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10042037-DS-5 | 10,042,037 | 25,017,311 | DS | 5 | 2165-10-04 00:00:00 | 2165-10-05 17:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Heroin withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with a h/o heroin and barbiturate use who
presents with heroin withdrawal. He reports that he has been
using oral heroin for the last 7 months and stopped two days
ago. Since then he has been experiencing vomiting, diarrhea,
abdominal pain, and diffuse muscle aches. He was previously
admitted in ___ for an opiate and barbiturate overdose
(somnolence) requiring naloxone and charcoal. He apparently has
access to barbiturates in his lab at ___.
.
In the ED initial VS were 97.4, 84, 114/79, 18, 100% RA. Labs
notable for neg tox screen, WBC 20.2 (91% PMN), K 3.0, Phos 6.9,
AG 21, UA neg. CXR neg for acute process. EKG showed SR w/o
ischemic changes. Patient was given diazepam 10mg.
.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- H/o heroin and barbiturate overdose
- H/o diverticulitis (___)
Social History:
___
Family History:
Mother with HTN. Father died at ___ of heart problems. Three
children are healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 99.6, 68, 126/77, 18, 97% on RA
GENERAL: NAD, comfortable, appropriate
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK: supple, no thyromegaly, no JVD
HEART: PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS: CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN: no rashes or lesions
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
.
DISCHARGE PHYSICAL EXAM:
VS: Tm 99.6, 101/63 (101-138/63-78), 55 (55-69), 18, 96-100% RA
GENERAL: NAD, somewhat uncomfortable, appropriate
HEENT: NC/AT, pupils dilated bilaterally, EOMI, sclerae
anicteric, MMM, OP clear
NECK: supple, no thyromegaly, no JVD
HEART: PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS: CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN: NABS, diffusely tender, soft/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN: no rashes or lesions
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Pertinent Results:
LABS ON ADMISSION:
___ 11:30AM BLOOD Glucose-149* UreaN-27* Creat-1.1 Na-139
K-3.0* Cl-91* HCO3-27 AnGap-24*
___ 11:30AM BLOOD Calcium-9.9 Phos-6.9*# Mg-2.2
___ 11:30AM BLOOD WBC-20.2*# RBC-5.70# Hgb-17.6# Hct-51.1
MCV-90 MCH-30.8 MCHC-34.3 RDW-12.8 Plt ___
___ 11:30AM BLOOD Neuts-91.7* Lymphs-3.7* Monos-3.6 Eos-0.9
Baso-0.1
___ 11:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:30AM BLOOD cTropnT-<0.01
___ 01:10PM BLOOD Lactate-1.8
___ 01:30PM URINE Color-Yellow Appear-Hazy Sp ___
___ 01:30PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-40 Bilirub-SM Urobiln-2* pH-5.0 Leuks-NEG
___ 01:30PM URINE RBC-1 WBC-6* Bacteri-FEW Yeast-NONE Epi-3
___ 01:30PM URINE CastHy-419*
.
LABS ON DISCHARGE:
___ 04:30AM BLOOD Glucose-140* UreaN-18 Creat-0.7 Na-136
K-3.6 Cl-99 HCO3-26 AnGap-15
___ 04:30AM BLOOD Calcium-8.4 Phos-2.4*# Mg-2.0
___ 04:30AM BLOOD WBC-11.9* RBC-4.42* Hgb-13.7*# Hct-40.6#
MCV-92 MCH-30.9 MCHC-33.7 RDW-12.9 Plt ___
.
MICRO:
Blood culture (___): pending
.
IMAGING:
CXR PA/LAT (___): PA and lateral chest radiographs
demonstrate no focal consolidation, pleural effusion, or
pneumothorax. The cardiomediastinal silhouette is normal.
Brief Hospital Course:
___ year old man with a history of heroin and barbiturate use who
presented with heroin withdrawal, leukocytosis, and an anion
gap.
.
# Heroin withdrawal: Patient presented after last taking oral
heroin 2 days ago. He denied any recent use of any IV drugs and
had no signs of this on his skin exam. His symptoms were
controlled with the following:
- Ondansetron 8mg IV Q8h prn nausea
- Acetaminophen 1g PO Q8h
- Lorazepam 1mg PO HS prn insomnia
- Loperamide 2mg PO QID prn diarrhea
- Clonidine patch 0.1mg, monitor BP and HR
- Methocarbamol 750mg PO Q6h prn muscle pain/cramps
- Dicyclomine 20mg PO Q4h prn stomach pain/cramps
The patient was able to tolerate small amounts of food and
fluids. He is being discharged to the ___ for further
treatment.
.
# Leukocytosis: Initial blood work showed a leukocytosis of 20.2
suspected to be a leukamoid reaction to catecholamine release
secondary to heroin withdrawal. Patient was afebrile with
unremarkable UA and normal CXR. No signs of cellulitis. No
cardiac murmurs and no history of recent IV drug use to suggest
endocarditis. By the following day the leukocytosis had resolved
to 11.9. Blood cultures are pending at the time of discharge.
.
# Anion gap: Initial blood work revealed an anion gap suspected
to be starvation ketoacidosis in the setting of poor PO intake
for the 2 days prior to admission. Dextrose was given via IV
fluids and the anion gap resolved by the following morning.
.
# Transitional Issues:
- Blood cultures pending at time of discharge, we will contact
the patient and the ___ facility should these return positive.
Medications on Admission:
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bismuth Subsalicylate 30 mL PO TID:PRN diarrhea
3. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QWED
4. DiCYCLOmine 20 mg PO Q4H:PRN stomach pain/cramps
5. Loperamide 2 mg PO QID:PRN diarrhea
6. Lorazepam 1 mg PO HS:PRN insomnia
7. Methocarbamol 750 mg PO Q6H:PRN muscle pain/cramps
8. Nicotine Patch 14 mg TD DAILY
9. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Heroin withdrawal
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 heroin withdrawal. Your
symptoms were treated with anti-emetics, Tylenol every 8 hours
for pain, anti-diarrheals, and intravenous fluids. You are being
discharged to the ___ for continued treatment.
Followup Instructions:
___
|
10042350-DS-2 | 10,042,350 | 23,080,531 | DS | 2 | 2118-06-01 00:00:00 | 2118-06-04 12:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
cephalexin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Percutaneous drainage of right lower quadrant abscess
History of Present Illness:
Mr. ___ is a ___ year-old male with a 1 week history of RLQ
pain, fevers (___), nausea, and decreased appetite. He
reports that he has had intermittent fevers for the last week.
He
also reports that the abdominal discomfort is mostly in the RLQ
for the last week associated with a decreased appetite. His last
colonoscopy was in ___ where they saw a hyperplastic polyp and
recommended a repeat colonoscopy in ___ years.
Past Medical History:
panic disorder, mitral valve prolapse,
psoriasis, osteoarthritis
Past Surgical History: R arm nerve decompression
Medications: alprazolam 1mg TID, ASA 81 daily
Allergies: cephalexin: rash
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: 98.9 73 132/77 18 100%RA
GEN: A&O3, 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, tender in the RLQ, no rebound or
guarding.
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 09:30PM BLOOD WBC-10.9* RBC-3.92* Hgb-11.5* Hct-33.0*
MCV-84 MCH-29.3 MCHC-34.8 RDW-13.6 RDWSD-42.1 Plt ___
___ 09:30PM BLOOD Glucose-122* UreaN-15 Creat-1.1 Na-128*
K-4.0 Cl-90* HCO3-24 AnGap-18
___ 06:05AM BLOOD WBC-10.8* RBC-3.44* Hgb-10.1* Hct-29.6*
MCV-86 MCH-29.4 MCHC-34.1 RDW-14.5 RDWSD-45.4 Plt ___
___ 06:05AM BLOOD Glucose-85 UreaN-15 Creat-0.9 Na-131*
K-3.7 Cl-93* HCO3-27 AnGap-15
___ 09:30PM BLOOD ALT-17 AST-23 AlkPhos-85 TotBili-0.4
Micro:
ABSCESS RLCE ABSCESS FROM APPENDICEAL RUPTURE.
ANAEROBIC CULTURE (Final ___:
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
BETA LACTAMASE POSITIVE.
Blood Culture, Routine (Final ___: NO GROWTH.
URINE CULTURE (Final ___: NO GROWTH.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
Radiology:
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 4:52 ___
8.5 cm walled off abscess in right lower quadrant consistent
with perforated appendicitis.
IMAGE CATH FLUID ___ Study Date of ___ 4:00 ___
Successful CT-guided placement of an ___ pigtail catheter
into the right lower quadrant collection with removal of 60 cc
purulent fluid. Culture and sensitivity sent.
CXR ___
The lungs are clear of interstitial or airspace opacity. No
pleural effusions or pneumothorax. The cardiomediastinal
silhouette is not enlarged. Multiple distended loops of colon
are visualized in the upper abdomen.
Brief Hospital Course:
Mr. ___ is a ___ year-old male who presented to the ED on
___ with a on week history of RLQ pain and fevers. A CT scan
demonstrated concern for perforated appendicits. The patient was
admitted to the General Surgical Service on ___ for
evaluation and treatment of abdominal pain. The patient was made
NPO and started on IVF and cipro/flagyl. After review the CT
scan with a GI radiologist the patient was determined to have
8.5 cm walled off abscess in right lower quadrant consistent
with perforated appendicitis and was scheduled for ___ guided
drainage. Intereventional radiology placed a drain on ___ and
aspirated 60cc of purulent
material which was sent for culture. The procedure went well and
without complication (reader referred to ___ note for details).
On ___ the patients WBC had increased from 12 the prior day to
17. The patients antiobiotic regimen was thus changed from
cipro/flagl to unasyn. Blood and urine cultures and a chest
film were obtained, all of which resulted negative for evidence
of infection. By the ___ the patients WBC had downtrended to
12.1. On ___ the patient had a WBC of 12 and had experienced
no further fevers in 24 hours.
During this hospitalization, the patient ambulated frequently
and actively participated in the plan of care. The patient
received subcutaneous heparin and venodyne boots were used
during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home with his drain in
place. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
alprazolam 1mg TID, ASA 81 daily
Discharge Medications:
1. ALPRAZolam 1 mg PO TID:PRN anxiety
2. Amoxicillin-Clavulanic Acid ___ mg PO Q8H Duration: 2 Weeks
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet(s) by mouth every eight (8) hours Disp #*42 Tablet
Refills:*0
3. Aspirin 81 mg PO DAILY
4. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia
RX *diphenhydramine HCl 25 mg 1 capsule(s) by mouth every twelve
(12) hours Disp #*20 Capsule Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
appendicits
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 ___ and
underwent percutaneous drainage of your ___
abscess. You are recovering well and are now ready for
discharge. Please follow the instructions below to continue your
recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
10042769-DS-20 | 10,042,769 | 23,079,910 | DS | 20 | 2154-03-10 00:00:00 | 2154-03-10 15:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Morphine
Attending: ___.
Chief Complaint:
right groin cyst pain, and RLE edema
Major Surgical or Invasive Procedure:
___ aspiration and drainage of right groin cyst fluid collection.
History of Present Illness:
This is ___ with history significant for chronic right hip/groin
cyst s/p multiple ___ drainage procedures. The patient presented
to the OSH with compaints of right groin pain and right lower
extremity edema. The patient's sister reports that this has been
a recurrent problem which began approximately ___ years ago
following the patient's second hip replacement. His cyst
has now reoccurred and it is very painful. This is associated
with right thigh pain.The patient underwent an ultrasound at OSH
which showed extensive right femoral DVT. He was transferred to
___ for further evaluation and treatment. The patient is well
known to Dr. ___ on the surgical service and was admitted for
___ drainage of right groin cyst and treatment of DVT.
Past Medical History:
CAD
thalassemia
vertigo
gout
mild dementia
gout
chronic RLE edema
PSH: right hip replacement and revision ___
Social History:
___
Family History:
There is no other family history of known coronary artery
disease or cancer.
Physical Exam:
VS: Tm 97.1, Tm 97.1, HR 59, BP 110/62, RR 19, 98% RA
General: NAD, AAOx3
Cardiac: RRR, faint heart sounds
Respiratory: CTA
Abdomen: Soft, NTND, normoactive bowel sounds
Extremities: right lower abdomen/groin site c/d/i, no hematoma,
no erythema
right lower extremity +2 edema, no erythema
Pertinent Results:
Admission Labs:
___ 06:40PM BLOOD WBC-4.2 RBC-4.67 Hgb-10.4* Hct-33.4*
MCV-72* ___.3* MCHC-31.1 RDW-16.7* Plt ___
___ 06:40PM BLOOD Neuts-61.4 ___ Monos-11.1*
Eos-6.8* Baso-2.6*
___ 04:50AM BLOOD ___
___ 06:40PM BLOOD Glucose-83 UreaN-18 Creat-1.0 Na-144
K-4.2 Cl-109* HCO3-26 AnGap-13
Coagulation Trend:
___ 06:40PM BLOOD ___ PTT-33.4 ___
___ 08:40AM BLOOD ___ PTT-69.4* ___
___ 11:00AM BLOOD ___ PTT-38.6* ___
___ 12:05PM BLOOD ___ PTT-69.8* ___
___ 05:20AM BLOOD ___ PTT-85.9* ___
___ 05:00AM BLOOD ___ PTT-44.9* ___
___ 04:50AM BLOOD ___
Brief Hospital Course:
Mr. ___ is a ___ year old male who presented to OSH an
accumulation of a chronic right groin cyst, as well as a new
right lower extremity DVT. The patient was admitted to the
inpatient general surgery unit under the care of Dr. ___
further evaluation and treatment.
The patient went to the ___ suite and underwent an aspiration of
the right groin cyst. The patient did not require placement of a
drain. The right groin site was monitored closely for signs and
symptoms of seroma and hematoma of which there were none. He
remained afebrile without leukocytosis.
For treatment of his DVT, Mr. ___ was started on
anticoagulation therapy and was maintained on a heparin gtt
during his hospitalization and bridged to Coumadin. His INR
levels were monitored closely and he was dosed appropriately.
Mr. ___ need to continue on long term anticoagulation
therapy and will be followed by his PCP for monitoring of his
INR and for Coumadin dosing. He was set up with home ___
who will check his INR on ___ and fax the results to his
PCP.
During this admission the patients pain was treated with
Oxycodone and Tylenol and he had adequate pain control. He was
ambulating plentifully throughout the admission and tolerating a
regular diet. The patient was discharged home in good condition
with follow-up instructions.
Medications on Admission:
sotalol 60 mg Po BID
aricept 10 mg PO QD
ASA 81 mg PO QD
tylenol prn
indomethacin 25 mg PO prn
imdur 30 qhs
antivert 25 prn
iron
folic acid
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
2. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO QHS (once a day
(at bedtime)).
4. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. meclizine 25 mg Tablet Oral
6. indomethacin 25 mg Capsule Oral
7. folic acid Oral
8. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. sotalol 120 mg Tablet Sig: ___ Tablet PO twice a day.
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO every other
day.
11. potassium Oral
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1.Right groin cyst
2.Right femoral DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you during this
hospitalization. You were hospitalized for continued management
of a right groin cyst and underwent ___ drainage. You also
presented with right leg swelling and were found to have a blood
clot also known as DVT (Deep vein thrombosis). During your
hospitilization you were treated on a Heparin drip and Coumadin
(blood thinners). Once your blood level was stable the heparin
drip was discontinued and you were started on Coumadin. You will
need to continue on Coumadin and have your blood level monitored
closely. We have arranged for your primary care provider to
monitor your blood level and dose your Coumadin. Starting today
you should start taking your coumadin (2 mg) at night. Your
visiting nurse ___ draw your blood to check your INR ___ and
fax the results to your primary Physician.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed. If you have any questions or
concerns please contact the office.
Thank you for letting us participate in your care. We wish you
a speedy recovery.
Followup Instructions:
___
|
10042793-DS-7 | 10,042,793 | 24,693,778 | DS | 7 | 2141-05-02 00:00:00 | 2141-05-02 15:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
shellfish derived
Attending: ___
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is ___ with PMH of PE/DVT on warfarin, Alzheimer's
(nonverbal at baseline) who presents as a transfer from ___
___ after evaluation of witnessed fall from her nursing home
today.
History and exam limited as patient has dementia and is
nonverbal at baseline.
Per ___ notes: ___ year old female with Alzheimer's,
nonverbal, presenting after a witnessed fall at her facility.
She struck her head and was transferred here. She is not
endorsing any pain or changes from her baseline. She has a 2cm
laceration on her right forehead and significant swelling and
bruising around her right eye. She takes warfarin."
At ___, Vitals: T100.6R 63 20 96% RA 133/60. Patient's PE
was significant for "tenderness to palpation and pain with
movement of the right wrist. Remainder of the exam was
unremarkable."
Labs were notable for INR of 2.1. CT head wo contrast showed
acute SAH along the frontal and temporal lobes bilaterally with
no midline shift. CT cervical spine wo contrast showed no
fracture or traumatic malalignment.
She received K Centra, splint was applied to right wrist, and
her laceration over her right eye was treated with dermabond
prior to transfer.
At ___, vitals were 98.8 64 143/60 19 98%RA
At the bedside, patient endorses pain in right wrist. Denies HA,
chest pain, or abdominal pain.
Past Medical History:
PMH:
-DVT/PE
-Alzheimers Dementia
-Volvulus
Social History:
___
Family History:
___: non-contributory
Physical Exam:
Physical:
General: NAD
Vitals: 101.0 70 139/69 16 96%RA
HEENT: PERRLA, 2cm laceration to right forehead with swelling
and ecchymosis around right eye
Cardio: RRR, II/VI systolic murmur
Pulm: breathing comfortably on RA
Abdomen: soft, NT, ND, no rebound or guarding
Neuro: AOx1 to self, believes she is at home; Responds to name;
intermittently follows commands; moving extremities
spontaneously; denies sensory deficits
Extremities: warm, well-perfused, trace peripheral edema; ace
wrap over right wrist
Skin: Grade 1 pressure ulcer to left of coccyx
Physical Exam At Discharge:
VS: 98.4, 132/68, 56, 18 95%Ra
HEENT: PERRLA, 2cm laceration R supraorbital healing, R
infraobrital hematoma healing
Cardio: RRR, soft II systolic murmur
Pulm: clear to auscultation bl
Abdomen: soft, NT, ND, no rebound or guarding
Neuro: AOx1 to self, not place or time, moving extremities
spontaneously with slow to respond on right lower extrem
Extremities: warm, well-perfused, trace peripheral edema; R arm
in cast
Pertinent Results:
Wrist XRay ___:
IMPRESSION: Overlying cast material obscures fine bony detail.
Similar appearance of slightly impacted, dorsally angulated
distal intra-articular fracture of the radius.
CT Head wo Con ___:
IMPRESSION: Slight increase in the volume of subarachnoid
hemorrhage, particularly in the right sylvian fissure, since the
prior study. Otherwise unchanged examination.
CXR ___:
IMPRESSION: No focal consolidation. Stable small hiatal hernia
and mild cardiomegaly.
Pelvis ___:
IMPRESSION: No evidence of acute fracture or dislocation with
limited evaluation of the
sacrum due to overlying bowel gas.
LABS:
___ 04:10AM cTropnT-0.01
___ 11:40PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:40PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD*
___ 11:40PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-1
___ 11:40PM URINE HYALINE-7*
___ 11:40PM URINE MUCOUS-RARE*
___ 11:07PM LACTATE-1.8 K+-4.0
___ 11:00PM GLUCOSE-132* UREA N-24* CREAT-1.0 SODIUM-137
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-27 ANION GAP-13
___ 11:00PM cTropnT-0.03*
___ 11:00PM WBC-12.4* RBC-4.00 HGB-11.8 HCT-36.6 MCV-92
MCH-29.5 MCHC-32.2 RDW-13.6 RDWSD-45.7
___ 11:00PM NEUTS-83.7* LYMPHS-7.9* MONOS-7.3 EOS-0.4*
BASOS-0.2 IM ___ AbsNeut-10.33* AbsLymp-0.98* AbsMono-0.90*
AbsEos-0.05 AbsBaso-0.03
___ 11:00PM PLT COUNT-228
___ 11:00PM ___ PTT-29.5 ___
Brief Hospital Course:
Ms. ___ was transferred to ___ from ___
after a witnessed fall at her facility with a right radius
fracture, supraorbital laceration and subarachnoid hemorrhage.
At the outside hospital she received K Centra, splint was
applied to right wrist, and dermabond over her right eye
laceration prior to transfer. When she presented to ___
___ she was febrile with urine sample consistent
with a urinary tract infection and was treated with ceftriaxone.
Her coumadin was held while in the hospital. On HD2 she was
noted to have evolution of the subarachnoid hemorrhage per
neurosurgery this is the expected sequelae. On HD2 she was
monitored for cardiac ectopy to further work up her fall, none
was reported by nursing as visualized by the monitor. She was on
telemetry and will discharge you with a holter monitor for
further cardiac workup. She was seen by orthopedics who placed a
brace on her right wrist. She was seen by neurosurgery who
determined no surgery was necessary. Tertiary trauma survey was
complete without new findings. She was discharged on HD3 to a
rehabilitation facility to continue physical therapy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 1 mg PO DAILY
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Donepezil 10 mg PO QHS
5. Multivitamins 1 TAB PO DAILY
6. Vitamin D Dose is Unknown PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
Please do not exceed 4000mg in 24 hours
2. Docusate Sodium 100 mg PO BID
3. Senna 17.2 mg PO HS
4. Vitamin D unknown PO DAILY
5. Donepezil 10 mg PO QHS
6. Furosemide 20 mg PO DAILY
7. Levothyroxine Sodium 150 mcg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. HELD- Warfarin 1 mg PO DAILY This medication was held. Do
not restart Warfarin until ___ and after you talk to your PCP
about the risks and benefits of this drug.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
mechanical fall
subarachnoid hemorrhage
radius fracture R
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were transferred to ___ from ___ after
a witnessed fall at her facility with a radius fracture on the
r, supraorbital laceration and subarachnoid hemorrhage. At the
outside hospital you received K Centra, splint was applied to
right wrist, and dermabond over your right eye laceration prior
to transfer. When you got to ___ you
were noted to have a urinary tract infection which we treated
with antibiotics. We placed you on telemetry and will discharge
you with a holter monitor for further cardiac workup. You were
seen by orthopedics who placed a brace on your right wrist. You
were seen by neurosurgery who determined no surgery was
necessary. You are doing well and are ready for discharge.
General Surgery:
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 new onset 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.
Holter:
*There was concern that your heart may be the case for your
falls.
*You were placed on a holter monitor at the time of discharge.
*Your cardiac monitor will be evaluated after 30 days.
*If you have any questions please call the office ___.
Medications:
*Please resume all regular home medications.
*Please hold Coumadin for total of 7days until at least ___ and
you talk to your PCP about the risks and benefits with
restarting this medication. *Also, please take any new
medications as prescribed.
General Care:
*Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
*Avoid lifting with your right arm until you are cleared by
physical therapy or your orthopedic surgeon as an outpatient.
*Avoid driving or operating heavy machinery while taking pain
medications.
Thank you for letting us participate in your care!
Followup Instructions:
___
|
10042896-DS-16 | 10,042,896 | 27,960,228 | DS | 16 | 2147-11-03 00:00:00 | 2147-11-05 18:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
RUQ abdominal/flank pain, R pleuritic chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with GERD, hiatal hernia, h/o thyroid Ca s/p thyroidectomy
___ years ago who presents with RUQ/lower R chest pain since
___. Patient reports pain started suddenly and was initially
concerned that it was muscle pull or reflux. She took pepcid
without benefit. Unable to sleep given pain. Took 6 tabs
ibuprofen without relief. Pain was worse with inspiration, worse
when lying on affected side. Denies chest pain, denies SOB,
denies lightheadedness, denies ___ edema. Not affected by eating
(pt does have a h/o gallstones). No f/c, N/V/D.
In the ED, initial vitals were: 97.9 111 139/60 8 97% RA
- Exam notable for:
Tachy to 111, otherwise VSS
Gen: well-appearing
CV: RRR, no M/R/G
Resp: unable to take deep breath, CTAB
Chest wall: no TTP
Abd: non-distended, soft, non-tender. Neg ___ sign
Ext: no swelling, no calf tenderness
- Labs notable for: DDimer 770
- Imaging was notable for:
CTA chest: 1. Segmental and subsegmental pulmonary emboli
within the right lower lobe associated with pulmonary infarction
in the peripheral anterior aspect of the right lower lobe. No CT
evidence for right heart strain. 2. Small right pleural
effusion.
CXR: Wedge-shaped opacity within the periphery of the right
lower lobe concerning for pulmonary infarction and further
assessment with chest CTA is recommended to evaluate for
pulmonary embolism. No pneumothorax.
- Patient was given: lovenox 70 mg SQ
- Vitals prior to transfer: 98.1 97 116/67 14 98% RA
Upon arrival to the floor, patient reports pain is persistent,
worse with inspiration, worse when lying on affected side.
Denies palpitations, lightheadedness, chest tightness, chest
pain.
Notably, denies long plane ___ car rides, recent
surgery or immobility. Last ___ within the year, had breast bx
that was negative for malignancy per pt report. Last pap smear ___
years ago, wnl per pt. No prior cervical bx. No weight loss,
fevers, chills, night sweats. Follows with endocrinologist at
___ for her hypothyroidism (s/p thyroidectomy), had bone scan
notable for osteoporosis. Does not have routine imaging for
thyroid malignancy follow up. No hormonal use. Never smoker
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
- GERD, hiatal hernia
-macular degeneration
-papillary thyroid Ca s/p partial thyroidectomy ___
-Hypothyroidism
-high cholesterol
Social History:
___
Family History:
father had ___ disease. Mother had breast cancer (___)
and dementia. One daughter has primary biliary cholangitis. No
___ blood clots, PE, DVT. Father was on ___ for unknown
indication
Physical Exam:
ADMISSION EXAM:
Vital Signs: 99.8 103/59 109 20 94 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: tachycardic, regular. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi. No chest wall tenderness
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE EXAM:
Vital Signs: T98.1 BP 102 / 55 73 18 96 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: tachycardic, regular. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Decreased breath sounds in RLL, otherwise clear to
auscultation bilaterally, no wheezes, rales, rhonchi. Posterior
chest wall tender to palpation
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
ADMISSION LABS
==============
___ 03:15PM BLOOD WBC-9.4# RBC-4.69 Hgb-14.1 Hct-42.4
MCV-90 MCH-30.1 MCHC-33.3 RDW-12.8 RDWSD-42.5 Plt ___
___ 03:15PM BLOOD Neuts-59.3 ___ Monos-11.9
Eos-0.1* Baso-0.4 Im ___ AbsNeut-5.55 AbsLymp-2.61
AbsMono-1.12* AbsEos-0.01* AbsBaso-0.04
___ 03:15PM BLOOD ___ PTT-26.6 ___
___ 03:15PM BLOOD Glucose-102* UreaN-12 Creat-0.8 Na-139
K-4.1 Cl-101 HCO3-22 AnGap-20
___ 03:15PM BLOOD ALT-32 AST-40 AlkPhos-64 TotBili-0.6
___ 03:15PM BLOOD Lipase-24
___ 03:15PM BLOOD cTropnT-<0.01 proBNP-111
___ 03:30PM BLOOD D-Dimer-740*
IMAGING
=========
CTA chest ___: 1. Segmental and subsegmental pulmonary
emboli within the right lower lobe associated with pulmonary
infarction in the peripheral anterior aspect of the right lower
lobe. No CT evidence for right heart strain. 2. Small right
pleural effusion.
CXR ___: Wedge-shaped opacity within the periphery of the
right lower lobe concerning for pulmonary infarction and further
assessment with chest CTA is recommended to evaluate for
pulmonary embolism. No pneumothorax.
DISCHARGE LABS
=============
___ 03:15PM BLOOD WBC-9.4# RBC-4.69 Hgb-14.1 Hct-42.4
MCV-90 MCH-30.1 MCHC-33.3 RDW-12.8 RDWSD-42.5 Plt ___
___ 06:10AM BLOOD ___ PTT-29.0 ___
___ 06:10AM BLOOD Glucose-83 UreaN-11 Creat-0.7 Na-139
K-3.5 Cl-101 HCO3-26 AnGap-16
___ 06:10AM BLOOD ALT-26 AST-24 LD(LDH)-179 AlkPhos-59
TotBili-0.8
___ 06:10AM BLOOD cTropnT-<0.01
___ 06:10AM BLOOD Albumin-3.9 Calcium-8.8 Phos-3.1 Mg-2.2
___ 06:10AM BLOOD TSH-1.5
Brief Hospital Course:
Mrs. ___ is a ___ year old female with a history of
papillary thyroid carcinoma s/p partial thyroidectomy in ___,
GERD and hiatal hernia who presented to the ___ ED with RUQ
abdominal/flank and right-sided posterior chest wall pleuritic
pain, found to have RLL segmental and subsegmental PEs, with
associated RLL pulmonary infarction.
ACTIVE ISSUES:
# Segmental and subsegmental PEs:
Patient presented with RUQ and right posterior chest wall pain,
which was noted to be pleuritic in nature and worsened with
inspiration. Initial CXR was concerning for a wedge like opacity
within the periphery of the right lower lobe concerning for
pulmonary infarction. CTA chest revealed segmental and
subsegmental PEs in the right lower lobe, accompanied with
pulmonary infarction in the peripheral anterior aspect of the
right lower lobe. Patient had no evidence of right heart strain
and cardiac markers (troponin and BNP) were negative. Underlying
etiology of forming a VTE is unclear at this time. Patient does
not endorse recent history of being immobile, and further denies
any medications associated with formation of PE. She has a
history of papillary thyroid cancer ___ years prior) but is s/p
thyroidectomy. Her age-appropriate cancer screening includes
regular colonoscopies with a known history of polyps, but last
colonoscopy in ___ was within normal (pt was recommended f/u
in ___ years), also up to date on mammography and pap smears.
Patient was treated as an unprovoked PE, and was initiated on
lovenox therapy, and transitioned to Rivaroxaban for 6 month
course for unprovoked PE. She will be seen as an outpatient by
hematology/oncology to assess etiology of PE and complete a
hypercoagulable workup.
TRANSITIONAL ISSUES:
====================
[] Pt was started on a 6 month course of Rivaroxaban for
unprovoked segmental and subsegmental PE, with associated
pulmonary infarct. Patient will take Rivaroxaban 15mg BID for 21
days (start date ___, end date ___, and then transition to
Rivaroxaban 20mg once daily for 6 months (end date ___.
She will further followup with her PCP and outpatient
hematologist for further hypercoagulable workup to guide length
of therapy.
[] Please readdress the length of anticoagulation required with
Rivaroxaban pending outpatient workup with hem/onc.
[] Please ensure patient is compliant with taking Rivaroxaban
daily to prevent future blood clots
[] Pt will benefit from f/u with endocrinologist to consider
repeat thyroid imaging including thyroid U/S as well as TSH/FT4
to ensure no evidence of recurrence of her thyroid ca, and to
determine if patients thyroid cancer history is related to
development of a PE .
[] Pt had incidentally found cholelithiasis noted on CT imaging,
however had normal LFTs on this admission. Pt will benefit from
repeating LFTs if pt becomes symptomatic in the future.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Famotidine 20 mg PO DAILY
2. Simvastatin 10 mg PO QPM
3. Levothyroxine Sodium 125 mcg PO DAILY
4. ALPRAZolam 0.25 mg PO QHS:PRN anxiety, insomnia
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 325 mg 2 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Rivaroxaban 15 mg PO BID Duration: 21 Days
Dose #1 of 2: Please take 15mg twice daily for 3 weeks, then
switch to Dose #2 of 2
RX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice daily
Disp #*42 Tablet Refills:*0
3. Rivaroxaban 20 mg PO DAILY
Dose #2 of 2: Please start 20mg daily after ___ complete 3 weeks
of 15mg twice daily
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. ALPRAZolam 0.25 mg PO QHS:PRN anxiety, insomnia
5. Famotidine 20 mg PO DAILY
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Simvastatin 10 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary Embolism (segmental and subsegmental PE)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ presented to the ___ ED with right flank and right upper
abdominal pain, accompanied with right-sided posterior chest
wall pain that worsened with inspiration. ___ were assessed with
labs and imaging, and a CT scan of your chest showed several
pulmonary emboli as well as an associated pulmonary infarction
(a damaged area of the lung due to lack of blood flow).
Due to the above finding of a pulmonary embolism and pulmonary
infarction, ___ were admitted to the inpatient service, where
___ were assessed with labs and monitored on telemetry. ___ had
no difficulty maintaining your oxygen saturation, and your pain
was well controlled while admitted to the inpatient service. ___
were transitioned from Lovenox to Rivaroxaban, a medication to
prevent further development of blood clots in your lungs or
elsewhere in your body. ___ will readdress how long ___ need to
be on your Rivaroxaban with your outpatient primary care
physician and outpatient hematologist, however ___ will likely
continue Rivaroxaban for a minimum of 6 months.
Please ensure that ___ take your prescribed medications as
instructed below, and ensure that ___ take this medication every
day to prevent future clots.
Please also followup at the appointments noted below that have
been arranged on your behalf.
It was a pleasure being involved in your care.
Your ___ care team
Followup Instructions:
___
|
10043039-DS-9 | 10,043,039 | 24,987,075 | DS | 9 | 2133-04-01 00:00:00 | 2133-04-01 11:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Imitrex / Penicillins
Attending: ___.
Chief Complaint:
Right tibial plateau fracture
Major Surgical or Invasive Procedure:
Right tibial plateau ORIF ___, ___
History of Present Illness:
___ male history hypertension, anxiety, depression, ADD,
alcohol abuse who presents with right knee pain status post fall
while ice skating yesterday. Denies head strike or loss of
consciousness. Unable to ambulate today which prompted his
visit
to urgent care. unable to take an x-ray at urgent care due to
severe pain, so transferred here for further workup. Noted to
have a cold foot with weak ___ pulse, so vascular surgery
consulted and CTA of the right leg performed. Denies numbness or
tingling.
Past Medical History:
HYPERTENSION
ANXIETY
DEPRESSION
ATTENTION DEFICIT DISORDER WITHOUT HYPERACTIVITY
ALCOHOL ABUSE
PSYCHIATRIST
Social History:
___
Family History:
nc
Physical Exam:
Discharge PE:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* dressing with scant serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* ___ strength
* SILT, NVI distally
* Toes warm
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right tibial plateau fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right tibial plateau ORIF which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home
with home ___ was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touchdown weightbearing in the right lower extremity, and will
be discharged on Lovenox 40 mg daily 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:
ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation
aerosol inhaler. 2 puffs inhaled every 4 hours as needed for
cough, wheeze, sob
CODEINE-GUAIFENESIN - codeine 10 mg-guaifenesin 100 mg/5 mL oral
liquid. 10 ml by mouth twice daily as needed for cough
DEXTROAMPHETAMINE-AMPHETAMINE - dextroamphetamine-amphetamine 15
mg tablet. 1 tablet(s) by mouth two times per day as needed for
concentration
HYDROCHLOROTHIAZIDE - hydrochlorothiazide 25 mg tablet. 1
tablet(s) by mouth once a day
LISINOPRIL - lisinopril 10 mg tablet. TAKE 1 TABLET BY MOUTH
DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QHS
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
5. Senna 8.6 mg PO BID
6. Amphetamine-Dextroamphetamine 15 mg PO BID
7. Hydrochlorothiazide 25 mg PO DAILY
8. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right 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. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Touchdown weightbearing right lower extremity in an unlocked
___
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox 40 mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
-You may take down your Ace wrap once home. You may change your
dressing if saturated in place a new clean gauze if draining
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
Physical Therapy:
Touchdown weightbearing right lower extremity in an unlocked
___, range of motion as tolerated
Treatments Frequency:
Remove ace wrap once home
Change dressings if saturated, apply dry sterile dressing daily
if needed after primary dressing removed
if not draining leave open to air
wound checks
staple removal and replace with steri-strips at follow up visit
in clinic
Followup Instructions:
___
|
10043321-DS-17 | 10,043,321 | 29,686,634 | DS | 17 | 2154-01-07 00:00:00 | 2154-01-07 22:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Penicillins / Sulfa (Sulfonamide
Antibiotics)
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with longstanding untreated OSA, DM, and HTN p/w
progressively worsening exertional dyspnea. She reports that
she has had DOE for nine months. She noted it primarily with
walking up stairs and it has been slowly progressive. No rest
symptoms, no chest pain/pressure during the past few months. She
has gained about 12 pounds over the past 6 months and attributed
her symptoms to that. Also has dry cough - feels like she needs
to clear sputum but is unable to. She went to PMD last week, who
heard crackles and felt she might have a bronchitis and told her
to use albuterol/flovent and return in a week. Seen again a few
days ago and still had crackles on exam. She obtained a CXR that
was consistent with pulmonary edema. A CXR in ___ showed no
active process. She was subsequently started on lasix 2 days
ago, which she has had 3 doses of. Given no clear etiology for
CHF, went to have stress echo performed today, at which she had
a profound desaturation to 78% after 4 min of exercise. Concern
for possible PE and sent to ED for evaluation. Denies any chest
pain during stress test, denies leg swelling, denies HA.
In the ED, initial VS were: 98.1 93 140/74 18 93%. Labs
significant for trop <0.01, WBC 16.9 (N:60 Band:0 ___ M:7 E:5
Bas:0 Atyps: 2), D-D-dimer 1550, proBNP: 73, CXR showed
increased pulm vascularity and prominence of interstitium, no
consolidation or effusion, mild cardiomegaly. Started on heparin
drip. CTA not done because of previous reaction so plan to admit
and V/Q scan in the am.
VS on transfer: 97.6 92 114/72 18 95%.
Currently, she feels well with no complaints. She notes
occasional posterior right sided chest pain with movement, not
pleuritic in nature. No leg swelling, PND, orthopnea. ___ years
ago was in ___, ___ year ago in ___, no recent travel
to ___, ___. Notes that her
ankles swell after eating salty food. No unusual exposures she
can think of although has worked as a histologist for ___ years
and so has been exposed to chemicals in that line of work.
Past Medical History:
HTN
Tubal ligation
Pancreatic cyst excision ___ with distal splenectomy,
pancreatectomy, and cholecystectomy
OSA
DM2
HLD
Migraine HA
h/o post-operative SBO
Submucosal fibroid
Leiomyoma
Rotator cuff tear
Social History:
___
Family History:
Father with CAD and CABG in late ___, mother with melanoma and
___, sister with breast cancer. Denies pulmonary
parencymal disease, blood clots, autoimmune disorders.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS:98.1 132/74 94 16 94%RA
Desaturated to 83% with gentle ambulation from her room to to
the end of the hallway.
GENERAL: well appearing, NAD
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, JVD: flat
LUNGS: late bibasilar crackles, inspiratory squeaks and pops
througout lung fields, especially RUL that did not clear with
coughing
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: obese, normal bowel sounds, soft, non-tender,
non-distended, no rebound or guarding, no masses
EXTREMITIES: no edema
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, normal gait
PHYSICAL EXAM ON DISCHARGE:
VS 97.6 106/63 69 16 94%RA
GEN NAD, comfortable
HEENT NCAT, OP mildly erythematous, clear nasal discharge
NECK Supple, no LAD
PULM Diffuse crackles and expiratory wheezes, bibasilar
crackles, unchanged
CV RRR normal S1/S2
ABD obese, soft NT ND normoactive bowel sounds
EXT WWP 2+ pulses bilaterally
Pertinent Results:
___ 05:46PM D-DIMER-1524*
___ 05:40PM proBNP-73
___ 05:40PM cTropnT-<0.01
___ 05:40PM WBC-16.9* RBC-4.91 HGB-15.7 HCT-46.9 MCV-96
MCH-32.0 MCHC-33.5 RDW-12.8
___ 05:40PM NEUTS-60 BANDS-0 ___ MONOS-7 EOS-5*
BASOS-0 ATYPS-2* ___ MYELOS-0
___ 05:40PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
___ 05:40PM PLT SMR-NORMAL PLT COUNT-355
___ 05:40PM ___ PTT-30.1 ___
___ 05:40PM GLUCOSE-137* UREA N-21* CREAT-0.7 SODIUM-139
POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-29 ANION GAP-15
___ 05:40PM ALT(SGPT)-22 AST(SGOT)-21 ALK PHOS-75 TOT
BILI-0.7
___ 05:40PM ALBUMIN-4.5
CT Chest
IMPRESSION:
1. Diffuse moderate to severe small airway obstruction, but no
particular
bronchial wall thickening, mucoid impaction, bronchiectasis, or
atelectasis.
The explanation for small airway obstruction is not obvious
radiographically.
2. Minimal regional fibrosis, both upper lobes, there is not a
generalized
process.
3. Probable pulmonary arterial hypertension conceivably but not
necessarily
that due to small airways obstruction.
4. Left anterior descending coronary atherosclerosis.
5. Fatty infiltration of the liver.
Brief Hospital Course:
___ with longstanding untreated OSA, NIDDM, and HTN p/w
progressively worsening exertional dyspnea, found to have
interstitial lung disease and mild-to-moderate pulmonary
hypertension.
#Hypoxemia: Etiology of acute hypoxemia unclear, as ambulatory
and nocturnal desaturations out of proportion to findings on CT
and TTE. Patient presents with six months of gradually worsening
exertional dyspnea, found to have mosaic CT attenuation and
mild-to-moderate pulmonary hypertension on echo. She was given
supplemental O2 2L/NC to keep O2>90% and albuterol nebs, with
some mild symptomatic improvement. A stress echocardiogram did
not reveal any evidence of an acute ischemic process, but was
terminated prematurely due to fatigue and exertional dyspnea
along with hypoxemia. Pulmonary saw her, and PFTs showed
moderate restriction and impaired diffusion, consistent with
interstitial pulmonary process. Patient's history of chronic
occupational exposures, fen-phen exposure, and smoking would
further support ILD. She underwent a rheumatologic workup as
well, for collagen vascular disease, sarcoidosis, and
vasculitis, with results pending on discharge. An early
interstitial process, coupled with pulmonary hypertension, is
likely contributing to her degree of hypoxemia. It is highly
possible that her pulmonary hypertension is likely attributable
to her h/o longstanding OSA with recurrent nocturnal hypoxemia
vs. diastolic dysfunction (LAE with high LVEF 70% would further
support this). D-dimer was elevated though CTA PE protocol
ruled-out pulmonary embolism. She had negative troponins,
reassuring EKG, and BNP 73, and recent stress echo without
evidence of ischemia. TEE with bubble study was negative. She
was clinically improved and was evaluated by physical therapy,
satting at 94% on room air, but still had persistent nocturnal
and exertional hypoxemia with desaturations to the mid-80s, thus
we initiated home supplemental oxygen on discharge along with
pulmonary rehab. She is scheduled to see pulmonology for further
work-up of her interstitial pulmonary process and pulmonary
hypertension. Plan for repeat sleep study, right heart cath for
further evaluation of pulmonary hypertension, will be performed
as an outpatient.
# Leukocytosis: Patient has had a chronic history of
intermittently elevated WBC in Atrius records dating back to
___. Etiology is unknown. Patient had elevated WBC during her
hospitalization: 16.9->16.8->12.4->11.2->13.8. This has been a
chronic, stable issue. No urinary symptoms concerning for UTI.
Differential with 5% eos and 2% atypicals. Further workup to be
performed as an outpatient.
# Diabetes mellitus: We held her metformin and covered with ISS
while she was admitted.
# Hypertension: Patient's BP was well controlled with ACEi and
thus we continue enalapril while she was inpatient.
# HLD: stable, patient was continued on home dose simvastatin
for dyslipidemia.
Transitional issues:
--------------------
- Will need outpatient RHC, sleep study, consideration for V/Q
scan
- Outpatient pulmonary follow up
- Will require coronary cath for LAD Atherosclerosis seen on CT,
probably can schedule with RHC if happening in the near future
- Discharged on oxygen 2 L NC to be used when ambulatory and
nocturnal
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Enalapril Maleate 40 mg PO DAILY
hold for SBP < 90
3. MetFORMIN (Glucophage) 1000 mg PO DAILY
4. Simvastatin 30 mg PO DAILY
5. Potassium Chloride 10 mEq PO DAILY
Hold for K >
6. Furosemide 20 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Simvastatin 30 mg PO DAILY
4. Enalapril Maleate 40 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO DAILY
7. Acetaminophen 500 mg PO Q6H:PRN Headache
8. Oxygen
Please provide oxygen at 2L/min through NC continuous pulse dose
for portability. Pulmonary hypertension.
9. Outpatient Physical Therapy
Evaluate and treat for pulmonary rehab. Pulmonary Hypetension
10. Potassium Chloride 10 mEq PO DAILY
Hold for K > 4.0
Discharge Disposition:
Home
Discharge Diagnosis:
Interstitial lung disease, pulmonary hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure participating in your care at ___
___. You came in with shortness of breath.
While you were here, we put you on supplemental oxygen, we
evaluated your cardiac, vascular, and pulmonary function with
cardiac echo, chest X-ray, chest CT, and pulmonary function
tests. The cardiac echocardiogram was reassuring from a cardiac
standpoint and detected some mild-to-moderate pulmonary
hypertension. Chest imaging revealed evidence of an
interstitial pulmonary process. We would like you to follow-up
with your pulmonologist and PCP following your discharge for
further evaluation of your pulmonary hypertension. No changes
were made to your home medications except for using oxygen when
ambulatory and at night.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10043622-DS-17 | 10,043,622 | 23,527,228 | DS | 17 | 2130-10-18 00:00:00 | 2130-10-18 16:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
Physical Exam:
Discharge physical exam
Vitals: VSS
Gen: NAD, A&O x 3
CV: RRR
Resp: no acute respiratory distress
Abd: soft, appropriately tender, no rebound/guarding
Ext: no TTP
Pertinent Results:
___ 05:44PM WBC-9.3 RBC-4.38 HGB-12.9 HCT-37.9 MCV-87
MCH-29.5 MCHC-34.0 RDW-13.4 RDWSD-41.7
___ 05:44PM NEUTS-59.2 ___ MONOS-10.3 EOS-0.9*
BASOS-0.2 IM ___ AbsNeut-5.53# AbsLymp-2.67 AbsMono-0.96*
AbsEos-0.08 AbsBaso-0.02
___ 05:44PM PLT COUNT-253
___ 10:00PM ___ PO2-28* PCO2-42 PH-7.41 TOTAL CO2-28
BASE XS-0 INTUBATED-NOT INTUBA
___ 10:00PM LACTATE-1.6
___ 09:21PM GLUCOSE-254* UREA N-17 CREAT-0.6 SODIUM-136
POTASSIUM-3.4 CHLORIDE-96 TOTAL CO2-24 ANION GAP-19
___ 09:21PM estGFR-Using this
___ 09:21PM WBC-15.9* RBC-4.26 HGB-13.0 HCT-37.1 MCV-87
MCH-30.5 MCHC-35.0 RDW-13.3 RDWSD-41.5
___ 09:21PM PLT COUNT-269
___ 08:20PM URINE HOURS-RANDOM
___ 08:20PM URINE UCG-NEGATIVE
___ 08:20PM URINE UHOLD-HOLD
___ 08:20PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 08:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:20PM URINE RBC-6* WBC-<1 BACTERIA-NONE YEAST-MOD
EPI-3
___ 08:20PM URINE MUCOUS-RARE
Brief Hospital Course:
On ___ MS. ___ was admitted to the Gynecology
service from the Emergency Department. She received IV morphine
in the ED for pain control. A UA was negative for infection
however showed red blood cells. An initial pelvic ultrasound
showed "Impression: Asymmetric enlargement of the left ovary
compared to the right without detection of vascular flow,
concerning for ovarian torsion. Small amount of simple left
adnexal free fluid." A chest Xray showed was negative. A CT scan
showed "Impression: 1. No nephrolithiasis or ureterolithiasis.
2. Asymmetric enlargement and hypodensity of the left ovary is
also seen on pelvic ultrasound from the same day, and may
reflect non vascularity seen on that exam." A repeat pelvic
ultrasound on ___ showed "Impression: Essentially unchanged
exam compared to the pelvic ultrasound from 6 hours prior, with
asymmetry of the ovaries. No detectable left ovarian
vascularity. Given no interval change, suspicion for torsion is
low. Additionally, the ovary does not look particularly
edematous, and decreased or undetectable ovarian blood flow can
be seen in postmenopausal woman. I think that torsion is
unlikely though not entirely excluded." Her WBC count was
initial 15.9, however downtrended to 9.3. For her diabetes, she
was placed on an insulin sliding scale and her blood glucose was
monitored.
