30 Capsule Refills:*0
9. Metoprolol Tartrate 25 mg PO BID
10. Omeprazole 40 mg PO DAILY
11. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
12. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until you see your
primary care doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Non alcoholic steatohepatosis cirrhosis
acute renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital because of abdominal pain and
concern that you had a blockage and infection in the ducts of
your liver, gallbladder and pancreas. Many of the procedures
that normally would have been done could not be performed
because of your weight. Fortunately, your liver got better on
its own.
You also had injury to your kidneys from the stress put on your
liver. You received dialysis while you were here but then came
off and now are on diuretics which help you urinate.
Followup Instructions:
___
|
10460886-DS-11 | 10,460,886 | 29,914,472 | DS | 11 | 2120-12-29 00:00:00 | 2120-12-31 11:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
abd pain
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
___ ___ presents w/abd cramping, nausea, NBNB emesis and
loose stools. Pt reports that she has had N/V/abd pain for about
1 month. +Anorexia, weight loss, fatigue, decreased PO intake.
For the past 2 days had had small amounts of non-bloody
diarrhea. No fevers, sick contacts, recent hospitalizations.
Took 2 days of azithromycin 1 month ago, no other antibiotics.
Saw doctor on ___ and called today w/ persistent pain and n/v
and was referred in for evaluation
In ED pt given zofran and CT abd which showed no acute process.
Past Medical History:
PAST MEDICAL HISTORY:
Hypertension
GERD
Possible Chron's Disease
PAST SURGICAL HISTORY:
C-section (X2)
Cholecystectomy (___)
Hysterectomy (___)
Appendectomy (___)
Social History:
___
Family History:
Sister, daughter with ___ disease. Father died of renal
disease. Mother died of stroke. No reported family history of
cancer or cardiac disease. Denies any history of liver or
pancreatic disease. No history of bleeding dyscrasias.
Physical Exam:
VS: 97.9 150/75 83 18 98%ra
Gen: nad
Heent: membranes dry
Chest: clear
CV: irreg, no m/r/g
Abd: soft, nt/nd, nabs
Ext: no e/c/c
Neuro: alert, follows commands
Pertinent Results:
Admission:
___ 02:20PM BLOOD WBC-13.6* RBC-3.88* Hgb-11.6* Hct-36.7
MCV-95 MCH-29.9 MCHC-31.6 RDW-14.2 Plt ___
___ 02:20PM BLOOD Neuts-88.1* Lymphs-9.6* Monos-2.3 Eos-0
Baso-0
___ 02:20PM BLOOD Glucose-124* UreaN-22* Creat-0.8 Na-139
K-4.0 Cl-102 HCO3-26 AnGap-15
___ 06:45AM BLOOD ALT-16 AST-16 AlkPhos-56
___ 06:45AM BLOOD Calcium-8.5 Mg-1.5*
Discharge:
___ 06:32AM BLOOD WBC-11.2* RBC-3.25* Hgb-9.8* Hct-30.7*
MCV-95 MCH-30.3 MCHC-32.0 RDW-14.8 Plt ___
___ 06:32AM BLOOD Glucose-84 UreaN-14 Creat-0.7 Na-143
K-3.6 Cl-109* HCO3-26 AnGap-12
Iron Studies:
___ 06:45AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.4* Iron-26*
___ 06:45AM BLOOD calTIBC-226* Ferritn-26 TRF-174*
___ 09:55PM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:55PM URINE Blood-SM Nitrite-POS Protein-300
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 09:55PM URINE RBC-1 WBC-2 Bacteri-MANY Yeast-NONE Epi-3
CT A/P - IMPRESSION:
1. No evidence of active ___. Chronic mild thickening of
the cecum.
2. Severe stenosis of the celiac and SMA arteries as described
in prior CT.
3. Large hiatal hernia.
BARIUM SWALLOW - IMPRESSION:
1. Large mixed sliding/paraesophageal hiatal hernia
2. Dysfunctional esophageal motility with only disordered
tertiary waves identified.
EGD:
___ esophagus
Large hiatal hernia
Ulcers in the stomach body and antrum (biopsy)
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
ASSESSEMENT & PLAN: ___ yo ___ disease presents with 1
month of nausea, emesis and abd pain and 2 days of diarrhea.
# N/V/D/Abd Pain: The patient was seen by GI and underwent EGD,
which showed many ulcers in the stomach. Her PPI was increased
to BID. Biopsies were pending at the time of discharge and will
need to be followed up.
# Anemia: Hct dropped somewhat during admission but then
remained stable. Iron studies were sent and reveal both low iron
and low TIBC. Hct will need to be followed in the outpatient
setting.
# Hypokalemia, Hypomagnesemia: Noted to be a chronic problem for
this patient. She was repleted while in house.
# Leukocytosis: Likelt ___ steroids. Remained relatively stable
throughout admission.
# HTN: ACEi was initially held but then restarted. Given
persistent hypertension while in house, labetalol was increased
to 200 BID. BP will need to be rechecked in approx. 1 week.
# Asymptomatic Bacteriuria: UA positive for bacteria, cx grew
ecoli and enterococcus. However, pt denied any urinary
complaints. No antibiotics were given.
TRANSITIONAL ISSUES:
- Bcx pending at the time of discharge and will need to be
followed up
- GI Biopsies pending at the time of discharge and will need to
be followed up
- Pt will need to follow up with PCP ___ 1 week for BP and lyte
check
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Budesonide 9 mg PO DAILY
2. Labetalol 100 mg PO BID
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >
6. PredniSONE 10 mg PO DAILY
7. Ranitidine 300 mg PO DAILY
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Budesonide 9 mg PO DAILY
3. Labetalol 200 mg PO BID
RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Lisinopril 20 mg PO DAILY
5. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
6. PredniSONE 10 mg PO DAILY
7. Ranitidine 300 mg PO DAILY
8. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
RX *lansoprazole [Prevacid SoluTab] 30 mg 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Gastric Ulcers
Presumed ___ Disease
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to the hospital with nausea, vomiting, and
abdominal pain. You were seen by our gastroenterology service
and had an endoscopy performed. This revealed multiple ulcers in
your stomach. For this, we are increasing the frequency of your
lansoprazole (Prevacid) to twice a day. You will follow up with
the gastroenterologists to discuss the results of the biopsies
that were taken during this procedure.
Your blood pressure was also noted to be elevated during your
hospitalization. To better control your blood pressure, the dose
of one of your medications (labetalol) was increased.
Please refer to the enclosed medication list for all changes to
your medications.
It was a pleasure taking part in your medical care.
Followup Instructions:
___
|
10460886-DS-13 | 10,460,886 | 26,350,813 | DS | 13 | 2121-01-26 00:00:00 | 2121-01-26 14:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Bactrim
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
___ angiogram with failed PTA for chronic mesenteric ischemia,
both right groin and left brachial access with L brachial
hematoma and AVF
History of Present Illness:
Mrs. ___ is an ___ with history of gatritis, PUD,
presumptive ___ with known mesenteric occlusive disease who
re-presented to the Medicine service with persistent nausea with
lower abdominal pain. She states the pain is more often
associated after meals, with an intermittent 'burning' reflux
pain. She denies a history of food fear or hesitance to ingest
food, but states she does not have much of an appetite. She has
lost weight over the past several months but cannot quantify how
much, probably 'at least ___ pounds.
She otherwise denied hematochezia or hematemesis. She has
undergone significant GI work-up, including colonoscopy, EGD,
and UGI series. She has a known hiatal hernia which appears to
be stable.
She has been evaluated in the out-patient setting by Dr. ___
___ recently, who has already reviewed her extensive imaging.
At that time, there was no role for intervention or successive
imaging given the collateralization seen on CT.
Past Medical History:
Presumptive ileocecal ___ disease (+serology), chronic
mesenteric occlusive disease with known SMA/celiac stenosis, hx
gastric ulcers, hx PUD, esophageal dilation, sliding
paraesophageal hernia, HTN, vit D deficiency
PAST SURGICAL HISTORY:
C-section (X2)
Cholecystectomy (___)
Hysterectomy (___)
Appendectomy (___)
Social History:
___
Family History:
Sister, daughter with ___ disease. Father died of renal
disease. Mother died of stroke. No reported family history of
cancer or cardiac disease. Denies any history of liver or
pancreatic disease. No history of bleeding dyscrasias.
Physical Exam:
Upon Admission:
General: Alert, oriented, no acute distress, lying in bed
Head: NCAT
E: Sclera anicteric
ENT: mucous membranes moist, oropharynx clear
Neck: supple, JVP not elevated, no LAD; anodular thyroid
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, Non tender, non-distended, + bowel sounds, no
rebound tenderness or guarding. Well healed lap scars
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII grossly intact
Skin: No rash.
Psych: pleasant, appropriate
Upon Discharge:
Vital signs stable, afebrile
General: Alert, oriented, no acute distress, lying in bed
Head: NCAT
E: Sclera anicteric
ENT: mucous membranes moist, oropharynx clear
Neck: supple, JVP not elevated, no LAD; anodular thyroid
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, Non tender, non-distended, + bowel sounds, no
rebound tenderness or guarding. Well healed lap scars
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, angio sites well healed, clean, dry, intact
Neuro: CN II-XII grossly intact
Skin: No rash.
Psych: pleasant, appropriate
Pertinent Results:
___ 09:32PM ___ PO2-43* PCO2-39 PH-7.41 TOTAL CO2-26
BASE XS-0 COMMENTS-GREEN TOP
___ 09:32PM LACTATE-1.0
___ 05:24PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 05:24PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-600
GLUCOSE-NEG KETONE-40 BILIRUBIN-SM UROBILNGN-2* PH-6.0 LEUK-TR
___ 05:24PM URINE RBC-3* WBC-22* BACTERIA-MOD YEAST-NONE
EPI-11
___ 05:24PM URINE HYALINE-3*
___ 05:24PM URINE MUCOUS-MANY
___ 01:20PM GLUCOSE-126* UREA N-15 CREAT-0.5 SODIUM-139
POTASSIUM-3.2* CHLORIDE-101 TOTAL CO2-28 ANION GAP-13
___ 01:20PM estGFR-Using this
___ 01:20PM ALT(SGPT)-11 AST(SGOT)-12 ALK PHOS-88 TOT
BILI-0.8
___ 01:20PM LIPASE-31
___ 01:20PM CALCIUM-7.8* PHOSPHATE-3.0 MAGNESIUM-1.2*
___ 01:20PM WBC-19.4*# RBC-3.37* HGB-9.9* HCT-30.8*
MCV-91 MCH-29.4 MCHC-32.2 RDW-14.3
___ 01:20PM NEUTS-87.4* LYMPHS-7.9* MONOS-4.3 EOS-0
BASOS-0.4
___ 01:20PM PLT COUNT-488*
___ 01:20PM ___ PTT-30.3 ___
IMPRESSION: (THE READ OF THIS CT SCAN WAS LATER INFORMALLY READ
BY ANOTHER RADIOLOGIST WHO THOUGHT THERE WERE CHANGES CONSISTENT
WITH ISCHEMIC COLITIS, NOT ___ FLARE)
1. Few regions of bowel inflammation including the terminal
ileum, ascending colon, and sigmoid colon, consistent with skip
lesions of ___ disease flare.
2. Small bilateral pleural effusions are new since ___.
3. Dense atherosclerosis of the abdominal aorta including large
plaques at the bases of the celiac axis and SMA.
4. Large hiatal hernia.
US UE ___
IMPRESSION:
Turbulent flow with both arterial and venous waveforms is noted
involving the left brachial artery in the mid arm and consistent
with an AV fistula
involving the left brachial artery and a left brachial vein.
Brief Hospital Course:
# Abdominal ___ Ischemia: Our initial
differential includes chronic gastric ulcer inflammation vs.
chronic mesenteric ischemia vs. ___ flare vs. UTI vs.
adrenal insufficiency vs. hepatic/gallbladder/pancreatic
pathology. The latter two are virtually ruled out by the normal
cortisol and LFT labs. Further, her symptoms are the same as
when she presented less than a week ago in which the primary
team along with GI and vascular surgery consults thought PUD was
the most likely scenario given her symptoms and alleviation with
IV pantoprazole. We continued pantoprazole 40 mg BID and
sucralfate 1 g QID. We continued the patient's budesonide 9 mg
and later downtrended to 6 mg after CT scan revealed ischemic
colitis rather than chron's flare. Additionally, cipro/flagyl
was added for empiric bowel flora coverage given high risk for
infection. GI was consulted and very involved in the patient's
care. Patient was kept on PPN and complete bowel rest during
this time. After patient's symptoms were thought to be
attributed to ischemic colitis, she was then transferred to the
vascular service where she underwent an angiogram with attempted
stenting of the ___ which was unsuccessful and complicated by a
brachial hematoma and small AV fistula. The patient was put on
TPN and slowly advanced to clear liquids which she tolerated in
small amounts. The patient was also started on Cipro and Flagyl
for treatment of ischemic colitis which she will remain on until
she has been revascularized. Several family meetings were held
discussing with the patient and her daughters that the only
treatment for her condition would be an ___ bypass. The patient
was unsure if she desired any further surgical intervention and
was discharged to an extended care facility on ___ with
outpatient follow with Dr. ___ to discuss any future
surgical interventions.
# Electrolyte abnormalities: Pt. admitted with hypokalemia and
hypomagnesemia likely due to combination of malnutrition and
chronic diarrhea/vomiting. Repleted upon admission and
throughout her stay through IV fluids.
# UTI: It was noted that patient was not treated for E.Coli on
last admission. Repeat UA and UCx showed infection with pan
susceptible E.Coli. Cipro was started. Patient only needed a 3
day course for this but cipro was kept on board for bowel
prophylaxis in the setting of ischemic colitis
Chronic Issues
# Fe deficiency anemia: w/u during previous hospitalization. Hct
stable. We continued to trend Hct, guaiac stools
# Hypertension: Chronic, stable. We continued labetolol 100mg
BID and lisionpril 20mg daily
# Proteinuria: Pt. with recurrent proteinuria throughout recent
hospitalizations. Thought to be due to hypertensive nephropathy
per past renal notes
The patient underwent selective aortic catheterization via
brachial artery access with abdominal aortogram, selective
catheterization of the inferior mesenteric artery with
mesenteric angiography, and balloon angioplasty of the inferior
mesenteric artery with technical failure. She was admitted to
the vascular surgery service post-operatively. Because of
difficulty with her PO intake, she was started on TPN at goals
per nutrition recommendations. She was maintained on clears as
tolerated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Budesonide 9 mg PO DAILY
2. Labetalol 100 mg PO BID
3. Lisinopril 20 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. Sucralfate 1 gm PO QID
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Budesonide 6 mg PO DAILY
RX *budesonide 3 mg 2 Capsules by mouth Once a day Disp #*60
Capsule Refills:*1
3. Labetalol 100 mg PO BID
4. Lisinopril 20 mg PO DAILY
5. Pantoprazole 40 mg PO Q12H
6. Sucralfate 1 gm PO BID
7. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth Once a day Disp
#*30 Tablet Refills:*3
8. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
RX *sodium chloride 0.9 % 0.9 % 10 mL IV Every 8 hours and as
needed for line maintenance Disp #*60 Syringe Refills:*3
9. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth Three times a day
Disp #*90 Tablet Refills:*3
10. Heparin Flush (10 units/ml) 5 mL IV PRN After each dose of
TPN
RX *heparin lock flush (porcine) [heparin lock flush] 10 unit/mL
5 milliliters IV Daily Disp #*30 Syringe Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Chronic Mesenteric Ischemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had were admitted to the hospital for nausea, vomitting and
abdominal pain and found to have chronic mesenteric ischemia.
You had an attempted stenting of your inferior messenteric
artery which was unsuccessful and was complicated by a hematoma
at the puncture site. It was determined you need an operation
to restore blood flow to your bowels but require improved
nutrition before being able to undergo surgery. You are going
to a facility to continue to gain strength and good nutrition
through TPN.
Incision Care: Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
-If you have staples, they will be removed during at your follow
up appointment.
Please call your doctor or return to the ER for 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.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within ___ hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* 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.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to ambulate several times per day.
* No heavy ___ lbs) until your follow up appointment.
Followup Instructions:
___
|
10461044-DS-10 | 10,461,044 | 24,015,726 | DS | 10 | 2193-01-21 00:00:00 | 2193-01-21 16:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Non-productive cough, chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year-old with CAD s/p CABG (___), COPD on
4L, remote anal cancer s/p resection, h/o low grade prostate
cancer with new lung mass concerning for primary lung cancer who
presents with non-productive cough and chest pain.
Over the past 4 weeks, had cough productive of blood tinged
sputum for two weeks. Was recently hospitalized at ___ from
___. CXR demonstrated bilateral interstitial
opacities and patient was treated for CAP. Chest CT on ___
found dominant RLL mass with bulky mediastinal and hilar
adenopathy as well as bilateral lymphangitic tumor spread
suspicious for primary lung malignancy. Patient did not want a
biopsy at that time and completed 7 day course of levofloxacin.
Patient was started on Prozac at that time due to passive SI but
patient has not been compliant with the medication. Since his
discharge, patient reports that his cough has improved,
especially on home O2, and is now nonproductive.
Over the last week, however, patient reports sharp anterior
chest pain with no radiation. Self-resolves within a few
seconds. No association with exertion. Not resolved with rest or
SL nitro.
In addition, patient would like to receive home palliative care.
Not interested in pursuing biopsy at this time because he feels
that he has had too many procedures done already. Patient's
goals is just to be as comfortable as he can.
In the ED, initial vitals: T 97.6, HR 75, BP 148/82, RR 18, O2
94% on 4L
Labs were significant for WBC 12, Hgb 13, K 2.8, bicarb 20, Cr
1.0. Initial trop < 0.01. Flu swab negative. AST 49, ALT 18, Alk
phos 190. INR 1.1. Albumin 3.5.
CXR showed b/l perihilar opacities c/f infection/malignancy
EKG revealed sub-mm ST depression in V4/V5, new from prior.
In the ED, he received: PO aspirin and lorazepam 0.5mg
Vitals prior to transfer: T 97.5, HR 75, BP 124/65, RR 18, O2
93% on 4L.
Currently breathing comfortably with on home 4L NC with
intermittent non-productive cough.
Past Medical History:
Unstable angina
Bicuspid aortic valve.
Pectus excavatum.
anal cancer ___ (s/p chemo and radiation therapy)
iron deficieny anemia
hypothyroidism
anxiety/depression
basal cell cancer of the face
gastroesophageal reflux
prostate cancer
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.6 131/78 83 20 99% on 4L
GEN: Chronically ill-appearing, lying in bed, no acute distress
HEENT: Dry MM, poor dentition, anicteric sclerae, no
conjunctival pallor
NECK: Supple without LAD
PULM: Diffuse rhonchi bilaterally
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: non-focal
DISCHARGE PHYSICAL EXAM:
GEN: Lying comfortably in bed, no respiratory distress.
PULM: CTAB anteriorly
CARD: RRR
ABD: Soft, non-tender non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: moving all extremities
MENTAL STATUS: Alert and oriented to self and place and ___.
Pleasant, smiling, coherent and answering questions
appropriately. Aware of situation and diagnosis.
Pertinent Results:
Admission Labs:
___ 06:18AM BLOOD WBC-12.6*# RBC-5.23 Hgb-13.2* Hct-41.5
MCV-79* MCH-25.2* MCHC-31.8* RDW-20.7* RDWSD-57.4* Plt ___
___ 06:18AM BLOOD Neuts-83.2* Lymphs-8.0* Monos-3.8*
Eos-3.7 Baso-0.3 Im ___ AbsNeut-10.47* AbsLymp-1.01*
AbsMono-0.48 AbsEos-0.47 AbsBaso-0.04
___ 06:18AM BLOOD ___ PTT-25.7 ___
___ 06:18AM BLOOD Glucose-90 UreaN-11 Creat-1.0 Na-135
K-2.8* Cl-97 HCO3-20* AnGap-21*
___ 06:18AM BLOOD ALT-18 AST-49* AlkPhos-190* TotBili-0.4
___ 06:18AM BLOOD cTropnT-<0.01
___ 06:18AM BLOOD Albumin-3.5
___ 03:15PM BLOOD TSH-11*
___ 03:11AM BLOOD Lactate-6.1*
___ 06:45AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
Interim Labs:
___ 06:30AM BLOOD WBC-11.4* RBC-4.81 Hgb-12.1* Hct-38.5*
MCV-80* MCH-25.2* MCHC-31.4* RDW-20.9* RDWSD-58.8* Plt ___
___ 03:08AM BLOOD Glucose-86 UreaN-12 Creat-0.9 Na-137
K-4.6 Cl-102 HCO3-12* AnGap-28*
___ 06:30AM BLOOD Glucose-84 UreaN-10 Creat-0.7 Na-140
K-4.1 Cl-104 HCO3-20* AnGap-20
___ 03:08AM BLOOD ALT-17 AST-51* CK(CPK)-307 AlkPhos-183*
___ 06:30AM BLOOD ALT-14 AST-41* AlkPhos-166* TotBili-0.4
___ 03:08AM BLOOD CK-MB-2 cTropnT-<0.01
___ 03:08AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.1
___ 06:30AM BLOOD Albumin-3.0* Calcium-8.9 Phos-2.0* Mg-2.0
___ 03:08AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-9*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:11AM BLOOD ___ pO2-90 pCO2-28* pH-7.37
calTCO2-17* Base XS--7
___ 09:57AM BLOOD ___ pO2-67* pCO2-35 pH-7.42
calTCO2-23 Base XS-0
___ 03:11AM BLOOD Lactate-6.1*
___ 09:57AM BLOOD Lactate-2.0
Imaging:
CXR ___
Bilateral perihilar opacities new since prior potentially due to
edema, infection and/or malignancy in light of patient's
history.
More focal opacity projecting over the lower lobes on the
lateral view, likely on the right based on the frontal which
could correlate with known malignancy. Additional opacity
projecting over the anterior right third rib could be due to rib
changes or underlying parenchymal abnormality.
CT head w/o contrast ___
1. Multiple bilateral masses measuring up to 13 mm appear
centered on the gray-white matter junction, with varying amounts
of surrounding vasogenic edema, consistent with metastases.
2. No significant mass effect. No hemorrhage.
3. Age-appropriate global involutional change. Extensive carotid
siphon calcifications.
CT chest without contrast ___ at ___
___)
Dominant right lower lobe mass with bulky bilateral mediastinal
and hilar adenopathy, bilateral lymphangitic tumor spread
suspicious for primary lung malignancy. Bilateral bulky hilar
adenopathy partially narrows the central airways. Tissue
sampling may be considered.
Bulky adenopathy partially imaged within the upper abdomen.
Brief Hospital Course:
___ year-old with CAD s/p CABG (___), COPD on 4L, anal cancer
s/p resection, prostate cancer with lung mass and brain lesions
concerning for new primary lung cancer with brain mets who
presented with non-productive cough and atypical chest pain with
nondiagnostic EKG changes and negative trops with course
complicated by seizure on ___.
Acute Issues:
# New RLL lung mass with brain mets: Chest CT at OSH
demonstrates new lung mass with bilateral adenopathy concerning
for primary lung cancer. CT head on ___ demonstrated multiple
lesions concerning for mets with surrounding edema. However,
patient does not want procedures, surgery or systemic
chemotherapy at this time. Patient clearly expressed his wishes
on the first day that he would like to receive home hospice care
and would not want any interventions even after meeting with
oncology and radiation oncology to discuss the options in depth.
Patient repeatedly confirmed during his hospitalization that he
would like to be kept as comfortable as possible. Therefore, he
will be going to hospice house per goals of care.
# Seizure: Found to have an episode of fecal and urinary
incontinence followed by AMS around 3am on ___. Was evaluated
by neurology and presumed seizure. Placed on seizure precautions
and started on Keppra 1g IV BID as well as decadron 4mg q8
tapered to BID. Unfortunately, the patient developed extreme
agitation and anxiety after steroid administration which was
treated with standing olanzapine and morphine boluses which were
transitioned to a low dose morphine drip. The steroids were
subsequently stopped and the patient's mental status returned to
his baseline A+Ox2-3, pleasant, cooperative, smiling. Patient
did not have repeat seizure episode during the rest of his
hospital stay.
# Chest pain: Patient has anterior chest pain which self-resolve
within seconds. Most likely MSK, possibly due to muscle strain
from prolonged coughing over the past month versus
cancer-related pain. Unlikely to be ACS given atypical
presentation and minimal EKG changes and neg troponin x2.
Chronic issues:
# Severe malnutrition: Poor PO recently. Nutrition recommended
supplements with Frappe w/ 2 pkt BeneProtein TID.
# CAD s/p CABG ___: Metoprolol Succinate XL was continued.
Aspirin and statin were stopped due to risk of intracranial
hemorrhage from brain mets as well as goals of care.
# Hypothyroidism: Home levothyroxine was continued
# HLD: Statin was stopped
# HTN: Metoprolol was stopped given goals of care.
# BPH: Tamsulosin was continued
# Insomnia: Ambien was stopped due to risk of delirium.
Transitional issues:
-Discharged to inpatient hospice
-Please see medication reconciliation for med changes
-MOLST form completed this admission: DNR/DNI, no non-invasive
ventilation, no transfer to hospital, no artificial nutrition,
no artificial hydration, no dialysis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. LORazepam 0.5 mg PO QHS:PRN anxiety
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Simvastatin 40 mg PO QPM
6. Tamsulosin 0.4 mg PO QHS
7. Zolpidem Tartrate 10 mg PO QHS
8. Aspirin 81 mg PO DAILY
9. Imodium A-D (loperamide) 2 mg oral QHS:PRN diarrhea
10. FoLIC Acid 1 mg PO DAILY
11. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Docusate Sodium 100 mg PO BID
4. Haloperidol 0.5-2 mg IV Q4H:PRN agitation
5. LeVETiracetam 1000 mg IV Q12H
6. Morphine Sulfate ___ mg IV Q1H:PRN pain
7. OLANZapine (Disintegrating Tablet) 5 mg PO QID:PRN agitation
8. Senna 17.2 mg PO HS
9. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Lung mass with brain metastasis
Secondary Diagnosis: Seizure
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___:
It was a pleasure taking care of you during your recent
hospitalization at ___. You were admitted because of concern
for chest pain. After some cardiac lab tests, we have determined
that your chest pain is most likely not related to a problem
with your heart but is most likely related to muscle strain due
to cough or pain from the new lung mass.
You also had a seizure while you were in the hospital, most
likely due to metastasis from your lung cancer to the brain. We
would like to remind you that for your own safety, you should
not go swimming or take baths without supervision as seizure
precaution. In addition, according to ___ Law, you
should not drive within 6 months. Given your previously stated
wishes to not receive any interventions and to remain as
comfortable as possible, we will be sending you to a hospice
house.
Because you have been sick recently, we asked our physical
therapist and occupational therapist to evaluate you and they
recommended that the best place for you to go after your
hospitalization was to a hospice house rather than going to your
own home with a hospice nurse visiting intermittently.
Please take your medications as prescribed and follow up with
your physicians as below.
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
10461065-DS-3 | 10,461,065 | 26,188,742 | DS | 3 | 2154-05-11 00:00:00 | 2154-05-11 18:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / clindamycin
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ year old female with sarcoidosis, bronchiectasis, depression
was admitted to the ICU for worsening dyspnea and complicated
hydropneumothorax.
Patient was seen at Urgent care on the ___ for a productive
cough x2 days of yellow/green sputum and low-grade fevers. CXR
showed multifocal pneumonia, along with effusion and air cavity.
She was treated with doxycycline, augmentin, and Tamiflu for
suspected pneumonia and question of influenza. Since that time,
she noted worsening in her SOB despite taking all of her
antibiotics. She called her pulmonologist who saw her on ___,
where she was noted to be sat-ting 80% on RA. She was started on
4L NC with sats improving into the ___. She had a CXR showing
persistence of a multi lobar infiltrative pattern now with
multiple areas of loculated fluid and air-fluid levels. She was
sent to ___ for evaluation.
At ___, her labs were notable for a WBC 20, otherwise
normal. She was given cefepime 2g, ketorolac 15mg, methylpred
80mg, duoneb. Due to her complicated lung pathology, she was
transferred to ___ for IP intervention.
Past Medical History:
sarcoidosis
bronchiectasis
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VITALS: Reviewed in MetaVision.
GENERAL: Sitting up in bed, comfortable no acute distres
HEENT: No appreciable JVD
CARDIAC: RRR, no murmurs
PULMONARY: Wheezes on the left with decreased breath sounds,
good airmovement on the right without rhonchi
ABDOMEN: Soft, NT, ND
EXTREMITIES: No edema, warm, well profused
SKIN: No appreciable rashes
NEURO: AAOx3
DISCHARGE PHYSICAL EXAM
=======================
VS: 24 HR Data (last updated ___ @ 1519)
Temp: 97.7 (Tm 98.6), BP: 138/81 (123-160/69-87), HR: 108
(92-108), RR: 18 (___), O2 sat: 93% (93-99), O2 delivery: 2L
(2L-3L), Wt: 100.97 lb/45.8 kg
GENERAL: NAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: L lung field with some referred sounds from air leak.
Wheezing heard on L lung field. Pneumostat in place.
Pertinent Results:
ADMISSION LABS
======================================
___ 05:54PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-40* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 05:54PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-<1 TRANS EPI-1
___ 04:57PM LACTATE-1.8
___ 04:52PM GLUCOSE-113* UREA N-8 CREAT-0.4 SODIUM-131*
POTASSIUM-4.9 CHLORIDE-94* TOTAL CO2-22 ANION GAP-15
___ 04:52PM estGFR-Using this
___ 04:52PM cTropnT-<0.01
___ 04:52PM WBC-21.8* RBC-4.43 HGB-13.6 HCT-40.1 MCV-91
MCH-30.7 MCHC-33.9 RDW-12.0 RDWSD-40.2
___ 04:52PM NEUTS-95.8* LYMPHS-2.4* MONOS-0.7* EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-20.92* AbsLymp-0.52*
AbsMono-0.15* AbsEos-0.01* AbsBaso-0.06
___ 04:52PM PLT COUNT-483*
IMAGING
======================================
___ CXR
Compared to chest radiographs, since ___, most recently ___.
1. New multiloculated large left hydropneumothorax with anterior
superior and posterior components, suggesting bronchopleural
connections. More pronounced consolidation in the lingula could
be acute pneumonia or relaxation atelectasis due to the adjacent
pleural collection. Severe bronchiectasis and chronic broncho
centric infection throughout right lung have worsened as well.
2. Small right pleural effusion is stable. No right
pneumothorax. Left heart border is obscured by
pleuroparenchymal abnormalities and therefore heart size is
indeterminate, but there are no findings to suggest cardiac
decompensation
___ CT CHEST WITHOUT CONTRAST
1. Large loculated left hydropneumothorax with pleural adhesions
and pleural thickening. Superinfection of the left pleural
fluid is difficult to exclude. Ground-glass opacities within the
right lung concerning for pneumonia.
2. Diffuse acute on chronic airways inflammation with
bronchiectasis and
mucous plugging.
3. No definite central PE or acute aortic process.
___HEST W/O CONTRAST
IMPRESSION:
Several suture cavities are noted in both lungs with thick walls
in
communication to the more distal airways, suggestive of infected
bronchiectasis. In a patient with prior history of MAC
infection, this could represent reactivation of disease as
opposed to other community-acquired pneumonias.
The large left hydropneumothorax seen in the prior study has
improved after placement of pleural tubes. The pleural effusion
has cleared entirely however a small to moderate pneumothorax
still remains.
A pseudo cavity in the left lower lobe shows clear communication
to the
pleural space, noted above.
___ Pulm/Sleep Pulmonary/PFT
IMPRESSION
MECHANICS: The FVC is severely reduced. The FEV1 is very
severely reduced. The FEV1/FVC ratio is normal.
FLOW-VOLUME LOOP: Severely reduced flows and volume with late
moderate expiratory coving.
Impression:
Results are consistent with a restrictive ventilatory defect.
TLC was normal when measured on ___
however compared to that study the FVC has decreased by 2.05 L
(-68%). Suggest repeat lung volume
measurements to assess interval change if clinically indicated.
Compared to the prior study of ___ the
FVC has decreased by 0.77 L (-44%) and the FEV1 has decreased by
0.52 L (-40%).
___ Imaging CHEST (PA & LAT)
IMPRESSION:
1. No PICC line visualized.
2. Moderate left hydropneumothorax is grossly unchanged in
appearance.
3. Stable diffuse bilateral pulmonary opacities.
___ Imaging PICC/MIDLINE PLACEMENT
IMPRESSION:
Successful placement of a right 37 cm brachial approach single
lumen PowerPICC
with tip in the distal SVC. The line is ready to use.
DISCHARGE LABS
======================================
___ 06:20AM BLOOD WBC-9.5 RBC-3.49* Hgb-10.8* Hct-32.9*
MCV-94 MCH-30.9 MCHC-32.8 RDW-14.2 RDWSD-48.3* Plt ___
___ 06:20AM BLOOD Glucose-88 UreaN-7 Creat-0.4 Na-139 K-5.0
Cl-99 HCO3-26 AnGap-14
___ 06:20AM BLOOD Calcium-9.3 Phos-5.0* Mg-2.2
Brief Hospital Course:
=====================================
PATIENT SUMMARY STATEMENT
=====================================
___ with history of chronic granulomatous disease diagnosed as
sarcoidosis admitted with likely fibrocavitary nontuberculous
mycobacterial infection (MAC) with lung abscess and L
hydropneumothorax s/p VATS ___ with ongoing air
leak and chest tube in place.
=====================================
ACTIVE ISSUES
=====================================
# Multiloculated hydropneumothorax
# Chest tube with air leak
Patient with history of bronchiectasis and positive MAC sputum
culture who presented with dyspnea and hypoxemia secondary to
hydropneumothorax and multi-focal pneumonia. Patient underwent
VATS with thoracotomy on ___, with improvement in her shortness
of breath. However, she continued to have residual pneumothorax
which was stable with a chest tube with continuous air leak. She
was discharged with a pneumostat chest tube in place and with
home O2, as well as with follow up with thoracics one week after
discharge.
#Pneumonia
#M. chimera intracellulare
Left lower lobe abscess with pus noted during procedure s/p BAL
of LLL. She was treated with Ceftazidime, vancomycin, and Flagyl
(day 1: ___. Her BAL was found to be positive for
acid fast bacilli, at which point infectious disease was
consulted and her antibiotic treatment was deescalated to
unasyn. Her BAL culture grew M. chimera intracellulare, a
species of MAC. She started MAC treatment on ___ with
rifampin/azithromycin/ethambutol/amikacin after baseline
audiology (normal hearing, slight high frequency hearing loss),
visual acuity, QTc (445 on ___, Cr (0.4), and LFTs (within
normal limits) were evaluated. She was discharged with plan to
continue augmentin until ___ in order to complete the full 21
day course for lung empyema. She will follow up with Dr.
___ infectious disease.
# Hyponatremia
Urine studies suggestive of SIADH likely in the setting of her
lung disease which resolved during her hospitalization. Sodium
on discharge was 139.
CHRONIC ISSUES:
================
#Depression/anxiety
Patient chronically on Latuda which prolongs QTc. During
admission she affirmed that she would like to continue taking
this, despite the risk of prolonged QTc with azithromycin. QTc
will need to be closely monitored given treatment with high-dose
azithromycin.
# Bronchiectasis
# Sarcoidosis/restrictive lung disease
At baseline, FEV1/FVC of 74, normal ratio. Not currently on
steroids or other systemic treatment outside of nebulizers. She
was continued on home salmetoral and albuterol.
#CODE STATUS: Full Code
#CONTACT: Husband ___: ___
=====================================
TRANSITION ISSUES
=====================================
#MAC Infection
[] Will be on MAC treatment of Amikacin 500mg IV 3X/week,
Azithromycin 500mg PO daily, Ethambutol 800mg daily, Rifabutin
300mg PO daily for MAC treatment
[] Discharged with PICC line in place (placed ___.
[] Will need to get an amikacin trough (30 minutes prior to
administration) and peak (30 minuntes after administration)
after the third treatment of amikacin ___ at 1600). The ___
will plan to draw these levels. The results should be sent to
Dr. ___: ___.
[] Still awaiting sensitivity testing of MAC infection (may take
several weeks).
[] Please obtain EKG at PCP follow up appointment (___) to
monitor QTc given Latuda and high dose Azithromycin.
[] Please check weekly CBC, Chemistry panel and LFTs.
#Hydropneumothorax
[] Discharged with a pneumostat (chest tube to water seal), to
be follow up by thoracic surgery
[] Will be on Augmentin to complete her current antibiotic
course for potential superimposed bacterial infection to end
___
About The Atrium Pneumostat:
The Atrium Pneumostat is made to allow air and a little fluid
to escape from your chest until your lung heals. The device will
hold 30ml of fluid. Empty the device as often as needed (see
directions below) and keep track of how much you empty each day.
Items Needed for Home Use:
Atrium Pneumostat Chest Drain Valve (provided by hospital)
___ syringes to empty drainage, if needed (provided by
hospital or ___ Nurse)
Wound dressings (provided by hospital or ___ Nurse)
Securing the Pneumostat:
Utilize the pre-attached garment clip to secure the Pneumostat
to your clothes. It is small and light enough that you won't
even feel it hanging at your side. Make sure to keep the
Pneumostat in an upright position as much as possible. Before
lying down to sleep or rest, empty the Pneumostat so there will
be no fluid to potentially leak out.
Wound Dressing:
You have a dressing around your chest tube. This should be
changed at least every other day or as prescribed by your
doctor.
Showering/Bathing:
Showering with a chest tube is all right as long as you don't
submerge the tube or device in water. No baths, swimming, or hot
tubs.
Note:
This device is very important and the tubing must stay attached
to the end of your chest tube.
If it falls off, reconnect it immediately and tape it
securely.
If it falls off and you can't get it back together, go to the
closest hospital emergency room.
Warnings:
1. Do not obstruct the air leak well.
2. Do not clamp the patient tube during use.
3. Do not use or puncture the needleless ___ port with a
needle.
4. Do not leave a syringe attached to the needleless ___ port.
5. Do not connect any ___ connector to the needleless
___ port located on the bottom of the chest drain valve.
6. If at any time you have concerns or questions, contact your
nurse or physician.
Emptying the Pneumostat
Keep the Pneumostat in an upright position and make sure the
tubing stays firmly attached to the end of your chest tube. Make
sure the Pneumostat stays clean and dry. Do not allow the
Pneumostat to completely fill with fluid or it may start to leak
out. If fluid does leak out, clean off the Pneumostat and use a
Q-tip to dry out the valve.
If the Pneumostat becomes full with fluid, empty it using a
___ syringe. Firmly screw the ___ onto the port
located on the bottom of the Pneumostat.
Pull the plunger back on the syringe to empty the fluid. When
the syringe is full, unscrew the syringe and empty the fluid
into the nearest suitable receptacle. Repeat as necessary. If it
becomes difficult to empty the fluid using a syringe, squirt
water through the port to flush out the blockage or consult your
nurse or physician. The Pneumostat may need to be changed out.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benzonatate 100 mg PO BID
2. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
3. lurasidone 5 mg oral DAILY
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
5. LORazepam 1 mg PO Q6H:PRN anxiety
6. Zolpidem Tartrate 15 mg PO QHS
7. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
The Preadmission Medication list is accurate and complete.
1. Benzonatate 100 mg PO BID
2. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
3. lurasidone 5 mg oral DAILY
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
5. LORazepam 1 mg PO Q6H:PRN anxiety
6. Zolpidem Tartrate 15 mg PO QHS
7. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
The Preadmission Medication list is accurate and complete.
1. Benzonatate 100 mg PO BID
2. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
3. lurasidone 5 mg oral DAILY
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
5. LORazepam 1 mg PO Q6H:PRN anxiety
6. Zolpidem Tartrate 15 mg PO QHS
7. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Amikacin 500 mg IV ONCE Duration: 1 Dose
RX *amikacin 500 mg/2 mL 500 mg Once Disp #*1 Vial Refills:*0
3. Amikacin 500 mg IV 3X/WEEK (___)
4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 8 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth Twice daily Disp #*15 Tablet Refills:*0
5. Azithromycin 500 mg PO DAILY
RX *azithromycin 500 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
6. Ethambutol HCl 800 mg PO DAILY
RX *ethambutol 400 mg 2 tablet(s) by mouth Daily Disp #*60
Tablet Refills:*0
7. Nasacort (triamcinolone acetonide) 55 mcg nasal DAILY
RX *triamcinolone acetonide [Nasacort] 55 mcg 1 puff daily Disp
#*2 Spray Refills:*0
8. Rifabutin 300 mg PO DAILY
RX *rifabutin 150 mg 2 capsule(s) by mouth Daily Disp #*60
Capsule Refills:*0
9. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
10. LORazepam 1 mg PO Q6H:PRN anxiety
11. lurasidone 5 mg oral DAILY
12. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
13. Zolpidem Tartrate 15 mg PO QHS
14.oxygen
Dx: D86.0, J94.8
Concentrator and portable tank via NC at 2L
___: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=================
Acute hypoxic respiratory failure
Mycobacteria Avium Complex Infection
Hydropneumothorax
Multifocal Pneumonia with Empyema
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You came to the hospital because you had worsening shortness
of breath.
What did you receive in the hospital?
- You had a lung infection that required treatment with
antibiotics and also placement of chest tubes to drain the air
and fluid around your lung. One small chest tube is still in
place to prevent air from accumulating around your lungs.
What should you do once you leave the hospital?
- Please continue taking Augmentin until ___
- Please take Amikacin through your PICC tomorrow (___), and
then MWF.
- Please have blood tests on ___ in order to measure the dose
of Amikacin in your blood.
- Please take your oral medications for your MAC treatment every
day.
- Please go to your appointments with your thoracic surgeon,
your infectious disease doctor, and your PCP listed below.
- A ___ will help you take care of your chest tube and give you
your medicine through your PICC. Please see instructions
regarding your chest tube below.
We wish you all the best!
- Your ___ Care Team
Caring for your Chest Tube with Pneumostat
You are ready to go home, but still need your chest tube. A
small device, called an Atrium Pneumostat, has been placed on
the end of your chest tube to help you get better.
About The Atrium Pneumostat:
The Atrium Pneumostat is made to allow air and a little fluid
to escape from your chest until your lung heals. The device will
hold 30ml of fluid. Empty the device as often as needed (see
directions below) and keep track of how much you empty each day.
Items Needed for Home Use:
Atrium Pneumostat Chest Drain Valve (provided by hospital)
___ syringes to empty drainage, if needed (provided by
hospital or ___ Nurse)
Wound dressings (provided by hospital or ___ Nurse)
Securing the Pneumostat:
Utilize the pre-attached garment clip to secure the Pneumostat
to your clothes. It is small and light enough that you won't
even feel it hanging at your side. Make sure to keep the
Pneumostat in an upright position as much as possible. Before
lying down to sleep or rest, empty the Pneumostat so there will
be no fluid to potentially leak out.
Wound Dressing:
You have a dressing around your chest tube. This should be
changed at least every other day or as prescribed by your
doctor.
Showering/Bathing:
Showering with a chest tube is all right as long as you don't
submerge the tube or device in water. No baths, swimming, or hot
tubs.
Note:
This device is very important and the tubing must stay attached
to the end of your chest tube.
If it falls off, reconnect it immediately and tape it
securely.
If it falls off and you can't get it back together, go to the
closest hospital emergency room.
Warnings:
1. Do not obstruct the air leak well.
2. Do not clamp the patient tube during use.
3. Do not use or puncture the needleless ___ port with a
needle.
4. Do not leave a syringe attached to the needleless ___ port.
5. Do not connect any ___ connector to the needleless
___ port located on the bottom of the chest drain valve.
6. If at any time you have concerns or questions, contact your
nurse or physician.
Emptying the Pneumostat
Keep the Pneumostat in an upright position and make sure the
tubing stays firmly attached to the end of your chest tube. Make
sure the Pneumostat stays clean and dry. Do not allow the
Pneumostat to completely fill with fluid or it may start to leak
out. If fluid does leak out, clean off the Pneumostat and use a
Q-tip to dry out the valve.
If the Pneumostat becomes full with fluid, empty it using a
___ syringe. Firmly screw the ___ onto the port
located on the bottom of the Pneumostat.
Pull the plunger back on the syringe to empty the fluid. When
the syringe is full, unscrew the syringe and empty the fluid
into the nearest suitable receptacle. Repeat as necessary. If it
becomes difficult to empty the fluid using a syringe, squirt
water through the port to flush out the blockage or consult your
nurse or physician. The Pneumostat may need to be changed out.
Followup Instructions:
___
|
10461065-DS-4 | 10,461,065 | 25,881,095 | DS | 4 | 2154-06-07 00:00:00 | 2154-06-07 16:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / clindamycin / latex / Benadryl Allergy
Attending: ___.
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
CT guided chest tube placement ___
History of Present Illness:
___ w/ sarcoidosis, bronchiectasis, recent L hydropneumothorax
(s/p VATS decortication) in the setting of ruptured
nontuberculous mycobacterial abscess (on
ethambutol/azithromycin/rifampin/amikacin), with persistent air
leak (requiring endobronchial valve placement), who presents
with recurrence of her L hydropneumothorax and hypoxemia.
Patient states that for the past 2 days there is clear fluid
that comes from her chest wall incision/CT site when she coughs.
She reports hearing gurgling noises from the incision suggestive
of it entraining air. This has been associated with worsening
dyspnea on exertion. She was seen in pulmonology clinic and
referred to the ED for admission and CT guided chest tube.
In the ED, she was noted to be hypoxic to 79% and ultimately
required NRB to maintain adequate sats. She was afebrile,
normotensive, and with normal heart rates. Chest imaging showed
increased air component of moderate left hydropneumothorax. CBC
and electrolytes were unremarkable. A VBG was 7.30/63.
Past Medical History:
Sarcoidosis
Bronchiectasis
Nontuberculous mycobacteria
Depression/anxiety
Social History:
___
Family History:
Not reviewed
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
VS: Reviewed in MetaVision
GEN: Well appearing adult female in NAD.
HEENT: Normocephalic, atraumatic. PERRL. EOMI. Sclera anicteric.
Oropharynx clear.
CV: RRR, normal S1/S2. No murmurs, rubs, or gallops
RESP: Reduced breath sounds on the left. Diffuse expiratory
wheezing.
GI: Soft, nontender, nondistended.
MSK: Normal bulk, tone
SKIN: Dry without lesions
NEURO: CNII-XII grossly intact. Moving all 4 extremities with
purpose. Answering all questions appropriately.
=======================
DISCHARGE PHYSICAL EXAM
=======================
Physical Exam:
==============
24 HR Data (last updated ___ @ 1028)
Temp: 98.4 (Tm 98.4), BP: 145/81 (144-159/81-99), HR: 92
(86-98), RR: 18, O2 sat: 95% (92-97), O2 delivery: 3L
GENERAL: Older woman lying in hospital bed with NC and chest
tube. Alert and interactive. In no acute distress.
HEENT: Normocephalic, atraumatic. PERRL. EOMI. Sclera anicteric
and without injection. MMM, discolored teeth. No cervical
lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Right basilar crackles. Absence of left basilar breath
sounds, left-sided inspiratory and expiratory wheezes. No
increased work of breathing. +left sided Ct clamped
ABDOMEN: Normal bowels sounds, soft, non distended, non-tender.
EXTREMITIES: 1+ bipedal edema. No cyanosis.
SKIN: Warm. No rash. anterior site of stitch c/d/I, posterior CT
hole w/ mild erythema, no fluctuance
NEUROLOGIC: grossly normal, moving all extremities
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 11:11AM BLOOD WBC-8.2 RBC-3.69* Hgb-11.4 Hct-36.1
MCV-98 MCH-30.9 MCHC-31.6* RDW-13.4 RDWSD-48.0* Plt ___
___ 11:11AM BLOOD ___ PTT-28.3 ___
___ 11:11AM BLOOD Glucose-118* UreaN-11 Creat-0.4 Na-136
K-4.7 Cl-98 HCO3-26 AnGap-12
___ 11:11AM BLOOD Calcium-9.3 Phos-4.8* Mg-2.1
==========================================
DISCHARGE AND PERTINENT LABORATORY STUDIES
==========================================
___ 02:34PM BLOOD Amkacin-<0.8*
___ 04:33PM BLOOD Amkacin-22.4
___ 05:36AM BLOOD WBC-5.8 RBC-3.56* Hgb-10.9* Hct-34.2
MCV-96 MCH-30.6 MCHC-31.9* RDW-13.2 RDWSD-46.5* Plt ___
___ 05:36AM BLOOD Glucose-92 UreaN-8 Creat-0.4 Na-139 K-4.6
Cl-100 HCO3-28 AnGap-11
___ 05:36AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.0
===========================
REPORTS AND IMAGING STUDIES
===========================
___ CT Chest without Contrast
IMPRESSION:
Compared to the prior CT of ___, several
endobronchial valves have been placed in the left lower lobe in
the thick-walled cavity with a previous bronchopleural fistula
has collapsed with no current communication identified. A small
left hydropneumothorax remains being drained by a pigtail
catheter. Subtle ground-glass opacities have improved in the
interim. The largest pseudocavity remains in the left upper lobe
with no clear communication with the pleura.
___ CXR
IMPRESSION:
Overall stable left hydropneumothorax. No significant interval
change.
============
MICROBIOLOGY
============
None
Brief Hospital Course:
=================
SUMMARY STATEMENT
=================
___ w/ sarcoidosis and bronchiectasis, recent L
hydropneumothorax (s/p VATS decortication) in the setting of
ruptured nontuberculous mycobacterial abscess (on
ethambutol/azithromycin/rifampin/amikacin), with persistent air
leak (requiring endobronchial valve placement), who presents
with recurrence/worsening of L hydropneumothorax, likely due to
a VATS incision entraining outside air. The incision was closed
off more securely, the collection was aspirated with an 8 fr
chest tube, which was subsequently pulled. Initially had
acute-on-chronic hypoxic respiratory failure requiring NRB, but
now weaned back to the nasal cannula oxygen requirement she has
been using since her last discharge.
============
ACUTE ISSUES
============
# Hydropneumothorax
Recent hospitalization with hydropneumothorax and mutli-focal
pneumonia who underwent VATS with thoracotomy on ___
complicated by residual pneumothorax followed by chest tube with
persistent air leak and pneumostat placement prior to discharge.
Found to be hypoxic in ___ clinic with evidence of worsening
hydropneumothorax on imaging. Now s/p CT guided chest tube with
IP. Tube initially placed to suction. There was suspicion that
an anterior chest incision may have been the source of her air
leak and thoracic surgery placed sutures and an occlusive
dressing on ___ to close this. Her chest tube was subsequently
clamped and then removed on ___.
# Nontuberculous mycobacterium
BAL during previous admission growing mycobacterium chimera
intracellulare. ID was consulted on the prior admission and
patient was started on MAC regimen. Her home ethambutol,
azithromycin, rifampin, and amikacin were continued on this
admission. Amikacin was continued at 500 mg IV 3x a week (Mo,
___, Fr)
#Fatigue
Patient reporting severe fatigue in the setting of her ongoing
infection and feels the need to take naps throughout the day.
She continues to work at her ___ job, even while in the
hospital. In order to assist her in maintaining professional
functionality in the face of increasing fatigue from her medical
illness, we gave her a 30-day trial of modafinil at discharge.
Please assess efficacy of this and renew if helpful for the
duration of her illness.
#Diarrhea
Patient w/ diarrhea ongoing. Has had negative CDiff.
- loperamide added PRN
==============
CHRONIC ISSUES
==============
# Depression/anxiety
Continue QOD Latuda (known QTc prolonging effects especially
while on azithromycin, QTc within normal limits). Continued prn
lorazepam.
# Bronchiectasis
# Sarcoidosis
FEV1/FVC 74. Continued albuterol, salmeterol. She will continue
to use her flutter valve.
TRANSITIONAL ISSUES:
====================
[] Patient has interventional pulmonary follow up scheduled for
1 week
[] Watch the patient's chest tube sites for signs of infection.
The anterior chest incision stitch was placed in non-sterile
conditions thus she should get early follow up if anything
changes
[] Patient has infectious disease follow up scheduled. She was
prescribed additional antibiotics on discharge, ensure she
continues to have scripts for her medications going forward
[] Monitor how modafinil is working for patient's fatigue,
continue if working, and discontinue if ineffective or not well
tolerated.