Her pain was controlled with Tylenol and toradol. She was
initially kept NPO for possible procedure, however her vital
signs remained stable and her pain remained well controlled. On
hospital day 1 her diet was advanced and she tolerated this
well. She was discharged to home in stable condition with
outpatient follow-up as scheduled.
Medications on Admission:
Lantus 20 QHS, pioglitazone, glimpiride
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H
Do not exceed 4,000mg in 24 hours.
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*50 Tablet Refills:*1
2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
Take with food or milk.
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*50 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to the gynecology service. You have recovered
well and the team believes you are ready to be discharged home.
Please call Dr. ___ office with any questions or
concerns. Please follow the instructions below.
General instructions:
* Take your medications as prescribed.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* You may walk up and down stairs.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No tub baths for 6 weeks.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
10043646-DS-10 | 10,043,646 | 25,354,589 | DS | 10 | 2184-02-10 00:00:00 | 2184-02-13 18:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Leg swelling and shortness of breath
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
___ with recent admission to ___ for asthma
exacerbation, was found to have new diagnosis of CHF and Afib.
After a 10 day stay at ___ she was discharge home yesterday
with ___ and now presenting with worsen ___ edema and SOB. She
notes that since she left the hospital yesterday, her legs were
getting "much bigger" and she had difficulty bringing them up to
bed. She had the ___ visiting her today who noticed that her
legs had ___ edema and she had a 5lb wt gain. She eat
a sandwich last night with lunch meat, but denies eating any
other salty foods. She had been started on Lasix 20mg which she
notes that she took it this AM and it did not do anything for
her. She also noted to have increase in SOB today, but overall
states that this was much better than on the prior week when she
was hospitalized. She denies having any chest pain, denies
fevers. She continues to have a cough- mainly non-productive and
occ wheezing. Recently started on coumadin and has a large area
of ecchymosis on her R flank which she thinks it has been
stable. She denies having any trauma to the area.
In the ED, initial vitals were: 97.2 79 174/65 24 100%. Her
physical exam was notable for diffuse wheezes bilaterally,
RRR+S1S2, obese abdomen with bruising on R flank, 3+ bilateral
pitting edema. speaking full sentneces. Her cxray showed no
pleural effusion or acute pulmonary process. She was given 40 mg
of IV lasix and she had 900cc urine out. Most recent vitals were
97.9 100 20 sat 98 ra 162/61 prior to admission.
On the floor, pt states that she is feeling much more
comfortable than earlier. She denies feeling SOB and is resting
comfortable in bed.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
HTN
Pulmonary TB
Varicose veins with chronic leg edema
Colon polyps
Cataract surgery in both eyes
Osteoarthritis
Asthma
Presnycope
Social History:
___
Family History:
Maternal grandmother had DM2. Her mother died
at ___ of throat cancer. Her father died young in an accident.
Her brother is ___ with DM2. She has a ___ sister but
does not know much about her medical condition.
Physical Exam:
On Admission:
VS: 98.7 160/57 (154-160) 72 18 98%RA
GENERAL: Well-appearing in NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MM-dry, OP clear.
NECK: Supple, no thyromegaly, JVD at 12 cm, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, except for exp wheezes heard throughout. No
crackles. Good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding,
large hematoma on the R abd/flank area which pt states that does
not think that this has changed in size
EXTREMITIES: WWP, no c/c with +2 pitting edema. 2+ peripheral
pulses.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout
On Discharge:
Vitals - 98.0 145/27 69 20 99%RA
Weight - 116.4-->114.3-->113.3-->110.3-->110.4-->107.7-->108.0
IO - ___
Peak flow - 250
GENERAL: Well-appearing in NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MM-dry, OP clear.
NECK: Supple, no thyromegaly, JVD at 10 cm, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat. No crackles. Good air movement, resp
unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding,
large hematoma on the R abd/flank area which is unchanged.
EXTREMITIES: WWP, no c/c with +1 pitting edema. 2+ peripheral
pulses.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout
Pertinent Results:
On Admission:
___ 06:35PM BLOOD WBC-10.9# RBC-3.09* Hgb-10.0* Hct-31.1*
MCV-101* MCH-32.3* MCHC-32.1 RDW-13.7 Plt ___
___ 06:35PM BLOOD ___ PTT-31.9 ___
___ 06:35PM BLOOD Glucose-167* UreaN-26* Creat-1.2* Na-139
K-4.8 Cl-101 HCO3-28 AnGap-15
___ 05:51AM BLOOD LD(LDH)-301* TotBili-0.4
___ 06:35PM BLOOD cTropnT-<0.01
___ 06:35PM BLOOD Calcium-8.7 Phos-2.4* Mg-2.4
___ 05:51AM BLOOD calTIBC-224* VitB12-1326* Folate-9.7
___ Ferritn-102 TRF-172*
___ 06:05AM BLOOD TSH-0.39
___ 05:51AM BLOOD tTG-IgA-2
On Discharge:
___ 06:33AM BLOOD WBC-5.9 RBC-3.20* Hgb-10.3* Hct-33.0*
MCV-103* MCH-32.3* MCHC-31.4 RDW-14.7 Plt ___
___ 06:33AM BLOOD ___ PTT-34.2 ___
___ 06:33AM BLOOD Glucose-108* UreaN-28* Creat-1.4* Na-139
K-4.3 Cl-100 HCO3-34* AnGap-9
___ 05:51AM BLOOD LD(LDH)-301* TotBili-0.4
___ 06:33AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.2
___ 05:51AM BLOOD calTIBC-224* VitB12-1326* Folate-9.7
___ Ferritn-102 TRF-172*
Studies:
ECG - The rhythm is sinus arrhythmia with premature atrial
complexes and a possible short run of supraventricular
tachycardia. Non-specific ST segment and T wave abnormalities.
Otherwise, no specific change compared to previous tracings.
CXR - IMPRESSION: No evidence of acute disease.
EGD - Impression: Small nonobstructing Schatzki's ring was noted
Normal mucosa in the duodenum Food was noted in the stomach
likely related to the pyloric stenosis Two nonbleeding ulcers
were noted in the pyloric channel with associated mild pyloric
narrowing (biopsy) Otherwise normal EGD to third part of the
duodenum
Brief Hospital Course:
Ms. ___ is an ___ year-old female with history of diastolic
CHF, asthma and atrial fibrillation (on coumadin) who presented
with shortness of breath and was treated for an exacerbation of
her congestive heart failure.
HOSPITAL COURSE
---------------
The patient presented with complaint of shortness of breath. In
the emgergency department she was given 40 mg of IV lasix and
she had 900cc urine out. Admitted to the cardiology floor.
.
On the cardiology floor the patient was continued on
intra-venous lasix with good urine output. Also started on
spironolactone. Her weight decreased and ___ edema improved. The
patient completed her steroid taper and was maintained on PRN
inhalers. Diltiazem/Digoxin were stopped and metoprolol started.
The patient's fluid balance continued to improve and she was
transitioned to PO lasix on ___. Discharged with plans to
continue 80mg PO lasix daily and close follow-up with her PCP
and cardiology. Weight at discharge was 107kg.
CHRONIC CONDITIONS
-------------------
# Atrial Fibrillation: The patient was in sinus rhythym for the
majority of her hospitalization but was noted to have
intermittent runs of afib on telemetry. She was continued on
coumadin with goal INR ___.
# Anemia/Gastric Ulcers: The patient had a macrocytic anemia on
presentation. She has a known B12 deficiency for which she
received B12 injections. Given a slowly declining hematocrit and
treatment with coumadin, the patient was seen by GI who
performed an endoscopy. The endoscopy revealed a narrow pyloris
and ulcers at the pylorus. She was placed on BID PPI. Her H.
pylori Ab returned (+) and she was started on triple therapy.
The patient will require repeat EGD 8 weeks after discharge.
# HTN: The patient's BP ran ~150 systolic throughout her stay.
Her lasix was increased and she was started on spironolactone.
Also uptitrated metoprolol.
TRANSITIONAL ISSUES
-------------------
- Cardiology f.u and titration of lasix dose to maintain dry
weight
- Repeat EGD in 8 weeks
- Uptitrate metoprolol as tolerated
Medications on Admission:
- colchicine [Colcrys] 0.6 mg Tablet 1 Tablet(s) by mouth once a
day
- cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution
1,000 mcg IM x 1 a month ___
- fluticasone-salmeterol [Advair Diskus] 100 mcg-50 mcg/Dose
Disk with Device 1 puff(s) ih twice a day
- ipratropium-albuterol [Combivent] 18 mcg-103 mcg (90
mcg)/Actuation Aerosol 2 puffs in q 6 h prn ___
- lisinopril 20 mg Tablet 1 Tablet(s) by mouth once a day
___
- pramipexole 0.125 mg Tablet 1 Tablet(s) by mouth at bedtime
- aspirin, buffered [Aspridrox]
- calcium carbonate-vitamin D3 [Calcium 500 + D]
- multivitamin-minerals-lutein [Centrum Silver]
- Lasix 20mg daily
- Digoxin 0.125 daily (which she had not picked up from her
pharmacy)
- Diltiazem Extended-Release 240 mg PO DAILY
- Coumadin 5mg once daily (uncertain about dose)
- Prednisone taper 30mg for 3days and 20mg for 3 days, then 10mg
per day
-Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: 1000
(1000) mcg Injection once a month.
3. Advair Diskus 100-50 mcg/dose Disk with Device Sig: One (1)
Puff Inhalation twice a day.
4. Combivent ___ mcg/actuation Aerosol Sig: Two (2)
Inhalation every ___ hours as needed for Wheezing.
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit Tablet
Sig: One (1) Tablet PO once a day.
9. Centrum Silver Tablet Sig: One (1) Tablet PO once a day.
10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Caps* Refills:*0*
11. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*120 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
13. metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
14. clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 8 days.
Disp:*32 Tablet(s)* Refills:*0*
15. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 ___: Please have your INR checked at your doctor's appointment
on ___.
Disp:*90 Tablet(s)* Refills:*0*
16. furosemide 40 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
17. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO once a day.
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*0*
18. Outpatient Lab Work
Please have a chemistry panel and coagulation studies checked at
your primary care visit on ___.
19. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia for 2 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Congestive Heart Failure
Asthma
Gastric Ulcers
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at ___!
You were admitted due to an excess of fluid on your body. In the
hospital you underwent diuresis and your breathing and leg
swelling greatly improved. Your fluid build up is due to a
stiffening of the heart muscle.
You also had an endoscopy performed due to anemia and trace
blood in your stool. The endoscopy revealed a narrowing of the
connection between your stomach and intestine. There were also
ulcers around this opening that were likely due to the pain
medications you have been taking over the past year.
See below for changes made to your home medication regimen:
1) Please START Furosemide 80mg daily
2) Please START Metoprolol Succinate 75mg daily
3) Please STOP Diltiiazem
4) Please STOP Digoxin
5) Please STOP Prednisone
6) Please START Spironolactone 25mg daily
7) Please START Omeprazole 40mg twice daily
8) Please START Metronidazole 500mg twice daily and continue for
8 additional days to complete a 10-day course
9) START Clarithromycin 500mg every 12 hours and continue for 8
additional days to complete a 10-day course
10) Please REDUCE your Warfarin dose to 3mg daily and have your
INR levels followed
11) Please STOP all non-steroidal pain medications including
Advil, Alleve, Ibuprofen, and Motrin. You can use Tylenol
(Acetaminophen) for minor aches and pain.
12) START Ambien 5mg. Please discuss further use of this
medication with your primary care doctor.
See below for instructions regarding follow-up care:
Followup Instructions:
___
|
10044189-DS-4 | 10,044,189 | 22,028,605 | DS | 4 | 2172-11-11 00:00:00 | 2172-11-15 15:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Decreased responsiveness; nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
Small Bowel Enteroscopy
History of Present Illness:
___ F with Hx of ___ disease and seizure disorder
presenting with AMS, weakness, and emesis x 1. ACS consulted for
question SMA syndrome seen on CT scan.
Per husband, patient has ___ disease and attends a day
program at ___ but lives with him at home. She
ate breakfast this morning, and her mental status was at
baseline (alert, conversing but forgetful.) In the afternoon,
she was walking to the bathroom with a staff member, when she
became weak, confused, and diaphoretic. She had one episode of
emesis.
Prior to today, she has had no emesis and has not had any
difficulty eating or early satiety. She was briefly constipated
last week and has occasionally complained of back pain and
abdominal pain over the last month. No BRBPR, diarrhea or
fevers/chills, per husband. She has lost about 20 lbs over the
last ___ years, but her weight has been stable over the last
year.
After discovery of massive gastric distension on CT, NGT was
placed in ED and so far has drained about 2 liters of
light-colored fluid.
Of note, the patient has a history of a seizure disorder (two
seizures in the last year, most recently one month ago) for
which she is on keppra.
Past Medical History:
___ disease x ___ years, Hx of breast CA s/p surgery
and radiation, cervical radiculopathy, HTN (no meds), seizures
Social History:
___
Family History:
non-contributory
Physical Exam:
Physical Exam on Admission-
VS: 98.6, 57, 134/76, 16, 100% RA
Gen - NAD, unresponsive to voice, nonverbal, NGT in place
Heart - RRR
Lungs - CTAB
Abdomen - soft, mildly distended, voluntary guarding throughout
but mostly on left
Extrem - warm, no edema
Physical Exam on Discharge:
VS: 98.0, 78, 141/77, 18, 97%RA
GEN: Pt is alert, oriented to self and date of birth. Unable to
state location, date/year, DOWB and reason for hospitalization.
Pt is agitated at moments but easily redirected.
CV: HRR, no m/r/g
RESP: LS diminished at bases, respirations even/unlabored
ABD: Soft, NT. +BS
EXT: No edema. +pulses
Pertinent Results:
___ 05:55AM BLOOD WBC-5.7 RBC-3.65* Hgb-11.0* Hct-34.1*
MCV-93 MCH-30.2 MCHC-32.4 RDW-13.4 Plt ___
___ 05:45AM BLOOD WBC-5.9 RBC-3.69* Hgb-11.3* Hct-33.6*
MCV-91 MCH-30.6 MCHC-33.7 RDW-13.0 Plt ___
___ 04:45AM BLOOD WBC-6.7 RBC-3.62* Hgb-10.7* Hct-33.6*
MCV-93 MCH-29.6 MCHC-31.8 RDW-13.5 Plt ___
___ 05:30AM BLOOD WBC-7.9 RBC-3.62* Hgb-10.9* Hct-33.4*
MCV-92 MCH-30.2 MCHC-32.7 RDW-13.5 Plt ___
___ 02:15PM BLOOD WBC-8.5 RBC-4.37 Hgb-13.4 Hct-40.4 MCV-92
MCH-30.7 MCHC-33.2 RDW-13.2 Plt ___
___ 05:35AM BLOOD Glucose-93 UreaN-5* Creat-0.9 Na-141
K-4.3 Cl-104 HCO3-28 AnGap-13
___ 05:55AM BLOOD Glucose-101* UreaN-6 Creat-0.9 Na-140
K-4.5 Cl-104 HCO3-29 AnGap-12
___ 05:45AM BLOOD Glucose-102* UreaN-6 Creat-0.9 Na-139
K-4.2 Cl-103 HCO3-28 AnGap-12
___ 04:00AM BLOOD Glucose-104* UreaN-6 Creat-0.9 Na-136
K-4.0 Cl-102 HCO3-28 AnGap-10
___ 03:45AM BLOOD Glucose-105* UreaN-7 Creat-0.8 Na-142
K-4.4 Cl-105 HCO3-29 AnGap-12
___ 05:35AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.2
___ 05:55AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0
___ 05:45AM BLOOD Albumin-3.7 Calcium-9.2 Phos-3.7 Mg-2.1
Iron-55
___ 04:00AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.1
___ 03:45AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.4
___ 02:15PM BLOOD ALT-19 AST-31 AlkPhos-82 Amylase-162*
TotBili-0.3
___: HEAD CT: No evidence of acute intracranial process.
___: CT ABD & PELVIS WITH CONTRAST: 1. Massively
distended, fluid-filled stomach and proximal duodenum with
caliber change at the level of the third portion of the duodenum
as it crosses between the aorta and SMA, possibly due to SMA
syndrome, although the appearance is somewhat atypical given
intervening fat plane between the SMA and collapsed duodenum.
No wall thickening or discrete mass seen. Focal narrowing of
the left renal vein is also noted at this level. 2. No
intra-abdominal free air or free fluid. 3. Scattered
subcentimeter hepatic hypodensities are too small to
characterize, but are statistically most likely to represent
cysts. 4. Nonspecific apparent jejunal wall thickening is
incompletely evaluated due to underdistension and may in part
relate to underdistention.
___: UGI: Evidence of holdup of contrast within the stomach
with slow movement throughout the duodenum into the small bowel,
similar to that seen on CT and findings, which may represent SMA
syndrome.
___: ABDOMEN XRAY: Passage of contrast out of the small
bowel, now present in the descending and sigmoid colon.
___: Small Bowel Enteroscopy Report: Erythema in the
stomach body compatible with NGT trauma. Otherwise normal small
bowel enteroscopy to jejunum. No evidence of obstructive mass or
lesion
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a PMH significant for
advanced Alzheimers disease and epilepsy who was admitted to
___ ___ for nausea, vomiting and management of a possible
SMA syndrome vs gastroenteritis vs small bowel obstruction. A
nasogastric tube was placed when she presented with immediate
output of 1.7 liters of bilious fluid. CT scan of the abdomen
showed increased rectal thickening, pneumatosis in ascending
colon and an UGI showed holdup of contrast in the stomach which
may represent SMA syndrome. Neurology was also consulted given
her change in mental status. They thought there was no evidence
of superimposed
encephalopathy and recommended seizure precautions and
continuing home medications once she was able to take
medications by mouth.
Overnight on HD1 she had very low urine output, for which she
received 2L of IV fluids with resumption of normal urine output.
Her urinalysis on HD2 was positive, and her urine culture grew
E. Coli sensitive to ciprofloxacin. She was treated with
ciprofloxacin.
GI was consulted and they performed a small bowel enteroscopy on
HD6. This showed Erythema in the stomach body compatible with
NGT trauma and an otherwise normal small bowel enteroscopy to
jejunum. There was no evidence of obstructive mass or lesion. GI
recommended a trial of high calorie liquid diet. Nutrition was
consulted and the patient was started on a liquid diet with high
protein Scandishakes TID. On HD7, the patients foley was
discontinued and she was voiding without difficulty. She was
tolerating the liquid diet without difficulty. She had
completed her course of ciprofloxacin for the UTI and she was
hemodynamically stable. Physical therapy was consulted to
evaluate the patient, as she was well below her baseline
functioning from her acute illness. Physical therapy recommended
she be discharged to a rehabilitative center to regain her
strength. On day of discharge, the patient was hemodynamically
stable and tolerating a full liquid high protien diet. She was
voiding without difficulty. Her abdominal exam was benign.
Discharge planning and instructions were discussed with the
patient and her family with voiced agreement. The patient will
follow up in the ___ clinic as well as with GI and neurology.
Medications on Admission:
DONEPEZIL [ARICEPT] - Aricept 10 mg tablet. one Tablet(s) by
mouth qam with food
LEVETIRACETAM - levetiracetam 250 mg tablet. one-half tablet(s)
by mouth bid for one week, then one bid
MEMANTINE [NAME___] - Name___ 10 mg tablet. one Tablet(s) by
mouth twice a day after starter pack
QUETIAPINE [SEROQUEL] - Seroquel 100 mg tablet. ___ to 1
Tablet(s) by mouth twice a day as needed for agitation
ASPIRIN - aspirin 81 mg chewable tablet. one Tablet(s) by mouth
once a day.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
do not exceed 3000mg/day
2. Donepezil 10 mg PO HS
3. Heparin 5000 UNIT SC TID
4. LeVETiracetam 250 mg PO BID
5. Memantine 10 mg PO BID
6. QUEtiapine Fumarate 50 mg PO BID
7. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Gastroenteritis vs SMA syndrome
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital with vomiting and abdominal
pain and were found to have an obstruction that was causing a
very distended stomach, requiring nasogastric decompression. You
were maintained on bowel rest with IV fluids for several days.
There was initially a concern for Superior mesenteric artery
(SMA) syndrome, but the GI doctors did ___ and found that
there was no blockage and you likely had a severe viral
gastroenteritis. You are now doing well with your full liquid
diet and you are ready to be discharged to a short term
___ facility to get back to your baseline of
functioning. You are to remain on a full liquid diet with high
protein supplements for the time being. Please note the
following discharge instructions:
Please call your doctor or come to the emergency room if you
develop any of the following:
-fever greater than 101
-nausea, vomiting, abdominal distention
-diarrhea or constipation
-inability to take in liquids
-any new or concerning symptoms
You will be following up with the GI doctors as ___ outpatient as
well as in the Acute Care Surgery (ACS) clinic. Please also
follow up with your neurologists and your primary care provider.
Followup Instructions:
___
|
10044997-DS-13 | 10,044,997 | 25,979,513 | DS | 13 | 2153-11-05 00:00:00 | 2153-11-05 16:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
shellfish derived / iodine
Attending: ___.
Chief Complaint:
Left hand table saw injury
Major Surgical or Invasive Procedure:
___: left hand washout of multiple open fractures thumb
index middle ring fingers, nerve repair x 1, PIP fusion ring
finger, first dorsal metacarpal artery flap for thumb pulp
recontruction
History of Present Illness:
___ is a ___ year old male
with PMH notable for hypertension presents with table saw
injury
to his left hand. He accidentally caught multiple digits and in
the saw. He was seen at an outside ED where he had a digital
block performed. He was given tetanus and Ancef. He is
right-hand dominant. He sustained multiple serious injuries to
the left hand fingers and was sent here for higher level of
care.
Denies any other injuries. Otherwise asymptomatic.
Past Medical History:
Hypertension
Social History:
___
Family History:
Noncontributory
Physical Exam:
GEN: AOx3 WN, WD in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR
PULM: unlabored breathing with symmetric chest rise, no
respiratory distress
EXT:
Flap pink, good cap refill, WWP
SILT over thumb and all digits, including flap site
Flexing/extending thumb IP joint, flap pink and well perfused
No erythema, no drainage
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the hand surgery team. The patient was found to
have multiple injuries to the left hand at all the digits
including the thumb except for the small finger and was admitted
to the hand surgery service. The patient was taken to the
operating room on ___ for procedure as noted above, 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 OT who determined that discharge to home
with outpatient occupational therapy 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
nonweightbearing in the left upper extremity. 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. amLODIPine 10 mg PO DAILY
2. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
Partial fill ok. Wean. No driving/heavy machinery.
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours as needed
Disp #*25 Tablet Refills:*0
3. amLODIPine 10 mg PO DAILY
4. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Discharge Disposition:
Home
Discharge Diagnosis:
Left hand third finger deep laceration, left hand fourth finger
partial amputation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER HAND SURGERY:
- You were in the hospital for hand surgery. It is normal to
feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Nonweightbearing left upper extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
FOLLOW UP:
Please follow up with your Hand Surgeon, Dr. ___
one week. Call ___ to schedule appointment upon
discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
Followup Instructions:
___
|
10045326-DS-17 | 10,045,326 | 25,966,591 | DS | 17 | 2152-11-23 00:00:00 | 2152-11-23 19:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tylenol / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___
Chief Complaint:
Shortness of breath, lethargy, weakness, poor appetite
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o man with pmhx of newly diagnosed lung ca,
who presents from home with ___ days of progressive dyspnea.
He states that he has been feeling badly for weeks now since
diagnosis of lung cancer nearly a month ago. He endorses poor PO
intake due to mild nausea but mostly no appetite. He has tried
dronabinol (terrible side effects of diarrhea and cramping) as
well as marijuana (now no drive to even use that). He endorses
nearly 30 pounds of weight loss over past few months.
More acutely, he for the past few days has had increasing
shortness of breath without significant cough or sputum
production. He denies any fevers or chills. Does have some
substernal pressure that is worse with coughing. No diagnosed
lung disease apart from lung cancer, but does have decades of
tobacco use and used to work in ___ so feels like
had lots of exposure to potential toxins. He feels that he
should have presented to ED multiple days ago, but did not have
the drive to. Finally pushed by mother and girlfriend to come
in.
Of note, patient most recently saw Dr. ___ Atrius
oncology on ___, at which point he was planned to start
chemotherapy (___) on ___. He did take dexamethasone
as instructed ___. He has not had any chemotherapy
yet. Detailed oncologic history as below.
In the ED, initial vitals were: 95.8 85 122/80 24 100% RA
- Exam notable for: diffuse expiratory wheezing bilaterally,
increased work of breathing with subcostal and supraclavicular
respiratory muscle involvement
- Labs notable for: WBC 39.8, flu A/B negative
- Imaging: CXR without acute process, known lung mass
- Duonebs and diazepam was given.
Upon arrival to the floor, patient endorses the above history.
He feels weak, +anorexia, hasn't slept in many days. He would
like a diazepam to help him sleep. Feels breathing is still not
at baseline. Has some mild chest tightness, but no other
symptoms.
REVIEW OF SYSTEMS: As per HPI.
Past Medical History:
Newly diagnosed lung cancer as below
History of alcohol abuse
History of substance abuse
Atrial septal defect
Stroke, small vessel in ___ without residual deficits, on
aggrenox
Tobacco dependence
Hypercholesteremia
Insomnia, unspecified
ONCOLOGIC HISTORY PER ATRIUS:
PATHOLOGY RESULTS:
___- cervical node biopsy (FNA)- non-diagnostic
___- left axillary node biopsy (FNA)- negative
___- EUS/Adrenal gland core biopsy:
- Poorly differentiated carcinoma with extensive necrosis.
Note: Immunohistochemical stains are performed. The tumor cells
are
positive for cytokeratin cocktail (AE1/3&CAM5.2) and CK7. CK20,
TTF-1,
Napsin, P40 and Inhibin are negative. The findings are not
specific for the origin of this tumor. Clinical/imaging
correlation is recommended.
Social History:
___
Family History:
No family history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITAL SIGNS: 98.2 116/76 87 18 96 RA
GENERAL: Chronically ill appearing, tired, but in NAD
HEENT: NC/AT, wearing glasses, dry mucous membranes, tongue
midline on protrusion
NECK: supple, symmetric
CARDIAC: RRR, no m/r/g
LUNGS: air movement with poor effort is present but poor in all
fields; no crackles, rhonchi, or wheezes can be appreciated in
this context; no increased work of breathing and speaking in
full senteces
ABDOMEN: Soft, mildly tender on palpation diffusely, non-rigid,
no r/g, BS+
EXTREMITIES: thin, WWP, no pitting edema, distal pulses intact
NEUROLOGIC: alert and oriented; moving all extremities;
symmetric smile, sensation to light touch symmetric and intact
in all divisions of CN5, UE, torso, ___ strength ___ in b/l UE,
able to lift both legs up against gravity and downward pressure
b/l
SKIN: no bruises or petechiae
DISCHARGE PHYSICAL EXAM
Vital Signs: T 97.6 PO BP 100 / 60 HR 86 RR 18 O2 93 RA
General: Sitting up on a chair, eating breakfast, no acute
distress
Head: Normocephalic/ atraumatic, teeth and gums normal
Lungs: Poor air movement throughout all lung fields, decreased
breath sounds, no increased work of breathing, speaks in full
sentences
Heart: regular rate and rhythm, S1, S2 normal
Abdomen: soft, non tender, normal bowel sounds
Extremities: warm, well perfused, no edema
Neuro: Alert and oriented, UE strength grossly normal, ___
strength normal. Sensation grossly intact throughout all
extremities
Pertinent Results:
ADMISSION LABS
---------------
___ 10:03PM BLOOD WBC-39.8* RBC-4.54* Hgb-12.7* Hct-38.9*
MCV-86 MCH-28.0 MCHC-32.6 RDW-14.2 RDWSD-43.8 Plt ___
___ 10:03PM BLOOD Neuts-86.0* Lymphs-5.8* Monos-4.7*
Eos-1.0 Baso-0.7 Im ___ AbsNeut-34.23* AbsLymp-2.30
AbsMono-1.89* AbsEos-0.38 AbsBaso-0.27*
___ 07:50AM BLOOD ___ PTT-29.7 ___
___ 10:03PM BLOOD Glucose-84 UreaN-15 Creat-0.9 Na-137
K-4.8 Cl-96 HCO3-23 AnGap-23*
___ 10:03PM BLOOD CK(CPK)-25*
___ 07:50AM BLOOD ALT-12 AST-13 LD(LDH)-320* AlkPhos-168*
TotBili-0.3
___ 10:03PM BLOOD CK-MB-<1 cTropnT-<0.01
___ 07:50AM BLOOD Albumin-3.1* Calcium-9.4 Phos-4.0 Mg-1.8
___ 07:50AM BLOOD Cortsol-15.4
___ 10:12PM BLOOD ___ pO2-25* pCO2-46* pH-7.42
calTCO2-31* Base XS-3
___ 10:12PM BLOOD Lactate-1.4
___ 10:35AM URINE Color-Yellow Appear-Cloudy Sp ___
___ 10:35AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 10:35AM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
MICROBIOLOGY
------------
Time Taken Not Noted Log-In Date/Time: ___ 7:26 pm
STOOL CONSISTENCY: NOT APPLICABLE Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
IMAGING
---------
CXR (___):
No acute cardiopulmonary process. Re- demonstration of left
apical mass,
better assessed on previous CT. Upper lobe predominant
emphysema.
CT CHEST (___): Growing left upper lobe lung mass. At least
3 rib metastases responsible for
pathologic fractures, one healed and 2 not healed, were present
in ___. No new metastases.
Coronary atherosclerosis. Findings below the diaphragm
including large
bilateral adrenal masses will be reported separately.
CT ABDOMEN/PELVIS (___):
1. 10 x 8 mm rounded soft tissue nodule in the left buttock deep
to the
gluteus musculature is new from the recent prior exam of ___,
worrisome for soft tissue metastasis.
2. Bilateral heterogeneously hypoenhancing adrenal metastases
are
significantly larger since ___, now measuring up to
6.5 cm on the
right and 5.5 cm on the left (previously up to 2.4 and 2.5 cm,
respectively).
3. Please see separate report for intrathoracic findings from
same-day CT
chest.
DISCHARGE LABS
---------------
___ 08:10AM BLOOD WBC-37.9* RBC-4.36* Hgb-12.1* Hct-37.4*
MCV-86 MCH-27.8 MCHC-32.4 RDW-14.1 RDWSD-43.7 Plt ___
___ 08:10AM BLOOD Glucose-50* UreaN-12 Creat-0.9 Na-139
K-4.4 Cl-97 HCO3-25 AnGap-21*
___ 08:10AM BLOOD Calcium-10.0 Phos-4.7* Mg-2.7*
Brief Hospital Course:
Mr. ___ is a ___ male with a ___ smoking history
and recent diagnosis of lung cancer in ___ with
metastasis to adrenal glands, who presents for failure to
thrive, leukemoid reaction, and progression of his metastatic
disease.
# Failure to thrive. In the setting of progression of his
metastatic lung cancer, Mr. ___ has been experiencing a
decline in his ability to care for himself. Notable weight loss
of ~20lbs in the past few months, decreased appetite, exhaustion
and decreased physical activity. He has taken Dronabinol in the
past but experienced significant diarrhea and cramping. Initial
concern for adrenal insufficiency due to adrenal metastases was
reassured by AM cortisol of 15. Patient was seen by physical
therapy, social work, palliative care, and nutrition. Palliative
care recommended symptomatic treatment of his constipation with
Milk of Magnesia and appetite stimulants were discussed
(consideration for dronabinol versus medical marijuana). He
should have a bowel movement at least once every three days. If
he does not, we advised him to take milk of magnesia till he has
a bowel movement. Patient declined any additional appetite
stimulants at this time; he did not want to be "stoned" during
the day. Nutrition advised nutritional supplementation with
Ensure supplements at meals. Patient remained hemodynamically
and clinically stable throughout his hospital stay. Ambulatory
O2sat on discharge was 98%.
# Leukemoid reaction. Patient presented with leukocytosis to
39.8 which was a significant rise from his last CBC (normal in
___, though prior to diagnosis of his lung cancer).
Clinically the patient did not appear infected (no fever, cough,
diarrhea). Infectious workup is negative to date (blood
cultures, urine culture, C. diff, CXR). Blood smear did not
reveal any concern for a primary hematologic disorder and was
consistent with a significant leukemoid reaction, likely in the
setting of his progressive, metastatic, lung cancer.
# Lung cancer, metastatic. Presenting with fatigue, general
malaise, poor appetite and worsening dyspnea in the setting of
recent diagnosis of lung cancer (___). CT abdomen and
pelvis on this admission is concerning for progression of his
adrenal metastasis and a new 10 x 8 mm rounded soft tissue
nodule in the left buttock deep to the gluteus musculature
(concerning for soft tissue metastasis). CT chest revealed
growing left upper lobe lung mass. After discussions with Atrius
oncology, patient will be discharged to begin chemotherapy on
___, as an outpatient. He will start Dexamethasone 4 mg daily
today for three days.
# Hyperlipidemia. Consider stopping statin given his shortened
life expectancy versus time required for benefit of statin.
# Insomnia. Patient has longstanding insomnia and is prescribed
diazepam 15mg qhs. He noted that he frequently takes anywhere
between ___ per night. He has not tried good sleep hygiene
practices. Additionally, his primary problem is maintenance of
sleep (not initiation) so it would be helpful for him to try
medicaitons for maintenance of sleep as he is slowly weaned off
diazepam (given his longstanding use of benzodiazepines for
sleep).
TRANSITIONAL ISSUES
-------------------
FAILURE TO THRIVE
[ ]Nutrition: Tried Dronabinol in the past but experienced
diarrhea and cramping. Medical marijuana was discussed as an
appetite stimulant, which he refuses at this time. PO
supplementation with Ensure shakes has been advised
[ ]Constipation: Patient has been advised to take Milk of
Magnesia as needed if he is not experiencing bowel movements at
least once every three days
LEUKEMOID REACTION
-WBC on discharge was 37.9
[ ]F/up on pending blood and urine cultures
LUNG CANCER, METASTATIC TO ADRENALS/RIBS/LEFT BUTTOCK
[ ]Patient to begin chemotherapy on ___
[ ]Advised to take Dexamethasone 4 mg daily on the day prior,
day of, day after chemotherapy. Start date ___. End date
___
INSOMNIA
[ ]Advised slowly titrating off Diazepam. Promotion of
maintenance of sleep medications (Ambien), not initiation of
sleep
-Continue to encourage good sleep hygiene
#Discharge weight: 57.4kg
#CODE: FULL CODE for now
#CONTACT: ___ Mother ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diazepam 15 mg PO QHS:PRN insomnia/anxiety
2. Dexamethasone 4 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Prochlorperazine 10 mg PO Q6H:PRN nausea
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. Multivitamins W/minerals 1 TAB PO DAILY
7. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain -
Moderate
8. Simvastatin 20 mg PO QPM
9. Dipyridamole-Aspirin 1 CAP PO BID
10. Sildenafil ___ mg PO PRN intercourse
Discharge Medications:
1. Milk of Magnesia 30 mL PO Q6H:PRN constipation
RX *magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 30 mL by
mouth every six (6) hours Refills:*2
2. Dexamethasone 4 mg PO DAILY Duration: 3 Days
3. Diazepam 15 mg PO QHS:PRN insomnia/anxiety
4. Dipyridamole-Aspirin 1 CAP PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain -
Moderate
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. Sildenafil ___ mg PO PRN intercourse
11. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses: Failure to thrive, Leukemoid reaction
secondary to progressive metastatic lung cancer, Constipation
Secondary diagnoses: Metastatic Stave IV lung cancer,
hyperlipidemia, insomnia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized at ___ for weakness, poor appetite,
decreased activity, and exhaustion. These symptoms are most
consistent with your underlying lung cancer and the progression
of the disease. We have advised nutritional supplementation with
Ensure, Milk of Magnesium for your constipation (to be taken if
you are not having a bowel movement every three days), and
physical therapy as tolerated. Imaging and labs are negative for
an infection at this time. You have an elevated white blood cell
count (a marker of inflammation or infection) and in this case,
we think it is a reflection of the progression of your lung
cancer (as confirmed on imaging).
We have spoken with the Oncology team at ___. They would like
you to start chemotherapy on ___. You will take three days of
Dexamethasone to begin today and to end on ___.
Please make sure to take your bowel regimen medication. You
should have a bowel movement atleast once every three days. If
you do not have a bowel movement by the third day please take
Milk of Magnesia till you have a bowel movement.
It is important that you attend the follow-up appointments
listed below.
It was a pleasure taking care of you! We wish you the best!
Your ___ Team
Followup Instructions:
___
|
10045326-DS-18 | 10,045,326 | 26,512,329 | DS | 18 | 2152-11-28 00:00:00 | 2152-11-28 21:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tylenol / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ yo man wit newly diagnosed poorly differentiated
metastatic lung cancer based upon a biopsy of an adrenal lesion
followed by Dr ___ admitted with right flank and RUQ
abdominal
pain and transient left leg discomfort and tingling.
Past Medical History:
Newly diagnosed lung cancer as below
History of alcohol abuse
History of substance abuse
Atrial septal defect
Stroke, small vessel in ___ without residual deficits, on
aggrenox
Tobacco dependence
Hypercholesteremia
Insomnia, unspecified
ONCOLOGIC HISTORY PER ATRIUS:
PATHOLOGY RESULTS:
___- cervical node biopsy (FNA)- non-diagnostic
___- left axillary node biopsy (FNA)- negative
___- EUS/Adrenal gland core biopsy:
- Poorly differentiated carcinoma with extensive necrosis.
Note: Immunohistochemical stains are performed. The tumor cells
are
positive for cytokeratin cocktail (AE1/3&CAM5.2) and CK7. CK20,
TTF-1,
Napsin, P40 and Inhibin are negative. The findings are not
specific for the origin of this tumor. Clinical/imaging
correlation is recommended.
Social History:
___
Family History:
No family history of cancer.
Physical Exam:
VS: 98.2 PO 92 / 55 102 18 93 RA
GEN: cachectic appearing in NAD
HEENT/Neck: anicteric sclera, MMM, OP clear, neck supple
HEART: RRR no m/r/g
LUNGS: CTAB no wheezes, rales, or crackles. Symmetric expansion
ABD: soft NT/ND +BS no rebound or guarding
EXT: warm well perfused, no pitting edema
NEURO: alert and oriented. Fluent speech. CN II-XII intact.
No
focal deficits on strength testing, ___ strength with gross
sensation intact
Pertinent Results:
___ 08:52PM LACTATE-1.0
___ 01:10PM URINE HOURS-RANDOM
___ 01:10PM URINE UHOLD-HOLD
___ 01:10PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 01:10PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-0 TRANS EPI-<1
___ 10:07AM TYPE-ART COMMENTS-GREEN TOP
___ 10:07AM LACTATE-1.5
___ 10:01AM GLUCOSE-79 UREA N-26* CREAT-0.8 SODIUM-135
POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-26 ANION GAP-18
___ 10:01AM ALT(SGPT)-72* AST(SGOT)-43* ALK PHOS-178* TOT
BILI-0.5
___ 10:01AM LIPASE-35
___ 10:01AM ALBUMIN-3.6
___ 10:01AM WBC-34.0* RBC-3.78* HGB-10.7* HCT-32.6*
MCV-86 MCH-28.3 MCHC-32.8 RDW-14.2 RDWSD-44.5
___ 10:01AM NEUTS-90.9* LYMPHS-5.3* MONOS-0.6* EOS-1.4
BASOS-0.3 IM ___ AbsNeut-30.93* AbsLymp-1.80 AbsMono-0.20
AbsEos-0.47 AbsBaso-0.11*
___ 10:01AM PLT COUNT-370
FINDINGS:
The liver appears normal in grayscale appearance and size
without focal lesion
of concern. No biliary ductal dilation. Gallstones noted
within the
gallbladder though there is no evidence for acute cholecystitis.
Sonographic
___ sign is negative. Common bile duct measures up to 3 mm.
The known
right adrenal metastasis is visualized though better
characterized on same-day
CT exam. A simple appearing cyst is seen in the right kidney
interpolar
region measuring 2 cm in diameter. Lymphadenopathy adjacent to
the pancreas
better assessed on same-day CT. No ascites.
IMPRESSION:
1. Cholelithiasis without evidence of cholecystitis.
2. Right adrenal mass and enlarged peripancreatic nodes better
assessed on
same-day CT exam.
IMPRESSION:
1. No evidence of acute pulmonary embolism or aortic
abnormality.
2. Interval worsening and enlargement of retroperitoneal lymph
nodes,
specifically with development of at least 3 centrally necrotic
lymph nodes
along the posterior aspect of the pancreas.
3. Slight interval increase in size of left gluteal soft tissue
nodule since ___.
4. Bilateral adrenal metastatic lesions are unchanged in size
from ___ but significantly larger than ___.
5. Unchanged left upper lobe pulmonary mass.
Brief Hospital Course:
___ yo M with poorly differentiated metastatic lung cancer with
adrenal mets, lymphadenopathy, s/p recent pemetrexed/carboplatin
___, who presented with R flank pain and episode of L leg
numbness
now resolved.
Acute R flank pain:
Work up as above and essentially negative except for
cholelithiasis. Resolved after 24 hrs. Cause unclear. ___ be
side effect from chemotherapy. ___ be biliary colic as well.
RUQ US without cholecystitis or evidence of obstruction.
Imaging re-assuring and not consistent with renal colic,
pancreatitis, or referred pain. Follow up with oncology
scheduled for day after discharge.
Metastatic poorly differentiated lung cancer:
s/p chemo on ___. Reviewed case with Dr. ___ ___
oncology. Cont Folate
LLE numbness:
Resolved. Possibly due to sciatica though no back pain.
Metastatic dz to spine is also to be considered, though PET
imaging was negative and symptoms resolved on their own
spontaneously. One would expect persistent symptoms if there
were a mass lesion.
- Outpatient follow up
Hypotension: IVF given
Anxiety: stable
h/o CVA: Continued aggrenox
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diazepam 15 mg PO QHS:PRN insomnia/anxiety
2. Dipyridamole-Aspirin 1 CAP PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain -
Moderate
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
8. Simvastatin 20 mg PO QPM
9. Sildenafil ___ mg PO PRN intercourse
10. Dexamethasone 4 mg PO DAILY
11. Milk of Magnesia 30 mL PO Q6H:PRN constipation
Discharge Medications:
1. Diazepam 15 mg PO QHS:PRN insomnia/anxiety
2. Dipyridamole-Aspirin 1 CAP PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Milk of Magnesia 30 mL PO Q6H:PRN constipation
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain -
Moderate
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Sildenafil ___ mg PO PRN intercourse
10. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic 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 evaluation of right sided pain and left
leg numbness. Evaluation was negative. Your symptoms improved.
Please stay well hydrated, take your medications as prescribed,
and follow up with your oncologist as scheduled tomorrow
Followup Instructions:
___
|
10045574-DS-6 | 10,045,574 | 26,471,529 | DS | 6 | 2194-06-12 00:00:00 | 2194-06-13 15:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ without any significant past medical history presents to ED
with one day of bitemporal headache, fever to 102 and nausea and
one episode of nonbloody nonbilious emesis.
She reports that she does not have any photophobia or
meningismus. No cough abdominal pain, diarrhea or dysuria or
increased urinary frequency. No fall or trauma. Denies history
of headaches. Also denies weakness, difficulty walking,
mylagias, sinus tenderness, nasal congestion. She has not been
around anyone else that is sick and has not recently traveled.
In the ED intial vitals were: 10 102.1 93 131/78 18 98% ra
- Labs were significant for wbc 17k, 78%N. Na was 132 and bicarb
21. U/A unremarkable and lactate normal. LP was done showing
normal protein, glucose and 2wbc + 8RBC. gram stain was neg.
CT head showed aerosolized secretions within paranasal sinuses
c/w ?acute sinusitis.
- Patient was given: 2000ml NS, tylenol ___
Vitals prior to transfer were: 3 99.2 86 128/78 18 99% RA
On the floor, pt's niece, ___ translated for me. She reports
that she feels much better and no longer has the headache. She
has not had a fever since this AM and has not had emesis since
this AM. Pt reports mild sore throat.
Past Medical History:
None
Social History:
___
Family History:
No family history of cancer.
Physical Exam:
ON ADMISSION:
Vitals- 99.1, 104/60, 83, 20, 100% RA
General- pleasant, no acute distress
HEENT- conjunctiva are injected bilaterally. no icterus, PERRLA,
EOMI, no photophobia with light. OP slightly erythematous
without exudates
Neck- ___ small shotty nontender cervical nodes.
Lungs- clear to auscultation bilaterally
CV- rrr no murmurs rubs or gallops
Abdomen- soft nontender nondistended, no rebound or guarding. No
organomegaly.
GU- deferred
Ext- pulses 2+ b/l in all extremities. No c/c/e.
Neuro- grossly intact, no meningismus
Skin - normal
LABS: see below
ON DISCHARGE:
Vitals: Tm 100.2 (1520), Tc 98.6 BP106/68 P73 RR20 100RA
General: ___ speaking, pleasant, no acute distress.
HEENT: Sclera anicteric, dry mucous membranes, enlarged tonsils
with exudate over left tonsil.
Neck: Supple, no JVD, no cervical or supraclavicular
lymphadenopathy.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm. Normal S1, loud P2. ___ systolic
murmur loudest at apex. No S3, S4.
Abdomen: +BS, soft, nondistended, nontender to palpation.
Ext: Warm, well perfused, 2+ pulses, no peripheral edema.
Skin: No rash.
Lymph nodes: No cervical, supraclavicular, axillary, and
inguinal lymph nodes palpated.
Neuro: CN II-XII grossly intact. Moves all extremities.
Pertinent Results:
ON ADMISSION:
=======================================
___ 01:40PM BLOOD WBC-17.8*# RBC-4.46 Hgb-12.8 Hct-38.1
MCV-85 MCH-28.8 MCHC-33.7 RDW-11.9 Plt ___
___ 01:40PM BLOOD Neuts-87.7* Lymphs-7.4* Monos-4.3 Eos-0.2
Baso-0.3
___ 08:39PM BLOOD ___ PTT-26.4 ___
___ 01:40PM BLOOD Glucose-115* UreaN-12 Creat-0.6 Na-132*
K-3.6 Cl-98 HCO3-21* AnGap-17
___ 01:40PM BLOOD ALT-15 AST-23 AlkPhos-107* TotBili-0.5
___ 07:30AM BLOOD Calcium-8.6 Phos-2.0* Mg-1.8
INFLAMMATORY MARKERS:
=======================================
___ 06:55AM BLOOD ESR-60*
___ 06:55AM BLOOD CRP-224.6*
ON DISCHARGE:
========================================
___ 06:44AM BLOOD WBC-15.2* RBC-4.17* Hgb-12.0 Hct-36.0
MCV-86 MCH-28.6 MCHC-33.2 RDW-12.2 Plt ___
___ 06:44AM BLOOD Glucose-109* UreaN-10 Creat-0.5 Na-138
K-3.8 Cl-101 HCO3-24 AnGap-17
___ 06:55AM BLOOD LD(LDH)-317*
MICROBIOLOGY:
========================================
___ 11:25 am THROAT FOR STREP
**FINAL REPORT ___
R/O Beta Strep Group A (Final ___:
Reported to and read back by ___ ___ @1341,
___.
BETA STREPTOCOCCUS GROUP A. MODERATE GROWTH.
___ 8:45 pm Influenza A/B by DFA
Source: Nasopharyngeal swab.
**FINAL REPORT ___
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
___ 6:26 pm CSF;SPINAL FLUID TUBE #3.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
___ 1:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
STUDIES:
===================================
EKG (___)
Sinus rhythm. Non-specific ST-T wave abnormalities. No previous
tracing
available for comparison.
CXR (___)
Heart size is normal. Mediastinal and hilar contours are
unremarkable. Lungs
are clear and the pulmonary vasculature is normal. No pleural
effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
CT HEAD w/o CONTRAST (___)
There is no acute hemorrhage, edema or shift of the midline
structures. The ventricles and sulci are of normal size and
configuration.
The gray white matter differentiation is preserved and there is
no evidence
for an acute territorial vascular infarction. The basal
cisterns are patent.
There are aerosolized secretions within the posterior ethmoidal
air cells and
minimal mucosal thickening involving the sphenoid and right
maxillary sinuses.
The mastoid air cells are well aerated. There is no fracture.
Adenoids
appear enlarged for age.
IMPRESSION:
1. No acute intracranial process. MRI is more sensitive for
detecting
intracranial lesions.
2. Aerosolized secretions within the paranasal sinuses may
indicate acute
sinusitis in the appropriate clinical setting.
3. Posterior nasopharyngeal mucosal thickening should be further
evaluated
with direct visualization.
CT TORSO (___)
CT THORAX: The thyroid gland is unremarkable. The airways are
patent to the
subsegmental level. There is no central or axillary
lymphadenopathy. The
heart and great vessels are within normal limits. There is no
pericardial
effusion. The esophagus is within normal limits without
evidence of wall
thickening or hiatal hernia. Lung windows do not show any focal
opacity
concerning for pneumonia. There are small bilateral pleural
effusions with
minimal associated bibasilar atelectasis. There is no
pneumothorax.
CT ABDOMEN: The liver enhances homogeneously, without focal
lesions or
intrahepatic biliary duct dilatation. The gallbladder is
unremarkable and the
portal vein is patent. The pancreas, spleen, adrenal glands are
within normal
limits. The kidneys show symmetric nephrograms and excretion of
contrast.
There is no hydronephrosis. A 6 mm hypodensity in the lower
pole of the left
kidney is too small to characterize but statistically likely a
simple cyst.
The small and large bowel are within normal limits, without
evidence of wall
thickening or dilatation to suggest obstruction. The appendix
is visualized
and is not inflamed. The aorta and its main branches are patent
and
nonaneurysmal. There is no mesenteric or retroperitoneal lymph
node
enlargement by CT size criteria. There is no ascites, abdominal
free air or
abdominal wall hernia.
CT PELVIS: The urinary bladder and ureters are unremarkable.
The uterus is
bulky compatible with multiple fibroids with one exophytic
fibroid measuring
2.2 cm originating from the left anterolateral aspect of the
uterus (2: 95).
There is no pelvic wall or inguinal lymphadenopathy. No pelvic
free fluid is
observed.
OSSEOUS STRUCTURES: There are no lytic or blastic lesions
concerning for
malignancy.
IMPRESSION:
Fibroid uterus. Otherwise unremarkable torso CT examination.
No
lymphadenopathy identified.
Brief Hospital Course:
___ with no significant PMH presents with 1 day of fever and
headaches.
# Fever:
Given fevers and severe headache, a lumbar puncture was
performed. CSF was unremarkable with with only 2 WBC, and
protein/glucose. Gram stain and cultures returned negative.
Nasopharyngeal swab returned negative for influenza. CXR and
urinalysis were also negative. CT head suggestive of acute
sinusitis, however we felt this did not correlate with her
significant leukocytosis with neutrophil predominance. Upon
arrival to the medical floor, patient only complained of sore
throat, occasional coughing of blood-tinged sputum, and night
sweats. Patient was unclear of her PPD status, however CXR was
negative. She denied other infectious symptoms such as cough,
sinus tenderness, shortness of breath, abdominal pain, diarrhea,
dysuria, rash, or joint pain. She denied any recent weight loss,
history of cancer in her family, or recent tuberculosis
exposure. Patient had a ___ systolic murmur that was
undocumented in outpatient records, however no other stigmata of
endocarditis. Blood cultures have also been negative to date.
Because lack of localizing infectious symptoms, antibiotics were
held. The patient continued to spike fevers, up to ___. Because
of elevated inflammatory markers and slightly elevated LDH, the
patient underwent a CT torso to evaluate for lymphadenopathy,
which was negative. One day prior to discharge, patient
developed an exudate on her left tonsil. The exudate was
swabbed, and cultures returned positive for Group A
beta-hemolytic strep. Patient was started on Augmentin, which
she will complete a 10 day course. Patient's WBC remained
elevated, however trended down by the time of discharge.
# Hyponatremia:
Likely secondary to hypovolemia as patient reports poor PO
intake. She was given 2L of IVF in the ED with resolution.
TRANSITIONAL ISSUES:
- Patient to complete a 10 day course of Augmentin for Group A
beta-hemolytic streptococcal pharyngitis.
- Consider ___ for resolution of leukocytosis.
- Consider influenza vaccine as patient has not received it this
season.
- CT head with thickening of nasopharyngeal mucosa. Per
radiology, can not differentiate between normal, infectious, vs
malignancy. Consider further evaluation should patient have
symptoms.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain, fever
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*18 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Group A beta hemolytic strep pharyngitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to the hospital with fevers and headache. A
variety of tests including a spinal tap, CT scan, and flu
testing were negative. We swabbed your throat, and the cultures
revealed a bacterial infection, which is why you are having
throat pain. We started you on antibiotics, Augmentin for which
you will complete a 10 day course (end date ___.
Please finish the course of antibiotics, as instructed. You can
continue to you acetaminophen (Tylenol) as needed for fever,
though do not use more than 3,000mg (3g) daily.
Please follow-up with your primary doctor (___) this week. An
appointment was made on your behalf.
It was a pleasure participating in your care, thank you for
choosing ___!
Followup Instructions:
___
|
10045854-DS-9 | 10,045,854 | 22,972,246 | DS | 9 | 2121-03-20 00:00:00 | 2121-03-24 18:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cipro
Attending: ___
Chief Complaint:
Consideration of cath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with ___ CAD/CABG (DES x2, unclear anatomy), HTN, HLD, DM,
who presented to BI-P with chest pain, found to have NSTEMI
(tropI 10) and ST depressions in anterolateral leads, ST
elevation in aVR, transferred to ___ for consideration of
cath.
Initially presented to BI-P on ___ with syncope (negative
trauma
evaluation) but with diffuse ST depressions on ECG and troponin
I
rise from 0.06 to 20 to peak of 70. He was asymptomatic at that
time. TTE at that time showed EF50% but akinetic infero-lateral
wall and basal to mid ___ wall. He received medical
management with ASA, IV heparin, plavix, beta blocker and was
discharged on discharged ___ from BI-P.
However this AM he developed crushing R chest pain (his anginal
equivalent) and thought he was "going to die." BIBEMS to BI-P,
there trop-I 10 and ECG again showed diffuse ST depressions and
ST elevation in aVR. CXR with pulmory edema edema. Received
ASA324mg, NTG paste, started on heparin gtt. Labs there also
noted mild stable anemia (Hb mid-high 9s) with negative FOBT,
chem panel with Cr 1.6 (baseline appears 1.6-1.8). Cardiology
evaluation there felt to have L main lesion requiring emergent
transfer for stenting. Pre-transfer, VSS and 95%RA.
At ___, pt reports currently is chest pain free. No abd pain,
nausea, vomiting, diaphoresis, fever, chills, diarrhea, urinary
c/o.
In the ED:
Initial VS: 98.0 84 154/79 16 96% RA
EKG: NSR with RBBB, LAFB, ST depressions in anterolateral leads,
and ST elevation in aVR
Labs notable for: tropT 3.8, CKMB 50, Cr 1.5, BNP 18435, Mg 1.4
Studies notable for: CXR Overall improvement in central
pulmonary edema, now mild-moderate. No focal consolidation.
Consults: cardiology
Patient was given: Iv heparin, IV Mg, clopidogrel 300 mg,
Vitals on transfer: 98 81 143/70 18 95% RA
On the cardiology service, he endorses the history above. He
reports the chest pain has resolved and he is not experiencing
any pain or pressure currently.
REVIEW OF SYSTEMS:
Positive per HPI.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope, or presyncope.
On further review of systems, denies fevers or chills. Denies
any
prior history of stroke, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains,
cough, hemoptysis, black stools or red stools. Denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CAD/remote CABG (?in ___) at ___, reportedly with
DES x2, unclear anatomy
3. OTHER PAST MEDICAL HISTORY
- GERD
Social History:
___
Family History:
NC
Physical Exam:
Admission exam
==============
VS: 98.0 143 / 70 ___
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: No JVD
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops. no thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric
Discharge exam
==============
24 HR Data (last updated ___ @ 1706)
Temp: 97.3 (Tm 99.2), BP: 103/57 (100-125/48-70), HR: 62
(61-82), RR: 16 (___), O2 sat: 96% (93-97), O2 delivery: RA
24 HR Data (last updated ___ @ 1706)
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: No JVD
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops. no thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
Admision labs
=============
___ 01:00PM BLOOD WBC-9.5 RBC-3.01* Hgb-9.2* Hct-30.1*
MCV-100* MCH-30.6 MCHC-30.6* RDW-13.6 RDWSD-49.7* Plt ___
___ 01:00PM BLOOD Neuts-74.6* Lymphs-13.1* Monos-9.3
Eos-2.2 Baso-0.3 Im ___ AbsNeut-7.11* AbsLymp-1.25
AbsMono-0.89* AbsEos-0.21 AbsBaso-0.03
___ 01:08PM BLOOD ___ PTT-102.5* ___
___ 01:00PM BLOOD Glucose-114* UreaN-15 Creat-1.6* Na-135
K-4.4 Cl-100 HCO3-20* AnGap-15
___ 08:39PM BLOOD ALT-13 AST-66* AlkPhos-92 TotBili-0.6
___ 01:08PM BLOOD CK-MB-50* MB Indx-10.2* ___
___ 01:00PM BLOOD Calcium-8.9 Phos-2.3* Mg-1.4*
___ 08:39PM BLOOD HDL-40* CHOL/HD-3.2
Discharge labs
==============
___ 06:40AM BLOOD WBC-11.3* RBC-2.53* Hgb-7.8* Hct-24.1*
MCV-95 MCH-30.8 MCHC-32.4 RDW-13.7 RDWSD-47.6* Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-168* UreaN-21* Creat-1.7* Na-131*
K-4.8 Cl-95* HCO3-24 AnGap-12
___ 06:40AM BLOOD ALT-10 AST-18 AlkPhos-82
___ 06:40AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.6
Imaging
=======
TTE ___
CONCLUSION:
The left atrial volume index is normal. There is normal left
ventricular wall thickness with a normal cavity size.
Overall left ventricular systolic function is
moderately-to-severely depressed secondary to hypokinesis of the
inferior free wall and akinesis (with focal dyskinesis) of the
posterior and lateral walls. The visually
estimated left ventricular ejection fraction is 30%. Left
ventricular cardiac index is depressed (less than
2.0 L/min/m2). There is no resting left ventricular outflow
tract gradient. Normal right ventricular cavity size
with depressed free wall motion. Tricuspid annular plane
systolic excursion (TAPSE) is depressed. The aortic
sinus diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch
diameter is normal with a normal descending aorta diameter. The
aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. There is trace
aortic regurgitation. The mitral valve leaflets are
mildly thickened with no mitral valve prolapse. There is
moderate [2+] mitral regurgitation. The pulmonic
valve leaflets are normal. The tricuspid valve leaflets appear
structurally normal. There is mild [1+] tricuspid
regurgitation. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: inferoposterolateral myocardial infarct
CXR ___
FINDINGS:
In comparison to the prior radiograph, diffuse bilateral
reticular opacities
and septal thickening are improved compared to the prior study.
There is
mild-moderate persistent central pulmonary edema slightly worse
on the left.
There is bronchovascular cuffing. Likely trace left pleural
effusion. No
pneumothorax. No large focal consolidation. The heart is
mildly enlarged.
The mediastinum is stable in size. Postsurgical changes after
median
sternotomy and CABG are demonstrated.
IMPRESSION:
Overall improvement in central pulmonary edema, now
mild-moderate. No focal consolidation.
Brief Hospital Course:
TRANSITIONAL ISSUES
====================
DISCHARGE WEIGHT: 66 kg(145.5 lb)
DISCHARGE Cr: 1.7
DISCHARGE DIURETIC: None
MEDICATION CHANGES:
- NEW: Nitroglycerin SL 0.3 mg, Atorvastatin 80 mg daily
- STOPPED: nifedipine 30mg daily, Simvastatin 80mg daily
- CHANGED: Increased Metoprolol succinate XL from 12.5mg daily
to 50 mg daily
TRANSITIONAL ISSUES:
[] Did not start ___ due to elevated Cr. and soft blood
pressures, can be considered as outpatient.
FOR PCP:
[] A1c 7.2%, will require continued monitoring as outpatient
[] please recheck sodium and creatinine within 1 week to ensure
not hyponatremic and no ___ --likely due to decreased PO Intake
from hospital food
[] continue to assess goals of care and ___ and need for rehab
# CODE STATUS: DNR/DNI
# CONTACT: Name of health care proxy: ___
___ number: ___
=========
SUMMARY
=========
___ with ___ CAD/CABG (DES x2, unclear anatomy), HTN, HLD, DM,
who presented to BI-P with chest pain, found to have NSTEMI
(tropI 10) and ST depressions in anterolateral leads, ST
elevation in aVR, transferred to ___ for consideration of
cath, now with plan for medical management.
CORONARIES: prior CABG, 2xDES, unknown coronary anatomy
PUMP: EF 50% ___
RHYTHM: NSR
===============
ACTIVE ISSUES:
===============
# Type I NSTEMI:
History of CAD and remote CABG and 2xDES (he doesn't remember
the details). Initial presentation on ___ to ___ for
syncope with rising troponin diffuse ST depressions with ST
elevation in aVR, concerning for diffuse ischemia such as L main
disease. He was medically managed with ASA, heparin gtt, BB,
plavix and discharged on ___. His peak troponin I was 70. He
then represented on ___ for chest pain and had troponin I of 10
___epressions as before. He was started on heparin gtt,
ASA 325 mg and transferred to ___ for consideration of cath.
At ___, he reported being chest pain free. TropT 3.8 with MB
down-trending 50 to 47. TTE ___ showed EF 30% with
inferoposterolateral myocardial infarct. Event was thought to be
>72 hours out and given his age and prior CABG, risks/benefits
were discussed with interventional attending and cardiology
fellow who recommended medical management and reassessment if he
were to develop chest pain. Discussed with patient and he would
rather avoid cath if possible. We discussed that if he were to
have worsening chest pain we may pursue this option and could
reverse his DNR/DNI ___. He and his family agree
with this noninvasive plan. Plan to optimize medical management.
He was treated with ASA 81mg, Plavix 75mg, Atorvastatin 80mg,
Metoprolol. Restarted his home isosorbide mononitrate 30mg
daily. Initally treated with IV heparin gtt. ACEI was not
started due to his Cr. Can be considered in outpatient if Cr.
improves. Stopped nifedipine 30mg daily as he his metoprolol was
increased.
#DM
A1c at BI-P 7.2%
- Restarted on home glipizide on discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 12.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4. NIFEdipine (Extended Release) 30 mg PO DAILY
5. Simvastatin 80 mg PO QPM
6. Pantoprazole 40 mg PO Q12H
7. GlipiZIDE XL 2.5 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. PARoxetine 10 mg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
2. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Take 1 tab every 5 mins as needed for chest pain, if pain
doesn't resolve after 3 tablets, call ___
RX *nitroglycerin 0.3 mg 1 tablet(s) sublingually Every 5 mins
Disp #*30 Tablet Refills:*0
3. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. GlipiZIDE XL 2.5 mg PO DAILY
RX *glipizide [Glucotrol XL] 2.5 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
8. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
9. PARoxetine 10 mg PO DAILY
RX *paroxetine HCl 10 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis
=================
Type I NSTEMI
Secondary diagnosis
===================
Type 2 Diabetes Mellitus
Hypertension
Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
================================================
DISCHARGE INSTRUCTIONS
================================================
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had a heart attack.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were found to have some damage to your heart. Together
with you, we decided to avoid looking inside the arteries of
your heart (Cardiac catherization). We gave you medications to
treat your heart instead.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
Followup Instructions:
___
|
10045960-DS-10 | 10,045,960 | 24,068,884 | DS | 10 | 2193-07-31 00:00:00 | 2193-07-31 18:03:00 |
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:
None
History of Present Illness:
Mr. ___ is a ___ year old man with a history of HFpEF
(EF 60%), COPD, AFib, CAD, OSA who presented with shortness of
breath. He describes developing sudden shortness of breath at
home yesterday evening which woke him from sleep. He describes
orthopnea at that point although he generally sleeps with two
pillows. He's had a dry cough for weeks, as well as insidious
weight gain. He has been going to pulmonary rehab as recommended
by his Pulmonologist, and underwent a session that morning. He
thinks his diet has been the same, has not had sick contact. His
only medication change was starting labetalol one week ago by
his PCP. He denies fever/chills, chest pain, lightheadedness,
palpitations. This morning he called EMS, who found him
hypertensive to the 200s. He received oral nitro and was placed
on CPAP on transfer.
Of note, he had PEA arrest in ___ in the setting of hypoxia
from a COPD exacerbation. He was diagnosed with AFib in that
occasion and given an event monitor. He was also recently
admitted on ___ with a CHF exacerbation which improved after
diuresing.
In the ED,
Initial vital signs: T 97.7, HR 60, BP 230/130, RR 18, O2 sat
100% CPap
Exam notable for: No exam documented.
EKG: Sinus bradycardia w/ 1st degree AV block (PR 219), old
anterioseptal MI (T wave inversions I, aVL, V4-6)
Labs were notable for: CBC - WBC 7, Hgb 14.4, Plt 126; coags
-INR 1.5; BMP - Cr 1; proBNP 1030; vBG 7.34/56/41 -> 7.42/45/55
; lactate 1.6, trop negative.
Studies performed include: CXR - Moderate pulmonary vascular
congestion and edema. Bibasilar opacifications likely reflect a
combination of atelectasis and edema, however a superimposed
pneumonia would be difficult to exclude. New elevation of the
left hemidiaphragm compared to ___. Probable small left
pleural effusion.
Patient was given: 4 SL nitro en route (1 additional in ED),
Duonebs x 2, 40 mg IV Lasix, ceftriaxone, azithromycin,
apixaban, aspirin, labetalol.
His ED course was notable for starting BiPap on arrival and plan
for ICU admission. However, his O2 requirement decreased to 5L
NC so he was admitted to the floor.
Vitals on transfer: HR 50, BP 163/85, RR 24, O2 sat 96% 5L NC
Upon arrival to the floor, he is feeling well although still a
little short of breath.
Past Medical History:
PEA arrest in the setting of hypoxia in ___
COPD
HFpEF (EF 60% in ___
CAD (s/p DES to LCX ___
AFib
Moderate AS
L diaphragmatic paralysis
OSA (ordered for outpatient BiPAP but declined this)
Social History:
___
Family History:
Father died from bone cancer at the age of ___. Mother died of
dementia in her ___.
Physical Exam:
ADMISSION
=========
VITALS: T 97.4, BP 185/84, HR 52, RR 18, O2 sat 97% 5L
GEN: In NAD.
HEENT: PERRL, moist mucous membranes, oropharynx clear without
exudates.
NECK: JVP to mandible, no cervical lymphadenopathy.
CV: RRR, soft systolic ejection murmur at base.
PULM: CTAB, no wheezing/crackles/rhonchi.
ABD: Soft, non tender, non distended.
EXTREM: Trace ___ edema. Pulses +2 ___P, ___ bilaterally.
SKIN: No rashes.
NEURO: A&Ox3, CN II-XII intact, motor and sensation grossly
intact.
DISCHARGE
=========
VITALS: Reviewed in OMR
GENERAL: Alert and oriented, no acute distress
ENT: NT/AC, MMM, EOMI
CV: Bradycardic, regular. No murmurs, rubs, or gallops
RESP: CTAB, normal work of breathing
GI: NT/ND, BS+
EXT: Warm and well perfused, non-edematous
NEURO: CNII-XII grossly intact, no focal neurologic deficits
Pertinent Results:
ADMISSION
=========
___ 04:47AM WBC-7.0 RBC-4.77 HGB-14.4 HCT-43.6 MCV-91
MCH-30.2 MCHC-33.0 RDW-14.5 RDWSD-48.9*
___ 04:47AM NEUTS-69.3 LYMPHS-18.0* MONOS-8.3 EOS-3.3
BASOS-0.7 IM ___ AbsNeut-4.82 AbsLymp-1.25 AbsMono-0.58
AbsEos-0.23 AbsBaso-0.05
___ 04:47AM PLT COUNT-126*
___ 04:47AM ___ PTT-33.5 ___
___ 04:47AM CALCIUM-9.0 PHOSPHATE-3.7 MAGNESIUM-1.9
___ 04:47AM proBNP-1030*
___ 04:47AM cTropnT-<0.01
___ 04:47AM GLUCOSE-156* UREA N-15 CREAT-1.0 SODIUM-142
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-26 ANION GAP-11
___ 05:02AM LACTATE-1.6
___ 05:02AM ___ PO2-41* PCO2-56* PH-7.34* TOTAL
CO2-32* BASE XS-2
___ 06:04AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 06:04AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:04AM URINE UHOLD-HOLD
___ 06:04AM URINE HOURS-RANDOM
___ 06:16AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 03:21PM ___ PO2-55* PCO2-45 PH-7.42 TOTAL CO2-30
BASE XS-3
___ 05:59PM GLUCOSE-85 UREA N-10 CREAT-0.7 SODIUM-147
POTASSIUM-3.1* CHLORIDE-114* TOTAL CO2-21* ANION GAP-12
DISCHARGE
=========
___ 06:15AM BLOOD WBC-6.0 RBC-5.15 Hgb-15.5 Hct-46.6 MCV-91
MCH-30.1 MCHC-33.3 RDW-14.5 RDWSD-47.8* Plt ___
___ 06:15AM BLOOD Glucose-117* UreaN-20 Creat-1.2 Na-145
K-4.3 Cl-101 HCO3-27 AnGap-17
IMAGING
=======
___ CXR:
1. Moderate pulmonary vascular congestion and edema.
2. Bibasilar opacifications likely reflect a combination of
atelectasis and edema, however a superimposed pneumonia would be
difficult to exclude.
3. New elevation of the left hemidiaphragm compared to ___.
4. Probable small left pleural effusion.
Brief Hospital Course:
Mr. ___ is a ___ w/ PMH HFpEF (EF 60%), COPD, AFib,
CAD, OSA presenting acute on chronic dyspnea presenting with
acute on chronic hypoxemic respiratory failure initially
requiring BiPAP but quickly transitioned to O2 via NC and then
room air with diuresis.
ACUTE ISSUES
============
#Dyspnea
#HFpEF exacerbation
Reported dry weight from last hospitalization 155 lb. Trigger
for exacerbation is unclear, possibly flash pulmonary edema in
the setting of labile BPs versus dietary indiscretion with
recent weight gain. He was direused with IV furosemide and
transitioned to oral torsemide.
#HTN
- Continued home ___ (losartan instead of non-formulary
olmesartan)
- Held home carvedilol, labetalol due to bradycardia, started on
amlodipine 5MG daily for BP control in ___ of these agents.
CHRONIC ISSUES
==============
#COPD
No wheezing, fevers, chills, productive cough, or other
signs/symptoms of COPD exacerbation this admission.
#CAD
#AS
Mild AS on TTE from ___.
- Continued aspirin, atorvastatin
#AFib
#S/p cardiac arrest
Patient with PEA cardiac arrest on ___, felt to be ___ acute
hypoxic respiratory failure, with negative cath and required
temporary pacer. Now with LINQ monitor. AFib developed during
that hospitalization.
- Held rate control with home carvedilol as above
- Continued rhythm control with amiodarone
- Continued AC with apixaban
TRANSITIONAL ISSUES
===================
Discharge Wt: 160 lb
Discharge Cr: 1.2
[] Patient was discharged on Torsemide 10MG daily, please
continue to monitor volume status closely and recheck CHEM7 at
PCP follow up.
[] Both carvedilol and labetalol were on the patient's
preadmission medication list. Both of these were held on
discharge due to bradycardia to the low ___ throughout this
admission.
[] Started on amlodipine 5MG for BP control in the setting of
stopping carvedilol/labetalol as above, consider increasing if
BP is still elevated or decreasing if beta blockers are
restarted.
[] Isolated thrombocytopenia this admission to 110-130s, no
signs/symptoms of bleeding, consider further workup as
outpatient if persistent.
[] Patient should be on BiPAP at night as outpatient, but has
been non-compliant. Would continue to reinforce using this as
his OSA is probably contributing to HTN issues and heart failure
exacerbations.
#CONTACT: ___ (Son) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. olmesartan 40 mg oral DAILY
2. CARVedilol 6.25 mg PO BID
3. Amiodarone 200 mg PO DAILY
4. Apixaban 5 mg PO BID
5. Atorvastatin 80 mg PO QPM
6. Furosemide 20 mg PO DAILY
7. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
8. Aspirin 81 mg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
10. dutasteride 0.5 mg oral QHS
11. Ranitidine 150 mg PO DAILY
12. Labetalol 300 mg PO BID
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Torsemide 10 mg PO DAILY
RX *torsemide 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Amiodarone 200 mg PO DAILY
4. Apixaban 5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
8. dutasteride 0.5 mg oral QHS
9. olmesartan 40 mg oral DAILY
10. Ranitidine 150 mg PO DAILY
11. Vitamin D ___ UNIT PO DAILY
12. HELD- CARVedilol 6.25 mg PO BID This medication was held.
Do not restart CARVedilol until Follow up with your
PCP/Cardiologist
13. HELD- Labetalol 300 mg PO BID This medication was held. Do
not restart Labetalol until follow up with your PCP/Cardiologist
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute on Chronic Diastolic Heart Failure
Secondary:
Hypertension
Hyperlipidemia
Chronic Obstructive Pulmonary Disease
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 privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were having trouble breathing
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Your trouble breathing what thought to be due to increased
fluid in your body that backed up into your lungs.
- You were treated with IV medications to help remove the fluid
and were transitioned to a stronger medication called torsemide
that you will continue to take on discharge.
- Your home blood pressure medications were held due to your low
heart rate and you were started on a new blood pressure
medication. You should follow up with your PCP and your
cardiologist about this.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Your weight at discharge is 160 lbs. Please weigh yourself
today at home and use this as your new baseline.
- Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs in one week.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10046166-DS-16 | 10,046,166 | 20,474,438 | DS | 16 | 2132-12-10 00:00:00 | 2132-12-10 18:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
erythromycin (bulk) / Sulfa (Sulfonamide Antibiotics) /
Fosphenytoin
Attending: ___
Chief Complaint:
right hand weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ RH man with
a PMHx significant for CAD s/p CABG and stent placement, DM2,
HTN, HL who presents today with acute onset right hand weakness
and numbness. He had been in his USOH until today, when he was
walking on a treadmill at the gym prior to going to work.
Approximately 45 minutes into his exercise, he noted that his
right hand began to feel weak, stating that his grasp was
progressively loosening on the handrail of the treadmill. He
estimates that this continued for a 15 minute period during his
workout. He also describes numbness, stating that his hand
didn't feel "right". No headache, no visual changes, no nausea,
no vomiting. He showered and was contemplating going to work,
but was concerned about his hand, which was still not moving
well. He then called his wife and drove home. There, his wife
notified his PCP and the covering physician advised him to
activate EMS and go to his local ED for urgent evaluation. EMS
was activated but he declined transport, stating that he didn't
want to go to his local OSH (he was coming from ___. His
daughter therefore agreed to drive them to the ___ ED for
urgent evaluation. Concerned about a stroke, a code STROKE was
activated and the neurology team was invited to emergently
consult.
Past Medical History:
1. CAD s/p CABG in ___ and stent placement
2. HTN
3. HL
4. DM2
Social History:
___
Family History:
Mother with dementia, brother with RA.
Physical Exam:
ADMISSION EXAM:
Physical Examination:
VS: T: 96.5 HR: 69 BP: 188/69 RR: 16 O2: 99%
Genl: Awake, alert, NAD
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally, no wheezes, rhonchi, rales
Abd: soft, NTND, NABS
Ext: No lower extremity edema bilaterally
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect, though became appropriately tearful towards the end of
exam. Oriented to person, place, and date. Attentive, says
presidents backwards through ___ I. Speech is fluent with
normal
comprehension and repetition; naming intact. No dysarthria.
Reading intact. No right-left confusion. No evidence of apraxia
or neglect.
Cranial Nerves: Pupils equally round and reactive to light, 3 to
2 mm bilaterally. Visual fields are full to confrontation.
Extraocular movements intact bilaterally without nystagmus.
Sensation intact V1-V3. Facial movement symmetric. Palate
elevation symmetric. Sternocleidomastoid and trapezius full
strength bilaterally. Tongue midline, movements intact.
Motor: Normal bulk and tone bilaterally. No observed myoclonus,
asterixis, or tremor. No pronator drift. Unable to perform
finger
tapping on right hand
Del Tri Bi WE WF FE FF IP H Q DF PF
R ___ ___ ___ ___
L ___ ___ ___ ___
Sensation: Intact to light touch, pinprick, vibration, position
sense, and cold sensation throughout. No extinction to DSS.
Reflexes: 1+ and symmetric throughout except UTO on b/l
achilles.
Toes downgoing bilaterally.
Coordination: finger-nose-finger slow on right hand but without
dysmetria.
Gait: deferred.
DISCHARGE EXAM
Notable for weakness of the right hand, with inability to fully
extend the fingers, and ___ FF, WE and WF.
Pertinent Results:
ADMISSION LABS:
___ 10:55AM BLOOD WBC-5.2 RBC-4.85 Hgb-14.2 Hct-41.8 MCV-86
MCH-29.4 MCHC-34.1 RDW-12.8 Plt ___
___ 10:55AM BLOOD Neuts-64.5 ___ Monos-3.8 Eos-2.5
Baso-1.1
___ 10:55AM BLOOD ___ PTT-28.0 ___
___ 10:55AM BLOOD UreaN-22*
___ 10:55AM BLOOD Creat-1.1
___ 10:55AM BLOOD ALT-15 AST-18 AlkPhos-85 TotBili-0.4
___ 10:55AM BLOOD TotProt-7.0 Albumin-4.3 Globuln-2.7
Calcium-9.6 Phos-3.0 Mg-1.7
___ 11:04AM BLOOD Glucose-177* Na-139 K-4.7 Cl-104
calHCO3-22
DISCHARGE LABS:
___ 05:45AM BLOOD WBC-5.5 RBC-4.46* Hgb-13.0* Hct-39.9*
MCV-90 MCH-29.1 MCHC-32.5 RDW-12.5 Plt ___
___ 05:45AM BLOOD Glucose-131* UreaN-12 Creat-0.8 Na-142
K-3.6 Cl-107 HCO3-27 AnGap-12
___ 05:45AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.8
___ 05:25AM BLOOD %HbA1c-7.6* eAG-171*
___ 05:25AM BLOOD Triglyc-122 HDL-40 CHOL/HD-3.9 LDLcalc-90
IMAGING:
CTA Head and neck:
IMPRESSION:
1. Left frontal lobe parenchymal hemorrhage, with no evidence of
underlying AVM or other vascular abnormality.
2. No CTA "spot sign" indicating active contrast extravasation
to suggest
risk of rapid expansion.
3. Persistent central relative low-attenuation with concerning
for cystic
necrosis within an underlying mass (though none is definitely
seen), given the findings, below.
4. Large superior mediastinal conglomerate lymph node mass, as
well as right hilar lymphadenopathy. Findings are concerning for
underlying malignancy, perhaps bronchogenic, with hemorrhagic
brain metastasis
MRI brain w/ and w/o contrast:
IMPRESSION:
1.Left frontal intraparenchymal hemorrhage with pronounced
___ edema and central enhancing lesion that most
likely represents a metastatic focus.
2. No evidence of additional enhancing masses.
3. Several subcortical foci of microhemorrhage for which
differential
considerations include long standing anti-coagulation or amyloid
disease among others.
CT Chest/Ab/Pelvis:
IMPRESSION:
1. Large necrotic mediastinal and hilar lymph nodes.
2. Solitary non-calcified right lower lobe 6 mm pulmonary
nodule.
3. Calcifications within the spleen, hilum and a pulmonary
nodule are
consistent with old granulomatous disease, likely
histoplasmosis.
4. Essentially normal exam of the abdomen and pelvis.
Brief Hospital Course:
Mr. ___ is a ___ RH man with a PMHx significant for CAD
s/p CABG and stent placement, DM2, HTN, HL who presented on
___ with acute onset right hand weakness and possible numbness
who was found to have left frontal intraparenchymal hemorrhage.
Etiology of hemorrhage was thought to be from a malignancy. He
was admitted for observation and management of his bleed and BP.
.
# Neuro: On his CTA in the ED he was incidentally found to have
2 large lymph nodes concerning for malignancy. His aspirin was
held. His MRI brain showed no evidence of microhemorrhage
making amyloid a less likely cause of his hemorrhage, and given
the lymph nodes noted on CTA, he underwent a CT torso to
evaluate for possible primary malignancy.
.
# CARDS: While here we treated pt with PRN hydralazine for SBP
>160. We continued his lisinopril. His SBP was occasionally in
the 160's so we increased his metoprolol to 50mg BID (from
metoprolol succinate 75mg QD). We stopped pt's simvasatin given
possible increased risk of bleeding. On ___ he experienced an
episode of chest pain that felt "just like" his usual stable
angina pain when he exercises. His cardiac enzymes were
negative x2, and no changes on EKG. As we had just recently
explained we were looking for a malignancy, and he was very
anxious about this, it was presumed that the anxiety elevated
his HR to the level it normally is to activate his stable
angina.
.
# PULM: patient's CTA incidentally showed 2 large lymph nodes
that were concerning for malignancy. He then underwent a CT
torso, which confirmed the CTA findings as well as showed
mulitple calcifications likely from a old histoplasmosis
infection. He underwent a broncoscopy guided biopsy of his
paratracheal node on ___. This necessitated general anethesia.
The results of this biopsy are still pending
.
# ENDO: patient's HGA1C was 7.6, indicating that he may need
tighter glucose control at home. While here because he was got
multiple CT's with contrast, we held his home glycemic oral
medications and treated him with an ISS. His home metformin was
restarted on discharge
.
# Prophylaxis:
-PPX: famotidine and pneumoboots (HELD subq heparin)
.
# CODE/CONTACT: FULL as confirmed with patient. HCP: wife
___:
cell: ___. home: ___. Daughter ___:
___
PENDING LABS:
Final biopsy results
TRANSITIONAL CARE ISSUES:
Patient will need to arrange for hematology/oncology follow-up.
He was given the number to arrange this and told it was very
important to follow-up for the results of his biopsy.
Medications on Admission:
Aspirin 325 mg Tab 1 Tablet(s) by mouth once a day
lisinopril 40 mg Tab one Tablet(s) by mouth once a day
simvastatin 40 mg Tab 1 Tablet(s) by mouth once a day
Glipizide SR 10mg 24 hr Tab (dose uncertain)
Metformin 500mg BID
metoprolol succinate ER 50 mg 24 hr Tab ___ Tablet(s) qday
Discharge Medications:
1. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. glipizide 10 mg Tablet Extended Rel 24 hr Oral
6. Ativan 1 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for anxiety for 1 weeks: DO NOT DRIVE UNTIL YOU
KNOW HOW THIS MEDICATION EFFECTS YOU.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Intracerebral hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
NEURO EXAM: RUE distal extensor weakness
Discharge Instructions:
Dear Mr. ___,
You were seen in the hospital because of hand weakness and were
shown to have had a small bleed in your head. While here, we
did an MRI which showed the same small bleed. We are not sure
what caused this bleed.
We made the following changes to your medications:
1) We CHANGED your METOPROLOL SUCCINATE to METOPROLOL TARTRATE
at 50mg twice a day.
2) We STARTED you on ATIVAN 1mg every 4 hours as needed for
anxiety for a 1 week supply. Do not drive while taking this
medication as it can make you dangerously sleepy. Do not drink
alcohol or take any other sedating medications as this can also
make you dangerously sleepy.
3) We DECREASED your ASPIRIN to 81mg once a day. We want you to
ONLY RESTART THIS ON ___. DO NOT RESTART THIS PREVIOUSLY.
Please continue to take your other medications as previously
prescribed.
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
___
|
10046166-DS-19 | 10,046,166 | 25,512,766 | DS | 19 | 2133-03-24 00:00:00 | 2133-03-24 17:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
erythromycin (bulk) / Sulfa (Sulfonamide Antibiotics) /
Fosphenytoin
Attending: ___.
Chief Complaint:
hypoglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: ___ yo M with HTN, DM2 on oral agents, melanoma with mets to
brain s/p L sided craniotomy with resection of met, cyberknife
treatment, and recent completion of whole brain radiation on
steroids, h/o seizures with recent admission (___) who was
routinely checking blood sugar this morning and had a
fingerstick of 29. Repeat testing by patient and EMTs confirmed
hypoglycemia even after breakfast and he was referred to the ED.
He was asymptomatic throughout with no sweating, palpitations.
He did have some seizure activity this morning (shaking right
hand) Of note, his metoprolol dose was doubled on his last
admission. His fingersticks were running in the 150-180s the day
before. He has been following a low carb diet in an effort to
improve glucose control. No other new symptoms. He continues to
have loose stools up to 5 per day without associated abd pain,
fevers.
In ER: (Triage Vitals: 97.7 84 140/67 16 97%RA) Meds Given: D50,
levetiracetam, dexamethasone, Fluids given: 2L NS, Radiology
Studies: R nodule, no acute process.
.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___: noted weakness in his right arm progressively
going into loss of sensation --> ___ ED
- CT revealed a 2.9 x 1.6 parenchymal hemorrhage in the superior
left frontal lobe with surrounding vasogenic edema and sulcal
effacement.A
focal hypodensity within the central portion of this hemorrhage
could represent clotted active hemorrhage; however, this is not
confirmed by post-contrast CTA images.
- MRI showed left frontal intraparenchymal hemorrhage with
pronounced perilesional edema and central enhancing lesion that
most likely represent metastatic focus.
- ___ - CT torso eval showed a large mediastinal mass measuring
40 x 33 mm, heterogeneously enhancing lymph node or conglomerate
of lymph nodes. There is a right hilar lymph node, which
measured 17 x 15 mm. In the right lower lobe, is a 6-mm round
pulmonary nodule adjacent to pleural surface that could
represent underlying lung cancer.
- ___ - bronchoscopy to eavluate LN in mediastinus revealed
metastatic melanoma.
- see in neuro-onc group and in biologic therapy clinic
- Left sided craniotomy for resection of met by Dr ___ on
___
- ___ - single fraction CyberKnife treatment to his right
parietal resection cavity (at 1800 cGY and 79% isodose)
- ___ - focal seizures of right hand started
- ___ - Brain MRI shows two brain lesions with vasogenic
edema and hemorrhage.
- hospitalized with seizures (___)
- whole brain radiation completed ___
- divalproex added for ongoing seizures
.
PAST MEDICAL HISTORY:
CAD status post CABG in ___ and stent placement
squamous cell carcinoma of the skin
hypertension
hyperlipidemia
diabetes type 2
cholecystectomy
Social History:
___
Family History:
Mother with dementia. Brother with rheumatoid arthritis.
Maternal grandfather with pancreatic cancer.
Physical Exam:
admission exam
T 97.0 P 79 BP 176/60 RR 16 O2Sat 96 RA ___- 403
GENERAL: alert, pleasant, sitting in chair, mentating clearly
Eyes: NC/AT, PERRL, EOMI, no scleral icterus noted
Ears/Nose/Mouth/Throat: +++ oral thrush, upper dentures
Neck: supple, no JVD appreciated
Respiratory: Lungs CTA bilaterally without R/R/W
Cardiovascular: Reg S1S2, no M/R/G noted
Gastrointestinal: soft, NT/ND, + bowel sounds, no masses or
organomegaly noted.
Genitourinary: no flank tenderness
Skin: no rashes or lesions noted. No pressure ulcer
Extremities: No C/C/E bilaterally, 2+ radial, DP and ___ pulses
b/l.
Lymphatics/Heme/Immun: No cervical, supraclavicular
lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: R upper extremity with ___ strength, normal bulk. No
abnormal movements noted.
No foley catheter/tracheostomy/PEG/ventilator support/chest
tube/colostomy
Psychiatric: pleasant and interactive
.
discharge exam
VS: 95.4 112/68-160/70 ___ 20 95% RA
GENERAL: alert, pleasant, sitting in chair, mentating clearly
HEENT: no scleral icterus, MMM
Respiratory: Lungs CTA bilaterally
Cardiovascular: Reg S1S2, no M/R/G noted
Gastrointestinal: soft, NT/ND, + bowel sounds, no masses or
organomegaly noted.
Skin: no rashes or lesions noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and ___ pulses
b/l.
Neurologic: Alert, oriented x 3. Pleasant and interactive
Pertinent Results:
admission labs
___ 11:00AM BLOOD WBC-11.6* RBC-4.40* Hgb-13.1* Hct-37.9*
MCV-86 MCH-29.8 MCHC-34.6 RDW-15.0 Plt ___
___ 11:00AM BLOOD Neuts-94.2* Lymphs-3.6* Monos-1.9*
Eos-0.2 Baso-0
___ 11:00AM BLOOD Glucose-47* UreaN-52* Creat-1.1 Na-130*
K-5.7* Cl-95* HCO3-11* AnGap-30*
___ 11:00AM BLOOD Calcium-9.7 Phos-3.9 Mg-1.9
___ 01:59PM BLOOD K-5.1
___ 10:19PM BLOOD Lactate-5.3*
.
other pertinent labs
___ 01:30PM BLOOD VitB12-___
___ 06:30AM BLOOD TSH-0.23*
.
discharge labs
___ 06:30AM BLOOD WBC-7.3 RBC-4.49* Hgb-13.1* Hct-39.1*
MCV-87 MCH-29.1 MCHC-33.5 RDW-15.3 Plt ___
___ 06:30AM BLOOD Neuts-91.8* Lymphs-4.6* Monos-3.0 Eos-0.6
Baso-0.1
___ 06:30AM BLOOD ___ PTT-20.8* ___
___ 06:30AM BLOOD Glucose-274* UreaN-32* Creat-0.9 Na-134
K-4.6 Cl-99 HCO3-27 AnGap-13
___ 06:30AM BLOOD ALT-17 AST-10 AlkPhos-50 TotBili-0.5
___ 06:30AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.9
.
micro
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___:
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
blood cx x 2 pending at time of discharge
.
studies
ECG:
Sinus rhythm. Possible prior inferior infarction with slurring
of the intial forces in leads III and aVF. Probable anterior
myocardial infarction as well.
The rate has slowed as compared with previous tracing of ___
and the
lateral ST-T wave abnormalities persist without diagnostic
interim change.
.
CXR
FINDINGS: Frontal and lateral views of the chest were obtained.
Rounded
calcified nodule in the region of the posterior right lung base
is seen and represents calcified granuloma on CTs dating back to
___, likely
secondary to prior granulomatous disease. Previously seen
pretracheal lymph node conglomerate and right hilar lymph nodes
are better seen/evaluated on CT.
No focal consolidation is seen. There is no pleural effusion or
pneumothorax. Cardiac and mediastinal silhouettes are stable
with possible slight decrease in right paratracheal prominence.
IMPRESSION: No radiographic findings to suggest pneumonia.
Brief Hospital Course:
___ yo M with DM2 on oral agents with labile blood sugars,
melanoma with mets to brain on steroids, recently completed
whole brain irradiation, HTN presents with hypoglycemia.
.
# DM2: poorly controlled (last A1c 9.2) and likely exacerbated
by steroids. Patient hypoglycemic on presentation with lactic
acidosis. Patient given D50 in the ED and finger sticks improved
to the 200s-400s. Electrolytes improved with IVF. Oral
hypoglycemics were discontinued. ___ was consulted. Patient
was started on insulin regimen which was titrated during
admission. He was discharged on levemir 12 units BID and 7 units
of humalog with meals with an additional sliding scale as
needed. He will need to be seen in ___
within 1 week of discharge.
.
# Anion Gap Metabolic acidosis - Patient presented with anion
gap metabolic acidosis. This was likely secondary to lactic
acidosis (lactate 5.3 initially) which may be due to high
metformin dosing. Patient given IVF and lactate trended down and
gap closed.
.
# Hyperkalemia: K was 6.4 on presentation. ECG showed more
pronounced T waves in v1-v4. Patient was given kayexalate on
admission and acidosis was corrected. ACE inhibitor was
initially held, but was restarted at a lower dose of 10mg daily.
Potassium normalized prior to discharge.
.
# Hyponatremia: Patient appeared hypo/euvolemic on exam. Sodium
low in the setting of high sugars, however, remained low despite
correction of glucose. Hyponatremia likely related to
hypovolemia as it improved with IVF to within normal range.
.
# HTN: Continued metoprolol. Initially held lisinopril and blood
pressures remained stable mostly in 110s-140 systolic. When K
normalized, lisinopril was restarted at a lower dose of 10 mg
daily. This can be uptitrated as blood pressure and potassium
levels allow.
.
# Metastatic melanoma with brain mets: Recently completed whole
brain irradiation. Patient continued on dexamethasone 4 mg every
6 hours.
.
# Seizures: characterized by right hand/arm shaking and right
eye drooping lasting ___ minutes. Last seizure on morning of
presenation. He was continued on levetiracetam and divalproex.
.
# CAD - continued beta blocker, statin. ACE inhibitor restarted
prior to discharge. Aspirin had been discontinued as an
outpatient and did not restart during this admission.
.
# Diarrhea: Stool studies negative for infection. Patient
treated with immodium prn with relief.
.
# Oral thrush: likely related to steroids. Patient denied
odynophagia. He was started on fluconazole 200 mg daily. He was
discharged with plans to complete a 2 week course.
.
# Leukocytosis: Patient had no fevers or localizing symptoms of
infection. Leukocytosis likely related to high dose steroids.
Urine culture negative. Blood cultures with no growth at time of
discharge.
.
Transitional Issues
- patient will need close follow up at ___. His insulin
regimen will likely need further adjustment
- lisinopril dose lowered from 40 to 10 mg daily as he was
normotensive when the lisinopril was held due to hypokalemia.
This can be uptitrated as blood pressure and potassium allows.
- patient reported diarrhea for 3 months. Infectious etiologies
were ruled out. He was started on immodium with symptomatic
relief. This may need further outpatient investigation
- TSH was low, this will need to be rechecked at follow up
- patient was started on a 2 week course of fluconazole for
thrush
- patient was full code on this admission
Medications on Admission:
pioglitazone 15mg
glipizide 20mg BID
metformin 1500mg BID
atovaquone solution 1500mg daily
divalproex delayed release 500mg BID
levetiracetam 1000mg TID
sertraline 50mg daily
metoprolol 50mg bid
nitro SL prn
simvastatin 40 mg daily
lisinopril 40mg daily
dexamethasone 4mg q 6 hours (taper to 2mg on ___
alprazolam 0.5mg qAM, 0.25mg qPM
cialis 20mg q 3 days
omeprazole 20mg daily
aspirin 81mg (recently discontinued)
Discharge Medications:
1. FreeStyle Lite Meter Kit Sig: One (1) kit Miscellaneous
use as directed.
Disp:*1 kit* Refills:*0*
2. FreeStyle Lite Strips Strip Sig: One (1) box
Miscellaneous use as directed.
Disp:*qs units* Refills:*2*
3. Levemir Flexpen 100 unit/mL (3 mL) Insulin Pen Sig: One (1)
injection Subcutaneous twice a day: please refer to your insulin
sliding scale.
Disp:*qs units* Refills:*0*
4. Humalog KwikPen 100 unit/mL Insulin Pen Sig: One (1)
injection Subcutaneous use as directed: please refer to your
insulin sliding scale.
Disp:*qs units* Refills:*0*
5. BD Insulin Pen Needle UF Short 31 X ___ Needle Sig: One
(1) needle Miscellaneous use as directed: please refer to the
insulin sliding scale.
Disp:*qs needles* Refills:*0*
6. Ketostix Strip Sig: One (1) strip Miscellaneous once a
day as needed for for glucose > 250.
Disp:*1 box* Refills:*0*
7. equipments
one hemiwalker
8. equipments
one wheelchair
9. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) mL PO DAILY
(Daily).
10. divalproex ___ mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
11. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
Disp:*100 Tablet(s)* Refills:*0*
15. alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
16. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
17. Cialis 20 mg Tablet Sig: One (1) Tablet PO every ___
(72) hours.
18. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
19. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
20. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea. Capsule(s)
21. diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO HS
(at bedtime).
22. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
23. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO three
times a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary diagnosis: hypoglycemia
secondary diagnosis: metastatic melanoma, type 2 diabetes,
hypertension, 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 caring for you while you were admitted to
___. You were admitted because you were found to have very low
blood sugars. You were given sugar in the emergency room and
treated with intravenous fluids. Your electrolyte abnormalities
were corrected. You were evaluated by the diabetes specialist
team from ___ and ___ were started on insulin to help better
control your blood sugars.
.
The following changes have been made to your medication regimen.
Please START taking
- levemir 12 units twice daily
- humalog 7 units before meals and as directed by sliding scale
- fluconazole 200 mg daily for 2 weeks for thrush
.
Please STOP taking
- metformin
- pioglitazone
- glipizide
.
Please CHANGE
- lisinopril from 40 to 10 mg daily (your doctor may increase
this dose in the future as your blood pressure and potassium
tolerates)
.
Please have your electrolytes checked on ___ when you follow
up with Dr. ___ in clinic
Followup Instructions:
___
|
10046166-DS-21 | 10,046,166 | 22,857,894 | DS | 21 | 2133-09-20 00:00:00 | 2133-09-21 09:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
erythromycin (bulk) / Sulfa (Sulfonamide Antibiotics) /
Fosphenytoin
Attending: ___.
Chief Complaint:
status post fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a ___ M with melanoma c/b brain mets s/p whole brain
radiation and cyberknife, who presents with worsening
instability
and generalized shaking with 2 episodes of near syncope.
His neurological problem began on ___ when he was
exercising
on a treadmill. He noticed a subacute loss of function in the
right hand over ___ minutes that eventually rendered the right
hand non-functional. This happened at about 07:30 a.m. He had
slight nausea but no vomiting. He came to the emergency
department at ___ and a head CT showed hemorrhage in the left
frontal brain. A subsequent head MRI showed an enhancing mass
with hemorrhage. He was admitted to NeuroMedicine Service,
placed on dexamethasone, and a torso CT on ___ revealed a
necrotic mediastinal mass with hilar lymphadenopathy. He
underwent a mediastinoscopy with biopsy on ___ that
eventually showed metastatic melanoma. He was discharged from
the hospital on ___.
He saw Dr. ___ from medical
oncology during his hospital stay. He later underwent an
FDG-PET
that showed the FDG-avid disease at mediastinum and left frontal
brain; in addition, he also had another FDG-avid lesion in the
left lateral pelvis adjacent to bowel thought to represent and
inflammed diverticula. He then underwent a surgical resection
of
a left frontal melanoma brain metastasis on ___ by
___, followed by CyberKnife radiosurgery to 1,800
cGy at 79% isodose line on ___. He started whole brain
cranial irradiation on ___.
He was admitted to the OMED Service at ___ for focal motor seizures in the right upper
extremity from ___ to ___.
He was hospitalized again in ___ from ___ to ___ for
hypoglycemia and metformin-induced lactic acidosis.
Over the course of ___, a new metastatic lesion was
identified in the left occipital lobe following which he
received
stereotactic radiosurgery to that region.
Since that time he was doing well but intermittent had
instability and generalized weakness. His wife reports that he
has been shaky and somewhat confused for several weeks. Last
week
he completed a course of cyberknife for his frontal lesion.
Today, he felt that his problems on weakness and instability
worsened. He was going to breakfast with his wife and when
attempted to get out of the car. He had a moment of freezing and
looked unwell and states that he felt as if he was going to pass
out but didnt. He then proceeded to go to the restaurant but
afte
rsitting down continued to have this presyncopal sensation. He
endorsed nausea and some lightheadedness. He went back to the
car
and his wife brought him home. At that point he was so generally
weak that his son needed to bring him up to bed. He slept
several
hours and his wife decided to bring him in. At 3 pm, when she
woke him up, he felt much better and walked to the car himself.
He was reportedly back to baseline.
He did not have LOC with these episodes or anywhere in between.
There was no rythmic shaking, tongue biting or incontinence. He
remembers every episode quite well. He does not feel any
different now than his did yesterday.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal 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:
Past Medical History: He has ___ year history of type II
diabetes. He has hypercholesterolemia and hypertension but no
COPD.
Past Surgical History: He had CABG x 4 vessels,
cholecystectomy,
and 2 mohs procedures (one at right forehead and the other at
left upper lip), and removal of 3 cysts from the scalp.
Social History:
___
Family History:
Mother with dementia. Brother with rheumatoid arthritis.
Maternal grandfather with pancreatic cancer.
Physical Exam:
Physical Exam on Admission:
Vitals: T:97.6 P:60 R: 16 BP: 138/64 SaO2: 95%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: 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 but
somewhat confused as to the timeline.
Attentive but not able to name ___ backward.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Pt. was able
to name both high and low frequency objects. Able to read
without difficulty. Speech was not dysarthric.
Able to follow both midline and appendicular commands.
There was no evidence of apraxia
? neglect of the right side.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to finger counting
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.
Pronator drift on the right.
High amplitude coarse tremor b/l worse on the right. No
asterixis
noted.
___ throughout except for the following:
RUE
___ movement in finger flexors,
4+/5 strength in biceps,
___ strength in triceps,
___ strength in deltoid.
RLE:
IP 4+/5
TA ___
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was mute bilaterally.
-Coordination: High amplitude intention tremor, unable to
perform
on the right, no clear dysmetria on FNF on the left.
-Gait: defered
Physical Exam on Discharge:
afebrile, vital signs stable
Relevant for right hemiparesis with 4+ hamstring, TA, ___ ___
in delts, triceps, finger extensors/flexors.
Coarse intention tremor in the right UE, intention and postural
Grasp reflex b/l, R>L
gait: steady, narrow based
Pertinent Results:
Labs on Admission:
___ 06:45PM WBC-7.2 RBC-3.52* HGB-10.6* HCT-31.4* MCV-89
MCH-30.2 MCHC-33.9 RDW-15.3
___ 06:45PM NEUTS-89.4* LYMPHS-6.6* MONOS-3.6 EOS-0.2
BASOS-0.2
___ 06:45PM VALPROATE-61
___ 06:45PM CALCIUM-8.8 PHOSPHATE-4.0 MAGNESIUM-1.9
___ 06:45PM GLUCOSE-216* UREA N-30* CREAT-1.0 SODIUM-134
POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-23 ANION GAP-18
___ 06:49PM GLUCOSE-204* LACTATE-2.7*
___ 08:19PM ___ PTT-26.5 ___
___ 08:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:45PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 08:45PM URINE RBC-38* WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 08:45PM URINE HYALINE-4*
___ 08:45PM URINE MUCOUS-RARE
Imaging:
Chest x-ray
Upright AP and lateral chest radiographs were obtained. The
lungs are low in volume, which obscure the right lower lung
calcified granuloma. No focal consolidation is seen. There is
no pleural effusion or pneumothorax. The heart is normal in
size with post-surgical changes including intact mediastinal
wires.
IMPRESSION: No acute intrathoracic process.
Non contrast head CT
FINDINGS: New hemorrhage with a hematocrit level is seen in a
17 x 20 mm
focus of metastasis in the left frontal lobe (2:18) along with
hemorrhage in a left parietal metastasis, measuring 14 x 9 mm.
Additional metastatic lesions with and surrounding vasogenic
edema are unchanged in the right frontal and left frontoparietal
and occipital lobes. Dense left periventricular metastasis is
also unchanged. No definite other metastatic deposits are seen,
though MR is more sensitive. The ventricles and sulci remain
minimally prominent, compatible with age-related involutional
changes. Gray-white matter differentiation is otherwise
preserved. There is no shift of normally midline structures.
Imaged osseous structures are unremarkable with post-craniotomy
changes in the left frontoparietal region. Soft tissues are
unremarkable. Imaged paranasal sinuses and mastoid air cells
are well aerated.
IMPRESSION: Hemorrhage in left frontal and left parietal
metastatic lesions as described above.
Brief Hospital Course:
Mr. ___ is a ___ yo man with known melanoma and brain mets
s/p cyber-knife and several doses of Whole brain radiation who
presents with acute on chronic unsteadiness and fall.
# Neuro: Patient was with his wife day prior to admission on his
way to a restaurant. In the car, he had some abdominal pian.
When he was stepping out of hte car he felt weak and fell down.
He went ot the restaurant, and there, felt lightheaded and
nauseaous, like he was going to pass out. His exam relevant for
right sided hemiparesis, RUE tremor, neuropathy in his feet b/l
(chronic per patient and wife) as well as bilateral grasp
reflex. Most relevant is that he was profoundly orthostatic.
Most likely, his fall was in the setting of orthostatic
hypotension which fits with presyncopal symptoms. On imaging,
CT head ___ and ___ show a new hemorrhagic left anterior
rontal lobe lesion not seen on prior ___ MRI head. Mr.
___ was treated with 1 L NS bolus and asked to
discontinue lisinopril. He was back to baseline on discharge.
He will follow up with ___ clinic with Dr. ___.
# Cardio: Orthostatic hypotension as above. Discontinued
lisinopril. Patient was offerred ___ services for BP
monitoring, but declined. Will monitor himself.
TRANSITIONS OF CARE:
- will f/u in ___ clinic
Medications on Admission:
1. ALPRAZolam 0.25 mg PO TID
2. Atovaquone Suspension 750 mg PO DAILY
3. Dexamethasone 2 mg PO DAILY
4. Divalproex (DELayed Release) 500 mg PO BID
5. LeVETiracetam 1000 mg PO TID
6. Omeprazole 20 mg PO DAILY
7. Simvastatin 40 mg PO DAILY
8. Sertraline 50 mg PO DAILY
9. insulin detemir *NF* 100 unit/mL Subcutaneous BID
per your sliding scale
10. HumaLOG KwikPen *NF* (insulin lispro) 100 unit/mL
Subcutaneous per sliding scale
per sliding scale
11. Nitroglycerin SL 0.4 mg SL PRN chest pain
take once per day as needed for chest pain; if persists, call
your doctor or 911
12. DiphenhydrAMINE 50 mg PO HS
13. Lisinopril 5mg PO qd
Discharge Medications:
1. ALPRAZolam 0.25 mg PO TID
2. Atovaquone Suspension 750 mg PO DAILY
3. Dexamethasone 2 mg PO DAILY
4. Divalproex (DELayed Release) 500 mg PO BID
5. LeVETiracetam 1000 mg PO TID
6. Omeprazole 20 mg PO DAILY
7. Simvastatin 40 mg PO DAILY
8. Sertraline 50 mg PO DAILY
9. insulin detemir *NF* 100 unit/mL Subcutaneous BID
per your sliding scale
10. HumaLOG KwikPen *NF* (insulin lispro) 100 unit/mL
Subcutaneous per sliding scale
per sliding scale
11. Nitroglycerin SL 0.4 mg SL PRN chest pain
take once per day as needed for chest pain; if persists, call
your doctor or 911
12. DiphenhydrAMINE 50 mg PO HS
Discharge Disposition:
Home
Discharge Diagnosis:
Orthostatic hypotension
Melanoma metastatic to the brain, new lesion
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 after you felt light headed
and fell. This fall was most likely due to dehydration and
lowering of your blood pressure with standing. At home, please
be careful to be hydrated. We offered to have a visiting nurse
___ come periodically to check your blood pressure. You
preferred to do this yourself, which fine. If you blood
pressures are less than 100/60, please drink more fluids and
recheck later in the day. If it continues to be low, please
call your doctor. We checked you for an infection as well, and
you did not have one. As we discussed, you have a new
metastatic lesion in your brain. Please follow up with Dr.
___ neuro-oncologist, as scheduled below, to discuss this
further.
We have made the following changes to your medications:
STOP taking Lisinopril (since your blood pressure is low)
Please attend your follow up appointments as listed below.
It was a pleasure taking care of you, we wish you all the best!
Followup Instructions:
___
|
10046241-DS-18 | 10,046,241 | 24,019,757 | DS | 18 | 2142-05-25 00:00:00 | 2142-05-30 20:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
weakness, malaise, vomiting, diarrhea
Major Surgical or Invasive Procedure:
EGD ___
ERCP ___
History of Present Illness:
___ year old male with history of alcoholism, HTN, new diagnosis
of diabetes here with 2 weeks of generalized weakness, malaise,
and 1 week of vomiting and diarrhea. Reports at recent PCP
appointment was told he might be diabetic but has not started
any meds. Went to urgent care on ___ where he was given
zofran and cyclobenzabrine for abdominal cramping and told that
he had the flu. He denies ever having a flu swab. The patient
has not had any tamiflu. The patient says that on 1 day prior to
admission he was unable to walk to the bathroom without becoming
extremely exhausted. The patient called his PCP on ___
morning and was told to come to the emergency room. Of note the
patient's creatinine on ___ was 0.8. Patient increased
his Lisinopril from 10mg to 20mg on the ___.
On arrival to the ED the patient was found to have vitals of 0
97.5 88 77/44 16 92% RA. Patient bolused fluids and his blood
pressure improved. The patient's labs were significant for a
transaminitis, Cr of 6.2, Na of 129 and hyperbilirubinemia of
2.1. The patient was seen by the GI team. US showed mild
dilation in bile duct, but no active signs of cholecystitis.
On arrival to the floor patient's vitals were 97.8 110/60 85 18
94 RA. Patient was anxious but not in acute distress.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
Chronic HYPERCHOLESTEROLEMIA
BPH
HYPERTENSION - ESSENTIAL, BENIGN
FATTY LIVER
ESOPHAGEAL REFLUX
Sleep apnea
Alcoholism
Type 2 diabetes mellitus, uncontrolled
Social History:
___
Family History:
Father passed away of bladder cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 97.8 110/60 85 18 94 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, ___, bowel sounds present,
no rebound tenderness or guarding, no organomegaly; no stigmata
of liver disease
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes, scars or legions
Neuro: WNL
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 97.9 Tmax 98.2 131/80 (___) 88 20 97 RA
lying 140/93 86
sitting 142/90 95
standing 146/99 102
General: Alert, oriented, no acute distress
HEENT: icteric sclera, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, ___, mildly distended, bowel sounds
present but soft, no rebound tenderness or guarding, no
organomegaly; no stigmata of liver disease
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: jaundiced; no rashes, scars or legions
Neuro: WNL
Pertinent Results:
ADMISSION LABS:
===============
___ 09:20AM ___ ___
___ 09:20AM PLT ___ LOW PLT ___
___ 09:20AM ___
___
___ 09:20AM ___
___
___ 09:20AM ___
___
___ 09:20AM ___
___ 09:20AM ___
___ 09:20AM ALT(SGPT)-99* AST(SGOT)-87* ALK ___ TOT
___ DIR ___ INDIR ___
___ 09:20AM ___ this
___ 09:20AM ___ UREA ___
___ TOTAL ___ ANION
___
___ 09:35AM ___
___ 09:35AM ___ NA+-133 K+-3.5
CL--84* ___
___ 09:20PM PLT ___
___ 09:20PM ___
___
___ 09:20PM ___
___ 09:20PM ___
___
___ 09:20PM ALT(SGPT)-83* AST(SGOT)-90* LD(LDH)-696*
CK(CPK)-464* ALK ___ TOT ___ DIR ___ INDIR
___
___ 09:20PM ___ UREA ___
___ TOTAL ___ ANION ___
___ 09:43PM ___
___ 09:43PM ___ TOTAL ___
BASE ___
___ 10:10PM URINE ___
___ 10:10PM URINE ___ UREA ___
___
DISCHARGE LABS:
===============
___ 06:25AM BLOOD ___
___ Plt ___
___ 06:35AM BLOOD ___
___
___ 06:25AM BLOOD Plt ___
___ 06:50AM BLOOD ___ ___
___ 06:25AM BLOOD ___
___
___ 06:25AM BLOOD ___ LD(LDH)-519* ___
___
___ 06:35AM BLOOD ___
___ 06:25AM BLOOD ___
___
___ 06:25AM BLOOD ___ TH
___
___ 06:25AM BLOOD ___
___ 02:45PM BLOOD ___
MICROBIOLOGY:
=============
___ 9:20 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
========
Cardiovascular ReportECGStudy Date of ___ 9:27:14 AM
Baseline artifact. Sinus rhythm. Intraventricular conduction
delay. Mild
ST segment elevation in leads V2, V5 and V6 of uncertain
significance. No
previous tracing available for comparison. Clinical correlation
is suggested.
Read ___.
___
___ CXR
IMPRESSION:
No acute cardiopulmonary process.
___ Renal US
IMPRESSION:
No hydronephrosis or focal renal lesion.
___ RUQUS
IMPRESSION:
1. Mild intrahepatic biliary ductal dilation partially imaged
without
evidence of acute cholecystitis. Gallbladder sludge without
definite stones
seen. GI consultation advised with possible MRCP or ERCP to
further assess
potential cause for biliary obstruction.
2. Markedly echogenic liver likely due to fatty deposition.
Please note, more
advanced forms of liver disease cannot be excluded on the basis
of this
appearance.
Radiology ReportMRI ABDOMEN W/O CONTRASTStudy Date of
___ 8:24 AM
IMPRESSION:
1. Findings suggestive of hemorrhage within the pancreatic head
tracking
along the mesentery and duodenum may be secondary to
pancreatitis, however
underlying pancreatic mass cannot be excluded.
2. Increased T1 signal within the right and left bile ducts
suggestive of
hemobilia.
3. Diffuse hepatic steatosis.
Radiology ReportCT ABD W&W/O CStudy Date of ___ 4:30 ___
IMPRESSION:
1. Necrotizing pancreatitis, predominately involving the
pancreatic head.
Underlying neoplasm cannot be excluded and repeat imaging is
suggested after
acute issues resolve. Extensive surrounding inflammation with
duodenitis. No
discrete fluid collection.
2. Nonocclusive thrombus within the main portal vein,
intrahepatic portal
venous branches, splenic vein and possibly the SMV with
occlusion of the
portal confluence. Perigastric and paraesophageal varices.
3. No evidence of arterial pseudoaneurysm.
___ ERCP with stent placed in CBD
Impression:
Edema, erythema and congestion in the duodenum compatible with
duodenitis likely ___ pancreatitis
The major papilla appeared normal. The surrounding duodenal
mucosa was edematous and obscured the papilla.
The scout film was normal.
The bile duct was deeply cannulated with the sphincterotome.
Contrast was injected and there was brisk flow through the
ducts. Contrast extended to the entire biliary tree.
There was a 3cm stricture in the ___ with
___ dilation.
This is likely secondary to external compression from severe
acute pancreatitis in the head of the pancreas.
The CBD was 9mm in diameter proximally. No other filling defects
identified. Opacification of the gallbladder was incomplete.
Given the significant surrounding duodenitis and the history of
upper GI bleed, a biliary sphincterotomy was not performed.
A ___ x 7cm plastic CBD stent was placed across the stricture
successfully.
Excellent bile and contrast drainage was seen endoscopically and
fluoroscopically.
Otherwise normal ercp to third part of the duodenum
Brief Hospital Course:
___ year old male with history of alcoholism, HTN, new diagnosis
of diabetes here with 2 weeks of generalized weakness, malaise,
and 1 week of vomiting and diarrhea. Found to have acute renal
failure, pancreatitis, transaminitis and hyperbilirubinemia with
concern for a gall stone in bile duct/pancreatic duct. Patient
started on IVF with goal UOP >1cc/kg/hr and made NPO. Patient
had melena on day 1 on admission and started on PPI IV gtt. H/H
decreasing initially with fluid boluses but stabilized on day
___ of admission. MRCP on day 1 without contrast showed concern
for pancreatitis of the head of the pancreas and cannot rule out
underlying mass. Patient evaluated by both ERCP and
Gastroenterology and determined for ___ ERCP w/EUS and
EGD.
Both procedures occurred on ___ showing no active
bleeding in the stomach. ECRP showed no gallstones in either
tracts but evidence of pancreatitis constricting the common bile
duct. A single stent was placed without complication. Please see
procedure note for full details. Patient had no complications
after procedure. On ___ patient had rising WBC count and had
CT w/wo contrast showing hemorrhagic pancreatic necrosis,
however no active bleeding, and also evidence of portal
thrombosis and splenic vein thrombosis. Patient's crits were
stable and WBC trending down at time of discharge. Patient ___
follow up with Atrius Gastroenterology and see Dr. ___ as an
outpatient. The patient ___ also follow up with Dr. ___
surgery.
Patient's ___ fully recovered with IVF hydration with creatinine
and BUN returning to baseline (cr<1). Patient's
___ held initially, however was hypertensive in
the post procedure setting. Patient starting on Labetalol and
Lisinopril for mngt of his blood pressure. Patient tolerated
full diet on ___ with improvement of lab values and clinical
improvement. Patient ___ follow up with his PCP and with ___ new
Gastroenterologist after discharge.
ACUTE ISSUES
# Pancreatitis with associated Transaminitis/Hyperbilirubinemia
The patient's transaminitis and hyperbilirubinemia are acutely
elevated. The differential for his LFT abnormalities include
cholelithiasis, hypotension, alcohol, autoimmune, wilsons,
hypothyroidism, malignancy or infection. It is likely
multifactorial in etiology. On ___ MRCP showed possible mass
at the head of the pancreas with atrophy of the body and tail.
The patient had evidence of gall bladder dilation without
evidence of gallstones.
The patient ERCP/EUS showed evidence of acute pancreatitis at
the head of the pancreas and cannot rule out an underlying mass.
The patient had a single stent placed in the CBD to allow for
drainage. The patient transaminitis and hyperbilirubinemia
decreased after placement of the stent. On ___ the patient
had resolving labs, except for increasing white count. CT with
contrast was completed showing hemmoragic pancreatic necrosis of
the head of the pancreas with drainage into the bile
duct/intestinal tract. The patient's H/H trended down slowly.
This finding on CT is very suggestive of acute pancreatitis and
cannot rule out underlying mass. F/u MRI in ___ weeks after
inflammation decreases to evaluate for underlying mass. CA 125
elevated to 210 and Ca ___ elevated to 116. Viral serologies
negative. Patient evaluated by the pancreatic surgery team due
to necrosis noted on CT scan. He ___ follow up with At___,
Dr. ___ and Dr. ___ after
discharge. It was emphasized to the patient that in order to
prevent recurrence the patient must abstain from alcohol.
# Hypertension
Patient has hypertensive prior to discharge, likely in the
setting of holding home ___ combined with alcohol
withdrawal and andrenergic tone from pancreatitis. Patient has
adequate control of blood pressures with labetalol and
lisinopril. ___ need to be readdressed as outpatient. Patient
started on labetalol 200mg PO BID and Lisinopril 20mg PO Daily.
# Melena/GI Bleed
Patient began having melanotic stools on ___ with symptoms of
orthostasis and mild lightheadedness. Resting heart rate was
around 100 BPM on exam/interview on ___. Patient claimed that
he had taken ___ doses of NSAIDS in the week prior to
admission. The patient also had been having mild to moderate
epigastric pain over the last week. Cr is resolving faster than
BUN with fluids with BUN/Cr >20 supporting evidence of acute GI
bleed. Patient'd EGD on ___ showed no evidence of bleeding in
the stomach or duodenum. CT scan on ___ with contrast showed
hemorrhagic pancreatic necrosis with drainage into the
intestinal tract. The patient's melana is likely from slow
drainage from the pancreatic hemorrhage. Patient continued on
protonix 40mg PO BID, PO thiamine/folate and ___ follow up with
the GI team per above.
# Acute Renal Failure
Patient presented with nausea, vomiting, anorexia and poor PO
intake. She was found to have acute elevation in his creatinine
of 6.2 which is elevated since last checked on ___
(baseline cr of ___. The cause of the ARF is likely
multifactorial including ___ azotemia combined with recent
elevation in Lisinopril. It is also possible that the patient
has a post renal obstruction secondary to BPH or renal stones,
however given no hydronephrosis on US, obstructive nephropathy
is unlikely. Intrinsic renal disease is a posibility and the
patient has elevated protein in the urine without significant
blood in the urine. Urine lytes/albumin on admission indicated a
___ picture. Patient creatinine returned to normal on
___ with high volume resuscitation.
# Hyponatremia
Patient hyponatremic on admission. Likely hypovolemic
hyponatremia vs SIADH. The patient appeared dry on physical
exam, with dry mucous membranes. He also endorsed low urine
output and decreased PO intake. Resolved on ___ with IV
fluids.
CHRONIC ISSUES
# Alcoholism
The patient admitted to binging on hard alcohol in the week
leading up to his symptoms. This is likely the etiology of the
patient's acute and chronic pancreatitis. The patient was given
multiple levels of counseling while inpatient by both his
primary, GI and social work team. The patient ___ have close
follow up as an outpatient.
# Uncontrolled Type II Diabetes Melitus- Possibly ___ to
patient's pancreatitis. Patient was controlled with ISS while in
the hospital. The patient was transitioned to metformin 500mg PO
daily on discharge.
# Hypertension: Held atenolol/lisinopril due to renal failure.
Transitioned to labetalol and lisinopril on discharge.
# HLD: Held atorvastatin on admission but restarted on
discharge.
# Insomnia: Continued trazedone.
TRANSITIONAL ISSUES
===========================
- in ___ weeks following discharge patient ___ need repeat MRCP
w/contrast to evaluate for possible mass at the head of the
pancreas
- ERCP recommended ___ days of Ciprofloxacin 500mg PO BID for
prophylaxis post stent (Day 1 was ___ given elevated WBC we
opted for 7 day course with final dose given with dinner on
___
- patient ___ need repeat CBC for HCT/WBC monitoring, Chem 7
(metformin and kidney f/u), LFTs (AST, ALT, TBili) at first PCP
appointment
- patient ___ need social work/support for continuing use of
alcohol; patient is at High risk of relapse; ___ need close
follow up as outpatient
- patient missed outpatient ___ of elevated PSA >6.0. Was
instructed to reschedule outpatient eval ___ be transitional
issue)
- ___ need f/u ERCP for stent removal: ERCP team ___ contact
- ___ need f/u MRCP and f/u with ___. ___
- ___ need f/u with PCP early next week with repeat CBC/Chem 7
(patient/wife prefers next ___ b/c son getting wisdom teeth out
___
- Patient ___ abstain from all NSAIDS, and Alcohol
NEW MEDS
- Ciprofloxacin 500mg BID PO (last day on ___
- Vitamin B12, Folate, Multivitamin, Thiamine
- Labetalol 200mg PO BID for high blood pressure
- Metformin 500mg PO Daily for Diabetes
- Protonix 40mg PO BID for Upper GI Bleed ___ continue until
follow up with PCP ___ GI)
MEDS DISCONTINUED
- atenolol (changed to Labetalol)
- aspirin (hemorrhagic pancreatitis)
PCP and surgical/GI teams were all updated prior to and on
discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Atenolol 25 mg PO DAILY
4. TraZODone 25 mg PO QHS:PRN insomnia
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth Daily Disp #*28 Tablet
Refills:*0
2. TraZODone 25 mg PO QHS:PRN insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*14 Tablet Refills:*0
3. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*9 Tablet Refills:*0
4. Cyanocobalamin 50 mcg PO DAILY
RX *cyanocobalamin (vitamin ___ [Vitamin ___ 50 mcg 1
tablet(s) by mouth Daily Disp #*28 Tablet Refills:*0
5. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*0
6. Labetalol 200 mg PO BID
RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*28
Tablet Refills:*0
7. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily ___ 1 tablet(s) by mouth
daily Disp #*28 Tablet Refills:*0
8. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*28
Tablet Refills:*0
9. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
10. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*28
Tablet Refills:*0
11. MetFORMIN (Glucophage) 500 mg PO DAILY
RX *metformin 500 mg 1 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
1. Acute on Chronic Pancreatitis with Common Bile Duct stricture
2. Acute Kidney Injury
3. Hypertension
4. Alcohol Withdrawal
5. Hyponatremia
6. Hypokalemia
7. Hypophosphatemia
8. Leukocytosis unspecified
9. Elevated PSA
10. Hepatitis
11. Hepatic steatosis
12. Thrombosed Mesenteric veins
13. Hemorragic Pancreatitis / Hematobilia
SECONDARY:
1. Uncontrolled Type II DM
2. HLD
3. Insomnia
4. Alcoholism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take part in your care during your stay
here at ___. You came into the hospital for nausea, mild
abdominal pain, and vomitting. In the Emergency Room you were
found to have labs concerning for damage to both your kidneys,
liver, and pancreas. You were admitted to the ___
Service.
On the floor you were evaluated by the Gastroenterology service
who were concerned for inflammation of your pancreas that was
causing constriction of your common bile duct (the duct that
connects your liver/gall bladder to your intestines). They
performed an ERCP and Endoscopy and found no evidence of stones,
but inflammation constricting the duct. You had a stent placed
with improvement of your blood tests. You also had a imaging
scan called a CT scan to evaluate your pancreas. You ___
continue on the medications started in the hospital and ___
follow up with your primary care provider and ___ new
gastroenterologist.
Thank you for allowing us to participate in your care during
your stay in the hospital.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10046241-DS-20 | 10,046,241 | 27,535,359 | DS | 20 | 2142-06-14 00:00:00 | 2142-06-14 15:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cc: thrombosis
Major ___ or Invasive Procedure:
None
History of Present Illness:
___ yo M with EtOH abuse admitted with pancreatitis early in
___ complicated by hemorrhage and necrosis now walled off,
discharged recently following an admission for symptomatic
hypotension who returns for initiation of anticoagulation for
SMV/portal vein thrombosis. Pt admitted from ___ due to
pancreatitis compliated by distal CBD stricture and
hemorrhage/necrosis at the head of the pancreas. Pt underwent
stenting of the CBD. Pt showed improvement and was discharged
home. He returned again on ___ after bing sent in by his
primary care physician for systolic blood pressure in the 80's
despite stopping one of two of his home antihypertensives. Pt
was taken off antihypertensives and given IVF during the
admission. Pt with stable anemia with no clinical GIB. CT
abdomen was done during that admission which showed progressive
thrombosis of the SMV and portal vein. Pt discharged home again
and followed up in surgery clinic today. Pt admitted by surgeon
for initiation of anticoagulation of his thrombosis in a
monitored setting.
Pt denies abdominal pain or nausea. He has been able to tolerate
a regular diet. No diarrhea, steatosis, hematochezia, or melena.
No EtOH intake since discharge. He does report that he feels
pre-syncopal when standing for too long or ambulating long
distances. He says this has persisted even with the
discontinuation of his BP meds. In fact, he states that it has
had these symptoms for about 4 months now.
ROS: negative except as above
Past Medical History:
PANCREATITIS - EtOH related, complicated by hemorrhage/walled
off necrosis and SMV/Portal Vein thrombus
BPH
HYPERTENSION - ESSENTIAL, BENIGN
FATTY LIVER
ESOPHAGEAL REFLUX
Sleep apnea
Alcoholism
Type 2 diabetes mellitus - recently diagnosed
Social History:
___
Family History:
Father with bladder CA.
Physical Exam:
Admission
Vitals: 98.4 130/86 108 17 99%RA
Gen: NAD
HEENT: moist mm
CV: rrr, no rmg
Pulm: clear b/l
Abd: soft, mild tenderness in epigastrum, no masses
Ext: no edema
Neuro: alert and oriented x 3, no focal deficits
Discharge:
Vitals: 98.8 122/80 110 16 98%RA
Gen: NAD
HEENT: moist mm
CV: rrr, no rmg
Pulm: clear b/l
Abd: soft, NT, ND, no masses
Ext: no edema
Neuro: alert and oriented x 3, no focal deficits
Pertinent Results:
___ 02:34PM WBC-5.8 RBC-3.08* HGB-10.4* HCT-30.6* MCV-99*
MCH-33.7* MCHC-33.9 RDW-13.2
___ 02:34PM PLT COUNT-278
___ 02:34PM GLUCOSE-140* UREA N-8 CREAT-0.6 SODIUM-142
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-25 ANION GAP-14
___ 02:34PM ALT(SGPT)-21 AST(SGOT)-23 ALK PHOS-99 TOT
BILI-1.0
___ 02:34PM LIPASE-10
___ 02:34PM ALBUMIN-3.6
___ 02:52PM LACTATE-1.6
___ 06:03PM ___ PTT-33.6 ___
___ 02:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 02:25PM URINE RBC-13* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
TTE ___:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF = 70%). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no pericardial effusion.
CTA Chest ___:
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Clear lungs.
3. Distended gallbladder, biliary dilation and varices formation
better
characterized on recent dedicated abdominal study.
Brief Hospital Course:
___ yo M with history of alcoholism, with history of recent
pancreatitis s/p ERCP and pancreatic duct stenting, also with
evidence of hemorrhagic pancreatitis amd SMV / portal vein
thrombosis, persistently tachycardic in the outpatient setting
and admitted for lightheadedness, tachycardia and close
monitoring anticoagulation initiation.
# SMV and Portal Vein Thromboses
# Hemorrhagic Pancreatitis
Likely alcohol related pancreatitis complicated by
hypercoagulability prior to admission. Biliary strictures s/p
ERCP with stenting during prior hospitalization. Dr. ___
___ patient in clinic and recommended anticoagulation so
patient admitted for close monitoring. He remains extemely high
risk for acute blood loss complications given pancreatic
hemorrhage. During admission he was placed on a Heparin drip
given reversibility and shorter half life than Lovenox and
bridged to Coumadin. ERCP and ___ surgery followed in
house. With therapeutic INR and PTT levels he had no evidence of
acute blood loss. Heparin discontinued. He received 5 mg of
coumadin from ___, his INR rapidly increased from 1.4 on ___
to 3.3 on ___. He was told to hold coumadin on ___ and
follow-up in Dr. ___ in ___ days for repeat INR.
# Type II Diabetes Melitus
Newly diagnosed, poorly controlled, non-insulin dependent, not
known to be complicated. Possibly related to pancreatitis /
necrosis. Held Metformin while in house and placed on HISS.
Restarted metformin on discharge.
# Hypertension:
Chronic, previously on atenolol / Labetalol and lisinopril.
Antihypertensives held during admission and his BPs remained in
good control with SBPs in 120s
# Tachycardia:
Persistent tachycardia following last hospitalization. This
could be related to poor cardiac filling in setting of SMV and
PV thrombosis. Potentially rebound from being off beta-blocker.
Appeared volume replete and did not improved after IVFs. No pain
or anxiety noted. CTA ruled out PE. TSH and Cortisol were
normal. TTE showing normal LVEF and cardiac filling wtihout
valvular pathology. His tachycardia was likely in part due to
beta-blocker cessation as he has chronically been on
beta-blockers. He was restarted on Toprol XL 25 mg daily and
tolerated this well, this can be titrated up as an outpatient as
needed. He was counselled to stop the Toprol if he developed
worsening dizziness or fainting.
# Dizziness
# Lightheadedness
Orthostatic based increase in HR with standing without change in
BP. Appropriate tachycardia when standing so dont expect
autonomic dysfunction, POTS a possibility but wrong demographic
and acuity more indicative of relation to recent acute medical
illnesses. Differential similar to tachycardia as above. He was
steady on his feet ambulating the hallways without assistance
and had no evidence of pre-syncope or syncope during admission.
# HLD:
Continued Atorvastatin
# Insomnia:
Continued Trazodone
# Alcoholism
Social work consult
Transitional Issues:
- Outpatient INR monitoring
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Cyanocobalamin 50 mcg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. TraZODone 25 mg PO QHS
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Cyanocobalamin 50 mcg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Pantoprazole 40 mg PO Q12H
6. TraZODone 25 mg PO QHS
7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY Duration: 1 Dose
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Portal vein thrombosis
Sinus tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were admitted for tachycardia. We performed a CT scan which
showed no clots near your lungs. We also performed an echo
which showed no significant abnormalities. Your tachycardia is
likely due to stopping your beta-blocker (the atenolol and
metoprolol). We restarted you on a low dose of metoprolol to
control your heart rates.
Because of your blood clots near your pancreas, we started you
on a medicine called warfarin, which you will need to continue
as directed by your primary care physician and Dr. ___. You
should follow up in Dr. ___ to have your INR checked
on either ___ or ___. As your INR level was too high on
discharge you should not take coumadin tonight.
Related to your pancreatitis, we also needed to start you on
medicine for diabetes.
Followup Instructions:
___
|
10046362-DS-21 | 10,046,362 | 25,444,237 | DS | 21 | 2189-02-05 00:00:00 | 2189-02-05 10:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left leg pain, difficulty walking
Major Surgical or Invasive Procedure:
None during this hospitalization
History of Present Illness:
___ y/o female s/p laminectomy and foraminotomy back in
___. The patient presents today with 1 week of back pain.
She saw Dr. ___ at clinic at that time and was placed on a
Medrol dose pack with no effect. Over the last couple of days
she
has developed a band like pain across her abdomen along with
worsening radiculopathy on the left leg. She presented to an OSH
and a CT of the lumbar spine was obtained which showed a fluid
collection. She was transferred here to ___ for further
evaluation. The patient denies n/v/c/d, bowel or bladder
incontinence.
Past Medical History:
arthritis, gout, diabetes, obesity
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
IP Q H AT ___ G
L 4+ 5 4 0 0 4+
Sensation: Intact to light touch, decreased sensation along the
outside of the left leg.
Reflexes: no clonus
On discharge:
Awake, alert, oriented. BUE full motor, RLE full, LLE ___ except
___ ___ at baseline. Baseline sensory.
Pertinent Results:
___: MRI L spine with and without contrast:
IMPRESSION:
1. Status post left L4-L5 hemilaminectomy with an irregular but
well -defined fluid collection within the postoperative bed,
most likely representing a seroma. Infection is felt to be less
likely, but should be correlated clinically.
2. Stable multilevel degenerative changes in the remainder of
the lumbar
spine.
___ LEFT LOWER EXTREMITY ULTRASOUND
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
Brief Hospital Course:
On ___ this patient presented to the ___ ED from an outside
hospital with complaints of worsening radiculopathy symptoms in
the left leg. She is s/p a laminotomy and foraminotomy in
___ and has tried a Medrol dosepak as outpatient
without improvement. A CT l-spine at the outside hospital showed
a fluid collection at the surgical site. An MRI was done which
also showed a fluid collection, likely a seroma per radiology
report. She was examined again on morning rounds and is now
reporting pain and decreased sensation on her RLE. Physical
therapy ordered for further evaluation of functional mobility.
On ___, the patient's neurological exam remained stable. A dose
of 10mg IV dexamethasone was given once per Dr. ___
inflammation control. The patient was evaluated by Physical
Therapy, who deemed that she would benefit from acute
rehabilitation. The insurance screening process for acute rehab
placement was initiated.
On ___, patient remains neurologically and hemodynamically
stable. Patient continues to complain of left leg pain, on exam
leg/foot is swollen, LLE ultrasound ordered to rule out DVT. For
pain medication, switched to percoset to ensure taking Tylenol.
Blood sugars continue to be high, changed diet to carb
controlled and will monitor closely however most likely related
to steroid use. Patient is denying going to acute care rehab due
to family concerns of distance away. It was discussed with the
patient that it is in her best interest to go to acute rehab
however continues to deny. On ___ she remained stable and was
discharged to an extended care facility.
Medications on Admission:
Medications prior to admission:
Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
Baclofen 20 mg PO TID
Bisacodyl 10 mg PO DAILY:PRN constipation
Diazepam 5 mg PO Q6H:PRN muscle spasm
Docusate Sodium 100 mg PO BID
Gabapentin 800 mg PO TID
lantus 40 Units Bedtime
OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN Pain
Pregabalin 100 mg PO QHS
TraZODone 100 mg PO QHS:PRN insomnia
Discharge Medications:
1. Baclofen 20 mg PO TID
2. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 800 mg PO TID
5. Pregabalin 100 mg PO DAILY
6. Tizanidine 4 mg PO TID
7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
8. TraZODone 100 mg PO QHS
9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
10. Methocarbamol 750 mg PO TID:PRN Muscle spasm
11. Heparin 5000 UNIT SC BID
12. Diclofenac Sodium ___ 75 mg PO TID
13. Bisacodyl 10 mg PO DAILY
14. Senna 8.6 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___.
Discharge Diagnosis:
Post-operative Pain
Seroma of the lumbar spine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Discharge Instructions
You were admitted for concern of infection, imaging showed no
signs of infection but of a fluid collection that should resolve
in time. Your pain was evaluated and a pain regimen selected.
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 improved pain control.
Otherwise
You make take leisurely walks and slowly increase your activity
at your own pace.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may take Ibuprofen/ Motrin for pain.
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:
___
|
10046436-DS-17 | 10,046,436 | 23,594,537 | DS | 17 | 2154-01-01 00:00:00 | 2154-01-02 08:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
foreign body ingestion
Major Surgical or Invasive Procedure:
___
History of Present Illness:
___ with history of Prader-Willi syndrome initially presented to
___ after being witnessed swallowing glass. He was
initially evaluated by GI at the outside hospital and they were
unsuccessful in their endoscopic attempts to remove the glass.
The duodenum was normal. Given lack of overtube it was felt that
the sharp objects could not be safely removed. The patient was
the transferred to ___ for further management.
In the ED, initial vitals: 98.1 85 ___ 94%. H/H was
___. He was noted not have any obvious bleeding, pain, or
respiratory issues. He was given 40mg IV pantoprazole. He had a
KUB which showed multiple layering linear densities in the
stomach corresponding to ingested foreign materials, with two
linear hyperdensities seen on the supine view cannot be
identified on the upright view and are not clearly within the
stomach. He underwent endoscopy with GI which found no glass in
the stomach before the pylorus.
On arrival to the MICU, patient was comfortable with no
complaints. Patient is unable to provide meaningful history.
Past Medical History:
Prader Willi Syndrome
Bipolar Disorder
Osteopenia
GERD
DM2
Hyperlipidemia
Social History:
___
Family History:
Non-contributory
Physical Exam:
ON ADMISSION:
Vitals- 97.6 126/80 16 100%RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
ON DISCHARGE:
VS - 98.4 136/89 86 18 100% on RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
___ 04:44AM ___ PTT-27.5 ___
___ 04:44AM ___ PTT-27.5 ___
___ 04:44AM PLT COUNT-194
___ 04:44AM NEUTS-72.2* ___ MONOS-7.1 EOS-1.3
BASOS-0.4
___ 04:44AM estGFR-Using this
___ 04:44AM GLUCOSE-139* UREA N-14 CREAT-0.9 SODIUM-134
POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-29 ANION GAP-13
___ 07:16AM GLUCOSE-123* UREA N-14 CREAT-0.9 SODIUM-134
POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-29 ANION GAP-13
___ 07:16AM CALCIUM-9.9 PHOSPHATE-4.8* MAGNESIUM-1.7
EGD ___:
No foreign body identified on this examination
KUB: ___:
IMPRESSION:
1. Multiple layering linear densities in the stomach
corresponding to ingested foreign materials. However, 2 linear
hyperdensities seen on the supine view cannot be identified on
the upright view and are not clearly within the stomach.
2. No evidence of free air.
EGD ___:
Upon entrance into the stomach multiple pieces of glass were
noted. The patient was then intubated and a gastric overtube was
placed and then over 20 pieces of varying sizes of glass was
removed from the stomach using rat tooth forceps and ___ nets
through the overtube. One piece was identified in the duodenal
bulb and was also removed. Numerous superficial ulcerations were
noted throughout the stomach. The overtube was then removed and
a repeat EGD was performed wtih full gastric insufflation and
deep duodenal intubation and no further pieces of glass were
identified.
Otherwise normal EGD to third part of the duodenum
KUB: ___:
IMPRESSION:
Shards of glass are seen in the mid right abdomen, perhaps
within the ascending colon. No free intraperitoneal air.
KUB: ___:
IMPRESSION:
No glass shards are visible, no free intraperitoneal air.
Brief Hospital Course:
Patient was admitted to the MICU on ___ in stable condition
after EGD performed by GI in the OR. No removable foreign body
was identified on EGD. Patient was evaluated by acute care
surgery who recommended serial abdominal exam and aggressive
bowel regimen. Patient reported acute increase in pain while in
the MICU but had a KUB without evidence of perforation. Patient
was pain controlled and remained hemodynamically stable.
Abdominal exam remained stable while in the MICU. Given the
stability of the patient, patient was transferred to the floor
on ___ for further monitoring. He denied abdominal pain
throughout the hospitalization. He had daily abdominal x-rays
which revealed continued presence of glass. On ___, a repeat
attempt was made to perform EGD and remove some glass visualized
in the stomach on KUB. This was sucessful but some glass was
left over beyond the duodenum which could not be removed. The
patient was observed closely for changes in abdominal exam or
pain but had none. He had a bowel movement with no resulting
injuries. Psychiatry was consulted to clear the patient prior to
discharge and found him safe to be transferred back to his group
home.
# Prader ___ - The patient had a 1:1 sitter
throughout hospitalization.
# Bipolar Disorder-Stable, home medications of lamotrigine and
ziprasidone were continued. He was evaluated by the psychiatry
team while admitted and there were not felt to be any acute
psychiatric issues. He was cleared by psychiatry to return to
his group home once medically ready.
# Diabetes - On glyburide as an outpatient. The glyburide was
held while the patient was hospitalizaed and an insulin sliding
scale was initated with resulting good glycemic control.
# GERD - stable, continued omeprazole.
Transitional Issues:
# Foreign Body Ingestion-Minimize ingestable objects and
supervise patient carefully to avoid repeat ingestion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rulox (alum-mag hydroxide-simeth) 30 mL oral TID
2. Flunisolide Inhaler 80 mcg/actuation inhalation BID
3. Omeprazole 20 mg PO DAILY
4. Simethicone 120 mg PO TID
5. Calcium Carbonate 500 mg PO BID
6. Vitamin D 400 UNIT PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. TraZODone 50 mg PO QHS
9. flaxseed oil 1,000 mg oral DAILY
10. Docusate Sodium 100 mg PO BID
11. LaMOTrigine 100 mg PO BID
12. naltrexone 50 mg oral QHS
13. Loratadine 10 mg PO DAILY
14. ZIPRASidone Hydrochloride 80 mg PO BID
15. Testosterone Cypionate 100 mg IM MONTHLY
16. GlyBURIDE 1.25 mg PO DAILY
17. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. LaMOTrigine 100 mg PO BID
4. Omeprazole 20 mg PO DAILY
5. ZIPRASidone Hydrochloride 80 mg PO BID
6. Calcium Carbonate 500 mg PO BID
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. flaxseed oil 1,000 mg oral DAILY
9. Flunisolide Inhaler 80 mcg/actuation inhalation BID
10. GlyBURIDE 1.25 mg PO DAILY
11. Loratadine 10 mg PO DAILY
12. naltrexone 50 mg oral QHS
13. Rulox (alum-mag hydroxide-simeth) 30 mL oral TID
14. Simethicone 120 mg PO TID
15. Testosterone Cypionate 100 mg IM MONTHLY
16. TraZODone 50 mg PO QHS
17. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Glass ingestion, Prader-Willi Syndrome
Secondary Diagnosis: Bipolar 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 caring for you at the ___
___. You were admitted because you swollowed glass.
An attempt was made to remove the glass from your stomach, and
while a great deal of the glass was able to be removed, some
remained so we performed daily x-rays of your abdomen until we
did not see any more glass. You passed the glass in your stool,
and you are now safe to be discharged. Ingesting glass is
extremely dangerous and we strongly recommend that you do not
ingest glass in the future. We wish you all the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10046436-DS-18 | 10,046,436 | 21,447,783 | DS | 18 | 2156-06-27 00:00:00 | 2156-06-27 15:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
shellfish derived
Attending: ___.
Chief Complaint:
glass ingestion
Major Surgical or Invasive Procedure:
EGD ___
Colonoscopy ___
History of Present Illness:
___ yo male with hx Prader-Willi Syndrome, NIDDM, GERD, and
multiple prior foreign body ingestions requiring EGD and
intubation presenting from ___ s/p glass ingestion
after punching a window at his group home.
He was reportedly agitated at OSH, was trying to hit police
officers, didn't want to go to the hospital. He received 5 mg IM
Haldol, 2 mg IM Ativan, D5NS at 110/hr, and tetanus vaccine.
Labs were stable: WBC 10.2 Hb 14.9 Hct 44.2 Plt 200, Cr 1.1,
Coags WNL. CT showed glass in the stomach and no free air.
He was then transferred to ___.
Upon arrival to ___ ED:
- vitals: T 97.4, 86, 110/80, 16, 99% RA
- Abdomen was soft, nontender
- Labs showed:
143 102 13
------------< 110
3.9 25 1.1
WBC 8.4 Hb 13.9 Plt 187
___: 11.4 PTT: 23.7 INR: 1.1
He was admitted for EGD and went directly to the endoscopy
suite. EGD was without abnormalities, but unfortunately the
glass had passed on out of view of the scope. ACS was consulted,
recommended repeat CT abdomen and serial abdominal exams.