#CODE STATUS: Full (confirmed)
#EMERGENCY CONTACT: Husband ___: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
2. Nasacort (triamcinolone acetonide) 55 mcg nasal DAILY
3. LORazepam 1 mg PO Q6H:PRN anxiety
4. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
5. Zolpidem Tartrate 20 mg PO QHS
6. Acetaminophen 650 mg PO Q6H
7. Amikacin 500 mg IV 3X/WEEK (___)
8. Azithromycin 500 mg PO DAILY
9. lurasidone 5 mg oral EVERY OTHER DAY
10. Ethambutol HCl 800 mg PO DAILY
11. Rifabutin 300 mg PO DAILY
12. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. LOPERamide 2 mg PO BID:PRN diarrhea
RX *loperamide [Anti-Diarrhea] 2 mg 1 tablet by mouth twice a
day as needed for diarrhea Disp #*60 Tablet Refills:*0
2. Modafinil 200 mg PO DAILY
RX *modafinil 100 mg ___ tablet(s) by mouth daily Disp #*14
Tablet Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours as needed
for pain Disp #*12 Tablet Refills:*0
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
5. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
6. Amikacin 500 mg IV 3X/WEEK (___)
RX *amikacin 500 mg/2 mL 500 mg IV ___ Disp #*12
Vial Refills:*0
7. Azithromycin 500 mg PO DAILY
RX *azithromycin 500 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Cetirizine 10 mg PO DAILY
9. Ethambutol HCl 800 mg PO DAILY
RX *ethambutol 400 mg 2 tablet(s) by mouth daily Disp #*60
Tablet Refills:*0
10. LORazepam 1 mg PO Q6H:PRN anxiety
11. lurasidone 5 mg oral EVERY OTHER DAY
12. Nasacort (triamcinolone acetonide) 55 mcg nasal DAILY
13. Rifabutin 300 mg PO DAILY
RX *rifabutin 150 mg 2 capsule(s) by mouth daily Disp #*60
Capsule Refills:*0
14. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
15. Zolpidem Tartrate 20 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
=======
Hydropneumothorax
Non-tuberculous mycobacterium
Secondary
==========
Anemia
Depression
Anxiety
Bronchiectasis
Sarcoidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You presented to the hospital with worsening of your known
pneumothorax
What did you receive in the hospital?
- You had a CT-guided chest tube placed with out interventional
radiology team
- You were followed by our interventional pulmonology team while
here
- You were offered a procedure know as a pleurodesis by our
thoracic surgery team but declined the procedure at this time.
What should you do once you leave the hospital?
- Please go to your appointments and take your medications as
described in this discharge summary.
- Please follow chest tube instructions by interventional
pulmonology.
- If your anterior chest site starts oozing, becoming more
painful, red, or if you develop fevers please call
interventional pulmonary
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10462084-DS-12 | 10,462,084 | 25,196,430 | DS | 12 | 2137-01-04 00:00:00 | 2137-01-07 14:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain/syncope
Major Surgical or Invasive Procedure:
Cardiac Catheterization ___
History of Present Illness:
___ w/pmh of cardiomyopathy, CAD s/p LAD and RCA stent in ___
presents with progressive exertional chest pain and dyspnea over
the last several days now and then collapse after using IV
fentanyl, found to have troponin elevation and EKG changes
concerning for ischemia and transferred to ___.
Patient was at his home and used what he thought was heroin, but
turned out to be fentanyl. He left his home and developed sudden
chest pressure and collapsed. He was found down and brought to
___. There he reported constant midsternal chest
pressure radiating to the left arm, worse with exertion and
improved with nitro. CT head and C spine were negative. EKG
showed ST elevation in V3 and V4. Trop-I was 0.05 and then 0.07.
Patient was given aspirin, heparin, and nitro there prior to
transfer to ___.
In the ED initial vitals were:
Temp. 98.5, HR 97,, BP 123/85, RR 21, SpO2 93% RA
EKG: J point elevation V2-V3; no reciprocal depressions
Labs/studies notable for:
Normal CBC, normal chemistry, trop < 0.01, and PTT of 80.
Patient was given:
IV Heparin Started 800 units/hr
IV DRIP Nitroglycerin (0.35-3.5 mcg/kg/min ordered) Started 0.35
IV Diazepam 10 mg
PO/NG Atorvastatin 80 mg
Vitals on transfer:
HR 102, BP 103/73, RR 18, 100% RA
Cardiology fellow reviewed case and agreed with admission to
___. Unable to see patient in ED due to inpatient emergency.
Recommended treatment for NSTEMI vs. unstable angina with plan
for trop X 3 with serial EKG, aspirin 325 mg, atorvastatin 80
mg, nitro and heparin drip.
On the floor patient reports chest pressure is improved but not
completely gone. He currently has no SOB, fever or chills and is
very hungry. He also is shaky, last drink was several days ago.
Does not know if he has ever had a withdrawal seizure before. He
is unclear of his medications but knows he has not taken his
clopidogrel for several days.
Past Medical History:
COPD
MI, CAD s/p stent to RCA and LAD in ___
Ischemic cardiomyopathy EF 25%
Etoh and drug use
GERD
HLD
HCV (not treated)
HTN
Retinal detachment
Social History:
___
Family History:
Brother with significant CAD and stents
Physical Exam:
Admission exam
VS: 97.8 104/70 89 20 93% on 1L
GENERAL: Adult male in NAD
HEENT: NCAT. R pupil > L pupil
NECK: Supple without JVD elevation
CARDIAC: RRR without MRG, normal S1 and S2
LUNGS: Wheezing bilaterally without crackles, no increased WOB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: WWP without edema
NEURO: CN II-XII intact, moving all ext
Discharge exam
Vitals: T= AF HR= 75 BP= 122/72 RR= 18 O2= 94% on RA
HEENT: NCAT. R pupil > L pupil
NECK: Supple without JVD elevation
CARDIAC: RRR without MRG, normal S1 and S2
LUNGS: CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: WWP without edema
NEURO: CN II-XII intact, moving all ext
Pertinent Results:
Admission labs
___ 04:36AM BLOOD WBC-7.1 RBC-4.79 Hgb-14.0 Hct-41.5 MCV-87
MCH-29.2 MCHC-33.7 RDW-13.5 RDWSD-43.3 Plt ___
___ 04:36AM BLOOD Neuts-54.4 ___ Monos-13.5*
Eos-0.0* Baso-0.3 Im ___ AbsNeut-3.84 AbsLymp-2.22
AbsMono-0.95* AbsEos-0.00* AbsBaso-0.02
___ 04:36AM BLOOD ___ PTT-80.2* ___
___ 04:36AM BLOOD Glucose-116* UreaN-11 Creat-0.7 Na-134
K-3.9 Cl-94* HCO3-25 AnGap-19
___ 11:05AM BLOOD ALT-28 AST-75* CK(CPK)-1104* AlkPhos-75
TotBili-0.8
___ 04:36AM BLOOD cTropnT-<0.01
___ 11:05AM BLOOD CK-MB-9 MB Indx-0.8 cTropnT-<0.01
___ 11:05AM BLOOD Albumin-4.2 Calcium-9.2 Phos-3.1 Mg-1.9
Cholest-PND
___ 11:05AM BLOOD %HbA1c-5.5 eAG-111
___ 11:10AM BLOOD Lactate-1.3
Discharge lab
___ 11:00AM BLOOD WBC-5.8 RBC-4.15* Hgb-12.3* Hct-38.1*
MCV-92 MCH-29.6 MCHC-32.3 RDW-14.0 RDWSD-47.4* Plt ___
___ 11:00AM BLOOD Plt ___
___ 11:00AM BLOOD Glucose-90 UreaN-11 Creat-0.7 Na-134
K-4.2 Cl-96 HCO3-30 AnGap-12
___ 11:00AM BLOOD Calcium-9.4 Phos-4.6* Mg-1.6
Imaging:
CXR ___
IMPRESSION:
Suspect background COPD, with possible pulmonary hypertension.
Mild cardiomegaly. No CHF, focal infiltrate or effusion is
detected.
Curvilinear lucency at right lung apex more likely represents a
skin fold than a pneumothorax. Clinical correlation is
requested. If there is clinical concern for pneumothorax, a
repeat film, obtained at end expiration of the respiratory cycle
could help for further assessment.
Probable normal variant or old posttraumatic synostosis of the
right fourth and fifth anterior ribs. Please see comment above.
No displaced rib fractures identified on these lung technique
films, to
suggest acute rib injury. 3.8 mm nodule abutting the lower left
chest wall. Further assessment with nonemergent chest CT is
recommended.
ECHO
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
There is severe regional left ventricular systolic dysfunction
with akinesis of the mid to distal anterior wall, apex and
septum with dyskinesis of the apex proper. The inferior wall is
hypokinetic. The lateral wall functions normally (biplane LVEF =
25%). There is an anteroapical left ventricular aneurysm. No
masses or thrombi are seen in the left ventricle. Doppler
parameters are most consistent with Grade I (mild) left
ventricular diastolic dysfunction. There is no ventricular
septal defect. The right ventricular cavity is mildly dilated
with focal hypokinesis of the apical free wall. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Moderately dilated left ventricle with severe
regional systolic dysfunction c/w LAD territory infarct.
Anteroapical aneurysm without thrombus. RCA territory is
hypokinetic. Focal apical right ventricular hypokinesis.
CATH REPORT
The LMCA was widely patent. The LAD had 90% stenosis at the
proximal edge of the prior LAD stent. The Cx had mild luminal
irregularities. The RCA stent with mild luminal irregularities
distal to the stent.
Interventional Details
A 6 ___ XBLAD3.5 guiding catheter was used to engage the LMCA
and provided adequate support. A 180 cm Prowater guidewire was
then successfully delivered across the lesion. Predilated with a
2.5 mm balloon and then deployed a 3,0 x 12 mm Synergy stent
that was then postdilated to 3.5 mm. FInal angiography revealed
normal flow, no dissection and 0% residual stenosis.
Impressions:
1. Successful ___ with Synergy stent for ISR of the LAD.
CXR ___
IMPRESSION:
In comparison with the study of ___, there is no evidence of
pneumothorax.
Remainder of the heart and lungs is unchanged.
Brief Hospital Course:
Mr. ___ is a ___ with PMH of ischemic cardiomyopathy, CAD
s/p LAD and RCA stent in ___ presents with progressive
exertional chest pain and dyspnea over the last several days now
and then collapse after using IV fentanyl, found to have an
NSTEMI. He underwent cardiac cath which found 90% occlusion of
LAD, now s/p drug eluting stent placement in proximal LAD on
___.
# NSTEMI: Patient has a history of CAD s/p stent to RCA and LAD
in ___. He presented with syncope though also reported
history of preceding chest pain and dyspnea. EKG showed J point
elevation in V3 and V4, otherwise unchanged. Troponin slightly
elevated to 0.07 at peak. The patient underwent cardiac
catheterization on ___, found to have 90% stenosis at proximal
edge of LAD stent concerning for instent restenosis, which was
treated with DES. The patient was continued on atorvastatin
80mg, aspirin and clopidogrel. He was discharged on metoprolol
50mg daily and lisinopril 2.5mg daily
# Syncope: Patient with reported syncopal episode with preceding
chest pain. It was unclear whether this was associated with
NSTEMI as above vs. related to IV fentanyl use. the patient was
evaluated with CT head and C-spine at OSH which was negative.
Given patient's history of ischemic cardiomyopathy and history
of syncope, further management with ICD was considered for
prophylaxis, however, this was felt to be high risk given
potential for infection with active IVDU. Also considered
prophylactic amiodarone given brief NSVT on teletry, however
this was deferred given risk for pulmonary and hepatic toxicity
in a patient with HCV and COPD.
# ___ Abuse: Patient treated for alcohol withdrawal
with CIWA using diazepam as needed. He was maintained off
opiates while hospitalized given active cardiac issues. He was
restarted on home suboxone when noted to have evidence of
withdrawal. He will f/u with his PCP for further management of
his suboxone prescription. He was discharged on MVI, thiamin,
folate.
# Chronic Systolic Heart Failure due to Ischemic cardiomyopathy
EF 25%: Patient remained euvolemic on admission. TTE repeated on
___ showed evidence of an old LAD infarct and scarring and right
wall hypokinesis with stable EF. Patient was noted to have
anteroapical aneurysm w/o thrombus (on TTE with contrast). The
patient was discharged on lisinopril and metoprolol 50mg. ICD
was considered as above. Weight at discharge 64 kg.
# COPD: Per reports, no PFTs on file. Noted to have wheezing on
exam. Though CXR w/o evidence of pneumonia. Patient was treated
with nebulizers. Consider PFTs as outpatient.
# HCV: with mild transaminitis. Reportedly untreated, found to
have VL 3.0. Consider treatment of HCV after discharge.
# HTN: continued lisinopril as above.
# Foot fracture, chronic pain: continued home gabapentin
Transitional Issues:
- Weight at discharge 64 kg.
- f/u with PCP for ___ abuse. Patient restarted on
suboxone while hospitalized.
- f/u HCV VL, consider treatment of HCV in the future if patient
qualifies
- TTE while hospitalized showed EF 25%, likely stable from prior
hospitalization at ___. Though patient presented with syncope
and history of ischemic cardiomyopathy, ICD was felt to pose
high risk for potential infection given active IVDU.
Furthermore, given ___ medical comorbidities (COPD and HCV), he
was felt not to be a candidate for amiodarone given potential
pulmonary and hepatic toxicity. Patient should f/u with
outpatient cardiology for further discussion of these agents.
- Patient with wheezing on admission suspicious for COPD,
treated with nebs while hospitalized. CXR w/o evidence of
infection. Consider evaluation with PFTs as outpatient and
optimization of medication regimen.
- Patient prescribed high dose statin given CAD. Continue to
monitor tolerance after discharge.
- Patient started on thiamine, MVI, folate given h/o alcohol
abuse.
- Home lisinopril decreased to 2.5mg from 10mg given BP. Please
monitor after discharge and uptitrate as needed.
- Home metoprolol increased to 50mg daily while hospitalized for
HR control. Please monitor HR after discharge.
- Pt noted to have microscopic hematuria with RBCs 6 on UA.
Please repeat after discharge.
- CXR on ___ showed 3.8 mm nodule abutting the lower left chest
wall. Further assessment with nonemergent chest CT is
recommended.
- Pt prescribed nicotine patch at discharge for assistance with
smoking cessation. Please continue to encourage this after
discharge particularly given patient's cardiac history.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Gabapentin 300 mg PO TID
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
3. Atorvastatin 10 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
2. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
4. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
5. Naloxone 0.04 mg IV ONCE Duration: 1 Dose
RX *naloxone 1 mg/mL 2 mL intranasal ONCE Disp #*2 Syringe
Refills:*0
6. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour apply to either arm every day Disp
#*28 Patch Refills:*0
7. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth every
day Disp #*30 Tablet Refills:*0
8. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
9. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
10. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth every day
Disp #*30 Tablet Refills:*0
11. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
12. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
13. Gabapentin 300 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: NSTEMI, syncope, alcohol withdrawal, opioid
withdrawal, anteroapical LV aneurysm
Secondary Diagnosis: Chronic Systolic Heart Failure,
Hypertension, Hepatitis C Virus, ___ Abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___
Thank you for allowing us to participate in your care at ___!
You were admitted to the hospital with chest pain and shortness
of breath and loss of consciousness. This may have been caused
by your heart or this may have been related to drug use. We
evaluated you with a procedure called a cardiac catheterization
which showed a narrowing in the blood vessel which supplies your
heart. We treated you with a stent to open this vessel.
After discharge, please continue your medications, particularly
your aspirin and clopidogrel. Please follow up with your primary
care doctor and your cardiologist for further management.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10462639-DS-22 | 10,462,639 | 21,472,089 | DS | 22 | 2170-11-29 00:00:00 | 2170-12-02 22:46:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
fentanyl
Attending: ___.
Chief Complaint:
rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness:
___ with stage IV primary peritoneal carcinoma, with lung mets,
s/p cycles of ___ x7, ___ and avastin
monotherapy, gemzar, taxol, ___ and now on Altima (last dose 9
days prior to admission), p/w severe and worsening painful rash
x 3 days and fever to 101. Her Rash is widespread, most severe
on trunk, confluent on flanks, and in some areas nonblanching.
She has a small area of cellulitis on L forearm which she thinks
is more red and worse since being started on cephalexin 2 days
ago. She has on-going abdominal pain which may be worse the last
couple of days. She denies other localizing symptoms of
infection. Rash started at least 1 day before cephalexin and
about 6 days after her first dose of Altmia. She inadvertently
did not receive Neupogen after Alimta.
.
In the ER, vitals 10 101.8 120 105/70 16 100% RA. She received
Clobetasol Propionate 0.05% Cream 1Appl TP and wrap in seran
wrap, Dilaudid 1mg IV x2, and Benadryl 50mg IV. Her pain
decreased from 10 to 5, and repeat vitals were Temp: 98 °F (36.7
°C) (Oral), Pulse: 86, RR: 17, BP: 113/62, O2Sat: 98, O2Flow:
(Room Air). ON arrival to the floor, she is wincing and moaning
in pain which is partially relieved with Dilaudid 1mg IV.
.
Review of Systems:
(+) Per HPI, shakes on day of admission, chronic tingling in
feet
(-) Denies fever, night sweats. Denies blurry vision, diplopia,
loss of vision, photophobia. Denies headache Denies chest
tightness, palpitations, lower extremity edema. Denies cough,
shortness of breath, or wheezes. Denies nausea, vomiting,
diarrhea, constipation, melena, hematemesis, hematochezia.
Denies dysuria, All other systems negative.
Past Medical History:
Past Oncology History:
___ Malignant ascites, extensive peritoneal disease, pleural
effusion and axillary nodes, papillary serous ca, stage IV. CA
___.
___ Carboplatin/taxol x 4
___ Expl lap, omentectomy, TAH/BSO, appendectomy with
radical debulking, Dr. ___, with all visible disease
removed or separated from adjacent organs. Pathology showed
papillary serous adenocarcinoma involving omentum and
peritoneum. Tumor involved left ovary and tube as serosal and
surface adhesions, with no parenchymal involvement.
___ ___ x 3. CA 125 5.
___ No Chemo.
___ CT torso: Stable pulm nodules, none new. Evidence of
recurrent disease as demonstrated by soft tissue thickening and
implants within the pelvis, as well as along the right paracolic
gutter, left upper quadrant, and perihepatic regions. New trace
ascites. Nodule along the wall of the gallbladder may represent
a focal peritoneal implant or gallbladder metastasis. CA125 156.
___ Carboplatin/Doxil x 6.
___ Avastin added.
___ CT Torso: No evidence of residual tumor within the
peritoneal cavity. Interval resolution of the ascites and left
pleural effusion. No evidence of residual left axillary
adenopathy. 3 2-mm nonspecific pulmonary nodules. CA 125=7
___ Cycle #6 given without Avastin due to HTN, epistaxis.
___ CT Torso:
IMPRESSION: No interval change since ___.
___ Avastin as monotherapy for maintenance - last dose
___ CT Torso: (CA 125 rising) Mild thickening and narrowing
of the distal ileum which is likely due to contraction. Clinical
correlation is recommended. Otherwise, the study is essentially
unchanged since previous examination.
___ CT Torso: New recurrent free fluid in the pelvis. New
and enlarging mesenteric lymph nodes. The largest lymph node
measures 12 mm in the small bowel mesentery within the pelvis.
This was not demonstrated previously. Unchanged small bilateral
pulmonary nodules. CA125 = 359
___ Evaluated at ___ for clinical trial but patient declined
participation for fear of alopecia.
___ Started gemzar. Tolerated poorly after 3 doses.
___ Hospitalized ___ with fever, malaise, SOB. VQ scan
low probability, chest CT some mediast adenopathy but no
infiltrate. Urine grew ___ colonies Coag neg staph
twice, and pt was discharged on cefpodoxime X 7 days.
___ CT Torso: Multiple lung nodules range in size from 2-6
mm in the right and left lung. The largest nodule, in the
lingula, is 6 mm. There is bilateral trace pleural effusion and
minimal basilar atelectasis. Thyroid gland is normal. In
addition to subcarinal 3.8 x 3 cm conglomerate lymph node mass,
enlarged lymph nodes are seen in the precarinal (15 mm), right
lower paratracheal (13.3 mm), left parasternal (12 mm), thoracic
inlet (14 mm right side) and right subclavicular regions (12
mm). Multiple other lymph nodes in the prevascular and
presternal region are less than 10 mm in short axis. Note is
made of diffuse smooth thickening of the lower esophageal wall.
The heart is normal size without pericardial effusion.
Atherosclerotic calcification in the left anterior descending
artery is mild. Abdomen/pelvis: Extensive peritoneal,
mesenteric, and omental metastases. Exam severely limited; no
acute process identified. 2. Sigmoid diverticula. The study and
the report were reviewed by the staff radiologist.
___ VQ Scan low probability of PE
___ Abd ultrasound showed ascites not extensive, too little
to tap.
___ Cardiac echo done for dyspnea. The left atrium is
elongated. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Received 2 u PC's.
___ Weekly taxol, 60 mg/m2 (120 mg) x 3 cycles.
___ CT Torso: 1. Significant interval increase in number,
size and extent of innumerable mesenteric, retroperitoneal and
pelvic lymph nodes and omental caking, as described, seen in
association with moderate volume perihepatic and perisplenic
ascites tracking into the dependent recesses of the peritoneal
cavity.
2. Scattered colonic diverticula, none acutely inflamed.
___ Start Carboplatin (lifetime dose #14)
___ ___ dose #2
___ ___ dose #3
___ ___ # 4 in FL
___ Gemzar in ___, last dose ___ (reduced by 50%) - No
response, marked myelosuppression.
___ Altima dose #1
.
Other PMH:
-Hypothyroidism
-Chronic kidney disease: Stage 3
-Mitral valve prolapse
-Dupuytren's disease
-Asthma
-Hypertension
-Anemia
-Menopause
-HSV-1
- Hospitalized ___ - ___ with ___ secondary to Bactrim use and
hypovolemia, discharge Cr 1.3
.
Social History:
___
Family History:
No history of breast or ovarian cancer. Both parents have lived
to advanced ages. Mother died of lung cancer, was a remote
smoker. Her sister died of head and neck cancer, perhaps
related to smoking, at the age of ___. She has several aunts,
all in good health.
Physical Exam:
On Admission:
Vitals T T 97.9 bp 110/60 HR 68 RR 16 SaO2 100 RA
GENERAL: well developed female, wincing and moaning in pain
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM,
good dentition, nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB on lateral fields
ABDOMEN: limited by severe pain to light touch but no rigidity,
rebound. distended
M/S: moving all extremities but painful to do so, no cyanosis,
clubbing or edema
PULSES: 2+ DP pulses bilaterally
SKIN: erythematous rash over trunk and left arm, wrapped in
saran wrap; pain limits complete exam, so please se derm note
for details.
NEURO: No focal deficits, Fluent speech.
On Discharge:
97.7 145/72 90 18 98% on RA
GENERAL: well developed female, wincing and moaning in pain
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM,
good dentition, nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB on lateral fields
ABDOMEN: limited by severe pain to light touch but no rigidity,
rebound. distended
M/S: moving all extremities but painful to do so, no cyanosis,
clubbing or edema
PULSES: 2+ DP pulses bilaterally
SKIN: marketly improve, minimally erythematous rash over trunk
and left arm.
NEURO: No focal deficits, Fluent speech.
Pertinent Results:
___ 08:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 08:00PM URINE RBC-<1 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 08:00PM URINE GRANULAR-3* HYALINE-7*
___ 05:22PM LACTATE-2.1*
___ 05:10PM GLUCOSE-119* UREA N-19 CREAT-1.1 SODIUM-129*
POTASSIUM-3.7 CHLORIDE-93* TOTAL CO2-22 ANION GAP-18
___ 05:10PM ALT(SGPT)-59* AST(SGOT)-58* ALK PHOS-130* TOT
BILI-1.0
___ 05:10PM LIPASE-21
___ 05:10PM ALBUMIN-3.2* CALCIUM-8.2* PHOSPHATE-2.4*
MAGNESIUM-1.1*
___ 05:10PM WBC-3.7*# RBC-2.82* HGB-9.0* HCT-27.5* MCV-97
MCH-31.9 MCHC-32.9 RDW-17.4*
___ 05:10PM NEUTS-92.0* LYMPHS-5.7* MONOS-0.9* EOS-1.3
BASOS-0.2
___ 05:10PM PLT SMR-LOW PLT COUNT-83*#
___ 05:10PM ___ PTT-25.8 ___
On Discharge:
___ 07:00AM BLOOD WBC-1.8* RBC-2.99* Hgb-9.6* Hct-27.9*
MCV-93 MCH-32.0 MCHC-34.3 RDW-17.0* Plt Ct-46*
___ 07:00AM BLOOD Neuts-58.2 Bands-0 ___ Monos-7.6
Eos-12.4* Baso-0.6
___ 07:00AM BLOOD ___ PTT-22.9* ___
___ 07:00AM BLOOD Glucose-91 UreaN-21* Creat-1.1 Na-134
K-4.2 Cl-103 HCO3-22 AnGap-13
___ 07:00AM BLOOD ALT-49* AST-48* LD(LDH)-395* AlkPhos-107*
TotBili-0.7
___ 07:00AM BLOOD Albumin-2.6* Calcium-8.1* Phos-2.8 Mg-1.7
Brief Hospital Course:
This is a ___ year old female with stage IV primary peritoneal
carcinoma s/p multiple chemotherapy regimen, most recently
Pemetrexed, who presented with a new diffuse erythematous rash
and T to 101 likely secondary to a hypersensitivity reaction to
Pemetrexed.
.
#Hypersensitivity reaction to Pemetrexed. The patient presented
with chest, abdomen, and pelvis diffuse coalescent painful and
pruritic macular erythema that blanched with pressure. In
addition, she presented with a well demarcated erythematous
macule on left dorsal forearm at previous site of IV bandage.
Dermatology was consulted and their recommendations were
followed. Clobetasol Propionate 0.05% Cream was applied and the
the body was wrapped with saran wrap daily for 3 days. The
patient was discharged with clobetasol 0.05% cream topically
twice daily for up to a total of 2 weeks. The patient's pain
was initially treated with a dilaudid PCA, but was discontinued
on HD#1 after the patient's pain improved. She did not require
pain medications at the time of discharge. The patient was
given benadryl prn for pruritis. The patient was initially
started on vancomycin given concern for cellulitis, but was
stopped on HD#1 given that cellulitis was highly unlikely. The
patient's rash improved with steroids, and remained afebrile off
antibiotics.
.
# Transaminitis: consistent with elevations at last admission,
which is consistent with chemotherapy side effect and there was
no evidence of biliary obstruction. LFT's were stable througout
her hospital stay.
.
# Metastatic papillary serous carcinoma of ovaries: The patient
will f/u with her medical oncologist for future evaluation and
management.
.
# Hypothyroidism: chronic, stable continued home levothyroxine
.
# Asthma: chronic, stable continued prn albuterol inhaler
Medications on Admission:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath, wheezing.
3. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for pain: please do not drive when you're
taking this medication as it can make you drowsy.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): please take the stool softener while you're taking
dilaudid.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): please take the stool softener while you're taking
dilaudid.
7. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO twice a day:
take this twice a day, on the day of and the day after
chemotherapy.
8. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a day
as needed for pain.
9. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
10. ondansetron HCl 4 mg Tablet Sig: ___ Tablets PO Q8H (every 8
hours) as needed for nausea.
11. magnesium 250 mg Tablet Sig: Two (2) Tablet PO once a day.
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) inhaled Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
3. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every ___
hours as needed for pain.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
9. magnesium oxide 250 mg Tablet Sig: Two (2) Tablet PO once a
day.
10. clobetasol 0.05 % Cream Sig: One (1) Appl Topical twice a
day.
Disp:*1 tube* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Primary peritoneal carcinoma
Drug rash
Secondary Diagnosis:
Chronic kidney disease
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital due to rash. You were seen by
the dermatology team, who felt that your rash was likely due to
your Alimta. You were given ointments and creams from the
dermatology team. You were also given blood for anemia.
Changes to your medications:
START clobetasol 0.05% cream topically twice daily - take this
until your rash improves. Do not use saran wrap at home.
Followup Instructions:
___
|
10462639-DS-23 | 10,462,639 | 26,651,221 | DS | 23 | 2171-01-18 00:00:00 | 2171-01-19 18:37:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
fentanyl / Cipro / Pemetrexed
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
___ with stage IV primary peritoneal carcinoma, with lung mets,
s/p cycles of ___ x7, ___ and avastin
monotherapy, gemzar, taxol, ___, last chemotherapy on ___
for Cycle #2 Cytoxan and Doxil with neulasta presents to the ER
with fever and malaise. She underwent therapeutic paracentesis
on ___ which removed 5 liters of fluid. The evening she was
home, she felt tired, weak but improved slightly over the next
day. On ___, she went to clinic and was given IVF with
Magnesium for these symptoms. The following morning, she had
shakes and chills but no fever at that time. She took tylenol
and went to the infucsion ___ 1 unit of PRBCs which did
not significantly change her energy level. Overnight, she has
an constipation after taking Dilaudid for her abdominal
discomfort which she states is chronic and not significantly
changed. When she was straining, felt gagged and threw up a
small amount which had blood streaks in it. After, she noted
blood on her toliet paper after her bowel movement (she denies
melena or black, tarry stools). She then says she had an episode
of loose stool x1. The morning of admission, she had fever to
101 and went to the ER. In the ER, initial vitals 96.2 109
128/77 22 99% RA; she received Dailudid 1mg IV, Zofran, 1L NS,
and Zosyn 4.5g. She complains of loose stools following oral
contrast, but on arrival to the floor, feels better with
additional IV Dilaudid and Zofran.
.
Review of Systems:
(+) Per HPI, 1 lb weight loss in 48 hours,
(-) Denies blurry vision, diplopia, loss of vision, photophobia.
Denies headache, sinus tenderness. Denies chest pain or
tightness, palpitations, lower extremity edema. Denies cough,
shortness of breath, or wheezes. Denies melena, hematemesis,
hematochezia. Denies dysuria, stool or urine incontinence.
Denies arthralgias or myalgias. Denies rashes or skin breakdown.
No numbness/tingling in extremities. All other systems negative.
..
Past Medical History:
Past Oncology History:
___ Malignant ascites, extensive peritoneal disease, pleural
effusion and axillary nodes, papillary serous ca, stage IV. CA
___.
___ Carboplatin/taxol x 4
___ Expl lap, omentectomy, TAH/BSO, appendectomy with
radical debulking, Dr. ___, with all visible disease
removed or separated from adjacent organs. Pathology showed
papillary serous adenocarcinoma involving omentum and
peritoneum. Tumor involved left ovary and tube as serosal and
surface adhesions, with no parenchymal involvement.
___ ___ x 3. CA 125 5.
___ No Chemo.
___ CT torso: Stable pulm nodules, none new. Evidence of
recurrent disease as demonstrated by soft tissue thickening and
implants within the pelvis, as well as along the right paracolic
gutter, left upper quadrant, and perihepatic regions. New trace
ascites. Nodule along the wall of the gallbladder may represent
a focal peritoneal implant or gallbladder metastasis. CA125 156.
___ Carboplatin/Doxil x 6.
___ Avastin added.
___ CT Torso: No evidence of residual tumor within the
peritoneal cavity. Interval resolution of the ascites and left
pleural effusion. No evidence of residual left axillary
adenopathy. 3 2-mm nonspecific pulmonary nodules. CA 125=7
___ Cycle #6 given without Avastin due to HTN, epistaxis.
___ CT Torso:
IMPRESSION: No interval change since ___.
___ Avastin as monotherapy for maintenance - last dose
___ CT Torso: (CA 125 rising) Mild thickening and narrowing
of the distal ileum which is likely due to contraction. Clinical
correlation is recommended. Otherwise, the study is essentially
unchanged since previous examination.
___ CT Torso: New recurrent free fluid in the pelvis. New
and enlarging mesenteric lymph nodes. The largest lymph node
measures 12 mm in the small bowel mesentery within the pelvis.
This was not demonstrated previously. Unchanged small bilateral
pulmonary nodules. CA125 = 359
___ Evaluated at ___ for clinical trial but patient declined
participation for fear of alopecia.
___ Started gemzar. Tolerated poorly after 3 doses.
___ Hospitalized ___ with fever, malaise, SOB. VQ scan
low probability, chest CT some mediast adenopathy but no
infiltrate. Urine grew ___ colonies Coag neg staph
twice, and pt was discharged on cefpodoxime X 7 days.
___ CT Torso: Multiple lung nodules range in size from 2-6
mm in the right and left lung. The largest nodule, in the
lingula, is 6 mm. There is bilateral trace pleural effusion and
minimal basilar atelectasis. Thyroid gland is normal. In
addition to subcarinal 3.8 x 3 cm conglomerate lymph node mass,
enlarged lymph nodes are seen in the precarinal (15 mm), right
lower paratracheal (13.3 mm), left parasternal (12 mm), thoracic
inlet (14 mm right side) and right subclavicular regions (12
mm). Multiple other lymph nodes in the prevascular and
presternal region are less than 10 mm in short axis. Note is
made of diffuse smooth thickening of the lower esophageal wall.
The heart is normal size without pericardial effusion.
Atherosclerotic calcification in the left anterior descending
artery is mild. Abdomen/pelvis: Extensive peritoneal,
mesenteric, and omental metastases. Exam severely limited; no
acute process identified. 2. Sigmoid diverticula. The study and
the report were reviewed by the staff radiologist.
___ VQ Scan low probability of PE
___ Abd ultrasound showed ascites not extensive, too little
to tap.
___ Cardiac echo done for dyspnea. The left atrium is
elongated. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Received 2 u PC's.
___ Weekly taxol, 60 mg/m2 (120 mg) x 3 cycles.
___ CT Torso: 1. Significant interval increase in number,
size and extent of innumerable mesenteric, retroperitoneal and
pelvic lymph nodes and omental caking, as described, seen in
association with moderate volume perihepatic and perisplenic
ascites tracking into the dependent recesses of the peritoneal
cavity.
2. Scattered colonic diverticula, none acutely inflamed.
___ Start Carboplatin (lifetime dose #14)
___ ___ dose #2
___ ___ dose #3
___ ___ # 4 in FL
___ Gemzar in ___, last dose ___ (reduced by 50%) - No
response, marked myelosuppression.
___ Altima dose ___ Seen for dehydration and drug rash, hydrated, given IV
steroids and benadryl, but
___ Admitted ___ for progressive allergic reaction
including essentially erythroderm, fever and rigors, no mucous
membrane involvement. Cultures negative
___ Cycle #1 Cytoxan and Doxil
___ underwent paracentesis at the ___ with removal of 5.3
liters of ascites
___ Seen at ___ for blood transfusion and orthostatic. Had
been started on Cipro ___ for UTI and had vomiting and
diarrhea.
___ neutropenic. Urine cx with Kleb pneumonie. Given 1 dose
Rocephin and course of Ceftin. Sx resolved.
___ Cycle #2 Cytoxan and Doxil with neulasta
___ Transfusion 1 unit pRBC at ___
___ Paracentesis at ___, 5 liters.
.
Other PMH:
-Hypothyroidism
-Chronic kidney disease: Stage 3
-Mitral valve prolapse
-Dupuytren's disease
-Asthma
-Hypertension
-Anemia
-Menopause
-HSV-1
- Hospitalized ___ - ___ with ___ secondary to Bactrim use and
hypovolemia, discharge Cr 1.3
.
Social History:
___
Family History:
No history of breast or ovarian cancer. Both parents have lived
to advanced ages. Mother died of lung cancer, was a remote
smoker. Her sister died of head and neck cancer, perhaps
related to smoking, at the age of ___. She has several aunts,
all in good health.
Physical Exam:
Admission PE:
VS: T 98.1 bp 144/76 HR 106 RR 18 SaO2 98RA
GEN: uncomfortable but awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP dry and
without lesion
NECK: Supple, no JVD
CV: Reg tachycardia, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, diffusely tender, mildly distended, bowel sounds
present
MSK: normal muscle tone and bulk
EXT: No c/c/e, 2+ ___ bilaterally
SKIN: No rash, warm skin
NEURO: oriented x 3, normal attention, no focal deficits, intact
sensation to light touch
PSYCH: appropriate
Discharge PE:
General: pleasant, well appearing woman, NAD, laying comfortably
in bed
HEENT: EOMI, PERRL, moist mucous membranes
CV: RRR S1 S2, no murmurs, rubs, gallops
lungs: clear to auscultation b/l, no wheezes, rhonchi, gallops
abdomen: softly distended, increased abdominal girth and
tension; no significantly changed from yesterday, slight fluid
wave appreciated, no rebound/guarding
extremities: warm, well perfused, 2+DP pulses
Neuro: CN2-12 grossly intact, muscle strength and sensation
grossly intact
Pertinent Results:
Admission labs:
___ 03:14PM LACTATE-2.1*
___ 03:06PM GLUCOSE-103* UREA N-13 CREAT-1.0 SODIUM-130*
POTASSIUM-3.1* CHLORIDE-92* TOTAL CO2-26 ANION GAP-15
___ 03:06PM ALT(SGPT)-34 AST(SGOT)-74* ALK PHOS-159* TOT
BILI-0.7
___ 03:06PM LIPASE-15
___ 03:06PM ALBUMIN-2.7* CALCIUM-8.0* PHOSPHATE-2.7
MAGNESIUM-1.5*
___ 03:06PM WBC-4.5# RBC-3.91* HGB-12.3 HCT-34.1* MCV-87
MCH-31.3 MCHC-35.9* RDW-18.5*
___ 03:06PM NEUTS-82* BANDS-0 LYMPHS-7* MONOS-9 EOS-1
BASOS-0 ___ METAS-1* MYELOS-0
___ 03:06PM PLT SMR-LOW PLT COUNT-146*#
___ 03:06PM ___ PTT-27.4 ___
___ 03:06PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL
Micro:
___ 6:07 am STOOL CONSISTENCY: WATERY
**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 ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Studies:
CT abdomen:
IMPRESSION:
1. Simple ascites without evidence of intra-abdominal hemorrhage
or
perforation.
2. Thickening of the sigmoid colon is compatible with an area of
colitis. Though diverticulitis is a possibility, no definite
inflamed diverticula are seen and the sigmoid colon involved is
slightly longer than typically seen. Differential
considerations include infectious, inflammatory and ischemic
pathology
3. Slight interval increase in the degree of lymphadenopathy
within the mesentery compared with the previous study.
4. Interval development of mild fullness of the right renal
collecting system.
Discharge labs:
___ 08:00AM BLOOD WBC-5.7 RBC-3.32* Hgb-10.2* Hct-29.3*
MCV-88 MCH-30.8 MCHC-34.9 RDW-18.5* Plt ___
___ 08:00AM BLOOD Neuts-79.9* Lymphs-7.8* Monos-11.7*
Eos-0.4 Baso-0.3
___ 08:00AM BLOOD ___ PTT-27.2 ___
___ 08:00AM BLOOD Glucose-105* UreaN-7 Creat-0.7 Na-126*
K-3.2* Cl-97 HCO3-23 AnGap-9
___ 08:00AM BLOOD ALT-26 AST-52* AlkPhos-130* TotBili-0.4
___ 08:00AM BLOOD Albumin-2.0* Calcium-7.4* Phos-2.1*
Mg-1.5*
Brief Hospital Course:
Ms. ___ is ___ with stage IV primary peritoneal carcinoma with
lung mets, s/p cycles of ___ x7, ___ and
avastin monotherapy, gemzar, taxol, ___, with last chemo on
___ for C2 Cytoxan and Doxil with neulasta who initially p/w
fever and malaise found to have sigmoid colitis on CT, initially
on Zosyn and she was ultimately transitioned to PO abx to
complete a total ___olitis: The patient had evidence suggestive of sigmoid
colitis on CT abdomen. The patient was found to be Cdiff
negative and stool studies were negative. The patient was also
initially evaluated by surgery in the ED, who felt that no
surgical intervention was needed at this time. The patient was
initially started on IV Zosyn. as well as IVF, and her diet was
advanced as tolerated. The patient was also given anti-emetics
as needed for nausea control. Once she was tolerating PO the
patient was transitioned to Augmetin/Flagyl. Of note, Cipro was
not used because of allergy. The patient was discharged on
Augmetin/Flagyl and instructed to complete a total ten day
course of antibiotics.
# hyponatremia: On admission, the patient's sodium was 130 and
it trended down as low as 126. The patient refused to give
urine sample to look at urine lytes, but upon discharge, sodium
was trending back up.
# stage IV primary peritoneal carcinoma, with lung mets
complicated by carcinomatous Ascites: The patient is s/p
paracentesis on ___. During this hospitalization, her
ascitic fluid was increasing, as her abdominal exam was noted
for progressing distension. The patient was seen by ___ for
possible placement of pleurex drain, given the recurrence of her
ascitic fluid. However, as per ___, the patient did not have
enough ascitic fluid to safely place drain. Placement of
pleurex should be addressed as an outpatient.
# Transaminitis: The patient has a history of baseline
transamintitis, likely secondary to chemotherapy. Her
transaminitis was similar to her baseline, and LFTs were
trended.
# Hypothyroidism: The patient was continued on levothyroxine 88
mcg daily.
# Asthma: The patient was continued on her albuterol nebs PRN.
Transitional Issues:
# R renal collecting system fullness: The patient was noted to
have R renal collecting system fullness on her CT. She was
asymptomatic and did not endorse any urinary symptoms; her urine
ouput was also normal. This finding will have to be monitored
as an outpatient and she will likely need repeat imaging to
assess for interval change.
Medications on Admission:
1. Folate 1mg PO daily
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) inhaled Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
3. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every ___
hours as needed for pain.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
9. magnesium oxide 250 mg Tablet Sig: Two (2) Tablet PO once a
day.
10. clobetasol 0.05 % Cream Sig: One (1) Appl Topical twice a
day.
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
2. albuterol sulfate 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
3. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO once a
day.
4. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every ___
hours as needed for pain.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
6. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day.
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
9. magnesium oxide 500 mg Tablet Sig: One (1) Tablet PO once a
day.
10. clobetasol 0.05 % Cream Sig: One (1) Topical twice a day.
11. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
12. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
colitis
peritoneal carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you while you were hospitalized
at ___. You were admitted to the hospital because you were
having some loose stools and fever at home. You were found to
have an infection in your intestines when we imaged your
abdomen. We started you on antibiotics through your veins and
we slowly advanced your diet.
Once you were eating and drinking well again, we transitioned
you to antibiotics by mouth. You should continue these
antibiotics for a total of ten days.
We made the following the changes to your medications:
START Flagyl 500 mg by mouth every 8 hours for four more days
STOP DATE ___
START Augmentin 875 mg by mouth twice daily for four more days
STOP DATE ___
Followup Instructions:
___
|
10462639-DS-24 | 10,462,639 | 21,519,992 | DS | 24 | 2171-01-24 00:00:00 | 2171-01-25 11:46:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
fentanyl / Cipro / Pemetrexed
Attending: ___
Chief Complaint:
Right shoulder pain s/p fall
Major Surgical or Invasive Procedure:
peritoneal catheter placement
History of Present Illness:
Ms. ___ is ___ with stage IV primary peritoneal carcinoma, with
lung mets, s/p cycles of ___ x7, ___ and
avastin monotherapy, gemzar, taxol, ___, last chemotherapy on
___ for Cycle #2 Cytoxan and Doxil with neulasta presents
with right shoulder pain following a fall.
The patient reports she was walking up the stairs when she felt
weakness in her legs, causing her to lose her balance. She then
fell back down three steps falling onto her right shoulder. She
reports hearing a "snap" but denies loss of consciousness or
hitting her head. She denies decreased sensations, but does
endorse decreased range of motion due to pain. She denies
dizziness, lightheadedness, chest pain, palpitations, and
dyspnea. The patient reports good PO intake at home, eating and
drinking well. However, also reports that she has been having
some nausea, stomach upset, and vomiting in the setting of
recent antibiotic use from last hospitalization (see below).
The patient was admitted from ___ for fever and malaise,
found to have sigmoid colitis on CT treated with a 10 day course
of Zosyn transitioned to Augmentin and Flagyl, to be completed
today (___). However, the patient reports that she self-d/ced
her antibiotics on on ___ night.
On ROS, denies any dizziness or lightheadedness. Denies any
headaches or trouble breathing. No chest pain or palpitations.
No abdominal pain. Denies any diarrhea. Does report some
abdominal bloating. No numbness or tingling.
In ED, initial vitals were 98.4 80 124/85 18 98%
Orthopedics was consulted and felt there was no need for
surgical intervention, but recommended non-weight bearing and no
internal/external rotation of the right arm, placement of cuff
and collar, f/u with ortho in 1 week. Ortho team saw the
patient and applied a sling, with recommendations to ___, no
internal/external rotation of the right arm. She was also seen
by ___, who felt the patient requires a commode at discharge,
which was issued and education provided. They also discussed
right shoulder pendulum exercises with the patient and
reinforced the restrictions of activity recommended by
orthopedics.
Vitals on transfer: 97.4,133/87,16,100, 99% RA. The patient
reports feeling well on the floor, with no complaints. She does
report having some arm pain, but otherwise feels well.
Past Medical History:
Past Oncology History:
___ Malignant ascites, extensive peritoneal disease, pleural
effusion and axillary nodes, papillary serous ca, stage IV. CA
___.
___ Carboplatin/taxol x 4
___ Expl lap, omentectomy, TAH/BSO, appendectomy with
radical debulking, Dr. ___, with all visible disease
removed or separated from adjacent organs. Pathology showed
papillary serous adenocarcinoma involving omentum and
peritoneum. Tumor involved left ovary and tube as serosal and
surface adhesions, with no parenchymal involvement.
___ ___ x 3. CA 125 5.
___ No Chemo.
___ CT torso: Stable pulm nodules, none new. Evidence of
recurrent disease as demonstrated by soft tissue thickening and
implants within the pelvis, as well as along the right paracolic
gutter, left upper quadrant, and perihepatic regions. New trace
ascites. Nodule along the wall of the gallbladder may represent
a focal peritoneal implant or gallbladder metastasis. CA125 156.
___ Carboplatin/Doxil x 6.
___ Avastin added.
___ CT Torso: No evidence of residual tumor within the
peritoneal cavity. Interval resolution of the ascites and left
pleural effusion. No evidence of residual left axillary
adenopathy. 3 2-mm nonspecific pulmonary nodules. CA 125=7
___ Cycle #6 given without Avastin due to HTN, epistaxis.
___ CT Torso:
IMPRESSION: No interval change since ___.
___ Avastin as monotherapy for maintenance - last dose
___ CT Torso: (CA 125 rising) Mild thickening and narrowing
of the distal ileum which is likely due to contraction. Clinical
correlation is recommended. Otherwise, the study is essentially
unchanged since previous examination.
___ CT Torso: New recurrent free fluid in the pelvis. New
and enlarging mesenteric lymph nodes. The largest lymph node
measures 12 mm in the small bowel mesentery within the pelvis.
This was not demonstrated previously. Unchanged small bilateral
pulmonary nodules. CA125 = 359
___ Evaluated at ___ for clinical trial but patient declined
participation for fear of alopecia.
___ Started gemzar. Tolerated poorly after 3 doses.
___ Hospitalized ___ with fever, malaise, SOB. VQ scan
low probability, chest CT some mediast adenopathy but no
infiltrate. Urine grew ___ colonies Coag neg staph
twice, and pt was discharged on cefpodoxime X 7 days.
___ CT Torso: Multiple lung nodules range in size from 2-6
mm in the right and left lung. The largest nodule, in the
lingula, is 6 mm. There is bilateral trace pleural effusion and
minimal basilar atelectasis. Thyroid gland is normal. In
addition to subcarinal 3.8 x 3 cm conglomerate lymph node mass,
enlarged lymph nodes are seen in the precarinal (15 mm), right
lower paratracheal (13.3 mm), left parasternal (12 mm), thoracic
inlet (14 mm right side) and right subclavicular regions (12
mm). Multiple other lymph nodes in the prevascular and
presternal region are less than 10 mm in short axis. Note is
made of diffuse smooth thickening of the lower esophageal wall.
The heart is normal size without pericardial effusion.
Atherosclerotic calcification in the left anterior descending
artery is mild. Abdomen/pelvis: Extensive peritoneal,
mesenteric, and omental metastases. Exam severely limited; no
acute process identified. 2. Sigmoid diverticula. The study and
the report were reviewed by the staff radiologist.
___ VQ Scan low probability of PE
___ Abd ultrasound showed ascites not extensive, too little
to tap.
___ Cardiac echo done for dyspnea. The left atrium is
elongated. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Received 2 u PC's.
___ Weekly taxol, 60 mg/m2 (120 mg) x 3 cycles.
___ CT Torso: 1. Significant interval increase in number,
size and extent of innumerable mesenteric, retroperitoneal and
pelvic lymph nodes and omental caking, as described, seen in
association with moderate volume perihepatic and perisplenic
ascites tracking into the dependent recesses of the peritoneal
cavity.
2. Scattered colonic diverticula, none acutely inflamed.
___ Start Carboplatin (lifetime dose #14)
___ ___ dose #2
___ ___ dose #3
___ ___ # 4 in FL
___ Gemzar in ___, last dose ___ (reduced by 50%) - No
response, marked myelosuppression.
___ Altima dose ___ Seen for dehydration and drug rash, hydrated, given IV
steroids and benadryl, but
___ Admitted ___ for progressive allergic reaction
including essentially erythroderm, fever and rigors, no mucous
membrane involvement. Cultures negative
___ Cycle #1 Cytoxan and Doxil
___ underwent paracentesis at the ___ with removal of 5.3
liters of ascites
___ Seen at ___ for blood transfusion and orthostatic. Had
been started on Cipro ___ for UTI and had vomiting and
diarrhea.
___ neutropenic. Urine cx with Kleb pneumonie. Given 1 dose
Rocephin and course of Ceftin. Sx resolved.
___ Cycle #2 Cytoxan and Doxil with neulasta
___ Transfusion 1 unit pRBC at ___
___ Paracentesis at ___, 5 liters.
.
Other PMH:
-Hypothyroidism
-Chronic kidney disease: Stage 3
-Mitral valve prolapse
-Dupuytren's disease
-Asthma
-Hypertension
-Anemia
-Menopause
-HSV-1
- Hospitalized ___ - ___ with ___ secondary to Bactrim use and
hypovolemia, discharge Cr 1.3
.
Social History:
___
Family History:
No history of breast or ovarian cancer. Both parents have lived
to advanced ages. Mother died of lung cancer, was a remote
smoker. Her sister died of head and neck cancer, perhaps
related to smoking, at the age of ___. She has several aunts,
all in good health.
Physical Exam:
Admission PE:
VS: T98 ___ 16 99RA
General: pleasant well appearing female, with R shoulder in a
sling, NAD, laying comfortable in bed
HEENT: EOMI, PERRL, moist mucous membranes
CV: RRR, S1 S2, no murmurs/rubs/gallops appreciated
lungs: anterior lung fields clear to auscultation b/l, exam
limited as patient unable to sit up for posterior lung field
exam given her pain
abdomen: +fluid wave, distended, nontender, +BS, increased in
size and much more tense compared to last week when she was
hospitalized
extremities: warm, well perfused, trace pedal edema, 2+ DP
pulses
MSK: R shoulder in sling in neutral position, +TTP around R
shoulder, with some associated bruising and swelling
Neuro: CN ___ grossly intact, normal lower extremity muscle
strength, unable to assess RUE given shoulder pain, intact
sensation throughout
Discharge PE:
VS: 98.5 114/59 (110-118/59-71) 108 (99-110) 16 97RA (94-100RA)
General: pleasant well appearing female, with R shoulder in a
sling, NAD, laying comfortable in bed
HEENT: EOMI, PERRL, moist mucous membranes
CV: RRR, S1 S2, no murmurs/rubs/gallops appreciated
lungs: anterior lung fields clear to auscultation b/l, exam
limited as patient unable to sit up for posterior lung field
exam given her pain
abdomen: soft, still slightly distended, nontender, +BS, R sided
peritoneal drainage catheter, dressing clean/dry/intact, slight
tenderness to palpation around the site
extremities: warm, well perfused, trace pedal edema, 2+ DP
pulses
MSK: R shoulder in sling in neutral position, +TTP around R
shoulder, with some associated bruising and swelling
Pertinent Results:
Admission labs:
___ 01:49AM BLOOD WBC-6.5 RBC-3.41* Hgb-10.7* Hct-30.8*
MCV-90 MCH-31.3 MCHC-34.7 RDW-18.8* Plt ___
___ 01:49AM BLOOD ___ PTT-27.3 ___
___ 01:49AM BLOOD Glucose-102* UreaN-9 Creat-0.8 Na-129*
K-3.1* Cl-96 HCO3-25 AnGap-11
___ 09:00AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.1*
Discharge labs:
___ 09:00AM BLOOD WBC-6.1 RBC-3.31* Hgb-10.5* Hct-29.4*
MCV-89 MCH-31.7 MCHC-35.7* RDW-18.9* Plt ___
___ 06:50AM BLOOD WBC-4.9 RBC-2.85* Hgb-8.7* Hct-25.6*
MCV-90 MCH-30.5 MCHC-33.9 RDW-19.1* Plt ___
___ 06:50AM BLOOD Glucose-84 UreaN-15 Creat-1.1 Na-129*
K-4.7 Cl-96 HCO3-29 AnGap-9
___ 06:50AM BLOOD Calcium-7.7* Phos-3.2 Mg-1.4*
Studies:
R arm plain film:
FINDINGS: There is a comminuted fracture of the right proximal
humerus at the level of the surgical neck extending into the
diaphysis with mild lateral angulation of the distal fracture
fragment. Ossific densities are visualized adjacent to the
fracture site representative of bony fragments. Otherwise, no
other acute fractures are identified. No dislocation. Mild AC
joint degenerative changes with spurring. The visualized right
lung and ribs are within normal limits.
IMPRESSION: Right proximal humerus fracture, as above.
shoulder plain film
IMPRESSION:
Minimally displaced comminuted fracture of the right humerus at
surgical neck level with continued articulation of remaining
proximal humerus with glenoid.
Brief Hospital Course:
Ms. ___ is ___ with stage IV primary peritoneal carcinoma with
lung mets, s/p cycles of ___ x7, ___ and
avastin monotherapy, gemzar, taxol, ___, with last chemo on
___ for C2 Cytoxan and Doxil with neulasta who initially p/w
fever and malaise recently here with sigmoid colitis s/p abx
which she self d/ced early ___ nausea, who is presenting from
home s/p fall found to have R humerus fracture.
# R humerus fracture: The patient is s/p mechanical fall onto R
shoulder, with subsequent R humerus fracture. She was seen by
Ortho in the ED who recommended conservative management. Ortho
recommendations included non-weight bearing and no
internal/external rotation of right arm. She was also
instructed to wear cuff and collar. Her pain was initially
controlled on PO and IV Dilaudid; upon discharge, the patient's
pain was well contolled on her home Dilaudid regimen. She will
have ortho follow up in two weeks.
# sigmoid colitis: The patient was found to have sigmoid
colitis on previous admission was sent home with
Augmentin/Flagyl to complete a total 10 day course. However,
the patient self d/ced her abx on ___ abdominal upset.
Antibiotics were not restarted during this hospitalization. She
was monitored clinically.
#. Stage IV primary peritoneal carcinoma: The patient has known
lung mets complicated by carcinomatous ascites. She has routine
scheduled therapeutic paracentesis as an outpatient, and was
seen by ___ during her prior admission for possible placement of
peritoneal drain, given the recurrence of her ascitic fluid.
However, as per ___, the patient did not have enough ascitic
fluid to safely place drain and placement of drain should be
addressed as an outpatient. During this admission, the patient
had placement of peritoneal catheter, which was done without any
complication. After the procedure the patient was noted to have
a crit drop (see transitional issues). This will have to
followed as an outpatient.
# Hyponatremia: The patient has a history of hyponatremia,
which was seen on recent admission, the patient's sodium was
126-130. She continued to be hyponatremic during this
admission, with sodium at discharge 129.
# Hypothyroidism: The patient was continued on her home
levothyroxine 88 mcg daily.
# Asthma: The patient was continued on her home albuterol nebs.
Transitional Issues:
- The patient was noted to have a crit drop s/p peritoneal
catheter placement from 29.4 --> 25.6. The patient did not want
to stay in the hospital for a ___ crit check, as she had an appt
at ___ that she needed to go to. She was instructed to have her
___ draw a CBC the day after discharge to follow her crit.
- The patient was noted to have a low mag at discharge. Because
she had to leave the hospital early in the morning to make an
appt for a clinical trial at ___, the patient did not want to
stay for magnesium repletion. She was instructed to double her
home oral magnesium dose for the next five days. This will have
to be followed up as an outpatient.
Medications on Admission:
folic acid 1 mg PO daily
albuterol sulfate 0.63mg/3mL q6h PRN SOB or wheeze
levothyroxine 88 mcg daily
hydromorphone 2 mg Tablet PO q4-6h PRN pain
docusate sodium 100 mg BID
senna 8.6 mg PO BID
gabapentin 300 mg BID
compazine 10 mg PO q6h
magnesium oxide 500 mg daily
clobetasol 0.05 % Cream BID
Augmentin 875-125 mg self d/ced on ___
Flagyl 500 mg Tablet self d/ced on ___
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. albuterol sulfate 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
3. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every ___
hours as needed for pain.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
9. magnesium oxide 500 mg Capsule Sig: One (1) Capsule PO once a
day.
10. clobetasol 0.05 % Cream Sig: One (1) Appl Topical BID (2
times a day).
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary diagnosis:
right humerus fracture
peritoneal carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you while you were hospitalized
at ___. You were admitted to the hospital after you fell and
you were found to have a humerus fracture. We were seen by the
orthopedic surgeons who said that no surgical intervention was
needed. We controlled your pain with medications by your mouth
and through your veins.
We also had a drain placed into your belly by the interventional
radiologists.
We made the following changes to your medications:
Please increase magnesium oxide from 1 pill to 2 pills daily for
the next five days.
Please have your ___ draw your CBC and electrolyte panel
tomorrow and fax the results to ___.
We did not make any changes to your medications. Please continue
to take all your medications as directed.
Followup Instructions:
___
|
10462684-DS-19 | 10,462,684 | 28,154,529 | DS | 19 | 2131-08-17 00:00:00 | 2131-08-17 17:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / amoxicillin / oxycodone
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old lady with PMH notable for migraines,
agenesis of the corpus collosum, colpocephaly, and Chiari
malformation (no shunt, or other treatment) who originally
presented to ___ with severe headaches and fevers.
She began having symptoms two days prior to presentation to the
outside hospital with acute onset of severe headaches,
nausea/vomiting, photophobia, and fever with a reported Tm of
102.3F. Patient is also endorsing neck pain and stiffness. She
had a head CT performed at ___ which reportedly showed
no acute change from prior, but was nevertheless transferred to
___ for further evaluation by Neurosurgery given her
underlying anatomy.
In the ED, her initial vitals: T 98.0 BP 114/76 HR 94 RR 18 95%
RA. Her physical exam was notable for neck stiffness, but
negative Kernig's and Brudzinski's sign. By report, she was
following most commands but overall poorly cooperative and
seemed drowsy (in the setting of getting pain meds). Labs were
notable for a leukocytosis of 29.6 (from 15 at the OSH) with 32%
bands, lactate of 5, bicarb of 19, INR of 1.6. She was evaluated
by Neurosurgery who reviewed both outside head CTs and concluded
that there was no indication for neurosurgical intervention
since there was no change in size of ventricles and no evidence
of hydrocephalus. Although CNS infection is highly suspected,
Neurosurgery could not approve LP due to the crowded foramen
magnum and risk of herniation. In the ED, patient received 3L of
NS with no improvement in her lactate. She also received IV
Ketorolac 30 mg, dilaudid 0.5 and 1mg IV, and Zofran. She was
started on empiric antibiotics for suspected meningitis with 1gm
IV CFTX, 1g IV vancomycin, and IV Acyclovir 550 mg. On transfer,
vitals were: BP 94/64 HR 93 RR 18 94% on RA.
On arrival to the MICU, Patient is ill appearing but HD stable.
She is mostly interactive and responding to questions, but
intermittently inattentive. She confirms history above, noting
___ pain, but states that her nausea has improved at the
moment. She reports runny nose an congestion that precedes
illness. She also notes photophobia and neck
stiffness/discomfort. She denies changes in vision (no blurry
vision, double vision). No sore throat, No chest pain, shortness
of breath, productive cough, skin rash, abdominal pain, diarrhea
or dysuria.
Past Medical History:
-migraines
-agenesis of the corpus collosum, colpocephaly, and Chiari
malformation
-hammer toes s/p surgical repair
Social History:
___
Family History:
Sister with ___ (patient is a carrier)
Physical Exam:
ADMISSION:
Vitals: afebrile BP: 102/68 P: 89 R: 18 O2: 94% on RA.
GENERAL: ill appearing and lethargic, no acute distress.
HEENT: anicteric sclera, EOMI, miotic
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: tachy, regular rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: warm to touch, no rashes or other lesions.
NEURO: ___ intact, ___ strength in upper and lower
extremities, gait deferred.
DISCHARGE:
Vitals: HR 50 T 98.5 BP 106/66 RR 17 96 % RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, dyr mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally, on anterior chest
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION/IMPORTANT LABS:
=========================
___ 02:45AM BLOOD WBC-29.6* RBC-3.41* Hgb-12.0 Hct-35.6
MCV-104* MCH-35.2* MCHC-33.7 RDW-13.0 RDWSD-49.1* Plt ___
___ 02:45AM BLOOD Neuts-61 Bands-32* Lymphs-2* Monos-4*
Eos-0 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-27.53*
AbsLymp-0.59* AbsMono-1.18* AbsEos-0.00* AbsBaso-0.00*
___ 02:45AM BLOOD ___ PTT-22.8* ___
___ 02:45AM BLOOD ___ 02:45AM BLOOD Glucose-174* UreaN-10 Creat-0.7 Na-141
K-3.3 Cl-105 HCO3-19* AnGap-20
___ 02:45AM BLOOD ALT-16 AST-21 LD(LDH)-190 AlkPhos-40
TotBili-1.6*
___ 02:54AM BLOOD Lactate-5.0*
___ 03:46AM BLOOD Lactate-1.3
LABS AT DISCHARGE:
==================
___ 07:00AM BLOOD WBC-8.2 RBC-3.04* Hgb-10.4* Hct-30.4*
MCV-100* MCH-34.2* MCHC-34.2 RDW-13.2 RDWSD-48.8* Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-89 UreaN-16 Creat-0.6 Na-143
K-3.3 Cl-110* HCO3-22 AnGap-14
___ 03:46AM BLOOD Lactate-1.3
MICRO:
======
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
CEFTRIAXONE-----------<=0.06 S
ERYTHROMYCIN---------- =>1 R
LEVOFLOXACIN---------- 1 S
MEROPENEM------------- S
PENICILLIN G----------<=0.06 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
IMAGING/OTHER STUDIES:
========================
CXR ___
Diffuse prominence of the pulmonary interstitium can be seen in
the setting of atypical bacterial or viral infection in the
appropriate clinical setting. No focal lung consolidation.
CT Head ___
Images available via lifeImage, no report. As per Neurosurgery,
no significant changes as compared to ___ CT.
Brief Hospital Course:
Ms. ___ is a ___ year old lady with PMH of migraines, agenesis
of the corpus collosum, colpocephaly, and Chiari malformation
who originally presented to ___ with severe
headaches,fevers, leukocytosis, and elevated lactate concerning
for CNS infection.
Severe Sepsis: in setting of bacteremia and likely bacterial
meningitis, sepsis physiology resolved at the time of discharge
Meningitis: leukocytosis/bandemia, tachycardia, fever, severe
headaches, neck stiffness, and photophobia in patient with
underlying anatomic malformation concerning for meningitis.
Unfortunately, given crowded foramen magnum, unable to safely
obtain LP for diagnostic evaluation. Today with headache and
nausea, some concern for increased ICP but unable to LP for
pressure measurement, and had CT at OSH with same symptoms.
Patient initially treated with empiric vanc, ceftriaxone, and
acyclovir. Acyclovir was discontinued after 24 hours. Blood
cultures ultimately grew Streptococcus pneumonia (___), later
determined to be sensitive to ceftriaxone, and patient had mid
line palced on ___ and was discharged home with plan for 14
days antibiotics from date of last negative culture (___)
#Hypoxemia: Observed to have oxygen saturation of 92% on
transfer from ICU, likely multifactorial to include atelectasis
in the setting of prolonged bedrest. Her oxygen saturation was
improved at the time of discharge, she is encouraged to
ambulate, utilize incentive spirometry, she should return to the
nearest ER immediately for shortness of breath, difficulty
breathing
#Anion-gap metabolic acidiosis: Likely secondary to poor
perfusion in setting of sepsis physiology. resolved at the time
of discharge
#Coagulopathy (INR 1.6)
In setting of suspected meningitis, concern for DIC. However,
normal fibrinogen and LDH is reassuring. INR increase likely in
the setting of sepsis, which peaked and 2.2, and slowly
downtrended as meningitis was treated with antibiotics, and INR
was 1.2 on day of discharge.
#Chiari malformation, Agenesis corpus collosum; colpocephaly.
As per surgery, stable on recent CT scan. No previous surgical
interventions and none indicated at this time. Monitored for
worsening in mental status as this would have prompted stat
repeat CT and reconsultation of Neurosurgical service. PAtient
was discharged with follow up in our neurology department
concerning migraine below (patient had been without neurologist
or neurosurgeon for years per family)
#Headache: Refractory to dilaudid and toradol and having
significant nausea. Patient started on fioricet with moderate
efficacy. She was given reglan PRN for nausea. Expected to
improve with treatment of meningitis (above). However, given
history above and persistent of migraine symptoms, in discussion
with family arrange for nerulogy follow up in 2 weeks for
migraine management. Patient discharged with short term
fioricet, metoclopramide, Zofran, and ibuprofen.
TRANSITIONAL ISSUES
========================================
-Patient to have 2 weeks of antibiotics from first negative
culture date (___), last day ___ of 2 grams q12 ceftriaxone
-For headaches, patient discharged with short term fioricet,
metoclopramide, Zofran, and ibuprofen. Patient will have F/U
with neurology for long term management re headaches.
-Patient's family in process of transitioning patient PCP;
hospital course in house will be provided to family on d/c
worksheet
-Please have PCP repeat CBC on next F/U visit; WBC on d/c 8
(from 29 on admission)
# Communication/HCP: Mother (___) ___ ___ (aunt)
___ . Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. CeftriaXONE 2 gm IV Q 12H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams iv q12
Disp #*23 Intravenous Bag Refills:*0
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
RX *butalbital-acetaminophen-caff 50 mg-300 mg-40 mg ___
capsule(s) by mouth every 6 hours Disp #*18 Capsule Refills:*0
3. Ibuprofen 400-600 mg PO Q6H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 8 hours Disp
#*40 Tablet Refills:*0
4. Metoclopramide 10 mg PO TID:PRN headaches
RX *metoclopramide HCl 10 mg 1 by mouth up to three times a
headahce Disp #*15 Tablet Refills:*0
5. Ondansetron 4 mg PO Q8H:PRN nausea/headache
RX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth every 8
hours Disp #*12 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Pneumococcal Meningitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to the hospital because you had a sever headache. At
the hospital it was determined that this was due to meningitis,
and infection of the fluid around your brain (cerebrospinal
fluid). You had an IV placed called a mid line, and will have
antibiotics administered at home.
We wish you all the best!
-Your ___ Care Team
Followup Instructions:
___
|
10462700-DS-19 | 10,462,700 | 21,591,466 | DS | 19 | 2163-12-04 00:00:00 | 2163-12-10 08:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chief Complaint: transferred from OSH for septic shock
Reason for MICU transfer: Septic Shock
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male with a history of IV drug use, hepC and
ischemic stroke presents from ___ after being
found down today this AM. Unknown down time. He states that he
woke up in the lawn of a house; he then crawled to the front
door and asked for help. Had pain in left lower back, which
limited mobility. Taken by EMS. He reports new weakness and
decreased sensation in LLE. Found to be hypotensive (80s),
hypoglycemic (___), tachycardic, and tachypneic at OSH. He was
started on vancomycin and Zosyn at OSH. A right IJ was placed.
He was given a total of 4 L of IV fluids and started on
norepinephrine drip. He was given insulin and D50 for
hyperkalemia prior to transfer.
He was then transfered to ___ for evaluation of endocarditis. At
___, received neuro consult and 1 additional liter. He was able
to be weaned off of levophed. Physical exam in the ED was
pertinent for alert and oriented, L leg decreased sensation and
flaccid paralysis.
Of note, was transfered from ___ detox facility to
___ to evaluate a pneumonia. He could not find placement
after discharge and attests this to his relapse. Would like
placement after discharge from ___.
In the ED, exam/labs were notable for:
___: 14.6 PTT: 29.5 INR: 1.4
wbc 29.1 hg/hct 14.5/43.7 platelets 118
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
CK ___ 30
--------------
6.0 23 3.5
Urine Opiates POS
Urine Benzos, Barbs, Cocaine, Amphet, Mthdne Negative
7.28 44 27 22
Lactate 3.3 --> 2.5
UA: 16 hyaline casts. +proteins, glucose, 15wbc, high spec
gravity
Hyperkalemia(K at OSH 7).
CK 56,000 (anuric currently)
Neuro consult in ED. Found to have decreased hearing in L ear.
Otherwise, consistent with peripheral nerve injury.
On arrival to the MICU, BP: 120/63 P: 75 R: 18 O2: 100 ___
Review of systems:
(+) Per HPI; endorses slight headache and subjective chills.
(-) Denies fever. Denies headache, sorethroat. Denies shortness
of breath. Denies chest pain. Denies nausea, vomiting, abdominal
pain. Denies dysuria, frequency, or urgency.
Past Medical History:
CVA (___) with short-term memory issues only deficits. On daily
baby ASA
Hep C - treated with unknown med 2 months ago
PNA - Seen at ___ 2 weeks ago; discharged with zyvox.
Social History:
___
Family History:
None
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- BP: 120/63 P: 75 R: 18 O2: 100 ___
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated
LUNGS: Clear to auscultation bilaterally anteriorly
CV: Regular rate and rhythm
ABD: soft, non-tender, non-distended, no rebound tenderness or
guarding
EXT: LLE deficits (weakness, numbness, areflexia at knee)
localize to L5-S1 distribution. Warm, well perfused, 2+ pulses,
no clubbing, cyanosis or edema. Pain with leg raise of L leg.
Pain with pelvic compression exam.
SKIN: tattoo on R thigh and L hand
NEURO: flaccid paralysis L leg, decreased sensation. 2+ pulses;
decreased hearing
Physical Exam on Discharge:
Vitals- 98 69 143/85 18 100%RA
General- NAD, discomfort noted upon movement due to pain in LLE
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no rales or rhonci.
Slight wheeze noted and increased work to breath.
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, nontedner. non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. superficial
tenderness/ecchymosis from heparin shot.
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
pitting edema noted to b/l ___. LLE with good passive/acitive
ROM, able to flex/extend hip. Slight tautness to anterolateral
thigh, painful to palpation. edema noted to thigh, decrease
noted. Ecchymosis/abrasion to lateral aspect thigh. Decreased
protective sensation to left lower extremity to right. Slight
edema noted to penile shaft and scrotrum, improved.
RLE: excoriations noted to dorsal aspect and medial aspect shin
of right lower extremity, no active bleeding
Neuro- CNs2-12 intact, motor function grossly normal , DTR
intact
___ Results:
Labs on Admission:
___ 01:30PM BLOOD WBC-29.1*# RBC-4.74 Hgb-14.5 Hct-43.7
MCV-92 MCH-30.6 MCHC-33.2 RDW-14.0 Plt ___
___ 01:30PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-OCCASIONAL
Polychr-NORMAL Ovalocy-1+ Pencil-OCCASIONAL
___ 01:30PM BLOOD ___ PTT-29.5 ___
___ 01:30PM BLOOD Glucose-68* UreaN-30* Creat-3.5*# Na-137
K-6.0* Cl-103 HCO3-23 AnGap-17
___ 01:30PM BLOOD ___
___ 01:30PM BLOOD cTropnT-0.30*
___ 08:05PM BLOOD Calcium-6.9* Phos-3.9 Mg-2.0
___ 01:59PM BLOOD ___ O2 Flow-3 pO2-36* pCO2-49*
pH-7.22* calTCO2-21 Base XS--8 Intubat-NOT INTUBA
Comment-CENTRAL VE
___ 02:04PM BLOOD Lactate-3.3*
___ 10:13PM BLOOD freeCa-1.04*
___ 01:50PM URINE Color-Brown Appear-Cloudy Sp ___
___ 01:50PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-100 Ketone-NEG Bilirub-SM Urobiln-0.2 pH-5.0 Leuks-NEG
___ 01:50PM URINE RBC-4* WBC-15* Bacteri-FEW Yeast-NONE
Epi-0
___ 01:50PM URINE CastHy-16*
___ 01:50PM URINE Mucous-RARE
___ 01:50PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
Labs on Discharge
___ 05:30AM BLOOD WBC-5.9 RBC-2.94* Hgb-8.9* Hct-26.3*
MCV-90 MCH-30.3 MCHC-33.8 RDW-16.2* Plt ___
___ 05:30AM BLOOD Plt ___
___ 05:30AM BLOOD Ret Aut-3.4*
___ 05:30AM BLOOD Glucose-86 UreaN-17 Creat-2.7* Na-141
K-4.3 Cl-104 HCO3-28 AnGap-13
___ 05:30AM BLOOD Calcium-8.4 Phos-5.3* Mg-1.7 UricAcd-8.2*
Iron-38*
Imaging:
CXR (___): Right central venous line in place, as
described above, with no evidence of pneumothorax. Focal right
middle lobe opacity.
MRI L Spine without Contrast (___): Gadolinium enhanced
study could not be performed because if renal failure which
slightly limits the evaluation for epidural abscess. No obvious
intra or paraspinal fluid collection seen or disc herniation
identified. No evidence of nerve root displacement or spinal
stenosis.
Bilateral Hip Xray (___): There is no evidence of acute
fracture. Joint spaces are preserved at both hip joints. Soft
tissues appear unremarkable
EKG (___): EKG without peaked T waves
Echo (___): The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The diameters of aorta at the sinus, ascending and arch
levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. No masses or vegetations are
seen on the aortic valve. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. No mass or vegetation is seen on the mitral
valve. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
MRI Thigh W/O Contrast (___): Focally abnormal signal
within the proximal vastus lateralis and lateral gluteus
maximus, extending cephalad adjacent to the hip. This may
reflect direct contusion, with other considerations including
muscle infection or infarction
-Asymmetric enlargement of the left thigh with diffuse
intermuscular fascial edema, muscle edema involving anterior and
posterior compartments and diffuse subcutaneous fat edema.
Nonspecific findings. Compartment syndrome is not excluded on
the basis of this study.
Venous Duplex (___): No evidence of deep venous
thrombosis in the left lower extremity veins.
Brief Hospital Course:
MICU COURSE:
Mr. ___ is a ___ year old male with history of IVDA, found down
in the setting of an overdose with subsequent rhabdomyolysis
complicated by renal failure and left lower extremity
pain/swelling
# Rhabdomyolysis. CK elevation to 50,000s, with resultant
increase in creatinine and potassium levels. Renal was consulted
who did not feel he required dialysis and felt that management
with IVF (150 NaHCO3 in D5W fluids) and lasix was appropriate.
He was transferred to medicine for ongoing management. On the
floor, patients was continued on IVF: NS 200cc/hour, which was
gradually decreased until IV fluids were stopped once CK reached
<5000 on ___ He did not require IV lasix to maintain
fluid output. Patients electrolytes were monitored closely and
replaced. His electrolyte abnl largely resolved prior to
discharge and creatinine appreciably improved.
# LLE weakness. ON admission patient with subjective complaints
and objective findings of lower left extremity weakness.
Neurology was consulted and thought findings were consistent
with peripheral nerve injury as MRI lumbar spine did not show a
collection suggestive of epidural abscess or other acute process
contributing to LLE weakness.
# LLE pain/swelling. Patient with significant swelling of LLE in
setting of aggressive IVF. Given his LLE pain out of proportion
to exam and rhabdomyolysis, orthopedics also evaluated him. MRI
revealed contusion to vastus lateralis and lateral gluteus
maximus with diffuse intermuscular fascial edemaDue to extremity
compressibility there was no concern for compartment syndrome.
Ortho provided serial exams and in house swelling gradually
improved and prior to discharge patient able to ambulate without
assistance.
# HCAP. Two weeks prior to presentation treatment initiated for
left lower lobe pneumonia with linezolid at an OSH. On admission
to the MICU, antibiotics were broadened for potential septic
physiology. Shortly after admission with cultures negative
decision made to discontinue Abx as patient had been adequately
treated for HCAP. Prior to discharge he was devoid of
respiratory complaints.
# Diarrhea: Early during hospitalization patient with frequent
lose stool thought secondary to opiod withdrawl +/- antibiotic
side effect. Cdiff negative.Resolved prior to discharge.
# IVDU: Patient with active heroin use prior to admission. Has
had previous episodes of sobriety however relapsed in setting of
increased social stressors. In house, SW consulted to discuss
discharge options to help optmize patients as an outpatient,
likely drug rehab program. At time of discharge, detox program
could not be arranged as patient was returning to ___ (no
known detox providers in the area). Patient planning to enroll
in Narcotics Anonymous and consider detox program enrollment.
# Transaminitis: Most likely due to shock liver in the setting
of hypotension. Gradually improved in house.
# troponemia: most likely due to systemic stress. TTE negative
for any cardiomyopathy, valve vegetations or abnl. Troponins
trended to peak.
# Hepatitis C. Untreated. Follow-up as patient
Transitional Issues
#Code Status: Full Code
#Gabapentin: continue at 300mg PO bid.
#Oxycodone 5 mg PO q3-4 hours PRN pain
#Lidocaine Patch 5% TD Qam
#Docusate Sodium 100 mg PO bid
#Patient will be discharged to his boyfriend ___ house and
will follow up with ___ Ministry tomorrow to see if a bed is
available.
####Check cbc, CMP and Uric Acid at 1 week. Patient given a
script to obtain this bloodwork.
#Unable to obtain a PCP in the area of ___, which is
requested by the patient. He understands that he will find a new
Primary care provider as there is none available through
care-connections near ___. He will need to provide this
physician with his lab results.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Fluoxetine 20 mg PO DAILY
3. TraZODone 100 mg PO HS:PRN insomnia
4. Loratadine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Linezolid ___ mg PO Q12H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
2. Fluoxetine 20 mg PO DAILY
RX *fluoxetine 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
3. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
4. TraZODone 100 mg PO HS:PRN insomnia
RX *trazodone 100 mg 1 tablet(s) by mouth at night Disp #*30
Tablet Refills:*0
5. Gabapentin 300 mg PO BID
RX *gabapentin 300 mg 1 capsule(s) by mouth twice daily Disp
#*60 Capsule Refills:*0
6. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) Apply patch to
painful area every morning Disp #*30 Patch Refills:*0
7. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 3 hours Disp #*100
Tablet Refills:*0
8. Loratadine 10 mg PO DAILY
RX *loratadine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*30 Capsule Refills:*0
10. Outpatient Lab Work
Please draw CBC, CMP, and uric acid as an outpatient.
Diagnosis: rhabdomyolysis
ICD-9: 728.88
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Rhabdomyolysis, Acute Kidney Injury
Secondary: Left Lower Extremity Pain, Pneumonia, Diarrhea
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you during your hospital visit
at ___. You were transferred from an outside hospital
following an unknown period of unconsciousness following a
heroin overdose.
You were in the intensive care unit where you were aggressively
replenished with fluid and were transferred to the medicine
floor.
You were treated with fluids and your kidney function improved.
You also presented with left lower extremity pain, weakness and
sensory changes. An Xray of your hip revealed no fractures and
MRI of your lumbar spine revealed no abnormalities. MRI of
lower extremity revealed soft tissue swelling without evidence
of compartment syndrome. You were started on Gabapentin, a
medication for your left lower extremity sensory deficits. Your
pain was adequately controlled with Oxycodone and a lidocaine
patch was added at the time of discharge.
Your kidney function will continue to improve, but will continue
to require monitoring. Long term follow up with the nephrologist
is not required at this time, but please follow up with a
primary care provider.
You have received prescriptions for Gabapentin, Oxycodone and
Lidocaine patch for control of pain. Please take these as
prescribed.
You have received a script to obtain blood work including a CBC,
CMP and Uric Acid. Please obtain this bloodwork one week post
discharge and have the results faxed to your new PCP.
We were unable to find a Primary care provider that is close to
your desired locations, but it was discussed the importance of
finding a primary care physician for appropriate follow up.
As we have discussed, it is very important that you abstain from
using drugs after your discharge.
We wish you the best of luck in the future,
Your team at ___
Followup Instructions:
___
|
10462838-DS-6 | 10,462,838 | 23,109,099 | DS | 6 | 2138-06-27 00:00:00 | 2138-06-28 16:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Leg swelling, pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ with h/o cellulitis who presents with 2 days of R lower
leg swelling. History obtained by ED, unable to obtain further
detailed history due to language barrier. Pt states that 2 days
ago R lower leg started to swell and hurt. He also noticed that
he had tenderness in his R inguinal area. Pt denies any fever,
SOB, recent travel,CP, history of PE or blood clot. Pt states
that he has had cellulitis in the past and had to be admitted
for this.
In the ED, initial VS: 98.7 100 175/79 16 99% RA. Labs notable
for WBC 15.1 with 90%N, Cr 1.3 (baseline 1), lactate 2.6. ___
negative for DVT. He was given 1L NS, Vancomycin 1 gram IV,
Zofran 4mg for 1 episode of emesis after Vanco given, and
percocet 10mg 1. Blood cultures were drawn. VS at transfer:
98.0, 147/76, 73, 98% RA.
Currently, he c/o pain in the R groin, mild pain in RLE.
ROS: + per HPI, otherwise negative.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
HTN
GERD
Chronic venous stasis with recurrent ___ cellulitis
Diverticulosis
Low back pain
Social History:
___
Family History:
FAMILY HISTORY: Non-contributory
Physical Exam:
Admission exam:
VS - Temp 97.5F, BP 134/79, HR 75, R 18, O2-sat 99% RA
GENERAL - well-appearing man 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, 1+ pitting edema in RLE, 2+ peripheral pulses
(radials, DPs)
SKIN - warmth noted over distal RLE, chronic venous stasis
changes with scarring in distal BLE
LYMPH - tender palpable 3cm lymph node in R inguinal chain
NEURO - awake, A&Ox3, moving all extremities
Discharge exam
Tm 98.7 Tc 98.2 130/69 67 99%RA 20 24: ___
General: no acute distress, non-toxic, non-diaphoretic
HEENT: NC/AT, OP clear, MMM, EOMI
CV: RRR no m/r/g
Pulm: non-labored, ctab no r/r/w
Abd: nabs, NT/ND, no r/g, no hsm
Extremities: wwp, old scar/contracture on right shin -
proximally trace pitting edema, distal to this trace pitting
edema today. The right shin is warm, but temperature decreased
since yesterday. The right DP is barely palpable; the left 2+.
Due to his skin color, it is difficult to note any erythema.
There is also a 2-3 cm area of fluctuant, palpable inguinal
fullness on the right which is not warm and only mildly tender
to palpation.
Neuro: fluent, appropriate, alert
Pertinent Results:
___ 06:35AM BLOOD WBC-4.9# RBC-3.72* Hgb-12.1* Hct-36.3*
MCV-98 MCH-32.6* MCHC-33.4 RDW-11.8 Plt ___
___ 06:35AM BLOOD Plt ___
___ 06:35AM BLOOD Glucose-87 UreaN-12 Creat-1.0 Na-140
K-3.8 Cl-105 HCO3-26 AnGap-13
___ 06:15PM BLOOD WBC-15.1*# RBC-4.19* Hgb-13.8* Hct-40.8
MCV-97 MCH-33.0* MCHC-33.9 RDW-11.6 Plt ___
___ 06:15PM BLOOD Neuts-90.1* Lymphs-6.5* Monos-2.7 Eos-0.6
Baso-0.1
___ 06:15PM BLOOD ___ PTT-27.6 ___
___ 06:15PM BLOOD Plt ___
___ 06:15PM BLOOD Glucose-108* UreaN-18 Creat-1.3* Na-138
K-3.8 Cl-102 HCO3-25 AnGap-15
___ 07:16PM BLOOD Lactate-1.2
___ 8:40 pm BLOOD CULTURE #2.
Blood Culture, Routine (Pending):
Brief Hospital Course:
ASSESSMENT & PLAN: ___ year old man with chronic venous stasis
and history ___ cellulitis, HTN who presents with right lower
extremity swelling and found to have leukocytosis and evidence
of cellulitis.
# Right lower extremity cellulitis: No evidence of DVT on ___.
Pt has a history of 15 episodes of cellulitis in the past ___
years, likely due to increased risk with chronic venous stasis
secondary to scarring of the shin after trauma. Supported by
leukocytosis with left shift. Also with painful inguinal lymph
node on the right which would support this. The patient was
initially treated with IV vancomycin and Unasyn to cover both
skin flora and MRSA. He did very well on this regimen and was
transitioned to PO Bactrim and Keflex for total 10 day course
(end date: ___. He remained afebrile throughout the
hospital course. His exam improved, the affected leg becoming
progressively less edematous and warm. His pain was well
controlled with oxycodone and acetaminophen. Blood cultures were
drawn and are pending at the time of discharge.
# ___: Cr 1.3 on admission from baseline of 1 with elevated
lactate. Most likely prerenal in setting of infection. Normal
UOP made obstruction unlikely. No recent hypotension to suggest
ATN, new meds to suggest AIN. His creatinine normalized morning
with IVF and the patient was able to resume his lisinopril, HCTZ
without event.
# HTN: normotensive after admission on home metoprolol,
lisinopril and HCTZ.
# GERD: stable. continued omeprazole through the course.
# Chronic Pain: unclear why pt. is taking this. Continued
amitryptiline.
# Incidental finding: Follow-up resolution of inguinal lymph
node as outpatient
# CODE: Full
# CONTACT: Son ___ ___
# ___ issues
- follow-up as outpatient regarding cellulitis
- follow-up right inguinal LAD, consider repeat US if persists
and further work-up
# Incidental findings
A right groin lymph node or cluster of nodes is enlarged and
hypervascular measuring 4.6 x 2.8 x 1.7 cm. This should be
followed clinically as an outpatient and if needed with repeat
ultrasound to asssess for resolution.
# Pending
- Blood cultures
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Amitriptyline 25 mg PO HS
2. Hydrochlorothiazide 25 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Ibuprofen 600 mg PO TID:PRN pain
5. Metoprolol Tartrate 25 mg PO BID
Hold for SBP<100, HR<55
6. Omeprazole 40 mg PO DAILY
7. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
8. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Amitriptyline 25 mg PO HS
2. Docusate Sodium 100 mg PO BID
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID
Hold for SBP<100, HR<55
6. Omeprazole 40 mg PO DAILY
7. Cephalexin 500 mg PO Q6H
d1 = ___. Take this tablet four times a day for 10 days. The
last day you will take this pill is ___.
RX *cephalexin 500 mg 1 Tablet(s) by mouth four times per day
Disp #*40 Tablet Refills:*0
8. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
hold if sedation, RR < 10
RX *oxycodone 5 mg ___ Tablet(s) by mouth up to every four hours
Disp #*24 Tablet Refills:*0
9. Sulfameth/Trimethoprim DS 1 TAB PO BID cellulitis
d1 = ___. Take this tablet twice a day for 10 days. The last
day you will take this pill is ___.
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 Tablet(s) by
mouth twice per day Disp #*20 Tablet Refills:*0
10. Ibuprofen 600 mg PO TID:PRN pain
11. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospital stay.
You were admitted with a skin infection of your right shin. We
began to treat you with IV drugs to resolve your infection. You
responded very well to these and we were able to switch you to
antibiotics taken by mouth. You continued to do very well. Your
condition was very painful and required an opiate painkiller
called oxycodone. You will be discharged on two antibiotics to
fight off the leg infection and oxycodone for pain.
Followup Instructions:
___
|
10462838-DS-9 | 10,462,838 | 27,444,133 | DS | 9 | 2145-11-07 00:00:00 | 2145-11-07 14:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
___ 08:44PM BLOOD WBC-7.7 RBC-4.36* Hgb-14.0 Hct-43.2
MCV-99* MCH-32.1* MCHC-32.4 RDW-12.3 RDWSD-45.1 Plt ___
___ 06:05AM BLOOD WBC-5.7 RBC-3.85* Hgb-12.4* Hct-38.0*
MCV-99* MCH-32.2* MCHC-32.6 RDW-11.7 RDWSD-41.9 Plt ___
___ 08:44PM BLOOD Glucose-154* UreaN-11 Creat-1.0 Na-141
K-5.0 Cl-102 HCO3-24 AnGap-15
___ 06:05AM BLOOD Glucose-99 UreaN-14 Creat-0.9 Na-137
K-4.2 Cl-99 HCO3-25 AnGap-13
___ 08:44PM BLOOD Calcium-9.6 Phos-3.7 Mg-2.3
___ 06:05AM BLOOD Vanco-12.7
CXR
IMPRESSION:
In comparison with the study of ___, there are
improved lung
volumes. Cardiomediastinal silhouette is stable and there is no
evidence of
acute pneumonia, vascular congestion, or pleural effusion.
RLE US
1. No evidence of deep venous thrombosis in the right lower
extremity veins.
2. Extensive soft tissue edema is seen overlying the right calf.
Brief Hospital Course:
ACUTE/ACTIVE PROBLEMS:
#Cellulitis
#Venous stasis ulcers
Risk factor for cellulitis most likely is chronic venostasis
along with severe tinea pedis
- continued vanc and ceftriaxone but switched to doxy and Keflex
on discharge
- elevate R leg at all time
- compression wraps to leg
- treated tinea pedis with terbinafine
BRADYCARDIA
- metoprolol downtitrated from xl 50 mg to xl 25 mg daily
SHORTNESS OF BREATH (intermittent):
CRACKLES AT BASES
- ECG NSR and nonischemic, CXR unremarkable
- placed patient on telemetry with no events
CHRONIC/STABLE PROBLEMS:
HTN: continued home regimen and held amlodipine which can result
in lower extremity edema. Restarted this on discharge
GERD: continued PPI.
BPH: continued Tamsulosin
TRANSITIONAL ISSUES
[] Needs derm follow up for tinea
[] discharged on 5 more days of doxy and Keflex
[] nonadherent with BP meds
[] consider MRSA decontamination if cellulitis recurs
[] metoprolol downtitrated to 25 mg daily due to HRs in ___.
>30 min spent on discharge planning including face to face time
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO QHS
2. Omeprazole 40 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. amLODIPine 10 mg PO DAILY
Discharge Medications:
1. Cephalexin 500 mg PO Q6H Duration: 5 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth every four (4) hours
Disp #*20 Capsule Refills:*0
2. Doxycycline Hyclate 100 mg PO Q12H cellulitis Duration: 5
Days
RX *doxycycline hyclate 100 mg 1 pill by mouth twice a day Disp
#*10 Capsule Refills:*0
3. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*60 Tablet Refills:*0
4. Terbinafine 1% Cream 1 Appl TP BID athlete's foot
RX *terbinafine HCl 1 % apply twice daily to right leg 14 days
Refills:*3
5. amLODIPine 10 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Lisinopril 10 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
Tinea Pedis
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 cellulitis. We think you
are predisposed to this because you have breaks in your skin
from a fungal infection called tinea. You should treat this
fungus with terbinafine cream to prevent future infections. You
should also take both of your antibiotics as prescribed. Please
follow up with your primary care doctor and consider a referral
to a dermatologist.
Followup Instructions:
___
|
10462866-DS-13 | 10,462,866 | 23,781,746 | DS | 13 | 2193-07-25 00:00:00 | 2193-07-25 17:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Omnipaque 240
Attending: ___
Chief Complaint:
Evaluation for acute stroke on ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old RH man with multiple vascular
risk
factors including HTN, HLD, IDDM and CAD s/p CABGx4 who present
with sudden onset L sided weakness/difficulty ambulating on
___.
He reports that he woke up on ___ and fell while trying to get
up. He called his PCP's office and was advised to go to the ED.
He was taken to ___ and was there ___ -
___.
He had MRI/MRA and was told that he had a stroke, but left AMA
as
he had a cruise planned for his wife's birthday and also because
he felt that they were not communicating with him appropriately
(he gives an example of someone coming him and telling him that
he had a stroke and leaving without further explanation). He
felt
that his symptoms of dizziness, gait difficulty and weakness
have
been improving since the onset, though he did require assistance
with walking and has been walking holding onto his wife. He also
describes "numbness" in his left hand, described as his left
hand
not listening to what he wants it to do.
He had some dysarthria in the beginning which has improved. No
headaches, double vision/blurry vision or difficulty with
eating/drinking. His wife does report few episodes of confusion,
described as him asking questions out of context, but no clear
aphasia.
He was seen in ___ ED on ___ when he came in for second
opinion, and was seen in Neuro Urgent Care today by Dr.
___. He was noted to have L sided ataxic hemiparesis, BP
in 200s and irregular heart rate so he was sent to ED for
evaluation and possible admission.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysphagia, lightheadedness, tinnitus or
hearing
difficulty. Denies difficulties producing or comprehending
speech. He has had increased urinary frequency recently.
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. Increased urinary
frequency/urgency but no dysuria or hematuria. Denies
arthralgias
or myalgias. Denies rash.
Past Medical History:
IDDM
Atypical nevus
Bladder stones
Diverticulitis
Hypertension
Hyperlipidemia
Prolactinoma
Anxiety
Prostate cancer followed with surveillance
CKD - baseline Cr 1.6-2.0
Insomnia - usually takes melatonin, ambien prn
Sleep Apnea on CPAP
CAD s/p quadruple bypass ___, ___, LIMA to LAD, SVG to
ramus, SVG to OM3, OM
History of MVC
Social History:
___
Family History:
Father passed away at age ___, had HTN and CHF. Mother
passed away at age ___, had brain aneurysm. Has a sister who
recently had "cyst surgery" but believes she's otherwise
healthy.
One daughter passed away from leukemia at age ___. Son is ___ and
healthy. No history of heart attacks or stroke in the family.
Physical Exam:
==============
ADMISSION EXAM
==============
Vitals: 97.6 91 186/85 16 98% -> BP down to 169/88 16 96% RA
without medications
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, warm to palpation
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. Speech
was not mildly dysarthric, more with lingual than
labial/gutteral
sounds. Able to follow both midline and appendicular commands.
There was no evidence of apraxia or
neglect. There was no evidence of left-right confusion as the
patient was able to accurately follow the instruction to touch
left ear with right hand.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline. Good strength pushing against
the hand bilaterally.
-Motor: Normal bulk, mild paratonia. L hand pronation but no
drift. Orbits around the left arm. No adventitious movements,
such as tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5 ___ 5 4+ 5 5 5- 5 5
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch or pinprick throughout.
Proprioception intact at the toes bilaterally. No extinction to
DSS.
-DTRs: 1+ throughout except for absent ankle jerks and slightly
increased L biceps/brachioradialis reflex. Plantar response was
upgoing on L. Equivocal on R.
-Coordination: No intention tremor. Slow RAM on L though no
clear
dysdiadochokinesia. Dysmetria on FNF and toe to finger on L.
-Gait: Broad based with standing; when asked to put his feet
together, becomes very unsteady, falling to left. Unsteady with
walking, requires one person assist even just taking few steps.
Unable to tandem.
==============
DISCHARGE EXAM
==============
Vitals: Tm ___ Tc 97.6 BP 152/84 (152-174) HR ___ RR 18 SaO2
98/ra Glucose 186
Awake. Alert. Oriented to name, ___, and date. Naming intact.
Speech fluent without paraphasic errors. L pupil > R. Both
briskly reactive. Very slight facial assymetry - right droop and
ptosis. EOMI. VFF. Sensation intact bl. Palatal elevation
symmetric. Tongue protrudes midline. Strength ___ bl in ___ and
___. Drift on L arm. Pronation of R arm. Intention tremor of R
hand. Sensation intact bl in ___ and ___. No extinction to DSS.
Some rebound on L leg elevation. Dysmetria on L FNF and HTS.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 05:52PM BLOOD WBC-10.5 RBC-5.02 Hgb-14.8 Hct-42.8
MCV-85 MCH-29.4 MCHC-34.5 RDW-14.6 Plt ___
___ 05:52PM BLOOD Neuts-68.8 ___ Monos-5.6 Eos-4.0
Baso-0.5
___ 05:52PM BLOOD Plt ___
___ 05:52PM BLOOD Glucose-230* UreaN-30* Creat-1.6* Na-140
K-3.7 Cl-103 HCO3-25 AnGap-16
___ 05:52PM BLOOD ALT-31 AST-20 AlkPhos-61 TotBili-0.3
___ 05:52PM BLOOD cTropnT-<0.01
___ 05:52PM BLOOD Albumin-3.9
___ 05:52PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
==============
PERTINENT LABS
==============
___ 12:50PM BLOOD %HbA1c-7.5* eAG-169*
___ 12:50PM BLOOD Triglyc-612* HDL-19 CHOL/HD-9.9
LDLmeas-73
___ 12:50PM BLOOD TSH-1.2
==============
DISCHARGE LABS
==============
___ 06:22AM BLOOD WBC-7.6 RBC-4.55* Hgb-13.7* Hct-39.4*
MCV-87 MCH-30.2 MCHC-34.8 RDW-14.6 Plt ___
___ 06:22AM BLOOD Glucose-201* UreaN-28* Creat-1.6* Na-140
K-3.9 Cl-104 HCO3-25 AnGap-15
___ 06:22AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.9
=======
IMAGING
=======
- MRI/MRA from ___ (___): MRI shows acute
right pontine stroke and white matter disease on FLAIR. MRA does
not show stenosis of posterior circulation, MRA of neck is of
poor quality but no obvious stenosis.
- CT HEAD (___):
1. Hypodense focus in the pons suggestive of a new infarct of at
least early subacute age.
2. Areas of white matter disease in the frontal lobes suggestive
of chronic small vessel ischemic disease.
3. Mild inflammatory changes involving paranasal sinuses.
- CXR (___): No acute intrathoracic process.
- VIDEO SWALLOW (___): Penetration with thin liquids. No
aspiration.
- TRANSTHORACIC CARDIAC ECHO (___): The left atrium is
mildly dilated. No thrombus/mass is seen in the body of the left
atrium. No atrial septal defect or patent foramen ovale is seen
by 2D, color Doppler or saline contrast with maneuvers. The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with mild basl inferior hypokinesis suggested. No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Mild to moderate (___) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
*** Compared with the prior study (images reviewed) of
___, mild inferior hypokinesis is now suggested.***
Brief Hospital Course:
Mr. ___ is a ___ year-old ___ man with multiple vascular
risk factors including HTN, HLD, IDDM and CAD s/p CABGx4 who
presented for evaluation and work-up for an acute right pontine
ischemic stroke. On ___ he developed acute onset weakeness and
difficulty ambulating and presented to ___
where an MRI/MRA showed a right pontine infarct. He left AMA,
went on a cruise for a week, and then presented to the ___ ED
on ___ for further evaluation. Given his stable condition he
was referred to outpatient Neurology. At his outpatient
Neurology visit on ___ he had SBP in the 200s and was sent to
the ___ ED where his blood pressure stabilized. He was
admitted to the stroke service for further evaluation.
- The location of his stroke is most consistent with small
vessel disease due to long-standing hypertension. To optimize
his blood pressure control, he was started on 10 mg lisinopril
daily.
- His HbA1c and LDL were within normal limits. However his TGs
were severely elevated at 612, and have been in the past. Pt was
started on fish oil and should f/u w/ PCP about management of
his hypertriglyceridemia.
- In clinic he had an irregular rhythm strip on telemetry so
there was concern he had an abnormal heart rhythm, and possibly
a cardiac source of emboli resulting in his stroke. Telemetry
showed no abnormal activity overnight.
- A TTE was done which showed mild inferior hypokinesis, but no
cardiac source of emboli.
- His blood glucose was somewhat controlled with a combination
of home lantus and insulin sliding scale while in the hospital,
but he still had BGs intermittently >200. ___ was consulted,
and pt is known to their service. He should resume his standard
home regimen upon discharge and follow-up with ___ Diabetes
as an outpatient as soon as possible.
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)? () Yes (LDL = ) -
() No
5. Intensive statin therapy administered? () Yes - () No [if LDL
>= 100, reason not given: ____ ]
(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? (X) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
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
TRANSITIONAL ISSUES:
====================
- Added lisinopril 10 for BP control
- Added fish oil for hypertriglyceridemia
- Continued home ASA and pravastatin
- Will need to follow-up with ___ Diabetes in clinic ASAP
- Will need to follow-up with cardiologist Dr. ___ to
discuss TTE results
- Will need to call to book outpatient carotid ultrasound
- Has follow-up appt with Dr. ___ at ___ ___
- Should make follow-up appt w/ PCP ___: BP med regimen,
long-term stroke risk factor modification
- ___ recs: Will need to use a cane for gait stability for 13
months (given prescription)
- OT recs: Has some baseline memory impairment, with new mild
impairment of executive functioning. Is safe at home without 24
hour supervision, but would benefit from supervision during
higher-level IADLs (medication management, ___ paying, etc).
Will get 1 week of home OT by ___ after discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. cabergoline 0.25 mg oral twice weekly
2. Aspirin 81 mg PO DAILY
3. fenofibrate 145 mg oral daily
4. Citalopram 20 mg PO DAILY
5. glimepiride 4 mg oral BID
6. Glargine 22 Units Bedtime
7. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous 1.8mL QHS
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Pravastatin 20 mg PO DAILY
10. Ranitidine 150 mg PO BID
11. Zolpidem Tartrate 10 mg PO HS
Discharge Medications:
1. cabergoline 0.25 mg oral twice weekly
2. fenofibrate 145 mg oral daily
3. Glargine 22 Units Bedtime
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Pravastatin 20 mg PO DAILY
6. Ranitidine 150 mg PO BID
7. Zolpidem Tartrate 10 mg PO HS
8. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Citalopram 20 mg PO DAILY
10. glimepiride 4 mg ORAL BID
11. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous 1.8mL
QHS
12. Cane
Diagnosis: Stroke
Prognosis: Good
Length of need: 13 months
13. Fish Oil (Omega 3) ___ mg PO DAILY
14. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Subacute ischemic stroke of the right pons
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of difficulty walking,
dizziness, difficulty with speech, and difficulty with left
sided coordination, resulting from an acute ischemic stroke, a
condition in which a blood vessel providing oxygen and nutrients
to the brain is blocked by a clot.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
1. High blood pressure
2. High triglycerides (fat) in your blood
3. Diabetes
4. Coronary artery disease
5. Obstructive sleep apnea
We are changing your medications as follows:
1. Adding Lisinopril 10 mg by mouth daily
2. Adding Fish oil, ___ mg by mouth daily, which you can
purchase over the counter
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
10462916-DS-7 | 10,462,916 | 29,604,051 | DS | 7 | 2193-08-17 00:00:00 | 2193-08-18 00:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Flagyl
Attending: ___.
Chief Complaint:
Diverticulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a pleasant ___ female with recurrent
diverticulitis who presents today for an opinion regarding her
recurrent diverticulitis. To review her history, she states
that
her first episode occurred in ___ approximately ___ years
ago. At that time, she received a dose of intravenous
antibiotics in the emergency room and had a CAT scan, which
confirmed diverticulitis; however, she was discharged from the
emergency room to complete outpatient antibiotics and did well.
She had six more episodes after that time. A few times, she
presented to ___ and had CAT scans to confirm
the sigmoid diverticulitis and three times she had CAT scans
here in ___ and ___ to confirm sigmoid
diverticulitis. At no point did she require hospitalization.
At no time did she have abscess, perforation or other
complication
and each time she had left lower quadrant pain, which improved
after she took outpatient antibiotic. Initially, she would take
Cipro and Flagyl; however, notes that she developed nausea with
the Flagyl.
In late ___, she presented to ___
Room again with recurrent left lower quadrant pain. She had no
fevers at that time, and the white count was normal. She states
that because her symptoms were so consistent with previous
symptoms of diverticulitis, she did not undergo CAT scan and she
was given a prescription for Augmentin by the emergency room
physician. She took this and after a couple of days, her pain
improved; however, on the first day of her pain, she did report
that there was some blood mixed in with the stool. This was the
first time that she has had new bleeding and she has not had any
recurrent bleeding since that time.
She states that she has never had a colonoscopy in the past.
She has questions regarding the possibility of preventing
recurrent diverticulitis though she is not interested in
surgery.
GI review of systems, as above. A 10-point review of systems is
otherwise negative. She is asymptomatic in between episodes of
diverticulitis.
Past Medical History:
1. BRCA1 positive and had an oophorectomy in ___.
2. History of breast biopsy.
3. History of dermoid ovarian cyst when she was younger.
4. Recurrent diverticulitis as detailed above
Social History:
___
Family History:
Paternal grandmother and her seven sisters, all had ovarian
cancer in her ___. Father had melanoma and throat cancer. She
is unaware of any colon cancer or colon polyps in the family.