Admitted to medicine in stable condition.
Past Medical History:
Prader Willi Syndrome
Bipolar Disorder
Osteopenia
GERD
DM2
Hyperlipidemia
Last hospitalization ___ for same presentation, reportedly
shattered a picture frame and ingested several pieces of glass,
which were not all able to be retrieved, had short course in
MICU and no e/o bowel perforation, followed by ACS, and cleared
by psychiatry to return to group home. Psychiatry felt his
behavior might be in response to family stress and changes in
staffing at the group home. OSH records indicate 9 prior EGDs
for ingestions.
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.4 PO ___ 18 96 RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclerae, pink conjunctiva, MMM
NECK: supple, no LAD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes, ecchymoses upper L chest mildly tender, R index finger
bandaged, R upper forehead 2 cm linear cut
DISCHARGE PHYSICAL EXAM:
Vitals: 98 PO 118/78 Sitting 96 20 99% RA
General: Reserved in conversation . in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear.
Neck: supple
CV: RRR, +S1/S2, no murmurs, rubs, gallops
Lungs: good inspiratory effort. Clear to auscultation
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ DP pulses
Neuro: Alert and oriented, no focal deficits appreciated
Pertinent Results:
ADMISSION LABS:
___ 05:30PM BLOOD WBC-8.4 RBC-4.72 Hgb-13.9 Hct-41.6 MCV-88
MCH-29.4 MCHC-33.4 RDW-12.1 RDWSD-39.0 Plt ___
___ 07:30AM BLOOD WBC-7.2 RBC-4.83 Hgb-14.3 Hct-43.0 MCV-89
MCH-29.6 MCHC-33.3 RDW-12.1 RDWSD-39.6 Plt ___
___ 07:35AM BLOOD WBC-6.4 RBC-4.97 Hgb-15.2 Hct-44.0 MCV-89
MCH-30.6 MCHC-34.5 RDW-12.2 RDWSD-39.5 Plt ___
___ 05:30PM BLOOD Glucose-110* UreaN-13 Creat-1.1 Na-143
K-3.9 Cl-102 HCO3-25 AnGap-16
___ 07:30AM BLOOD Glucose-126* UreaN-11 Creat-1.0 Na-140
K-4.4 Cl-100 HCO3-25 AnGap-15
IMAGING:
CXR: ___
In comparison with study of ___, there again are low
lung volumes. Cardiac silhouette is within normal limits
without vascular congestion. Mild opacification at the left
base most likely reflect combination of atelectasis and pleural
fluid. However, in the appropriate clinical setting, it would
be difficult to exclude superimposed aspiration/pneumonia.
KUB ___:
Surgical clips within the right upper quadrant are unchanged in
configuration. The ingested foreign bodies originally seen on
the ___ CT examination are no longer visualized
radiographically.
KUB ___:
Larger glass fragment in the descending colon, smaller glass
fragment at the hepatic flexure.
KUB ___:
2.5 and 1.1 cm linear hyperdensities in the right lower quadrant
correspond to previously described radiodense glass fragments on
prior CT exam and appear located in the cecum and/or proximal
ascending colon.
CT AP ___:
Unchanged position of the 2 radiodense objects with the 25 mm
fragment within the cecal base and the 10 mm fragment within the
appendiceal base. Given location, especially the fragment
within the appendiceal base, these are felt unlikely to progress
distally. No bowel rupture or adjacent colonic irritation.
CT AP ___:
Both of the radiopaque foreign objects are now within the cecum,
measuring 2.6 cm and 0.9 cm. No evidence of perforation or
bowel obstruction.
CT AP ___:
Ingested radiopaque foreign body has migrated distally and is
seen within a loop of distal small bowel in the right lower
quadrant. Another small
radiopaque object is noted within the cecum which may represent
a detached fragment. No evidence of bowel perforation or
obstruction.
PROCEDURES:
EGD ___:
2 pills were found in the stomach. Both were mobile and not
sharp. One was suctioned but the other was not able to be
suctioned.
No foreign body identified. No evidence of injury to the mucosa.
No evidence of injury to the mucosa.
No foreign body identified. No evidence of injury to the mucosa.
Otherwise normal EGD to third part of the duodenum
Colonoscopy ___:
The prep was inadequate and several areas, including the cecum
were unable to be completely visualized. Small pieces of glass
could be missed in areas of poor prep. There was no glass seen
near the appendiceal orifice.
Otherwise normal colonoscopy to cecum
DISCHARGE LABS:
Patient declined laboratory draw on ___ day of discharge.
___ 09:25AM BLOOD WBC-9.8 RBC-4.27* Hgb-12.9* Hct-38.4*
MCV-90 MCH-30.2 MCHC-33.6 RDW-13.2 RDWSD-43.3 Plt ___
___ 09:25AM BLOOD Glucose-311* UreaN-24* Creat-0.8 Na-134
K-4.7 Cl-90* HCO3-25 AnGap-19*
___ 03:20PM BLOOD Glucose-267* UreaN-24* Creat-0.7 Na-136
K-4.7 Cl-94* HCO3-26 AnGap-16
___ 09:25AM BLOOD Calcium-9.4 Phos-3.8 Mg-1.8
___ 07:27AM BLOOD WBC-8.1 RBC-4.84 Hgb-14.1 Hct-42.6 MCV-88
MCH-29.1 MCHC-33.1 RDW-11.9 RDWSD-38.2 Plt ___
___ 07:49AM BLOOD WBC-7.8 RBC-4.61 Hgb-14.2 Hct-39.6*
MCV-86 MCH-30.8 MCHC-35.9 RDW-12.1 RDWSD-37.6 Plt ___
___ 06:40AM BLOOD WBC-6.7 RBC-4.84 Hgb-14.8 Hct-42.4 MCV-88
MCH-30.6 MCHC-34.9 RDW-12.1 RDWSD-39.0 Plt ___
___ 07:27AM BLOOD Glucose-168* UreaN-6 Creat-0.8 Na-136
K-4.6 Cl-93* HCO3-28 AnGap-15
___ 07:49AM BLOOD Glucose-158* UreaN-7 Creat-0.8 Na-137
K-4.6 Cl-95* HCO3-29 AnGap-13
___ 06:40AM BLOOD Glucose-174* UreaN-3* Creat-0.8 Na-139
K-4.7 Cl-96 HCO3-27 AnGap-16
Brief Hospital Course:
Patient Summary for Admission:
==============================
___ yo male with h/o Prader-Willi Syndrome, NIDDM, and GERD, with
multiple prior foreign body ingestions requiring EGD and
intubation who presented from ___ s/p glass
ingestion in the setting of being agitated at his home facility.
Patient was transferred to ___ for endoscopic evaluation.
Patient was evaluated by GI who attempted an EGD but were
unsuccessful in retrieving the glass. He was also evaluated by
ACS, but given the lack of evidence of perforation, he did not
require surgery. The location of the glass was monitored with
serial CT images of the abdomen, and a colonoscopy on ___ was
performed but was unsuccessful in retrieving the glass. Given
the patient's clinical stability, the patient was transitioned
back to a regular diet and bowel regimen and subsequently passed
the glass spontaneously. Hospital course was complicated by
hyperglycemia following initiation of a regular diet. Patient
initially required sliding scale insulin and long acting insulin
to control blood sugars. Patient was not adhering with a
carbohydrate controlled diet and with improved enforcement of
the ordered dietary restrictions, blood sugars trended down.
Subsequently glucose control was achieved through increased
Glyburide, with plans to restart home Januvia at time of
discharge. Patient was discharged once blood sugars were
stabilized with plan for close primary care provider follow up.
___ Medical Issues Addressed:
================================
#Glass Ingestion:
Patient ingested glass at his home facility and was subsequently
transferred to ___ on ___ for endoscopic retrieval. EGD
was performed and glass was unable to be retrieved. CT Abdomen
and Pelvis completed ___ was notable for a 2.1cm piece of glass
in the small bowel. Patient was evaluated by ACS who did not
feel acute surgical intervention was needed given there was no
evidence of perforation. Mr. ___ had serial abdominal exams,
which remained benign. Given low concern for perforation,
patient was monitored for passage of the glass. He had not
spontaneously passed the glass as of ___P was
completed on ___ and ___ which demonstrated the glass migrated
to the cecum but remained in the cecum. Patient had a
colonoscopy ___, but the glass was not able to be retrieved
due to poor prep. Following a discussion with the ___ team and
given the patient's hemodynamic stability, the patient was
allowed to eat a regular diet and subsequently patient passed
the glass spontaneously, which was confirmed with repeat KUB.
Patient's abdomen remained without clinical change during
admission.
# Type 2 diabetes with hyperglycemia:
Patient was initially transitioned to sliding scale insulin when
admitted and home Glyburide and Januvia were held. Blood sugar
was well controlled with HISS while patient was NPO and on a
clear diet in anticipation of passing the ingested glass. With
transition back to a carb controlled diet patient's blood sugars
increased to 300-500. Initial concern was for infection driving
the worsening hyperglycemia, however CXR and urine analysis were
unrevealing for infection. On ___ patient's anion gap increased
to 20 with trace ketones present in urine. With increased fluid
and short acting insulin patient's gap subsequently closed. It
later became obvious patient was ordering multiple trays at
meals which was driving the hyperglycemia. ___ was consulted
during admission due to new insulin initiation; however with
improvement of sugars the patient was transitioned back to oral
agents with an increase Glyburide dose of 10mg daily and plans
to restart home Januvia (not on formulary inpatient) at time of
discharge. Patient's blood sugars were approximately 120-250 at
time of discharge, and he will require close follow up with his
primary care provider for ongoing management.
# Bipolar Disorder: Patient became agitated at group home
resulting in foreign body ingestion. Patient was continued on
home Lamotrigine and Ziprasidone and was evaluated by Psychiatry
who did not recommend any acute medical changes. Patient had a
1:1 sitter while inpatient.
CHRONIC ISSUES:
===============
# Prader Willi Syndrome: Patient has a history of Prader Willi
as well as impulsivity. Patient had a 1:1 sitter during
hospitalization and was continued on home Naltrexone,
ziprasidone and lamotrigine. Patient was evaluated by Psychiatry
who did not recommend acute medication changes.
# GERD: Patient continued home omeprazole, however Simethicone
and Rulox were held while patient was waiting to pass the glass.
Simethicone and Rulox were started again at time of discharge.
# Insomnia: Patient continued home trazodone.
Transitional Issues:
======================
Medications Stopped:
-Rulox and Simethicone were held during admission but restarted
at time of discharge
-Januvia 100mg Daily held while inpatient, restarted at time of
discharge
Medications Added:
-Glyburide increased from 1mg to 10mg daily
[]Patient's Glyburide dose increased significantly while
inpatient with addition of Januvia 100mg at time of discharge.
This medication change may need to be adjusted as patient
returns to usual diet
[]Patient should check FSBG three times daily with a morning
fasting glucose for the next few weeks until blood glucose
stabilizes.
[]Patient will require close follow up by PCP for ongoing
management of hyperglycemia
[]Patient will follow up with PCP ___ ___ at 1 pm
Code Status: Full Code
HCP: ___ (mother) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Gas Relief (simethicone) 125 mg oral TID W/MEALS
2. Calcium Carbonate 600 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. flaxseed oral unknown
5. ZIPRASidone Hydrochloride 80 mg PO BID
6. Loratadine 10 mg PO DAILY
7. Naltrexone 50 mg PO QHS
8. Fluticasone Propionate NASAL 2 SPRY NU BID
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Omeprazole 20 mg PO QAM
11. multivitamin with iron 1 tab oral DAILY
12. Rulox (alum-mag hydroxide-simeth) 30 mL oral TID BEFORE
MEALS
13. TraZODone 50 mg PO QHS
14. Vitamin D 400 UNIT PO BID
15. Januvia (SITagliptin) 100 mg oral QAM
16. Testosterone Cypionate unknown IM QMONTHLY
17. Phos-Flur (fluoride (sodium)) 0.02 % (0.044 % sod. fluoride)
dental unknown
18. GlyBURIDE 1 mg PO DAILY
Discharge Medications:
1. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
2. GlyBURIDE 10 mg PO DAILY
RX *glyburide 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
3. Calcium Carbonate 600 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. flaxseed oral Frequency is Unknown
7. Fluticasone Propionate NASAL 2 SPRY NU BID
8. Gas Relief (simethicone) 125 mg oral TID W/MEALS
9. Januvia (SITagliptin) 100 mg oral QAM
10. LamoTRIgine 125 mg PO BID
11. Loratadine 10 mg PO DAILY
12. multivitamin with iron 1 tab oral DAILY
13. Naltrexone 50 mg PO QHS
14. Omeprazole 20 mg PO QAM
15. Phos-Flur (fluoride (sodium)) 0.02 % (0.044 % sod.
fluoride) dental unknown
16. Rulox (alum-mag hydroxide-simeth) 30 mL oral TID BEFORE
MEALS
17. Testosterone Cypionate unknown IM QMONTHLY
18. TraZODone 50 mg PO QHS
19. Vitamin D 400 UNIT PO BID
20. ZIPRASidone Hydrochloride 80 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
===================
Intentional Ingestion (glass)
Hyperglycemia
Diabetes Mellitus Type 2
Secondary Diagnosis:
===================
Prader-___ Syndrome
Bipolar Disorder
GERD
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 be a part of your care at ___
___!
Why was I in the hospital?
-You were admitted to the hospital after you swallowed a piece
of glass.
What was done while I was in the hospital?
-While you were in the hospital you were evaluated by the GI
team and the Surgical team.
-The GI team place a camera in your stomach but were unable to
remove the glass.
-We continued to watch you and you did not have belly pain or
pain in your bottom.
-We watched the glass as it made its way through your gut with
repeat images of your belly.
-You had a colonoscopy on ___, but we were not able to
remove the glass.
-You were given back a regular diet and you were able to pass
the glass on your own.
-Your blood sugars were very high and we had to use insulin
initially to decrease your blood sugar
-We started you on new medications to decrease your blood sugars
What should I do when I go home?
-You should continue taking your medications as prescribed.
-You should check your blood sugar first thing in the morning
and two more times during the day.
-You should also follow up with your primary care provider early
next week to discuss your blood sugar.
We wish you the best!
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10046543-DS-17 | 10,046,543 | 21,402,025 | DS | 17 | 2155-03-20 00:00:00 | 2155-03-24 08:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
s/p fall, back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year-old woman with a history of PMR
on a prednisone taper, osteoporosis, prior thoracic compression
fractures who presented to the ___ ED on ___ with 3 weeks
of atraumatic back pain which which acutely worsened yesterday
after leaning back to sit in her recliner but fell onto
her buttocks. She is typically independent and fully mobile at
baseline. She was evaluated by Ortho Spine who recommended TLSO
brace for comfort, ED obs for pain control and a ___ evaluation.
She was evaluated by ___ who found the patient to be motivated to
return home and engage in outpatient physical therapy. Today the
patient has been ambulating at baseline, however, in certain
positions such as leaning forward or standing her back pain
increases. She states she prefers to be admitted for one more
night for pain control before going home. On exam the patient
still denies fevers, chills, chest pain, palpitations, nausea,
vomiting, numbness, tingling, weakness, saddle anesthesia, loss
of bowel or bladder function.
Past Medical History:
Past Medical/Surgical History:
PMR
Osteoporosis
Thoracic compression fractures
MGUS
Glaucoma
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
Gen: NAD, A&Ox3, pleasant, conversant
HEENT: Normocephalic, atraumatic, sclera anicteric
Neck: Trachea midline, supple, no c-spine tenderness
Resp: Breathing comfortably on room air
CV: RRR
Back: Tender to palpation in lower thoracic spine, upper lumber
spine
Abd: Soft, non-tender, non-distended
Ext: Warm, well perfused, minimal edema, no abrasions or
lacerations noted
Discharge Physical Exam:
VS: 97.6, 101/66, 79, 18, 95 Ra
GEN: A&O x3. sitting up in chair NAD
HEENT: WNL
CV: HRR
PULM: LS ctab
ABD: soft NT/ND
EXT: WWP no edema.
Neuro: low back pain
Pertinent Results:
Imaging:
CT Head ___: There is no evidence of acute intracranial
hemorrhage, midline shift, mass effect, or acute large vascular
territorial infarct. Mild periventricular and subcortical white
matter hypodensities are nonspecific. Extensive calcifications
are seen along the cavernous portions of the bilateral carotid
arteries. Vertebral artery calcification is also noted.
CT Chest ___: Compression deformities of T8, T10, and L1
vertebral bodies compatible fractures of unknown chronicity. L1
fx has acute/subacute appearance. Question of R 3rd rib
nondisplaced fx.
CT C-Spine ___: Multilevel degenerative changes of C-spine.
No evidence of acute fx or traumatic malalignment.
Brief Hospital Course:
Ms. ___ is a ___ year-old woman with a history of PMR on a
prednisone taper, osteoporosis, prior thoracic compression
fractures who presented to the ___ ED on ___ with 3 weeks
of atraumatic back pain which acutely worsened, found to have
T8, T10, L1 compression fracture (acute vs subacute). She was
admitted to the acute care surgery service for pain management.
Ortho Spine was consulted who recommended no surgical
intervention, TLSO for comfort, and no bending or twisting.
On the floor, she was advanced to a regular diet, her home
medication was restarted, she was started on oral medication for
pain control with good affect. The TLSO brace was ordered and
came to bedside but the patient stated she was unable to ___ the
brace by herself. She was evaluated by physical therapy who felt
she would need to go to rehab.
At the time of discharge, she was afebrile and hemodynamically
stable, pain was well controlled on oral medication alone,
tolerating a regular diet, voiding adequately and spontaneously,
she was ambulating with assistance in the TLSO, and she was
deemed stable for discharge to rehab. She was discharged home
with appropriate instructions and follow up and verbalized
agreement with the plan
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
3. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine [Lidocaine Pain Relief] 4 % apply one to lower
back daily once a day Disp #*10 Patch Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
4. Senna 8.6 mg PO BID:PRN Constipation
5. TraMADol ___ mg PO Q6H:PRN Pain - Severe
RX *tramadol 50 mg 0.5 -1 tablet(s) by mouth every six (6) hours
Disp #*10 Tablet Refills:*0
6. Vitamin D 1000 UNIT PO DAILY
7. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. PredniSONE 5 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
T8, T10, L1 compression fracture
subacute R 3rd rib fx
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 after you sustained a fall
and were found to have a several spine compression fractures,
unclear whether acute or chronic, and a subacute right 3rd rib
fracture. You were treated with oral pain medication. You were
seen by physical therapy who recommended you be discharged home
with home physical therapy You are now ready for discharge home.
Please follow these instructions to aid in a speedy recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
If you have any questions, you may reach the Acute Care Surgery
Clinic at the following number: ___
Best Wishes
Your ___ Surgery Team
Followup Instructions:
___
|
10046630-DS-18 | 10,046,630 | 20,836,768 | DS | 18 | 2171-04-06 00:00:00 | 2171-04-06 21:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hip pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ w/ hx of HTN presented to the ED with pelvis pain and was
found to be confused so was admitted to medicine for pain
control and confusion workup.
He was seen here on ___ with a diagnosis of pelvic ramus
fracture. Kept overnight for ___ and CM; sent home with a walker
and home services. He returned today with continued pain. He
says it is not worse, but it is not better either and it is
limiting his ability to function at home. He has been taking
Tylenol and ibuprofen. Is still able to ambulate.
In the ED, initial vitals were: 97.4 68 180/80 20 98% RA
His labs revealed H/H of 12.___, chem7 wnl
Imaging revealed
- Bilateral LENIS - distal isolated tibial vein thrombosis. No
evidence DVT.
- Hip/pelvic films - Minimally displaced and comminuted
fractures involving the left superior and inferior pubic rami
not significantly changed in overall appearance relative to
prior examinations dated ___. No new fracture is
seen.
He received:
___ 16:22 PO TraMADOL (Ultram) 25 mg
___ 20:58 PO TraMADOL (Ultram) 25 mg
___ 20:58 PO Acetaminophen 1000 mg
___ 01:32 PO/NG Acetaminophen 650 mg
___ 01:32 PO OLANZapine 5 mg
___ 10:48 IVF 20 mEq Potassium Chloride / 1000 mL ___
NS
He was going to be discharged from the ED, however woke up this
morning altered. Head CT was negative. He was admitted to the
floor for further work up for altered mental status.
On the floor, with the assistance of a ___ interpreter, the
patient says that he has pain in his legs. He is confused so did
not answer any other ROS questions.
Past Medical History:
Per wife, HTN only
Social History:
___
Family History:
not pertinent to current admission
Physical Exam:
ADMISSION EXAM
==============
Vital Signs: 98.4 180/95 64 16 99% RA
General: Lying in bed, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, no JVD. PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB, no w/r/c
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII grossly intact. ___ strength in upper
extremities, lower extremity exam limited by pain but has ___
strength on plantarflexion of feet
DISCHARGE EXAM
==============
Vital Signs: 97.8 66-71 ___ 20 96-100% RA
General: Lying in bed, appears comfortable
HEENT: Head AT/NC, PERRL, EOMI
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB anteriorly only, no w/r/c
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Legs slightly cool to touch, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
Neuro: CN II-XII grossly intact, moving all extremities
spontaneously, A&Ox3
Pertinent Results:
ADMISSION LABS
==============
___ 04:35PM GLUCOSE-94 UREA N-20 CREAT-0.9 SODIUM-138
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16
___ 04:35PM WBC-7.3 RBC-3.63* HGB-11.0* HCT-32.7* MCV-90
MCH-30.3 MCHC-33.6 RDW-13.2 RDWSD-43.0
___ 04:35PM NEUTS-85.8* LYMPHS-4.6* MONOS-8.6 EOS-0.3*
BASOS-0.3 IM ___ AbsNeut-6.28* AbsLymp-0.34* AbsMono-0.63
AbsEos-0.02* AbsBaso-0.02
___ 04:35PM GLUCOSE-94 UREA N-20 CREAT-0.9 SODIUM-138
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16
___ 04:47PM URINE RBC-2 WBC-0 BACTERIA-FEW YEAST-NONE
EPI-0 TRANS EPI-<1
___ 04:47PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 04:47PM URINE COLOR-Yellow APPEAR-Clear SP ___
DISCHARGE LABS
==============
___ 07:34AM BLOOD WBC-7.8 RBC-3.65* Hgb-10.9* Hct-33.1*
MCV-91 MCH-29.9 MCHC-32.9 RDW-13.2 RDWSD-43.7 Plt ___
___ 07:34AM BLOOD Glucose-118* UreaN-28* Creat-0.9 Na-135
K-3.9 Cl-102 HCO3-26 AnGap-11
___ 07:34AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.0
IMAGING
=======
___ CT HEAD W/O CONTRAST
IMPRESSION:
No acute intracranial process. Small vessel disease with age
related
involutional change.
___ CHEST (SINGLE VIEW)
No acute intrathoracic process
___ BILAT LOWER EXT VEINS
IMPRESSION:
1. Nonocclusive thrombus in a single posterior tibial vein on
the left.
2. No evidence of deep venous thrombosis in the right lower
extremity veins.
___ DX PELVIS & HIP UNILATE
IMPRESSION:
Minimally displaced and comminuted fractures involving the left
superior and inferior pubic rami not significantly changed in
overall appearance relative to prior examinations dated ___. No new fracture is seen.
MICROBIOLOGY
============
UCx ___ - consistent with skin flora
BCx ___ x 2, NGTD
Brief Hospital Course:
BRIEF SUMMARY
==============
Mr. ___ is a pleasant ___ M s/p fall and fracture of the
left inferior and superior pubic rami on ___, who presented
with ongoing pain hip pain and was noted to be confused while in
the ED and was found to have a superficial clot of the right
lower tibial vein. He was evaluated for causes of delirium with
no obvious abnormality. The likely cause of his delirium was
pain, medication effect (he was initially treated with oxycodone
2.5 mg for pain), lack of sleep (he did not sleep at all the
night prior to his confusion), and being hospitalized in the
setting of chronic small vessel disease of the brain. With
normalization of his sleep-wake cycle, limiting sedating
medications, and administration of fluids he had significant
improvement in his mental status and was discharged to rehab.
ACUTE ISSUES
============
#Delirium: The patient was noted to be confused upon waking the
morning after being seen in the emergency department for
continued hip pain in the setting of a pubic ramus fracture two
weeks prior to admission. He was admitted to the medicine
service, where he underwent a workup for causes of delirium.
While on the floor, he exhibited waxing and waning of his mental
status, ranging from A&Ox3 to somnolent and barely interactive.
A general delirium workup was performed and was negative (see
labs for further details). The likely cause of his delirium was
a combination of pain, medication effect (he was initially
treated with oxycodone 2.5 mg for pain), lack of sleep (he did
not sleep at all the night prior to his confusion), and being
hospitalized in the setting of chronic small vessel disease of
the brain. He underwent a head CT in the ED, which was negative
for acute findings. We acquired records from a stay at ___.
___ in ___ at which time he was evaluated for
slowing of speech/movement with concern for ___ Disease;
an MRI brain from that stay showed enlarged cerebral ventricles,
with question of NPH. Given that he was acutely delirious, had
fallen recently, and was having incontinence while on the floor,
we had our radiologists read the MRI from the outside hospital.
They felt that there was no change in the size of his ventricles
from this MRI versus his CT scan this admission. The patient was
given fluids, Seroquel for sleep, and was put on delirium
precautions with improvement in his mental status. He was
discharged to rehab and will follow up at ___ with a neurologist
later in the month for further evaluation per the patient's
wife.
#TIBIAL VEIN THROMBOSIS: The patient has a superficial tibial
vein thrombosis but with no evidence of DVT. No need to
anticoagulate given superficiality of clot.
#PELVIC FRACTURE: Sustained fracture of his superior and
inferior left pelvic ramus on ___, with no need for
operative management per orthopedics. He went home with a walker
but had continued pain so returned as above. His pain was
initially treated with oxycodone 2.5 mg and standing tylenol,
but the oxycodone was discontinued due to concern for worsening
of his delirium as above.
CHRONIC ISSUES
#HYPERTENSION: The patient has a hx of HTN, controlled with PRN
metoprolol per wife. On presentation to the floor, patient had
SBP to 180 so was give 12.5 mg of PO captopril. He was placed on
captopril 6.25 mg TID with improvement in pressures, however he
did experience SBPs in the ___ so his captopril was
discontinued. He may need addition of an antihypertensive as an
outpatient depending on his blood pressure control.
#Normocytic anemia: Iron studies were performed and were
consistent with anemia of chronic disease; his iron was wnl,
TIBC low normal, and ferritin elevated. His H/H remained stable
during his course
TRANSITIONAL ISSUES
===================
- The patient was noted to have labile blood pressures, with his
initial SBP at 180. He was placed on captopril 6.25 mg TID with
improvement in his pressures, but did experience a couple of
SBPs in the ___. This medication was discontinued prior to
discharge, and his blood pressures should be further evaluated
with possible addition of antihypertensive medication.
- The patient was noted to have a normocytic anemia with Hgbs in
the ___. Iron studies were consistent with anemia of chronic
disease
- The patient was evaluated for possible ___ disease at
___ in ___ after experiencing slowing
of speech/movement. Per his wife, he has an appointment w/
neurology at ___ on ___ for further evaluation.
- The patient was started on Seroquel 25 mg QHS for problems
with sleep/wake cycle, however he experienced cognitive slowing
so this was discontinued. He may be sensitive to antipsychotics
given his possible ___ Disease
- Per the patient's PCP, he takes Sinemet ___ 0.5 tab BID for
?___ Disease but the patient was reluctant to take any
psychoactive medications due to concern for possible cognitive
side-effects
# CODE: Full
# CONTACT: ___, wife, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Carbidopa-Levodopa (___) 0.5 TAB PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Lovaza (omega-3 acid ethyl esters) 1 gram oral BID
5. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Vitamin D 1000 UNIT PO DAILY
4. Acetaminophen 650 mg PO Q6H
5. Lovaza (omega-3 acid ethyl esters) 1 gram oral BID
6. Carbidopa-Levodopa (___) 0.5 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#delirium
#Superficial tibial vein thrombosis
#hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
you were admitted to the hospital after you were found to be
confused while visiting the emergency department due to leg
pain. We performed several tests to identify the cause of your
confusion, but no cause was found. It is likely that your
confusion was caused by a combination of pain, pain medications
(which can be sedating), being in a different environment, lack
of sleep, and having some chronic age-related brain changes. You
were also found to have a small clot in your right leg, but this
did not need treatment.
You were seen by our physical therapists who recommended rehab.
You were discharged to a rehab facility to help you get
stronger.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
10046724-DS-18 | 10,046,724 | 25,792,614 | DS | 18 | 2178-09-10 00:00:00 | 2178-09-10 16:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Found AMS
Major Surgical or Invasive Procedure:
___ Left Craniotomy for subdural hematoma evacuation.
History of Present Illness:
___ M with Hx of alcohol abuse, was found altered by his friend
on the morning of ___ with Right sided weakness. He was
brought to ___ where a CT brain was obtained
which demonstrated an acute L SDH with max diameter 2cm and 1cm
midline shift. EtOH 240, was transferred to ___.
Past Medical History:
EtOH abuse
Social History:
___
Family History:
noncontributory
Physical Exam:
ON ADMISSION:
GCS 12
right facial weakness
tongue protrudes midline
speech slurred, confused
follows commands
RUE ___, RLE ___
LUE ___, LL%E ___
Babinski + R
tremorous
ON DISCHARGE:
Alert, oriented x3
PERRL. EOMI. ___. TML.
Strength ___ throughout
Sensation grossly intact
no pronator drift
left crani incision c/d/I - staples removed. no erythema or
discharge
Pertinent Results:
Please refer to OMR for pertinent imaging and lab results.
Brief Hospital Course:
___ is a ___ year old male who was transferred from ___.
___, after being found with altered mental status,
and new CT findings of Left subdural hematoma.
#Left subdural hematoma
Mr. ___ was transferred from ___ on
___ with CT findings of Left SDH max diameter 2mm with
1mm midline shift. Patient's ___ score was 12 at initial
presentation. Patient was intubated, and it was determined that
the patient needed emergent surgical intervention, and he was
immediately taken to the OR that day for a Left Craniotomy and
Subdural Hematoma Evacuation with a JP drain placed
intra-operatively. Mr. ___ was transferred to the Neuro ICU
post-operativly for further management and was started on Keppra
for seizure prophylaxis. On ___ Mr. ___ was extubated and
JP drain was removed with no complications. Patient remained
neuro intact and was transferred out of the ICU to the
neurosurgery floor on ___. Mr. ___ remained stable through
the rest of his admission. He was evaluated by ___ and OT who
recommended him to be discharge home with ___ services. Patient
was medically cleared for discharge home on ___. Staples were
removed prior to discharge - incision remained c/d/I.
#EtOH withdrawal
At the time of admission patient blood alcohol content was 240.
Once patient was neurosurgically stable, he was started on
multivitamins, thiamine and folic acid. Patient was started on
phenobarbital before coming out of the ICU for withdrawals. Mr.
___ continued on a phenobarbital taper ___ and remained
medically stable.
#Anxiety
Mr. ___ continues to take his home Valproic Acid for
management of anxiety during his admission.
Medications on Admission:
Divalproex, Gabapentin, Trazodone
Discharge Medications:
1. Acetaminophen-Caff-Butalbital 1 TAB PO Q4H:PRN Headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth every 4 hours as needed Disp #*30 Tablet
Refills:*0
2. Docusate Sodium 100 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth pain, headache Disp
#*32 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
6. Gabapentin 300 mg PO TID
7. Valproic Acid ___ mg PO ASDIR
250mg qAM, 250mg at 3pm, 500mg qHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Subdural Hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Surgery
You underwent a surgery called a craniotomy to have blood
removed from your brain.
Your staples were removed prior to discharge. You may shower.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply ice
or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain
medications on a daily basis unless prescribed by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10047172-DS-14 | 10,047,172 | 26,942,178 | DS | 14 | 2162-08-03 00:00:00 | 2162-08-03 18:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / sitagliptin / fesoterodine / Statins-Hmg-Coa
Reductase Inhibitors / saxagliptin / pioglitazone /
canagliflozin / fenofibrate
Attending: ___.
Chief Complaint:
Asymptomatic fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with past history of metastatic pancreatic
cancer (to liver) on chemotherapy who presents ED with fever.
Last chemo gem/abraxane ___, neulasta ___, developed chills on
___ after chemo and then temp to 102 on ___ after neulasta. He
denies cough, shortness of breath, chest pain, nausea/vomiting,
headaches, abd pain, diarrhea, rashes.
ED COURSE:
v/s 18:28 0 98.5 70 157/56 16 100% RA
Labs: lactate 1.6. UA unremarkable other than glycosuria. Chem w
glucose of 363, Na 129, K 5.0, BUn/cr ___. LFTS elevated but
stable compared to prior w ALT 100 and AP 460 tbili only 0.6.
WBC
12.8 with 83% pmns and 5 bands. Hct stable at 26. Plts 120
slightly down from prior. Pt received 10u of SC insulin at 10pm.
CXR unread but on my review unchanged from prior on ___ and no
obvious infiltrate o0r effusion.
On the floor he appears well and has no complaints. He does note
that he skipped his insulin last night and had to take extra
(total of 20u) this morning (humalog). Denies dysuria.
Past Medical History:
___ was diagnosed pancreatic adenocarcinoma
metastatic to the liver in ___ when he was admitted
for
painless jaundice. CT showed 3.3cm pancreatic head mass and MRI
showed a 1.8cm left kidney lesion concerning for RCC as well as
2
sub-cm liver masses. FNA of pancreas showed 'suspicious' cells.
His pancreatic mass was deemed unresectable due to abutting the
SMV and portal vein. He was treated with three cycles of
FOLFIRINOX ___ which was halted due to rising CA
___
and increased size of liver metastases. In ___, CA
___ elevated to 23K and considered potentially related to left
finger infection in setting of diabetes. Imaging shows increased
size of liver metastases. In ___ he started
gemcitabine/Abraxane. Imaging ___ showing slight decrease
in
the size of the liver metastases with stable disease at the
pancreas. Gem/Abraxane given at full dose in every other week
regimen due to counts. Course complicated by right thigh muscle
infarct presumed ___ in ___. Primary chemotherapy
side effect has been neuropathy on the bottoms of b/l feet
without impairment of ADLs.
Other PMHx/PSHx:
- T2DM
- Hypertension
- Hyperlipidemia
- s/p L hip replacement
- heart murmur
- s/p nose fracture
Social History:
___
Family History:
Mother: dementia
Father: bladder cancer at older age
Cancers in the family: paternal cousin with primary liver
cancer
Physical Exam:
GEN: NAD
ECOG: 1
VITAL SIGNS: 100.3 136/56 74 18 100% on RA
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2, III/VI low pitched holosystolic murmur at the
base - old per patient
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown, excoriation on the right
leg,
scar on the left second digit
NEURO: Nonfocal
Pertinent Results:
___ 07:30PM LACTATE-1.6
___ 07:20PM URINE HOURS-RANDOM
___ 07:20PM URINE HOURS-RANDOM
___ 07:20PM URINE UHOLD-HOLD
___ 07:20PM URINE GR HOLD-HOLD
___ 07:20PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:20PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 07:20PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 07:20PM URINE MUCOUS-RARE
___ 07:15PM GLUCOSE-363* UREA N-27* CREAT-1.2 SODIUM-129*
POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-19* ANION GAP-18
___ 07:15PM ALT(SGPT)-100* AST(SGOT)-101* ALK PHOS-460*
TOT BILI-0.6
___ 07:15PM LIPASE-7
___ 07:15PM ALBUMIN-3.8
___ 07:15PM WBC-12.8*# RBC-2.89* HGB-9.0* HCT-26.1*
MCV-90 MCH-31.1 MCHC-34.5 RDW-13.7 RDWSD-45.1
___ 07:15PM NEUTS-83* BANDS-5 LYMPHS-9* MONOS-0 EOS-0
BASOS-0 ___ METAS-2* MYELOS-1* AbsNeut-11.26* AbsLymp-1.15*
AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 07:15PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 07:15PM PLT SMR-LOW PLT COUNT-120*
CXR negative for PNA
US negative for acute process, cholecystitis.
Brief Hospital Course:
This is a ___ year old male with pancreatic cancer on long term
modified gemcitabine and NAB paclitaxel who is newly on Neulasta
for blood count support and is now admitted with asymptomatic
fever. Neulasta and gemcitabine both can cause fever, and he may
actually have had one with his last dose, but did not check it.
There are no localizing signs or symptoms. RUQ US this admission
showed no evidence of cholecystitis.
1. Fever: Likely related to gemcitabine and Neulasta. Received a
dose of ibuprofen 200 mg with good effect. Cultures, CXR, UA,
and RUQ US negative.
2. Pancreatic cancer: Treating with palliative intent with
gemcitabine plus NAB paclitaxel.
3. Diabetes: Sugars were actually low this admission, consistent
with a non-infectious etiology of his presentation.
4. Hypertension: Continue home Carvedilol 12.5 mg PO/NG BID
5. BPH: Continue home Tamsulosin 0.4 mg PO QHS
6. Hyponatremia: Likely dry from chemo fatigue and NPO. Improved
with fluids.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
2. Carvedilol 12.5 mg PO BID
3. Amlodipine 10 mg PO DAILY
4. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Carvedilol 12.5 mg PO BID
3. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
4. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Pancreatic cancer, chemotherapy induced fever
Secondary: Diabetes, hypertension, mitral stenosis
Discharge Condition:
VITAL SIGNS: 100.3 136/56 74 18 100% on RA
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2, III/VI low pitched holosystolic murmur at the
base - old per patient
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown, excoriation on the right
leg,
scar on the left second digit
NEURO: Nonfocal
Discharge Instructions:
Dear Mr. ___,
You were admitted for a asymptomatic fever. You are being
treated for pancreatic cancer with gemcitabine plus NAB
paclitaxel with the addition of filgrastim to prevent
infections. Gemcitabine and filgrastim can both cause fevers
that are not due to infection. Your blood tests, urine tests,
chest Xray, and abdominal ultrasound showed no evidence of
infection. Given this, the most likely explanation for your
fever is gemcitabine or filgrastim.
You can take low dose acetominophen or ibuprofen for fever as
long as you feel otherwise completely well.
Also, please stay well hydrated on chemotherapy and be sure to
eat regularly.
Followup Instructions:
___
|
10047172-DS-17 | 10,047,172 | 28,178,907 | DS | 17 | 2163-05-30 00:00:00 | 2163-06-06 15:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
sitagliptin / fesoterodine / Statins-Hmg-Coa Reductase
Inhibitors / saxagliptin / pioglitazone / canagliflozin /
fenofibrate
Attending: ___.
Chief Complaint:
anasarca
Major Surgical or Invasive Procedure:
therapeutic paracentesis with ___
History of Present Illness:
Professor ___ is a pleasant ___ w/ T2DM, HTN, DL and
pancreatic cancer metastatic to the liver (biopsy proven), dx
___, currently on C1D10 Gemcitabine and erlotinib, who p/w
leaking paracentesis site on his LLQ, increased abdominal
distention, increased b/l ___. His last paracentesis was ___,
and 3L removed. He denied any F/CP/SOB but found to have new
small b/l pleural effusions
Past Medical History:
ONCOLOGIC HISTORY:
Mr. ___ was diagnosed pancreatic adenocarcinoma metastatic to
the liver in ___ when he was admitted for painless
jaundice. CT showed 3.3cm pancreatic head mass and MRI
showed a 1.8cm left kidney lesion concerning for RCC as well as
2
sub-cm liver masses. FNA of pancreas showed 'suspicious' cells.
His pancreatic mass was deemed unresectable due to abutting the
SMV and portal vein. He was treated with three cycles of
FOLFIRINOX ___ which was halted due to rising CA
___
and increased size of liver metastases. In ___, CA
___ elevated to 23K and considered potentially related to left
finger infection in setting of diabetes. Imaging shows increased
size of liver metastases. In ___ he started
gemcitabine/Abraxane. Imaging ___ showing slight decrease
in
the size of the liver metastases with stable disease at the
pancreas. Course complicated by right thigh muscle infarct
presumed ___ diabetes in ___. Primary chemotherapy side
effect has been neuropathy on the bottoms of b/l feet without
impairment of ADLs. Has required multiple dose and schedule
adjustments in order to maximize quality of life, minimize
marrow
toxicity and maintain control over tumor (primarily assessed by
tumor marker). Imaging has showed mixed response in early ___:
given discordance with ___, unclear if true progression vs
variations due to reduced chemotherapy exposure at various time
points for various toxicity and scheduling reasons. In setting
of
increasing side effects and mixed response by imaging/markers,
changed to CapOx on ___ scans show a mixed response to treatment, regimen
changed to modified FOLFIRINOX
-___: Began modified FOLFIRINOX with dose reduction ___
IVP and Leucovorin held from regimen) (Per OMR, patient
previously given this regimine at ___ for 3 cycles ___ ago)
-___: CT scan showed progression of disease with an interval
increase in size of the innumerable hepatic masses, increased
abnormal soft tissue in the retroperitoneum, and
increasing ascites.
-___: Patient started on erlotinib with plan for C1D1 of
gemcitabine on ___.
-Admitted to ___ on ___ for hyperbilirubinemia, fevers,
n/v,
and acute urinary retention.
OTHER PAST MEDICAL HISTORY :
- T2DM
- Hypertension
- Hyperlipidemia
- s/p L hip replacement
- heart murmur
- s/p nose fracture
- kidney lesion determined to be 2.4cm hemmorhagic cyst on MRI
___
Social History:
___
Family History:
Mother: dementia
Father: bladder cancer at older age
Cancers in the family: paternal cousin with primary liver
cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: 97.8F 156/72 91 18 97% 158 lbs
General: NAD, Resting in bed comfortably, well nourished
HEENT: MM dry, + mild thrush along the mandible folds
CV: RR, NL S1S2 no ___ apical SEM
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, distended, dressing over LLQ saturated
LIMBS: WWP, 2+ pitting ___, no tremors
SKIN: No rashes on the extremities, port site looks well, skin
overlying left picc intact
NEURO: Grossly normal
DISCHARGE PHYSICAL EXAM:
VITAL SIGNS: 97.5 Axillary 140 / 70 92 19 95 RA
General: NAD, Resting in bed comfortably, evidence of wasting
though with distended abdomen
HEENT: MM dry, + mild thrush along the mandible folds
CV: RR, NL S1S2 no ___ apical SEM
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, notably distended, LLQ suture in place
LIMBS: WWP, 2+ pitting ___, no tremors
SKIN: No rashes on the extremities, port site looks well, skin
overlying left picc intact
NEURO: Grossly normal
Pertinent Results:
ADMISSION LABS
___ 12:08PM BLOOD WBC-2.4*# RBC-2.47* Hgb-8.0* Hct-23.6*
MCV-96 MCH-32.4* MCHC-33.9 RDW-19.1* RDWSD-65.4* Plt ___
___ 12:08PM BLOOD AbsNeut-1.57*#
___ 12:08PM BLOOD Plt ___
___ 09:35PM BLOOD Glucose-172* UreaN-35* Creat-1.1 Na-137
K-4.1 Cl-102 HCO3-23 AnGap-16
___ 09:35PM BLOOD ALT-38 AST-76* LD(LDH)-321* AlkPhos-949*
TotBili-1.4
___ 09:35PM BLOOD TotProt-6.1* Albumin-2.6* Globuln-3.5
___ 09:45PM BLOOD Lactate-2.7*
DISCHARGE LABS
___ 05:44AM BLOOD WBC-4.8 RBC-2.95* Hgb-9.2* Hct-27.7*
MCV-94 MCH-31.2 MCHC-33.2 RDW-19.1* RDWSD-62.6* Plt ___
___ 09:35PM BLOOD Neuts-63 Bands-1 ___ Monos-10 Eos-0
Baso-0 ___ Myelos-0 Hyperse-3* AbsNeut-3.42
AbsLymp-1.17* AbsMono-0.51 AbsEos-0.00* AbsBaso-0.00*
___ 09:35PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 05:44AM BLOOD Plt ___
___ 05:44AM BLOOD ___
___ 05:44AM BLOOD Glucose-156* UreaN-32* Creat-1.0 Na-136
K-4.1 Cl-102 HCO3-23 AnGap-15
___ 05:44AM BLOOD ALT-36 AST-74* LD(LDH)-305* AlkPhos-933*
TotBili-1.5
___ 05:44AM BLOOD Albumin-2.4* Calcium-7.8* Phos-3.1 Mg-1.9
IMAGING:
MRI Liver ___
Progression of disease with an interval increase in size of the
innumerable hepatic masses, increased abnormal soft tissue in
the
retroperitoneum, and increasing ascites. Additionally, the
primary pancreatic cancer in the pancreatic head is very
minimally increased in size.
CT CHEST w/ CON ___
New irregular nodule in the right upper lobe and interval
increase of the right lower lobe nodules concerning for
progressive metastatic disease.
ERCP ___
EUS was performed using a linear echoendoscope at ___ MHz
frequency
The head and uncinate pancreas were imaged from the duodenal
bulb and the second / third duodenum.
The body and tail [partially] were imaged from the gastric body
and fundus.
Mass: A 3.5 cm X 4 cm ill-defined mass was noted in the head of
the pancreas.
The mass was hypoechoic and heterogenous in echotexture.
The borders of the mass were irregular and poorly defined.
The mass is involving the confluence, especially the SMV with
narrowing of vessel diameter.
FNB was performed. Color doppler was used to determine an
avascular path for needle aspiration. A 22-gauge needle with a
stylet was used to perform biopsy.
Six needle passes were made into the mass.
Biopsies were sent for pathology.
Scan of the left hepatic lobe reveled multiple hypoechoic
lesions measured between 0.5-2cm, highly suspected for
metastatic
disease, FNB was performed from 3 different hepatic lesions
Otherwise normal upper eus to third part of the duodenum
CXR ___
1. Left PICC tip in the low SVC. No pneumothorax.
2. Small bilateral pleural effusions, new in the interval, with
bibasilar atelectasis.
Brief Hospital Course:
___ w/ T2DM, HTN, DL and pancreatic cancer metastatic to the
liver (biopsy proven), dx ___, currently on C1D10
Gemcitabine and erlotinib, recent biliary sepsis s/p
stent/completed abx
course for klebsiella bacteremia (last dose zosyn ___ who p/w
leaking paracentesis site on his LLQ and increased anasarca with
___ edema and new asymptomatic ___ pleural effusions, patient
is now s/p therapeutic paracentesis ___. He was seen by his
primary oncologist and will follow up with her on ___ and
will continue with 1000 mg xeloda bid X 14 days, 7 days off and
tarceva continuously once home delivery complete.
# Increased Anasarca
# Ascites
# Leaking Paracentesis site
Since ___, pt has gained 24 lbs. Likely multifactorial, but will
discuss w/ onc whether this maybe due to capillary leak syndrome
from gemcitabine. Other causes include pancreatic ca,
pseudocirrohsis from liver mets, protein calorie malnutrition,
iatrogenic fluid overload from TPN. INR and LFTs largely stable
w/o evidence of hepatic decompensation. He was started on lasix
on most recent admission.
- home amlodipine, lisinopril held while patient was admitted so
that diuretic regimen could be increased. started on 50mg daily
and 20mg Lasix daily. TPN was held for contribution to fluid
overload. Patient underwent ___ guided therapeutic para ___
# Pancreatic Ca
Diagnosed ___ stage 4, progressed on modified FOLFIRINOX, C1
Gemzar ___ received erlotinib. Dr ___ followed
through inpatient admission. Did not administer Gemcitabine
while inpatient. pt will follow up as outpatient for
Gemcitabine, dosing schedule per Dr. ___.
___ consider every other week dosing given significant fatigue,
weigh benefits and AEs of chemo.
Continued Ritalin and Ativan prn, continued creon 2 caps w/
break, 2 w/ lunch, 1 w/ dinner, 0 w/ snacks
# Gastric/Duodenal outlet obstruction
# Protein Calorie Malnutrition.
Per recent discharge note, he is not a candidate for duodenal
stent given high likelihood of migration. He was started on TPN.
SHould continue to evaluate contribution of TPN to fluid
overload. TPN held during hospitalization for diuresis.