Physical Exam:
Admission:
Vitals: 98.3/98.3, 72, 100/65, 17 100% RA
General: AAOx3
Cardiac: Normal S1 S2
Respiratory: Breathing comfortably on room air
Abdomen: Soft, tender in left lower quadrant, no rebound or
guarding
Skin: No lesions
Discharge:
VS: 98.2 86 107/58 18 100% RA
Gen: AOx3, NAD
CV: RRR no MRG
Resp: CTAB no WRC
Abd: Soft, NT, ND
Ext: 2+ pulses no CCE
Pertinent Results:
IMAGING:
CT Abdomen/Pelvis w/ contrast ___
Acute sigmoid diverticulitis with perforation. No drainable
fluid collection or fistula
PATHOLOGY:
None
MICROBIOLOGY:
Blood culture x2 ___
NGTD
LAB VALUES:
___ 11:00PM BLOOD WBC-13.0*# RBC-4.71 Hgb-13.5 Hct-40.7
MCV-86 MCH-28.7 MCHC-33.2 RDW-13.2 RDWSD-41.5 Plt ___
___ 11:00PM BLOOD Neuts-77.7* Lymphs-18.1* Monos-2.6*
Eos-1.2 Baso-0.1 Im ___ AbsNeut-10.05* AbsLymp-2.35
AbsMono-0.34 AbsEos-0.16 AbsBaso-0.01
___ 12:25PM BLOOD WBC-8.4 RBC-4.27 Hgb-12.3 Hct-36.3 MCV-85
MCH-28.8 MCHC-33.9 RDW-13.0 RDWSD-40.0 Plt ___
___ 04:25AM BLOOD Glucose-106* UreaN-6 Creat-0.8 Na-140
K-4.0 Cl-104 HCO3-26 AnGap-14
___ 04:25AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0
___ 11:18PM BLOOD Lactate-1.2
Brief Hospital Course:
Ms. ___ was admitted from the ED on ___ with fever,
leukocytosis, abdominal tenderness and an abdominal CT scan
demonstrating acute perforated diverticulitis in the context of
___ years of relapsing and remitting episodes of diverticulitis
managed conservatively. Upon admission she was made NPO, given
IVF hydration and started on IV ciprofloxacin and metronidazole.
On HD 2 she had return of flatus and stooling, improved
tenderness and resolution of her leukocytosis. She was advanced
to clear liquids, which she tolerated well. On HD 3 she was
given a regular diet which she tolerated well. She was
transitioned to PO Augmentin d/t a history of nausea with PO
Flagyl, but did not tolerate it well, having about 90 minutes of
vague discomfort and malaise. She was thus transitioned to PO
ciprofloxacin and flagyl which she tolerated well along with
zofran. With her symptoms resolved and acute goals of care met,
she was discharged to home on a total 14 day course of
antibiotics with plans to follow up with ACS as an outpatient as
well as establish care with Colorectal surgery to be evaluated
for a future laparoscopic colectomy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hyoscyamine 0.125 mg SL Q4H:PRN Cramps
2. Aspirin 81 mg PO DAILY
3. Loestrin ___ (21) (norethindrone ac-eth estradiol) 1.5-30
mg-mcg oral DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Hyoscyamine 0.125 mg SL Q4H:PRN Cramps
3. Loestrin ___ (21) (norethindrone ac-eth estradiol) 1.5-30
mg-mcg oral DAILY
4. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*24 Tablet Refills:*0
5. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*37 Tablet Refills:*0
6. Ondansetron 4 mg PO Q8H:PRN Nausea
Stop taking if you feel faint or have heart palpatations and
call your doctor's office
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ and
treated for acute diverticulitis with antibiotics and bowel
rest. You are recovering well and are now ready for discharge.
You will be discharged with a course of antibiotics to complete
at home. Outpatient appointments have been made for you with
Acute Care Surgery and Colorectal Surgery to discuss a future
laparoscopic colectomy. It has been a pleasure taking part in
your care.
Sincerely,
___ Acute Care Surgery Team
Followup Instructions:
___
|
10462916-DS-8 | 10,462,916 | 27,489,711 | DS | 8 | 2193-09-25 00:00:00 | 2193-09-25 15:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Diverticultis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI per colorectal surgery consult note:
HPI: ___ yo F with ___ history of intermittent recurrent
diverticulitis who presents with 6 hours of LLQ abdominal pain
and distention. Of note, she was admitted to the ___ in
___ for a perforated diverticulitis (her first
episode of perforation) which was treated conservatively with IV
antibiotics, fluids. Her CT scan at that time showed
intraperitoneal free air reflective of macro perforation. She
was subsequently seen in clinic by Dr. ___ with a plan for
an
elective laparoscopic sigmoid colectomy later this month (___) which she very much prefers at this time.
She notes that since her last hospitalization (see below), she's
been eating lightly (soups, smoothies), but reports having eaten
a regular meal (solid food) quickly today at 4PM and shortly
after, developing sharp pain in her LLQ. She notes associated
subjective fevers and chills. She had her last BM this
afternoon,
which was wnl compared to baseline, with no hematochezia. She
has
been passing gas and belching intermittently. She denies nausea
or vomiting. She notes having severe ___ pain while driving
over bumps in the ambulance.
Past Medical History:
1. BRCA1 positive and had an oophorectomy in ___.
2. History of breast biopsy.
3. History of dermoid ovarian cyst when she was younger.
4. Recurrent diverticulitis as detailed above
Social History:
___
Family History:
Paternal grandmother and her seven sisters, all had ovarian
cancer in her ___. Father had melanoma and throat cancer. She
is unaware of any colon cancer or colon polyps in the family.
Physical Exam:
General: Doing well, tolerating a regular diet, minimal pain
VSS
Neuro: A&OX3
Cardio/Pulm: rrr, no shortness of breath or chest pain
Abd: minimally tender, nondistended
___: no lower extremity edema
Pertinent Results:
___ 06:44AM BLOOD WBC-8.9 RBC-4.11 Hgb-11.6 Hct-35.0 MCV-85
MCH-28.2 MCHC-33.1 RDW-12.4 RDWSD-38.1 Plt ___
___ 07:10AM BLOOD WBC-9.8 RBC-4.10 Hgb-11.5 Hct-34.7 MCV-85
MCH-28.0 MCHC-33.1 RDW-12.6 RDWSD-38.7 Plt ___
___ 11:50PM BLOOD WBC-13.6*# RBC-4.72 Hgb-13.3 Hct-39.8
MCV-84 MCH-28.2 MCHC-33.4 RDW-12.8 RDWSD-39.2 Plt ___
___ 11:50PM BLOOD Neuts-91.3* Lymphs-5.5* Monos-2.5*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-12.44*# AbsLymp-0.75*
AbsMono-0.34 AbsEos-0.01* AbsBaso-0.03
___ 06:44AM BLOOD Glucose-98 UreaN-2* Creat-0.7 Na-137
K-3.3 Cl-106 HCO3-24 AnGap-10
___ 07:10AM BLOOD Glucose-107* UreaN-3* Creat-0.6 Na-138
K-3.1* Cl-108 HCO3-23 AnGap-10
___ 11:50PM BLOOD Glucose-115* UreaN-12 Creat-0.7 Na-135
K-5.7* Cl-100 HCO3-22 AnGap-19
___ 06:44AM BLOOD Calcium-8.6 Phos-2.5* Mg-1.9
___ 07:10AM BLOOD Calcium-8.2* Phos-1.9* Mg-1.9
___ 11:50PM BLOOD Calcium-8.9 Phos-3.1 Mg-1.9
___ 11:54PM BLOOD Lactate-1.3 K-3.8
Brief Hospital Course:
___ was admitted to the inpatient colorectal surgery
service with diverticulitis despite being treated with
Cipro/Flagyl. The CT scan did not show any large perforation or
abscess. She was conservatively treated and received IV Cipro
Flagyl which did improve her symptoms however, she was changed
to Augmentin which she tolerated well. Her white blood cell
count improved from 13 to 8 prior to discharge. Her pain was
significantly improved and she was able to tolerate a regular
diet. She will return home to complete a course of Augmentin
prior to returning for surgery at the end of this month. She was
given appropriate discharge instruction.
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Hyoscyamine 0.125 mg SL Q4H:PRN Cramps
3. Loestrin ___ (21) (norethindrone ac-eth estradiol) 1.5-30
mg-mcg oral DAILY
4. Ciprofloxacin HCl 500 mg PO Q12H
5. MetRONIDAZOLE (FLagyl) 500 mg PO TID
6. Ondansetron 4 mg PO Q8H:PRN Nausea
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 14 Days
please take for 14 days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*27 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Loestrin ___ (21) (norethindrone ac-eth estradiol) 1.5-30
mg-mcg oral DAILY
please use back up method if sexuality active as you have missed
doses
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the inpatient Colorectal Surgery Service
with Diverticulitis for which you are scheduled for surgery on
___. Until that time, you will take the antibiotic
Augmentin for a total of two weeks. Our hope is that the
antibiotics will decrease the inflammation in your abdomen
enough to give you the optimal result from surgery. Please
continue to eat a low residue diet. Please monitor your bowel
function closely. 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 develop 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.
Our office will be in contact with you to give you instructions
related to your surgery.
Followup Instructions:
___
|
10462972-DS-11 | 10,462,972 | 24,392,431 | DS | 11 | 2182-03-18 00:00:00 | 2182-03-21 15:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Influenza Virus
Vacc,Specific / Oxycodone / atorvastatin
Attending: ___
Chief Complaint:
R leg numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Reason for consult: code stroke
Neurology at bedside for evaluation after code stroke activation
within: 3 minutes
Time (and date) the patient was last known well: ___
___ Stroke Scale Score: 2
t-PA given: No Reason t-PA was not given or considered: known
hemorrhage on CT
___ Stroke Scale score was: 2
1a. Level of Consciousness: 0
1b. LOC Question: 1 (couldn't say ___
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: 1
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
Reason for consult: code stroke, L thalamic hemorrhage
HPI:
Ms. ___ is a ___ yo woman with history of HTN and HLD who
present with sudden onset R leg numbness, found to have L
thalamic hemorrhage.
She was at her doctor's office, to get the result of her
"stomach
study." She walked to the bathroom, urinated and then had a
sudden onset R leg numbness. She was taken to local ED and was
found to have L thalamic hemorrhage and transferred here. No new
symptoms.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness. 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:
- HTN
- HLD
Social History:
___
Family History:
Non-contributory.
Physical Exam:
Admission Exam:
Vitals: 98.1 72 171/82-210/59 16 97% RA
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, awake. Able to relate history without
difficulty. Attentive to the examination. Language is fluent
with
intact repetition and comprehension. Normal prosody. There were
no paraphasic errors. Difficulty with naming low frequency
objects. Speech was not dysarthric. Able to follow both midline
and appendicular commands. There was no evidence of neglect.
There was no evidence of left-right confusion as the patient was
able to accurately follow the instruction to touch left ear with
right hand.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to 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 IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
-Sensory: Decreased LT and pinprick in right leg. Otherwise
intact. 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 dysmetria on FNF
bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing.
Discharge Exam:
T 98.1
HR ___
BP 115/61
RR 18
O2 >97% on RA
Gen: NAD, up in chair
Neuro:
Mental status: Awake, alert, able to relate history with fluent
language, no dysarthria.
Cranial nerves: EOMI. Face symmetric.
Motor: Strength ___ bilaterally, except Tri 4+/5.
Sensory: Intact temperature, fine touch, and proprioception.
Coordination: intact finger-nose testing.
Gait: narrow based, no ataxia. Negative Romberg.
Pertinent Results:
___
CXR
Mild cardiomegaly. No focal consolidation.
___
CT Head
1. Stable small focus of hemorrhage at the junction of the left
thalamus with the posterior limb of the internal capsule.
2. Right sphenoid sinus disease.
___
CTA Head
1. Stable left thalamic hemorrhage. No vascular etiology
identified.
2. Questionable 2 mm right supraclinoid ICA/right ophthalmic
artery aneurysm versus infundibulum (series 4, image 56).
___ 07:25AM BLOOD WBC-9.2 RBC-4.16* Hgb-12.0 Hct-37.3
MCV-90 MCH-28.7 MCHC-32.0 RDW-15.9* Plt ___
___ 07:25AM BLOOD ___ PTT-28.4 ___
___ 07:25AM BLOOD Glucose-113* UreaN-21* Creat-0.9 Na-136
K-3.6 Cl-100 HCO3-24 AnGap-16
___ 12:20PM BLOOD %HbA1c-5.8 eAG-120
___ 07:25AM BLOOD Triglyc-180* HDL-44 CHOL/HD-3.3
LDLcalc-66
___ 12:20PM BLOOD TSH-1.2
Brief Hospital Course:
Ms. ___ is a ___ yo woman with HTN, HLD who present with R leg
numbness, found to have L thalamic hemorrhage. Likely etiology
hypertensive hemorrhage because pt had SBP 170-200s on
admission. The patient was monitored overnight. She had complete
resolution of her sensory symptoms and was discharged home, with
follow up in Stroke Clinic.
NEURO:
- hemorrhage stable on repeat CT head, no vascular etiology such
as AVM identified
- no MRI because pt has rods in R leg after remote fracture
- HOLD aspirin, NSAIDs, other anti-platelet agents. Can resume
aspirin after 1 week.
- LDL 66, continue Crestor 40 mg daily
- CE neg
- A1c 5.8
- TSH 1.2
CV:
- CEs neg
- goal SBP < 140
- will resume home antihypertensives
ENDO:
- HbA1c 5.8 - no need for treatment
Toxic/Metabolic:
- urine and serum tox screens neg
ID:
- UA neg
AHA/ASA Core Measures for Intracerebral Hemorrhage
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? ()
Yes - (x) No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. 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)
5. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. lisinopril-hydrochlorothiazide unknown oral daily
3. Metoprolol Succinate XL Dose is Unknown PO DAILY
Discharge Medications:
1. Rosuvastatin Calcium 40 mg PO DAILY
RX *rosuvastatin [Crestor] 40 mg 1 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*3
2. Aspirin 81 mg PO DAILY
3. lisinopril-hydrochlorothiazide 0 unknown ORAL DAILY
4. Metoprolol Succinate XL 0 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
L thalamic hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of R leg numbness/tingling
resulting from an ACUTE HEMORRHAGIC STROKE, a condition in which
a blood vessel providing oxygen and nutrients to the brain
bleeds. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from bleeding can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
High blood pressure, atherosclerotic disease
We are changing your medications as follows:
Hold aspirin for 1 week, then resume
Continue Crestor 40 mg daily
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
10463724-DS-21 | 10,463,724 | 25,279,698 | DS | 21 | 2137-12-06 00:00:00 | 2137-12-06 13:47:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Ativan
Attending: ___
Chief Complaint:
fatigue, streak hemoptysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with inoperable NSCLC adenocarcinoma stage IIIA (T1N2M0) in
a heavy smoker as well as comorbid CAD and CHF (EF 35-40%) s/p
carboplatin paclitaxel x6 as a sensitizing regmen with
definitive XRT. His last dose of chemotherapy was on ___
C6 Carboplatin 2 AUC paclitaxel 50 mg/m2 and completed XRT with
6660 cGy to the tumor and nodes on ___. Since that time, he
has experienced intermittant dysphagia and odynophagia and was
prescribed Magic Mouthwash which he did not take because his
wife did not get instructions from the pharmacist on how to use
it. The day after his last radiation therapy he experienced
nausea, dysphagia, faticue, and difficulty swallowing as well as
insomnia. He did not initially take "Those pills for the
Schizophrenics" (Zyprexa) because his wife looked it up on the
internet and thought it was a bad idea. He has been
experiencing progressive dysphagia, fatigue and has new cough
with streak hemoptysis which is new. In the ER, he received 1L
IVF and reports feeling better on arrival to the floor.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies acute blurry vision, diplopia, loss of vision,
photophobia. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies shortness of breath, or wheezes. Denies
diarrhea, abdominal pain, melena, hematemesis, hematochezia.
Denies dysuria, stool or urine incontinence. Denies arthralgias
or myalgias. Denies rashes or skin breakdown. No
numbness/tingling in extremities. All other systems negative.
Past Medical History:
Past Oncologic History:
___ adenocarcinoma stage IIIA (T1N2M0)
- ___ Presented with cough and unintentional weight loss of
30 lbs
- ___ CT chest ordered given symptoms, ongoing tobacco
abuse
revealed 2 spiculated nodules and necrotic mediastinal
adenopathy
- ___ PET CT showed that the 2 pulmonary nodules were FDG
avid with lymphadenopathy of at least two nodes in the left
paratracheal station
- ___ Brain MRI w/o evidence of metastatic disease
- ___ Bronchoscopic Bx of the mediastinal nodes revealed
NSCLC adenocarcinoma
- ___ Met with Medical Oncology and Radiation Oncology.
Given cardiac comorbidities, planned to proceed with XRT with
concomitant carboplatin paclitaxel
- ___ C1 Carboplatin 2 AUC paclitaxel 50 mg/m2 with
concomitant XRT
- ___ C2 Carboplatin 2 AUC paclitaxel 50 mg/m2 with
concomitant XRT
- ___ C3 Carboplatin 2 AUC paclitaxel 50 mg/m2 with
concomitant XRT
- ___ C4 Carboplatin 2 AUC paclitaxel 50 mg/m2 with
concomitant XRT
- ___ C6 Carboplatin 2 AUC paclitaxel 50 mg/m2 with
concomitant XRT
- ___ C6 Carboplatin 2 AUC paclitaxel 50 mg/m2 with
concomitant XRT
- ___ Completed XRT with 6660 cGy to the tumor and nodes
Other Past Medical History:
- Ongoing tobacco abuse
- CAD s/p MI in ___ and ___
- CABG ___
- Stress test ___ with mild ischemic disease
- Distant CVA with some redisual left-sided weakness
- s/p CEA
- Depression
- HTN
- Hyperlipidemia
- Hypothyroidism
- Right macular degeneration on an intraoccular injection
clinical trial at ___ which has improved his disease
- s/p right hip replacement
Social History:
___
Family History:
- Mother: CAD
- Father: CAD
- Grandmother: ___ cancer
Physical Exam:
VS: T97.5 bp 120/82 HR 102 SaO2 98RA RR 17 SaO2 98 RA
GEN: Elderly man in NAD, awake, alert, talkative
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP dry and
without lesion
NECK: Supple, no JVD appreciated
CV: Reg tachycardia, normal S1, S2. No m/r/g appreciated
CHEST: Resp unlabored, no accessory muscle use. decreased breath
sounds on the right side; no crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, no HSM, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c/e, 2+ ___ bilaterally
SKIN: No rash, warm skin
NEURO: oriented x 3, normal attention, CN II-XII intact,
slightly weak on left side compared to right, intact sensation
to light touch
PSYCH: appropriate
Pertinent Results:
___ 05:09PM ___ PTT-27.1 ___
___ 04:00PM GLUCOSE-146* UREA N-14 CREAT-1.1 SODIUM-138
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16
___ 04:00PM cTropnT-<0.01
___ 04:00PM CALCIUM-8.8 PHOSPHATE-3.7 MAGNESIUM-1.9
___ 04:00PM WBC-4.1 RBC-2.97* HGB-9.6* HCT-28.5* MCV-96
MCH-32.4* MCHC-33.7 RDW-17.0*
___ 04:00PM NEUTS-84.8* LYMPHS-6.6* MONOS-6.8 EOS-1.7
BASOS-0.1
___ 04:00PM PLT COUNT-185
CTA ___:
1. NO pulmonary embolism
2. Left paratracheal mass (primary tumor or lymph node
conglomerate) with
indentation of the left main pulmonary artery and with
encasement of the left
main stem bronchus (both of which remain patent).
3. Mass also involves the mid-esophagus which shows wall
thickening at this
level, but remains open.
EKG: sinus rhythm with normal intervals, when compared to
previous tracing, do not see any acute ischemic changes; older
signs of his completed inferior infarct are present
Brief Hospital Course:
## Odynophagia and hemoptysis: Mr. ___ was admitted for
evaluation of mild hemoptysis that was exacerbated by coughing.
He had a contrast CT chest in the ED, which was negative for
pulmonary embolism but demonstrated the known mass and possible
radiation-induced mid-esophagitis. He was managed conservatively
with magic mouthwash. His odynophagia had mostly resolved
overnight, and he was able to tolerate a complete solid
breakfast the following morning. His presenting complaints of
odynophagia and hemoptysis are both likely related to both his
tumor and a side effect of radiation. His Aspirin was held at
time of discharge. If the hemoptysis worsens, he should be
further evaluated by Pulmonary to consider bronchoscopy. This
was deferred in-house since the hemoptysis was relatively scant.
.
## CAD and chronic systolic CHF with EF 35-40%: Aspirin was held
as above in setting of hemoptysis. This can be resumed at a
later date per discretion of his PMD. No other changes were made
to his cardiac meds.
.
## NSCLC adenocarcinoma s/p chemotherapy and radiation: No
active issues during this admission. He is scheduled for a
staging CT on ___. Further Oncologic management will be
deferred to his outpatient Oncologist.
.
## Social: Per Oncologist request, social work was consulted,
who met with the patient and his daughter. Apparently due to a
hostile relationship between patient and his wife, the patient
has been more withdrawn and fatigued. SW advised that he
follow-up with the NP at his ___ clinic at least once a
week to ensure that he is not declining from a psychological and
nutritional standpoint.
.
## Code status: FULL CODE as confirmed with patient during this
admission.
Medications on Admission:
Medications - Prescription
ATENOLOL - 100 mg Tablet - 1 Tablet(s) by mouth daily
ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 Tablet(s) by mouth
once
a day
DOXAZOSIN [CARDURA] - 4 mg Tablet - 1 (One) Tablet(s) by mouth
at
bedtime
FLUOXETINE [PROZAC] - 40 mg Capsule - 1 Capsule(s) by mouth
daily
LEVOTHYROXINE [LEVOXYL] - 175 mcg Tablet - 1 Tablet(s) by mouth
once a day Brand Name necessary, no substitution - No
Substitution
___ [FIRST-MOUTHWASH ___] - 400
mg-400
mg-40 mg-25 mg-200 mg/30 mL Mouthwash - 1 teaspoon by mouth
every
4 hours as needed for throat pain from radiation therapy
NITROGLYCERIN [NITROSTAT] - 0.3 mg Tablet, Sublingual - 1
Tablet(s) sublingually once as needed for chest pain
OLANZAPINE [ZYPREXA] - 2.5 mg Tablet - ___ Tablet(s) by mouth HS
as needed for insomnia
ONDANSETRON - 8 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth
up to every 8 hours as needed for nausea
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
up
to every 6 hours as needed for nausea
TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - apply twice a day for
management of psoriasis
Medications - OTC
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day
MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1
(One) Tablet(s) by mouth once a day
Discharge Medications:
1. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
may repeat after 5 minutes, then again, then call doctor.
7. olanzapine 2.5 mg Tablet Sig: ___ Tablets PO HS (at bedtime)
as needed for nausea, insomnia.
8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
9. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Appl
Topical BID (2 times a day) as needed for dry skin.
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. ___ 200-25-400-40 mg/30 mL
Mouthwash Sig: One (1) teaspoon Mucous membrane every four (4)
hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Mild hemoptysis
Dysphagia
Non-small cell lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for difficulty swallowing and blood in your
phlegm. A CAT scan did not show a clot in your lungs or blockage
of your major airways.
MEDICATION CHANGES:
- you should stop taking Aspirin for the time being. Your doctor
may re-start at a later date.
Followup Instructions:
___
|
10464228-DS-5 | 10,464,228 | 21,562,040 | DS | 5 | 2144-01-29 00:00:00 | 2144-01-29 17:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
latex / milk
Attending: ___
Chief Complaint:
Gait instability, word-finding difficulty
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ year-old man with history of left MCA stroke
on Coumadin, with mild residual word finding difficulties,
significant L ICA stenosis, history of laparoscopic right
colectomy, HTN, HLD, DM, gout and CML s/p whole body radiation
and bone marrow transplant in ___, tobacco abuse who presents
with two day history of intermittent difficulty ambulating.
Briefly, the patient endorses that he felt unstable three days
ago, while walking his dog. He lost his balance, about a quarter
of a mile into the walk with an acute loss of feeling in his
left leg. He reports he tried to lean heavily on the left leg to
support himself, but that his leg wasn't cooperating. He does
note that he veered to the left when these events occurred. He
held onto a tree for support for about 5 minutes for support,
before he felt back to his baseline and was able to ambulate
home without difficulty. He had no spinning vertigo, denies
visual changes, denies hearing loss, denies tinnitus, denies
lighthheadedness, denies any chest pain, denies shortness of
breath, denies any exertional angina.
A few hours later, he had a similar episode, again while walking
his dog.This also occurred after
walking some distance before symptom onset. This episode was
briefer, lasting just one minute. He had an additional episode
the following day. As a result of his unsteadiness, he began
using a cane for added stability. He had a cane in his house
that he had intermittently used due to knee arthritis issues,
but never for balance.
Finally, patient had his fourth episode on the morning prior to
his presentation to the ED, while at an antique store. He
reports that while walking into the parking lot after leaving
the store, he had a similar episode to before (gait
unsteadiness, decreased sensation and difficulty using left leg,
"veering' to the left). This time, he needed to sit down for a
more prolonged period of time for it to resolve.
He has had no further episodes since yesterday's episode, but
notes that he has not pushed himself much due to concern for
laving another episode. Prior to these episodes, he denies any
recent ilnesses; denies fevers/chills; denies any medication
changes; denies any headache.
Of note, patient is scheduled for left CEA on ___ for severe
carotid stenosis. He is maintained on coumadin, which has been
supratherapeutic recently. In preparation for the surgery he
was instructed to discontinue the coumadin tonight.
Patient saw his neurologist Dr. ___ where concern was
raised for these events being ischemic in nature, for which he
was referred to ___ ED.
On neuro ROS, the pt reports his baseline left temporal
throbbing
headache (always present) and baseline mild word finding
difficulties. Otherwise denies 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.
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:
Neurologic History:
-___: Patient had L temporoparietal ischemic stroke in L MCA
territory. Neither he nor his partner recall this event
particularly well including what his presentation was. At that
time, he had a normal MRA, normal TTE, and was started on
aspirin
81mg daily.
-___: In ___, had a recurrent L MCA stroke, got tPA.
Afterwards, only residual deficit was mild dysarthria and word
finding difficulties. Regimen changed from aspirin 81mg daily to
aspirin 325mg daily.
-___: had recurrence of symptoms, attributed to a TIA,
discharged home.
-Feburary ___: In ___, had third stroke after presenting
with nonfluent aphasia, affecting inferior division of L MCA.
Was
discharged with a 30 Day Holter monitor that did not demonstrate
Afib. TTE with bubble negative for PFO.
-___: Had severe left temporal headache and
elevated CRP, underwent temporal artery biopsy that was
negative.
In ___, had extensive vascular imaging with MRA, which revealed
significant stenosis of L MCA branches including L inferior MCA
division and high grade stenosis of the L PCA, mild stenosis of
R
PCA and moderate stenosis of L carotid artery at the origin.
-Subsequent vascular imaging has reveled L ICA 50% stenosis, 40%
R ICA stenosis, and fusiform 2mm anuerysm in the right M2.
Subsequent carotid doppler has revealed increasing L ICA
stenosis
that his of moderate severity, and CEA was planned for next
week.
Cardiac History:
Embolic strokes, unclear etiology, now on coumadin
HTN
CAD status post bare-metal stent to OM 2 in ___, relook
cath in ___ was similar . Has chronic atypical chest
pain
CAS
s/p TEE without vegetations or PFO (___)
Other medical history:
Social History:
___
Family History:
mother had a stroke (and died from it - was ___ yo); father
had cancer, unspecified (not colon cancer)
Physical Exam:
EXAM ON ADMISSION:
Physical Exam:
Vitals: T 97.7F, HR 57, BP 152/75, RR 16, O2 100% RA
Orthostatics
Supine HR 58, BP 158/86
Seated HR 55, BP 166/82
Standing HR 67, BP 147/79
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused; regular on telemetry
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time and
situation. Able to relate history without difficulty. Attentive,
able to name ___ backward without difficulty. Language is
notable
for very mild word finding difficulties, 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. The pt had
good knowledge of current events. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: Anisocoria L 3>2, R 2.5>2. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. No skew. 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
R 5 ___ 5 ___ 5 5 5 5 5
-Sensory: Mild vibratory loss at the toes. Otherwise No deficits
to light touch, pinprick, cold sensation, proprioception
throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 2 1
R 1 1 1 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally. Negative cerebellar
mirroring test. No truncal ataxia.
-Gait: ___ notable for drifting to the left. Good
initiation. Gait is slightly wide based, with mild veering tho
the left, with normal stride and arm swing. Unable to walk in
tandem. Romberg absent.
EXAM ON DISCHARGE:
Objective:
VS: T98.5, BP 132-166/70-95, HR60-70, RR18, SaO2 96%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, no lesions noted in
oropharynx, ? carotid bruit in left
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused; regular on telemetry
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time and
situation. Able to relate history with moderate word-finding
difficulty. Can name ___ objects but not
low-frequency objects. Attentive, able to name ___ backward
without difficulty. Repetition and comprehension intact. 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 L 5>3, R 3.5>2.5 with anisocoria. VFF to
confrontation.
III, IV, VI: EOMI without nystagmus. No skew. Normal saccades.
V: Facial sensation intact to light touch.
VII: R NLF, symmetric 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.
Note: h/o right eye surgery with elevated palpebral fissure on
right
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted. Pronation bilaterally with no drift.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 ___ 5- 5- 5 5 5
R 5 ___ 5 ___ ___ 5 5
-Sensory: Mild vibratory loss at the toes. Mild proprioception
deficits in big toes bilaterally. Otherwise no deficits
to light touch. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 2 1
R 1 1 1 2 1
Plantar response was mute.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally. No truncal ataxia.
-Gait: Gait is slightly wide based with left-bias. Normal stride
and arm swing. Leans to left when asked to ___ in place with
eyes closed. Unable to walk in tandem. Swaying when stands with
eyes closed but does not lean or fall.
Pertinent Results:
INR on admission: 4.5
INR on discharge: 3.1
LDL: 89, TgL 192, HDL: 44
A1C: 5.1%
IMAGING RESULTS:
TTE ___: no PFO, no vegetations
MRI/MRA Head ___:
Significant encephalomalacia of the left temporal lobe with ex
vacuo
dilatation of the occipital horn left lateral ventricle,
unchanged from prior. No evidence of acute hemorrhage or
infarction.
CXR ___ no acute cardiopulmonary process
CTA Head/neck ___
Reviewed. Notable for relatively stable ICA stenosis L>R ,
diffuse intracranial calficications. Prelim report: "There is
encephalomalacia of the left temporal lobe with ex vacuo-
dilatation of the occipital horn of the left lateral ventricle.
There is no large vascular territory infarction or evidence of
hemorrhage. Large mucous retention cyst in the left maxillary
sinus. There is no evidence occlusion, stenosis, aneurysm
formation or dissection of the circle ___ and principal
intracranial branches. There is 75 % stenosis of the left
internal carotid artery by NASCET criteria. No significant
stenosis of the right internal carotid artery. Bilateral
vertebral arteries are unremarkable. Dural venous sinuses are
patent.
Brief Hospital Course:
Mr. ___ is a ___ yo man w/ sig stroke history,
atherosclerosis here for transient gait instability suspected to
be secondary to TIA in distribution of right ACA. His exam on
admission was notable for slight left-gearing on gait and
word-finding difficulty with intact strength. Imaging was
negative for acute infarct, though his CTA was suspicious for a
possible calcium emboli versus calcification of the A2 segment
of the R-ACA. It is possible that Mr. ___ harbors a
___ vasculopathy given his history of WBRT (___)
and negative cardiac work-up (no arrhythmias by loop x2, no
vegetations or PFO by TEE, TTE).
1. Left-sided weakness, Gait instability: Concern for TIA with
source likely due to ___ vasculopathy vs
cholesterol/calcium emboli. No stroke on MRI.
- patient has had extensive work-up (see PMH), including 2 loop
records and TEE without identification of arrythmmia, heart
valve vegetation or PFO to date)
- LDL 89, A1c 5.1
- TTE: mildly dilated left atrium, no PFO, no vegetations
- orthostatics resolved with 2L IVF NS
- maintained on atorvastatin 80mg
- coumadin held for INR 4.5 on admission
- not on dual anticoagulation with ASA or clopidogrel
- lisinopril 5 mg qday held on discharge until ___ s/p CEA or
per Dr. ___
# Hyperlipidemia, CAD s/p stents, atherosclerosis with 70%
occlusion left ICA
- cont. atorvastatin 80mg
- not on dual anticoagulation with ASA or clopidogrel, will
defer to outpatient
cardiologist
- held Coumadin for INR 4.5 on admission
- no events on telemetry
- lisinopril 5 mg qday held on discharge until ___ s/p CEA or
per Dr. ___
# DM2
- A1C 5.1 on this admission, euglycemic
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. Febuxostat 40 mg PO DAILY
5. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID
6. Gabapentin 300 mg PO TID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. FoLIC Acid 1 mg PO DAILY
9. Lisinopril 5 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. PARoxetine 20 mg PO DAILY
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain
13. ___ MD to order daily dose PO ONCE
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. Febuxostat 40 mg PO DAILY
5. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID
6. Gabapentin 300 mg PO TID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. FoLIC Acid 1 mg PO DAILY
9. Lisinopril 5 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. PARoxetine 20 mg PO DAILY
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain
13. ___ MD to order daily dose PO ONCE
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. Febuxostat 40 mg PO DAILY
5. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID
6. Gabapentin 300 mg PO TID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. FoLIC Acid 1 mg PO DAILY
9. Lisinopril 5 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. PARoxetine 20 mg PO DAILY
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain
13. ___ MD to order daily dose PO ONCE
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. Febuxostat 40 mg PO DAILY
5. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID
6. Gabapentin 300 mg PO TID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. FoLIC Acid 1 mg PO DAILY
9. Lisinopril 5 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. PARoxetine 20 mg PO DAILY
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain
13. ___ MD to order daily dose PO ONCE
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. Enoxaparin Sodium 90 mg SC Q12H Duration: 4 Doses
3. Pyridoxine 50 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
7. Febuxostat 40 mg PO DAILY
8. Fluocinolone Acetonide 0.025% Cream 1 Appl TP BID
9. FoLIC Acid 1 mg PO DAILY
10. Gabapentin 300 mg PO TID
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain
14. PARoxetine 20 mg PO DAILY
15. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until After your CEA on ___. HELD- ___ MD to order daily dose PO ONCE This
medication was held. Do not restart Warfarin until ___ ___ or
as directed by Dr. ___ Dr. ___
___ Disposition:
Home
Discharge Diagnosis:
Transient ischemic attack
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 leg weakness
resulting from a TRANSIENT ISCHEMIC ATTACK, a condition where a
blood vessel providing oxygen and nutrients to the brain is
TEMPORARILY restricted by a blockage. The brain is the part of
your body that controls and directs all the other parts of your
body, so damage to the brain from being deprived of its blood
supply can result in a variety of symptoms. If the brain is only
deprived of blood for a short amount of time (TRANSIENTLY), then
your symptoms can resolve. In these situations, imaging of your
brain will be normal.
We imaged your brain during your hospitalization and did not
find any signs that you had a recent stroke, suggesting that you
had TRANSIENT ISCHEMIC ATTACK.
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 Transient Ischemic
Attacks, we plan to modify those risk factors. Your risk factors
are:
High cholesterol
Cholesterol accumulation in the vessels going to your brain
History of whole brain radiation therapy
You are already on a strong medicine (atorvastatin) to reduce
your cholesterol. You are also on warfarin to reduce the chance
of emboli in your blood. You came in with a high INR suggesting
that your warfarin dose may not be optimal. We held your
warfarin on discharge and temporarily replaced your blood
thinner with ENOXAPARIN, as previously arranged with Dr. ___.
Please continue to follow with Dr. ___ Dr. ___
instructions regarding the continuation of your warfarin your
___ clinic to make sure your warfarin dose is correct.
MEDICATION CHANGES ON THIS ADMISSION:
Warfarin - hold this medication and replace with lovenox
(enoxaparin) as previously arranged with Dr. ___,
___ ___
Lisinopril - STOP taking this medication until AFTER your CEA on
___ (stopped for orthostatic
hypotension/dehydration on admission)
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:
___
|
10464490-DS-9 | 10,464,490 | 26,308,462 | DS | 9 | 2116-10-30 00:00:00 | 2116-10-30 08:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
b/l feet numbness and saddle numbness
Major Surgical or Invasive Procedure:
L5-S1 Microdiscectomy
History of Present Illness:
___, healthy, referred in after outpatient MRI for concern for
cauda equina syndrome. She was lifting groceries from her car on
___ when she felt sharp LBP. She developed R posterior
thigh numbness that night. ___, she developed L posterior
thigh numbness and saddle numbness. The back pain resolved with
time. She saw her PCP yesterday, who referred her to get MR ___
spine for saddle anesthesia. She was called by her PCP with
results showing a large L5-S1 disc herniation, to come to the ED
for concern for cauda equina syndrome. She denied back pain, leg
pain, weakness, or changes in bowel/bladder symptoms. She has
mild numbness in b/l feet and mild saddle numbness.
Social History:
Works as an ___. She speaks ___ and ___.
Physical Exam:
Admission PHYSICAL EXAMINATION:
In general, the patient is in NAD.
Vitals: 99.4 93 ___
Spine exam:
Vascular
Radial: L2+, R2+
DPR: L2+, R2+
Motor-
Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory:
Sensory UE
C5 (Ax) R nl, L nl
C6 (MC) R nl, L nl
C7 (Mid finger) R nl, L nl
C8 (MACN) R nl, L nl
T1 (MBCN) R nl, L nl
T2-L2 Trunk R nl, L nl
Sensory ___
L2 (Groin): R nl, L nl
L3 (Leg) R nl, L nl
L4 (Knee) R nl, L nl
L5 (Grt Toe): R nl, L nl
S1 (Sm toe): R nl, L nl
S2 (Post Thigh): R nl, L nl
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
___: neg
Babinski: downgoing
Clonus: none
Perianal sensation: decreased
Rectal tone: intact
Physical ___
General-Well appearing laying in bed,comfortable,NAD,pleasant
Heart-RRR
Lungs-CTAB
Abd-soft,ntnd,+bs's
Extremities-wwp,2+rad,2+dp pulses
___ BLE ___
+SILT b/l
Pertinent Results:
___ 06:30AM BLOOD WBC-15.7*# RBC-4.42 Hgb-14.0 Hct-40.9
MCV-93 MCH-31.6 MCHC-34.1 RDW-13.7 Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-118* UreaN-17 Creat-0.7 Na-135
K-4.0 Cl-99 HCO3-27 AnGap-13
___ 08:24AM BLOOD ALT-13 AST-17 AlkPhos-42 TotBili-1.0
___ 11:25AM BLOOD Calcium-10.4* Phos-3.2 Mg-2.4
___ 08:24AM BLOOD TSH-4.0
___ 08:24AM BLOOD Triglyc-95 HDL-71 CHOL/HD-3.1 LDLcalc-128
___ 08:24AM BLOOD 25VitD-54
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled oral pain medication. Diet was advanced as
tolerated. The patient continued on oral pain medication when.
Foley was removed on POD#1. The patient was ambulating
independently. Hospital course was otherwise unremarkable. On
the day of discharge the patient was afebrile with stable vital
signs, comfortable on oral pain control and tolerating a regular
diet.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
may take over the counter
2. Docusate Sodium 100 mg PO BID
please take while on pain medication
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*20 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
please do not operate heavy machinery,drink alcohol or drive
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
L5-S1 Disc Herniation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Microdiscectomy
You have undergone the following operation: Minimally Invasive
Microdiscectomy
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit or stand more than ~45 minutes without moving around.
Rehabilitation/ Physical Therapy:
___ times a day you should go for a walk for
___ minutes as part of your recovery. You can walk as much as
you can tolerate.
Limit any kind of lifting.
Diet: Eat a normal healthy diet. You may have
some constipation after surgery.
Brace: You do not need a brace.
Wound Care: Remove the dressing in 2 days. If
the incision is draining cover it with a new sterile dressing.
If it is dry then you can leave the incision open to the air.
Once the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead. You can either
have them mailed to your home or pick them up at the clinic
located on ___ 2. We are not allowed to call in narcotic
prescriptions (oxycontin, oxycodone, percocet) to the pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
At the 2-week visit we will check your incision,
take baseline X-rays and answer any questions. We may at that
time start physical therapy.
We will then see you at 6 weeks from the day of
the operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound
Followup Instructions:
___
|
10464640-DS-15 | 10,464,640 | 26,536,752 | DS | 15 | 2157-03-30 00:00:00 | 2157-03-31 14:10:00 |
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
Major Surgical or Invasive Procedure:
___ Diagnostic Paracentesis
History of Present Illness:
___ y/o F hx of primary sclerosing cholangitis c/b cirrhosis (CP
C), grade 1 varices, HE, and ascites undergoing transplant eval
and ulcerative colitis presenting with abdominal pain, nausea,
and emesis. Of note, patient was recently admitted to liver
service for failure to thrive/malnutrition and discharged with
Dobhoff tube on ___.
Patient presents from home with one day of RLQ/suprapubic
abdominal pain as well as pain in RUQ, nausea, and vomiting. She
describes the RLQ pain as sharp, radiating to her back
associated with several episodes of nausea and nonbloody,
nonbilious vomiting. She has had mild chills but no fevers. She
states she has been having a difficult time tolerating PO intake
over the last couple weeks. She can sometimes keep down noodles
or mashed potatoes, tolerates water, but otherwise vomits up
anything she eats. She gets very nauseous with lactulose too and
cannot keep that down. She has been running her tube feeds at 45
cc/hr continuously since discharge in late ___ (interrupted
recently when ___ fell out- but it was replaced a few days
ago) and hasn't had nausea related to tube feeds. She requests
restart of her tube feeds at this time. She feels quite
dehydrated and states she has polyuria. Sugars have been running
high (300-400s) lately despite taking 40 Units of Lantus
nightly. She also takes sliding scale Humalog every morning, but
not at any other time of day.
She denies cough, dyspnea, chest pain, or dysuria. She has
loose stools ___ per day) but these are at her baseline. No
change in stool odor or color.
In the ED, initial vital signs were: pain 9, T 98.0, HR 90, BP
111/68, RR 17, O2 99% RA
- Exam was notable for: Benign abdominal exam with negative
___ sign and negative fluid wave. Asterixis was absent.
- Labs were notable for:
CBC: 5.3>10.2/30.7<116
BUN/Cr 32/1.1 ___ on ___
ALT/AST 85/190 (38/104 on ___
Alkphos 1386 (813 on ___
TBili 8.1 (8.0 on ___
INR 1.0
UA with 1000 glucose, negative WBCs
- Imaging:
*RUQ U/S w/Doppler showed (1) Patent hepatic vasculature and
(2) Left renal cysts, one of which contains apparent
calcifications. (3) Trace ascites
*CXR: Subtle right basilar interstitial abnormality may
represent resolving edema
*KUB: Transesophageal tube terminates likely in the proximal
jejunum. No definite evidence of bowel obstruction.
-The patient was given:
___ 00:57 IV HYDROmorphone (Dilaudid) .5 mg
___ 00:57 SC Insulin 10 Units
___ 06:30 IV Albumin 25% (12.5g / 50mL) 50 g
___ 08:38 IV Ciprofloxacin 400 mg
___ 09:51 IV MetRONIDAZOLE (FLagyl) 500 mg
___ 12:04 SC Insulin 12 UNIT
___ 19:56 IV MetRONIDAZOLE (FLagyl) 500 mg
___ 19:56 PO/NG Lactulose 30 mL
___ 19:56 PO/NG Docusate Sodium 100 mg
___ 19:56 PO/NG Multivitamins 1 TAB
___ 19:56 PO Pantoprazole 40 mg
___ 19:56 PO/NG Senna 8.6 mg
___ 19:56 PO/NG Sertraline 75 mg
___ 20:07 SC Insulin Lispro 12 UNIT
Vitals prior to transfer were: Pain 0, HR 90, BP 109/70, RR 18,
O2 97% RA, sugar 431 at ___
Upon arrival to the floor, the patient was tired and sleeping
comfortably. She endorsed ongoing abdominal pain and nausea. She
had 1 episode of emesis just prior to transport to floor after
getting lactulose and Colace.
Past Medical History:
-Primary sclerosing cholangitis - diagnosed about ___ years ago,
now c/b cirrhosis, on transplant list
-Ulcerative colitis
-s/p TAH in ___ for fibroids
Social History:
___
Family History:
Father - DM, alive (___). Mother - DM, alive (___). Two sons with
HTN. Daughter healthy. No family history of liver disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITALS - T 98.8, BP 100/64, HR 85, RR 16, O2 99%RA, Wt 46.2kg,
Pain ___, glucose 321
GENERAL - pleasant, cachectic, sleeping as I walked into the
room, wakes easily to voice
HEENT - normocephalic, atraumatic, + scleral icterus, PERRLA,
EOMI, OP clear. Dry MM. Dobhoff in right nare.
NECK - supple, no LAD, no thyromegaly, JVP = flat
CARDIAC - regular rate & rhythm, normal S1/S2. Systolic murmur
throughout.
PULMONARY - clear to auscultation bilaterally, without wheezes
or rhonchi
ABDOMEN - normal bowel sounds, soft, very tender to palpation in
RUQ without rebound or guarding. Less tender in suprapubic/RLQ
region, non-distended.
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
SKIN - without rash
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout. Gait assessment deferred
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
DISCHARGE PHYSICAL EXAM:
========================
VS - 98.3 100/59 76 18 99%/RA FSG 129-320
Weight history: 50.5kg (___), 49.0kg (___) 48.8 kg
(___) 47.9kg (___), 46.5 kg (___), 46.3 kg (___),
prior: 46.6 kg (___), 54 kg (___), 56 kg (___)
BMI: 17.5
GENERAL - pleasant, cachectic, woman, alert and awake
HEENT - normocephalic, atraumatic, + scleral icterus, PERRLA,
EOMI, OP clear. Dry MM. Dobhoff in right nare.
NECK - supple, no LAD, no thyromegaly, JVP flat
CARDIAC - regular rate & rhythm, normal S1/S2, systolic murmur
at apex
PULMONARY - mild bibasilar crackles, otherwise clear to
auscultation
ABDOMEN - normal bowel sounds, soft, non-tender to deep
palpation, palpable liver edge, spleen tip palpable, abdomen
distended and tympanitic to percussion.
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
SKIN - without rash
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout. Gait assessment deferred
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
Pertinent Results:
ADMISSION LABS:
===============
___ 08:27PM WBC-5.3 RBC-3.62* HGB-10.2* HCT-30.7* MCV-85
MCH-28.2# MCHC-33.2 RDW-25.4* RDWSD-77.5*
___ 08:27PM NEUTS-70.7 ___ MONOS-5.9 EOS-2.1
BASOS-0.6 IM ___ AbsNeut-3.73 AbsLymp-1.08* AbsMono-0.31
AbsEos-0.11 AbsBaso-0.03
___ 08:27PM PLT COUNT-116*
___ 08:27PM ALT(SGPT)-85* AST(SGOT)-190* ALK PHOS-1386*
TOT BILI-8.1*
___ 08:27PM LIPASE-431*
___ 08:27PM ALBUMIN-2.9*
___ 08:27PM GLUCOSE-470* UREA N-32* CREAT-1.1 SODIUM-135
POTASSIUM-4.3 CHLORIDE-95* TOTAL CO2-25 ANION GAP-19
___ 08:31PM LACTATE-3.3*
___ 10:13PM ___ PTT-30.6 ___
___ 11:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-TR BILIRUBIN-SM UROBILNGN-2* PH-6.0
LEUK-MOD
___ 11:05PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 11:05PM URINE RBC-1 WBC-3 BACTERIA-MOD YEAST-NONE
EPI-21
___ 11:05PM URINE OSMOLAL-644
___ 11:05PM URINE HOURS-RANDOM UREA N-873 CREAT-97
SODIUM-26 POTASSIUM-27 CHLORIDE-10
DISCHARGE LABS:
===============
___ 19:23PM ART pO2-80* pCO2-29* pH-7.49* calTCO2-23
___ 06:50AM BLOOD WBC-3.3* RBC-3.15* Hgb-9.0*# Hct-27.4*#
MCV-87 MCH-28.6 MCHC-32.8 RDW-25.2* RDWSD-77.9* Plt ___
___ 06:50AM BLOOD Glucose-141* UreaN-9 Creat-0.5 Na-134
K-3.8 Cl-100 HCO3-26 AnGap-12
___ 06:50AM BLOOD ALT-31 AST-82* AlkPhos-641* TotBili-7.7*
___ 06:50AM BLOOD Albumin-3.4* Calcium-8.8 Phos-2.4* Mg-2.1
IMAGING:
========
MRCP ___
IMPRESSION:
Background hepatic cirrhosis with primary sclerosing cholangitis
and stable segmental intrahepatic ductal dilatation within
segments 8, 4B, and in the caudate lobe. No new sites of
intrahepatic ductal dilatation. No MR features of cholangitis.
No hepatic abscess.
Along the periphery of the right lobe of the liver there are a
few arterially enhancing lesions, largest measuring up to 3.1 cm
within segment 6, which demonstrate no washout or a pseudo
capsule. In this vicinity there is evidence of ___ venous
shunt, and therefore these lesions may be perfusional. However
close attention on follow-up imaging is recommended.
Sequelae of portal hypertension as evidenced by small volume
ascites, upper abdominal varices and splenomegaly.
Stable 1.3 cm cystic pancreatic lesion within the pancreatic
tail. As per
departmental protocol, a follow-up MRCP in ___ years time is
recommended.
1.6 x 1.4 cm Bosniak 2 left renal cyst.
Duplex Doppler Abdominal/Pelvic, RUQ Ultrasound ___
IMPRESSION:
1. Patent hepatic vasculature.
2. Left renal cysts, one of which contains apparent
calcifications.
Abdominal KUB ___
IMPRESSION:
Transesophageal tube terminates likely in the proximal jejunum.
No definite evidence of bowel obstruction.
CXR ___
IMPRESSION:
Subtle right basilar interstitial abnormality may represent
resolving edema.
ECHO ___
IMPRESSION: Preserved biventricular systolic function. No
clinically significant valvular disease. Normal pulmonary artery
systolic pressure.
Compared with the prior study (images reviewed) of ___,
the severity of tricuspid regurgitation has decreased. The
pulmonary artery systolic pressure is lower.
PFTs ___
Impression:
Results are within normal limits. There are no previous studies
available for comparison.
Brief Hospital Course:
___ y/o F hx of primary sclerosing cholangitis c/b cirrhosis (CP
C), grade 1 varices, HE, and ascites undergoing transplant eval
and ulcerative colitis presenting with abdominal pain, diarrhea,
nausea, and inability to tolerate PO, treated empirically for
cholangitis.
ACTIVE ISSUES
=============
#Abdominal pain: The differential was broad in this cirrhotic
patient which included SBP, portal vein thrombosis, and acute
cholangitis. Cholangitis was of highest concern given history of
PSC, and mixed elevations of both transaminases and alk
phos/Tbili on admission. Patient was empirically started on
cipro/flagyl in ED because patient is at high risk for
cholangitis given biliary strictures secondary to PSC. Patient
has only had two documented cholangitis episodes in the past
___ and ___, microbiology has always been negative. MRCP was
negative for acute biliary pathology, no abscess or cholangitis
seen. PVT was ruled out with RUQ ultrasound. Infectious
etiologies of abdominal pain and diarrhea were ruled out with
negative stool studies for C. diff, campylobacter, Yersinia, E.
Coli O157:H7, vibrio cholera, salmonella, shigella and GNRs.
Patient improved symptomatically on cipro/flagyl antibiotics for
presumed cholangitis, reported improved abdominal pain and
tolerated solid foods at discharge. Patient is also at risk for
pancreatic carcinoma, given her abdominal pain radiating to the
back and previous MRCP showing pancreatic lesion in tail of the
pancreas associated with dilation in the pancreatic duct.
Patient has history of elevated CA ___ for at least ___s pancreatic cysts, though her CA ___ has increased from
571 -> 808 in the past 6 months. Recommend also outpatient
follow up for cholangiocarcinoma and HCC screening.
#Severe Malnutrition: Patient has been losing weight as
outpatient and has been working with transplant nutritionist
closely. She was assessed by nutrition here and was resumed on
home tube feeds and tolerated them well. Patient was recently
admitted to liver service for failure to thrive and discharged
with post-pyloric Dobhoff on ___. She was started on Glucerna
1.5 @ 20ml/hr, advanced by 10ml/hr q6h to goal rate of 45ml/hr
(1620kcal, 89g protein). Given recent emesis, she was given
thiamine for 5 days. Patient gained weight appropriately once
tube feeds were resumed during this hospitalization, and was set
up to continue these supplemental tube feeds as outpatient.
#Cirrhosis: A result of longstanding PSC, MELD 15 on admission
labs. Liver transplant work-up was furthered, she received an
ECHO, PFT and ABGs in house. Patient has previously been
evaluated by nutrition and social work in preparation for
transplant as well. She was continued on home lactulose,
rifaximin and ursodiol. Diuretics were initially held in setting
of suspected infection and also recent poor PO intake, then
restarted when her volume status improved. She had ___
paracentesis for ascites, 20cc of clear, straw-colored ascitic
fluid was drained which showed <250 neutrophils and no bacteria,
making SBP unlikely.
#Acute Kidney Injury: Cr 1.1 on initial labs from baseline 0.8,
improved with PO intake. This was likely pre-renal in setting of
vomiting/diarrhea as well as polyuria from uncontrolled DM.
#Hyponatremia: Patient developed hyponatremia to 130, likely
hypervolemic hyponatremia in the setting of chronic liver
disease. Patient was given IV albumin 25% followed by diuretics
and her hyponatremia resolved. Patient was restarted on home
diuretics prior to discharge.
#Diabetes: Poor control with most recent A1c 10.2% (___).
Glucose elevated to 300s on arrival to ED. Ongoing hyperglycemia
in setting of missed Lantus dose last night. Although patient
had been ill with poor PO tolerance, her sugars have remained
high at home likely related to inflammation/possible infection.
Given persistent hyperglycemia, her insulin was uptitrated to
Lantus 25 Units qAM and 40 Units QHS and sliding scale Humalog
was titrated as needed.
#Anemia: Patient had normocytic anemia to 7.1/___.8 on admission,
which appeared to be chronic. Patient's iron studies showing low
transferrin and TIBC were consistent with anemia from chronic
liver disease. Serum iron levels normal. Recent colonoscopy at
___ showing no evidence of malignancy, as well as EGD in ___
showing benign hyperplastic gastric polyp. Patient was
transfused with 1 unit pRBC on ___ for Hgb<7 with appropriate
Hgb/Hct response.
CHRONIC ISSUES
==============
# Ulcerative Colitis: continued home Asacol HD, pantoprazole,
multivitamins
# Depression: continued home Sertraline 75mg daily
TRANSITIONAL ISSUES
===================
-Continue antibiotics Ciprofloxacin 500 mg q12 and Flagyl 500 mg
q8(end date ___ for cholangitis
-Patient was persistently hyperglycemic during her
hospitalization, insulin regimen was increased to Lantus 25units
qAM and 40 units QHS,
-Patient to follow-up with her outpatient hepatologist, Dr.
___ supplemental tube feeds as outpatient
-Held furosemide and spironolactone while inpatient given ___
that resolved, restarted both at home doses (Furosemide 20,
Spironolactone 100) prior to discharge
-Patient has history of pancreatic cysts and elevated CA ___,
which markedly increased from 571 -> 808 in the past 6 months.
Consider repeat CA ___ and abdominal imaging as outpatient
-Patient has history of signet cells seen from prior
paracentesis, consider cholangiocarcinoma and ___ screening as
outpatient
-Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rifaximin 550 mg PO BID
2. Calcium Carbonate 1250 mg PO BID
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Furosemide 20 mg PO DAILY
5. Lactulose 30 mL PO TID
6. Senna 8.6 mg PO BID:PRN constipation
7. Sertraline 75 mg PO DAILY
8. Spironolactone 100 mg PO DAILY
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
10. Ursodiol 300 mg PO TID
11. Vitamin D ___ UNIT PO 1X/WEEK (WE)
12. Pantoprazole 40 mg PO Q12H
13. Multivitamins 1 TAB PO DAILY
14. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
15. Glucerna 1.5 Cal (nut.tx.gluc.intol,lac-free,soy) 45 mL/hr
Dobhoff Continuous
16. Asacol HD (mesalamine) 2400 mg oral BID
Discharge Medications:
1. Calcium Carbonate 1250 mg PO BID
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Glargine 25 Units Breakfast
Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 25 Units before
BKFT; 40 Units before BED; Disp #*5 Vial Refills:*0
5. Lactulose 30 mL PO TID
6. Multivitamins 1 TAB PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. Rifaximin 550 mg PO BID
9. Senna 8.6 mg PO BID:PRN constipation
10. Sertraline 75 mg PO DAILY
11. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
13. Ursodiol 300 mg PO TID
14. Vitamin D ___ UNIT PO 1X/WEEK (WE)
15. Ciprofloxacin HCl 500 mg PO Q12H Duration: 6 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*12 Tablet Refills:*0
16. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*21 Tablet Refills:*0
17. Asacol HD (mesalamine) 2400 mg oral BID
18. Glucerna 1.5 Cal (nut.tx.gluc.intol,lac-free,soy) 45 mL/hr
Dobhoff Continuous
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
-Abdominal Pain/Cholangitis
-Primary Sclerosing Cholangitis c/b Cirrhosis
-Severe malnutrition
Secondary Diagnosis:
-Ulcerative Colitis
-Diabetes mellitus
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 ___ on ___ for abdominal pain.
What was done?
===============
-You were treated with antibiotics to cover a possible infection
of your bile ducts, which are near your liver
-You had an MRCP done (a picture of your liver) which did not
show any obvious infection, though a small infection is still
possible
-You are at high risk of infections near your liver given your
history of primary sclerosing cholangitis so we treated you for
an infection
-Fluid was collecting in your abdomen, so we did a
radiology-guided paracentesis (belly tap) which did not show any
infection.
What should I do next?
========================
-Please continue your antibiotics ciprofloxacin (TWICE a day),
and flagyl (THREE TIMES a day) until ___.
-Please continue your regular tube feeds at home
-Please take 25 units of lantus (long acting insulin) with
breakfast, and continue your home dose of 40 units at bedtime.
This will help cover your sugars better during the day.
-Please follow-up with your liver doctor, ___
___ wish you the best of health moving forward.
Best,
Your ___ Team
Followup Instructions:
___
|
10464640-DS-16 | 10,464,640 | 29,676,235 | DS | 16 | 2157-04-12 00:00:00 | 2157-04-14 17:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
jaundice, hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ with PMHx of IDDM, primary sclerosing
cholangitis c/b cirrhosis (CP C), grade 1 varices, HE, and
ascites on transplant list presenting to the ED with jaundice
and hyperglycemia.
Mrs ___ was recently hospitalized at ___ from ___ to
___ where she was treated for cholangitis. Since her
discharge, she has continued to take her ciprofloxacin and
metronidazole (her scheduled antibiotic end date was ___. The
___ visiting RN noticed worsening scleral icterus on ___
and also that her FSBS had been increasing over the same time
period. She had several readings greater than limit. The patient
herself notes a continued feeling of fullness in her RUQ, but
not necessarily pain. She has also had full body itching for 2
days. For these reasons she came in to the ED.
ED COURSE
- Initial Vitals: 0 98.1 90 103/66 18 100% RA
- Labs: H/H ___ new ___ 0.5 -> 0.9 ALT/AST 64/222 (elevated
from last discharge 2 days ago) TBili 11.4 (increased from 7) Na
131, BUN/Cr ___ Glucose 269. U/A with bacteria, pyuria, and
glucosuria without ketonuria
- RUQUS demonstrated sluggish hepatopetal flow within the main
portal
vein and no detectable flow within the right portal venous
branches.
- Consults: Hepatology was consulted, who recommended admission
- Pt was given: 1000mL: NS
- Vitals on transfer: 0 98.5 79 116/64 16 99% RA
On the floor, the patient easily recalled above history. She
also reported dysuria and increased frequency in the past 24
hours. Denies any recent sick contacts. While in the ED she had
1 loose bowel movement that was watery but not obviously bloody.
Past Medical History:
-Primary sclerosing cholangitis - diagnosed about ___ years ago,
now c/b cirrhosis, on transplant list
-Ulcerative colitis
-s/p TAH in ___ for fibroids
Social History:
___
Family History:
Father - DM, alive (___). Mother - DM, alive (___). Two sons with
HTN. Daughter healthy. No family history of liver disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: Tm 98.1 108/68 54 18 92%RA
GENERAL: Pleasant, jaundiced cachectic, woman, alert and awake
HEENT: NCAT, + scleral icterus, PERRLA,
EOMI, OP clear. Dry MM. ___ in right nare.
NECK: supple, no LAD, no thyromegaly, JVP flat
CARDIAC: RRR normal S1/S2, systolic murmur at apex
PULMONARY: CTAB without wheezes or crackles
ABDOMEN: NABS, soft, non-tender to deep
palpation, grossly palpable liver edge, spleen tip palpable,
abdomen
distended and tympanitic to percussion.
EXTREMITIES; WPP, no cyanosis, clubbing or edema
SKIN - without rash
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout. Gait assessment deferred
PSYCHIATRIC: listen & responds to questions appropriately
DISCHARGE PHYSICAL EXAM
VS: Tm 98.6, BP 97/60, P 69, RR 18, 98%RA
GENERAL: Pleasant, jaundiced cachectic, woman, alert and awake
HEENT: NCAT, + scleral icterus, PERRLA
EOMI, OP clear. Dry MM. ___ in right nare.
NECK: supple, no LAD, no thyromegaly, JVP flat
CARDIAC: RRR normal S1/S2, systolic murmur at apex
PULMONARY: CTAB without wheezes or crackles
ABDOMEN: NABS, soft, non-tender to deep palpation. Firm liver
edge palpable 4 finger breadths below costal margin, spleen tip
palpable,
abdomen distended and tympanitic to percussion.
EXTREMITIES; WPP, no cyanosis, clubbing or edema
SKIN - without rash
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout. Gait normal.
PSYCHIATRIC: listen & responds to questions appropriately
Pertinent Results:
ADMISSION LABS
___ 12:00PM BLOOD WBC-4.4 RBC-3.36* Hgb-9.7* Hct-29.7*
MCV-88 MCH-28.9 MCHC-32.7 RDW-24.6* RDWSD-76.1* Plt ___
___ 12:00PM BLOOD Neuts-68.9 ___ Monos-7.8 Eos-1.6
Baso-0.5 Im ___ AbsNeut-3.00 AbsLymp-0.90* AbsMono-0.34
AbsEos-0.07 AbsBaso-0.02
___ 12:00PM BLOOD ___ PTT-30.0 ___
___ 12:00PM BLOOD Glucose-269* UreaN-33* Creat-0.9 Na-131*
K-3.9 Cl-94* HCO3-25 AnGap-16
___ 12:00PM BLOOD ALT-64* AST-222* AlkPhos-846*
Amylase-214* TotBili-11.4* DirBili-7.9* IndBili-3.5
___ 12:00PM BLOOD Lipase-210* GGT-333*
___ 12:00PM BLOOD Albumin-3.8 Calcium-10.6* Phos-3.6 Mg-2.4
UricAcd-5.0
___ 03:29PM URINE Color-Yellow Appear-Hazy Sp ___
___ 3:40 pm URINE CULTURE (Final ___: MIXED BACTERIAL
FLORA (>= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
IMAGING
RUQUS ___ FINDINGS: The liver is coarsened and heterogeneous
consistent with known cirrhosis. There is sluggish hepatopetal
blood flow within the main portal vein with velocity measuring
approximately 11.5 centimeters/seconds. No detectable flow is
seen within the right portal venous branches. The left portal
vein is patent with hepatopetal flow. There is a recannulized
umbilical vein. The gallbladder wall is thickened though there
are no stones. Sonographic ___ sign is not elicited. No
ascites. Splenomegaly again noted at 13.3 cm. Right kidney
measures 11.9 cm and appears normal. A simple appearing cyst
arising from the lower pole left kidney measures 4.4 x 3.6 x 3.5
cm. Otherwise left kidney appears normal. No ascites.
IMPRESSION:
1. Severe hepatic cirrhosis. Sluggish hepatopetal flow within
the main portal vein and no detectable flow within the right
portal venous branches. Left portal vein remains patent likely
due to a recannulized umbilical vein.
2. Splenomegaly, no significant ascites.
CXR ___:
No acute cardiopulmonary process.
CT ABD/PELVIS, w/contrast ___:
IMPRESSION:
1. No evidence of a portal vein thrombus.
2. Background hepatic cirrhosis, with primary sclerosing
cholangitis and stable segmental intrahepatic ductal dilatation
within segments 4B, 8 and caudate lobe. No evidence of a
hepatic abscess.
3. Venovenous shunt is re- demonstrated within the periphery of
the liver.
4. Stable 1.3 cm cystic lesion within the pancreatic tail.
Again, and MRCP in ___ year is recommended for further evaluation.
DISCHARGE LABS
___ 06:30AM BLOOD WBC-2.4* RBC-2.71* Hgb-7.9* Hct-24.8*
MCV-92 MCH-29.2 MCHC-31.9* RDW-25.1* RDWSD-81.9* Plt Ct-90*
___ 06:30AM BLOOD Glucose-183* UreaN-13 Creat-0.6 Na-134
K-4.4 Cl-103 HCO3-21* AnGap-14
___ 06:30AM BLOOD ALT-60* AST-187* AlkPhos-622*
TotBili-9.0*
___ 5:58 am STOOL
C. difficile DNA amplification assay (Final ___: Negative
FECAL CULTURE (Final ___ SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Pending):
FECAL CULTURE - R/O VIBRIO (Pending):
FECAL CULTURE - R/O YERSINIA (Pending):
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI
0157:H7 FOUND.
Brief Hospital Course:
Summary
___ with PMHx of IDDM, primary sclerosing cholangitis c/b
cirrhosis (CP C), grade 1 varices, HE, and ascites on transplant
list presenting to the ED with jaundice and hyperglycemia.
Acute issues
# Infectious cholangitis
# Hyperglycemia
# IDDM
She was recently admitted for infectious cholangitis and there
was concern for recurrent infectious cholangitis in the setting
of labile blood sugars. She was treated with ceftriaxone and
flagyl for 1 week duration with significant improvement in her
meld labs. She was also quickly hypoglycemic on her home
regimen. There was concern that she was not taking her insulin
properly. Her regimen was adjusted and significant time was
spent on teaching her diabetic education. She was in good
condition and discharged home with ___ services and home ___.
Chronic issues
# Cirrhosis with slow PV flow: ___ longstanding PSC. Childs
Class C. MELD-Na 22 on admission, currently 24. Previously
decompensated by ascites, HE, jaundice and varices. Pt now
presents with refractory jaundice in the setting of
sluggish/absent portal vein flow. No e/o clot. Concern for
infectious cholangitis as below. CT was negative for PVT.
Continued lactulose, rifaximin, Lasix 20 and spironolactone 100.
# Severe Malnutrition: Patient was previously losing weight as
outpatient and was discharged with NGT and TF. Discharge weight
50.5kg, admission weight 45.5kg. Continued tube feeds and
nutrition consulted as inpatient.
# Normocytic Anemia: Pt with history of bleeding gastric polyps,
s/p resection. Transfused last admission. Admission H/H higher
than previous discharge value.
# Signet cells: seen on previous paracentesis, concerning for ew
development of malignancy. Evidence of Signet cells on repeat
paracentesis (___). Cytology of ascetic fluid negative for
malignancy.
# Ulcerative Colitis: Continued asacol
# Depression: Continued sertraline
Transitional issues
- Home insulin regimen was adjusted to lantus 12u QAM, 16u QPM.
Ideally, ___ will be able to supervise her night time lantus
dose and a sliding scale dose with dinner. Then in the morning
her daughter can supervise her morning lantus dose and a sliding
scale with breakfast.
- She was instructed to call her PCP or endocrinologist if she
has blood sugars consistently >300 or <60.
- Significant time was spent on educating proper insulin
technique and general diabetic education.
- She continued her liver transplantation work up and will
continue to follow with the ___.
- She completed 7 days of antibiotics on ___ and was not
discharged on antibiotic therapy.
# CODE: Full
# CONTACT: Patient and ___ (Daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 1250 mg PO BID
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Furosemide 20 mg PO DAILY
4. Lactulose 30 mL PO TID
5. Multivitamins 1 TAB PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Rifaximin 550 mg PO BID
8. Senna 8.6 mg PO BID:PRN constipation
9. Sertraline 75 mg PO DAILY
10. Spironolactone 100 mg PO DAILY
11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
12. Ursodiol 300 mg PO TID
13. Vitamin D ___ UNIT PO 1X/WEEK (WE)
14. Asacol HD (mesalamine) 2400 mg oral BID
15. Glucerna 1.5 Cal (nut.tx.gluc.intol,lac-free,soy) 45 mL/hr
Dobhoff Continuous
16. Glargine 25 Units Breakfast
Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Calcium Carbonate 1250 mg PO BID
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Furosemide 20 mg PO DAILY
4. Lactulose 30 mL PO TID
5. Multivitamins 1 TAB PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
8. Senna 8.6 mg PO BID:PRN constipation
9. Sertraline 75 mg PO DAILY
10. Spironolactone 100 mg PO DAILY
11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
12. Ursodiol 300 mg PO TID
13. Vitamin D ___ UNIT PO 1X/WEEK (WE)
14. Asacol HD (mesalamine) 2400 mg oral BID
15. Glucerna 1.5 Cal (nut.tx.gluc.intol,lac-free,soy) 45 mL/hr
Dobhoff Continuous
16. Glargine 12 Units Breakfast
Glargine 16 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
17. FreeStyle Lite Strips (blood sugar diagnostic)
miscellaneous TID
RX *blood sugar diagnostic [FreeStyle Lite Strips] three times
a day Disp #*100 Strip Refills:*0
18. lancets 18 gauge miscellaneous TID
RX *lancets 30 gauge three times a day Disp #*100 Each
Refills:*0
19. FreeStyle Lite Meter (blood-glucose meter) miscellaneous
TID
RX *blood-glucose meter [FreeStyle Lite Meter] 1 three times a
day Disp #*1 Kit Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Infectious cholangitis
Secondary:
Primary sclerosing cholangitis
Insulin dependent DM
Severe malnutrition
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to the ___ with jaundice and high blood
sugars.
What was done?
===============
-___ were treated with antibiotics to cover a possible infection
of your bile ducts, which are near your liver
-___ were given a CT scan to look for any evidence of clotting
or other obstructions in or around the liver. This scan came
back negative.
-___ are at high risk of infections near your liver given your
history of primary sclerosing cholangitis so we treated ___ for
an infection
What should I do next?
========================
-Please continue your antibiotics...... until ..........
-Please continue your regular tube feeds at home
-Please take 40 units of lantus (long acting insulin) with
breakfast, and 55 units at bedtime. This will help cover your
sugars better during the day.
-Please follow-up with your liver doctor, ___
___ wish ___ the best of health moving forward.
Best,
Your ___ Team
Followup Instructions:
___
|
10464640-DS-27 | 10,464,640 | 26,797,962 | DS | 27 | 2158-11-01 00:00:00 | 2158-11-02 20:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Epistaxis, worsening liver function
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with primary sclerosing
cholangitis complicated by Child's C cirrhosis (with ascites,
varices and HE), ulcerative colitis and T2DM with malnutrition,
with recent NJ placement for tube feeds after clogged dobhoff,
and inactivated from transplant due to poor compliance and
support, who is presenting for epistaxis.
Patient was discharged from this hospital in late ___ for
failure to thrive had a dobhoff placed which subsequently was
clogged. NJ tube placed under endoscopy 2 weeks ago. Patient
states that night prior to arrival, she began to have large
amounts of epistaxis from both nares, and large clots passing,
and swallowing significant blood. Continued throughout the day,
and patient came into the hospital. Denies CP, SOB,
lightheadedness, N/V. Notes no diarrhea. Her bleeding resolved
while in the ED.
In the ED, initial VS were: 98.1 83 120/77 18 100% RA
Exam notable for:
Dobbhoff tube in place with a large clot in the left nares,
Right
naris is clear. Oropharynx is blood in the back of the throat
with no clots.
Regular rate and rhythm, Clear to auscultation bilateral
Large distended positive fluid wave no tenderness to palpation
Cranial nerves II through XII intact
No asterixis
Labs showed:
Lytes notable for Na 132, normal K, Cr 0.6
WBC 3.4, Hgb 8.6 (recent baseline 7.2-9.6), Plts 79, INR 1.2
ALT/AST 43/106, AP 1519, Lip 289, Tbili 8.1, Alb 2.6
No new imaging
Patient received:
___ 01:53 SC Insulin ___s afrin per report
Hepatology was consulted - noted that bleeding currently
controlled. Recommended supportive care but noted "no good
alternatives to NJ given that she needs the nutrition if she is
going to be re-listed for transplant and cannot get a PEG due to
advanced cirrhosis with ascites."
Transfer VS were: 98.1 83 120/77 18 100% RA
On arrival to the floor, patient corroborates above history, and
notes that aside from the epistaxis earlier in the day she feels
at her baseline, with no abdominal pain, CP, SOB. No diarrhea,
dysuria, cough. No hematuria, hematochezia or melena.
REVIEW OF SYSTEMS:
Negative aside from as mentioned above
Past Medical History:
- Primary sclerosing cholangitis with decompensated cirrhosis
(Child C c/b varices, ascites, encephalopathy, malnutrition)
-Ulcerative colitis on 5-ASA
-Recurrent cholangitis
-C diff on PO vancomycin
-TAH in ___ for fibroids
-IDDM Type 2
Social History:
___
Family History:
Father - DM, alive (___).
Mother - DM, alive (___).
Two sons with HTN.
Daughter healthy.
No family history of liver disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 97.9 ___ 18 98% RA
GENERAL: NAD, resting in bed
HEENT: AT/NC, EOMI, PERRL, icteric sclera. Dry blood in
bilateral
nares. Oropharynx without appreciable bleeding. Lower lips with
dry blood, excoriated lips. MMM
NECK: supple, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: distended, +fluid wave. nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing, scant edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, no tongue
fasciculations, not tremulous
SKIN: warm and well perfused, no excoriations or lesions aside
from lower lip as mentioned above, no rashes
DISCHARGE PHYSICAL EXAM
VS: 98.4 PO 115 / 65 80 18 97 Ra
GENERAL: Pleasant, middle-aged woman, in NAD, resting in bed
HEENT: AT/NC, EOMI, icteric sclera. Dry blood in bilateral
nares.
MMM.
HEART: RRR, normal S1/S2, no murmurs, gallops, thrills, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: distended, minimal fluid wave. Non-tender in all
quadrants, no rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or lower extremity edema,
warm and well perfused
NEURO: A&Ox3, moving all 4 extremities with purpose, no tongue
fasciculations, not tremulous. no asterixis.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
___ 09:07PM BLOOD WBC-3.4* RBC-2.95* Hgb-8.6* Hct-27.1*
MCV-92 MCH-29.2 MCHC-31.7* RDW-21.7* RDWSD-72.8* Plt Ct-79*
___ 09:07PM BLOOD Neuts-67.1 ___ Monos-6.7 Eos-2.6
Baso-0.3 Im ___ AbsNeut-2.31 AbsLymp-0.79* AbsMono-0.23
AbsEos-0.09 AbsBaso-0.01
___ 09:07PM BLOOD Glucose-460* UreaN-16 Creat-0.6 Na-132*
K-4.6 Cl-98 HCO3-23 AnGap-11
___ 09:07PM BLOOD ALT-43* AST-106* AlkPhos-1519*
TotBili-8.1*
___ 09:07PM BLOOD Albumin-2.6*
PERTINENT LABS
___ 04:57AM BLOOD ___ PTT-31.1 ___
___ 04:57AM BLOOD ALT-40 AST-99* LD(LDH)-222 AlkPhos-1319*
TotBili-7.7*
___ 04:57AM BLOOD Glucose-168* UreaN-14 Creat-0.6 Na-136
K-3.6 Cl-102 HCO3-22 AnGap-12
___ 04:57AM BLOOD Albumin-2.3* Calcium-8.2* Phos-2.1*
Mg-1.9
DISCHARGE LABS
___ 05:33AM BLOOD WBC-2.6* RBC-2.50* Hgb-7.5* Hct-23.3*
MCV-93 MCH-30.0 MCHC-32.2 RDW-22.0* RDWSD-74.6* Plt Ct-77*
___ 05:33AM BLOOD ___ PTT-29.7 ___
___ 05:33AM BLOOD Glucose-157* UreaN-9 Creat-0.5 Na-140
K-4.1 Cl-107 HCO3-22 AnGap-11
___ 05:33AM BLOOD ALT-42* AST-134* AlkPhos-1043*
TotBili-6.1*
___ 05:33AM BLOOD Albumin-2.0* Calcium-8.0* Phos-3.1 Mg-2.0
IMAGING/STUDIES
Abdomen XR (___)- The tip of the feeding tube projects over
the proximal jejunum.
Nonobstructive bowel gas pattern.
Brief Hospital Course:
Ms. ___ is a ___ year-old woman with Child's C cirrhosis
secondary to primary sclerosing cholangitis (complicated by
ascites, varices and hepatic encephalopathy), ulcerative
colitis, and poorly controlled type 2 diabetes, who presented
with epistaxis
likely from irritation from recent NJ tube placement, as well as
elevated alkaline phosphatase and bilirubin from baseline on
labs.
ACUTE ISSUES
#Epistaxis: Patient with episodes of epistaxis, which resolved
after Afrin use in the ED. Hemoglobin remained at the patient's
baseline, and patient had no respiratory symptoms to suggest
aspiration. Vitals remained stable. The etiology was thought to
be ___ to recent NJ tube placement.
#PSC c/b Child's C cirrhosis: Patient with MELD Na 21 on
admission. History of esophageal varices, ascites,
encephalopathy, malnutrition. She was on the transplant list,
but decision was recently made to inactivate her until her
malnutrition is further treated and compliance with meds
achieved. No signs of decompensation on this admission, though
patient was noted to have small non-tappable pockets of ascites.
Tbili and Alk phos were elevated from baseline, likely ___ to
PSC flare and were downtrending at the time of discharge.
#Failure to thrive: Patient with NJ tube in place. Initially
became clogged, but ultimately was unclogged with warm ___
and patient was restarted on home tube feeds.
#Type 2 diabetes: Patient admitted with blood sugars >400, with
no signs of DKA or HHS. She had similarly high sugars on last
admission. Sugars improved on ___ insulin regimen.
CHRONIC ISSUES
#Anemia: Per recent d/c summary, patient with chronic anemia
likely from chronic disease, cirrhosis and slow GI oozing, as
well as epistaxis. Remained at baseline, without symptoms of
anemia currently.
#UC: No diarrhea or abdominal pain during this admission.
Patient had approximately 3 non-bloody bowel movements daily.
TRANSITIONAL ISSUES
[]Ultrasound showed small pockets of ascites that were unable to
be tapped on the floor; could consider increasing diuretic
dosing as outpatient
[]Has poorly controlled diabetes on outpatient; should remain on
insulin
[]Dobhoff unclogged during this admission, likely will need
continued long-term tube feeding, follow up with hepatology
[]Follow-up scheduled with PCP and ___
#CODE: FULL CODE (presumed)
#CONTACT: ___, HCP/daughter, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild
2. Calcium Carbonate 1000 mg PO DAILY
3. Cetirizine 10 mg PO DAILY
4. Ciprofloxacin HCl 500 mg PO Q24H
5. FoLIC Acid 1 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Lactulose 30 mL PO TID
8. Mesalamine ___ 2400 mg PO BID
9. Pantoprazole 40 mg PO Q24H
10. Rifaximin 550 mg PO BID
11. Sertraline 75 mg PO DAILY
12. Simethicone 40-80 mg PO QID:PRN bloating
13. Simvastatin 40 mg PO QPM
14. Spironolactone 100 mg PO DAILY
15. Thiamine 100 mg PO DAILY
16. Ursodiol 500 mg PO BID
17. Vancomycin Oral Liquid ___ mg PO BID
18. Vitamin D ___ UNIT PO 1X/WEEK (TH)
19. Glargine 22 Units Breakfast
Glargine 22 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Oxymetazoline 1 SPRY NU BID:PRN active bleeding Duration: 3
Days
RX *oxymetazoline [Afrin (oxymetazoline)] 0.05 % 1 spray IN BID
PRN Disp #*60 Spray Refills:*0
2. Glargine 22 Units Breakfast
Glargine 22 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild
4. Calcium Carbonate 1000 mg PO DAILY
5. Cetirizine 10 mg PO DAILY
6. Ciprofloxacin HCl 500 mg PO Q24H
7. FoLIC Acid 1 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Lactulose 30 mL PO TID
10. Mesalamine ___ 2400 mg PO BID
11. Pantoprazole 40 mg PO Q24H
12. Rifaximin 550 mg PO BID
13. Sertraline 75 mg PO DAILY
14. Simethicone 40-80 mg PO QID:PRN bloating
15. Simvastatin 40 mg PO QPM
16. Spironolactone 100 mg PO DAILY
17. Thiamine 100 mg PO DAILY
18. Ursodiol 500 mg PO BID
19. Vancomycin Oral Liquid ___ mg PO BID
20. Vitamin D ___ UNIT PO 1X/WEEK (TH)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Epistaxis
Secondary:
Primary sclerosing cholangitis and Child Class C cirrhosis
Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You were having a nosebleed that was not stopping
What was done while I was in the hospital?
- You were given a medication that helped stop your nosebleed
- You were monitored and your feeding tube was unclogged
What should I do when I get home from the hospital?
- Please continue to take all of your home medications as
prescribed
- If you have another nosebleed, please call your liver doctor
before using the nose spray to try to stop the bleeding
- Make sure to attend all of your follow-up appointments with
your primary care doctor and your liver doctor
- If you have fevers, chills, feel your belly is more swollen,
or generally feel unwell, please call your liver doctor or come
to the emergency room
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
10464640-DS-30 | 10,464,640 | 23,861,195 | DS | 30 | 2159-07-07 00:00:00 | 2159-07-08 16:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
Ms. ___ is a ___
female with a history of PSC cirrhosis (Child C) historically
decompensated by ascites/SBP, hepatic encephalopathy, esophageal
varices, and malnutrition as well as ulcerative colitis,
recurrent C. diff colitis on suppressive vancomycin,
insulin-dependent type II diabetes, and recent admission for
acute blood loss anemia transferred from interventional
radiology
for incidental hyperglycemia to 500-range during elective
paracentesis.
Patient presented to interventional radiology this morning for
elective paracentesis, where she was found to have blood glucose
495, but was reportedly asymptomatic. She apparently was
compliant with her morning Lantus and Humalog. Her ___
provider recommended an additional 10 units of Humalog; however,
her blood glucose remained greater than assay one hour later.
Routine hepatology labs also revealed total bilirubin 13.3,
prompting referral to the emergency department. She had 2.9 L
of
ascitic fluid removed prior to transfer. She she was otherwise
entirely well with the exception of non-productive cough of 7
days duration. Patient reports that her husband developed a
cough prior to her. No other sick contacts. Denies fevers,
chills, nausea, vomiting, abdominal pain, diarrhea,
constipation,
urinary symptoms. States that she does not have any other
associated symptoms with the cough. Reports that it is a
nonproductive cough that has improved over the past 7 days.
In the ED, initial vitals: T 97.4, HR 82, BP 101/53, RR 17, O2
100% RA
Exam notable for: scleral icterus, fluid wave
Labs notable for:
CBC 3.5, Hgb 7.7, Plt 63, INR 1.2
Na 137 -> 132, K 3.9 -> 8.9 (hemolyzed), HCO3 16, AG 23 -> 16,
BUN 19, Cr 0.9, Glucose 743 -> 532, Osm 313
ALT 42, AST 80, TB 13.3 (DB 8.3) ALK 1104
Lactate 4.7 -> 3.3
UA glucose 1000, trace ketones, small bilil
Peritoneal fluid ___ nuc cells (15% PMN), RBC 24,000+, prot 1.1
Imaging notable for:
LIVER ULTRASOUND (___):
IMPRESSION:
1. Patent portal venous vasculature with no evidence of
thrombosis.
2. Cirrhotic liver with associated splenomegaly, recanalized
umbilical vein, and moderate ascites.
CHEST PA & LATERAL (___):
IMPRESSION:
Mild basilar atelectasis without definite focal consolidation.
Subtle rounded retrocardiac opacity only seen on the lateral
view
has been
grossly stable since at least ___, may represent a
vascular
structure.
Patient was given:
-NS 2L
-Albumin 25 g
-Insulin lispro 14U SC
Vitals prior to transfer: T 98.0, HR 84, BP 116/61, RR 16, O2
100% RA
On arrival to the floor, patient confirmed aforementioned
history. She also noted that she had missed her dose of Lantus
the evening prior to arrival. She also seemed to be confused
about her Lantus and Humalog in terms of when each type of
insulin was supposed to be taken. She reported that she had not
taken any medications today. Otherwise had no complaints.
Denies constitutional symptoms such as night sweats or changes
in
weight and no glands. Patient also denies worsening pruritus or
symptoms that she experienced when she had cholangitis in the
past. Reports that she felt much better after getting a
paracentesis.
REVIEW OF SYSTEMS: 10-point review of systems negative, except
as
noted above.
Past Medical History:
- Primary sclerosing cholangitis with decompensated cirrhosis
(Child C c/b varices, ascites, encephalopathy, malnutrition)
-Ulcerative colitis on 5-ASA
-Recurrent cholangitis
-C diff on PO vancomycin
-TAH in ___ for fibroids
-IDDM Type 2
Social History:
___
Family History:
Father - DM, alive (___).
Mother - DM, alive (___).
Two sons with HTN.
Daughter healthy.
No family history of liver disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.9PO, 106/66, 84, 18, 97% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, + scleral icterus, injected
conjunctiva, MMM, poor dentition
NECK: supple, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Intermittent crackles at left lung base otherwise clear
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, right lower and left lower quadrant
paracentesis sites without active extravasation
EXTREMITIES: No peripheral 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:
24 HR Data (last updated ___ @ 723)
Temp: 97.9 (Tm 98.3), BP: 100/44 (100 -116/44-64), HR: 65
(61-65), RR: 18 (___), O2 sat: 97% (96-100), O2 delivery: RA,
Wt: 114.4 lb/51.89 kg
GENERAL: NAD, sitting upright in bed, frail, sarcopenic
HEENT: scleral icterus, oropharynx clear
NECK: supple, no LAD, JVP flat
HEART: RRR, S1/S2, no m/r/g
LUNGS: unlabored, scattered bibasilar crackles
ABDOMEN: soft, protuberant, fluid wave, non-tender, paracentesis
sites c/d/i
EXTREMITIES: warm, pulses palpable and symmetric, without edema
NEURO: non-focal
Pertinent Results:
ADMISSION LABS:
___ 06:14PM LACTATE-3.3*
___ 03:30PM ASCITES TOT PROT-1.1 GLUCOSE-584
___ 03:30PM ASCITES TNC-557* ___ POLYS-15*
LYMPHS-18* ___ MESOTHELI-1* MACROPHAG-66*
___ 02:55PM ___ PO2-35* PCO2-31* PH-7.41 TOTAL
CO2-20* BASE XS--3
___ 02:55PM O2 SAT-58
___ 02:45PM GLUCOSE-532* UREA N-19 CREAT-0.9 SODIUM-132*
POTASSIUM-8.5* CHLORIDE-100 TOTAL CO2-16* ANION GAP-16
___ 02:45PM CALCIUM-8.3* PHOSPHATE-3.1 MAGNESIUM-2.4
___ 02:45PM OSMOLAL-313*
___ 02:45PM WBC-3.5* RBC-2.78* HGB-7.7* HCT-24.4* MCV-88
MCH-27.7 MCHC-31.6* RDW-21.2* RDWSD-65.9*
___ 02:45PM NEUTS-60.2 ___ MONOS-9.2 EOS-1.4
BASOS-0.6 NUC RBCS-0.6* IM ___ AbsNeut-2.09 AbsLymp-0.97*
AbsMono-0.32 AbsEos-0.05 AbsBaso-0.02
___ 02:45PM PLT COUNT-63*
___ 02:32PM URINE HOURS-RANDOM
___ 02:32PM URINE UHOLD-HOLD
___ 02:32PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000* KETONE-TR* BILIRUBIN-SM* UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 09:55AM GLUCOSE-743* UREA N-19 CREAT-1.0 SODIUM-137
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-16* ANION GAP-23*
___ 09:55AM estGFR-Using this
___ 09:55AM ALT(SGPT)-42* AST(SGOT)-80* ALK PHOS-1104*
TOT BILI-13.3* DIR BILI-8.3* INDIR BIL-5.0
___ 09:55AM ALBUMIN-2.9* CALCIUM-8.8 PHOSPHATE-3.3
MAGNESIUM-2.5
___ 09:55AM WBC-3.8* RBC-3.00* HGB-8.3* HCT-27.1* MCV-90
MCH-27.7 MCHC-30.6* RDW-20.5* RDWSD-65.5*
___ 09:55AM PLT COUNT-120*
___ 09:55AM ___
DISCHARGE LABS:
___ 04:38AM BLOOD WBC-2.3* RBC-2.76* Hgb-7.8* Hct-23.8*
MCV-86 MCH-28.3 MCHC-32.8 RDW-21.3* RDWSD-62.7* Plt Ct-62*
___ 04:38AM BLOOD Plt Ct-62*
___ 04:38AM BLOOD ___ PTT-50.8* ___
___ 04:38AM BLOOD Glucose-249* UreaN-8 Creat-0.7 Na-132*
K-3.7 Cl-103 HCO3-19* AnGap-10
___ 04:38AM BLOOD ALT-39 AST-118* AlkPhos-711* TotBili-8.3*
___ 04:38AM BLOOD Calcium-7.1* Phos-2.1* Mg-2.0
IMAGING:
cxr ___
IMPRESSION:
Mild basilar atelectasis without definite focal consolidation.
Subtle rounded retrocardiac opacity only seen on the lateral
view has been
grossly stable since at least ___, may represent a
vascular
structure.
ruqus ___
IMPRESSION:
1. Patent portal venous vasculature with no evidence of
thrombosis.
2. Cirrhotic liver with associated splenomegaly, recanalized
umbilical vein,
and moderate ascites.
cxr ___
IMPRESSION:
No focal consolidation.
mcrp ___
IMPRESSION:
1. No imaging evidence of cholangitis is identified. Liver
cirrhosis, large
ascites, splenomegaly, and portosystemic varices.
2. Multiple cystic lesions in the pancreas are similar to before
and likely
side-branch intraductal papillary mucinous neoplasms. Continued
attention is
advised on ___ follow up.
MICROBIOLOGY:
___ 11:25 am PERITONEAL FLUID PERITONEAL FLUID.
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 (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 10:09 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
BLOOD CULTURES NEGATIVE
Brief Hospital Course:
___ female with a history of Child C PSC cirrhosis
decompensated by ascites/SBP, hepatic encephalopathy, esophageal
varices, and malnutrition as well as ulcerative colitis,
recurrent C. diff colitis on suppressive vancomycin,
insulin-dependent type II diabetes, and recent admission for
acute blood loss anemia transferred from interventional
radiology for incidental hyperglycemia to
500-range during elective paracentesis, which later peaked in
700-range, and acute to subacute doubling of total bilirubin.
ACUTE ISSUES
#) Hyperbilirubinemia
#) Primary sclerosis cholangitis, Child C/MELD-Na 23
Subacute doubling of total bilirubin on admission with isolated
fever concerning for cholangitis though otherwise well appearing
with acceptable hemodynamics. MRCP later unrevealing. MRCP
without evidence of cholangitis, cholangiocarcinoma, or liver
lesions. Her other transaminases are at baseline rendering other
hepatidities improbable. Hyperbilirubinemia in the setting of
glucose lability likely ___ glyogenic hepatopathy vs.
progression of underlying disease. Tbili downtrending on d/c:
8.3. Management of complications of cirrhosis as below:
-Volume: held home Lasix 60 mg, spironolactone 100 mg on
admission, resumed on d/c. Added midodrine 10 mg TID.
-Hemorrhage: h/o esophageal varices; recent EGD in ___ with
evidence of grade ___ varices and portal hypertensive
gastropathy. Underwent repeat EGD ___ for 1 point Hgb drop
requiring 1u pRBC with appropriate response as well to evaluate
for repeat banding which showed small oozing polyps in the
stomach that stopped without intervention, no repeat banding was
done.
-Infection: peritoneal fluid studies negative for SBP.
Infectious w/u with CXR, urine studies negative. No diarrhea.
Initially on zoysn pending cholangitis r/o, resumed on home
cipro for SBP ppx on d/c.
-Hepatic encephalopathy: continued home rifaximin 550 mg BID and
lactulose 30 ml TID
-Transplant status: active
#) Hyperglycemic emergency
#) Insulin-dependent type II diabetes
Initially presented with trace ketonuria and minor anion gap
suggested of HHNK, likely ___ to poor home insulin adherence.
Labile sugars at baseline. Evaluated by ___ with home insulin
regimen adjusted to 16 units Lantus QAM, 6 units of Humalog with
meals.
CHRONIC/STABLE ISSUES
#) Ulcerative colitis: continued home mesalamine 2400 mg BID.
#) Malnutrition, moderate: h/o prolonged enteral feeding. Plan
for repeat NGT placement in the future. Discharge weight: 117.4
lbs.
#) h/o recurrent C. diff colitis: continued home suppressive
vancomycin 125 mg PO daily.
TRANSTIONAL ISSUES
==================
- Insulin regimen adjusted to 16 units Lantus QAM, 6 units of
Humalog with meals.
- Please monitor blood sugars on adjusted insulin regimen,
patient to call Dr. ___ with blood sugar values over the
weekend on ___ at ___.
- Discharge tbili: 8.3
- Added midodrine 10 mg TID for BP support.
- MRCP: Multiple cystic lesions in the pancreas are similar to
before and likely
side-branch intraductal papillary mucinous neoplasms. Continued
attention is advised on ___ follow up.
- Please check chem-10, and LFTs within 7 days of d/c. Please
fax results to ___.
- Scheduled for outpatient therapeutic paracentesis on ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Benzonatate 100 mg PO TID:PRN cough
2. Spironolactone 100 mg PO DAILY
3. Furosemide 60 mg PO DAILY
4. Lactulose 30 mL PO TID
5. Pantoprazole 40 mg PO Q24H
6. Simvastatin 40 mg PO QPM
7. Ursodiol 300 mg PO BID
8. Cholestyramine 4 gm PO DAILY:PRN itching
9. Ciprofloxacin HCl 500 mg PO Q24H
10. Ferrous Sulfate 325 mg PO DAILY
11. Calcium Carbonate 1000 mg PO DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Mesalamine ___ 2400 mg PO BID
14. Rifaximin 550 mg PO BID
15. Thiamine 100 mg PO DAILY
16. Vancomycin Oral Liquid ___ mg PO BID C,diff prophylaxis
17. Sertraline 75 mg PO DAILY
18. Glargine 28 Units Breakfast
Glargine 28 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Midodrine 10 mg PO TID
RX *midodrine 10 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
2. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Vitamin A ___ UNIT PO DAILY Duration: 10 Days
RX *vitamin A 10,000 unit 1 capsule(s) by mouth daily Disp #*7
Capsule Refills:*0
4. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days
RX *zinc sulfate 220 mg (50 mg zinc) 1 capsule(s) by mouth daily
Disp #*12 Capsule Refills:*0
5. Glargine 16 Units Breakfast
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Benzonatate 100 mg PO TID:PRN cough
7. Calcium Carbonate 1000 mg PO DAILY
8. Cholestyramine 4 gm PO DAILY:PRN itching
9. Ciprofloxacin HCl 500 mg PO Q24H
10. Ferrous Sulfate 325 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Furosemide 60 mg PO DAILY
13. Lactulose 30 mL PO TID
14. Mesalamine ___ 2400 mg PO BID
15. Pantoprazole 40 mg PO Q24H
16. Rifaximin 550 mg PO BID
17. Sertraline 75 mg PO DAILY
18. Simvastatin 40 mg PO QPM
19. Spironolactone 100 mg PO DAILY
20. Thiamine 100 mg PO DAILY
21. Ursodiol 300 mg PO BID
22. Vancomycin Oral Liquid ___ mg PO BID C,diff prophylaxis
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hyperglycemia
Hyperbilirubenemia
Acute on chronic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with high blood sugars. Our
diabetes doctors ___ your ___ insulin regimen. You also
had fevers but we did not find any sources of infection in you.
You had an endoscopy while here to see if you needed banding of
your varices again. It is now safe for you to go home. Please
monitor your blood sugars and call Dr. ___ with the values on
___ at ___. It was a pleasure caring for you!
Wishing you the best,
Your ___ Team
Followup Instructions:
___
|
10464640-DS-31 | 10,464,640 | 27,299,156 | DS | 31 | 2159-08-08 00:00:00 | 2159-08-08 18:27:00 |
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, encephalopathy
Major Surgical or Invasive Procedure:
Diagnostic Paracentesis (___)
Diagnostic and Therapeutic Paracentesis (___)
Diagnostic and Therapeutic Paracentesis (___)
History of Present Illness:
Ms. ___ is a ___ female with a history of PSC
cirrhosis (Child C) historically decompensated by ascites/SBP,
hepatic encephalopathy, esophageal varices, and malnutrition as
well as ulcerative colitis, recurrent C. diff colitis on
suppressive vancomycin, insulin-dependent type II diabetes ___
recent admission for hyperglycemic emergency, presenting with
4-day history of diarrhea unable to keep up with her fluid
intake. ALl history from ___ as patient somnolent on arrival
to floor. Patient reports nausea and tender belly at this time.
Patient denies any fever, chills, shortness of breath, chest
pain, dysuria at this time. She had 4.3 L para on ___.
Past Medical History:
- Primary sclerosing cholangitis with decompensated cirrhosis
(Child C c/b varices, ascites, encephalopathy, malnutrition)
-Ulcerative colitis on 5-ASA
-Recurrent cholangitis
-C diff on PO vancomycin
-TAH in ___ for fibroids
-IDDM Type 2
Social History:
___
Family History:
Father - DM, alive (___).
Mother - DM, alive (___).
Two sons with HTN.
Daughter healthy.
No family history of liver disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
T 97.1 HR 62 BP 106/58 RR 18 SaO2 99% RA
GA: Comfortable
HEENT: + scleral icterus
Cardiovascular: Normal S1, S2, regular rate and rhythm, no
murmurs/rubs/gallops, 2+ peripheral pulses bilaterally
Pulmonary: Clear to auscultation bilaterally
Abdominal: Soft, nontender, distended, no masses
Extremities: No lower leg edema
Integumentary: No rashes noted
DISCHARGE PHYSICAL EXAM
========================
T 98.7 HR 74 BP 106 / 63 RR 16 SaO2 98% Ra
GENERAL: Adult woman laying in bed
HEENT: icteric sclera, MMM
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi
GI: abdomen soft, non-tender, mildly distended, normoactive BS
EXTREMITIES: warm, no edema
NEURO: A&Ox3, CN grossly intact, spontaneously moving all
extremities, (-) asterixis
Pertinent Results:
ADMISSION LABS
=======================
___ 10:55PM BLOOD WBC-3.1* RBC-2.91* Hgb-8.7* Hct-25.4*
MCV-87 MCH-29.9 MCHC-34.3 RDW-25.8* RDWSD-76.2* Plt ___
___ 10:55PM BLOOD Neuts-65.9 ___ Monos-7.4 Eos-3.2
Baso-0.6 NRBC-0.9* Im ___ AbsNeut-2.04 AbsLymp-0.70*
AbsMono-0.23 AbsEos-0.10 AbsBaso-0.02
___ 10:55PM BLOOD ___ PTT-26.7 ___
___ 10:55PM BLOOD Plt ___
___ 10:55PM BLOOD Glucose-353* UreaN-24* Creat-0.9 Na-134*
K-6.2* Cl-101 HCO3-20* AnGap-13
___ 10:55PM BLOOD ALT-57* AST-244* AlkPhos-1072*
TotBili-12.6*
___ 10:55PM BLOOD Albumin-2.8*
___ 10:59PM BLOOD Lactate-2.2* K-4.5
___ 10:55PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 10:55PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-100* Ketone-TR* Bilirub-MOD* Urobiln-2* pH-6.5 Leuks-NEG
___ 10:55PM URINE RBC-1 WBC-4 Bacteri-FEW* Yeast-NONE
Epi-<1
___ 10:55PM URINE CastHy-4*
___ 10:55PM URINE Mucous-RARE*
DISCHARGE LABS
========================
___ 04:47AM BLOOD WBC-1.4* RBC-2.56* Hgb-7.7* Hct-23.0*
MCV-90 MCH-30.1 MCHC-33.5 RDW-22.7* RDWSD-72.3* Plt Ct-73*
___ 04:47AM BLOOD Plt Ct-73*
___ 04:47AM BLOOD ___ PTT-35.8 ___
___ 04:47AM BLOOD Glucose-158* UreaN-14 Creat-0.7 Na-133*
K-4.7 Cl-102 HCO3-20* AnGap-11
___ 04:47AM BLOOD ALT-23 AST-71* AlkPhos-634* TotBili-8.2*
___ 04:47AM BLOOD Albumin-2.8* Calcium-7.7* Phos-1.5*
Mg-2.2
PERTINENT LABS
========================
___ 03:35PM ASCITES TNC-91* RBC-4693* Polys-2* Lymphs-5*
Monos-1* Mesothe-2* Macroph-90*
___ 09:14AM ASCITES TNC-41* RBC-6814* Polys-2* Lymphs-15*
Monos-78* Mesothe-5* Other-0
___ 03:35PM ASCITES TotPro-1.1
___ 09:14AM ASCITES TotPro-0.9 Glucose-320 LD(LDH)-37
Albumin-0.3
___ 01:50AM BLOOD WBC-5.2 RBC-2.49* Hgb-7.2* Hct-23.0*
MCV-92 MCH-28.9 MCHC-31.3* RDW-26.2* RDWSD-88.7* Plt ___
___ 08:55AM BLOOD WBC-3.5* RBC-2.83* Hgb-8.4* Hct-25.7*
MCV-91 MCH-29.7 MCHC-32.7 RDW-25.1* RDWSD-80.4* Plt Ct-94*
___ 04:38AM BLOOD WBC-1.5* RBC-2.35* Hgb-6.9* Hct-21.4*
MCV-91 MCH-29.4 MCHC-32.2 RDW-24.1* RDWSD-77.8* Plt Ct-76*
___ 05:01AM BLOOD WBC-1.7* RBC-3.00* Hgb-8.8* Hct-26.8*
MCV-89 MCH-29.3 MCHC-32.8 RDW-23.0* RDWSD-73.0* Plt Ct-84*
MICROBIOLOGY/PATHOLOGY
-=======================
___ 6:05 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 1:27 pm PERITONEAL FLUID PERITONEAL 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..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
___ 12:50 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 3:35 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
**FINAL REPORT ___
Fluid Culture in Bottles (Final ___: NO GROWTH.
___ 3:35 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 4:25 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
Reported to and read back by ___ ___ 12:01PM.
POSITIVE. (Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of
C. difficile and Therefore, positive C. diff PCR tests
trigger
reflex C. difficile toxin testing, which is highly
specific for
CDI.
C. difficile Toxin antigen assay (Final ___:
NEGATIVE. (Reference Range-Negative).
PERFORMED BY EIA.
This result indicates a low likelihood of C. difficile
infection
(CDI).
___ 9:14 am FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
**FINAL REPORT ___
Fluid Culture in Bottles (Final ___: NO GROWTH.
___ 9:14 am PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 10:55 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 10:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
RADIOLOGY
=========================
EGD (___)
Normal mucosa in the whole esophagus. Congestion, petechiae, and
mosaic mucosal pattern in the stomach fundus and stomach body
compatible with portal hypertensive gastropathy. Small
inflammatory polyp noted in stomach body. An NJ tube was placed
past the third portion of the duodenum. The tube was moved from
the mouth into the nose and bridled at 110cm. The tube flushed
without difficulty. Normal mucosa in the whole examined
duodenum.
CHEST X RAY (___)
IMPRESSION:
Left basilar opacity likely atelectasis though infection is not
excluded.
CT ABDOMEN (___)
IMPRESSION:
1. Diffuse wall thickening of the colon, likely reflecting
portal colopathy.
Collapse of the colon (from the mid transverse colon distally),
diffuse
mesenteric stranding and large volume ascites limits evaluation
for infectious
process.
2. Cirrhotic liver with large volume ascites, splenomegaly, and
upper
abdominal varices.
3. Pancreatic cystic lesions are better characterized on prior
MRCP.
LIVER/GALLBLADDER US (___)
IMPRESSION:
1. Cirrhotic liver, with splenomegaly and large volume ascites.
2. Patent main portal vein with slow flow.
Brief Hospital Course:
PATIENT SUMMARY
================
Ms. ___ is a ___ female with a history of PSC
cirrhosis historically decompensated by ascites/SBP, hepatic
encephalopathy, esophageal varices, and malnutrition as well as
ulcerative colitis, recurrent C. diff colitis on suppressive
vancomycin, insulin-dependent type II diabetes with recent
admission for hyperglycemic emergency. She presented with a
4-day history of diarrhea and abdominal pain, and was managed
inpatient for hepatic encephalopathy and ascites.
ACUTE MEDICAL ISSUES
==================
# Hepatic Encephalopathy.
Ms. ___ initially presented with significant somnolence and
received naloxone and lactulose, with improvement of her mental
status. Following several days of treatment with lactulose and
rifaximin, her encephalopathy had resolved and she had returned
to her baseline mental status without any overt impairment.
# Abdominal Pain, Diarrhea
Ms. ___ presented with significant right upper quadrant
abdominal pain and worsening alkaline phosphatase and bilirubin.