# Thrombocytopenia
This is most likely due to his hepatic disease and splenomegaly,
as well as chemo. However there was c/f HIT on recent admission
but ruled out. avoided hsq for now until further clarified w/ Dr
___. continued TEDS
# Normocytic Anemia: due to inflammatory block from neoplasm and
antineoplastic therapy
# Recent Klebsiella bacteremia: completed treatment course with
Zosyn on ___.
# T2DM: At home takes metformin w/ Glargine 10U w/ breakfast and
ISS. Here will hold and keep only on ISS. Of note, he also has
insulin in his TPN.
# HTN: held amlodipine (which can cause ___ and lisinopril in
favor of lasix and aldactone
# Heart murmur: chronic x ___ years per his report
# BPH: cont tamsulosin bid.
TRANSITIONAL ISSUES
==================================
-home amlodipine 10 mg and lisinopril 5 mg daily held for BP
room as patient started on spironolactone 50 mg for increased
diuresis
-Please F/U BP, Cr and next apt; d/c weight 158 lbs; presumed
dry weight 136 lbs, d/c creatinine 1.0
-Patient advised to call PCP and oncologist regarding extreme
weight changes
-Left message for ___ TPN center to try to concentrate home
TPN to help reduce fluid overload
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amlodipine 10 mg PO DAILY
2. Creon ___ CAP PO TID W/MEALS
3. DULoxetine 30 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. MethylPHENIDATE (Ritalin) 20 mg PO DAILY:PRN fatigue,
decreased concentration
6. MethylPHENIDATE (Ritalin) 20 mg PO QAM
7. Pyridoxine 50 mg PO DAILY
8. Simethicone 80 mg PO TID:PRN gas
9. LORazepam 0.5 mg PO Q6H:PRN nausea or sleep
10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
11. Nystatin Oral Suspension 5 mL PO QID
12. Tamsulosin 0.4 mg PO BID
13. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Creon ___ CAP PO TID W/MEALS
2. DULoxetine 30 mg PO DAILY
3. LORazepam 0.5 mg PO Q6H:PRN nausea or sleep
4. MethylPHENIDATE (Ritalin) 20 mg PO DAILY:PRN fatigue,
decreased concentration
5. MethylPHENIDATE (Ritalin) 20 mg PO QAM
6. Nystatin Oral Suspension 5 mL PO QID
7. Pyridoxine 50 mg PO DAILY
8. Simethicone 80 mg PO TID:PRN gas
9. Tamsulosin 0.4 mg PO BID
10. Spironolactone 50 mg PO DAILY
RX *spironolactone [Aldactone] 50 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
11. Furosemide 20 mg PO DAILY
12. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
13. Erlotinib ___ mg PO DAILY
dosing per outpatient oncologist
14. Capecitabine 1000 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
pancreatic cancer
malignant ascites
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 continued leakage after
undergoing paracentesis. You had stitches placed to good effect
to stop the leaking. While in the hospital, you underwent
paracentesis with the interventional radiology team and your
diuretics were increased to add spironolactone 50mg daily on
top of your furosemide 20 mg daily to prevent fluid from
accumulating. You are now safe for discharge home with close
follow up.
We left a message with out TPN team to adjust and concentrate
your home TPN. You should also follow up with Dr. ___ in
___. You will continue your chemotherapy at home as planned
until you get home delivery of xeldoa (1000 mg twice a day for
two weeks on, then one week off) and Tarceva.
It was a pleasure caring for you - we wish you well!
Sincerely,
Your ___ Oncology Team
Followup Instructions:
___
|
10047297-DS-12 | 10,047,297 | 28,528,068 | DS | 12 | 2130-02-23 00:00:00 | 2130-02-23 10:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim DS / Purinethol / simvastatin / lovastatin
/ Pravastatin / Fosamax / Niaspan Extended-Release / Cholest Off
/ colestipol / citalopram
Attending: ___.
Chief Complaint:
weakness, AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
CC: weakness, ams
HPI(4):
___ female with moderate to severe dementia, on
treatment
for C. difficile, ulcerative colitis presents with presyncope,
altered mental status.
Per ED, patient had recurrence of diarrhea yesterday. Today she
was increasingly weak and fatigued, not acting as her normal
self. The family believes that she was sufficiently weak that
they believe that she was close to passing out. They report that
her mental status is improved at the time of evaluation. The
patient denies any active pain. Denies any fevers. Family denies
any history of cough, fevers, report of abdominal pain,
vomiting.
Per ED she is currently being treated for C Diff.
Per ED has PNA and UTI will treat with rocephin and azithro
Per nursing, patient presents after experiencing a near syncopal
episode earlier today. Patient is actively being treated for
cdiff with PO vanco. Per family, patient became drowsy and
"talking slow" and denies LOC. Denies hitting head/injury.
Denies
complaints. Reports decreased PO intake.
I reviewed VS, labs, orders, imaging, old records.
VSS, HR 90 on arrival, BP was 98/55, improved w/ IVF, RR 23 at
max, satting well.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
PROTHOMBIN GENE MUTATION
ARTHRITIS
SCIATICA
TOTAL ABDOMINAL HYSTERECTOMY
HEART MURMUR
IMPAIRED FASTING GLUCOSE
INSOMNIA
HYPERCHOLESTEROLEMIA
ALLERGIC RHINITIS
GASTROESOPHAGEAL REFLUX
HEART MURMUR
HYPERCHOLESTEROLEMIA
IMPAIRED FASTING GLUCOSE
OSTEOPENIA
PROTHOMBIN GENE MUTATION
ULCERATIVE COLITIS
OBESITY
DEMENTIA
Social History:
___
Family History:
FAMILY HISTORY:
Relative Status Age Problem Onset Comments
Mother ___ DEMENTIA
Father ___ LUNG CANCER smoker
Sister ___ LEUKEMIA
Brother Living ___
Brother Living ___
Son Living ___ PROTHROMBIN GENE
Son Living ___ DEEP VENOUS
THROMBOPHLEBITIS
PROTHROMBIN GENE
Physical Exam:
Admission Exam
===================================
EXAM(8)
VITALS: Afebrile and vital signs stable (see eFlowsheet)
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: soft, diffusely tender abdomen
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Discharge Exam
========================================
Pertinent Results:
ADMISSION LABS
=========================
___ 11:35PM BLOOD WBC-15.1* RBC-4.80 Hgb-12.9 Hct-40.2
MCV-84 MCH-26.9 MCHC-32.1 RDW-15.6* RDWSD-46.8* Plt ___
___ 11:35PM BLOOD Neuts-73.5* Lymphs-14.2* Monos-6.8
Eos-2.7 Baso-0.8 Im ___ AbsNeut-11.06*# AbsLymp-2.14
AbsMono-1.02* AbsEos-0.41 AbsBaso-0.12*
___ 11:35PM BLOOD Plt ___
___ 11:35PM BLOOD Glucose-84 UreaN-15 Creat-0.7 Na-143
K-3.3 Cl-103 HCO3-21* AnGap-19*
___ 11:35PM BLOOD ALT-16 AST-21 AlkPhos-77 TotBili-0.2
___ 10:20PM BLOOD Calcium-8.4 Phos-3.4 Mg-1.8
___ 05:55AM BLOOD calTIBC-216* Ferritn-204* TRF-166*
___ 10:43PM BLOOD ___ pO2-108* pCO2-34* pH-7.47*
calTCO2-25 Base XS-1
___ 09:28AM BLOOD Lactate-1.6
DISCHARGE LABS:
=========================
MICRO
=========================
UCx (___): ___ yeast
Stool Cx (___): negative
UCx (___): mixed flora
BCx (___): pending
STUDIES:
=========================
EKG (___)
NSR at 61 bpm, LAD, PR 116, QRS 88, QTC 458, TWI III (similar to
___
EKG (___):
NSR at 72 bpm, borderline LAD, PR 147, QRS 97, QTC 461, TWI
III/V3 (QTC increased from 433 in ___
CXR (___):
The patient is rotated, limiting evaluation however persisting
opacities in the right lower lung are likely not significantly
changed.
NCHCT (___):
Exam is limited by motion despite multiple attempted repeats.
Within this limitation, there is no acute intracranial process.
CXR (___):
Probable right lower lobe pneumonia.
Brief Hospital Course:
___ w/ dementia, UC (on prednisone/mesalamine), C. diff (on PO
vanco since ___ p/w diarrhea and presyncopal episode.
# Pre-syncopal episode:
# AMS:
# Possible UTI:
# Possible CAP:
The patient presented with confusion and a near syncopal
episode, likely in the setting of increased diarrhea and
hypovolemia secondary to undertreated C.diff (patient reportedly
non-adherent to PO Vancomycin). WBC initially 15.1, electrolytes
and lactate WNL. UA positive, although patient without clear
urinary symptoms and UCx with mixed flora (likely contaminated,
repeat with yeast). CXR with possible RLL pneumonia, but no
clear respiratory symptoms. NCHCT negative for intracerebral
hemorrhage. S/S evaluation showed no e/o aspiration. Legionella
Ag negative, Strep pneumo pending at discharge. BCx NGTD at
discharge. Received IVFs and was started on CTX/azithromycin
with resolution of leukocytosis and rapid return to baseline
mental status. On the night of ___ the patient was noted
to be difficult to arouse after receiving seroquel and ramelteon
for insomnia. Labs and VBG were reassuring, and the episode was
attributed to medication effect. She was again at baseline
mental status the following morning. Although suspicion for
infection was relatively low, given her initial leukocytosis and
rapid improvement on antibiotics (or perhaps despite
antibiotics), she was narrowed to cefpodoxime (PCN allergy and
prolonged QTC) and discharged to complete a 10d course
(___). She is being discharged to rehab for ___ and
additional support in the setting and acute infections.
# Diarrhea:
# C diff:
# Ulcerative colitis:
Patient presented with diarrhea in setting of recently diagnosed
C.diff and concern for PO Vancomycin non-adherence (husband was
reportedly not giving her the medication 4x/d). The GI service
was consulted and thought a UC flare less likely. Vancomycin was
re-initiated, with improvement in her diarrhea (only ___ loose
stools documented daily). Given likely non-adherence, her start
date for vancomycin should be considered ___ (not ___ when
originally prescribed), with duration of course to be determined
by outpatient GI (Dr. ___ but likely 2 weeks after completion
of antibiotics (through ___. The patient's home prednisone was
changed from 6mg alternating with 6.5mg to 6.5mg daily for ease
of administration per GI. Of note, the patient was often
unwilling to take mesalamine (didn't appear to have difficulty
swallowing capsules but would spit them out). This medication
was continued on discharge, but the patient's outpatient
gastroenterologist, Dr. ___, was notified that medication
adjustment may be necessary in the outpatient setting.
# Leukocytosis:
WBC 15.1 on admission. Improved with fluids, resumption of PO
Vancomycin, and antibiotics for possible PNA vs UTI. On ___
slightly uptrended to 12.4, without clear evidence of new
infection. ___ be secondary to known C.diff, for which she is
being treated. WBC 10.5 on discharge.
# Dementia:
# Sundowning:
Severe, likely fronto-temporal dementia at baseline (AOx1,
pleasant, conversant but largely nonsensical, dependent in most
ADLs). Per son, ___., patient is now back to baseline. Home
memantine was continued (although limited data in
fronto-temporal dementia). She frequently tried to get up
without nursing assistance and sundowned in the evenings.
Seroquel was trialed initially; in combination with ramelteon it
caused hypersomnolence. Given borderline prolonged QTC
(450s-460s), trazodone 25mg was trialed without effect. All
efforts should be made to minimize pharmacologic treatments if
possible. Should pharmacologic options be necessary, QTC should
be monitored closely. QTC at discharge was 480.
# Microcytic/normocytic anemia:
Hct 40.2 on admission, downtrended to 33 and 34.8 on discharge.
Ferritin 204, TIBC 216. No e/o active bleeding. Further w/u was
deferred to outpatient providers.
# Hypernatremia:
# Hypophosphatemia:
Intermittently mildly hypernatremia and hypophosphatemic, likely
due to poor PO intake. Phos was repleted and PO intake
encouraged (often required prompting to eat), with resolution of
both.
# Concern for inadequate home support:
The patient's dementia is significant enough that she needs 24
hour help, including with most ADLs. There was concern that her
husband (and primary caregiver) may suffer from some dementia
himself and is partly unwilling and partly unable to provide
necessary around-the-clock care. After a family meeting on ___,
the family agree to rehab placement and is considering
completion of a ___ application to have long-term care as
an option afterwards, which she will likely need. The patient's
husband is opposed to this plan but is not the HCP and cannot
care for her at home. The patient's HCP confirms that she
remains FULL CODE for now as they discuss as a family.
** TRANSITIONAL **
[ ] f/u BCx (pending at discharge)
[ ] f/u Strep pneumo Ag (pending at discharge)
[ ] check electrolytes, including Na, K, Phos on ______
[ ] monitor QTC if QTC prolonging medications resumed
[ ] cefpodoxime course ___
[ ] outpatient gastroenterologist (Dr. ___ to consider
alternatives to mesalamine if patient unwilling to take
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ketoconazole 2% 1 Appl TP BID:PRN rash
2. Memantine 10 mg PO BID
3. Mesalamine 800 mg PO 2 IN AM 3 AT NIGHT
4. PredniSONE 6.5 alternating with 6 mg PO DAILY
5. QUEtiapine Fumarate 50 mg PO QHS:PRN agitation
6. Sertraline 50 mg PO DAILY
7. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
8. Vancomycin Oral Liquid ___ mg PO Q6H
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
2. PredniSONE 6.5 mg PO DAILY
3. TraZODone 25 mg PO QHS:PRN insomnia
4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
5. Ketoconazole 2% 1 Appl TP BID:PRN rash
6. Memantine 10 mg PO BID
7. Mesalamine 800 mg PO 2 IN AM 3 AT NIGHT
8. Sertraline 50 mg PO DAILY
9. Vancomycin Oral Liquid ___ mg PO Q6H
10. HELD- QUEtiapine Fumarate 50 mg PO QHS:PRN agitation This
medication was held. Do not restart QUEtiapine Fumarate until
told to do so by your primary care doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pre-syncope
Clostridium difficile
Possible UTI
Possible CAP
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with confusion and a near
fainting episode, likely secondary to dehydration in the setting
of diarrhea. Infection was thought unlikely, but given some
evidence for a urinary tract infection you were started on
antibiotics, continued at discharge (cefpodoxime through ___.
Given the status of your heart, Seroquel is likely not the ___
medication for sleep. Please follow up with your primary care
doctor to consider alternatives, recognizing that there are no
good options available unfortunately.
You are being discharged to a rehab facility, where you will
have additional assistance with your medications and self care
while you recover your strength.
With ___ wishes,
___ Medicine
Followup Instructions:
___
|
10047484-DS-2 | 10,047,484 | 29,910,256 | DS | 2 | 2160-11-04 00:00:00 | 2160-11-04 21:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Demerol / Iodinated Contrast- Oral and IV Dye
Attending: ___.
Major Surgical or Invasive Procedure:
NGT placement ___
EGD ___ no interventions
NGT placement ___
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 04:15PM BLOOD WBC-11.4* RBC-5.01 Hgb-15.5 Hct-45.6
MCV-91 MCH-30.9 MCHC-34.0 RDW-13.2 RDWSD-43.2 Plt ___
___ 01:34AM BLOOD ___ PTT-22.8* ___
___ 04:15PM BLOOD Glucose-136* UreaN-14 Creat-0.9 Na-135
K-5.9* Cl-97 HCO3-19* AnGap-19*
___ 04:15PM BLOOD ALT-46* AST-60* AlkPhos-114 TotBili-0.5
___ 04:15PM BLOOD Albumin-4.5
___ 04:45AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.9
___ 04:40PM BLOOD Lactate-3.2* K-4.1
IMAGING:
===============
RUQ Ultrasound ___:
Echogenic liver consistent with steatosis. Other forms of liver
disease including steatohepatitis, hepatic fibrosis, or
cirrhosis cannot be excluded on the basis of this examination.
See recommendations below.
___ Ultrasound ___:
"IMPRESSION:
Acute deep venous thrombosis of the left common femoral,
femoral, popliteal and posterior tibial veins. Minimal flow in
the common femoral vein, but there is complete occlusion of the
remaining veins.
No right lower extremity deep venous thrombosis."
CXR ___:
"IMPRESSION:
No acute cardiopulmonary abnormality."
CT Abdomen without contrast ___:
"IMPRESSION:
1. Multiple, partially imaged small bowel loops, fluid-filled
and dilated to
approximately 3.2 cm, with a relatively decompressed terminal
ileum. These
findings can be seen in the setting of a gastroenteritis,
particularly given
the presence of fluid within the colon, but an ileus or partial
small-bowel
obstruction is not definitely excluded. Further assessment with
CT imaging of
the pelvis may be helpful for further evaluation.
2. Mild pneumobilia within the left hepatic lobe, which could
reflect prior
sphincterotomy and correlation with any history of endoscopy
recommended."
CXR ___:
"IMPRESSION:
The enteric tube extends below the level of diaphragm, with the
tip projecting
over the stomach."
CTA Chest ___:
IMPRESSION:
1. Acute, nonocclusive thrombus within the left pulmonary artery
that extends
distally to involve the left upper and lower lobe arteries and
several of
their proximal segmental branches. Several nonocclusive thrombi
are also seen
within the segmental branches of the right pulmonary artery.
2. No evidence of interventricular septal bowing to suggest
right heart
strain.
3. No evidence of parenchymal opacification to suggest pulmonary
infarct.
4. Mildly ectatic ascending thoracic aorta, measuring up to 4.1
cm in
diameter.
5. Moderate coronary atherosclerotic disease."
KUB for Colonic Transport ___:
"IMPRESSION:
Persistent small bowel obstruction."
KUB Portable ___:
"IMPRESSION:
1. Persistent partial small bowel obstruction as evidence by
progression of
the oral contrast into the colon.
2. Suggest advancing nasogastric tube 5 cm into the stomach."
TTE ___:
"IMPRESSION: Suboptimal image quality. Mild right ventricular
cavity dilation but with preserved free wall motion. Mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function. Mild aortic root dilation. Unable
to quantify pulmonary artery systolic pressure.
CLINICAL IMPLICATIONS: Based on the echocardiographic findings
and ___ ACC/AHA
recommendations, antibiotic prophylaxis is NOT recommended."
EGD ___:
"Normal mucosa in the whole esophagus. Normal mucosa in the
whole stomach. Normal mucosa in the whole examined duodenum.
Normal major papilla."
KUB ___:
IMPRESSION:
No evidence of obstruction.
CXR - line placement ___:
"IMPRESSION:
2 sequential images demonstrate advancement of an enteric tube
which
ultimately projects over the stomach."
CT A/P ___
IMPRESSION:
1. Uncomplicated mild acute diverticulitis involving a
diverticula along the
markedly redundant sigmoid colon in the right upper quadrant,
corresponding to
site of tenderness.
2. No evidence of bowel obstruction.
3. Mild left hepatic lobe pneumobilia, slightly increased since
previous
examination. Status post cholecystectomy.
KUB ___
1. Small stool burden within the colon.
2. No dilated loops of small or large bowel.
DISCHARGE LABS:
=================
___ 05:55AM BLOOD WBC-6.7 RBC-4.39* Hgb-13.4* Hct-40.8
MCV-93 MCH-30.5 MCHC-32.8 RDW-13.4 RDWSD-45.2 Plt ___
___ 05:55AM BLOOD Glucose-115* UreaN-9 Creat-0.8 Na-142
K-4.0 Cl-107 HCO3-21* AnGap-14
DISCHARGE PHYSICAL EXAM:
====================
24 HR Data (last updated ___ @ 631)
Temp: 97.7 (Tm 98.5), BP: 120/77 (119-148/73-84), HR: 72
(64-87), RR: 18 (___), O2 sat: 94% (94-98), O2 delivery: Ra
GENERAL: resting comfortably, NAD
HEENT: NCAT, PERRLA. R eye with medial conjunctival injection
and
watery tearing/discharge. No purulence. + rosacea
CARDIAC: RRR, normal S1 and S2. No m/r/g
LUNGS: CTAB, no w/r/r. No increased work of breathing.
ABDOMEN: + BS, distended, tympanic to percussion. No epigastric
tenderness to deep palpation
EXTREMITIES: 1+ LLE non-pitting edema, L>R. Mild pedal edema
bilaterally. Pulses DP/Radial 2+ bilaterally.
SKIN: Warm.
NEUROLOGIC: awake, alert and interactive. Moving all extremities
with purpose
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[] Medications STARTED: amox-clav 875mg PO Q8H, warfarin
[] Medications STOPPED: furosemide 40mg
[] GI
- Consider capsule study to evaluate potential etiology of pSBO
[] PCP:
- ___ dose warfarin as needed with a goal INR of ___, repeat
INR on ___. Patient discharged with 10 days of lovenox as well
as warfarin. Discharge INR 1.5 and warfarin dose on day of
discharge 6.5mg.
- Please follow-up resolution of abdominal pain from
diverticulitis with completion of 10 days amox-clav (last day
___
- Please refer to GI for follow-up with capsule study for UGIB
- Noted to have pneumobilia on imaging, EGD consistent with
prior sphincterotomy. If he develops RUQ pain, would have low
threshold to image to ensure pneumobilia is not source of the
pain
- Found to have echogenic liver consistent with steatosis,
consider fibroscan/MRE in the outpatient setting to r/o
cirrhosis/fibrosis
- Recommend outpatient therapy for rosacea
# CONTACT:
Health care proxy: ___
Relationship: Husband
Phone number: ___
Cell phone: ___
BRIEF HOSPITAL COURSE:
=======================
Mr. ___ is a ___ yo M with hx of bipolar disorder
and HTN who presented with bilateral leg swelling, dyspnea on
exertion, abdominal pain, nausea and coffee ground emesis found
to have acute PE, extensive LLE DVT and pSBO. He was bridged
initially with heparin, but transitioned to lovenox while
starting warfarin, which will be continued on discharge. In
regards to his pSBO, NGT was placed, which put out coffee ground
emesis. He was managed conservatively and improved with bowel
rest and transitioned to a regular diet. GI was consulted for
concern of UGIB and the patient underwent an EGD on ___, which
did not find a source of the upper GI bleed. He subsequently
developed recurrent abdominal distention with concern for SBO,
but CT demonstrated mild diverticulitis, which was treated with
amox-clav, which was continued on discharge. He was discharged
home and his PCP ___ manage his warfarin moving forward.
ACUTE ISSUES:
==============
# Acute PE
# Extensive LLE DVT
Patient presented with dyspnea on exertion and worsening leg
swelling over the past ___ weeks, found to have acute
nonocclusive thrombus within left PA extending distally to
involve the left upper and lower lobe arteries and several of
their proximal segmental branches. Several nonocclusive thromi
were also seen within segmental branches of right pulmonary
artery. Also found to have acute DVT of left common femoral,
popliteal, and posterior tibial veins with minimal flow in
common femoral vein but complete occlusion of remaining veins.
No clear provoking factor but patient does report more sedentary
lifestyle since his husband has been ill. He was treated with a
heparin gtt initially before starting a lovenox bridge to
warfarin. Of note, DOACs were not started due to ineraction with
his antipsychotic medications. His primary care physician ___
manage his anticoagulation in the outpatient setting. He is
being discharged with Lovenox bridge and warfarin 6.5mg daily
with script to have INR checked on ___.
# partial Small bowel obstruction: resolved
Presented with nausea and emesis found to have multiple,
partially imaged dilated, fluid filled small bowel loops to 3.2
cm with decompressed terminal ileum. Seen by ACS in ED who
placed an NGT. He was managed conservatively and SBO was
persistent on gastrograffin study but then resolved with KUB at
later point. He was maintained on mIVF while NPO. The partial
SBO resolved with bowel rest and he improved with time. He was
able to tolerate a regular diet prior to discharge, was passing
flatus, and having bowel movements. The etiology of the pSBO was
though to be from local inflammation in the setting of
diverticulitis as noted below.
# Mild diverticulitis:
In setting of recurrent abdominal distension and abdominal
discomfort there was initial concern for SBO recurrence. NG tube
was placed and ACS was reconsulted. Due to decreased NGT output,
CT was obtained and demonstrated acute, mild diverituclitis
without evidence of complications. He was started on amox-clav
due to ciprofloxacin interactions with his warfarin. His diet
was slowly advanced until he was tolerating a regular PO diet.
Prior to discharge he had a normal bowel movement. He is
discharged with total 10 day course of amoxicillin-clav with
last day ___.
# Coffee ground emesis: resolved
# Concern for UGIB
Patient with hx of GERD and ___ esophagus and noted
increasing abdominal discomfort over the last week. He reported
episode of black emesis and noted to have coffee ground emesis
from NGT in ED and ICU. was treated with IV PPI BID and his
hemoglobin remained stable. GI was consulted and the patient
underwent an EGD on ___ that did not find the source of the
bleeding. He should follow-up with GI as an outpatient to
consider capsule study.
# Acute hypoxemic respiratory failure - resolved
Patient with low level O2 requirement in ICU and transition to
floor which resolved with use of incentive spirometer. This was
likely secondary to PE vs. atelectasis from sedentary lifestyle.
# Pneumobilia: noted to have pneumobilia on CT imaging as an
inpatient and during EGD, per GI, he was noted to have a history
of spinchterotomy in the past, which can help to explain the
persistent pneumobilia. There was no further intervention
indicated.
# Irritant conjunctivitis: He was noted to have conjunctival
injection/conjunctivitis, likely irritant in setting of eyelash
given that patient notes history of prior episodes. He had no
purulent drainage, visual changes, eye pain or headaches, and
his irritant conjunctivitis improved prior to discharge.
# Rosacea:
Noted to have progression of his rosacea while inpatient. He
would benefit from additional outpatient therapy.
CHRONIC/STABLE ISSUES:
======================
# Hypothyroidism: Continued levothyroxine 88mcg daily
# Bipolar disorder: continued risperidone 1mg qhs, carbamazepine
100mg qAM, 200mg qPM, clonazepam 0.25mg BID, buspirone 30mg BID
# HTN: restarted home amlodipine
# Insomnia: continued melatonin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 88 mcg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Benzonatate 200 mg PO TID:PRN cough
4. Pantoprazole 40 mg PO Q12H
5. RisperiDONE 1 mg PO QHS
6. CarBAMazepine 100 mg PO QAM
7. CarBAMazepine 200 mg PO QPM
8. ClonazePAM 0.5 mg PO BID
9. BusPIRone 30 mg PO BID
10. Cyanocobalamin 1000 mcg PO DAILY
11. amLODIPine 5 mg PO DAILY
12. melatonin 10 mg oral QHS
13. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q8H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every eight (8) hours Disp #*13 Tablet Refills:*0
2. Enoxaparin (Treatment) 120 mg SC Q12H
RX *enoxaparin 120 mg/0.8 mL 120 mg IM twice a day Disp #*20
Syringe Refills:*0
3. Warfarin 6.5 mg PO DAILY16
Take daily until instructed to change dose by a doctor
4. amLODIPine 5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. BusPIRone 30 mg PO BID
7. CarBAMazepine 100 mg PO QAM
8. CarBAMazepine 200 mg PO QPM
9. ClonazePAM 0.5 mg PO BID
10. Cyanocobalamin 1000 mcg PO DAILY
11. Furosemide 40 mg PO DAILY
12. Levothyroxine Sodium 88 mcg PO DAILY
13. melatonin 10 mg oral QHS
14. Pantoprazole 40 mg PO Q12H
15. RisperiDONE 1 mg PO QHS
16.Outpatient Lab Work
ICD-9: 415.1
Please draw ___ on ___
Fax results to Dr. ___. FAX: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
====================
Acute pulmonary embolism
Acute deep venous thrombosis
Diverticulitis
SECONDARY DIAGNOSIS:
====================
partial small bowel obstruction
Acute hypoxemic respiratory failure
Concern for upper GI bleed, coffee ground emesis
Hypothyroidism
Bipolar disorder
Hypertension
Insomnia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for trouble breathing, abdominal pain, and
bloody vomit.
What was done for me while I was in the hospital?
- We found a blood clot in your leg and lungs.
- You were started on medications (warfarin and lovenox) to help
prevent further blood clots
- You underwent an endoscope to evaluate the cause of your
bloody vomit and you were started on a medication to help
prevent any more episodes of bloody vomiting.
- You had a tube placed in your nose to help relieve the
obstruction in your bowels
- You were started on antibiotics to help treat diverticulitis,
an infection of the bowel
What should I do when I leave the hospital?
-Please take all of your medications as prescribed. Please go to
all of your follow up appointments as scheduled.
-Please have blood work drawn on ___ at the ___ lab
(___) so your PCP can help adjust
your dose of blood thinner medication (warfarin).
-If you find you are not having a daily bowel movement, you may
try taking Miralax (polyethylene gycol) which is available over
the counter.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10048001-DS-10 | 10,048,001 | 20,362,822 | DS | 10 | 2182-05-06 00:00:00 | 2182-05-06 15:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with history of ___ disease c/b cirrhosis,
esophageal varices and recurrent episodes of cholangitis and VRE
bacteremia on suppressive medications presenting for low grade
fever and dyspnea.
Patient notes onset of dyspnea with dry cough on ___. Shortness
of breath present while lying down or sitting up. No chest pain,
pleuritic symptoms, lightheadedness/dizziness. No history of
asthma or COPD but feels like he has been wheezing. Notes low
grade fever 99.5 at home. Denies abdominal pain, chills,
diarrhea, blood in stool or black stools. Has been eating and
drinking well. No sick contacts.
Of note, patient was recently admitted with concern for upper GI
bleed form gastropathy with EGD only showing grade I varices and
acute cholangitis with Enterococcus bacteremia treated with
Daptomycin for 2 weeks. Patient had previously been on
suppressive antibiotics with levofloxacin and cefpodoxime since
___ without infections. Given recurrent resistant bacterial
infections and resistance profile of bacteria, prophylaxis
regimen was changed to 1 month of cefpodoxime alternating with 1
month of Augmentin at recent ID visit. He was started on
Augmentin on ___ at which point right arm PICC was also removed.
He has started Augmentin on ___ as well though has previously
taken this medication without issues.
In the ED initial vitals:
T 99.4 HR 82 BP 104/53 RR 20 100%RA -->94% 2L
- Exam notable for:
PULM: Mild end expiratory wheeze throughout, dry cough, no
accessory mm.
ABDOMINAL: Nontender, mildly distended, no rebound/guarding, no
peritonitic signs
- Labs notable for:
WBC 5.3
Hgb 11.3/35.3
Plt 43
137/100/17
-----------<112
4.0/23/1.2
ATL 23, AST 48 AP 133 Tbili 2.2 Alb 3.1
Lipase 19
Trop <0.01
Lactate 2.6
Flu negative
UA: negative
- Imaging notable for:
CXR:
Low lung volumes with bibasilar atelectasis.
abdominal U/s:
No tappable pocket on abdominal u/s
- Patient was given:
1L LR
On the floor, patient appears to be in acute respiratory
distress, sitting up at the side of the bed. Denies chest pain
but confirms history above with worsening shortness of breath
since ___. No recent travel or pain in the ___. Notes stable mild
generalized abdominal pain that remains stable without other
symptoms. Stat CTA obtained on the floor consistent with
bilateral PE.
REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS
reviewed and negative.
Past Medical History:
-___ Syndrome with recurrent cholangitis and bacteremia, most
recent from highly resistant E. coli treated with tigecycline
(finished late ___
-Cirrhosis
-Depression
-Osteopenia
-Seasonal allergies
-Inguinal hernia repair in ___
Social History:
___
Family History:
ther is alive with heart disease. Father died at ___ of
?cancer. No family history of liver disease or polycystic kidney
disease.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
T 98.6 BP 125/72 HR 92 RR 24 Sat 95% 3L NC
GENERAL: sitting up in acute respiratory distress with use of
accessory muscles, tripoding, able to complete full sentences,
coughing intermittently
HEENT: EOMI, PERRL, anicteric sclera, MMM
NECK: supple, no JVD
HEART: tachycardic, regular rhythm, no murmurs, gallops, or rubs
LUNGS: tachypneic, Diffuse wheezing bilaterally, no rhonchi or
crackles, otherwise as above
ABDOMEN: Mildly TTP diffusely, easily reducible umbilical
hernia,
+hepatomegaly, no rebound or peritoneal signs
EXTREMITIES: no ___ edema, no calf tenderness, Right upper
extremity without tenderness or swelling
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis
DISCHARGE PHYSICAL EXAM:
========================
GENERAL: laying in bed comfortably, does not appear in
respiratory distress. A&Ox3
HEENT: EOMI, PERRL, anicteric sclera, MMM
NECK: supple, no JVD
HEART: RRR
LUNGS: CTAB, breathing comfortably
ABDOMEN: Mildly distended but soft, nontender.
EXTREMITIES: no ___ edema, no calf tenderness, Right upper
extremity without tenderness or swelling. Bilateral upper
extremities appear symmetrical.
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis
Pertinent Results:
ADMISSION LABS:
===============
___ 08:54PM URINE HOURS-RANDOM
___ 08:54PM URINE UHOLD-HOLD
___ 08:54PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 08:54PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 07:50PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 06:39PM LACTATE-2.6*
___ 04:30PM GLUCOSE-112* UREA N-17 CREAT-1.2 SODIUM-137
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-23 ANION GAP-14
___ 04:30PM estGFR-Using this
___ 04:30PM ALT(SGPT)-23 AST(SGOT)-48* ALK PHOS-133* TOT
BILI-2.2*
___ 04:30PM LIPASE-19
___ 04:30PM cTropnT-<0.01 proBNP-906*
___ 04:30PM ALBUMIN-3.1*
___ 04:30PM WBC-5.3 RBC-3.63* HGB-11.3* HCT-35.3* MCV-97
MCH-31.1 MCHC-32.0 RDW-19.7* RDWSD-69.0*
___ 04:30PM NEUTS-77.7* LYMPHS-7.4* MONOS-11.4 EOS-2.3
BASOS-0.4 IM ___ AbsNeut-4.08 AbsLymp-0.39* AbsMono-0.60
AbsEos-0.12 AbsBaso-0.02
___ 04:30PM ___ PTT-31.1 ___
___ 04:30PM PLT COUNT-43*
PERTINENT STUDIES:
==================
___ Imaging CHEST (PA & LAT)
Low lung volumes with bibasilar atelectasis.
___ Imaging CTA CHEST
Large bilateral pulmonary emboli with evidence of right heart
strain. No signs of associated pulmonary infarct.
___ Imaging BILAT LOWER EXT VEINS
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
___ Imaging UNILAT UP EXT VEINS US
Nonocclusive thrombus within the right axillary vein and
proximal
to mid right basilic vein.
___ Imaging DUPLEX DOPP ABD/PEL
1. Heterogeneous hepatic parenchyma with patent paraumbilical
vein and retrograde flow of the right portal vein into the left
portal vein. No evidence of thrombosis.
2. Splenomegaly, measuring 19.6 cm, previously 18.5 cm.
___ Imaging CHEST (PORTABLE AP)
Mild pulmonary edema, new.
___ TTE
IMPRESSION: Preserved biventricular systolic function. Mild to
moderate tricuspid regurgitation. Mild mitral regurgitation.
Moderate to severe pulmonary hypertension. Very small
pericardial
effusion.
DISCHARGE LABS:
===============
___ 06:17AM BLOOD WBC-2.5* RBC-3.04* Hgb-9.5* Hct-29.7*
MCV-98 MCH-31.3 MCHC-32.0 RDW-20.5* RDWSD-73.1* Plt Ct-39*
___ 06:17AM BLOOD ___ PTT-36.2 ___
___ 06:17AM BLOOD Glucose-84 UreaN-15 Creat-1.1 Na-145
K-4.2 Cl-110* HCO3-22 AnGap-13
___ 06:17AM BLOOD ALT-19 AST-26 AlkPhos-108 TotBili-1.0
___ 06:17AM BLOOD Albumin-2.8* Calcium-8.8 Phos-3.4 Mg-1.6
Iron-31*
___ 06:17AM BLOOD calTIBC-203* Ferritn-95 TRF-156*
___ 05:52AM BLOOD CMV IgG-NEG CMV IgM-NEG CMVI-There is n
EBV IgG-POS* EBNA-POS* EBV IgM-NEG EBVI-Results in
Brief Hospital Course:
___ male with past medical history notable for Caroli
disease complicated by recurrent episodes of cholangitis and VRE
bacteremia on suppressive regimen, resultant cirrhosis with
esophageal varices and portal gastropathy, presented with low
grade fevers and dyspnea. Found on CTA to have acute bilateral
PE with signs of RV strain but otherwise hemodynamically stable.
Patient was anticoagulated first on heparin drip and then
transitioned to rivoraxaban.
TRANSITIONAL ISSUES:
====================
[ ] Please obtain repeat echocardiogram in ___ weeks to monitor
pulmonary artery pressures. TTE from this admission showed
estimated PA pressures were 52 mmHg likely from PE.
[ ] Pulmonary embolus presumed to be provoked in setting of PICC
associated DVT. Would reevaluate after 6 months of therapy if
anticoagulation needs to be continued indefinitely.
[ ] Patient's transferrin saturation was 15% (iron 31, calTIBC
203, ferritin 95, transferrin 156). Please consider outpatient
iron supplementation
ACUTE ISSUES:
============
#Hypoxia
#Acute Submassive PE
Patient presented with dyspnea and CTA ___ demonstrated acute
bilateral PE. Patient recently had PICC removed on ___ after
finishing IV daptomycin course for recent admission for
enterococcus bacteremia. Doppler of right upper extremity
demonstrating DVT, lower extremity dopplers negative. In this
setting, PE presumed to be provoked. Surface echocardiogram with
significant pulmonary hypertension with PA systolic pressure of
52mmHg. Cardiac biomarkers checked and BNP elevated to 900's.
Patient Initially required 2L NC for hypoxia and weaned to room
air at rest and ambulation by discharge. During admission,
patient was initially started on heparin drip and transitioned
to rivaroxaban for anticipated 6 month course of
anticoagulation.
#Fever
Fever to 101.3 noted on ___ in absence of other clinical
symptoms; was on suppressive daily augmentin at this time per
outpatient infectious disease for bacteremia. He was started on
vancomycin/cefepime. After 48 hours of negative cultures and
negative CXR and chest CT, patient was trialed off antibiotics
and was afebrile without any localizing symptoms. Fever presumed
to be in setting of clot burden.
___
Presented with creatinine to 1.2 from baseline 0.9; resolved by
discharge. Thought to be prerenal.
CHRONIC ISSUES:
=============
#___ Syndrome complicated by Cirrhosis
EGD in ___ demonstrated portal gastropathy and duodenal
ectasia (cauterized). Due to concern for possible bleeding while
on anticoagulation, home diuretics and beta blockade were held.
At discharge these were restarted
- Restarted nadolol 20mg qdaily at discharge
- Restarted furosemide 40mg qdaily and amiloride 10mg qdaily at
discharge.
# CODE: confirmed DNR/DNI
# CONTACT: Wife, ___, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. aMILoride 10 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Magnesium Oxide 400 mg PO DAILY
6. Nadolol 20 mg PO DAILY
7. Ursodiol 600 mg PO BID
8. Lactulose 30 mL PO Q2H
9. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
DAILY
10. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction
11. Loratadine 10 mg PO DAILY
12. Pantoprazole 40 mg PO Q24H
13. Sildenafil 50 mg PO DAILY:PRN sexual activity
14. rifAXIMin 550 mg PO BID
15. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath
2. Rivaroxaban 15 mg PO BID
3. aMILoride 10 mg PO DAILY
4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
5. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
DAILY
6. Citalopram 20 mg PO DAILY
7. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction
Duration: 1 Dose
8. Furosemide 40 mg PO DAILY
9. Lactulose 30 mL PO Q8H:PRN As needed to have ___ Bowel
Movements per day
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. Loratadine 10 mg PO DAILY
12. Magnesium Oxide 400 mg PO DAILY
13. Nadolol 20 mg PO DAILY
14. Pantoprazole 40 mg PO Q24H
15. rifAXIMin 550 mg PO BID
16. Sildenafil 50 mg PO DAILY:PRN sexual activity
17. Ursodiol 600 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
#Acute Pulmonary Embolism
SECONDARY DIAGNOSIS
___ disease complicated by recurrent episodes of cholangitis
and VRE bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for coming to ___ for your care. Please read the
following directions carefully:
Why was I admitted to the hospital?
-You were admitted to the hospital because were having
difficulty breathing
-We found that you had blood clots in your lungs
What was done for me while I was in the hospital?
-You were placed on blood thinners to prevent the blood clots
from getting worse
What do I need to do when I leave the hospital?
-Your primary care doctor can help arrange for short term
disability
-Please take your medications as listed below
-Please keep your appointments as below
We wish you the best with your care!
-Your ___ care team.
Followup Instructions:
___
|
10048001-DS-11 | 10,048,001 | 26,430,797 | DS | 11 | 2182-05-18 00:00:00 | 2182-05-18 16:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hypotension ugib
Major Surgical or Invasive Procedure:
EGD, colonoscopy ___
History of Present Illness:
___ with ___'s disease (communicating cavernous ectasia, or
congenital cystic dilatation of the intrahepatic biliary tree)
cirrhosis, recurrent cholangitis and sepsis, recent PE with RV
strain on anticoagulation now with hematemesis, fever, headache
after fall.
Pt was in his usual state of health until ___ (the day prior
to admission) morning, when he woke up around ___ to go to the
bathroom. He reports that his feet got tangled in the covers and
he tripped getting out of bed - falling, and hitting the left
side of his head on the wooden radiator cover. He had immediate
pain, but went to the bathroom and then went back to bed. Wife
reports that he slept more than usual on the day on ___.
___ evening, he felt feverish and reports taking his
temperature, which was ___. Went to bed and slept normally. The
morning of admission, he woke up and "felt weak." Carried a load
of laundry downstairs and put laundry in the washing machine, at
which point he became very nauseated. Dry heaved ___ times
before vomiting a moderate amount of dark red blood with small
clots. Shortly thereafter, he had a bowel movement, which he
reports was black and soft. Several hours later, he had bright
red blood per rectum. Called his PCP, who recommended that he
come in to be evaluated.
Of note, the patient was recently admitted on ___ for
confusion and melena - treated for hepatic encephalopathy; found
to have Enterococcus faecalis bacteremia and acute cholangitis.
Underwent MRCP without any specific changes in biliary ducts.
EGD showed portal hypertensive gastropathy with bleeding on
contact as well as small duodenal vascular ectasia that was
treated with APC. Completed two week course of daptomycin for
cholangitis and was started on Augmentin for suppressive
therapy. Patient had previously been on suppressive antibiotics
(alternating between levofloxacin and cefpodoxime) since ___
without infections. Given recurrent resistant bacterial
infections and resistance profile of bacteria, prophylaxis
regimen was changed to 1 month of cefpodoxime alternating with 1
month of Augmentin at recent ID visit. He was started on
Augmentin on ___ at which point right arm PICC was also removed.
He was again admitted on ___ for hypoxia and found to have an
acute submassive PE. At that time the patient recently had PICC
removed on ___ after finishing IV daptomycin course for recent
admission for enterococcus bacteremia. Doppler of right upper
extremity demonstrating DVT, lower extremity dopplers negative.
In this setting, PE presumed to be provoked. Discharged on
rivaroxaban for anticipated 6 month course of anticoagulation.
In the ED,
Initial Vitals:
T 97.5, HR 75, BP 90/48, RR1 8, O2 100%
Exam:
Unremarkable (including neuro exam), aside from guiaic positive
stool.
Labs:
CBC: WBC 8.8 Hgb 9.8, Hct 29.8 Plt 58,
LFT: ALT 59 ASt 140 AP 142 T bili 2.8 ALb 2.8
BMP Na 135 K 4.4 Cl 101 Bicarb 18 BUn 45 Cr 1.2
Lactate 3.7
Imaging:
*CXR: Low lung volumes with mild bibasilar atelectasis.
*Liver US:
1. Cirrhotic liver morphology with saccular intrahepatic biliary
ductal dilatation in the right hepatic lobe consistent with
patient's known ___'s syndrome. The portal veins are patent
with redemonstration of reversed flow in the right portal vein.
2. Sludge within a distended gallbladder without evidence of
acute
cholecystitis.
3. Redemonstration of marked splenomegaly and patent umbilical
vein.
*CT Head w/out contrast:
No acute intracranial abnormality. No acute fracture.
Consults:
Hepatology: no need for urgent scope, admit for monitoring and
management of GI bleed
Interventions:
-Patient had 2 PIV placed, he recieved 1 U PRBC and 1 L fluid
-Patient recieved 1 gram CTX IV, octreotide IV and pantoprazole
40mg IV
VS Prior to Transfer: HR 66, BP 88/51, RR 20, SpO2 97% 2L NC
On arrival to the MICU, he reports feeling "okay." Wants to know
when he'll be able to eat. He denies lightheadedness, dizziness,
shortness of breath, chest pain, abd pain, nausea. Had one
episode of BRBPR in ED, but none since and no further vomiting.
Past Medical History:
-___ Syndrome with recurrent cholangitis and bacteremia, most
recent from highly resistant E. coli treated with tigecycline
(finished late ___
-Cirrhosis
-Depression
-Osteopenia
-Seasonal allergies
-Inguinal hernia repair in ___
Social History:
___
Family History:
Mother has heart disease. Father died at age ___ from cancer and
there is no other liver disease in his family that is known.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: BP 96/60, HR 73, RR 26, SpO2 95%/RA
GEN: tired-appearing man, sitting up in bed, NAD
HEENT: mildly icteric sclera, PERRL. OP clear, dry MM.
NECK: supple, no LAD.
CV: RRR, S1+S2, no M/R/G
RESP: CTAB, no W/R/C
GI: non-distended, soft, non-tender
MSK: WWP, no edema
SKIN: bronzed skin, no skin lesions or breakdown
NEURO: alert, oriented. No asterixis.
PSYCH: pleasant, euthymic
DISCHARGE PHYSICAL EXAM:
=======================
VITALS: 24 HR Data (last updated ___ @ 1212)
Temp: 97.9 (Tm 98.2), BP: 115/70 (99-122/61-75), HR: 80
(78-90), RR: 18, O2 sat: 95% (92-96), O2 delivery: Ra, Wt:
218.69
lb/99.2 kg
GENERAL: Alert and interactive, in no acute distress.
HEENT: Sclera anicteric and without injection. Moist mucous
membranes
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
Pertinent Results:
ADMISSION LABS:
====================
___ 02:56PM WBC-8.8 RBC-3.13* HGB-9.8* HCT-29.8* MCV-95
MCH-31.3 MCHC-32.9 RDW-19.2* RDWSD-67.0*
___ 02:56PM ___ PTT-39.3* ___
___ 02:56PM ALT(SGPT)-59* AST(SGOT)-140* ALK PHOS-142*
TOT BILI-2.8*
___ 02:56PM LIPASE-17
___ 02:56PM ALBUMIN-2.8* CALCIUM-8.4 PHOSPHATE-2.1*
MAGNESIUM-1.9
___ 02:56PM GLUCOSE-128* UREA N-45* CREAT-1.2 SODIUM-135
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-18* ANION GAP-16
___ 03:10PM LACTATE-3.7*
RELEVANT IMAGING:
====================
___ EGD: portal hypertensive gastropathy, 3 grade I varices
___ ___: internal hemorrhoids without stigmata of bleeding
___ CT head w/o con: no acute intracranial process
___ TTE:
CONCLUSION:
The left atrial volume index is SEVERELY increased. The right
atrium is mildly enlarged. There is no evidence for an atrial
septal defect by 2D/color Doppler. The right atrial pressure
could not be estimated. There is mild symmetric left ventricular
hypertrophy with a normal cavity size. There is normal regional
and global left ventricular systolic function. Quantitative
biplane left ventricular ejection fraction is 75 % (normal
54-73%). There is no resting left ventricular outflow tract
gradient. Tissue Doppler suggests a normal left ventricular
filling pressure (PCWP less than 12mmHg). Mildly dilated right
ventricular cavity with normal free
wall motion. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch
diameter is normal. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. There is trace
aortic regurgitation. The mitral valve leaflets are mildly
thickened with no mitral valve prolapse. There is trivial mitral
regurgitation. The pulmonic valve leaflets are normal. The
tricuspid valve leaflets appear structurally normal. There is
mild [1+] tricuspid regurgitation. There is moderate to severe
pulmonary artery systolic hypertension. There is no pericardial
effusion. Compared with the prior TTE (images reviewed) of
___ , right ventricle is now dilated. Estimated pulmonary
artery pressures are similar. Trivial aortic regurgitation is
present.