She remained afebrile, but demonstrated marked tenderness to
palpation on abdominal exam. C. difficile antigen was negative,
while stool PCR was positive, consistent with colonization but
not active infection. Diagnostic paracentesis was performed to
evaluate for spontaneous bacterial peritonitis, revealing
___ fluid with a SAAG of 2.5 suggesting
portal hypertension likely due to PSC cirrhosis, but with WBC of
41, less suggestive of recurrent SBP. However, given the acuity
of decompensation and severity of abdominal tenderness, Ms.
___ was treated empirically with ceftriaxone for SBP. Blood
and ascites cultures subsequently demonstrated no growth to
date, and SBP suppressive therapy with ciprofloxacin was
resumed. Given negative work-up, abdominal pain was likely
secondary only to distension caused by worsened ascites.
Symptoms subsequently improved following diuresis and
therapeutic paracentesis on ___. The patient subsequently
reaccumulated ascites in the setting of fluid administration,
transfusion, and holding diuretics for multiple days iso GI
bleeding and creatinine elevation. Given hyponatremia in setting
of diuresis and plan for regular outpatient paracenteses, home
furosemide and spironolactone were held on discharge.
# Rectal Variceal Bleeding
The patient developed bright red blood per rectum overnight on
___ likely secondary to known rectal varices noted on ___
colonoscopy. Lower suspicion for esophageal variceal bleeding
given character of blood, hemodynamic stability, and absence of
symptoms. Patient was started on octreotide for rectal variceal
bleeding (discontinued ___, IV pantoprazole. IV ceftriaxone,
and made NPO. Pantoprazole was subsequently switched to PO given
low suspicion for variceal bleeding, and diet was advanced.
Patient received additional blood transfusion morning of ___
for Hgb 6.9. The patient subsequently had no further gross
bleeding, with normal, non-bloody or melenic stools for more
than two days prior to discharge. She completed a 5 day course
of ceftriaxone.
# Decompensated Cirrhosis Secondary to Primary Sclerosing
Cholangitis
Patient with history of primary sclerosis cholangitis cirrhosis,
decompensated this admission by hepatic encephalopathy, ascites,
and rectal variceal bleeding and treated as discussed above.
Home lactulose and rifaximin were continued as above for
encephalopathy. Home diuretics were discontinued in the setting
of elevated creatinine and hyponatremia as above. Severe
malnutrition in the setting of cirrhosis was treated with
placement of a feeding tube and initiation of tube feeds for
nutritional support. Bleeding from rectal varices was treated as
above.
# Severe Malnutrition
Patient underwent nutritional evaluation and was started on tube
feeds as discussed above.
#Hyperglycemia, Insulin-dependent type II diabetes. Ms. ___
presented with persistent hyperglycemia ranging to >400 despite
continuation of her home insulin regimen. ___ was consulted
and she required uptitration of her home insulin while here. Due
to initiation of tube feeds, the patient's insulin regimen was
changed to 20U lantus in the morning, with 16U 70/30 Novolog mix
with breakfast and 16U 70/30 with dinner.
CHRONIC ISSUES
==================
# Ulcerative Colitis
Patient continued home mesalamine 2400 mg BID.
# C. Difficile Infection
Patient continued PO vancomycin. Dose initially increased to
empirically cover for possible C. difficile infection to QID in
setting of antibiotics for 7 days after last antibiotic dose
until ___, will reduce to BID after.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benzonatate 100 mg PO TID:PRN cough
2. Calcium Carbonate 1000 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Furosemide 60 mg PO DAILY
5. Lactulose 30 mL PO TID
6. Rifaximin 550 mg PO BID
7. Sertraline 75 mg PO DAILY
8. Simvastatin 40 mg PO QPM
9. Spironolactone 100 mg PO DAILY
10. Thiamine 100 mg PO DAILY
11. Ursodiol 300 mg PO BID
12. Vancomycin Oral Liquid ___ mg PO BID C,diff prophylaxis
13. Midodrine 10 mg PO TID
14. Multivitamins 1 TAB PO DAILY
15. Cholestyramine 4 gm PO DAILY:PRN itching
16. Ciprofloxacin HCl 500 mg PO Q24H
17. Ferrous Sulfate 325 mg PO DAILY
18. Pantoprazole 40 mg PO Q24H
19. Zinc Sulfate 220 mg PO DAILY
20. Vitamin A ___ UNIT PO DAILY
21. Mesalamine ___ 2400 mg PO BID
22. Glargine 16 Units Breakfast
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Discharge Medications:
1. NovoLOG Mix ___ U-100 (insulin asp prt-insulin
aspart) 100 unit/mL (70-30) subcutaneous BID
16 units with breakfast AS DIR
16 units at bedtime AS DIR
RX *insulin asp prt-insulin aspart [Novolog Mix ___
U-100] 100 unit/mL (70-30) AS DIR at breakfast, at bedtime Disp
#*10 Syringe Refills:*0
2. 70/30 16 Units Breakfast
70/30 16 Units Bedtime
Glargine 20 Units Breakfast
3. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day
Disp #*70 Capsule Refills:*0
4. Benzonatate 100 mg PO TID:PRN cough
5. Calcium Carbonate 1000 mg PO DAILY
6. Cholestyramine 4 gm PO DAILY:PRN itching
7. Ciprofloxacin HCl 500 mg PO Q24H
8. Ferrous Sulfate 325 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Lactulose 30 mL PO TID
11. Mesalamine ___ 2400 mg PO BID
12. Midodrine 10 mg PO TID
13. Multivitamins 1 TAB PO DAILY
14. Pantoprazole 40 mg PO Q24H
15. Rifaximin 550 mg PO BID
16. Sertraline 75 mg PO DAILY
17. Simvastatin 40 mg PO QPM
18. Thiamine 100 mg PO DAILY
19. Ursodiol 300 mg PO BID
20. Vitamin A ___ UNIT PO DAILY
21. Zinc Sulfate 220 mg PO DAILY
22. HELD- Furosemide 60 mg PO DAILY This medication was held.
Do not restart Furosemide until cleared by your liver doctors.
23. HELD- Spironolactone 100 mg PO DAILY This medication was
held. Do not restart Spironolactone until cleared by your liver
doctors.
24.Tube Feeds
Glucerna 1.2
@ 65 mL/hr over 24 hours (1872 kcal, 94 g pro, ~1260 mL H20)
Flush with 30 mL q6 hours
Dispense 1 month supply with 2 refills
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
================
Hepatic Encephalopathy
Abdominal Pain, Diarrhea
Rectal Variceal Bleeding
Decompensated Cirrhosis Secondary to Primary Sclerosing
Cholangitis
Severe Malnutrition
Hyperglycemia
Secondary Diagnoses
================
Ulcerative Colitis
C. Difficile Colonization
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because of confusion and
accumulation of fluid (ascites) in your abdomen.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were treated with medications and a paracentesis to
remove excess fluid from your abdomen
- You were treated with lactulose to reduce confusion related to
chronic liver disease
- You developed bleeding from your gut and received a blood
transfusion and medications to stabilize the bleeding
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10464640-DS-32 | 10,464,640 | 26,146,815 | DS | 32 | 2159-08-25 00:00:00 | 2159-08-27 18:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hyperglycemia, anemia
Major Surgical or Invasive Procedure:
___ - Flex sigmoid
History of Present Illness:
Ms. ___ is a ___ with PSC cirrhosis c/b cholangitis with
malnourishment, HE, ascites (gets therapeutic taps on ___
and ___ and esophageal varices s/p banding (___).
Of note, the patient had a bleeding episode in ___, underwent
EGD on ___ which showed two gastric polyps that had some
bleeding, which spontaneously resolved. She then had BRBPR in
___, thought to be due to her known rectal varices, responded
with conservative management. She was discharged about one week
ago.
EGD (___)
Normal mucosa in the whole esophagus. Congestion, petechiae, and
mosaic mucosal pattern in the stomach fundus and stomach body
compatible with portal hypertensive gastropathy. Small
inflammatory polyp noted in stomach body. An NJ tube was placed
past the third portion of the duodenum. The tube was moved from
the mouth into the nose and bridled at 110cm. The tube flushed
without difficulty. Normal mucosa in the whole examined
duodenum.
She comes in now with no complaints, was seen in ___
today, and found on labs to have Hb 6.6, ALP 1176 and Glucose in
600s. She was sent into ED and was noted to have gross
red-tinged blood intermixed with her stool, which the patient
hadn't noticed before. She had no symptoms of orthostasis and
remained HD stable.
On exam, she was found to have nonspecific RLQ abd pain, no
fevers or leukoctyosis to suggest cholangitis. Of note, she's
had history of cholangitis in the past but recently has had
elevated ALP thought likely due to progressive PSC rather than
obstruction. Additionally, her rise in ALP may be secondary to
glycogen hepatopathy in the setting of her elevated glucose.
Her initial vitals in the ED were:
T 97.2 HR 78 BP 105/56 RR 18 O2 Sat 100% RA
Presentign CBC: Hgb 6.6, Hcg 20.7
Her most recent CBC shows Hgb 5.8 and Hct 18.2 at 6:30 ___. She
is notably also leukopenic (WBC 2.3) and thrombocytopenic (92).
Her coags: ___ 15.2 INR 1.4
LFTs: AST 155 ALT 45 AP 1176 Tbili 12.2 Alb 3.3
Vitamin D low at 7
Chem 10: Na 129 -> Decreased to 124, K 5.4, Bicarb 18 ->
Decreased to 13, Cr 0.9, Mg 2.7
Her glucose was 778 at 6:30pm down to 329 at 10:50 pm
She has gotten 1U of blood and has gotten 2L fluids. She
received insulin drip at 9U/hr starting at 10PM. There is a plan
to trend CBC q8h. She was started on octreotide drip and
ceftriaxone for infection prophylaxis. An abdominal ultrasound
was done which showed cirrhosis but unchanged portal flow.
Liver US with duplex ___:
Cirrhotic liver splenomegaly with patent hepatic vasculature
demonstrating slow portal venous flow, similar to prior, and
biphasic left portal venous flow.
She has chronic, diffuse abdominal pain and increased abdominal
girth. She denies fevers/chills, n/v/d/c, confusion, HA,
weakness, masses/swelling, rashes and changes in vision.
She fell on her knees yesterday while out with her daughter; she
was wearing flip flops and tried to jump over a puddle. On
presentation, she was endorsing bilateral thigh pain and knee
pain. She denied headstrike, LOC, and difficulty ambulating. An
XR of her knee was unremarkable.
On her recent discharge, she had been here for 4 days for
hepatic encephalopathy and abdominal pain with diarrhea. She
received lactulose and naloxone with rifaximin and her
encephalopathy resolved. She underwent a paracentesis showing
and was empirically treated with ceftriaxone for SBP (and
resumed on prophylactic cipro). She also had a couple of
therapeutic paracenteses. She also had rectal variceal bleeding
on ___ and had no further bleeding. She had sugars > 400
and had her insulin regimen uptitrated to 20U Lantus in AM, 16U
70/30 Novolog mix with breakfast and 16U 70/30 with dinner.
Past Medical History:
-Primary sclerosing cholangitis cirrhosis historically
decompensated by ascites/SBP, hepatic encephalopathy, esophageal
varices, and malnutrition
-Ulcerative colitis on 5-ASA
-Recurrent cholangitis
-Insulin dependent type II diabetes
-Recurrent C. diff colitis on suppressive vancomycin
-Total abdominal hysterectomy for fibroids (___)
Social History:
___
Family History:
-Paternal h/o DM
-Maternal h/o DM
-No familial history of liver disease
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
General: cachectic-appearing middle-aged female in NAD
VS: hypotensive
HEENT: NC, AT. NG tube in place. IMMM. Scleral icterus present.
Neck: no lymphadenopathy
Back: no CVA tenderness, no bruises present, no spinal
tenderness
Chest: CTAB
CV: Systolic murmur with radiation sternum, displaced PMI
Abdomen: protruberent, tender to LUQ and epigastrum.
Ext: trace pitting edema present to bilateral ankles
Neuro: AOx3, no asterixis, CN2-12 intact, strength ___ in all
extremities.
=======================
DISCHARGE PHYSICAL EXAM
=======================
GENERAL: Alert and interactive. In no acute distress.
HEENT: Scleral icterus
CARDIAC: Normal sinus rhythm, normal S1/S2, no m/r/g
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
ABDOMEN: Increased abdominal distension, pain and ascites
EXTREMITIES: No edema.
Pertinent Results:
=====================
ADMISSION LAB RESULTS
=====================
___ 10:40AM BLOOD WBC-2.3* RBC-2.14* Hgb-6.6* Hct-20.7*
MCV-97 MCH-30.8 MCHC-31.9* RDW-24.9* RDWSD-85.4* Plt Ct-92*
___ 10:40AM BLOOD ___
___ 10:40AM BLOOD UreaN-27* Creat-0.9 Na-129* K-5.4 Cl-95*
HCO3-18* AnGap-16
___ 10:40AM BLOOD ALT-45* AST-155* AlkPhos-1176*
TotBili-12.2*
___ 10:40AM BLOOD Albumin-3.3* Calcium-8.4 Phos-2.8 Mg-2.7*
___ 06:55PM BLOOD pO2-98 pCO2-28* pH-7.38 calTCO2-17* Base
XS--6
=============
IMAGING/OTHER
=============
___ RUQ Ultrasound
1. Cirrhotic liver with patent hepatic vasculature but
demonstrating slowportal venous flow, similar to prior, and
biphasic left portal venous flow. 2. Splenomegaly. 3. Moderate
ascites.
___ Bilateral Knee Xray
AP, lateral and oblique views of both knees were provided. No
fracture, dislocation, joint effusion or significant arthritis
is seen at either knee.
___ CXR for PICC location
"1. Right PICC line terminates in the right atrium
approximately 2-3 cm from the cavoatrial junction.
2. Retrocardiac atelectasis, which is decreased. Otherwise no
focal
consolidation."
___ Colonoscopy
Impressions
"High residue material was noted throughout. Multiple attempts
were made to irrigate the colon but the mucosa could not be
visualized adequately. Portal colopathy with friability and
oozing throughout in the entire colon. Rectal varices."
DISCHARGE LABS:
---------------
___ 04:56AM BLOOD WBC-5.1 RBC-2.37* Hgb-7.7* Hct-23.2*
MCV-98 MCH-32.5* MCHC-33.2 RDW-25.0* RDWSD-87.6* Plt Ct-86*
___ 04:56AM BLOOD Glucose-157* UreaN-36* Creat-1.0 Na-133*
K-4.8 Cl-103 HCO3-20* AnGap-10
___ 04:56AM BLOOD ALT-32 AST-112* LD(LDH)-287* AlkPhos-826*
TotBili-9.1*
___ 04:56AM BLOOD Calcium-7.6* Phos-3.8 Mg-2.6
Brief Hospital Course:
Ms. ___ is a ___ female with a history of PSC
cirrhosis (Child C) historically decompensated by ascites/SBP,
hepatic encephalopathy, esophageal varices, and malnutrition as
well as ulcerative colitis, recurrent C. diff colitis on
suppressive vancomycin, insulin-dependent type II diabetes with
recent admission for hyperglycemic emergency and recent
admission for HE and ascites, who presented after having
hyperglycemia and anemia at an outpatient visit.
============
ACUTE ISSUES
============
# Hyperglycemia
Patient was found to be hyperglycemic. No gap. Likely in the
setting of poor adherence to insulin. She was started on an
insulin drip, which was transitioned (end ___ to subcu insulin
once her sugars were more well controlled. Her blood sugars
remained labile during hospitalization, c/w brittle ___
was consulted. After callout from the ICU, on the floor, insulin
SSI and fixed dose regimens were titrated per ___
recommendations. Patient was on continuous tube feeds with
dobhoff in place. Her final discharge insulin regimen was as
follows:
- 70/30 mixed insulin (pen device) 42 units each morning with
breakfast meal and 22 units each evening with dinner
- Monitor BG levels at minimum twice daily (prior to insulin
administration), but ideally 4x/day - pre-meals and bedtime.
- Call ___ if there is any disruption in tube feeds for >3
hours, if glucoses are < 70mg/dL or greater than 250mg/dL.
- Patient should be seen at ___ in 1 week for outpatient
follow-up by Dr. ___ NP. ___ will call with this
appointment.
#Anemia
#Esophageal Varices
Patient presented with anemia and concern for GI bleed in the
setting of known esophageal varices. She underwent flexible
sigmoidoscopy by hepatology on ___. Flex sig findings c/w
portal colopathy as bleeding etiology, EGD deferred. Hgb stable
s/p 2u pRBC. After callout from the ICU, on the floor, given
reduced concern for existence of active variceal process,
octreotide was D/Ced. Patient was maintained on PO PPI. CBC was
trended during course, and remained stable without any other
signs of bleeding on the floor. Her discharge hemoglobin was
7.5.
# Hyperbilirubinemia
# Primary sclerosis cholangitis, Child C/MELD-Na 23
Historically, the patient has had hyperbilirubinemia in the
setting of glucose lability, attributed to glycogenic
hepatopathy. Low concern for cholangitis given negative imaging,
stable vital signs. Progressive PSC or cholangiocarcinoma is
also conceivable and would require MRCP for further
characterization. Ciprofloxacin prophylaxis was continued.
Patient's home medications, including home rifaximin 550 mg BID
and lactulose 30 ml TID (for hepatic encephalopathy), ursodiol,
cholestryamine PRN, and multivitamin/folic acid/thiamine were
continued. Lasix 60 mg and spironolactone 100 mg were held in
the setting of GIB and BPs (90s-100s SBP). While patient was
initially on ceftriaxone, this was discontinued while continuing
patient's home ciprofloxacin (ppx). A therapeutic paracentesis
was scheduled for ___. On ___, while on the floor, patient
began to endorse greater abdominal distention and discomfort,
and in the evening, experienced greater tenderness to palpation,
though no visible veins or erythema.
==============
CHRONIC ISSUES
==============
#Ulcerative colitis
Followed by GI at ___. Did have prior lower GI bleed requiring
admission in that setting. Home mesalamine was continued.
# Malnutrition
Previously with a history of prolonged tube feeding via dobhoff.
She was continued on tube feeds while inpatient. Also continued
multivitamin and folate.
# Depression
Continued home sertraline during admission
# H/o c.diff
Patient was placed on prophylactic PO vancomycin in the setting
of ciprofloxacin for SBP prophylaxis.
===================
TRANSITIONAL ISSUES
===================
[] Followed by ___ while inpatient for labile blood sugars:
Discharge insulin regimen was as follows:
- 70/30 mixed insulin (pen device) 42 units each morning with
breakfast meal and 22 units each evening with dinner
- Monitor BG levels at minimum twice daily (prior to insulin
administration), but ideally 4x/day - pre-meals and bedtime.
[] ___ follow-up appointment has been scheduled: ___
with ___, NP at 8:00am, check-in time of 7:30am.
[] Please draw Hgb at first follow up: Discharge Hgb was 7.5
[] Therapeutic paracentesis on ___: Please schedule
therapeutic paracentesis in the late morning if possible as will
make easier for adherence to insulin regimen
[] Consider MRCP for further characterization of worsening PSC
or cholangiocarcinoma
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Benzonatate 100 mg PO TID:PRN cough
2. Calcium Carbonate 1000 mg PO DAILY
3. Cholestyramine 4 gm PO DAILY:PRN itching
4. Ferrous Sulfate 325 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Lactulose 30 mL PO TID
7. Mesalamine ___ 2400 mg PO BID
8. Midodrine 10 mg PO TID
9. Multivitamins 1 TAB PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. Rifaximin 550 mg PO BID
12. Sertraline 75 mg PO DAILY
13. Simvastatin 40 mg PO QPM
14. Thiamine 100 mg PO DAILY
15. Ursodiol 300 mg PO BID
16. Vitamin A ___ UNIT PO DAILY
17. Zinc Sulfate 220 mg PO DAILY
18. Vancomycin Oral Liquid ___ mg PO QID
19. Ciprofloxacin HCl 500 mg PO Q24H
20. Furosemide 60 mg PO DAILY
21. Spironolactone 100 mg PO DAILY
22. NovoLOG Mix ___ U-100 (insulin asp prt-insulin
aspart) 100 unit/mL (70-30) subcutaneous BID
Discharge Medications:
1. Ascorbic Acid ___ mg PO BID
RX *ascorbic acid (vitamin C) 500 mg 1 capsule(s) by mouth Twice
daily Disp #*60 Capsule Refills:*0
2. NovoLOG Mix ___ U-100 (insulin asp prt-insulin
aspart) 100 unit/mL (70-30) subcutaneous BID
42 units each morning with
breakfast meal and 22 units each evening with dinner
RX *insulin asp prt-insulin aspart [Novolog Mix ___
U-100] 100 unit/mL (70-30) As Directed Twice daily Disp #*1 Box
Refills:*0
3. Vitamin D ___ UNIT PO 1X/WEEK (___) Duration: 8 Weeks
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth Every ___ Disp #*7 Capsule Refills:*0
4. Ferrous Sulfate 325 mg PO BID
5. Midodrine 20 mg PO TID
6. Vancomycin Oral Liquid ___ mg PO BID
7. Benzonatate 100 mg PO TID:PRN cough
8. Calcium Carbonate 1000 mg PO DAILY
9. Cholestyramine 4 gm PO DAILY:PRN itching
10. Ciprofloxacin HCl 500 mg PO Q24H
11. FoLIC Acid 1 mg PO DAILY
12. Furosemide 60 mg PO DAILY
13. Lactulose 30 mL PO TID
14. Mesalamine ___ 2400 mg PO BID
15. Multivitamins 1 TAB PO DAILY
16. Pantoprazole 40 mg PO Q24H
17. Rifaximin 550 mg PO BID
18. Sertraline 75 mg PO DAILY
19. Simvastatin 40 mg PO QPM
20. Spironolactone 100 mg PO DAILY
21. Thiamine 100 mg PO DAILY
22. Ursodiol 300 mg PO BID
23. Vitamin A ___ UNIT PO DAILY
24. Zinc Sulfate 220 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
=================
PRIMARY DIAGNOSES
=================
Portal colopathy
Acute anemia
Hyperglycemia
===================
SECONDARY DIAGNOSES
===================
Primary sclerosing cholangitis cirrhosis
Ulcerative colitis
Recurrent cholangitis
Insulin dependent type II diabetes
Recurrent C. diff colitis on suppressive vancomycin
Discharge Condition:
Mental status:
Level of consciousness:
Activity status:
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because:
- You were found to have anemia and high blood sugars.
While you were in the hospital:
- You were seen by our Diabetes specialists, and your blood
sugars were treated with insulin, initially with a drip, and
then with a sliding scale and fixed dose regimen
- You were given blood transfusions for your anemia
- Your intestine was examined through a colonoscopy, and based
on the findings, changes in the colon wall were suspected to be
the source of bleeding that contributed to your anemia
When you leave:
- Please follow-up with your primary care provider.
- Please take your medications as prescribed.
It was a pleasure to care for you during your hospitalization.
Your ___ care team
Followup Instructions:
___
|
10464640-DS-33 | 10,464,640 | 29,692,395 | DS | 33 | 2159-09-10 00:00:00 | 2159-09-10 16:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fatigue, BRBPR
Major Surgical or Invasive Procedure:
Rectal varice embolization
History of Present Illness:
Ms. ___ is a ___ woman with a history of PSC
cirrhosis (Child's C) historically decompensated by ascites/SBP,
hepatic encephalopathy, esophageal/rectal varices, and
malnutrition, as well as ulcerative colitis, recurrent C. diff
colitis on suppressive vancomycin, and insulin-dependent type II
diabetes
with recent admission for hyperglycemia and anemia, who presents
with
fatigue and BRBPR, ultimately found to be hypotensive in the ED
to ___ and anemic with a hemoglobin of 4.8.
The day prior to admission (___), the patient underwent a
therapeutic paracentesis with removal of 5.75L of ascites and
repletion with 37.5g of albumin. After the procedure, the
patient
went home. That evening, she noted a small amount of bleeding
from her rectum. The following morning, she noted a significant
amount of bright red blood per rectum with clots. She then began
to experience problems with her vision, stating that it felt
very
blurry, as if she could not see. At one point, she reports
walking to her kitchen when she passed out. She does not recall
exactly what happened, and is unsure whether she hit her head.
This constellation of symptoms prompted her to call EMS.
ED Course notable for:
Initial vitals: T 98.8, HR 90, BP 79/42, RR 16, O2 sat 100% RA
Exam notable for: warm; Guaiac positive brown stool
Labs notable for: Hgb 4.8, alk phos 651, AST 125, ALT 36, Tbili
8.4, Dbili 6.1, albumin 2.0, lipase 204, BUN 59, Cr 1.8, INR 2.0
UA: few bacteria, trace protein
VBG: 7.32/32, lactate 5.2, Na 130, K 4.2, Cl 108, glucose 242
Imaging notable for: RUQUS- 1. Cirrhotic liver, without evidence
of focal lesion. Moderate amount of ascites.
2. No evidence of biliary obstruction.
3. Hepatofugal flow in the main portal vein which represents a
change from prior ultrasound.
CXR- No acute cardiopulmonary process, no focal consolidation.
Vitals prior to transfer: T 97.8, HR 70, BP 98/52, RR 15, O2 sat
99% RA
In the ED, the patient received 3U pRBCs, 12.5g albumin, and was
started on Levophed, which was titrated up to 0.21. She was also
given morphine for pain. For her INR of 2.0 she was given FFP.
Given concern for infection, she was given 1g of vancomycin and
2g of ceftriaxone.
On arrival to the MICU, the patient states that she is feeling
much better. She still notes some blurry vision, but is feeling
less tired. She states she is a little bit chilly, but does not
note fevers. Also does not report chest pain, shortness of
breath, nausea, vomiting, abdominal pain, and lower extremity
swelling.
REVIEW OF SYSTEMS: 10-point review of systems negative, except
as
above.
Past Medical History:
-Primary sclerosing cholangitis cirrhosis historically
decompensated by ascites/SBP, hepatic encephalopathy, esophageal
varices, and malnutrition
-Ulcerative colitis on 5-ASA
-Recurrent cholangitis
-Insulin dependent type II diabetes
-Recurrent C. diff colitis on suppressive vancomycin
-Total abdominal hysterectomy for fibroids (___)
Social History:
___
Family History:
-Paternal h/o DM
-Maternal h/o DM
-No familial history of liver disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Reviewed in MetaVision
GENERAL: Alert and oriented x3, no acute distress, pleasant
HEENT: Sclera icteric, dry mucous membranes, oropharynx clear
NECK: supple, JVP not elevated, no LAD, prominent carotid pulse
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, ___ systolic murmur
heard base at the L sternal border; no rubs, gallops
ABD: soft, non-tender, moderately distended, + fluid wave, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: dry, warm, jaundiced
NEURO: A&Ox3, moving all 4 extremities with purpose
Patient was made comfort measures only and passed away at 2:45
AM on ___
Pertinent Results:
Patient was made comfort measures only and passed away at 2:45
AM on ___
Brief Hospital Course:
Patient was made comfort measures only and passed away at 2:45
AM on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 1000 mg PO DAILY
2. Cholestyramine 4 gm PO DAILY:PRN itching
3. Ciprofloxacin HCl 500 mg PO Q24H
4. Ferrous Sulfate 325 mg PO BID
5. Lactulose 30 mL PO TID
6. Mesalamine ___ 2400 mg PO BID
7. Midodrine 20 mg PO TID
8. Rifaximin 550 mg PO BID
9. Sertraline 75 mg PO DAILY
10. Simvastatin 40 mg PO QPM
11. Ursodiol 300 mg PO BID
12. Vancomycin Oral Liquid ___ mg PO BID
13. Vitamin A ___ UNIT PO DAILY
14. Zinc Sulfate 220 mg PO DAILY
15. Ascorbic Acid ___ mg PO BID
16. Thiamine 100 mg PO DAILY
17. Benzonatate 100 mg PO TID:PRN cough
18. FoLIC Acid 1 mg PO DAILY
19. Furosemide 60 mg PO DAILY
20. Multivitamins 1 TAB PO DAILY
21. Pantoprazole 40 mg PO Q24H
22. Spironolactone 100 mg PO DAILY
23. Vitamin D ___ UNIT PO 1X/WEEK (___)
24. NovoLOG Mix ___ U-100 (insulin asp prt-insulin
aspart) 100 unit/mL (70-30) subcutaneous BID
Discharge Medications:
Patient was made comfort measures only and passed away at 2:45
AM on ___
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient was made comfort measures only and passed away at 2:45
AM on ___
Discharge Condition:
Patient was made comfort measures only and passed away at 2:45
AM on ___
Discharge Instructions:
Patient was made comfort measures only and passed away at 2:45
AM on ___
Followup Instructions:
___
|
10464834-DS-11 | 10,464,834 | 21,980,738 | DS | 11 | 2180-06-12 00:00:00 | 2180-06-12 13:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
No procedures performed during this hospitalization
History of Present Illness:
___ M with a history of 2 prior episodes of diverticulitis who
presents to ___ on ___ with about 40 hours of left lower
quadrant pain and flatulence, and the pain was spontaneously
relieved by yesterday morning , but then soon returned as a
sharp continuous LLQ pain. Reports having nonbloody bowel
movements on the day of presentation and passing flatus. Denies
fevers, nausea, and vomiting
Past Medical History:
___
HTN
2 prior episodes of diverticulitis
___
___ L inguinal hernia repair
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS T 97.5 HR 66 BP 123/62 RR 16 SaO2 97% RA
GEN: Comfortable, not in acute distress
CV: RRR
Pulm: nonlabored breathing on room air, CTAB
abd: soft, mildly tender in the LlQ, non distended
Extremities: well perfused, no edema
DICHAPHYSICAL EXAM
VITALS T 97.5 HR 66 BP 123/62 RR 16 SaO2 97% RA
GEN: Comfortable, not in acute distress
CV: RRR
Pulm: nonlabored breathing on room air, CTAB
abd: soft, contender, non distended
Extremities: well perfused, no edema
Pertinent Results:
___ 05:00PM WBC-10.3* RBC-4.42* HGB-13.3* HCT-37.8*
MCV-86 MCH-30.1 MCHC-35.2 RDW-13.1 RDWSD-39.9
___ 05:00PM NEUTS-74.2* LYMPHS-17.2* MONOS-5.6 EOS-2.4
BASOS-0.3 IM ___ AbsNeut-7.65* AbsLymp-1.78 AbsMono-0.58
AbsEos-0.25 AbsBaso-0.03
___ 05:00PM LIPASE-30
___ 05:00PM ALT(SGPT)-15 AST(SGOT)-17 ALK PHOS-104 TOT
BILI-0.7
___ 05:00PM GLUCOSE-89 UREA N-13 CREAT-1.0 SODIUM-139
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-24 ANION GAP-14
___- CT ABD & PELVIS WITH CONTRAST
Acute sigmoid diverticulitis complicated by 2.9 x 2.0 pelvic
abscess. No
pneumoperitoneum. Slight bladder wall thickening is likely
reactive.
Brief Hospital Course:
Mr. ___ presented to ___ on ___ for abdominal pain and CT
imaging concerning for sigmoid diverticulitis with an abscess,
and he was admitted to the Acute Care Surgery team for
management and monitoring.
Patient was initially made NPO, started on IV fluids, and
received IV antibiotics, Ciprofloxacin and Metronidazole. His
WBC was monitored through his stay to ensure he was not
worsening.
On HD2, pain was well controlled. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay. He was switched to oral antibiotics, cipro/flagyl.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
Due to work related constraints, he wanted to wait a few months
before undergoing elective surgery and appropriate follow up at
the outpatient Acute Care Surgery Clinic was established. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
Medications on Admission:
Losartan 25 mg PO daily
Metamucil
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override:
Please talk as needed for mild pain control
2. Ciprofloxacin HCl 500 mg PO Q12H
Please take the antibiotic until completion
3. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
Please take as needed for mild pain
4. MetroNIDAZOLE 500 mg PO TID
Please complete this antibiotic to completion
5. Psyllium Powder 1 PKT PO TID:PRN conspitation
Please take as needed for constipation. Hold for loose stools
6. Simethicone 40-80 mg PO QID:PRN distension
Please take as needed for abdominal pain related to gas.
7. Losartan Potassium 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
sigmoid diverticulitis with abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for
lower abdominal pain and were found to have sigmoid
diverticulitis with a pus collection, or abscess. During your
stay, you were started on antibiotics to treat your abdominal
infection, which you are to continue at home for several days.
You are recovering well and are now ready for discharge. Please
follow the instructions below to continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
YOUR BOWELS:
-Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
-If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
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.
Warm regards,
Your ___ Surgery Team
Followup Instructions:
___
|
10464871-DS-22 | 10,464,871 | 20,023,065 | DS | 22 | 2195-01-03 00:00:00 | 2195-01-03 18:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Keflex / Celebrex / Prednisone
/ Penicillins / NSAIDS / aspirin / aspirin / Latex, Natural
Rubber
Attending: ___.
Chief Complaint:
lightheadedness, nausea, hyponatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ ___ year-old female with history of bipolar
disorder, fibromyalgia, migraine, s/p Roux-en-Y gastric bypass
___ recent admissions for hyponatremia who presents with
lightheadedness, migraine headache, and nausea/vomiting.
She was recently hospitalized at ___ from ___ and
___ for hyponatremia, thought to be secondary to SIADH from
medications, and possible contributions of hypothyroidism,
polydipsia, and hypovolemia. During her ___ hospitalization,
hyponatremia was attributed to SIADH with concurrent
hypovolemia. On that admission, she had diuretics stopped,
verapamil decreased (240 to 140), and her Trileptal was stopped.
She was successfully weaned off of Klonopin. She noted increase
fluid intake between admissions, which may have contributed to
recurrence of hyponatremia. On ___ admission, urine lytes
were suggestive of SIADH (increased UOsm, elevated UNa). She was
fluid restricted at 1.5L for 2 days and 1L for one day with
subsequent improvement in serum sodium to 134. TFTs were
consistent with subclinical hypothyroidism and she was also
started on low dose levothyroxine. She was also orthostatic
during that admission. It was thought that her hyponatremia had
multifactorial etiology, secondary to multiple psychiatric
medications contributing to SIADH, polydipsia, and
hypothyroidism. She was discharged on salt tabs and 1.5 liter
fluid restriction daily. She ran out of salt tabs ___, and
notes that she has probably been drinking more than 1.5L at home
due to thirst.
She felt well upon leaving the hospital but a few days prior to
admission began to feel worse, with increasing dizziness and
unsteadiness, headache, and nausea. She notes her dizziness is
often worse when standing up. She has not fallen but notes that
she "blacks out" when standing up. She reports that she tends to
feel worse when her sodium is low. She has not had any numbness,
tingling, cloudy thinking, or changes in speech.
She has a long history of migraines, which she controls with
toradol, tramadol, and sometimes excedrin migraine. She has
gotten botox injections for migraine, which have not happened
since ___ years ago. Her migraines are often accompanied by
nausea. She has had occasional NBNB emesis over the last month,
which occurs even in the absence of migraine. She has been
mildly constipated, without diarrhea, BRBPR, melena,
hematemesis. She has not had any fevers, chills, abdominal pain,
dysura, CP or palpitations, or SOB.
In the ED, initial vitals: 98.6 74 136/71 18 98% RA
- Exam notable for: Slightly dry mucous membranes
- Labs notable for: Na 122, K 4.2, Cl 86, Cr 0.8; nl CBC; UA w/
mod leuk, neg nit, few bact
- Imaging notable for:
- Pt given: 30 mg toradol IV, 4 mg Zofran IV
- Vitals prior to transfer: 98 83 1342/84 17 99 RA
On arrival to the floor, she reports ___ headache pain and mild
nausea. She otherwise feels well.
Past Medical History:
Bipolar Disorder
Fibromyalgia
Migraines
Low back pain
Obesity
Rosacea
IBS
HL
GERD
s/p Roux-en-Y gastric bypass ___
Social History:
___
Family History:
Mother - DM
Father - CAD
Physical Exam:
================================
ADMISSION EXAM:
Vitals: 97.6 147/72 69 18 99
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, mucous membranes slightly dry,
oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: CTAB no wheezes, rales, rhonchi
CV: RRR, Nl S1, S2, No MRG. Patient became dizzy when asked to
sit up for lung exam.
Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no suprapubic tenderness
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN2-12 intact, no focal deficits
================================
DIACHARGE EXAM:
Vitals: 97.3 107/46 76 18 100 RA
Orthostatics: lying: BP 107/46 HR 76
sitting: BP 97/46 HR 80
standing: BP 81/45 HR 109
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: CTAB no wheezes, rales, rhonchi
CV: RRR, Nl S1, S2, No MRG.
Abdomen: soft, NT/ND, bowel sounds present, no rebound
tenderness or guarding, no suprapubic tenderness
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN2-12 intact, no focal deficits
Pertinent Results:
===========================
ADMISSION LABS
___ 11:45AM BLOOD WBC-9.6 RBC-4.38 Hgb-12.7 Hct-37.0 MCV-85
MCH-29.0 MCHC-34.3 RDW-12.3 RDWSD-37.1 Plt ___
___ 11:45AM BLOOD Neuts-82.7* Lymphs-11.4* Monos-5.1
Eos-0.1* Baso-0.2 Im ___ AbsNeut-7.92* AbsLymp-1.09*
AbsMono-0.49 AbsEos-0.01* AbsBaso-0.02
___ 11:45AM BLOOD Glucose-100 UreaN-8 Creat-0.8 Na-122*
K-4.2 Cl-86* HCO3-22 AnGap-18
___ 09:52PM BLOOD Calcium-8.9 Phos-3.6 Mg-1.8
___ 11:45AM BLOOD Osmolal-253*
___ 03:30PM URINE Hours-RANDOM Creat-99 Na-131
___ 03:30PM URINE UCG-NEGATIVE Osmolal-543
===========================
INTERVAL LABS
___ 11:45AM BLOOD Glucose-100 UreaN-8 Creat-0.8 Na-122*
K-4.2 Cl-86* HCO3-22 AnGap-18
___ 09:52PM BLOOD Glucose-126* UreaN-9 Creat-0.7 Na-122*
K-4.4 Cl-88* HCO3-23 AnGap-15
___ 06:00AM BLOOD Glucose-87 UreaN-7 Creat-0.7 Na-126*
K-4.5 Cl-91* HCO3-22 AnGap-18
___ 03:20PM BLOOD Glucose-104* UreaN-8 Creat-0.9 Na-127*
K-4.4 Cl-93* HCO3-23 AnGap-15
___ 09:30AM BLOOD Glucose-57* UreaN-8 Creat-1.0 Na-132*
K-4.7 Cl-94* HCO3-25 AnGap-18
___ 03:47PM BLOOD Na-131* K-4.4
___ 06:00AM BLOOD Cortsol-3.6
___ 09:30AM BLOOD Cortsol-14.8 (before cosyntropin
administration)
___ 11:10AM BLOOD Cortsol-35.5* (60 min after cosyntoprin
administration)
===========================
IMAGING
___ CXR: Blunting of the posterior costophrenic angles,
potentially trace effusions or atelectasis. Otherwise, no acute
cardiopulmonary process.
___ MRI brain/pituitary:
1. Study is mildly degraded by motion.
2. No evidence of intracranial mass.
3. No pituitary mass identified.
4. Please note that diffusion imaging is not included in this
examination. If concern for acute infarct, consider noncontrast
brain MRI for further evaluation.
===========================
DISCHARGE LABS
___ 12:40PM BLOOD Glucose-120* UreaN-13 Creat-1.1 Na-139
K-4.4 Cl-107 HCO3-21* AnGap-15
___ 12:40PM BLOOD Calcium-8.8 Phos-4.8* Mg-1.8
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of bipolar
disorder, migraine, s/p Roux-en-Y gastric bypass (___) and
recent admissions for hyponatremia who presented with
lightheadedness, headache, and nausea/vomiting and hyponatremia
to 122 in the ED.
#Hyponatremia: Her labs were consistent with SIADH here, with
Serum Na 122, Serum Osm 253, Urine Na 131, Urine Osm 543. During
her most recent hospitalization, hyponatremia was thought to be
related to SIADH from psychiatric medications, polydipsia, and
subclinical hypothyroidism. She had been on low-dose
levothyroxine, salt tabs, and fluid restriction since discharge,
possibly with excess fluid intake at home. She continues to be
on multiple psychiatric medications associated with SIADH. She
had been weaned off of or stopped other medications associated
with SIADH on prior admissions, including trileptal,
chlorthalidone, and klonopin.
She was noted to have orthostatic hypotension during her
admission (see below). Adrenal insufficiency was also on the
differential given hypotension. MRI brain/pituitary showed no
evidence of intracranial mass. Endocrinology was consulted
regarding possible adrenal insufficiency and felt her
presentation was consistent with SIADH due to side effects of
psychiatric medications, with polydipsia at home. She later had
a cortisol stimulation test with normal AM cortisol and
appropriate increase after cosyntropin administration.
Endocrinology recommended stopping levothyroxine given normal
TFTs a short time after starting low-dose levothyroxine.
Psychiatry was also consulted, and recommended against any
changes to her regimen given her prior volatile psychiatric
history and current stability.
Her sodium increased to 132 over 48 hours and her symptoms
abated with resolution of hyponatremia. She continued to be
orthostatic and was given IVF with subsequent increased serum Na
and improved symptoms. This suggested her hyponatremia was
likely multifactorial, due in part to SIADH from psychiatric
medication, and in part to hypovolemia. Her sodium stabilized at
normal levels (139) and she was discharged on 2 salt tabs BID
and a plan to titrate her fluid restriction as needed based on
orthostatic symptoms and blood pressure at home, as well as
close follow-up with her PCP.
#Orthostatic hypotension: She has a history of lightheadedness
accompanying hyponatremia. She was also orthostatic here, with
SBPs as low as ___ and lightheadedness with standing. Her
verapimil (taken for migraine prophylaxis) and atenolol were
discontinued, which improved her orthostasis. She later appeared
hypovolemic on exam and was given IVF with subsequent increased
serum Na and improved symptoms. She was discharged with a
prescription for a blood pressure cuff, and was instructed to
take her blood pressure daily at home nad liberalize her fluid
restriction as needed for orthostasis or SBP<90.
#Headache: Patient has a long history of migraines. However, her
headaches improved with correction of hyponatremia, making HA
related to electrolyte abnormality more likely. Her home tylenol
PRN, tramadol PRN were continued with rare requirement of
toradol IV. Her verapamil was discontinued given orthostasis.
#Nausea/vomiting: Her nausea and vomiting improved with
correction of hyponatremia. Likely multifactorial, related to
hyponatremia as well as known history of migraines.
#Long QTc: Patient has a history of prolonged QTc, likely
related to psychiatric meds (chloropromazine, trazoone). ED EKG
with QTc 498 ___. Repleted K>4 and Mg>2.
CHRONIC ISSUES:
======================
#Bipolar Disorder: Continued home chlorpromazine, lamotrigine,
benztropine, trazodone. Attempted to contact outpatient
psychiatrist: ___ @ ___ ___.
#HTN: Held chlorthalidone (held since ___ admission), given
possible contribution to hyponatremia. Also held atenolol given
orthostasis as above. SBPs in the 100s-110s here.
#GERD: Continued home omeprazole and ranitidine.
#Asthma: Continued home fluticasone nasal spray, albuterol prn.
Patient will restart azelastine and fluticasone mono-inhaler
upon discharge.
#IBS: Held home lomotil (diphenoxylate/atropine) prn given
history of constipation prior to this admission. ___ restart on
discharge.
============================
TRANSITIONAL ISSUES
- Pending labs on discharge: ___ ACTH, renin, aldosterone.
House officer or hospitalist will call the patient and/or her
PCP with these results.
- The patient's verapamil (taken for migraine prophylaxis) and
atenolol were discontinued due to orthostasis with SBP drop to
the ___ and lightheadedness upon standing. We continued to
hold her chlorthalidone for low-normal BPs and hyponatremia.
- Levothyroxine was discontinued based on normal TFTs here a
short time after starting low-dose levothyroxine, per
Endocrinology recommendations. TFTs should be re-checked 6 weeks
after discharge.
- She was discharged on 2g salt tabs BID (from 1 tab BID).
- She was given a prescription for a blood pressure cuff. She
was instructed to continue a 1.5L fluid restriction at home. She
should take her blood pressure daily in the morning. If she
feels dizzy or has SBP<90, she should drink 0.5-1L of
electrolyte-containing fluids to minimize orthostasis.
- She should follow-up with her PCP and have frequent testing of
Na levels to monitor for recurrence of hyponatremia. If her
sodium begins to drop, her volume status should be carefully
assessed. She may require reinforcement of fluid restriction if
euvolemic vs. increased PO fluid if hypovolemic and orthostatic.
- The patient would like to resume Botox injections for migraine
control, and has been in touch with the ___ headache clinic to
arrange this.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB, wheeze
2. azelastine 137 mcg (0.1 %) nasal BID
3. Benztropine Mesylate 2 mg PO QHS
4. ChlorproMAZINE 100 mg PO QAM
5. ChlorproMAZINE 50 mg PO LUNCH
6. ChlorproMAZINE 100 mg PO QHS
7. Diphenoxylate-Atropine 1 TAB PO BID:PRN diarrhea
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. Ketorolac 30 mg IM 1X/WEEK PRN migraine
11. LamoTRIgine 200 mg PO QAM
12. LamoTRIgine 300 mg PO QPM
13. Omeprazole 40 mg PO BID
14. Ranitidine 300 mg PO QHS
15. TraMADol 50 mg PO BID:PRN Pain - Moderate
16. TraZODone 450 mg PO QHS
17. Verapamil 120 mg PO DAILY
18. Chlorthalidone 12.5 mg PO DAILY
19. Atenolol 12.5 mg PO QHS
20. nystatin 100,000 unit/gram topical BID:PRN
21. Ascorbic Acid ___ mg PO DAILY
22. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
23. Cetirizine 10 mg PO DAILY
24. Cyanocobalamin 500 mcg PO DAILY
25. Multivitamins 1 TAB PO DAILY
26. Polyethylene Glycol 17 g PO DAILY:PRN constipation
27. Psyllium Powder 1 PKT PO BID
28. Sodium Chloride 1 gm PO BID
29. Levothyroxine Sodium 25 mcg PO DAILY
Discharge Medications:
1. blood pressure test kit-large miscellaneous Once
RX *blood pressure test kit-large Please take blood pressure
daily in the morning Disp #*1 Kit Refills:*0
2. Sodium Chloride 2 gm PO BID
RX *sodium chloride 1 gram 2 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB, wheeze
4. Ascorbic Acid ___ mg PO DAILY
5. azelastine 137 mcg (0.1 %) nasal BID
6. Benztropine Mesylate 2 mg PO QHS
7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
8. Cetirizine 10 mg PO DAILY
9. ChlorproMAZINE 100 mg PO QAM
10. ChlorproMAZINE 50 mg PO LUNCH
11. ChlorproMAZINE 100 mg PO QHS
12. Cyanocobalamin 500 mcg PO DAILY
13. Diphenoxylate-Atropine 1 TAB PO BID:PRN diarrhea
14. Fluticasone Propionate 110mcg 2 PUFF IH BID
15. Fluticasone Propionate NASAL 2 SPRY NU DAILY
16. Ketorolac 30 mg IM 1X/WEEK PRN migraine
17. LamoTRIgine 200 mg PO QAM
18. LamoTRIgine 300 mg PO QPM
19. Multivitamins 1 TAB PO DAILY
20. ___ ___ unit/gram TOPICAL BID:PRN yeast infx
21. Omeprazole 40 mg PO BID
22. Polyethylene Glycol 17 g PO DAILY:PRN constipation
23. Psyllium Powder 1 PKT PO BID
24. Ranitidine 300 mg PO QHS
25. TraMADol 50 mg PO BID:PRN Pain - Moderate
26. TraZODone 450 mg PO QHS
27. HELD- Atenolol 12.5 mg PO QHS This medication was held. Do
not restart Atenolol until instructed by your PCP. This
medication may contribute to lightheadedness.
28. HELD- Chlorthalidone 12.5 mg PO DAILY This medication was
held. Do not restart Chlorthalidone until instructed by your
PCP. This medication may contribute to low sodium levels.
29. HELD- Verapamil 120 mg PO DAILY This medication was held.
Do not restart Verapamil until instructed by your PCP or
neurologist. This medication may contribute to lightheadedness.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Hyponatremia
SECONDARY DIAGNOSIS
Orthostatic hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your hospitalization.
You were admitted with low sodium levels accompanied by nausea,
vomiting, headache, and generalized weakness. We continued you
on salt tabs and resumed your fluid restriction, which improved
your sodium levels and your symptoms. Further testing did not
show evidence of any problems with your adrenal glands and you
had a normal brain MRI. Psychiatry came to see you and
recommended that we not alter your psychiatric medication
regimen. Endocrinology also saw you and felt your low sodium was
likely due to side effects of your psychiatric medications,
called SIADH (syndrome of inappropriate antidiuretic hormone),
which leads to low sodium. They felt you did not need to keep
taking levothyroxine - your thyroid function can be rechecked by
your PCP ___ 6 weeks.
You should continue salt tabs and 1.5L fluid restriction at home
to keep your sodium levels up. However, we also noticed that you
were lightheaded with decreased blood pressure while standing.
To address this, we stopped your verapamil and atenolol, and
gave you IV fluids. This lessened your symptoms and further
improved your sodium levels.
At home, you should take 2 salt tabs twice a day (4g total). You
should continue a 1.5L fluid restriction. Take your blood
pressure every day in the morning; if you feel dizzy or your
systolic blood pressure (the higher number) is less than 90, you
should drink extra fluid that day (extra ~500 ml to 1 L). Try
drinking fluid with electrolytes, like Ensure, Pedialyte, or
Gatorade.
Please follow-up closely with your PCP to check your sodium
levels. You should have these monitored closely for the first
___ weeks after discharge. Based on your symptoms and your
sodium levels, you can then have your sodium levels checked less
frequently.
Please keep your follow-up appointments as listed below.
Thank you for the opportunity to participate in your care! We
wish you the very best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10464871-DS-24 | 10,464,871 | 26,707,209 | DS | 24 | 2195-10-13 00:00:00 | 2195-10-14 13:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Keflex / Celebrex / Prednisone
/ Penicillins / NSAIDS / aspirin / aspirin / Latex, Natural
Rubber
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old R-handed woman who presents
with
an episode of confusion. History is per patient. She requested I
speak with her sister ___ (___), who I attempted to
contact, but she was not available by phone.
For details of her overnight ED visit (___), please see
excellent note by Dr. ___. Briefly, neurology was consulted
for an episode of 30 minute episode 1 week prior of left
monocular vision loss with "" sparkles and left hemiparesis
which
resolved spontaneously in the setting of a mild generalized
headache. She had a previous episode like this ___ year prior.
The episode was felt to be either acephalgia and complex
migraine and neurology urgent care follow-up was recommended.
Of
note she has a history of migraines that consist of classical
migraines, basilar migraines with diplopia, loss of
consciousness
and weakness of all 4 extremities) as well as migraines with
right-sided monocular vision loss. She is not currently on any
prophylactic medications but was previously on verapamil Topamax
and magnesium. She currently self administers IM Toradol
several
times a week for her headaches. She had initially presented to
the ED last night for chest pain in the setting of
hypomagnesemia
the prolonged QTC that improved after magnesium supplementation.
Her neurology review of systems was negative at that time.
She returns to the emergency room today for an episode of
confusion. She did not sleep at all overnight while she was in
the emergency room (the last time she had sleep was overnight on
___. When she went home, she was speaking with her cousin
on the phone, her cousin's had told her that she was not making
sense. Her cousin told her that on the phone she mentions that
there were "horses in the emergency room that were taking
attention away from the doctor's.". She does not recall saying
this. Her cousin, who is a nurse, was concerned and called the
ambulance to bring her pick her up and bring her back to the
emergency room.
For the past several months, she has had difficulty with her
cognition. She states she has difficulty finding her words and
difficulty with her thoughts. She then pauses (no staring) and
then states "this is what happens, I go blank
I guess we are
talking about what brings me here to the emergency room". She
feels that these difficulties have been constant and are not
episodic. She also notes that she has episodes where she
forgets
chunks of time and when she feels disoriented. When asked to
describe an episode, she states that when she goes to the mall
she loses track times there may end up spending several hours at
the moment without realizing it. She denies loss of
consciousness with these episodes. She does not endorse
significant stressors in the last several months, friend since
she was a had to put her cat down. She then states "every day
as
a stressor, conversations are stressors. "
On neuro ROS, the pt denies diplopia, vertigo, numbness. She
endorses occasional slurring of her words. She endorses
difficulty forming her words, which she describes as difficulty
pronouncing the end of the words. Feels her left side is weaker
than her right side. Endorsed that she cannot grip a cup. She
endorses frequent falls. She endorses that her taste is ruined.
She states that she cannot write her name. She states "all this
should is from the psychiatric medications". she denies funny
smells or rising sensation in her stomach or déjà ___.
Of note her neurologic review of systems was negative on ___ overnight in the emergency room.
On general review of systems, the pt endorses unintentional
weight loss of 30 pounds in the past 3 months. She endorses
chronic cough, nausea, urinary incontinence and vomiting. She
denies diarrhea or dysuria. denies recent fever or chills.