DISCHARGE LABS:
=================
___ 06:34AM BLOOD WBC-2.5* RBC-2.99* Hgb-9.3* Hct-29.4*
MCV-98 MCH-31.1 MCHC-31.6* RDW-19.9* RDWSD-71.3* Plt Ct-50*
___ 06:34AM BLOOD ___ PTT-34.1 ___
___:34AM BLOOD Glucose-90 UreaN-15 Creat-0.9 Na-143
K-4.3 Cl-109* HCO3-20* AnGap-14
___ 06:34AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.6
MICRO:
======
___ 6:08 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 3:05 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
Brief Hospital Course:
PATIENT SUMMARY:
====================
___ with ___'s disease (communicating cavernous ectasia,
orcongenital cystic dilatation of the intrahepatic biliary tree)
cirrhosis, recurrent cholangitis and sepsis, recent PE with RV
strain on rivaroxaban, who presented with hematemesis, fever,
and headache after fall. He remained hemodynamically stable
while in house, with stable hemoglobin levels. His
anticoagulation was switched to Lovenox (from rivaroxaban).
TRANSITIONAL ISSUES:
====================
#GI Bleed
#Acute Blood Loss Anemia:
[] H/H check on ___: no active bleeding identified on
___ this admission, f/u H/H after starting lovenox for PE
treatment on ___.
#Cirrhosis
[] Electrolyte check on ___: Lasix restarted at
discharge, f/u K Mg Cr.
[] F/u BP: home nadolol held in setting of GI bleed and
hypotension, restarted nadolol for esophageal varices at
discharge. BP 110s-120s/70s on day of discharge.
#PE:
[] AC switched to Lovenox, to be continued through ___,
then discontinued.
[] Consider TTE after completion of anticoagulation course, as
RV was newly dilated on TTE ___.
#CODE STATUS: DNR/DNI - if there was a treatable/fixable problem
that would require temporary intubation, patient would be okay
with intubation in that setting.
#EMERGENCY CONTACT: Wife, ___, ___
ACTIVE/ACUTE ISSUES:
====================
# GI bleed
# GAVE
# Hypotension
Patient presented with hematemesis x1, melena x1, BRBPR x2 -
consistent with either very brisk UGIB or both UGIB and LGIB.
Initially intermittently hypotensive in the ICU, blood pressure
responsive to IV albumin and blood transfusions. Suspect that
his hypotension was secondary to initial blood loss in
combination with vasoplegia from underlying liver disease.
Hemoglobin remained stable throughout admission and EGD and
colonoscopy showed no identifiable source of bleeding, only
showed his baseline GAVE. No other acute findings. Source of the
GI bleed could be a small bowel source/AVMs vs. GAVE associated
oozing. He was treated with IV pantoprazole 40mg BID, octreotide
drip x72 hours, and ceftriaxone prophylaxis in setting of acute
bleed (___). Transitioned back to home PPI at discharge.
# ___
Baseline creatinine 0.9-1.2. Creatinine initially at baseline,
but increased to 1.8 in setting of hypotension and bleed. Most
likely pre-renal injury, resolved after volume resuscitation.
# Coagulopathy
Has some degree of coagulopathy at baseline in setting of
cirrhosis, but presented with INR 4.9. Unknown etiology of this
elevation, could have been mild elevation from rivaroxaban in
combination with recent daptomycin and Augmentin causing some
vitamin K malabsorption. Received IV vitamin K 10mg in the ED
with normalization of INR.
# PE
# Catheter associated UE DVT
Patient diagnosed with upper extremity DVT and submassive PE in
___. Planned for six months of anticoagulation for provoked
thrombosis (through mid ___. Had been on rivaroxaban BID
(loading dose) as an outpatient prior to admission. Rivaroxaban
held during this admission in setting of GI bleed. After
negative EGD/colonoscopy, patient was started on heparin gtt
with stable Hgb. Vascular medicine was consulted for assistance
with ongoing management of AC, recommended avoiding DOACs. He
was transitioned from heparin gtt to lovenox BID (more rapid
reversal than warfarin in event of recurrent bleeding) on ___.
___ TTE demonstrated dilated R ventricle, similar pulmonary
artery pressures to most recent TTE on ___, no evidence of R
heart failure.
# Transaminitis
Mild transaminitis, likely due to hypotension. Improving at time
of discharge.
# Fall
Sounds mechanical in nature, per patient. No bleeding prior to
fall, does not sound syncopal. CT head with no evidence of
intracranial pathology or skull trauma. ___ was consulted, felt
that there were no acute ___ needs.
# ___ syndrome
# Cirrhosis
# Thrombocytopenia
Childs class B cirrhosis; MELD-Na 31 on admission (largely
driven by INR). History of hepatic encephalopathy, although none
this admission. ___ EGD with one cord grade I varices,
gastropathy, duodenal vascular ectasia status post APC, history
of esophageal banding. EGD this admission with 3 cords of grade
I varices in distal esophagus, nonbleeding, and portal
hypertensive gastropathy. No tappable ascites pocket in the ED,
no history of SBP. Continued home lactulose. Held nadolol and
furosemide given recent GIB, restarted at time of discharge.
CHRONIC ISSUES:
====================
# History of recurrent cholangitis
Recurrent episodes of cholangitis due to biliary ductal dilation
from ___'s disease. US on admission without evidence of
cholangitis. History of CRE. Continued prophylactic Augmentin
850mg BID, ursodiol 600 mg BID.
# Depression: continued citalopram 20mg daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. aMILoride 10 mg PO DAILY
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
3. Citalopram 20 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Loratadine 10 mg PO DAILY
7. Nadolol 20 mg PO DAILY
8. Ursodiol 600 mg PO BID
9. rifAXIMin 550 mg PO BID
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath
11. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
DAILY
12. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction
13. Lactulose 30 mL PO Q8H:PRN As needed to have ___ Bowel
Movements per day
14. Magnesium Oxide 400 mg PO DAILY
15. Pantoprazole 40 mg PO Q24H
16. Sildenafil 50 mg PO DAILY:PRN sexual activity
17. Rivaroxaban 15 mg PO BID
Discharge Medications:
1. Acyclovir 400 mg PO Q8H Duration: 5 Days
RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp
#*9 Tablet Refills:*0
2. Enoxaparin Sodium 100 mg SC Q12H
RX *enoxaparin 100 mg/mL 1 ml SC every twelve (12) hours Disp
#*60 Syringe Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath
4. aMILoride 10 mg PO DAILY
5. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
6. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
DAILY
7. Citalopram 20 mg PO DAILY
8. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction
Duration: 1 Dose
9. Furosemide 40 mg PO DAILY
10. Lactulose 30 mL PO Q8H:PRN As needed to have ___ Bowel
Movements per day
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. Loratadine 10 mg PO DAILY
13. Magnesium Oxide 400 mg PO DAILY
14. Nadolol 20 mg PO DAILY
15. Pantoprazole 40 mg PO Q24H
16. Sildenafil 50 mg PO DAILY:PRN sexual activity
17. Ursodiol 600 mg PO BID
18.Outpatient Lab Work
ICD-___
Please check CBC and chem ___
Fax results to Dr. ___ at ___
and Dr. ___ at ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
GI Bleed
Secondary:
___ disease
Childs class B cirrhosis
Pulmonary embolism
Catheter-associated upper extremity DVT
Coagulopathy
Thrombocytopenia
___
Fall
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 being a part of your care at ___!
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had a fall at
home, fever, headache, and had blood in vomit and stool.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- You were found to have very low blood pressure. You were
admitted to the ICU and given medications and blood transfusions
to support your blood pressure and replace blood loss.
- You were given medication to stop the bleeding.
- You had an EGD and colonoscopy which did not identify any
active sites of bleeding.
- Your blood counts were monitored and remained stable.
- Your home medication rivaroxaban was discontinued and you were
started on enoxaparin (lovenox) to treat your pulmonary embolism
and deep vein thrombosis (blood clots).
WHAT SHOULD YOU DO WHEN YOU LEAVE?
- You should get blood work checked on ___.
- You should follow up with your PCP, ___, and Infectious
Disease doctors in outpatient ___ as listed below.
- Please seek medical attention immediately if you feel
dizzy/lightheaded, notice bloody or black stools, or have any
other symptoms that concern you.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10048001-DS-12 | 10,048,001 | 22,128,147 | DS | 12 | 2182-06-06 00:00:00 | 2182-06-06 17:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
Midline placed ___
History of Present Illness:
___ M with PMH ___'s disease (communicating cavernous
ectasia, or congenital cystic dilatation of the intrahepatic
biliary tree) cirrhosis, recurrent cholangitis and sepsis,
recent
PE with RV strain on lovenox who presents with dyspnea on
exertion and dry cough.
Patient reports symptoms began on ___. He reports dyspnea
with
walking around living room. He reports SOB improved with
seating.
He reports exacerbation of dry cough with lying flat but does
not
have worsening shortness of breath with lying flat. Patient
reports that SOB worsened with walking to bathroom overnight.
He denies fevers, chills, chest pain, productive cough,
palpitations, lightheadedness. He denies blood in stool or black
stool.
- In the ED, initial vitals were:
T 98.9 HR 86 BP 100/59 RR 22 SPO2 99% RA
- Exam was notable for: JVP elevated to the mandible at 45
degrees, with HJR. Ext warm with 2+ pitting edema. No crackles
appreciated
- Labs were notable for:
136 | 103 | 23
-------------- 188 AGap=13
3.9 | 20 | 1.2
WBC 4.4 HGB 10.3 PLT 40
___: 16.0 PTT: 46.9 INR: 1.5
LFTs not elevated. Tbili: 2.4
Lactate 3.2 to 2.3
proBNP: 775
Trop-T: <0.01
UA wnl
- Studies were notable for:
- CTA chest : improvement in pulmonary arterial thrombus
burden,
with persistent though small nonocclusive thrombus seen within
the distal left main pulmonary artery and basal segmental
branches. No substantial clot burden in the right pulmonary
artery. Persistent dilatation of the left main pulmonary artery
to 2.8 cm, otherwise no CT evidence of right heart strain. No
evidence of underlying pulmonary infarction.
- The patient was given:
Furosemide 40 mg, Ipratropium-Albuterol Neb 1 NEB
On arrival to the floor, the patient reports dyspnea on exertion
but no positional component with orthopnea or platypnea. No
subjective fevers/chills, abdominal pain, n/v/d, blood in the
stool, confusion. Reports his weight at home has been stable at
205 lb.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
-___ Syndrome with recurrent cholangitis and bacteremia, most
recent from highly resistant E. coli treated with tigecycline
(finished late ___
-Cirrhosis
-Depression
-Osteopenia
-Seasonal allergies
-Inguinal hernia repair in ___
Social History:
___
Family History:
Mother has heart disease. Father died at age ___ from cancer and
there is no other liver disease in his family that is known.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 103.0 BP 99 / 62 HR 91 RR 18 SpO2 96
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: JVP to jaw at 45 degrees
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: No rhonchi or rales. No increased work of breathing.
expiratory wheezing noted bilaterally
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, mildly distended but no notable
fluid wave, non-tender to deep palpation in all four quadrants.
No ___ sign
EXTREMITIES: No clubbing, cyanosis. 1+ edema in b/l calves.
Pulses DP/Radial 2+ bilaterally. wwp
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. no
asterixis.
able to recite days of week backwards
DISCHARGE EXAM:
===============
PHYSICAL EXAM:
==============
24 HR Data (last updated ___ @ 707)
Temp: 97.6 (Tm 98.7), BP: 109/72 (96-109/60-72), HR: 69
(64-92), RR: 17 (___), O2 sat: 95% (95-97), O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
CARDIAC: RRR no m/r/g
LUNGS: Bilateral wheezing
ABDOMEN: Soft, NT, ND, +BS
Pertinent Results:
ADMISSION LABS:
===============
___ 01:40PM BLOOD WBC-4.4 RBC-3.27* Hgb-10.3* Hct-31.5*
MCV-96 MCH-31.5 MCHC-32.7 RDW-18.9* RDWSD-67.6* Plt Ct-40*
___ 01:40PM BLOOD Neuts-77.4* Lymphs-7.8* Monos-13.9*
Eos-0.2* Baso-0.2 Im ___ AbsNeut-3.39 AbsLymp-0.34*
AbsMono-0.61 AbsEos-0.01* AbsBaso-0.01
___ 01:40PM BLOOD ___ PTT-46.9* ___
___ 01:40PM BLOOD Glucose-188* UreaN-23* Creat-1.2 Na-136
K-3.9 Cl-103 HCO3-20* AnGap-13
___ 01:40PM BLOOD ALT-17 AST-34 AlkPhos-97 TotBili-2.4*
___ 01:40PM BLOOD proBNP-775*
___:40PM BLOOD Albumin-3.3* Calcium-8.6 Phos-1.5* Mg-1.6
___ 01:40PM BLOOD Lactate-3.2*
IMAGING:
========
___ Imaging CHEST (PA & LAT)
IMPRESSION:
No interval change in cardiac silhouette size, no evidence of
substantial
pulmonary vascular congestion or pulmonary edema. Overall
slight improvement in lung aeration bilaterally. No focal
consolidation.
___ Imaging CTA CHEST
IMPRESSION:
Overall improvement in pulmonary arterial thrombus burden, with
persistent
though smaller nonocclusive thrombus seen within the distal left
main
pulmonary artery and basal segmental branches. No substantial
clot burden in the right pulmonary artery. Persistent
dilatation of the left main pulmonary artery to 2.8 cm,
otherwise no CT evidence of right heart strain. No evidence of
underlying pulmonary infarction.
___ Imaging US ABD LIMIT, SINGLE OR
FINDINGS:
Targeted grayscale ultrasound images were obtained of the 4
quadrants of the abdomen, revealing no ascites.
IMPRESSION:
No ascites.
___ Cardiovascular Transthoracic Echo Report
CONCLUSION:
The left atrial volume index is normal. The right atrium is
moderately enlarged. 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. There is normal regional and global left
ventricular systolic function. Quantitative biplane left
ventricular ejection fraction is 74 % (normal 54-73%). There is
no resting left ventricular outflow tract
gradient. Diastolic function could not be assessed. 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 normal ascending aorta
diameter for gender. The aortic arch diameter is normal with a
normal descending aorta diameter. There is no evidence for an
aortic arch coarctation. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. There is no
aortic regurgitation. The mitral valve leaflets are mildly
thickened with no mitral valve prolapse. There is trivial mitral
regurgitation. The pulmonic valve leaflets are normal. The
tricuspid valve leaflets appear structurally normal. There is
mild [1+] tricuspid
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. Compared with
the prior TTE (images reviewed) of ___ , the estimated
pulmonary artery systolic
pressure is now lower. The right ventricular cavity size is
smaller.
___ Imaging MRCP (MR ABD ___
IMPRESSION:
1. Cirrhosis with findings of portal hypertension, including
marked
splenomegaly and perigastric varices. Saccular dilatation of
the intrahepatic bile ducts involving the right hepatic lobe,
similar to prior exams, compatible with known ___'s syndrome.
No suspicious hepatic lesion. No evidence of active cholangitis.
DISCHARGE LABS:
===============
___ 07:00AM BLOOD WBC-2.4* RBC-2.93* Hgb-9.2* Hct-28.5*
MCV-97 MCH-31.4 MCHC-32.3 RDW-18.4* RDWSD-66.0* Plt Ct-56*
___ 07:00AM BLOOD Glucose-88 UreaN-13 Creat-1.0 Na-144
K-3.9 Cl-107 HCO3-23 AnGap-14
___ 07:00AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.5*
Brief Hospital Course:
___ M with PMH ___'s disease (communicating cavernous
ectasia, or congenital cystic dilatation of the intrahepatic
biliary tree) cirrhosis, recurrent cholangitis and sepsis,
recent
PE with RV strain on lovenox who presents with dyspnea/ cough
found to have fever to 103 with blood cultures growing
enterococcus.
TRANSITIONAL ISSUES:
====================
[ ] Please continue your IV antibiotics until ___
[ ] Please follow-up with your physicians as scheduled
[ ] Please reach out to your infectious disease doctor about
restarting your prophylactic antibiotics once you finish your IV
course.
[ ] Follow-up platelet levels and consider decreasing enoxaparin
dose.
ACUTE/ACTIVE ISSUES:
====================
# Fever
# History of recurrent MDR cholangitis
Fever to 103 upon arrival to floor. No localized sx except
cough, SOB but with recurrent episodes of cholangitis due to
biliary ductal dilation from Caroli's disease. History of MDR
infections with VRE bacteremia and Carbapenem resistant E. coli.
Alternates suppressive augmentin with cefpodoxime at home. MRCP
showed no evidence of cholangitis and was unrevealing for a
cause, thus it was felt that the source of the bacteremia was
transient gut translocation. Blood cultures returned positive
for enterococcous. He was initially treated with
Dapto/Cefepime/flagyl and then transitioned to zosyn for a ___, end date ___.
# Dyspnea on Exertion
# Pulmonary Hypertension
Patient presenting with DOE/dry cough with JVP elevation, ___
edema without e/o of pulm edema on exam or CXR overall
concerning
for R heart failure. Known RV strain iso PE with PASP 50,
however
patient on AC with lovenox and CTPE with improved clot burden.
TTE showed improvement in right heart strain. Symptoms improved
with diuresis.
# ___ syndrome
# Cirrhosis
# Thrombocytopenia
Childs class B cirrhosis; MELD-Na 31 on admission (largely
driven
by INR). History of hepatic encephalopathy on lactulose, varices
on Nadolol. No hx of ascites but on Lasix. EGD last admission
___ with 3 cords of grade I varices in distal esophagus,
nonbleeding, and portal hypertensive gastropathy. His home
furosemide and nadolol were initially held in the setting of
infection but were restarted prior to discharge.
# Lactic acidosis
Lactic 3.2 downtrended to 2.3 in ED without fluid. Concern for
infection given fever and hx of recurrent cholangitis. Improved.
CHRONIC/STABLE ISSUES:
======================
# Depression:
Continued home citalopram 20mg daily
> 30 minutes spent on discharge activities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath
2. aMILoride 10 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Lactulose 30 mL PO Q8H:PRN As needed to have ___ Bowel
Movements per day
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Loratadine 10 mg PO DAILY
7. Ursodiol 600 mg PO BID
8. Sildenafil 50 mg PO DAILY:PRN sexual activity
9. Nadolol 20 mg PO DAILY
10. Magnesium Oxide 400 mg PO DAILY
11. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction
12. Pantoprazole 40 mg PO Q24H
13. Enoxaparin Sodium 100 mg SC Q12H
14. Furosemide 40 mg PO DAILY
15. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
DAILY
16. Cefpodoxime Proxetil 200 mg PO Q12H
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth q8hr Disp #*12 Tablet
Refills:*0
2. Piperacillin-Tazobactam 4.5 g IV Q8H
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of breath
4. aMILoride 10 mg PO DAILY
5. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
DAILY
6. Citalopram 20 mg PO DAILY
7. Enoxaparin Sodium 100 mg SC Q12H
8. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction
Duration: 1 Dose
9. Furosemide 40 mg PO DAILY
10. Lactulose 30 mL PO Q8H:PRN As needed to have ___ Bowel
Movements per day
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. Loratadine 10 mg PO DAILY
13. Magnesium Oxide 400 mg PO DAILY
14. Nadolol 20 mg PO DAILY
15. Pantoprazole 40 mg PO Q24H
16. Sildenafil 50 mg PO DAILY:PRN sexual activity
17. Ursodiol 600 mg PO BID
18. HELD- Cefpodoxime Proxetil 200 mg PO Q12H This medication
was held. Do not restart Cefpodoxime Proxetil until you speak
with your infectious disease doctor.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Enterococcus Bactermia
Volume Overload
Secondary Diagnoses:
Caroli syndrome
Cirrhosis
Thrombocytopenia
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 because you had a fever and
we were worried tat you had an infection due to your liver
disease.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While you were in the hospital we did some imaging which
showed you did not have an infection in your biliary system.
- Some blood tests showed that you had bacteria in your blood.
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:
___
|
10048001-DS-13 | 10,048,001 | 28,243,528 | DS | 13 | 2182-09-28 00:00:00 | 2182-09-28 15:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___ syndrome complicated by gram positive bacteremia
Major Surgical or Invasive Procedure:
TEE ___: No discrete vegetation or abscess seen. Mild mitral
regurgitation.
History of Present Illness:
___ yo M PMHx ___'s disease c/b cirrhosis with hx varices, HE,
recurrent cholangitis and E. faecalis bacteremia, recent PE with
RV strain on LMWH presented to ED with fevers that started
___
night and dry cough that started on ___ found to have GPCs
in blood.
The patient reports a 2 day history of fevers at home as well as
a dry cough that started ___. He otherwise reports some
mild
nausea and chronic diarrhea ___ lactulose but otherwise no
abdominal pain, chest pain, vomiting, headache, black/bloody
stools. He takes suppressive Augmentin since his last infection
in ___ and reports no missed doses.
The patient has multiple hospitalizations for bacteremia and
cholangitis, most recently in ___. He is on chronic
suppression with Augmentin. He has also been hospitalized
recently in ___ for a submassive PE ___ PICC-associated
DVT,
originally started on apixaban but had hematemesis, BRBPR,
hypotension requiring a MICU admission. Now on Lovenox. He has a
history of CRE E. Coli in ___ and reportedly VRE bacteremia per
documentation review although not in ___ records. His recent
E.
faecalis species have been pan-sensitive. Regarding his
cirrhosis, he has a history of HE on lactulose and grade I
varices on nadolol as of his most recent EGD in ___. No
clear
history of ascites although he does take amiloride and
furosemide
as home medications.
In the ED:
- Initial vital signs were notable for: Temp 98.4, HR 81, BP
136/74, RR 16 satting 99% on RA
Past Medical History:
-___ Syndrome with recurrent cholangitis and bacteremia, most
recent from highly resistant E. coli treated with tigecycline
(finished late ___
-Cirrhosis
-Depression
-Osteopenia
-Seasonal allergies
-Inguinal hernia repair in ___
Social History:
___
Family History:
Mother has heart disease. Father died at age ___ from cancer and
there is no other liver disease in his family that is known.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___ @ 1835)
Temp: 100.2 (Tm 100.2), BP: 116/67, HR: 95, RR: 18, O2 sat:
95%, O2 delivery: RA
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. EOMI. Sclera anicteric.
ENT: MMM. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Mild wheezes throughout. No rhonchi or rales. No
increased
work of breathing.
ABDOMEN: Soft, Non-distended, non-tender to deep palpation in
all four quadrants. No organomegaly.
MSK: No CVA tenderness. No clubbing, cyanosis, or edema. Pulses
DP/Radial 3+ bounding bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: AOx3. CN2-12 grossly intact. Able to say days of
the
week backwards. No asterixis.
PSYCH: appropriate mood and affect
DISCHARGE PHYSICAL EXAM:
==============
24 HR Data (last updated ___ @ 741)
Temp: 98.2 (Tm 99.3), BP: 128/79 (118-129/72-79), HR: 93
(91-99),
RR: 20 (___), O2 sat: 94% (93-95), O2 delivery: Ra, Wt: 218.3
lb/99.02 kg
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. Sclera anicteric.
ENT: MMM. JVP elevated
CARDIAC: Regular rhythm, normal rate.
RESP: decreased breath sounds on R side. No increased work of
breathing.
ABDOMEN: Soft, Non-distended, non-tender to deep palpation in
all
four quadrants. +umbilical hernia
MSK: No CVA tenderness. Trace peripheral edema.
SKIN: Warm. No rash.
NEUROLOGIC: AOx3. moving all extremities.
Pertinent Results:
ADMISSION LABS:
===================
___ 12:52PM BLOOD WBC-2.4* RBC-3.30* Hgb-9.3* Hct-30.4*
MCV-92 MCH-28.2 MCHC-30.6* RDW-17.3* RDWSD-58.5* Plt Ct-60*
___ 12:52PM BLOOD Neuts-69.5 Lymphs-13.2* Monos-15.7*
Eos-0.8* Baso-0.4 Im ___ AbsNeut-1.68 AbsLymp-0.32*
AbsMono-0.38 AbsEos-0.02* AbsBaso-0.01
___ 02:37PM BLOOD ___ PTT-41.2* ___
___ 12:52PM BLOOD Glucose-135* UreaN-16 Creat-1.0 Na-138
K-4.7 Cl-106 HCO3-20* AnGap-12
___ 07:49AM BLOOD ALT-14 AST-20 AlkPhos-149* TotBili-0.5
DirBili-0.2 IndBili-0.3
___ 12:52PM BLOOD Albumin-3.5 Calcium-8.7 Phos-2.4* Mg-1.9
___ 07:36AM BLOOD CRP-101.7*
___ 01:20PM BLOOD Lactate-1.5
DISCHARGE LABS:
==================
___ 06:06AM BLOOD WBC-2.3* RBC-2.82* Hgb-7.9* Hct-25.9*
MCV-92 MCH-28.0 MCHC-30.5* RDW-17.5* RDWSD-58.8* Plt Ct-49*
___ 06:06AM BLOOD Neuts-70.6 Lymphs-17.1* Monos-10.1
Eos-0.9* Baso-0.4 Im ___ AbsNeut-1.61 AbsLymp-0.39*
AbsMono-0.23 AbsEos-0.02* AbsBaso-0.01
___ 06:06AM BLOOD Glucose-97 UreaN-11 Creat-0.8 Na-145
K-4.3 Cl-111* HCO3-24 AnGap-10
___ 06:06AM BLOOD ALT-14 AST-20 AlkPhos-142* TotBili-0.6
___ 06:06AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.7
MICROBIOLOGY DATA:
======================
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
Daptomycin MIC OF 2 MCG/ML test result performed by
Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ <=0.5 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by ___ ___ AT
8:40AM.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
___ 11:14 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECIUM.
Identification and susceptibility testing performed on
culture #
___ ___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
___ 11:14 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECIUM.
Identification and susceptibility testing performed on
culture #
___ ___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
TTE
CONCLUSION:
There is no spontaneous echo contrast or thrombus in the body of
the left atrium/left atrial appendage.
The left atrial appendage ejection velocity is normal. No
spontaneous echo contrast or thrombus is seen
in the body of the right atrium/right atrial appendage. There is
no evidence for an atrial septal defect by
2D/color Doppler. Overall left ventricular systolic function is
normal. The right ventricle has normal free
wall motion. There are no aortic arch atheroma with no atheroma
in the descending aorta to 30 cm from
the incisors. The aortic valve leaflets (3) are mildly
thickened. No masses or vegetations are seen on the
aortic valve. No abscess is seen. There is trace aortic
regurgitation. The mitral valve leaflets appear
structurally normal with no mitral valve prolapse. No masses or
vegetations are seen on the mitral valve.
No abscess is seen. There is mild [1+] mitral regurgitation. The
tricuspid valve leaflets appear
structurally normal. No mass/vegetation are seen on the
tricuspid valve. No abscess is seen. There is
trivial tricuspid regurgitation. There is no pericardial
effusion.
IMPRESSION: No discrete vegetation or abscess seen. Mild mitral
regurgitation.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
====================
___ yo M PMHx Caroli's disease c/b cirrhosis with hx varices, HE,
recurrent cholangitis and E. faecalis bacteremia, recent PE with
RV strain on LMWH admitted for fevers that started ___ night
and dry cough, found to have ampicillin-resistant enterococcus.
He was treated with IV Vanc 1000mg q12 hours.
TRANSITIONAL ISSUES:
==================
[ ] TTE showing mod-severe pulm hypertension (PAp 58; given
concern for this contributing to DOE, was referred to cardiology
to follow up outpatient. TTE will need to be repeated in future
[ ] Midline placed for IV abx for gram positive bacteremia, will
be followed by ___ Infectious Disease clinic, with projected
end date ___. Will get weekly lab work for this.
[ ] ___ at ___ will
be the Primary Care Physician to write scripts for outpatient IV
abx.
HEPATOLOGY:
[ ] Diuretics (Amiloride and Lasix) held on discharge given
active infection, will restart after checking with Dr. ___
(___).
[ ] Will plan to start Rifaxamin after IV daptomycin course for
chronic suppressive therapy with Caroli Syndrome. Will need to
follow up regarding insurance coverage past the end of this
year.
[ ] Stopped prophylactic Bactrim given he developed bacteremia
on this. Will plan to use Rifaxamin as suppressive therapy after
course of IV abx.
ACUTE ISSUES:
=============
#Ampicillin-resistant enterococcus
#History of Cholangitis
Given the patient's history of recurrent cholangitis and E.
faecalis bacteremia, and now again with enterococcus in blood,
there was high suspicion for biliary source. Of note,
enterococcus was previously ampicillin sensitive, but grew
ampicillin resistant this admission. Bacteremia occurred while
on suppressive Amox/clav. TEE was performed and showed no
evidence of endocarditis. He was changed from IV vancomycin (D1:
___ to IV Daptomycin due to medication-induced neutropenia,
and was discharged on IV dapto to be followed by ___ clinic
with projected end date ___.
#Cirrhosis
#___'s disease
___ A. Meld-Na 11. Well-compensated when not actively
infected.
- VARICES: EGD ___ with grade I varices in distal esophagus.
Also PHGP noted in stomach. History of banded varices per
patient. Will hold home nadolol for now given risk for
decompensation iso bacteremia.
- ASCITES: No ascites noted on RUQUS. Patient reports never
requiring a paracentesis. Held home diuretics despite evidence
of volume overload in setting of infection. Will continue to
hold until following up with Dr. ___.
- HE: Continued home lactulose.
- Continued ursodiol
#Pulmonary embolism
History of PE with RV strain ___. Unable to tolerate DOAC due
to bleeding. Switched to Lovenox which he is tolerating well. No
chest pain, shortness of breath, hypoxia, or e/o bleeding.
- Continued home LMWH 100 mg SC BID
#Dry cough
#Dyspnea upon exertion
#Pulmonary HTN
Patient is asymptomatic and not hypoxic or platypneic to suggest
hepatopulmonary syndrome. No ascites for hepatic hydrothorax.
CXR
in ED unremarkable. Most recent ECHO with PASP 34 mmHg. TTE this
admission with higher pulmonary artery pressure, which may
explain DOE. Received duonebs PRN, will need to follow up with
cardiologist.
#Depression:
Continued citalopram 20 mg daily
#GERD
Continued home pantoprazole
#Glaucoma
Continued home latanoprost
#CODE: Full code (confirmed)
#CONTACT: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 100 mg SC Q12H
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
3. Ursodiol 600 mg PO BID
4. Nadolol 20 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Magnesium Oxide 400 mg PO DAILY
7. Citalopram 20 mg PO DAILY
8. aMILoride 5 mg PO DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Furosemide 40 mg PO DAILY
11. Lactulose 30 mL PO Q8H:PRN encephalopathy
Discharge Medications:
1. Daptomycin 600 mg IV Q24H
2. Heparin Flush (10 units/ml) 2 mL IV X1 PRN For Midline
Insertion
3. aMILoride 5 mg PO DAILY
4. Citalopram 20 mg PO DAILY
5. Enoxaparin Sodium 100 mg SC Q12H
6. Furosemide 40 mg PO DAILY
7. Lactulose 30 mL PO Q8H:PRN encephalopathy
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Magnesium Oxide 400 mg PO DAILY
10. Nadolol 20 mg PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Ursodiol 600 mg PO BID
13.Outpatient Lab Work
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
DAPTOMYCIN: WEEKLY: CBC with differential, BUN, Cr, CPK
ICD9: 790.7 Bacteremia
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMRARY DIAGNOSIS:
=================
Ampicillin-resistant enterococcus bacteremia
SECONDARY DIAGNOSIS:
===================
Cirrhosis secondary to Caroli's Syndrome
History of Pulmonary embolism
Thrombocytopenia secondary to cirrhosis
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 in the hospital because you were having fevers.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were diagnosed with bacteremia, or bacteria in your blood.
- You were started on IV antibiotics.
- You got imaging studies of your heart to rule out
endocarditis(infection or inflammation of your heart valves)
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.
-You will need to follow up with Infectious Disease doctors in
___, but should take your IV daptomycin until ___.
After you finish this course, resume taking the oral medication
called Rifaxamin for suppression of infection.
- We are holding your diuretics (Amiloride and Lasix) on
discharge because you have an active infection and it could make
your blood pressure too low. Check with Dr. ___ resuming
these.
- Weigh yourself daily, and if your weight increases more than 3
lbs in 2 days or 5 lbs in 1 week, call Dr. ___ as you may need
to restart antibiotics.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10048001-DS-4 | 10,048,001 | 28,426,278 | DS | 4 | 2175-02-13 00:00:00 | 2175-02-14 10:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever, pain
Major Surgical or Invasive Procedure:
ERCP with stent placement
History of Present Illness:
___ h/o cirrhosis ___ Caroli syndrome, who presents to our ED as
a transfer from OSH, w/ recent fever to 104, cough, dyspnea,
diffuse abdominal pain, general malaise, headache. Patient has
had a fever since ___ (five days ago). Fever has been
variable, going up and down over the past few days. Saw PCP
recently and was treated with a course of Tamiflu for suspected
influenza. Since starting tamiflu has had diarrhea, with ___
BMs yesterday. Has had no appetite for a week. Very poor PO
intake. Today went to outside hospital ED, was ill-appearing
with multiple laboratory abnormalities including
thrombocytopenia to 18, acute renal failure, and they were
initially concerned for DIC. At OSH, received solumedrol (due to
meningitis in ddx given his headache), CTX 2 g, vanc, Zosyn,
acyclovir. BP stable en route here, received 4L IVF en route to
___ ED.
In the ED inital vitals were: 97.8 111 116/76 24 96% 4L
Pt received 4 L NS in total between OSH and here as of ___.
-pCXR: limited AP w/ poor insp effort, but no obvious
infiltrates.
-Labs in ED: ARF, elevated LFTs/bili, tcp, no schistocytes,
INCREASED fibrinogen.
-ABG: pH7.40 pCO2 22 pO2 95 HCO3 14 primary anion gap metabolic
acidosis
-Foley: 800 cc UOP
-R IJ, sterile, placed in ER, OK to use
-scvO2: 80
-Discussed plan w/ ERCP: given h/o Caroli, high suspicion for
cholangitis until proven otherwise, agree w/ non-con CT, though
will be limited. please re-page if becomes more unstable, e.g.
starting pressors, or if remarkable results on CT. will plan for
ERCP first in AM, if crashing, can do ICU ERCP o/n.
-CT torso: cirrhotic liver w/ large cysts c/w ___'s disease
characterized on ___ MR; splenomegaly, patent umbilical vein,
and small amt of ascites; R lung base atelectasis; can't r/o
superimposed infection.
- unlikely to be DIC, given no schistocytes, not decreased
fibrinogen. his markedly worsened tcp is likely due to sepsis,
on top of liver disease
-VS on transfer: T 98.7 BP 132/75 HR 73 pOx 98 4L
On arrival to the ICU, patient's initial vital signs were 97.9
96 ___ 96% 4L CVP 5. Patient awake, alert, conversant,
in pain and in moderate respiratory distress. Family at
bedside.
Review of systems:
(+) Per HPI
(-) Denies sinus tenderness, rhinorrhea or congestion. Denies
chest pain, chest pressure, palpitations. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
___ Syndrome
Cirrhosis
Inguinal hernia repair in ___.
NKDA
Social History:
___
Family History:
He denies any history of kidney or liver disease in the family.
No colitis in the family. His father died with "tumors" that
ruptured. He does not know what type of cancer they were. His
father was also diagnosed with diabetes right before he died.
His
mother has coronary artery disease and is ___. Two brothers with
hip replacements and back problems.
Physical Exam:
Admission Physical Exam:
97.9 96 ___ 96% 4L CVP 5
General: Alert, oriented
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD, no tenderness to
palpation of neck. negative Kernig and Brudzinski. FROM of
neck.
Lungs: Pt using some accessory muscles for breathing, rare
crackles scattered
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mildly protuberant, umbilical herniation,
hepatomegaly with 3cm liver palpable, no splenomegaly
appreciated on exam, tenderness to palpation diffusely, mild
guarding, no overt peritoneal signs, negative ___ sign
GU: foley in place
Skin: no spider angiomas appreciated; no bruising or rash
Ext: warm, well perfused, 2+ distal pedal pulses, no clubbing,
cyanosis or edema
Neuro: PERRL, EOMI, strength of upper and lower extremities
intact
Pertinent Results:
___ 09:00PM BLOOD WBC-10.7# RBC-3.91* Hgb-13.2* Hct-37.2*
MCV-95 MCH-33.8* MCHC-35.5* RDW-14.9 Plt Ct-31*#
___ 09:00PM BLOOD Neuts-70 Bands-6* Lymphs-4* Monos-15*
Eos-0 Baso-0 ___ Metas-3* Myelos-1* Promyel-1* Other-0
___ 03:36AM BLOOD WBC-8.8 RBC-3.59* Hgb-11.6* Hct-34.1*
MCV-95 MCH-32.3* MCHC-34.0 RDW-15.1 Plt Ct-23*
___ 03:36AM BLOOD Neuts-87* Bands-2 Lymphs-4* Monos-6 Eos-0
Baso-0 ___ Metas-1* Myelos-0
___ 05:53AM BLOOD WBC-8.1 RBC-3.49* Hgb-11.2* Hct-32.8*
MCV-94 MCH-32.2* MCHC-34.2 RDW-15.4 Plt Ct-35*
___ 04:22AM BLOOD Neuts-89* Bands-0 Lymphs-4* Monos-5 Eos-0
Baso-0 Atyps-1* Metas-1* Myelos-0 NRBC-1*
___ 04:22AM BLOOD WBC-14.0* RBC-3.97* Hgb-12.9* Hct-38.1*
MCV-96 MCH-32.6* MCHC-34.0 RDW-15.3 Plt Ct-57*
___ 04:00AM BLOOD Neuts-92* Bands-0 Lymphs-6* Monos-2 Eos-0
Baso-0 ___ Myelos-0
___ 03:38AM BLOOD WBC-16.0* RBC-3.58* Hgb-11.7* Hct-33.4*
MCV-93 MCH-32.6* MCHC-34.9 RDW-15.4 Plt Ct-50*
___ 04:00AM BLOOD WBC-17.5* RBC-3.57* Hgb-11.7* Hct-33.7*
MCV-94 MCH-32.7* MCHC-34.6 RDW-15.4 Plt Ct-59*
___ 09:00PM BLOOD ___ PTT-30.8 ___
___ 04:00AM BLOOD ___ PTT-33.3 ___
___ 09:08PM BLOOD ___
___ 09:00PM BLOOD Glucose-192* UreaN-119* Creat-4.1*#
Na-137 K-3.6 Cl-105 HCO3-15* AnGap-21*
___ 05:45PM BLOOD Glucose-179* UreaN-82* Creat-1.9* Na-142
K-4.0 Cl-114* HCO3-17* AnGap-15
___ 04:00AM BLOOD Glucose-118* UreaN-39* Creat-1.0 Na-140
K-4.0 Cl-112* HCO3-19* AnGap-13
___ 09:00PM BLOOD ALT-189* AST-128* LD(___)-340*
AlkPhos-119 TotBili-3.6* DirBili-3.2* IndBili-0.4
___ 03:36AM BLOOD ALT-156* AST-104* LD(___)-322*
AlkPhos-107 TotBili-3.0*
___ 05:53AM BLOOD ALT-131* AST-79* LD(___)-283*
AlkPhos-131* TotBili-2.3*
___ 04:22AM BLOOD ALT-135* AST-86* AlkPhos-188*
TotBili-2.4*
___ 03:38AM BLOOD ALT-136* AST-113* LD(___)-308*
AlkPhos-222* TotBili-3.5*
___ 04:00AM BLOOD ALT-122* AST-85* LD(___)-321*
AlkPhos-260* TotBili-3.6*
___ 09:00PM BLOOD Lipase-40
___ 05:53AM BLOOD Lipase-79*
___ 09:00PM BLOOD Albumin-2.8* Calcium-7.4* Phos-2.8 Mg-2.2
UricAcd-7.9*
___ 03:38AM BLOOD Hapto-67
___ 09:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:06PM BLOOD ___ pO2-108* pCO2-22* pH-7.39
calTCO2-14* Base XS--9 Comment-GREEN TOP
___ 08:57PM BLOOD Type-MIX pO2-72* pCO2-33* pH-7.35
calTCO2-19* Base XS--6 Comment-GREEN TOP
___ 09:06PM BLOOD Lactate-2.6*
___ 02:35PM BLOOD Lactate-1.5
OSH and ED Labs
pH 7.40 pCO2 22 pO2 95 HCO3 ___
Fibrinogen 768
Na 137 K 3.6 Cl 105 Bicarb 15 Bun 119 Cr 4.1 Gluc 192
Ca 7.4 Mg 2.2 P2.8
Serum Tox Neg
ALT: 189 AP: 119 Tbili: 3.6 Alb: 2.8
AST: 128 LDH: 340 Dbili: 3.2 Lip: 40
UricA:7.9
___: 15.0 PTT: 30.8 INR: 1.4
WBC 10.7 Hct 37.2 Hgb 13.2 Plt 31
N:79 Band:0 ___ M:15 E:0 Bas:0 Promyel: 1 Other: 1
UA: 1.011 pH 5.5 Bact MOD WBC 7 RBC 11 Prt 30 Blood Sm
MICRO:
Direct Influenza Antigen (___): Negative
Bloood Culture (___): NGTD
Urine Culture (___): No growth
___ 10:41 am STOOL CONSISTENCY: LOOSE Source:
Stool.
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Pending):
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___:
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
___ 4:18 pm THROAT FOR STREP
R/O Beta Strep Group A (Pending):
Images:
CT Torso w/out contrast (___):
1. cirrhotic liver w/ large cysts c/w Caroli's disease
characterized on ___ MR.
2. splenomegaly, patent umbilical vein, and small amt of
ascites.
3. R lung base atelectasis; can't r/o superimposed infection.
CXR (___): R IJ in place in the cavo-atrial junction
CXR (___): The lung volumes are low with pronounced elevation of
the right hemidiaphragm with bibasilar atelectasis, likely worse
on the right than the left. There is no pneumothorax. The heart
is of normal size.
CXR (___): FINDINGS: In comparison with the study of ___, the
right IJ line has been removed. Again they are extremely low
lung volumes with atelectatic changes at the bases. No evidence
of congestive failure or acute pneumonia on this quite limited
study.
CXR (___): Lung volumes are quite low. The right lung base is
particularly elevated, most likely due to right upper quadrant
mass effect or fluid and/or right subpulmonic pleural effusion.
Heart is mildly enlarged. Mediastinal veins are engorged, but I
doubt that there is pulmonary edema. No pneumothorax.
CXR (___): The current study continues to redemonstrate low
lung volumes. There is no evidence of pneumothorax. There is
minimal amount of pleural effusion demonstrated. The lungs are
essentially clear with no definitive evidence of new
consolidation to suggest aspiration process.
RUQ U/S (___): 1. Distended gallbladder, also seen on the
___ examination. No gallbladder wall thickening.
Pericholecystic fluid and mild ascites.
2. No sonographic ___ sign.
3. If there is continued concern for cholecystitis, a HIDA scan
can be
obtained for further evaluation.
HIDA (___): Heterogenous tracer uptake into the hepatic
parenchyma and minimal amount of tracer excretion in the small
bowel signifies underlying liver disease or obstruction. The
findings are compatible with cholestasis. Given the poor
excretion, the biliary system cannot be evaluated.
EKG: sinus tachycardia at 101bpm; TWI III. nl axis. EKG
unchanged from ___
MCRP ___:
1. No MR evidence for a hepatic abscess.
2. The two cystic lesions in the superior aspect of the right
lobe of the liver which previously homogenously hyperintense on
T2-weighted images now contain air indicative of continuity with
the biliary tree given the recent ERCP.
3. The distended gallbladder contains gas, suggesting that air
can travel from through the sphincterotomy and biliary tree. The
gallbladder is unchanged in appearance since a prior study of
___.
4. Splenomegaly, increased since the prior study.
5. Moderate ascites.
.
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___:
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Brief Hospital Course:
___ h/o cirrhosis ___ ___ syndrome who presented with fever,
cough, diffuse abdominal pain, concerning for cholangitis. Pt
initially admitted to ___ and had ERCP with stent placement on
___.
# Cholangitis:
Initially, Pt presented with fever to 104, WBC 10.7 (no bands),
upper quadrant abdominal pain. Considering abdominal pain and
hx of Caroli disease, most likely source is cholangitis.
Outside hospital cultures growing Rauoltella Planticola (an
enteric GNR previously in the klebsiella family) that is
pan-sensitive. Flu negative. s/p ERCP w/ stent placement on day
of admission. Patient with increasing WBC since ___. No
evidence of infection on CXR. UA negative. Patient did have
one day of diarrhea, but was c. diff negative. HIDA scan unable
to give any other definitive answer. MRCP performed on ___ to
evaluate for intrahepatic abscess, which pts can be predisposed
to with Carolis disease, was negative for abcess. No fevers
since ___. Patient was continued on Meropenem, and
transitioned to oral regimen of Cipro/flagyl per ID
recommendations once afebrile for 3 days.
.
# Blepharitis: HSV possibly from immunocomprimise from sepsis.
Per optho, no eye involvement. Pt received Bacitracin/Polymyxin
B Sulfate Opht drops. Continue Acyclovir 400mg q8hrs x10 days.
Continue artificial tears.
.
# Acute Renal Failure: Resolved from peak Cr of 4 now to Cr 1.0.
Likely prerenal in addition to poor nutrition. Pt was fluid
resuscitated and Cr resolved. Pt has had good urine output.
.
# Cirrhosis ___ ___ Disease: Pt with increased bilirubin
during stay, discussed with Dr. ___, and thought
to be secondary to infection and cholestasis. Pt was restarted
on ursodiol while treating underlying infection. He also
developed ascites with ___ edema after aggressive hydration in
the FICU. He was started on diuretics with good response and
will continue on current doses to be followed by Dr ___
week.
.
# Thrombocytopenia: Platelets initially 31K from most recent
measurement of 86 in ___ on admission. Likely secondary to
sepsis (marrow suppression) in the setting of underlying splenic
sequestration ___ cirrhosis. Trended up appropiately, >100 on
discharge.
.
#SOB: Persistent SOB, atelectasis and R hemidiaphrgam elevation
on CXR, no evidence of pneumonia and no clinical suspicion of
this. oxygenating well, no signs of PE. Symptoms are most likely
related to atelectasis, increased ascites and hemidiaphragm
elevation. Pt was given incentive spirometer and encouraged to
use it 10 times an hr, with some improvement, while diuresing as
above. On discharge, pt was feeling much better.
.
# Anemia: Hct 33.7 (stable from yesterday) from b/l 42. Current
hct consistent with hospital range. Likely anemia from bone
marrow suppression secondary to sepsis upon arrival. Remained
stable, with no evidence of bleeding. Haptoglobin wnl. Unlikely
hemolysis. Single positive guiac stool.
Medications on Admission:
Medications (per medical record):
ursodiol 600 mg BID
vitamin C
vitamin D
glucosamine
loratadine
Discharge Medications:
1. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: ___
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
4. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
5. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
8. codeine-guaifenesin ___ mg/5 mL Syrup Sig: ___ MLs PO Q6H
(every 6 hours) as needed for cough./wheeze.
9. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Cepacol Sore Throat ___ mg Lozenge Sig: One (1) Mucous
membrane twice a day as needed for sore throat.
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Cirrhosis due to Caroli Syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ were admitted with a severe infection of the biliary tree
(cholangitis) and had a stent placed to improve the flow of bile
as well as antibiotic treatment. ___ will continue treatment
for this infection for 2 more weeks, when ___ will see the
infectious disease doctors.
___ also had increased swelling and ascites and were started on
diurectics. Dr. ___ continue to follow your ascites and
will make any adjustments to the diurectics as needed.
Followup Instructions:
___
|
10048001-DS-8 | 10,048,001 | 21,687,712 | DS | 8 | 2178-05-03 00:00:00 | 2178-05-06 20:29:00 |
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, fever
Major Surgical or Invasive Procedure:
Mid-line placement
History of Present Illness:
___ yo M PMhx ___'s Disease complicated by cirrhosis and
recurrent cholangitis with MDR E. coli presents with 1 day of
fever 101.5 with rigors, diaphoresis, headache, generalized
weakness, one episode of nonbloody/nonbilious emesis, dyspnea,
nonproductive cough, and wheeze. Patient had sudden onset of
dyspnea last similar similar to prior episodes of cholangitis.