Past Medical History:
Bipolar Disorder
Fibromyalgia
Migraines
Low back pain
Obesity
Rosacea
IBS
HL
GERD
s/p Roux-en-Y gastric bypass ___
Social History:
___
Family History:
Mother - DM
Father - CAD
Physical Exam:
Admission Physical Exam:
Vitals: 97.8 78 152/92 18 99% RA
General: Awake, cooperative, NAD. Wearing sunglasses.
HEENT: NC/AT, no scleral icterus, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: breathing comfortably on room air
Cardiac: RRR
Abdomen: soft
Extremities: No C/C/E bilaterally
Skin: multiple thin linear scars on LUE,
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,
occasional pauses in speech to find words. Pt was able to name
both high and low frequency objects. Speech was not dysarthric.
Able to follow both midline and appendicular commands. Pt was
able to register 3 objects and recall ___ -> ___ with cue 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. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, 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 bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Actasia Abasia on tandem. Romberg absent.
Discharge Physical Exam:
Vitals: ___, 102/69, HR 85, RR 20, O2 95% on RA
General: Awake, cooperative, NAD. Wearing sunglasses.
HEENT: NC/AT, no scleral icterus, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: breathing comfortably on room air
Cardiac: RRR
Abdomen: soft
Extremities: No C/C/E bilaterally
Skin: multiple thin linear scars on LUE,
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,
occasional pauses in speech to find words. Pt was able to name
both high and low frequency objects. Speech was not dysarthric.
Able to follow both midline and appendicular commands. Pt was
able to register 3 objects and recall ___ -> ___ with cue 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. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, 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 bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Actasia Abasia on tandem. Romberg absent.
Pertinent Results:
EEG: negative for seizures
MRI/MRA brain: negative
___ 11:07PM BLOOD WBC-6.1 RBC-4.64 Hgb-11.6 Hct-37.3
MCV-80* MCH-25.0* MCHC-31.1* RDW-14.2 RDWSD-41.1 Plt ___
___ 04:50AM BLOOD WBC-4.8 RBC-4.26 Hgb-10.9* Hct-34.6
MCV-81* MCH-25.6* MCHC-31.5* RDW-14.4 RDWSD-42.5 Plt ___
___ 11:07PM BLOOD Neuts-53.9 ___ Monos-9.5 Eos-1.1
Baso-0.7 Im ___ AbsNeut-3.31 AbsLymp-2.12 AbsMono-0.58
AbsEos-0.07 AbsBaso-0.04
___ 01:15PM BLOOD Neuts-54.8 ___ Monos-10.3 Eos-1.4
Baso-0.6 Im ___ AbsNeut-2.77 AbsLymp-1.65 AbsMono-0.52
AbsEos-0.07 AbsBaso-0.03
___ 11:07PM BLOOD Glucose-92 UreaN-10 Creat-0.8 Na-143
K-3.0* Cl-106 HCO3-22 AnGap-18
___ 04:50AM BLOOD Glucose-76 UreaN-11 Creat-0.8 Na-142
K-3.6 Cl-106 HCO3-22 AnGap-18
___ 01:15PM BLOOD ALT-26 AST-28 AlkPhos-86 TotBili-0.5
___ 04:58AM BLOOD cTropnT-<0.01
___ 04:50AM BLOOD Calcium-9.1 Phos-4.5 Mg-2.0
___ 04:50AM BLOOD VitB12-396 Folate-5
___ 01:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
___ woman with a history of bipolar disorder with
multiple psychiatric admissions and suicide attempts as well as
migraine with aura who presented with symptoms of confusion and
word finding difficulties, which are constant and have been
worsening over time. Her neurologic exam showed mild
inattentiveness with some poor recall and variable word finding
difficulty. Psychiatry was consulted who recommended
discontinuation of Cogentin and outpatient follow up with
current therapist/psychiatrist. She underwent 24 hours of EEG
monitoring which was normal even though she had episodes of word
finding difficulty. She also had an MRI/MRA brain which was
negative. Normal B12 and Folate. Etiology of her symptoms were
thought to be secondary to a multifactorial process, including
the effects of long term psych medications, prior ECT and her
concurrent neuropsychiatric
syndromes. She should have outpatient neuropsych testing to
identify specific deficits and areas for potential therapy.
Transitional issues:
[ ] neuropsych testing
[ ] transitioning psychiatrists
[ ] outpatient nutrition follow per PCP ___. Of note
patient requesting help with diet (post gastric bypass ___ ago)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ketorolac 15 mg IM DAILY:PRN Pain - Moderate
2. ChlorproMAZINE 100 mg PO QAM
3. ChlorproMAZINE 50 mg PO QHS
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
5. Ascorbic Acid ___ mg PO DAILY
6. azelastine 137 mcg (0.1 %) nasal BID
7. Benztropine Mesylate 2 mg PO QHS
8. Cetirizine 10 mg PO DAILY
9. Cyanocobalamin 500 mcg PO DAILY
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. LamoTRIgine 200 mg PO QAM
12. LamoTRIgine 300 mg PO QHS
13. Multivitamins 1 TAB PO DAILY
14. Nystatin Cream 1 Appl TP BID:PRN yeast infection
15. Omeprazole 40 mg PO BID
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Psyllium Powder 1 PKT PO BID
18. TraMADol 50 mg PO BID:PRN Pain - Moderate
Discharge Medications:
1. Thiamine 100 mg PO DAILY Duration: 3 Days
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*3 Tablet Refills:*0
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
3. Ascorbic Acid ___ mg PO DAILY
4. azelastine 137 mcg (0.1 %) nasal BID
5. Cetirizine 10 mg PO DAILY
6. ChlorproMAZINE 100 mg PO QAM
7. ChlorproMAZINE 50 mg PO QHS
8. Cyanocobalamin 500 mcg PO DAILY
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY
10. Ketorolac 15 mg IM DAILY:PRN Pain - Moderate
11. LamoTRIgine 200 mg PO QAM
12. LamoTRIgine 300 mg PO QHS
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 40 mg PO BID
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Psyllium Powder 1 PKT PO BID
17. TraMADol 50 mg PO BID:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Word finding difficulties
Bipolar disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for word finding difficulty. Your work-up
included an EEG which did not show any evidence of seizures. You
also had an MRI/A which was negative. You were seen by
psychiatry recommended you discontinue Cogentin which seems to
have helped.
Please take your medications as prescribed. Please follow up
with your PCP, ___, psychiatrist and neurologist as
outpatient. We recommend neuropsych testing as an outpatient for
further work-up.
It was a pleasure taking care of you,
Your ___ Neurologists
Followup Instructions:
___
|
10465118-DS-19 | 10,465,118 | 29,491,888 | DS | 19 | 2135-08-28 00:00:00 | 2135-08-28 14:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, drainage from wound
Major Surgical or Invasive Procedure:
___ Lumbar wound exploration and wash out
History of Present Illness:
___ yo male with medically intractable neurogenic claudication of
the BLE and moderate to severs lumbar stenosis from L2-L4. He
failed non-operative therapy and is s/p L2-L4 decompressive
laminectomy. He was discharged to rehab on ___, but presents
with fevers and copious drainage from his wound.
Past Medical History:
DVT, lumbar stenosis, gastric bypass, left inguinal hernia,
asthmas, depression, IVC filter
Social History:
___
Family History:
N/A
Physical Exam:
Physical Exam on Discharge:
Alert and oriented x 3. PERRL. EOMI. ___. TML.
BUE ___
BLE IP ___, Quad 4-, Ham 4+, ___ ___
Sensation grossly intact
Pertinent Results:
___ MRI LSPINE W/ & W/OUT CONTRAST
IMPRESSION:
1. Postsurgical changes from laminectomy at L2-4 with a
peripherally enhancing fluid collection at the laminectomy site
extending anteriorly to the level of the spinal canal and
resulting in severe spinal canal stenosis at L2 with ANTERIOR
displacement of the nerve roots at this level from mass effect.
Posterior extension of the fluid collection to the subcutaneous
soft tissues, directly underlying the skin. This presumably
reflects a large postoperative seroma, however early
superimposed infection cannot be entirely excluded.
2. Degenerative changes, as described above.
___ CT LSPINE W/ & W/OUT CONTRAST
IMPRESSION:
1. Subcutaneous fluid, possibly a collection, is seen just deep
to the
surgical staples, extending into the laminectomy bed. Several
foci of air are seen, which may be postsurgical in nature.
Infection is not excluded. Imaging is severely limited on a
noncontrast CT. MR imaging may be far more helpful.
___ ECHO:
Very suboptimal image quality. No definite valvular pathology or
pathologic flow identified. Grossly normal left ventricular
systolic function.
___ LENIS:
Nonocclusive thrombus involves bilateral mid to distal femoral
veins, left
popliteal vein. Given eccentric appearance within nondistended
veins, these
are likely chronic.
Similar chronic appearing nonocclusive deep venous thrombosis in
the right
greater saphenous vein.
___ RUE US for clot:
Thrombus extends from the mid subclavian vein through the
basilic vein
associated with a PICC. While proximally nonocclusive, this
becomes nearly
occlusive within the axillary and basilic veins.
___ CT L-spine:
1. Redemonstration of subcutaneous fluid collection, posterior
to the surgical
site and extending into the laminectomy bed overall slightly
improved since
prior CT examination. Infection cannot be excluded.
___ CTA chest:
1. No evidence of acute pulmonary embolism or aortic
abnormality.
2. Peribronchiolar ground-glass opacities in the right upper
lobe, likely
reflecting an infectious or inflammatory process.
___ portable abdomen xray:
Gaseous distention of large and small bowel suggestive of ileus
Brief Hospital Course:
On ___, Mr. ___ returned to the ED febrile to 104 with serous
drainage from wound with concern for CSF leak. He urgently went
to MRI which was notable for peripherally enhancing fluid
collection at the laminectomy site with posterior extension to
subcutaneous soft tissues. The patient's INR as 1.7 so he was
given FFP and then went to the operating room or washout. A
subdural lumbar drain was left in place. The patient went to the
ICU post-operatively.
On ___, Mr. ___ neurological exam remained stable. Lumbar
drain was functioning appropriately, draining ___.
On ___, patient is neurologically stable, difficult to assess
RLE due to patient cooperation but grossly stable. Lumbar drain
flushed due tissue in drain. Patient continues to complain of
pain, patient was started on Gabapentin and medications
adjusted. He was transferred out of the ICU to step-down.
On ___, the patient's neurological exam remained stable. Dr.
___ was at the bedside to assess the incision. The dressing was
changed. A Dilaudid PCA was started for pain management. The
patient consented for ___ placement for long-term antibiotic
treatment.
On ___ the patients exam remained stable. His lumbar drain
remained in place and withiin goal output of ___
(294/111).
On ___ the patient remained hemodynamically and neurologically
stable. His lumbar drain was not draining the goal of ___
per hour, therefore it was assessed and troubleshot multiple
times until the drain was removed mid afternoon at 1630, one
___ was placed and a dressing was placed over the site. The
patients dressing was changed, initially was saturated with
serosanginous drainage then with minimal drainage on the ABD
pad. A dressing later in the afternoon was re-applied.
Infectious disease recommended current regimen of antibiotics
and recommended LFTs to be ordered for the morning as his LFTs
were uptrending possibly due to antibiotic use. Per ID no need
for daily blood cultures as we have multiple cultures pending,
and with final results of staph aureus. A CT L spine was ordered
per Dr. ___. The patient was stating that he was having
difficulty "catching my breath", bilateral lower extremity
ultrasounds and chest xray were ordered. The patient was also
noted to have right upper extremity edema and erythema,
therefore a right upper extremity ultrasound was ordered.
On ___ the patient went to the OR with Dr. ___ wound
washout. A right upper extremity ultrasound was performed for
concern of DVT as the patient was found to have erythemia and
edema to his right upper arm and results were consistent with
DVT along PICC in subclavian, axilla, basillic veins. A CTA
chest was performed given occasional complaints of mild SOB to
assess for PE, and this was negative.
On ___ the patient remained neurologically and hemodynamically
stable. Cultures from the OR were pending, and the gram stain
did not show any organisms. His right upper extremity was
wrapped and elevated.
On ___ the patient remained stable. His dressing was clean,
dry,and intact. He continued to be on flat bedrest until ___.
Infectious disease was contacted for recommendations and stated
to continue current antibiotics, suggested a new placement of a
PICC, and ESR to be checked weekly. His sodium was 133, a repeat
was ordered for ___.
On ___, neurologically patient remains stable. Lumbar dressing
is clean and dry. Patient was started on a heparin drip for
acute DVT in right arm. Patient complains of not having a bowel
movement, medications adjusted and KUB ordered showing ileus.
On ___, remains neurologically stable. Heparin drip being
titrated to maintain PTT between 60-80.
On ___, neuro stable. Patient will remains on flat bedrest one
more day. Pain management, patient is being transitioned off of
hydromorphone PCA to PO regimen. Heparin drip being management
to maintain PTT 60-80.
On ___ his heparin gtt continued to be titrated for goal PTT
60-80. He also was on coumadin and his INR was found to be 3.2
in the afternoon up from 2.7 in the morning. as a result his
heparin gtt was held and his evening coumadin dose was held as
well pending further labs. In additon he also began having his
HOB elevated and planned to mobilize.
On ___ his activity was liberalized to be out of bed. His back
dressing was noted to be saturated - this was closely monitored
with dressing changes TID. Foley catheter was removed.
On ___ he remained neurologically stable. INR was therapeutic
at 2.5 and he was continued on Coumadin 2.5. Gabapentin was
increased to 200 mg TID for pain management. He required
straight catheterization x1 for urinary retention.
On ___ he remained neurologically intact with improving
strength in his lower extremities. Wound remained dry without
drainage or foul smell. He was stable for discharge to rehab.
INR remained therapeutic at 2.8. He required straight
catheterization x1 for urinary retention and bladder scan >
400cc. This should be closely monitored at rehab, as he may need
foley replaced.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ARIPiprazole 20 mg PO QHS
2. Elmiron (pentosan polysulfate sodium) 100 mg oral QPM
3. ClonazePAM 0.5 mg PO BID
4. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation Q12H
5. Calcium Carbonate 500 mg PO TID
6. Meclizine 12.5 mg PO TID
7. Sucralfate 1 gm PO QID
8. Polyethylene Glycol 17 g PO DAILY
9. Albuterol 0.083% Neb Soln 1 NEB IH BID
The Preadmission Medication list is accurate and complete.
1. ARIPiprazole 20 mg PO QHS
2. Elmiron (pentosan polysulfate sodium) 100 mg oral QPM
3. ClonazePAM 0.5 mg PO BID
4. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation Q12H
5. Calcium Carbonate 500 mg PO TID
6. Meclizine 12.5 mg PO TID
7. Sucralfate 1 gm PO QID
8. Polyethylene Glycol 17 g PO DAILY
9. Albuterol 0.083% Neb Soln 1 NEB IH BID
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Acetaminophen 325-650 mg PO Q6H:PRN for fever or pain
3. CefazoLIN 2 g IV Q8H
to be continued for ___ weeks, determined by outpatient
infectious disease
4. Warfarin 2.5 mg PO DAILY16
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
6. ARIPiprazole 20 mg PO QHS
7. Calcium Carbonate 500 mg PO TID
8. Miconazole Powder 2% 1 Appl TP TID:PRN left flank rash
9. Polyethylene Glycol 17 g PO DAILY
10. Sucralfate 1 gm PO QID
11. Albuterol Inhaler 2 PUFF IH Q4H:PRN Sob
12. Meclizine 12.5 mg PO TID
13. BuPROPion (Sustained Release) 100 mg PO BID
14. Cyanocobalamin 1000 mcg PO DAILY
15. Diazepam 5 mg PO TID
16. Docusate Sodium 100 mg PO BID
17. Ferrous Sulfate 325 mg PO DAILY
18. Finasteride 5 mg PO DAILY
19. Fluticasone Propionate NASAL 1 SPRY NU DAILY
20. FoLIC Acid 1 mg PO DAILY
21. Gabapentin 200 mg PO TID
22. Milk of Magnesia 30 mL PO Q12H:PRN constipation
23. Multivitamins 1 TAB PO DAILY
24. Senna 17.2 mg PO QHS
25. Tamsulosin 0.4 mg PO QHS
26. Tiotropium Bromide 1 CAP IH DAILY
27. TraZODone 100 mg PO QHS:PRN insomnia
28. Elmiron (pentosan polysulfate sodium) 100 mg ORAL QPM
29. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
INHALATION Q12H
30. ClonazePAM 0.5 mg PO BID
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Acetaminophen 325-650 mg PO Q6H:PRN for fever or pain
3. CefazoLIN 2 g IV Q8H
to be continued for ___ weeks, determined by outpatient
infectious disease
4. Warfarin 2.5 mg PO DAILY16
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
6. ARIPiprazole 20 mg PO QHS
7. Calcium Carbonate 500 mg PO TID
8. Miconazole Powder 2% 1 Appl TP TID:PRN left flank rash
9. Polyethylene Glycol 17 g PO DAILY
10. Sucralfate 1 gm PO QID
11. Albuterol Inhaler 2 PUFF IH Q4H:PRN Sob
12. Meclizine 12.5 mg PO TID
13. BuPROPion (Sustained Release) 100 mg PO BID
14. Cyanocobalamin 1000 mcg PO DAILY
15. Diazepam 5 mg PO TID
16. Docusate Sodium 100 mg PO BID
17. Ferrous Sulfate 325 mg PO DAILY
18. Finasteride 5 mg PO DAILY
19. Fluticasone Propionate NASAL 1 SPRY NU DAILY
20. FoLIC Acid 1 mg PO DAILY
21. Gabapentin 200 mg PO TID
22. Milk of Magnesia 30 mL PO Q12H:PRN constipation
23. Multivitamins 1 TAB PO DAILY
24. Senna 17.2 mg PO QHS
25. Tamsulosin 0.4 mg PO QHS
26. Tiotropium Bromide 1 CAP IH DAILY
27. TraZODone 100 mg PO QHS:PRN insomnia
28. Elmiron (pentosan polysulfate sodium) 100 mg ORAL QPM
29. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
INHALATION Q12H
30. ClonazePAM 0.5 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Lumbar stenosis s/p L2-4 laminectomy complicated by wound
infection
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
Your incision may be open to the air without a dressing.
Your incision is closed with sutures. You will need suture
removal. Please keep your incision dry until suture removal.
Do not apply any lotions or creams to the site.
Please avoid swimming for two weeks after suture removal.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your activity
at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Medications
You have been cleared by your neurosurgeon to start Coumadin.
Please do not take any other blood thinning medication (Aspirin,
Ibuprofen, Plavix) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if you
are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs.
Followup Instructions:
___
|
10465217-DS-13 | 10,465,217 | 21,196,468 | DS | 13 | 2165-03-26 00:00:00 | 2165-03-26 23:01:00 |
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, weakness
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ man with recent diagnosis of minimal change disease,
HTN, who presented with fatigue.
He was admitted ___ with acute glomerulonephritis
with nephrotic syndrome range proteinuria. He was given
solumedrol and received renal biopsy showing acute tubular
nephrosis and minimal change vs FSGS, after which he was
transitioned to prednisone.
Patient reports that he developed fatigue, generalized weakness,
poor appetite for the past 2 days. Also had intermittent nausea
and vomiting. He presented to ED because he felt weak. No f/c,
CP, SOB, cough, diarrhea, constipation, melena, hematochezia,
___. He reports epigastric "burning" that he corresponds to
reflux but no abdominal pain. He reports dysuria. No sick
contacts.
Past Medical History:
- Latent TB infection in setting of childhood BCG vaccine,
confirmed he was never treated.
- Mild hepatic steatosis (___)
Social History:
___
Family History:
Father deceased. Had asthma. Mother alive and healthy at ___. 3
grown children who live in ___. 6 siblings, all relatively
healthy. No known history of renal disease, autoimmune disease,
early MI, or malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VITALS: 97.7PO, 161 / 85L Lying, 92, 18, 97 Ra
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. EOMI. Sclera anicteric and without injection.
ENT: supple
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
MSK: no pitting ___
SKIN: Warm. No rash.
NEUROLOGIC: AOx3. motor ___
PSYCH: appropriate mood and affect
DISCHARGE PHYSICAL EXAM:
======================
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. EOMI. Sclera anicteric and without injection.
ENT: neck supple. Moist mucous membranes.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
MSK: no pitting ___
SKIN: Warm. No rash.
NEUROLOGIC: AOx3. motor ___
PSYCH: appropriate mood and affect
Pertinent Results:
ADMISSION LABS:
==============
___ 01:01PM BLOOD WBC-14.4* RBC-5.58 Hgb-16.0 Hct-46.8
MCV-84 MCH-28.7 MCHC-34.2 RDW-12.3 RDWSD-36.9 Plt ___
___ 01:01PM BLOOD Neuts-92.4* Lymphs-5.2* Monos-1.3*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-13.28* AbsLymp-0.74*
AbsMono-0.18* AbsEos-0.02* AbsBaso-0.03
___ 01:01PM BLOOD ___ PTT-30.0 ___
___ 05:05PM BLOOD UreaN-31* Creat-1.5* Na-136 K-3.8 Cl-86*
HCO3-30 AnGap-20*
___ 01:01PM BLOOD ALT-19 AST-17 AlkPhos-63 TotBili-0.4
___ 01:01PM BLOOD Lipase-34
___ 01:01PM BLOOD cTropnT-<0.01
___ 07:11PM BLOOD cTropnT-<0.01
___ 12:24PM BLOOD cTropnT-<0.01
___ 05:05PM BLOOD Albumin-4.0 Cholest-382*
___ 05:05PM BLOOD Triglyc-113 HDL-172 CHOL/HD-2.2
LDLcalc-187*
___ 04:32PM URINE Color-Straw Appear-Clear Sp ___
___ 04:32PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 04:32PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
DISCHARGE LABS:
==============
___ 06:01AM BLOOD WBC-12.9* RBC-5.44 Hgb-15.7 Hct-46.1
MCV-85 MCH-28.9 MCHC-34.1 RDW-12.6 RDWSD-38.3 Plt ___
___ 06:01AM BLOOD Glucose-79 UreaN-15 Creat-0.9 Na-136
K-3.1* Cl-90* HCO3-31 AnGap-15
___ 06:01AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.1
MICROBIOLOGY:
=============
URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING:
=======
CT Abdomen/Pelvis - ___
1. No acute findings in the abdomen or pelvis to explain
patient's symptoms.
2. Possible 1.5 cm hypodense lesion in the pancreatic neck.
Recommend nonemergent MRCP for further evaluation.
Brief Hospital Course:
Mr. ___ is a ___ man with recent diagnosis of
minimal change disease and HTN, who presented with nausea and
vomiting with fatigue.
DISCHARGE WBC: 12.9 K
DISCHARGE Cr: 0.9
DISCHRGE K: 3.1 (REPLETED)
DISHCARGE Na: 136
#CODE: Full
#CONTACT: ___
Relationship: Wife
Phone number: ___
TRANSITIONAL ISSUES:
==================
[] Ensure that patient is taking omeprazole 40 mg instead of
20mg
[] Patient instructed to hold his torsemide on days when he has
limited po intake or inability to tolerate POs due to vomiting.
[] Please follow-up on incidental pancreatic hypo-density
measuring 1.5 cm at the neck of pancreas.
ACUTE ISSUES:
=============
# Nausea/Vomiting:
Admitted from ED for inability to tolerate PO with otherwise
unremarkable workup including CT A/P. Patient reports nausea and
vomiting on ___ with fatigue. Patient endorses epigastric
burning without tenderness on examination. Upon arrival to the
floor, he was able to tolerate PO intake. His symptoms were
thought to be due to combination of possible gastroenteritis
along with gastritis in the setting of steroid therapy.
Omeprazole was increased to 40 mg daily up from 20 mg.
# ___:
On initial ED labs on presentation Cr 1.5, which has since
improved to 0.9 after fluids. His Cr is improved from prior
admission as his minimal change disease is being improving on
steroids. Patient was recommended to hold his torsemide if he
experiences poor oral intake, vomiting or diarrhea.
# Weight loss:
Patient admission weight 71.3 Kg (157.19 lbs) down from 84.6 Kg
(186.5 lbs) from his last discharge. This is likely due to
diuresis and resolving minimal change disease.
CHRONIC ISSUES:
===============
# Minimal change disease
- continued home prednisone 60
- continued home Bactrim ppx
# HTN
- restarted lisinopril on discharge.
- cont amlodipine 10
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Torsemide 20 mg PO DAILY
3. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
4. PredniSONE 60 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
2. amLODIPine 10 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. PredniSONE 60 mg PO DAILY
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
6. Torsemide 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
==================
Nausea/vomiting
Secondary diagnosis:
====================
___
Minimal change disease
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital with nausea nd fatigue.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Your anti-acid stomach medication was increased from 20 to 40
mg.
- You were able to tolerate oral intake (food) and felt better.
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 continue to take increased dose of omeprazole of 40mg.
-Please hold your torsemide if your oral intake decreased or you
had nausea and vomiting.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10465217-DS-14 | 10,465,217 | 29,097,931 | DS | 14 | 2165-03-30 00:00:00 | 2165-03-30 21:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope, RUQ pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a h/o latent TB, HTN, and recent
admission for n/v/fatigue on ___ in the setting of a recent
diagnosis of acute glomerulonephritis with nephrotic syndrome
(___) presenting with RUQ pain and syncope.
Patient reports that last night he was experiencing right upper
quadrant abdominal pain, 8 out of 10 in severity, that prevented
him from sleeping. At approximately 4 AM he woke up sweating and
felt his heart racing. His wife reports that he got up and tried
to walk, but that he was swaying and looked unsteady. She held
him and lowered him down to the bed. Unclear if he had full LOC;
no head strike. She reports that he awoke after she splashed
cold
water on his face but seemed confused (he asked her how to sit
on the bed).
She reports that he was unconscious for approximately 10
minutes. He reports numbness to his face. Pt states that he has
been eating and drinking, however since his nephrotic syndrome
diagnosis, he says that he has avoided eating all salt. He also
follows a very low potassium diet. He denies any history of
previous syncopal episodes. Of note, pt endorses 3 days of
intermittently blurry vision, but is able to read print on a TV
in the room. He just notes that his vision appears more blurred
than normal. Unchanged by covering eye. No symptoms at present.
On ROS, patient denies dizziness, vertigo, headache, focal
weakness/numbness/tingling, chest pain, shortness of breath,
fevers, nausea, vomiting, dysuria, hematuria, dark stools,
incontinence or tongue biting.
In the ED:
Initial vital signs were notable for:
T 98.0 HR 93 BP 160/92 RR 16 Pox 100% RA
Exam notable for:
Constitutional: In no acute distress
HEENT: Normocephalic, atraumatic, Extraocular muscles intact. No
nystagmus.
Resp: Clear to auscultation bilaterally, normal work of
breathing
Cardiovascular: Regular rate and rhythm, normal ___ and ___
heart sounds
Abd: Soft, Nondistended, mild right upper quadrant discomfort
without tenderness, rebound, guarding
GU: No costovertebral angle tenderness
MSK: No deformity or edema
Skin: No rash, Warm and dry
Neuro: Alert and oriented to person, place, and time. Moving all
extremities. Cranial nerves II-XII intact. Strength ___ in upper
and lower extremities. Sensation intact to light touch in upper
and lower extremities. DTRs intact. Finger to nose and heel to
shin within normal limits. Gait within normal limits.
Psych: Appropriate mood/mentation
Labs were notable for:
-WBC 16.2 Hb 15.0 43.4 Plt 214
-Na 126 K 3.1 Cl 84 Bicarb 26 BUN 25 Cr 1.1 Agap 16
-ALT 23 AST 16 AP 51 Tbili 0.8 Lip 64
-Lactate 1.8 Trop <0.01
Studies performed include:
RUQ US- Normal abdominal ultrasound. No sonographic evidence of
acute cholecystitis.
CXR (PA & Lat)- IMPRESSION: No acute intrathoracic process.
Patient was given:
-Potassium 40 meq PO once
-Aluminum-mag hydrox-simethicone 30 mL PO once
-Acetaminophen 1000 mg PO Once
-1000mL NS bolus
Vitals on transfer:
T 98.0 HR 72 BP 119/75 RR 20 Pox 96% RA
Upon arrival to the floor, patient is stable and reporting no
complaints at this time. Wife is at the bedside.
Past Medical History:
- Latent TB infection in setting of childhood BCG vaccine,
confirmed he was never treated.
- Mild hepatic steatosis (___)
Social History:
___
Family History:
Father deceased. Had asthma. Mother alive and healthy at ___. 3
grown children who live in ___. 6 siblings, all relatively
healthy. No known history of renal disease, autoimmune disease,
early MI, or malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 98.0 BP 144/74 HR 90 RR 18 O2 sat 97 RA
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection.
ENT: MMM. Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
MSK: No spinous process tenderness. No CVA tenderness. No
clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
PSYCH: appropriate mood and affect
DISCHARGE PHYSICAL EXAM:
Vitals: temp 97.9, BP 107 / 65, HR 78, RR 18, O2 sat 98 Ra
GENERAL: Alert and awake, in no acute distress.
EYES: PERRL. EOMI. Sclera anicteric
ENT: No cervical lymphadenopathy. No JVD.
CARDIAC: Normal rate, regular rhythm. No murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Soft, non-tender, non-distended to palpation in all
quadrants. Normal bowels sounds.
MSK: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Normal gait. AOx3.
PSYCH: appropriate mood and affect
Pertinent Results:
Admission labs:
___ 06:50AM BLOOD WBC-16.2* RBC-5.25 Hgb-15.0 Hct-43.4
MCV-83 MCH-28.6 MCHC-34.6 RDW-12.1 RDWSD-36.6 Plt ___
___ 06:50AM BLOOD Neuts-72.5* Lymphs-14.8* Monos-10.9
Eos-0.9* Baso-0.2 Im ___ AbsNeut-11.77* AbsLymp-2.39
AbsMono-1.76* AbsEos-0.14 AbsBaso-0.03
___ 12:27PM BLOOD ___ PTT-26.1 ___
___ 06:50AM BLOOD Glucose-108* UreaN-25* Creat-1.1 Na-126*
K-3.1* Cl-84* HCO3-26 AnGap-16
___ 06:50AM BLOOD ALT-22 AST-19 AlkPhos-54 TotBili-0.5
___ 06:50AM BLOOD Lipase-68*
___ 06:50AM BLOOD cTropnT-<0.01
___ 06:50AM BLOOD Albumin-3.5 Calcium-8.8 Phos-2.7 Mg-1.8
___ 06:50AM BLOOD Osmolal-260*
___ 06:00AM BLOOD CRP-0.7
___ 06:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 07:11AM BLOOD Lactate-1.8
Discharge labs:
___ 06:00AM BLOOD WBC-13.3* RBC-5.04 Hgb-14.5 Hct-43.3
MCV-86 MCH-28.8 MCHC-33.5 RDW-12.7 RDWSD-39.1 Plt ___
___ 06:00AM BLOOD Glucose-77 UreaN-19 Creat-1.1 Na-136
K-4.6 Cl-95* HCO3-27 AnGap-14
___ 06:00AM BLOOD CRP-0.7
Imaging studies:
CXR ___
FINDINGS:
Lungs are fully expanded and clear. Cardiomediastinal and hilar
silhouettes and pleural margins are normal.
IMPRESSION:
No acute intrathoracic process.
RUQ ultrasound ___
IMPRESSION:
Normal abdominal ultrasound. No sonographic evidence of acute
cholecystitis.
Brief Hospital Course:
Mr. ___ is a ___ male with a h/o HTN and recent
admission for n/v/fatigue on ___ in the setting of a recent
diagnosis of acute glomerulonephritis with nephrotic syndrome
(___) presenting with RUQ pain and syncope.
Notably, patient had complete sodium restriction and strict
potassium restriction for 2 weeks prior to presentation in the
setting of starting a loop diuretic from his last admission.
Most likely etiology of patient's symptoms was orthostasis
episode in the setting of hypovolemic hyponatremia. Patient was
give 1.5 L of NS with good response and oral potassium
repletion. His torsemide was discontinued. CXR and RUQ US were
unremarkable. Patient was stabilized and discharged home with
___ services.
DISCHARGE Na 136
DISCHARGE K 4.6
DISCHARGE Cr 1.1
DISCHARGE WBC 13.3
TRANSITIONAL ISSUES:
====================
[] Stop torsemide in the setting of normal renal function and
euvolemia.
[] Follow-up with non-emergent MRCP for unknown pancreatic head
lesion found on CT abd/pelvis during prior admission.
[] Sodium restriction <2 g per day and liberalize potassium
[] Please f/u on patient's weight
ACUTE ISSUES:
=============
# Hyponatremia
Pt presented to the ED with sodium of 126. Of note, this is in
the setting of strict sodium restriction after diagnosis of his
nephrotic syndrome. Urine sodium <20 and high osmolality,
appropriate in the clinical setting of hyponatremia, despite
being on a loop diuretic. Labs consistent with pre-renal
azotemia, given BUN:Cr ratio of >20:1. Likely hypovolemic
hyponatremia in the setting of strict sodium restriction and
overdiuresis after recently starting torsemide. Patient fluid
responsive with 1.5 L of NS and sodium normalized to 136 on
discharge. Per discussion with nephrology, torsemide was
discontinued given patient is euvolemic on examination.
# ?Syncope
Patient with question of loss of consciousness overnight on
___. No head strike. Most likely etiology was orthostasis in
the setting of hypovolemia given his recent diuretic use and
sodium restriction. Pt denies chest pain during episode and
EKG/trops were negative.
# Hypokalemia
Patient presenting to the ED with a potassium of 3.1, in the
setting of low potassium diet and of recently starting a loop
diuretic. Patient asymptomatic on presentation without
concerning EKG findings. Patient responsive to oral repletion.
Concerning for urinary losses of potassium with poor PO intake.
On discharge, K was 4.6.
# Leukocytosis
Elevated to 16.2 on admission, up from 12.9 on last discharge.
Downtrended to baseline 13.3 overnight. Of note, this is in the
setting of starting pred 60 mg for treatment of minimal change
disease. Patient afebrile on presentations and pressures
elevated; unlikely septic. However, in the setting of recent
syncopal episode would be concerned for infections etiology.
Patient on prophylactic Bactrim therapy. Blood and urine
cultures obtained and will follow-up outpatient. WBC 13.3 on
discharge.
# RUQ Pain, resolved
Patient with normal RUQ US in the ED. Of note, patient had
recent CT abd pelvis which was benign except for possible 1.5 cm
hypodense lesion in the pancreatic neck. Recommendations for
nonemergent MRCP for further evaluation.
CHRONIC ISSUES:
===============
# Acute glomerulonephritis with nephrotic
Patient recently admitted ___ with edema,
hypertension, hematuria with RBC casts, hypoalbuminemia,
hyperlipidemia, proteinuria (urine protein/Cr > 3.5), and
rapidly progressing ___ s/p renal biopsy. Patient was found to
have minimal change disease. ___ now resolved with Cr of 1.1 on
admission and at discharge. Home prednisone 60 was continued
with plan for a total 6 month course until ___. Home
Bactrim prophylaxis was continued. Torsemide was discontinued as
patient no longer hypervolemic.
# HTN
Continued lisinopril 40 mg PO daily and amlodipine 10 mg PO
daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. PredniSONE 60 mg PO DAILY
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
6. Torsemide 20 mg PO DAILY
Discharge Medications:
1. Lisinopril 40 mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. PredniSONE 60 mg PO DAILY
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
==================
Hyponatreamia
Hypokalemia
Dehydration
Secondary diagnosis:
====================
Acute glomerulonephritis
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had an episode of loss of consciousness and were found to
have low electrolytes (sodium and potassium) and likely
dehydration.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received intravenous fluids to help with your dehydration,
which improved your low sodium to normal.
- We gave you oral potassium, which improved your low potassium
to normal.
- You had a chest x-ray in the emergency department which did
not show any concerning features.
- You had an ultrasound of your abdomen, which was normal.
- After discussion with your kidney doctor, your torsemide was
discontinued.
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 weigh yourself everyday. Call your primary care doctor
if your weight is increased by 2 lbs or more in 3 days, or it is
increased by 5 lbs in 7 days.
- Please go to your primary care doctor appointment with Dr.
___ on ___ at 9:20 AM
- Please go to your appointment with Dr. ___ on
___ at 4:00 ___.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10465217-DS-15 | 10,465,217 | 27,701,895 | DS | 15 | 2165-04-05 00:00:00 | 2165-04-05 17:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pressure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of HTN, acute glomerulonephritis with nephrotic
syndrome, and recent admission ___ for hyponatremia in the
setting of recent diuretic use who presented from home with
chest
pressure.
Patient states he woke up at around 2AM with left substernal
"squeezing" sensation in his chest with increased heart rates.
It
was associated with diaphoresis. Denied any shortness of
breath,
nausea, vomiting, radiation, or lightheadedness. He checked his
blood pressures at home monitor with SBP 180s and presented to
the ED from his home.
He was recently discharged 3 days ago on ___ for
hypovolemic hyponatremia and his home torsemide was stopped. He
saw his PCP the next day ___ at which point he had
dizziness with positive orthostasis, attributed to iatrogenic
hypotension. His home amlodipine 10 mg was discontinued. He
states he has been taking all his medications as prescribed. He
is also been drinking fluids and does not feel he is dehydrated.
He denies any recent fevers or chills. No abdominal pain,
nausea, vomiting, diarrhea.
In the ED...
- Initial vitals: T 99.3, HR 117, BP 174/94, RR 16, O2 99% RA
- EKG: NSR
- Labs/studies notable for: TropT <0.01 x3, Na 130, Hb 13.3,
WBC
13.3, UA neg
- Patient was given: Nitroglycerin 0.4 mg, nitroglycerin drip,
atorvastatin 10 mg, prednisone 20 mg, Bactrim 1 tab, omeprazole
40 mg, ASA 325 mg, prednisone 40 mg, lisinopril 20 mg
On the floor, he is well-appearing and conversational without
distress. He still describes some ongoing squeezing pain in his
left chest. No associated shortness of breath, dizziness,
abdominal pain, nausea, vomiting.
REVIEW OF SYSTEMS:
Positive for above. Otherwise negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
Minimal Change Disease
Social History:
___
Family History:
Father deceased. Had asthma. Mother alive and healthy at ___. 3
grown children who live in ___. 6 siblings, all relatively
healthy. No known history of renal disease, autoimmune disease,
early MI, or malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
================================
VITALS: ___ Temp: 99 PO BP: 134/69 R Lying HR: 99 RR:
20 O2 sat: 98% O2 delivery: RA Pain Score: ___
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No crackles
ABDOMEN: Soft, NTND.
EXTREMITIES: 1+ bilateral lower extremity edema.
DISCHARGE PHYSICAL EXAMINATION:
=================================
___ 1122 Temp: 97.8 BP: 111/63 HR: 78 RR: 17 O2 sat: 95% O2
delivery: Ra
___ Total Intake: 340ml PO Amt: 340ml
___ Total Output: 500ml Urine Amt: 500ml
GENERAL: Well-appearing male, no acute distress, pleasant
CARDIAC: Regular rate, rhythm, no murmurs, rubs, gallops, JVP
not
elevated at 30 degrees
RESP: Clear to auscultation bilaterally, no crackles, wheezing
ABD: NDNT, BS+ in all 4 quadrants
EXT: No ___ edema
REPORTS
===================
___ TTE
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global biventricular systolic
function. No valvular pathology or pathologic flow identified.
High normal pulmonary artery systolic pressure.
___ ECHO STRESS TEST
CONCLUSION: Average functional exercise capacity for age and
gender. No ischemic ECG changes with no symptoms to achieved
treadmill stress. No 2D echocardiographic evidence of inducible
ischemia to achieved high workload. There is no change in
severity of mitral regurgitation post exercise. Moderately
increased pulmonary artery systolic pressure at rest with a
moderate increase after exercise. Normal resting blood pressure
with a normal blood pressure and a normal heart rate response to
achieved workload.
Pertinent Results:
ADMISSION LABS
___ 04:59AM BLOOD WBC-13.3* RBC-4.59* Hgb-13.3* Hct-38.9*
MCV-85 MCH-29.0 MCHC-34.2 RDW-12.5 RDWSD-37.7 Plt ___
___ 04:59AM BLOOD Neuts-76.6* Lymphs-11.3* Monos-9.7
Eos-1.3 Baso-0.1 Im ___ AbsNeut-10.19* AbsLymp-1.50
AbsMono-1.29* AbsEos-0.17 AbsBaso-0.01
___ 04:59AM BLOOD Plt ___
___ 04:59AM BLOOD Glucose-95 UreaN-12 Creat-0.7 Na-130*
K-4.1 Cl-93* HCO3-25 AnGap-12
___ 04:59AM BLOOD Calcium-9.0 Phos-2.2* Mg-2.0
DISCHARGE LABS
___ 06:50AM BLOOD WBC-10.3* RBC-4.35* Hgb-12.5* Hct-38.3*
MCV-88 MCH-28.7 MCHC-32.6 RDW-12.9 RDWSD-41.6 Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD Glucose-108* UreaN-18 Creat-0.9 Na-134*
K-4.2 Cl-96 HCO3-27 AnGap-11
___ 06:50AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.1
___ 07:24AM BLOOD calTIBC-259* Ferritn-237 TRF-199*
Brief Hospital Course:
TRANSITIONAL ISSUES:
=======================
[] Monitor blood pressure and ___ medical regimen as
indicated. Presented with significant hypertension, discharged
on home lisinopril 40mg.
[] Recommend outpatient anemia work-up. Hemoglobin 1113 during
admission. Iron studies consistent with anemia of chronic
disease
[] Ensure patient is up-to-date with all applicable vaccinations
and age-appropriate malignancy screenings
[] Patient started on baby aspirin and increased statin to
high-intensity therapy
[] Consider evaluation of non-cardiac pain etiologies such as
GERD, MSK on outpatient basis
[] Encourage Sodium restriction <2 g per day
[] Regularly monitor weights, discharge weight 71.7 kg
From recent prior discharge summary "[] Follow-up with
non-emergent MRCP for unknown pancreatic head lesion found on CT
abd/pelvis during prior admission."
SUMMARY:
===============
___ with history of HTN, HLD, minimal-change disease (on
prednisone), recent admission on ___ for hypovolemic
hyponatremia in the setting of very limited salt and potassium
intake who presented from home with chest pressure at rest,
found with negative troponin and ECG and stress echo without
ischemic changes. His chest pain is likely of noncardiac
etiology, with some component of acid reflux given that he had
some burning epigastric pain that improved with antacids and
Tums. He was discharged on aspirin, high-dose statin, Tums, and
continued his home medications of omeprazole, lisinopril,
prednisone and Bactrim.
# Chest pain
Presented with acute onset of chest pressure at rest, found with
negative troponin x4 and EKG without ischemic changes. Of note
patient exerted himself earlier in the day and walked several
miles, but denied chest pain with exertion but reports improved
pain within minutes after SLNG. He was started on nitroglycerin
drip for chest pain. He had one episode while in hospital of
substernal chest pain at rest that resolved spontaneously. He
had a separate episode with similar burning pain that resolved
with Tums. An echocardiogram that showed preserved EF and mild
symmetric LVH. He had a stress echo that did not show any
ischemic changes. His chest pain was most likely attributed to
acid reflux that have been improved with antacids. He has
limited cardiac risk factors including hypertension,
hyperlipidemia, no history of cardiac disease or family history.
He is low-risk with TIMI score 0, ___ score 65. He was started
on metoprolol and high-dose atorvastatin, the metoprolol was
discontinued at discharge given no cardiac etiology of chest
pain. The high-dose statin was continued given hyperlipidemia.
He was started on baby aspirin and antacids. His low-dose statin
was increased to atorvastatin 80 mg daily.
# Hypertension
Presented with SBP in 150s without signs of end-organ damage,
home BP reading in 180s. Likely triggered by discontinuation of
amlodipine (due to significant orthostasis) and home torsemide
(due to hyponatremia), on top on known nephrotic syndrome ___
minimal change disease. His elevated blood pressures were
lowered on nitroglycerin drip for chest pain. He was previously
on metoprolol that was discontinued after negative stress test.
He was continued on home lisinopril 40 mg. Blood pressures
resolved to 100/65 on discharge.
# Normocytic anemia
Presented with hemoglobin 13.3, decreased from 13.7 at discharge
last admission. There was no evidence of bleeding or hemolysis,
and he had a normal reticulocyte count. He may have some
component of iron deficiency anemia and anemia of chronic
disease. Iron labs were largely unremarkable (iron low normal,
TIBC low, transferrin low, transferrin sat 27%).
# Leukocytosis
Leukocytosis with WBC 13 with neutrophilic predominance. This is
likely in setting of steroid use, and is stable from prior
admission. He had no localizing symptoms to suggest infection.
CXR showed no evidence of infiltrate. Urine negative. Of note,
he had a previous admission had ___ blood culture positive for
coag negative staph, likely contaminant from staph epidermidis.
No blood cultures were needed at this admission.
# Nephrotic syndrome
Recent diagnosis of minimal-change disease. He was continued on
his home prednisone with plan from prior admission for 6-month
course until ___. He continued receiving his Bactrim
prophylaxis.
# HLD
His home atorvastatin was increased to atorvastatin 80mg.
# Hyponatremia:
Presented with hyponatremia with sodium 130, slightly decreased
from discharge on ___ with sodium 131. This improved to sodium
134 at discharge. He has known nephrotic syndrome, likely
attributing to hypervolemic hyponatremia.
CORE MEASURES
=============
#CODE: FC
#CONTACT: ___
Relationship: Wife
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Lisinopril 40 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. PredniSONE 60 mg PO DAILY
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO QID:PRN stomach upset
3. Atorvastatin 80 mg PO QPM
4. Lisinopril 40 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. PredniSONE 60 mg PO DAILY
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Noncardiac chest pain
SECONDARY DIAGNOSIS
Hypertension
Dyslipidemia
Minimal Change Disease
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had chest pain
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You received medications to reduce your chest pain and control
your high blood pressure
- You had an exercise test that did not show any abnormalities
in your heart to explain your chest pain, it was normal.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
- Please take a baby aspirin every day to improve your cardiac
health
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10465306-DS-7 | 10,465,306 | 20,717,359 | DS | 7 | 2183-05-30 00:00:00 | 2183-05-30 07:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left Arm Pain
Major Surgical or Invasive Procedure:
ORIF left distal Humerus
History of Present Illness:
Patient is an ___ with a hx of stroke on pradaxa, a fib, who was
transferred from ___ after an unwittnessed fall on
___ at her nursing home, and found to have L distal humerus
fracture. Patient and her daughter report that at some point on
the evening of ___, the patient had an unwitnissed fall. She
does not remember the events preceeding this, but at 8AM on
___ was found down in her house by aid. She was only c/o L
arm pain since that time, and denies any current L arm/hand
numbness/tingling. she does not remember any preceeding cp, sob,
palpitation, light headedness. Denies any currenty ha, neck
pain, visual changes, vomiting, chest pain, abd pain, back pain,
___ pain, hip pain, RUE pain. Otherwise denies hx of recent f/c,
sore throat, cough, night sweats, decrease po intake, confusion,
dysuria.
Past Medical History:
PMH/PSH: atrial fibrillation, CVA, HLD, HTN, depression, UTI.
hysterectomy, L TKR
Social History:
___
Family History:
NC
Physical Exam:
NAD, Pain Controlled
AFVSS
PE:
LUE: +EPL/FPL/IO, SILT u/m/r, WWP, +mild edema
Pertinent Results:
left elbow xray before and after surgical fixation
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 distal humerus fx and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF left distal humerus which the
patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab 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 nwb in the left upper extremity,
and will be discharged on dabigatran for DVT prophylaxis. The
patient will follow up in two weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge.
Medications on Admission:
atorvastatin 20 mg tablet oral
1 tablet(s) Once Daily
Pradaxa 150 mg capsule oral
1 capsule(s) Twice Daily
lisinopril 20 mg tablet oral
1 tablet(s) Once Daily
Miralax 17 gram/dose oral powder oral
1 powder(s) Once Daily
senna 8.6 mg capsule oral
1 capsule(s) Twice Daily
prednisone 5 mg tablet oral
1 tablet(s) Once Daily
Natural Calcium -- Unknown Strength
1 tablet(s) Twice Daily
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Atorvastatin 20 mg PO QPM
3. Calcium Carbonate 500 mg PO TID
4. Dabigatran Etexilate 150 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Lisinopril 20 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY
10. PredniSONE 5 mg PO DAILY
11. Senna 17.2 mg PO HS
12. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left Distal Humerus Fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with assistance
Discharge Instructions:
After your Chest Xray, a chest CT is recommended for non
emergency basis to exclude the possibility of mediastinal
lymphadenopathy. We recommend follow up with your PCP to discuss
the plan and chest xray findings.
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 Dabigatran as usual
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.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- Non weight bearing in left upper extremity
- Please keep left upper extremity elevated
Physical Therapy:
ACTIVITY AND WEIGHT BEARING:
- Non weight bearing in left upper extremity
- Please keep left upper extremity elevated
Treatments Frequency:
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Followup Instructions:
___
|
10465643-DS-7 | 10,465,643 | 26,231,639 | DS | 7 | 2169-02-01 00:00:00 | 2169-02-01 18:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
GPC bacteremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old gentleman with a history of
seizure disorder with a recent admission for ___ who
presents with blood cultures notable for GPCs. He had a recent
hospitalization (___) for ___ s/p craniotomy and
resection of dural AVF, EVD placement, trach/PEG, with hospital
course complicated by UTI and lower extremity DVT treated with
heparin gtt with plan to transition to Coumadin. He was
discharged with a PICC line placed for access (for heparin gtt)
now transferred back from rehab after positive blood cultures
noted in ___ bottles.
Infectious Disease was consulted via phone ___ and they
recommended removing the PICC, reculturing and starting the
patient on Vancomcyn while awaiting speciation of the blood
cultures. This was communicated to the covering Physician at
___ who felt that it was in the patient's best
interest to be transferred to BI.
In the ED initial vitals were: 98.6 HR 100 BP 124/86 RR 16 96%
RA
- Labs were significant for WBC 12.6 Hct 34.9 Plt 179. Lactate
1.0. INR 1.3. Normal chemistry panel. UA notable for large leuk
est, negative blood, negative nitrite, WBC 109, bacteria few,
Epi 0.
- Patient was given Vancomycin 1 g, 1L NS, and started on a
heparin gtt. Ceftriaxone ordered but not given prior to
transfer.
- He was seen by neurosurgery in the ED who noted that there are
no acute neurosurgical issues at this time.
Vitals on transfer: 98.3 143/94 96 20 97% RA
On the floor, he is comfortable and without complaints.
Review of Systems: Endorses sense that his UTI "is not fully
treated," though cannot describe symptoms due to word finding
difficulties. Denies headache, vision changes, numbness,
tingling, congestion, sore throat, cough, dyspnea, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia.
Past Medical History:
PMHx:
Subarachnoid Hemorrhage
Left Temporal Intraparenchymal Hemorrhage
Seizure disorder (last seizure was ___ years ago).
Hypertension
Sleep apnea
Tetanus
Kidney stones
PSH:
___ Angiogram for embolization and L craniotomy with
resection of dural AVF
___ R EVD
___ Trach and PEG
Social History:
___
Family History:
Denies knowledge of any family medical conditions.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.3 143/94 96 20 97% RA
GENERAL: Lying in bed in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
thrush on tongue, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. PEG in place, c/d/i.
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in the upper and lower
extremities bilaterally, sensation grossly intact. Oriented to
self but not hospital or date. Severe word finding difficulties
and occasional garbled speech
SKIN: Erythema surrounding previous trach site
DISCHARGE EXAM:
Vitals: Tm/Tc 98.3, HR 100 (80s-100s), BP 127/86, RR 20, SaO2
100% RA
GENERAL: Obese gentleman lying in bed, appears comfortable
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
thrush on tongue, good dentition
NECK: Supple, 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, no rebound/guarding, no
hepatosplenomegaly. PEG in place with overlying dressing, c/d/i.
EXTREMITIES: No cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: Oriented to self and "hospital." Word finding
difficulties and occasional garbled speech. CN II-XII intact,
strength ___ in the upper and lower extremities bilaterally,
sensation grossly intact.
SKIN: Erythema surrounding previous trach site, no induration or
drainage, nontender.
Pertinent Results:
ADMISSION LABS:
___ 07:15PM BLOOD WBC-12.3* RBC-4.16* Hgb-12.9* Hct-36.5*
MCV-88 MCH-31.0 MCHC-35.3* RDW-15.3 Plt ___
___ 07:25PM BLOOD Neuts-78.1* Lymphs-13.5* Monos-6.6
Eos-1.5 Baso-0.2
___ 07:25PM BLOOD ___ PTT-36.7* ___
___ 07:25PM BLOOD Glucose-123* UreaN-15 Creat-0.7 Na-137
K-4.0 Cl-100 HCO3-25 AnGap-16
___ 07:25PM BLOOD ALT-23 AST-17 AlkPhos-119 TotBili-0.3
___ 07:25PM BLOOD Albumin-4.0
___ 07:17PM BLOOD Lactate-1.0
___ 09:20PM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:20PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 09:20PM URINE RBC-7* WBC-109* Bacteri-FEW Yeast-NONE
Epi-0
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-12.3*# RBC-3.82* Hgb-12.1* Hct-33.9*
MCV-89 MCH-31.6 MCHC-35.6* RDW-14.5 Plt ___
___ 06:00AM BLOOD ___ PTT-42.0* ___
___ 06:00AM BLOOD Glucose-104* UreaN-14 Creat-0.8 Na-136
K-3.9 Cl-100 HCO3-25 AnGap-15
___ 06:00AM BLOOD Calcium-9.2 Phos-4.5 Mg-2.1
MICROBIOLOGY:
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
OF TWO COLONIAL MORPHOLOGIES.
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT 2300.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
___ 9:00 pm CATHETER TIP-IV Source: PICC line.
WOUND CULTURE (Final ___: No significant growth.
URINE CULTURE (Final ___: NO GROWTH.
Blood cultures from ___, and ___ pending
IMAGING:
TTE ___:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. No masses or vegetations are seen on the
aortic valve. The mitral valve leaflets are mildly thickened. No
masses or vegetations are seen on the mitral valve, but cannot
be fully excluded due to suboptimal image quality. Physiologic
mitral regurgitation is seen (within normal limits). No masses
or vegetations are seen on the tricuspid valve, but cannot be
fully excluded due to suboptimal image quality. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Limited study. No vegetations or
clinicall-significant regurgitant valvular disease seen.
CXR ___:
PA and lateral views of the chest provided. A right upper
extremity PICC line is again seen with its tip extending into
the low SVC. Lung volumes are somewhat low without focal
consolidation, effusion or pneumothorax. Cardiomediastinal
silhouette is stable. Bony structures are intact. No free air
below the right hemidiaphragm is seen.
Brief Hospital Course:
Mr. ___ is a ___ gentleman with a history of
seizure disorder and recent admission for ___/IPH s/p craniotomy
who presents with GPC bacteremia.
# GPC bacteremia: Patient was called back to the hospital after
cultures from ___ ___ site (drawn on last admission as part
of infectious work-up for persistent tachycardia) grew GPCs in
___ bottles; ___ bottles drawn peripherally from the same day
showed no growth to date. He was asymptomatic, vital signs were
stable, and leukocytosis resolved (though WBC increased to 12.3
on discharge). PICC was removed. Patient was started on
vancomycin, but this was discontinued after speciation returned
coag-negative staph as this was thought to represent a
contaminant. A TTE revealed no evidence of vegetation. Daily
surveillance blood cultures showed no growth to date.
# UTI: Patient was continued on ceftriaxone for a UTI (started
on ___, which was switched to cefpodoxime on discharge.
Urine culture sent on admission was negative (but this was in
the setting of 2 days of antibiotics). Patient should continue
cefpodoxime through ___ to complete a 7 day course for
complicated cystitis.
# DVT: Patient's recent hospital course was complicated by RLE
DVT. He was started on heparin as a bridge to Coumadin during
his last admission (Coumadin 5 mg daily was started on ___.
Patient was continued on a heparin gtt, which was switched to
Lovenox on day prior to discharge. INR was therapeutic on
discharge so Lovenox was discontinued.
# Sinus tachycardia: Patient's last hospital course was notable
for sinus tachycardia, possibly related to autonomic
dysfunction. CTA had showed no evidence of pulmonary embolism.
Patient was continued on metoprolol during this admission and
heart rate was ___.
# Hyperglycemia: Patient was put on a Humalog sliding scale for
hyperglycemia. Blood sugars were well-controlled. (Patient had
been discharged on NPH with a regular insulin sliding scale
during his last admission, likely in the setting of tube feeds.)
# S/P SAH/IPH: Patient has residual expressive aphasia and mild
dysarthria from his SAH. He was evaluated in the ED by
neurosurgery, who believed that he remained neurologically
stable (neuro exam unchanged from discharge). Patient will
follow-up with neurosurgery as scheduled in ___.
TRANSITIONAL ISSUES:
[ ] Patient should continue cefpodoxime through ___ (give
one dose tonight and last dose tomorrow morning)
[ ] Patient was continued on Coumadin 5 mg daily and INR was
therapeutic on discharge (2.4).
[ ] Patient's blood sugar was well-controlled on a Humalog
sliding scale. Please continue to monitor.
[ ] Patient was started on tamsulosin but failed a voiding trial
so Foley was reinserted.
[ ] ___ was 12.3 on discharge. Recommend rechecking CBC in one
week to ensure resolution of leukocytosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. LaMOTrigine 200 mg PO BID
5. Valsartan 320 mg PO DAILY
6. Senna 17.2 mg PO QHS
7. Nystatin Oral Suspension 5 mL PO QID
8. LeVETiracetam Oral Solution 1000 mg PO BID
9. Acetaminophen 650 mg PO Q6H:PRN pain/fever
10. Albuterol Inhaler 4 PUFF IH Q4H:PRN wheeze
11. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
12. Docusate Sodium 100 mg PO BID
13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
14. Glucose Gel 15 g PO PRN hypoglycemia protocol
15. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
16. Warfarin 5 mg PO DAILY16
17. CeftriaXONE 1 gm IV Q24H
18. Metoprolol Succinate XL 150 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Coagulase-negative staphylococcus bacteremia
Urinary tract infection
Secondary diagnoses:
Deep vein thrombosis
Tachycardia
Hyperglycemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted because bacteria was growing in your blood.
You were started on antibiotics but these were stopped after the
bacteria was thought to be a contaminant (not harmful). You
remained clinically stable without symptoms and it was
determined that you were safe to return to rehab. Please
continue to take your medications as prescribed and keep your
follow-up appointments.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10466436-DS-18 | 10,466,436 | 26,264,185 | DS | 18 | 2189-11-05 00:00:00 | 2189-11-05 15:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of CHF, anemia, and recent admission for falls
thought secondary to autonomic dysfunction and hypovolemia in
setting of diarrhea presenting with dizziness. The patient was
recently discharged to rehab on ___ for similar symptoms,
now setup with ___ after his rehab stay. The ___ came to his
apartment for the first time today at which time the patient
endorsed dizziness with standing. Patient reports continued
diarrhea everyday despite loperamide. This was worked up on the
previous admission without identified etiology despite
colonoscopy. His home ___ reports that he fell yesterday while at
home; patient denies head trauma or LOC.
In the ED intial vitals were 98 60 119/66 16 100%RA. Initial
labs demonstrated a HCT 30.6% (at baseline), creatinine 1.2
(baseline ~1.0), normal coags, BNP 1462, lactate 1.5, and a
negative UA. A CXR was unchanged. A CT head was without acute
process. Orthostatics in the ED were negative. The patient was
given 500mL IVF bolus and admitted for rehab placement.
Upon arrival to the floor, 97.7 127/70 77 20 100%RA. The patient
corroborated the above history, though was a poor historian,
likely secondary to dementia. He wanted to sleep and was without
further complaint.
Past Medical History:
Gout
Blindness in left eye
Past EtOH abuse
Dementia - unable to give clear history
Cardiac history - CHF
Anemia- gets procrit injections every 2 weeks, H/o abnormal EKG,
cardiac cath ___, Gout, OA, CKD, Edema, S/p small bowel
obstruction and resection about ___ years ago, increase PSA per
PMD in ___ note, CAD s/p cath ___.
Social History:
___
Family History:
Unknown
Physical Exam:
Admission Labs:
Vitals- 97.7 127/70 77 20 100%RA
General- Sleeping no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- Supple, JVP difficult to evaluate, 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, 2+ ___ edema
Neuro- CNs2-12 intact, motor function grossly normal
Discharge Labs:
Vitals- 97.9 90-103/59-63 ___ 20 100% RA
General- Sleeping no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- Supple, JVP difficult to evaluate, 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, 2+ ___ edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
Admission Labs:
___ 05:30PM BLOOD WBC-6.2 RBC-2.92* Hgb-9.4* Hct-30.6*
MCV-105* MCH-32.3* MCHC-30.8* RDW-12.8 Plt ___
___ 05:30PM BLOOD Neuts-53 Bands-0 ___ Monos-7 Eos-0
Baso-0 ___ Myelos-0
___ 05:30PM BLOOD Glucose-83 UreaN-23* Creat-1.2 Na-139
K-4.7 Cl-103 HCO3-29 AnGap-12
___ 05:30PM BLOOD proBNP-1462*
___ 06:09PM BLOOD Lactate-1.5
Discharge Labs:
___ 07:20AM BLOOD WBC-5.1 RBC-2.51* Hgb-8.0* Hct-26.7*
MCV-106* MCH-32.0 MCHC-30.1* RDW-13.2 Plt ___
___ 07:20AM BLOOD Glucose-63* UreaN-24* Creat-1.1 Na-138
K-3.4 Cl-106 HCO3-26 AnGap-9
___ CT Non-Contrast
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema,
mass effect or shift of normally midline structures. The
gray-white matter interface is preserved without evidence of
acute major vascular territorial infarct. The ventricles and
sulci are slightly prominent compatible with mild age related
parenchymal volume loss. The basal cisterns appear patent. A
left frontal subgaleal lipoma is incidentally noted measuring 12
x 3 mm. The imaged paranasal sinuses, middle ear cavities and
mastoid air cells are well pneumatized and aerated bilaterally.
An old fracture of the right lamina papyracea is incidentally
noted. The bony calvaria appear intact.
IMPRESSION:
No evidence of acute intracranial process.
FINDINGS:
AP and lateral views of the chest. Again seen is elevation of
the left
hemidiaphragm. Persistent opacity projects over the right
midlung as well as
linear opacities at the left lung base. There is no effusion or
pneumothorax.
The cardiomediastinal silhouette is stable. No acute displaced
fractures
identified.
IMPRESSION:
No significant interval change. Persistent right midlung
opacity as detailed
on prior report
Brief Hospital Course:
___ with history of CHF, anemia, and recent falls attributed to
orthostasis/autonomic dysfunction attributed to ___ body
dementia presenting with episodes of presyncope.
#Presyncope. Given history, patient's symptoms appear to be
unresolved from the previous admission due to missing doses of
medications. One medication was loperamide for which he was
started following a extensive and largely negative workup for
diarrhea in the previous admission. He was given IV fluids and
resumed on home medications with resolution of symptoms. The
dizziness, however resumed with ambulation with appears to be
baselie.
#Diarrhea
Worked-up on previous admission without identification of
etiology. Stool studies were negative. Colonoscopy and biopsies
unremarkable. Fecal fat testing was abnormal suggesting possible
fat malabsorption. Alpha-1 antitrypsin was normal. Pancreatic
elastase remains pending. He was continued on loperamide.
___: Creatinine mildly elevated beyond baseline, currently 1.2
from 1.0. Likely secondary to hypovolemia in setting of
persistent diarrhea. Improved with fluids.
#Lower extremity edema
Patient with bilateral edema with recent echo EF 50-55%. LENIs
were completed during last hospitalization without DVT.
#Anemia
Unclear etiology. Iron studies last admission demonstrating low
TIBC with high-normal ferritin suggesting a chronic disease
component. MCV elevated, possibly related to past etOH use.
TRANSITIONAL ISSUES
- Full code
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
2. Multivitamins 1 TAB PO DAILY
3. Aspirin 81 mg PO DAILY
4. Acetaminophen 650 mg PO Q8H
5. FoLIC Acid 1 mg PO DAILY
6. Midodrine 2.5 mg PO BID
7. Thiamine 100 mg PO DAILY
8. Bismuth Subsalicylate 15 mL PO BID
9. Omeprazole 20 mg PO DAILY
10. Fludrocortisone Acetate 0.1 mg PO QPM (___)
11. LOPERamide 2 mg PO TID:PRN diarrhoea
12. Duloxetine 20 mg PO DAILY
13. Fludrocortisone Acetate 0.2 mg PO QAM
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. Bismuth Subsalicylate 15 mL PO BID
4. Duloxetine 20 mg PO DAILY
5. Fludrocortisone Acetate 0.1 mg PO QPM (___)
6. Fludrocortisone Acetate 0.2 mg PO QAM
7. FoLIC Acid 1 mg PO DAILY
8. LOPERamide 2 mg PO TID:PRN diarrhoea
9. Midodrine 2.5 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Thiamine 100 mg PO DAILY
13. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Diarrhea
Autonomic dysfunction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You came because of dizziness. This
was likely due to dehydration because of diarrhea. You were
given fluids and continued on medications to slow down your
diarrhea. These therapies improved your symptoms and now you are
ready to go to rehabilitation. Please continue to take the rest
of your medications
Followup Instructions:
___
|
10466788-DS-13 | 10,466,788 | 25,285,441 | DS | 13 | 2171-06-22 00:00:00 | 2171-06-23 07:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
cough, fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/PMHx stage II NSC lung Ca and RCC with brain metastasis
s/p XRT/cyberknife, presenting with nonproductive cough and
fatigue for approx 1 week. Patient reports getting only ___
hours of sleep per night due to the cough. He reports that
several weeks ago, he was able to bring up some "chunks", but
since that time, his cuogh has been dry. He feels fatigued, but
reports that he doesn't know what he baseline is anymore. He
attributes his fatigue to his cancer and his pacemaker. He
denies fever, chills, mylagias, nausea, vomiting, diarrhea, sick
contacts. Separately, he reports R ankle swelling for the past 2
days. He reports falling ___ weeks ago while going up an
escalator with bags. He fell backwards, but the people behind
him caught him. Since that time, he feels his gait is "off" as
if he were "drunk" - he denies actually drinking. He also notes
a headach 2 days ago that has since resolved. He denies changes
in vision, parathesias, numbness.
Past Medical History:
ONCOLOGIC HISTORY:
___: Non-small cell lung cancer, stage II, diagnosed in ___
status post right upper lobectomy and radiation therapy.
___: Renal cell carcinoma diagnosed in ___, status post
nephrectomy.
___: CT scan in ___ showed new pulmonary lesions
with a biopsy consistent with metastatic renal cell carcinoma in
___. CT scan subsequently revealed disease
progression. The patient initially attempted therapy with
homeopathic or herbal remedies.
___: Avastin started in ___: Chest wall tumor excision from right side ___: Left ileal lesion treated with XRT completed ___: Final Avastin dose given, C40 on ___, progression
on Avastin.
___: Started Sutent on ___, C1D1 at 25 mg with
titration to 37.5mg. Stopped in ___ due to side effects,
feet pain.
___: Started pazopanib (votrient) on ___. Dose
reduced to 400 mg daily because of foot pain, nausea
___: Developed shortness of breath and hemoptysis, and
___ CT scan concerning for right lower lobe endobronchial
lesion. He underwent flexible bronchoscopy on ___ and then on
___ rigid bronchoscopy and successful tumor debridement and
relief of airway obstruction. Pathology from both procedures
consistent with metastatic renal cell carcinoma.
___ restart votrient (400 mg daily) following his procedures.
Dose reductions, schedule interruptions and adjustments for foot
pain, pale complexion, fatigue, oral ulcers/mucositis and
___ skin paleness.
___ CT with slight decreased in size of pulmonary nodule
and two mediastinal nodes, unchanged left iliac lesion.
___ CT torso with interval slight enlargement of subcarinal
necrotic lymph node but other mediastinal adenopathy, left upper
lobe nodules, and osseous metastasis stable.
___ Mr. ___ complains of left hip and leg pain >right leg
pain with some weakness
___ CT of pelvis - Stable osseous metastasis of the left
ilium.
___ CT of the lumbar spine - no new metastatic disease to
the bones but progressive degenerative disease, disc bulging and
severe central stenosis in L4-L5.
___ Bronchoscopy for hemoptysis. Endobronchial bx + for
metastatic RCC.
___ Progressive fatigue, decrease in ET, increase in cough.
___ Start of anti-PD1 therapy, ___, DF/HCC protocol
___ port placement.
PAST MEDICAL HISTORY:
Stage II NSCLC sp RUL lobectomy and RT in ___
HTN
borderline HL
+ PPD
Lower back pain - Scoliosis with sciatica, L4/5 stenosis, L5/S1
right foraminal stenosis
Complete heart block s/p dual chamber PPM (presented with
syncopein ___
PAST SURGICAL HISTORY:
- left nephrectomy for renal cell cancer on ___
- right upper lobe lung resection for squamous cell carcinoma on
___.
Social History:
___
Family History:
He has 2 grown children, one of whom has schizophrenia. No
history of cancer in family.
Physical Exam:
ADMISSION EXAM:
VS: 98.0 124/60 79 22 100%RA
General: Thin, elderly male in NAD.
HEENT: PERRL, anicteric, MMM
CV: RRR nl s1/s2 no mrg
LYMPH: no ant or post cervical, SCV or occipital LAD
Chest: well-healed surgical scar at base of R posterior lung
field, left sided PPM scar
PULM: clear to auscultation bilaterally, good air movement
ABD: flat, + BS, soft, no ttp, no masses or HSM
EXT: R ankle slightly edematous compared to right, non-pitting,
non-tender
NEURO: no focal deficits
BACK: no spinal TTP
DISCHARGE PHYSICAL EXAM:
VS: 97.9 124/70 88 20 95%RA
General: Thin, elderly male in NAD.
HEENT: PERRL, anicteric, MMM
CV: RRR nl s1/s2 no mrg
PULM: clear to auscultation bilaterally, good air movement
ABD: flat, + BS, soft, no ttp, no masses or HSM
EXT: R ankle slightly edematous compared to right, non-pitting,
non-tender
NEURO: no focal deficits
Pertinent Results:
ADMISSION LABS:
___ 01:10PM BLOOD WBC-12.4* RBC-4.57* Hgb-10.5* Hct-34.5*
MCV-75* MCH-22.9* MCHC-30.4* RDW-20.1* Plt ___
___ 01:10PM BLOOD Neuts-93.7* Lymphs-3.6* Monos-2.1 Eos-0.4
Baso-0.2
___ 01:10PM BLOOD Glucose-140* UreaN-30* Creat-1.0 Na-134
K-6.4* Cl-102 HCO3-20* AnGap-18
IMAGING:
___ ULTRASOUND:
IMPRESSION: No right lower extremity deep venous thrombosis.
CXR PA/LAT:
IMPRESSION:
New right basilar consolidative opacity concerning for
infection. Patient's known bilateral pulmonary nodules and
subcarinal mass are better assessed on recent chest CT of
___.
HEAD CT:
IMPRESSION: Hyperdense lesion in the left frontal operculum is
unchanged in
size from ___, though it appears slightly more hyperdense
on today's
study. Given the unchanged size, it is unlikely there is
interval hemorrhage
into the lesion. However, the surrounding edema has increased,
which may
represent a post-treatment effect, but a supervening acute
abnormality cannot
be excluded.
Brief Hospital Course:
___ w/PMHx stage II NSC lung Ca and RCC with brain metastasis
s/p XRT/cyberknife, presenting with several days of fatigue and
dry nonproductive cough and headache.
# WEAKNESS/COUGH: R basilar opacity on CXR with patient's
symptoms of fatigue and cough, and leukocytosis, consistent with
pneumonia. No recent hospitalizations, therefore mostly likely
CAP. Other cause for weakness could be hypothyroidism, however
on synthroid. UA negative. Patient denied fever, chills,
myalgias, therefore low clinical suspicion for flu. Started on
levaquin for CAP and continued on home nebs with good effect,
had improvement in cough and fatigue. Also received
codeine-guaifinesin for symptomatic relief. Since the patient
was complaining of a headache at admission, a CT head was done
that did not show an acute process. Headache resolved before
patient reached the floor, no further workup was done.
# HTN: Patient was continued on his home meds upon admission.
However, he was found to have hyperkalemia (admission K 6.2, K
on HD1 5.7) and spironolactone and losartan were subsequently
discontinued. He remained normotensive with SBP 110s-120s for
the remainder of his stay on clonidine and carvedilol.
# R ___ EDEMA: Right ankle swelling, very slight, non pitting,
non erythematous, not warm, non-tender. Right ___ ultrasound
negative for DVT at admission. Swelling spontaneously resolved,
not present on hospital day 2.
# RCC: metastatic (to the left iliac, T7, lungs, paratracheal/
subcarinal/hilar LNs) s/p XRT to the iliac lesion, cyberknife to
the subcarinal mass, s/p avastin, sutent, pazopanib, anti-PD1
(c/b hypothyroidism). RCC treatment deferred to Drs. ___
___. He was continued on daily allopurinol and
megestrol, and on prescribed dexamethasone taper.
# Complete heart block. s/p dual chamber PPM. LVef 30% primarly
due to pacing-induced dyssynchrony. Cards considering BiV pacing
per ___ last note. Continued on carvedilol. No interventions
during this admission, but losartan discontinued for
hyperkalemia.
At the time of discharge, K was 4.6, VSS with no hypoxia on room
air. Patient was discharged home on a 7-day course of po
levaquin, had onc follow-up and home nursing and ___ services.
TRANSITIONAL ISSUES
1-CAP: To complete 7 day course of Levaquin
2-Hyperkalemia/HTN: Home spironolactone, losartan held for
hyperkalemia. SBP 110s-120s during hospitalization.
3-TSH low-normal at 0.26, no overt signs of hyperthyroidism, no
adjustments made to levothyroxine dose
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dexamethasone 4 mg PO Q12H
2. Losartan Potassium 100 mg PO HS
3. Allopurinol ___ mg PO DAILY
4. Ipratropium Bromide Neb 1 NEB IH Q6H
5. Tiotropium Bromide 1 CAP IH DAILY
6. Megestrol Acetate 400 mg PO DAILY
7. Benzonatate 100 mg PO Q6H:PRN cough
8. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
9. Carvedilol 25 mg PO BID
10. Timolol Maleate 0.5% 1 DROP RIGHT EYE BID
11. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE BID
12. Docusate Sodium 100 mg PO BID
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Senna ___ TAB PO DAILY:PRN constipation
15. CloniDINE 0.1 mg PO BID
16. Pravastatin 20 mg PO DAILY
17. Spironolactone 12.5 mg PO QAM
18. Omeprazole 20 mg PO BID
19. Albuterol Sulfate (Extended Release) 4 mg PO Q12H
20. traZODONE ___ mg PO HS:PRN insomnia
21. Levothyroxine Sodium 137 mcg PO DAILY
22. Hydralazine 10mg qam PRN SBP>140
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Benzonatate 100 mg PO Q6H:PRN cough
3. Carvedilol 25 mg PO BID
4. CloniDINE 0.1 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE BID
7. Ipratropium Bromide Neb 1 NEB IH Q6H
8. Levothyroxine Sodium 137 mcg PO DAILY
9. Megestrol Acetate 400 mg PO DAILY
10. Omeprazole 20 mg PO BID
11. Pravastatin 20 mg PO DAILY
12. Senna ___ TAB PO DAILY:PRN constipation
13. Timolol Maleate 0.5% 1 DROP RIGHT EYE BID
14. traZODONE ___ mg PO HS:PRN insomnia
15. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL ___ ml by mouth every
6 hours Disp #*200 Milliliter Refills:*0
16. Dexamethasone 2 mg PO DAILY Duration: 1 Doses
Please take one dose on ___. Do not take any more until
you have discussed with your oncologists.
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
19. Levofloxacin 500 mg PO Q24H
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*6
Tablet Refills:*0
20. Lactulose 30 mL PO DAILY:PRN constipation
RX *lactulose 20 gram/30 mL 30 ml by mouth daily Disp #*300
Milliliter Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Renal cell carcinoma
Non small cell lung cancer
Community acquired pneumonia
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 onoclogy service at ___ for cough and
fatigue. Chest x-ray suggested pneumonia. For this, you were
treated with antibiotics. Please continue the Levaquin until
___.
Your potassium level was found to be high. Since this can be a
side effect of losartan and spironolactone, we stopped these
medications. Your potassium level improved. Your blood pressure
remained normal without these meds, and you did not need any
hydralazine. Please do not start these medications without
speaking to your doctors ___.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
10466973-DS-11 | 10,466,973 | 22,751,209 | DS | 11 | 2175-08-04 00:00:00 | 2175-08-03 09:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
trazodone
Attending: ___.
Chief Complaint:
___ year old male with h/o T7 chance fracture and DISH with
junctional failure treated on ___ with T3-T11 PSIF. Patient
readmitted with with wound drainage, UTI ecoli and OR culture
showing p acnes and
Major Surgical or Invasive Procedure:
None during this admission
Previous hospitalization: T3-T11 posterior instrumented fusion
by Dr. ___ on ___
History of Present Illness:
___ year old male readmitted from rehab with wound drainage and
OR cultures showing p acnes.
Past Medical History:
BACK PAIN
HEART DISEASE
HYPERTENSION
SEASONAL ALLERGIES
DIABETES TYPE II
ANXIETY
DEPRESSION
SLEEP APNEA
Social History:
___
Family History:
Non-contributory
Physical Exam:
NAD, A&Ox4
nl resp effort
RRR
dressing with minimal serosanguinous drainage
incision c/d/i
Sensory:
___
L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R SILT SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT SILT
Motor:
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
Pertinent Results:
___ 03:11PM WBC-7.2 RBC-4.45* HGB-11.7* HCT-37.0* MCV-83
MCH-26.3 MCHC-31.6* RDW-14.9 RDWSD-45.1
Brief Hospital Course:
Patient admitted on ___ from rehab with wound drainage and OR
cultures showing p acnes. Infectious disease consulted.
Recommended 6 weeks IV ceftriaxone. PICC placed. Discharge home
with services.
Medications on Admission:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever
2. Aspirin 325 mg PO DAILY
3. Baclofen 20 mg PO TID:PRN Back Pain
4. Bisacodyl ___AILY
5. BuPROPion XL (Once Daily) 150 mg PO DAILY
6. Chlorthalidone 25 mg PO DAILY
7. Diltiazem Extended-Release 240 mg PO DAILY
8. Docusate Sodium 100 mg PO TID
9. Eplerenone 25 mg PO DAILY
10. Finasteride 5 mg PO DAILY
11. Gabapentin 1200 mg PO QHS
12. Gabapentin 800 mg PO TID
13. HYDROmorphone (Dilaudid) 4 mg PO DAILY
14. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate
15. Glargine 40 Units Breakfast
Glargine 40 Units Bedtime
Humalog 14 Units Breakfast
Humalog 14 Units Lunch
Humalog 14 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
16. Losartan Potassium 50 mg PO BID
17. Morphine SR (MS ___ 15 mg PO BREAKFAST
18. Morphine SR (MS ___ 30 mg PO QHS
19. Morphine Sulfate ___ 15 mg PO DAILY:PRN Pain - Severe
20. Pantoprazole 40 mg PO Q24H
21. Polyethylene Glycol 17 g PO DAILY
22. Rosuvastatin Calcium 5 mg PO QPM
23. Senna 17.2 mg PO QHS
24. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm IV daily
Disp #*42 Intravenous Bag Refills:*0
2. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever
3. Aspirin 325 mg PO DAILY
4. Baclofen 20 mg PO TID:PRN Back Pain
5. Bisacodyl ___AILY
6. BuPROPion XL (Once Daily) 150 mg PO DAILY
7. Chlorthalidone 25 mg PO DAILY
8. Diltiazem Extended-Release 240 mg PO DAILY
9. Docusate Sodium 100 mg PO TID
10. Eplerenone 25 mg PO DAILY
11. Finasteride 5 mg PO DAILY
12. Gabapentin 1200 mg PO QHS
13. Gabapentin 800 mg PO TID
14. HYDROmorphone (Dilaudid) 4 mg PO DAILY
15. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate
16. Glargine 40 Units Breakfast
Glargine 40 Units Bedtime
Humalog 14 Units Breakfast
Humalog 14 Units Lunch
Humalog 14 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
17. Losartan Potassium 50 mg PO BID
18. Morphine SR (MS ___ 15 mg PO BREAKFAST
19. Morphine SR (MS ___ 30 mg PO QHS
20. Morphine Sulfate ___ 15 mg PO DAILY:PRN Pain - Severe
21. Pantoprazole 40 mg PO Q24H
22. Polyethylene Glycol 17 g PO DAILY
23. Rosuvastatin Calcium 5 mg PO QPM
24. Senna 17.2 mg PO QHS
25. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
T7 chance fracture with DISH and junctional failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Immediately after the operation:
Activity:You should not lift anything greater than 10 lbs for
2 weeks.You will be more comfortable if you do not sit in a car
or chair for more than~45 minutes without getting up and walking
around.
Rehabilitation/ Physical ___ times a day you should go
for a walk for ___ minutes as part of your recovery.You can
walk as much as you can tolerate.Limit any kind of lifting.
TLSO brace to be worn when out of bed.
Wound Care: Dressing changes as needed. Please keep wound
covered until followup appointment. Keep wound clean and dry.
You should resume taking your normal home medications
You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___.We are not allowed to call in narcotic prescriptions
(oxycontin,oxycodone,percocet) to the pharmacy.In addition,we
are only allowed to write for pain medications for 90 days from
the date of surgery.
Follow up:
Followup with infectious disease and Dr. ___ been
scheduled.
Please call the office if you have a fever>101.5 degrees
Fahrenheit,drainage from your wound,or have any questions.
Physical Therapy:
TLSO brace when out of bed.
Treatments Frequency:
Keep incision covered with dressing. Dressing changes as
needed. Please keep incision clean and dry.
Followup Instructions:
___
|
10467237-DS-7 | 10,467,237 | 20,000,019 | DS | 7 | 2159-03-23 00:00:00 | 2159-03-24 06:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever, nausea/vomiting, flank pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Ms. ___ is a ___ year old ___ speaking lady with DM2 and
HTN who was evaluated in the ED ___, diagnosed with UTI and
treated with macrobid, who returned with bilateral flank pain
L>R, fevers, chills, sweats, nausea, vomiting, headache,
dysuria. Denied neck stiffness. She was evaluated in ED
initially with dizziness, headache, fever, found ot have a UTI
and discharged home w macrobid, which she took, but felt worse
today. She endorses minimal urine output that is dark.
In the ED, initial vs were: ___ pain 99.3 97 151/53 16 96%
yest. Today initial vitals were ___ pain 101.2 94 123/46 18 96%
RA. Today ED physical exam significant for bilateral
costovertebral angle tenderness as well as mild suprapubic
tenderness, no meningismus clear lungs, normal heart exam. Labs
in ED sig for leukocytosis to 19.0 and a lactate of 3.0 ___s a bump in her creatinine from 1.2-1.3. Given the patient's
ongoing symptoms rising leukocytosis as well as elevated lactate
and bilateral flank pain, she was given 1500 cc NS, 1 gram
ceftriaxone, 1g acetaminophen for pyelonpehritis/fever,
underwent renal u/s to evaluate for renal abscesses or
hydronephrosis (negative).
Vitals on Transfer: ___ pain 98.0 65 106/50 16 100%
On the floor, vs were as below. She endorsed feeling somewhat
better but continued suprapubic discomfort and flank pain L>R.
Past Medical History:
Type 2 diabetes
Asthma
Hyperlipidemia
Hypertension
Social History:
___
Family History:
She has a sister deceased with endometrial cancer. No history of
ovarian, breast or colon cancer. No history of hypertension or
diabetes in the family.
Physical Exam:
ADMISSION EXAM:
Vitals: tmax 101.2, tc 98.___ fs 207
General: Alert, oriented, no acute distress, lying in bed with
family at bedside
HEENT: Sclera anicteric, MM dry
Neck: supple, no meningismus, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild tenderness to deep palp @ suprapubic area,
non-distended, bowel sounds present, no rebound tenderness, no
organomegaly
Back: + CVA tenderness, L > R (mild on R)
Ext: Warm, well perfused, no edema
Skin: moist, no rashes, no petechiae
Neuro: speech fluent, linear, appropriate, no meningismus,
oriented x3, moving all 4 extremities, did not assess gait.
.
DISCHARGE EXAM:
PHYSICAL EXAM:
General: Alert, oriented, no acute distress, lying on bed
Abdomen: soft, non-tender, obese, bowel sounds present, no
rebound tenderness, no organomegaly
Back: CVA tenderness resolved
Ext: Warm, well perfused, no edema
Pertinent Results:
ADMISSION LABS:
___ 10:39PM LACTATE-1.6
___ 09:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-LG
___ 09:00PM URINE RBC-21* WBC-34* BACTERIA-FEW YEAST-NONE
EPI-2 TRANS EPI-<1
___ 07:27PM LACTATE-3.0*
___ 07:17PM GLUCOSE-210* UREA N-21* CREAT-1.3*
SODIUM-130* POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-22 ANION GAP-18
___ 07:17PM WBC-19.2* RBC-3.65* HGB-11.0* HCT-31.1*
MCV-85 MCH-30.1 MCHC-35.4* RDW-12.6
___ 07:17PM NEUTS-84.8* LYMPHS-10.1* MONOS-4.4 EOS-0.4
BASOS-0.3
___ 07:17PM PLT COUNT-204
.
RELEVANT LABS:
.
___ blood cultures: ___ bottles:
___ 7:17 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___. ___ ___ 08:13AM.
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
.
.
subsequent blood cultures negative.
.
.
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
.
DISCHARGE LABS:
.
___ 10:50AM BLOOD WBC-6.1 RBC-2.82* Hgb-8.3* Hct-24.4*
MCV-87 MCH-29.5 MCHC-34.1 RDW-12.3 Plt ___
___ 10:50AM BLOOD Plt ___
___ 07:15AM BLOOD Glucose-177* UreaN-14 Creat-0.9 Na-138
K-3.9 Cl-102 HCO3-26 AnGap-14
___ 10:50AM BLOOD LD(LDH)-125 TotBili-0.4
___ 10:50AM BLOOD Iron-21*
___ 07:15AM BLOOD Calcium-8.9 Phos-2.7 Mg-1.7
___ 10:50AM BLOOD calTIBC-215* Hapto-224* Ferritn-333*
TRF-165*
Brief Hospital Course:
___ was admitted on ___ for fevers, flank pain,
nausea/vomiting and headache. She had been admitted ___ for
urinary tract infection and discharged on nitrofurantoin. She
represented on ___, found to be febrile, with urinalysis
consistent with infection, and was started on IV ceftriaxone.
Renal ultrasound was preformed, showing only a 8mm simple cyst.
Subsequent blood cultures showed GNR.
.
ACUTE ISSUES:
.
# Pyelonephritis and Sepsis: Fever, dysuria, flank pain.
treating initially w/ iv ceftriaxone. Renal u/s w/o e/o abscess
or stone as nidus. Patient was started on IV ceftriaxone, and
transitioned to PO cipro
plan ___: Likely in setting of volume depletion given insensible
losses (fever), vomiting, poor PO intake, as evidence by
elevated lactate and creatinine.
- Cr 1.3 on admission --> .9 on discharged, resolved with IV
fluids
.
Anemia: requires outpatient evaluation. Iron studies and lysis
labs above.
.
CHRONIC ISSUES:
.
# Type 2 DM: Given acute infection, held glipizide and
metformin.
- insulin humalgos sliding scale
- qid fingersticks
- restarted on metformin, glipizide on discharge.
.
# Hyponatremia: Improved with hydration.
.
# Asthma: asymptomatic, not wheezing, monitor.
.
# Hyperlipidemia: Continue statin, aspirin
.
# Hypertension: held indapamide during stay for low-normal BPs,
did not restart indapamide, to be restarted at discretion of PCP
.
Follow-up:
.
To follow up with PCP to ensure resolution of symptoms as well
as to follow up anemia.
.
To follow up with renal as scheduled prior to this inpatient
stay.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
2. Aspirin 81 mg PO DAILY
3. Simvastatin 40 mg PO HS
4. Lisinopril 20 mg PO DAILY
please hold for SBP<100, HR<60
5. GlipiZIDE 5 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Indapamide 1.25 mg PO DAILY
please hold for SBP<100
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Simvastatin 40 mg PO HS
3. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*23 Tablet Refills:*0
4. Acetaminophen ___ mg PO Q6H:PRN pain,fever, headache
RX *acetaminophen 500 mg 1 tablet(s) by mouth q6hrs Disp #*60
Tablet Refills:*0
5. GlipiZIDE 5 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
# Sepsis, secondary to pyelonephritis
Secondary Diagnosis:
# Diabetes Type II
# Hypertension
# Hyperlipidemia
# Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking part in your care at ___
___.
___ were admitted for an infection in your blood and in your
kidneys, after recently being diagnosed and treated for a
urinary tract infection. Your kidney and blood infection were
treated with IV antibiotics. ___ also had temporary kidney
injury resulting from dehydration, which improved with
intravenous fluids. An ultrasound was preformed to look at your
kidneys, and everything looked normal.
___ did not have a fever on the day of discharge. PLease buy a
thermometer for home. ___ should take your temperature several
times a day for the next few days. If your temperature is
greater than 102 degrees, ___ should return to the ED.
___ are discharged on ciprofloxacin 500mg twice a day for 14
days, to be completed on ___.
___ should follow up with your PCP, ___ week
___ should follow up your kidney doctor on ___ as planned.
Followup Instructions:
___
|
10467410-DS-24 | 10,467,410 | 29,916,917 | DS | 24 | 2155-08-04 00:00:00 | 2155-08-04 15:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers and jaundice
Major Surgical or Invasive Procedure:
ERCP
Percutaneous biliary drain placed by interventional radiology
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
Date: ___
Time: 430 AM
_
________________________________________________________________
PCP:
Name: ___
Location: ___ PRIMARY CARE AT ___
Address: ___, ___
Phone: ___
Fax: ___
=======================
Primary hematologist:
Name: ___. MD
Location: ___ ONCOLOGY AND HEMATOLOGY
Address: ___
Phone: ___
Fax: ___
_
________________________________________________________________
HPI:
The patient is a ___ y.o. M with h/o unresectable pancreatic
cancer ___ gastrojejunostomy without vagotomy in ___
___ XRT and chemotherapy who presents with
fevers to 104.5 and jaundice x2.5 weeks. He was transferred from
an OSH. + 30 lb weight loss in one year. + intermittent brown
floating diarrhea. - DOE. He has chronic RUQ pain which takes
his breath away at times and at other times is tolerable at
___. He also has diffuse aches in his chest but does not report
pain with walking or DOE. His pain is well controlled with
oxycodone 5 mg bid. He has had nausea without emesis. He has
mild HA. He has not had other neuro sx apart from a headache or
new rashes.
Of note the patient was most recently admitted in ___
for one day when he was transferred from an OSH with fevers ?
elevated bilirubin which normalized without intervention. He was
diagnosed at the OSH with cdiff. Upon transfer here he was seen
by ___ and it was determined that there was no need for
intervention. He was also found to have a sub acute portal vein
thrombus asociated with tumor and the decision was made to defer
anticoagulation to his o/p providers. He was given zosyn at the
OSH prior to transfer. He has had rhinorrhea and ear popping for
some time now. He does not have sinus headaches. He is not
coughing. No abx since ___.
VS on presentation to the ED: 98 69 110/68 16 97%
Tbili on presentation = 6.3 (last bili in ___ was 0.3)
No meds given in the ED.
In ER: (Triage Vitals:98 69 110/68 16 97% )
He was not given any meds. He is currently not in any pain.
.
___ pain in RUQ
[X]all other systems negative except as noted above
Past Medical History:
# Pancreatic Cancer - ___ chemotherapy and xrt. ___ open biopsy,
liver biopsy, retroperitoneal LN biopsy, open CCY and open
gastrojejunostomy without vagotomy in ___ ___.
# ___ PTBD ___
# Portal thrombus associated with tumor
# ___ appendectomy
Social History:
___
Family History:
There is no family history of pancreatic cancer.
Mother with h/o liver CA, died at ___.
Physical Exam:
PHYSICAL EXAM: I3 - PE >8
pain = ___. VS T = 97.8 P = 65 BP = 101/67 RR = 18 O2Sat on _95% on RA
GENERAL: Thin male laying in bed who looks chronically ill. +
temporal wasting
Nourishment: OK
Grooming:OK
Mentation: alert,speaking in full sentences
2. Eyes: [] WNL
+ jaundice
3. ENT [] WNL
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [] WNL
[X] Regular [] Tachy [X] S1 [X] S2 [-] Systolic Murmur /6,
Location:
[X] Edema RLE None
[X] Edema LLE None
[X] Vascular access [] Peripheral [] Central site:
5. Respiratory [ ]
[X] CTA bilaterally [ ] Rales [ ] Diminshed
6. Gastrointestinal [ ] WNL
[X] Soft [-] Rebound [] No hepatomegaly [X] Non-tender []
Tender [] No splenomegaly
7. Musculoskeletal-Extremities [X] WNL
[ ] Tone WNL [X]Upper extremity strength ___ and symmetrical [
]Other:
[ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica
[ ] Other:
[X] Normal gait [X]No cyanosis [ ] No clubbing [] No joint
swelling
8. Neurological [] WNL
+ HOH
[ X] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ ] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [] WNL
+ jaundice
[] Warm [] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
[ ] Cool [] Moist [] Mottled [] Ulcer:
None/decubitus/sacral/heel: Right/Left
10. Psychiatric [X] WNL
[X] Appropriate [] Flat affect [] Anxious [] Manic []
Intoxicated [] Pleasant [] Depressed [] Agitated [] Psychotic
[]
Pertinent Results:
___ 03:34AM ___ COMMENTS-GREEN TOP
___ 03:34AM LACTATE-1.0
___ 03:22AM WBC-5.3# RBC-3.41* HGB-10.2* HCT-31.9* MCV-93
MCH-29.9 MCHC-32.0 RDW-15.0
___ 03:22AM NEUTS-73.4* LYMPHS-15.4* MONOS-6.3 EOS-4.1*
BASOS-0.8
___ 03:22AM PLT COUNT-226#
___ 03:22AM ___ PTT-28.8 ___
===================
Abdominal CT scan: ___
IMPRESSION:
1. Migrated biliary stent in the ileum without evidence of
bowel obstruction or perforation.
2. Status post interval placement of 2 biliary stents draining
right and left biliary systems. Stable moderate medial left
intrahepatic biliary dilation is likely due to lack of draining
through the stent.
3. Grossly increased local extent of ill-defined pancreatic
head mass with associated pancreatic ductal dilation and
atrophy. No evidence of metastatic disease in the abdomen or
pelvis.
4. Unchanged bowel wall thickening of the right colon may
represent changes related to local inflammation.
5. Enlarged prostate.
The study and the report were reviewed by the staff radiologist.
.
RUQ US:
Sonography of the liver demonstrates liver to be homgeneous in
echotexture with intrahepatic biliary ductal dilatation and
biliary air. Is ___ CCY.Biliary stent is identified in place.
The CBD measure 13mm. +hepatopedal flow.
=====================
CT Abd ___
IMPRESSION:
1. Right and left biliary stents appear in unchanged location.
Intrahepatic
biliary duct dilation is relatively unchanged since ___ but has
increased since ___.
2. No new liver hypodensity concerning for an abscess.
3. Relatively unchanged pancreatic head mass and pancreatic
duct dilation.
4. Unchanged bowel wall thickening of the right colon and
hepatic flexure,
which may be a reactive colitis related to local inflammation.
5. Unchanged prostatomegaly.
ERCP ___
Impression: Previous gastrojejunostomy of the stomach.
The 2 percutaneously-placed metal biliary stents were seen
fluoroscopically.
The duodenoscope could not be positioned under the metal stent
for access and clearance.
Only the left stent was visualized, which appeared to be
embedded in the duodenum.
Fluoroscopically the right stent appeared distal to the left
stent, and could not be visualized endoscopically.
Given the inability to access the metal biliary stents, the
procedure was aborted at this time.
Recommendations: Return to hospital floor.
Follow for response and complications.
Discuss with ___ regarding percutaneous options.
Follow-up with Dr. ___ as scheduled.
Follow-up with Dr. ___ as necessary.
___ Perc drain placement
IMPRESSION:
Percutaneous right-sided biliary access, and temporary left
sided access
during the procedure. Successful clearing of the stents with a
balloon sweep
of the right stent and saline flushes of the left.
Right sided percutaneous biliary drain placement with a destrung
8 ___
internal external drain The drain was left open to a bag for
drainage
overnight.
___ 06:25AM BLOOD WBC-5.1 RBC-3.40* Hgb-10.2* Hct-32.5*
MCV-96 MCH-29.9 MCHC-31.3 RDW-15.9* Plt ___
___ 06:45AM BLOOD Glucose-85 UreaN-4* Creat-0.7 Na-137
K-4.5 Cl-105 HCO3-27 AnGap-10
___ 06:25AM BLOOD ALT-46* AST-54* AlkPhos-445* TotBili-4.2*
Brief Hospital Course:
___ man with history of pancreatic cancer ___ gastrojejunostomy
and metal biliary stent, p/w jaundice, fever to 104.5. Seen at
outside hospital, RUQ US revealed dilated ducts, given IV Zosyn
for cholangitis, transferred to ___.
Biliary obstruction due to pancreatic cancer: The patient's
imaging, labs and clinical history were consistent with
obstructed stents. ERCP on ___ revealed biliary stents embedded
in duodenum that could not be reached via endoscope so on ___
patient had a percutaneous biliary drain placed by ___ and both
internal biliary stents cleared under fluoro. His drain was
still draining bilious fluid but the patient felt well and
tolerated a regular diet. He was given cipro and flagyl to
complete a 10day course for cholangitis. Blood cultures were no
growth to date. When the drain is no longer draining any fluid
pt will cap drain.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Zenpep (lipase-protease-amylase) 25,000-85,000- 136,000 unit
oral QACHS and QHS
2. Omeprazole 40 mg PO DAILY
3. Metoclopramide 5 mg PO TID:PRN nausea
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q6 Disp #*15 Tablet
Refills:*0
2. Omeprazole 40 mg PO DAILY
3. Metoclopramide 5 mg PO TID:PRN nausea
4. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*8 Tablet Refills:*0
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*12 Tablet Refills:*0
6. Zenpep (lipase-protease-amylase) 25,000-85,000- 136,000 unit
oral QACHS and QHS
7. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 cap by mouth bidprn Disp #*15
Capsule Refills:*0
8. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth bidprn Disp
#*15 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Biliary obstruction
Pancreatic cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with fevers due to a biliary obstruction
related to your cancer. You had an ERCP which was not successful
in relieveing the obstruction, so then you had a percutaneous
biliary drain placed by interventional radiology, which did
relieve the obstruction.
Followup Instructions:
___
|
10467410-DS-25 | 10,467,410 | 24,401,234 | DS | 25 | 2155-11-06 00:00:00 | 2155-11-06 21:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
jaundice
Major Surgical or Invasive Procedure:
Cholangiogram
History of Present Illness:
___ w/pancreatic cancer presents with jaundice. Pt reports 3
days of increasing jaundice, weakness, abdominal pain and
distension. No fever, nausea or emesis. Last week was at an
outside hospital due to fever and was given antibiotics and
discharged home.
In ED pt given zosyn, dilaudid. ___ and ERCP consulted.
On arrival to the floor pt denies nausea. Normal BMs. Minimal
drain output.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
# Pancreatic Cancer - s/p chemotherapy and xrt. s/p open biopsy,
liver biopsy, retroperitoneal LN biopsy, open CCY and open
gastrojejunostomy without vagotomy in ___ ___.
# s/p PTBD ___
# Portal thrombus associated with tumor
# s/p appendectomy
Social History:
___
Family History:
There is no family history of pancreatic cancer.
Mother with h/o liver CA, died at ___.
Physical Exam:
Vitals: T:98.4 BP:110/71 P:77 R:18 O2:100%ra
PAIN: 5
General: nad
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, distended, tender RUQ
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Pertinent Results:
___ 03:55PM GLUCOSE-88 UREA N-6 CREAT-0.7 SODIUM-131*
POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-28 ANION GAP-9
___:55PM ALT(SGPT)-67* AST(SGOT)-152* ALK PHOS-867*
TOT BILI-16.3*
___ 03:55PM LIPASE-5
___ 03:55PM ALBUMIN-2.8*
___ 03:55PM WBC-5.5 RBC-3.05* HGB-9.3* HCT-28.3* MCV-93
MCH-30.6 MCHC-33.0 RDW-17.8*
___ 03:55PM NEUTS-72.8* LYMPHS-14.8* MONOS-8.4 EOS-3.2
BASOS-0.9
___ 03:55PM PLT COUNT-233
___ 03:55PM ___ PTT-29.3 ___
RUQ US
1. Pancreatic duct dilatation measuring 1.1 cm.
2. Pneumobilia with biliary stents in place.
3. Patent right and main portal vein. The left portal vein is
not well
visualized.
4. 2.2 x 2.4 x 0.6 cm hypervascular lesion in the spleen
CT chest: 1. No evidence of intrathoracic metastasis.
CT Abdomen: IMPRESSION: 1. Moderate to severe intrahepatic
biliary dilation with pnemobilia concerning for obstruction of
the biliary catheter and stents due to degree of dilatation
despite the presense of pneumobilia. The percutaneous biliary
catheter appears to be pulled in and as a result the proximal
catheter side hole is within the right hepatic duct stent. No
side holes are visualized within the intrahepatic
or common bile duct.
2. Circumferential thickening around the celiac and superior
mesenteric
artereis appears somewhat increased since ___. The mass
in the
pancreatic head is relatively unchanged since ___.
3. Trace perihepatic ascites.
4. Mild prostatomegaly.
Tube cholangiogram
Successful balloon dilatation of the left intrahepatic duct
stricture with exchange for a new 10 ___ right percutaneous
transhepatic biliary drainage catheter.
Upper extremity ultrasound
Deep vein thrombosis within the left internal jugular,
subclavian
and axillary veins.
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-3.7* RBC-2.93* Hgb-9.0* Hct-27.7*
MCV-94 MCH-30.6 MCHC-32.5 RDW-19.5* Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-88 UreaN-2* Creat-0.7 Na-139
K-3.8 Cl-104 HCO3-29 AnGap-10
___ 06:45AM BLOOD ALT-38 AST-55* AlkPhos-567* TotBili-10.0*
Brief Hospital Course:
___ yo M with unresectable pancreatic cancer presents with
another biliary obstruction.
# Biliary obstruction: The patient had a CT scan of the abdomen
and chest that showed a stable pancreatic mass. Cholangiogram
was performed and revealed mild narrowing of the left
intrahepatic ducts. Patient underwent successful balloon
dilatation of the left intrahepatic duct stricture with exchange
for a new 10 ___ right percutaneous transhepatic biliary
drainage catheter. His symptoms improved. His liver function
tests improved. His biliary drain was able to be capped. He was
instructed to call ___ if any fever, abdominal pain, or leakage
around the catheter. He was instructed to make an appointment
with ___ in three months to have the drain exchanged. He was
instructed to follow up with oncology or PCP this week to check
LFT as his labs are improving but not yet normalized at time of
discharge.
# DVT: Patient was noted to have left arm swelling. An
ultrasound revealed a DVT. He was started on lovenox. He was
given a prescription for 1mg/kg BID lovenox - for insurance
reasons this was written for a 21 day supply but he should
continue anticoagulation for at least three months.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
2. Omeprazole 40 mg PO DAILY
3. Metoclopramide 5 mg PO TID:PRN nausea
4. Zenpep (lipase-protease-amylase) 25,000-85,000- 136,000 unit
oral QACHS and QHS
5. Senna 8.6 mg PO BID:PRN constipation
6. Docusate Sodium 100 mg PO BID:PRN constipation
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. Omeprazole 40 mg PO DAILY
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
4. Senna 8.6 mg PO BID:PRN constipation
5. Enoxaparin Sodium 60 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 60 mg/0.6 mL 1 Q12 Disp #*42 Syringe Refills:*0
6. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 3 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 by mouth Q12
Disp #*6 Tablet Refills:*0
7. Metoclopramide 5 mg PO TID:PRN nausea
8. Zenpep (lipase-protease-amylase) 25,000-85,000- 136,000 unit
oral QACHS and QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pancreatic cancer
Biliary obstruction
Deep vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a biliary obstruction. You were treated
with antibiotics and an interventional radiology procedure to
unclog your biliary drain. Your condition improved. You will
take three more days of antibiotics (augmentin). You will need
to schedule a follow up appointment with the interventional
radiologists to have your drain exchanged in three months
(telephone: ___. Your liver function tests improved
but have not yet returned to normal - you should follow up with
your primary care physician or oncologist this week for repeat
blood work.
If you develop any fever, worsening abdominal pain, leakage
around the catheter site, or other symptoms concerning for you
related to the drain please call the Interventional Radiology
department at ___.
You were also diagnosed with a deep vein thrombosis in your left
arm. You were started on lovenox, a blood thinner. You were
given a presciprtion for the next three weeks. You will need to
be on this medication for several months - when you follow up
with your oncologist you can get a refill prescription.
Followup Instructions:
___
|
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