Of note, patient was previously doing well on
suppressive/prophylaxis therapy of rifaxmin, recent switch to
TMP-SMZ in late ___ due to high cost of rifaximin.
On ___ night, patient awoke in middle of night drenched in
sweat; he changed in pajamas and went back to bed. On ___
morning at 7:00, he went to put out trash and afterwards had to
sit to rest for 101-5 minutes. His wife told him he looked
terrible, took a temp of 101. Patient called Dr. ___
about above and was told to come to ___ ED for
workup/culture/antibiotics. He has also had a brief headache
for a few days (no neck stiffness) resolved with APAP in ED. He
has had "wheeze" ("working to breath") without cough. He had
___ dry heaves in the ED. Patient has normally 2 BMs/day
without notable change.
ROS: Per HPI, positive for recent travel to ___ on
___, 2 weeks of tingling in left finger tips and bottom of
food. Denies weight/appetite changes, chest pain/palpitations,
abdominal pain, emesis/hematemesis, melena/hematochezia,
dysuria/hematuria, change in color of stools or urine, visual or
hearing changes, and focal weakness.
In the ED, initial vitals were ___, 100.4, 105, 108/67, 24,
SaO2 96% on ?NC/CPAP. Patient later had BP 85/52 and T102.7.
His total bilirubin was near baseline, patient had no other foci
of infection, CXR notable for mild volume overload felt to be
secondary to hydration. A CVL was placed in his right femoral.
He was given acetaminophen 1g, 3L NS,
vancomycin/cefepime/metronidazole. He was briefly placed on
NIPPV due to dyspnea but due to feeling better he was trialed on
4L NC. Vitals on transfer were ___, 98.6, 94, 97/67, 30, 95% on
4L NC.
Past Medical History:
-___ Syndrome with recurrent cholangitis and bacteremia, most
recent from highly resistant E. coli treated with tigecycline
(finished late ___
-Cirrhosis
-Inguinal hernia repair in ___
-Depression
-Osteopenia per patient
-Seasonal allergies
-Bee allergy
Social History:
___
Family History:
Mother is alive with heart disease. Father died at ___ of
?cancer. No family history of liver disease or polycystic kidney
disease.
Physical Exam:
ADMISSION EXAM:
================
Vitals: Afebrile, 86, 93/66, 20, 96% on 4L
GENERAL: Tired, oriented, no acute distress
HEENT: Sclera slightly icteric, MMM, oropharynx clear
NECK: Supple, JVP not elevated, no LAD, no meningeal signs
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi, no signs of respiratory distress
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Soft, non-tender, mildly distended with air, bowel sounds
present, no rebound tenderness or guarding, no organomegaly,
umbilical hernia
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: R Fem Line in place C/D/I, no rashes, warm and
well-perfused
NEURO: A+Ox3, no asterixis, ___ ___ strength, sensation intact
throughout
DISCHARGE EXAM:
================
Vital Signs: T 97.9, HR 98, BP 118/68, RR 20, SaO2 95% RA
General: Alert, oriented, no acute distress
HEENT: Very mild conjunctival injection of R eye (improved from
yesterday), open area on medial aspect of R lower eyelid, EOMI,
no pain with eye movement, no periorbital swelling
Neck: Supple, no JVD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Lungs: Breathing comfortably, CTAB
Abd: +BS, mildly distended, soft, nontender, no hepatomegaly.
Umbilical hernia.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAOx3, no asterixis
Pertinent Results:
ADMISSION LABS:
================
___ 11:00PM BLOOD WBC-3.6* RBC-3.89* Hgb-13.2* Hct-38.0*
MCV-98 MCH-33.9* MCHC-34.7 RDW-14.7 Plt Ct-25*#
___ 11:00PM BLOOD Neuts-88* Bands-4 Lymphs-4* Monos-4 Eos-0
Baso-0 ___ Myelos-0
___ 01:44AM BLOOD ___ PTT-40.3* ___
___ 09:58AM BLOOD ___
___ 09:58AM BLOOD FacVIII-200
___ 03:16PM BLOOD Glucose-142* UreaN-27* Creat-1.5* Na-136
K-3.6 Cl-101 HCO3-19* AnGap-20
___ 03:16PM BLOOD ALT-37 AST-58* AlkPhos-57 TotBili-2.6*
___ 03:16PM BLOOD Lipase-22
___ 03:16PM BLOOD cTropnT-<0.01 proBNP-363*
___ 03:16PM BLOOD Albumin-3.7 Calcium-8.7 Phos-0.8*#
Mg-1.5*
___ 09:58AM BLOOD Hapto-28*
___ 02:56PM BLOOD pO2-88 pCO2-22* pH-7.53* calTCO2-19* Base
XS--1
___ 02:56PM BLOOD Lactate-3.6*
___ 03:10PM URINE Color-Amber Appear-SlHazy Sp ___
___ 03:10PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 03:10PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-1
___ 03:10PM URINE CastGr-2* CastHy-3*
___ 03:10PM URINE Mucous-FEW
DISCHARGE LABS:
================
___ 04:00AM BLOOD WBC-3.6* RBC-3.30* Hgb-10.9* Hct-32.0*
MCV-97 MCH-33.1* MCHC-34.2 RDW-16.5* Plt Ct-46*
___ 04:00AM BLOOD ___ PTT-35.5 ___
___ 04:00AM BLOOD Glucose-99 UreaN-11 Creat-0.8 Na-141
K-3.7 Cl-107 HCO3-23 AnGap-15
___ 04:00AM BLOOD ALT-25 AST-24 AlkPhos-71 TotBili-1.0
___ 04:00AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.8
MICROBIOLOGY:
==============
___ 1:30 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.
ESCHERICHIA COLI. ___ MORPHOLOGY. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage regimen
of
2g every 8h.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 16 I 16 I
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ 0249 ON
___ -
___.
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
___ 2:19 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
ESCHERICHIA COLI. SECOND MORPHOLOGY.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ 0249 ON
___ -
___.
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
___: Blood culture negative
___: Blood culture negative
___: Blood culture negative
___: Blood culture pending
___: Blood culture pending
___: C diff negative
IMAGING/STUDIES:
=================
CTA (___):
IMPRESSION:
1. No evidence of central or segmental pulmonary embolism.
Evaluation of
subsegmental pulmonary artery is limited due to motion artifact.
2. Slight interval increase in small bilateral pleural effusion
with adjacent atelectasis.
3. ___'s disease with ductal dilatation, cirrhosis, and
splenomegaly,
better evaluated on ___ MRI.
TTE (___):
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. Overall left ventricular systolic function
is normal (LVEF = 65%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of ___, the findings are similar.
TTE (___):
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: No late contrast seen in left
heart suggesting absence of intrapulmonary shunting.
Conclusions
No late contrast is seen in the left heart (suggesting absence
of intrapulmonary shunting).
Chest CT (___):
IMPRESSION:
1. Bibasilar atelectasis and small bilateral non-hemorrhagic
pleural
effusion.
2. Sequelae of ___'s disease with biliary duct dilatation,
cirrhotic
liver, and splenomegaly as well as distended gallbladder, better
characterized on prior MRI from ___.
___ (___): Negative
CXR (___):
IMPRESSION:
No acute cardiopulmonary abnormality.
RUQ US (___):
IMPRESSION:
1. Cirrhosis with splenomegaly. No ascites.
2. Unchanged, marked distention of the gallbladder without
specific evidence for acute cholecystitis. No intrahepatic
biliary ductal dilation or gallstones.
Brief Hospital Course:
Mr. ___ is a ___ gentleman with a past medical
history significant for ___'s syndrome complicated by
cirrhosis and recurrent cholangitis with MDR E. coli who
presented in septic shock and was found to have E. coli
bacteremia, presumably from a biliary source.
# Septic shock/E. coli bacteremia: Patient with a history of
recurrent cholangitis presented with
fever/tachycardia/leukopenia and ___ not responsive
to 20mL/kg bolus in setting of suspected infectious source from
biliary tree. TBili was elevated but CBD did not appear dilated
on RUQ ultrasound. There were no signs or symptoms to suggest
alternative source of infection. Patient was admitted to the
ICU for pressors and was initially started on
vancomycin/cefepime/Flagyl. Once blood cultures grew GNR (which
later speciated to E. coli), vancomycin was discontinued.
Patient was quickly weaned off pressors. Once E. coli
sensitivities returned, patient was narrowed to ceftriaxone. A
midline was placed so he could complete a 14 day course of
ceftriaxone as an outpatient.
# Cirrhosis: Patient with known cirrhosis secondary to Caroli
syndrome. MELD 22 on admission. He has a history of esophageal
variceal bleed in ___. No signs of bleeding, ascites, or
encephalopathy on admission. TBili was 2.6 on admission but
then normalized. RUQ ultrasound did not show any biliary ductal
dilation. Home diuretics (Lasix 20 mg daily, amiloride 5 mg
daily) and nadolol were initially held given septic shock, but
these were later restarted after patient stabilized.
# Dyspnea/hypoxia: Patient reported resting dyspnea and was
initially hypoxic, requiring up to 4L O2. Work-up included CXR
(limited study, mild pulmonary edema, no obvious infiltrate),
chest CT (bibasilar atelectasis, small pleural effusions), TTE
with bubble (normal EF, bubble study negative, no evidence of
HPS), and CTA negative for PE. Diuresis was trialed. Patient's
dyspnea resolved and he was able to be weaned off O2.
# Pancytopenia: On review of OMR, patient has a chronic
pancytopenia, likely secondary to cirrhosis. WBC and Hg were
near baseline but thrombocytopenia was worse than baseline,
likely a stress response in the setting of sepsis. There was no
clinical or laboratory evidence of DIC. SQ heparin was held.
All cell lines improved.
# HSV lesions: Patient had three HSV lesions on his face,
including one near his right eye with associated conjunctivitis.
He was evaluated by ophthalmology and started on po acyclovir
400 mg tid. He will complete a 10 day course. He was also
given erythromycin ointment and artificial tears for comfort.
His conjunctivitis improved.
# Depression: Citalopram was held given
coagulopathy/thrombocytopenia. It was restarted on discharge.
TRANSITIONAL ISSUES:
=====================
-Patient recently changed his prophylactic antibiotics from
rifaximin to Bactrim as his insurance change would not allow an
affordable copay. Salix pharmaceuticals has given him a free 10
day supply while the liver transplant clinic tries to work with
his insurance company to make this medication more affordable.
He will resume prophylactic antibiotics once he finishes his
course of ceftriaxone.
-Pt's PCP wrote the ceftriaxone prescription and faxed it to the
___ where he will get his daily dose.
They have coordinated with their ED to get him infusions on the
weekend. First dose with their clinic will be 2 pm on ___.
-Will complete 10 day course of acyclovir and erythromycin for
conjunctivitis. If symptoms do not resolve he can follow up with
ophtho as an outpatient. Erythromycin ointment finishes ___,
acyclovir finishes ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO BID
2. Citalopram 20 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Ursodiol 600 mg PO BID
5. Nadolol 20 mg PO DAILY
6. Amiloride HCl 5 mg PO DAILY
7. Loratadine 10 mg Oral daily
8. Magnesium Oxide 400 mg PO DAILY
Discharge Medications:
1. Amiloride HCl 5 mg PO DAILY
2. Ascorbic Acid ___ mg PO BID
3. Furosemide 20 mg PO DAILY
4. Ursodiol 600 mg PO BID
5. Acyclovir 400 mg PO Q8H Duration: 10 Days
Last day ___
RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp
#*26 Tablet Refills:*0
6. Artificial Tear Ointment 1 Appl RIGHT EYE PRN pain irritation
RX *artificial tears ointment [Artificial Tears] 1 drop daily
Refills:*0
7. CeftriaXONE 2 gm IV Q24H
8. Citalopram 20 mg PO DAILY
9. Loratadine 10 mg Oral daily
10. Magnesium Oxide 400 mg PO DAILY
11. Nadolol 20 mg PO DAILY
12. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE TID Duration:
10 Days
right eye and lower lid
3x/day. Last day ___
RX *erythromycin 5 mg/gram (0.5 %) 1 cm three times a day
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
-E. Coli bacteremia
-Septic Shock
Secondary
-Caroli syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to ___ for
infection in your biliary tree. We gave you antibiotics and you
improved. The infection spread to your blood which will require
IV antibiotics for 2 weeks. We have set you up with the
community clinic at ___ to continue your IV
antibiotics through ___. During the weekends, you will go
to the ___ room who will infuse the
medication.
If there is any problems with the mid-line (irritation, redness,
pain), please call your pcp's office or go to the emergency room
It was a pleasure taking care of you
-___ Team
Followup Instructions:
___
|
10048001-DS-9 | 10,048,001 | 24,319,281 | DS | 9 | 2182-04-19 00:00:00 | 2182-04-19 14:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Confusion, upper GI bleeding
Major Surgical or Invasive Procedure:
EGD ___: APC to vascular ectasia in the duodenum
PICC line placement ___
History of Present Illness:
Mr. ___ is a ___ year old man with a history of Caroli
disease and well compensated cirrhosis who presents from ___
with
confusion, abdominal pain and vomiting.
He was just on vacation in ___ and approximately 3d ago
his wife noticed that he wasn't acting like himself, was
confused, and asking repetitive questions. He had diarrhea for
one week, some of which was black of dark red. He also had some
abomdinal pain that was not significantly different from normal,
but did have some nausea and vomiting with bright red blood in
the emesis. He has a history of cholangitis and typically has
fevers and chills, which he hasn't had.
He presented to the ___ ED. At ___ had WBc 13.8, INR 1.4, T bili
2.4, AST/ALT 143/123, Lactate 2.1, BNP 582, TropT 0.39. CTA
without PE. CTAP with distended gallbladder with pericholecystic
fluid and stone at gallbladder neck. A blood culture grew gram
positive organisms in short chains.
On arrival to the floor, he reports still feeling somewhat
confused. He has not had further nausea/vomiting. He is very
thirsty.
EMERGENCY DEPARTMENT COURSE
Initial vital signs were notable for:
- T 96.9, HR 86, BP 129/71, RR 16, O2 95% RA
Exam notable for:
- Benign abdomen
Labs were notable for:
- ALT 108
- AP 246
- T bili 2.3
- AST 115
- Cr 1.3, BUN 43
- Lactate 2.3
Patient was given:
- Zosyn
- Protonix
- Urosodiol 600mg
- Lasix 40mg PO
- Nadolol 20mg
- Amliloride 10mg
- Vancomycin
Consults:
- Hepatology
=================
REVIEW OF SYSTEMS
=================
Complete ROS obtained and is otherwise negative.
Past Medical History:
-___ Syndrome with recurrent cholangitis and bacteremia, most
recent from highly resistant E. coli treated with tigecycline
(finished late ___
-Cirrhosis
-Inguinal hernia repair in ___
-Depression
-Osteopenia per patient
-Seasonal allergies
-Bee allergy
Social History:
___
Family History:
Mother is alive with heart disease. Father died at ___ of
?cancer. No family history of liver disease or polycystic kidney
disease.
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
VITALS: T 98.9, BP 127/77, HR 78, RR 22, ___
GENERAL: Tired appearing, lying in bed, arousable to voice
HEENT: Pupils equal and reactive, mild scleral icterus, dry
mucous membranes,
CARDIAC: S1/S2 regular with no murmurs, rubs or S3/S4
LUNGS: Poor air movement, bibasilar rales, diminished lung
sounds
bilaterally
BACK: No CVA tenderness
ABDOMEN: Soft, mildly tender to palpation diffusely, worse in
LUQ. Umbilical hernia soft and reducible.
EXTREMITIES: 2+ pitting edema to upper shins
SKIN: Scattered superficial abrasions throughout abdomen
NEUROLOGIC: A+Ox3, though slow to identify date. Mild asterixis.
CNII-XII normal.
=======================
DISCHARGE PHYSICAL EXAM
=======================
General: Elderly gentleman, sitting up in chair
HEENT: Sclera anicteric, mucous membranes moist
Lungs: vesicular breath sounds bilaterally
CV: Regular rate and rhythm, no murmurs
Abdomen: obese, distended, no tenderness to palpation, reducible
umbilical hernia
Ext: Warm, well perfused, ___ bilateral pitting edema of lower
extremities up to knees. Patient had removed compression
stockings just prior to exam.
Neuro: Alert, cranial nerves grossly intact
Pertinent Results:
=======================
ADMISSION LAB RESULTS
=======================
___ 04:13AM BLOOD WBC-12.5* RBC-3.55* Hgb-10.7* Hct-32.6*
MCV-92 MCH-30.1 MCHC-32.8 RDW-18.6* RDWSD-56.5* Plt Ct-82*
___ 04:13AM BLOOD Neuts-87* Bands-1 Lymphs-4* Monos-2*
Eos-0* ___ Myelos-6* NRBC-0.2* AbsNeut-11.00* AbsLymp-0.50*
AbsMono-0.25 AbsEos-0.00* AbsBaso-0.00*
___ 04:13AM BLOOD ___ PTT-28.2 ___
___ 04:13AM BLOOD Glucose-115* UreaN-43* Creat-1.3* Na-138
K-8.2* Cl-108 HCO3-20* AnGap-10
___ 04:13AM BLOOD ALT-113* AST-175* AlkPhos-217*
TotBili-2.1*
___ 04:13AM BLOOD Lipase-39
___ 04:13AM BLOOD Albumin-2.6*
======================
DISCHARGE LAB RESULTS
======================
___ 07:34AM BLOOD WBC-3.2* RBC-2.97* Hgb-9.1* Hct-29.1*
MCV-98 MCH-30.6 MCHC-31.3* RDW-21.2* RDWSD-75.1* Plt Ct-72*
___ 07:34AM BLOOD Glucose-88 UreaN-12 Creat-0.9 Na-142
K-4.6 Cl-109* HCO3-24 AnGap-9*
___ 07:34AM BLOOD ALT-27 AST-28 LD(LDH)-236 AlkPhos-130
TotBili-1.7*
===============
MICRO DATA
===============
________________________________________________________
___ 12:46 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 10:42 am BLOOD CULTURE #2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 8:51 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 5:03 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECALIS.
Identification and susceptibility testing performed on
culture #
___ (___).
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS.
__________________________________________________________
___ 7:20 am BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECALIS.
Identification and susceptibility testing performed on
culture #
___ ___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
__________________________________________________________
___ 7:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
Daptomycin MIC = 1.0 MCG/ML.
Daptomycin test result performed by Etest.
TETRACYCLINE Susceptibility testing requested per
___
(___) (___).
TETRACYCLINE IS NOT INTENDED FOR THE PRIMARY TREATMENT
OF BLOOD
STREAM INFECTIONS.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- 2 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by ___ @2149 ON
___.
=====================
IMAGING AND REPORTS
=====================
RUQ ULTRASOUND ___
IMPRESSION:
1. No biliary dilation or gallstones. Distended gallbladder
without wall
thickening, as seen previously. MRCP could further evaluate for
cholangitis and the gallbladder distention.
2. Cirrhotic liver with stable splenomegaly and redemonstrated
patent
paraumbilical vein. Patent portal vein.
CHEST X-RAY ___
IMPRESSION:
Low lung volumes with mild pulmonary edema and trace left
pleural effusion. Persistent bibasilar atelectasis.
MRCP ___
IMPRESSION:
1. No MR evidence of acute cholangitis. Apparent 4 mm central
filling defect in the distal CBD likely represents a flow void,
without definite evidence of choledocholithiasis.
2. Well distended gallbladder without signs of acute
cholecystitis, may be due to fasting state.
3. Overall stable saccular dilation of predominantly right-sided
intrahepatic bile ducts, together with cirrhotic liver
morphology and portal hypertension, consistent with known ___
syndrome.
TRANSTHORACIC ECHO ___
IMPRESSION: No 2D echocardiographic evidence for endocarditis.
Mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global biventricular systolic function.
Moderate
tricuspid regurgitation. Moderate pulmonary hypertension.
Compared with the prior TTE (images not available for review) of
___ , the estimated pulmonary artery systolic pressure is
now increased. Tricuspid regurgitation is more prominent.
UPPER ENDOSCOPY ___
1. One cord of grade I varices in the distal esophagus. Not
bleeding.
2. Diffuse congestion, petechiae and mosaic mucosal pattern of
the stomach with contact bleeding in the fundus and body.
Compatible with PHG.
3. Single small non bleeding localized angioectasia seen in the
second part of the duodenum. Angioectasia was ablated
completely. APC was successfully applied for hemostasis.
Brief Hospital Course:
Mr. ___ is a ___ year old man with a history of Caroli
disease, cirrhosis, known esophageal varices who developed
confusion and upper GI bleeding while on vacation in ___.
He was treated for acute cholangitis, upper GI bleed likely from
portal hypertensive gastropathy, and hepatic encephalopathy. He
was discharged on his home medications with the addition of
lactulose and daptomycin. He will follow up with PCP, infectious
disease and hepatology for further management.
ACUTE PROBLEMS:
===============
# Acute cholangitis
# Enterococcus faecalis bacteremia
Patient has history of recurrent cholangitis due to intrahepatic
biliary ductal dilation from ___'s disease. He has been on
maintenance outpatient antibiotics and hasn't had any infections
since about ___. Patient developed nausea, hematemesis and
bloody bowel movement while on vacation with his wife in ___.
___. The episodes were self-limited, and they presented to
nearest ER on return to ___ (which was ___. He was
transferred to ___. Here, MRCP did not show any specific
changes in biliary ducts. However, given that his disease is
intra-hepatic, imaging may not be sensitive enough to identify
changes. His blood cultures grew Enterococcus faecalis, and his
initial broad antibiotic coverage was adjusted to Daptomycin
with input from infectious disease team. He underwent placement
of PICC line on ___ and was discharged with plan to follow up
with ID. Routine TTE for bacteremia was normal.
# Upper GI bleed
Patient has history of bleeding esophageal varices that were
previously banded. Most recent EGD was in ___ and showed grade
I varices in the esophagus. Due to report of hematemesis and
dark stool several days prior to admission, patient underwent
EGD. This showed portal hypertensive gastropathy with bleeding
on contact as well as small duodenal vascular ectasia that was
treated with APC. There was no evidence of variceal bleeding on
this exam. Colonoscopy was not done but should be pursued
outpatient given that upper endoscopy findings were relatively
underwhelming. He likely developed bleeding secondary to
bacteremia from a biliary source. He was maintained on PPI and
will follow up with hepatology at discharge, at which time
colonoscopy should be discussed.
# Acute decompensated cirrhosis: hepatic encephalopathy, volume
overload, UGIB
# ___'s disease
Admission MELD-NA of 18. Patient has ___'s disease and
subsequent liver cirrhosis for about ___ years. On this
admission, his cirrhosis was decompensated by hepatic
encephalopathy, volume overload and portal hypertensive
gastropathy with GI bleeding. He likely developed bacteremia
from cholangitis, which subsequently precipitated both GI bleed
and hepatic encephalopathy.
Patient was started on lactulose due to encephalopathy. Wife
reported that over the last several weeks patient was showing
signs of forgetfulness and confusion, and then developed altered
sleep pattern while on vacation. This likely occurred in the
setting of infection and GI bleeding. Patient will be discharged
on lactulose titrated to ___ bowel movements daily (has not
previously been on lactulose).
GI bleeding was addressed as above. Underwent APC this
admission, no varices. He was restarted on home nadolol at
discharge.
Home diuretics were initially held due to acute kidney injury.
After EGD, he underwent IV diuresis due to worsening lower
extremity edema and dyspnea. This improved and he was restarted
on home diuretics at discharge. He was continued on home
ursodiol. He will follow up with liver clinic (Dr. ___.
# Acute kidney injury
Baseline creatinine is about 1. On initial presentation to ___
it was elevated to 1.4. It improved with fluid and albumin for
volume resuscitation. He likely was volume depleted after
vomiting and diarrhea. Discharge creatinine was 0.9.
CHRONIC PROBLEMS:
================
# Depression
- Continue home citalopram
==============================
TRANSITIONAL ISSUES
==============================
[] Patient will be receiving Daptomycin once a day at the
___ at ___. ___ and ___, he will get
it at their ___. The rest of the days of the week,
he will need to go to the ___, located in the
emergency room at ___.
#CODE: Full, limited trial of life sustaining measures,
confirmed
#CONTACT: Wife, ___, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. aMILoride 10 mg PO DAILY
2. Cefpodoxime Proxetil 200 mg PO Q12H
3. LevoFLOXacin 500 mg PO Q24H
4. Citalopram 20 mg PO DAILY
5. Nadolol 20 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Ursodiol 600 mg PO BID
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Magnesium Oxide 400 mg PO DAILY
10. Sildenafil 50 mg PO DAILY:PRN sexual activity
11. Furosemide 40 mg PO DAILY
12. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction
13. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
DAILY
14. Loratadine 10 mg PO DAILY
Discharge Medications:
1. Daptomycin 850 mg IV Q24H
2. Lactulose 30 mL PO Q2H
RX *lactulose 20 gram/30 mL 30 ml by mouth once a day Disp #*1
Bottle Refills:*0
3. rifAXIMin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
4. aMILoride 10 mg PO DAILY
5. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
DAILY
6. Citalopram 20 mg PO DAILY
7. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction
Duration: 1 Dose
8. Furosemide 40 mg PO DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Loratadine 10 mg PO DAILY
11. Magnesium Oxide 400 mg PO DAILY
12. Nadolol 20 mg PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. Sildenafil 50 mg PO DAILY:PRN sexual activity
15. Ursodiol 600 mg PO BID
16. HELD- Cefpodoxime Proxetil 200 mg PO Q12H This medication
was held. Do not restart Cefpodoxime Proxetil until discussion
with infectious disease team
17. HELD- LevoFLOXacin 500 mg PO Q24H This medication was held.
Do not restart LevoFLOXacin until discussion with the infectious
disease team
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Acute cholangitis
-Enterococcus bacteremia
-Acute decompensated liver cirrhosis
SECONDARY:
-Hepatic encephalopathy
-Upper GI bleed
-Acute kidney injury
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for confusion, bleeding and
concern for cholangitis.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- You had an imaging study of your abdomen that did show some
possibility of cholangitis.
- Your blood cultures grew bacteria called Enterococcus. This
was treated with IV antibiotics.
- You had an endoscopy done which showed changes in your stomach
due to your liver disease. You had a chemical treatment done to
prevent from bleeding. No banding was done.
- You had a PICC line placed so that you could get IV
antibiotics at home.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed below.
- Show up to your appointments as listed below.
- You are scheduled to get antibiotics at the ___
___. ___ and ___, you will get it at their infusion
center. The rest of the days of the week, you will need to go to
the ___, located in the emergency room at ___
___.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10048061-DS-4 | 10,048,061 | 23,628,963 | DS | 4 | 2169-04-24 00:00:00 | 2169-04-24 20:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Transfer for fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o female with a history of Still's disease
who presented to OSH (___) with fevers to 104.8 and
arthralgia and transferred for rheumatology evaluation.
She first developed Still's symptoms in ___. Her
symptoms were a fever to 103+ and rash. In ___, she was
diagnosed with Still's disease and began following with Dr.
___ in Rheumatology (___, ___). She was initially
started on prednisone 60 mg and a biologic. She was remained on
the prednisone for ___ years but had several side effects
including weight gain and osteoporosis, so this was stopped. She
has also developed several infections as a result of her
biologic
therapy including a jaw infection and a breast abscess which
required significant surgical intervention. Due to her
infections
on biologics, she was stopped on biologics by her
rheumatologist.
She has instead been maintained on hydroxychloroquine 400 mg qhs
and sulfasalazine 1000 mg daily. At baseline, her Still's
symptoms are: ___ pain in various joints (changes every day),
morning nausea, morning sore throat, and fevers twice a day
between 103.7 and 104s.
A few days before this admission, she developed severe pain in
her left wrist, right wrist, and left ankle along with a fever
to
104.8 which is higher than normal for her. She took a cold
shower
for 8 minutes but the fever did not improve at all. She called
her Rheumatologist who recommended presenting to the hospital.
She presented to ___ in ___ on ___. While
there, her vital signs were stable. Labs showed WBC 12.2, hgb
11.9, lactate 1.3, procal < 0.05, cr 0.63, UA bland, LFTs
normal,
albumin 4, trop negative, CRP 5.6, ESR 50, flu negative. She was
transferred to ___ for specialist care.
In the ED at ___, initial vitals were T 98.8, HR 70, BP
130/80,
RR 16, O2 100% RA. Labs notable for WBC 9.5 (35% lymph), hgb
11.4, Cr 0.7, LFTs normal, lipase 15, INR 1.2, UA bland, lactate
0.9, CRP 5.1. A CT abd/pelvis with contrast did not show any
intraabdominal pathology. She was given ketorolac x1 and
oxycodone.
Upon arrival to the floor, patient reports the above history.
She
feels significant pain in her wrists and left ankle. She says
she
hasn't had gabapentin in >24 hours. She denies dysuria,
frequency, chest pain, cough, headache, visual changes. She does
not feel she has an infection, and instead feels like this is an
exacerbation of her underlying Still's. She denies any recent
travel, changes in medication, changes in diet, or sick
contacts.
Past Medical History:
Still's disease
Social History:
___
Family History:
Mother died from complications of RA.
Father with plaque psoriasis and psoriatic arthritis. Sister
with
plaque psoriasis.
Physical Exam:
ADMISSION EXAM
VITAL SIGNS: T 98.3, BP 145 / 86, HR 76, RR 20 99 RA
GENERAL: Distressed appearing female sitting in bed
HEENT: MMM, OP clear, external ear canal normal
NECK: Soft, no masses
CARDIAC: RRR, normal s1,s2, no m/r/g
LUNGS: CTAB
ABDOMEN: Soft, nontender, nondistended
EXTREMITIES: Right wrist is tender to palpation. Limited
mobility
of first three fingers due to pain. Left wrist tender to
palpation. Both wrists with mild swelling and erythema. Left
ankle is significantly tender to palpation and is swollen in the
lateral aspect. Right ankle normal.
NEUROLOGIC: A&Ox3, strength exam limited by pain, sensation
intact to light touch
SKIN: No facial rashes noted
DISCHARGE EXAM
===========
___ ___ Temp: 98.0 PO BP: 130/79 HR: 64 RR: 18 O2 sat: 99%
O2 delivery: Ra
GENERAL: resting comfortably in bed seated up right
HEENT: anicteric sclera, no scleral injection
NECK: Soft, no masses
CARDIAC: RRR, normal s1,s2, no m/r/g
LUNGS: CTAB
ABDOMEN: Soft, nontender, nondistended
EXTREMITIES: Right wrist is tender to palpation. Limited
mobility
of first three fingers due to pain. Left wrist tender to
palpation. Right wrist without marked overlying erythema or
swelling in comparison to left wrist, no palpable synovitis or
joint effusions.
Left ankle with tender to palpation at the joint line but no
overlying malleolus effusions, erythema or swelling
NEUROLOGIC: A&Ox3, strength exam limited by pain, sensation
intact to light touch
SKIN: No facial rashes noted
Pertinent Results:
ADMISSION LABS
___ 03:15AM BLOOD WBC-9.5 RBC-4.32 Hgb-11.4 Hct-35.4 MCV-82
MCH-26.4 MCHC-32.2 RDW-14.9 RDWSD-45.1 Plt ___
___ 03:15AM BLOOD Neuts-56.1 ___ Monos-6.1 Eos-2.1
Baso-0.4 Im ___ AbsNeut-5.34 AbsLymp-3.33 AbsMono-0.58
AbsEos-0.20 AbsBaso-0.04
___ 03:15AM BLOOD ___ PTT-29.4 ___
___ 03:15AM BLOOD Glucose-82 UreaN-10 Creat-0.7 Na-142
K-4.4 Cl-105 HCO3-24 AnGap-13
___ 03:15AM BLOOD ALT-10 AST-16 AlkPhos-72 TotBili-0.3
___ 03:15AM BLOOD Lipase-15
___:15AM BLOOD Albumin-4.0 Calcium-8.6 Phos-3.7 Mg-2.0
Iron-67
___ 03:15AM BLOOD calTIBC-432 Ferritn-21 TRF-332
___ 03:15AM BLOOD CRP-5.1*
___ 03:21AM BLOOD Lactate-0.9
INTERVAL LABS
___ 09:00AM BLOOD RheuFac-<10 ___
___ 03:15AM BLOOD CRP-5.1*
DISCHARGE LABS
MICROBIOLOGY
IMAGING
CT A/P With Contrast ___
1. Soft tissue density just distal to the duodenal jejunal
junction suspicious
for small bowel mass for which further characterization can be
obtained by
endoscopy if amenable by location or MRE.
2. No acute intra-abdominal or pelvic abnormalities to correlate
with
patient's symptoms, specifically no evidence of intra-abdominal
abscess.
CXR ___
Heart size is normal. Mediastinum is normal. Lungs are clear.
There is no
pleural effusion. There is no pneumothorax
ANKLE MRI: ___
IMPRESSION:
-Thickening of syndesmotic ligaments with some adjacent tibial
cortical
irregularity posteriorly suggestive of prior syndesmotic
ligament injury. The
ATFL appears slightly irregular also most likely due to prior
injury. No
acute ligamentous injury is identified.
-There is tibiotalar osteoarthritis with full-thickness
cartilage loss along
the superomedial aspect of the talar dome and the adjacent
tibial plafond.
There is associated associated subchondral bone marrow edema,
osteophytosis
and mild synovitis.
-Some stranding of the fat with loss of normal signal in sinus
tarsi is
demonstrated, this may be seen in setting of sinus tarsi
syndrome.
-Plantar fasciitis with associated plantar calcaneal spur.
-Mild atrophy of the abductor digiti minimi muscle which may be
seen in the
setting of Baxter neuropathy.
-Minimal extensor digitorum tenosynovitis.
___, MD electronically signed on SUN ___ 8:15
___
Microbiology:
=========
___ 5:10 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 3:26 am BLOOD CULTURE X2
Blood Culture, Routine (Pending): NGTD
D/C Labs:
___ 06:20AM BLOOD WBC-7.1 RBC-4.20 Hgb-11.0* Hct-34.9
MCV-83 MCH-26.2 MCHC-31.5* RDW-14.7 RDWSD-44.6 Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD Glucose-113* UreaN-13 Creat-0.7 Na-141
K-4.1 Cl-100 HCO3-27 AnGap-14
___ 06:20AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.0
Brief Hospital Course:
Summary:
=======
Ms. ___ is a ___ year old female with a history of Still's
disease, initially diagnosed in ___ previously on prednisone
and biologics, currently maintained on hydroxychloroquine and
sulfasalazine who initially presented with fever to 104+ and
worsening arthralgias to ___, evaluated by
rheumatology and ultimately per their assessment and negative
laboratory and imaging findings determined not to have an acute
flare of Adult onset Still's disease as a cause of her
presentation.
# Still's disease
# Degenerative joint disease
# Fever, joint pain
Patient has a history of Still's disease initially diagnosed in
___, previously on prednisone and biologics, currently
maintained on hydroxychloroquine and sulfasalazine. She
previously did not tolerate biologics due to severe jaw and
subsequent breast infection. At baseline has daily fevers
measuring approximately 103-104, however presented with fever to
104.8 and severe worsening bilateral wrist and left ankle pain.
Patient was evaluated by rheumatology, with recommendations
including that she should follow up with her regular
rheumatologist and could consider discontinuing her home
regiment of sulfasalazine and plaquenil since it has not given
her significant relief and worsened her nausea. Given severe
left ankle swelling and pain, a left ankle MRI was obtained
which showed largely degenerative joint disease without
inflammatory changes. There was low suspicion for concomitant
infection given low procalcitonin at OSH, no leukocytosis, or
other localizing symptoms or signs consistent with infection.
Given report of left-sided abdominal pain on admission, CT
abdomen and pelvis was obtained which showed no obvious sources
of infection, however did show soft tissue density distal to the
duodenal-jejunal junction suspicious for small bowel mass.
Patient was continued on home sulfasalazine and
hydroxychloroquine. Pain was managed with Tylenol, ibuprofen,
and oxycodone. Ultimately after a negative testing with a normal
ferritin, negative ___, normal rheumatoid factor, their
assessment was that this presentation was not consistent with a
flair of her known Still's disease.
# Possible small bowel mass - CT A/P on admission showed a soft
tissue density just distal to the duodenal jejunal junction
suspicious for small bowel mass. This will need further
outpatient GI work up.
TRANSITIONAL ISSUES
===================
[ ] New/Changed Medications
-None
[ ] Discontinued medications
-None
[ ] patient with degenerative changes of left ankle, consider
Ortho evaluation as an outpatient
[ ] Recommend GI clinic visit for ongoing work-up of possible
small bowel mass
# CODE: full (presumed)
# CONTACT: ___
Relationship: OTHER
Phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydroxychloroquine Sulfate 400 mg PO QHS
2. SulfaSALAzine_ 1000 mg PO DAILY
3. Gabapentin 800 mg PO TID
4. Vitamin D ___ UNIT PO 1X/WEEK (MO)
5. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
6. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Mild
7. Methocarbamol 750 mg PO BID:PRN muscle spasm
8. Omeprazole 20 mg PO QAM
9. Zolpidem Tartrate 10 mg PO QHS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times daily
Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
3. Nystatin Oral Suspension 5 mL PO QID Duration: 6 Days
RX *nystatin 100,000 unit/mL 5 mL by mouth four times daily
Refills:*0
4. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight hours Disp
#*28 Tablet Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp
#*60 Tablet Refills:*0
6. Gabapentin 800 mg PO TID
7. Hydroxychloroquine Sulfate 400 mg PO QHS
8. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
9. Methocarbamol 750 mg PO BID:PRN muscle spasm
10. Omeprazole 20 mg PO QAM
11. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - Mild
RX *oxycodone 5 mg 2 tablet(s) by mouth every six hours Disp
#*16 Tablet Refills:*0
12. SulfaSALAzine_ 1000 mg PO DAILY
13. Vitamin D ___ UNIT PO 1X/WEEK (MO)
14. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Discharge Worksheet-Discharge ___,
MD on ___ @ 1024
PRIMARY DIAGNOSIS
Degenerative joint disease
Chronic Still's disease
Possible sinus tarsi syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why did you come to the hospital?
-You initially presented to an outside hospital with worsening
fever and joint pains
-You were transferred to ___
for rheumatology evaluation
- After the rheumatology evaluation it was determined that this
round of pain was likely not due to a flare of your
rheumatologic condition.
- You also had an MRI of you left ankle which showed some
degenerative changes of your ankle.
What happened during her hospitalization?
- You are evaluated by the rheumatology team and found not to
have an acute exacerbation of your Still's disease
- A MRI of your left ankle was obtained which showed
degenerative changes
- A Cat Scan of your abdomen showed a possible mass that will be
further evaluated in the outpatient setting
Which should you do when you leave the hospital?
- Continue to take all your medications as prescribed
- Follow-up with your primary care physician ___ 1 week
- Please keep all the other scheduled healthcare appointments
listed below
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10048244-DS-11 | 10,048,244 | 21,843,889 | DS | 11 | 2121-05-27 00:00:00 | 2121-05-28 11:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin / Phenytoin / NSAIDS / Tetracycline / Carbamazepine /
Oxycodone / pantoprazole
Attending: ___.
Chief Complaint:
Acute kidney injury
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with history of HCV cirrhosis
complicated by ___ s/p liver transplant ___, course c/b
mild acute rejection ___ and recurrent HCV now s/p cure,
recurrent cirrhosis, CVA in ___ with residual right sided
weakness, and newly diagnosed focal segmental
glomerulosclerosis, who is presenting with worsening renal
function and chills.
The patient was most recently discharged ___, for
subcapsular/perinephric hematoma after renal biopsy was done for
increasing creatinine and proteinuria. Although his renal
function had moderately improved with decreasing tacrolimus
level, final biopsy results showed FSGS.
He went for routine follow up in primary care clinic yesterday
(___) and labs showed creatinine had increased to 3.1, from 2.5
at discharge (baseline low 2s). He was sent to the ED when the
labs resulted. Prior to coming to the ED, the patient was
feeling well. He has had no fevers, nausea, vomiting, diarrhea,
back/flank pain, dysuria, hematuria, or change in urine output,
and no ___ swelling. He has had occasional chills. His wife also
thought he was more fatigued than usual.
In the ED initial vitals: 98.9 79 130/82 16 100RA. Exam was
notable for shivering, sleepiness, bibasilar crackles, no
ascites and residual RUE and RLE weakness. Labs were notable for
Cr 3.2, H/H 8.1/26.1 (baseline), WBC 6.3, LFTs wnl. UA was
notable for small blood, few bacteria, RBC 1, WBC 4, >300
protein. Urine protein/cr ratio was 3.8 (was 6.2 ___. Renal
ultrasound showed no hydronephrosis, left perinephric hematoma
measuring 7.3 x 3.7 x 3.1 cm. CXR had no acute processes. He was
given 50 g albumin and 650mg acetaminophen.
Upon arrival to the floor, the patient endorses headache, which
has been persistent for some time. He denies new numbness or
weakness. He denies chest pain, dyspnea, ___ edema, abdominal
distension, decreased appetite, pruritus.
REVIEW OF SYSTEMS: as per HPI.
Past Medical History:
# Liver Transplant (___) -- HCV cirrhosis and HCC
-- c/b anastamotic bile leak and stricture (stented ___
-- c/b mild acute rejection (biopsy ___
-- c/b recurrent HCV s/p treatment and cure
# Cirrhosis
# Hepatocellular Carcinoma
# History of Cavitary Pneumonia -- Mycobacterium fortuitum
# Severe Esophagitis -- EGD (___)
# Hypertension
# Alcohol Abuse History
# Seizure Disorder -- none in many years
# Ruptured Cerebral Aneurysm (___)
-- residual right hemiparesis and aphasia
# Craniotomy with Clot Evacuation (___)
# Left Knee Surgery
# Ulnar Neuropathy History
# CVA with right sided weakness
Social History:
___
Family History:
No family history of liver disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITAL SIGNS - 99.6 PO 163 / 74 R Lying 85 20 98 RA
GENERAL - well appearing, no acute distress
HEENT - MMM
NECK - JVP not elevated
CARDIAC - RRR, nl S1 S2, no murmurs/rubs/gallops
PULMONARY - clear to auscultation bilaterally, no wheeze, rales,
rhonchi
ABDOMEN - soft, NT, ND, NABS
GENITOURINARY - no foley
EXTREMITIES - no edema, WWP
SKIN - no rash visualized
NEUROLOGIC - baseline right arm and leg weakness
PSYCHIATRIC - normal mood and affect
DISCHARGE PHYSICAL EXAM
VITAL SIGNS - 98.3, 150s/80s, 70s, 18, 97% RA
GENERAL - well appearing, no acute distress
HEENT - MMM
CARDIAC - RRR, nl S1 S2, no murmurs/rubs/gallops
PULMONARY - clear to auscultation bilaterally, no wheeze, rales,
rhonchi
ABDOMEN - soft, NT, ND, NABS
GENITOURINARY - no foley
EXTREMITIES - no edema, WWP
SKIN - no rash visualized
NEUROLOGIC - baseline right arm and right leg weakness
Pertinent Results:
ADMISSION LABS
------------------
___ 01:45PM BLOOD WBC-5.4 RBC-3.28* Hgb-7.9* Hct-24.4*
MCV-74* MCH-24.1* MCHC-32.4 RDW-13.1 RDWSD-35.3 Plt ___
___ 09:30AM BLOOD Neuts-73.1* Lymphs-18.1* Monos-7.3
Eos-0.8* Baso-0.2 Im ___ AbsNeut-4.60# AbsLymp-1.14*
AbsMono-0.46 AbsEos-0.05 AbsBaso-0.01
___ 09:30AM BLOOD ___ PTT-33.3 ___
___ 01:45PM BLOOD UreaN-36* Creat-3.1* Na-139 K-4.6 Cl-106
HCO3-19* AnGap-19
___ 01:45PM BLOOD ALT-14 AST-24 AlkPhos-115 TotBili-0.3
___ 01:45PM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.4 Mg-1.9
___ 01:45PM BLOOD tacroFK-2.3*
___ 10:15AM BLOOD Lactate-1.3 K-4.5
___ EVEROLIMUS,LC/MS/MS,BLOOD 4.9
___ 10:20AM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:20AM URINE Blood-SM Nitrite-NEG Protein->300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 10:20AM URINE RBC-1 WBC-4 Bacteri-FEW Yeast-NONE Epi-<1
___ 10:20AM URINE Hours-RANDOM UreaN-545 Creat-197 Na-20
K-41 Cl-<20 TotProt-750 Calcium-<0.8 Phos-47.7 Mg-1.7
Prot/Cr-3.8*
___ 10:20AM URINE Osmolal-383
DISCHARGE LABS:
---------------
___ 05:44AM BLOOD WBC-4.7 RBC-3.04* Hgb-7.5* Hct-22.7*
MCV-75* MCH-24.7* MCHC-33.0 RDW-13.1 RDWSD-35.4 Plt ___
___ 05:44AM BLOOD ___ PTT-30.9 ___
___ 05:44AM BLOOD Glucose-137* UreaN-30* Creat-2.7* Na-138
K-4.6 Cl-106 HCO3-21* AnGap-16
___ 05:44AM BLOOD ALT-14 AST-20 LD(LDH)-307* AlkPhos-104
TotBili-0.2
___ 05:44AM BLOOD Calcium-8.8 Phos-2.4* Mg-2.0
___ 05:44AM BLOOD tacroFK-2.6*
___ 05:30AM BLOOD Hapto-318*
IMAGING
---------
RENAL ULTRASOUND ___: 1. No hydronephrosis. Left
perinephric hematoma, extent of which is not clearly defined.
Follow-up is recommended. RECOMMENDATION(S): Recommend
follow-up.
CXR (___): No acute cardiopulmonary process. Stable pleural
calcifications.
MICROBIOLOGY
----------------
___ 10:20 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
Mr. ___ is a ___ year old man with history of HCV cirrhosis
complicated by ___ s/p liver transplant ___, course c/b
mild acute rejection ___ and recurrent HCV now s/p cure, CVA
in ___ with residual right sided weakness, and newly diagnosed
focal sclerosing glomerulonephritis, presenting with worsening
renal function and chills with concern for worsening FSGS, now
with slightly improving renal function after stopping everolimus
and decreasing the dose of tacrolimus.
___ on CKD, Focal segmental glumerosclerosis: Patient
presenting with proteinuria and creatinine 3.2 above baseline
low 2s, and discharge Cr of 2.5 (___). Given recent FSGS
diagnosis, concerned for worsening disease, as it may be rapidly
progressive in some people. Although his biopsy does not
comment, suspect FSGS is secondary type and may be secondary to
HCV. Patient denied decreased po intake and denies infectious
symptoms. Renal ultrasound showing no hydronephrosis and stable
left perinephric hematoma. Urine prot/cr worsening (6.5 from
3.8). Renal was consulted who felt that the acute worsening of
his renal function could likely be attributed to his
immunosuppressants so they recommended minimizing Everolimus and
Tacrolimus. He was discharged on a decreased dose of Tacrolimus
(2.5 mg bid), OFF of Everolimus, and Prednisone 7.5 mg daily was
initiated.
#HCV cirrhosis c/b ___ s/p liver Transplant ___, with
recurrent cirrhosis: Patient unfortunately developed recurrent
cirrhosis despite HCV cure with simeprevir and sofosbuvir. He
has had no identified liver lesions c/f HCC. He is currently on
a study drug to treat fibrosis. He has no varices on recent EGD,
no ascites, and no documentation of recent encephalopathy. He
was continued on home study drug (per Dr. ___, and the
following immunosuppressants: He was discharged on a decreased
dose of Tacrolimus (2.5 mg bid), OFF of Everolimus, and
Prednisone 7.5 mg daily was initiated. He will follow up at
transplant clinic on ___.
#Hypertension: As above, BPs may be more elevated than in his
past with the current FSGS and worsening renal function.
Currently elevated BP most likely due to missed doses of home
medications while in the ED, and BP stabilized but were still
elevated to 150's systolic during the hospitalizations. We
continue home labetolol 200 mg BID, amlodipine 10 mg PO daily on
discharge. Would recommend eventually initiating ___ once
kidney function stabilizes. Spironolactone 50 mg daily was held
in setting of ___, and remained off on discharge. He should
discuss this with his outside providers.
# Anemia: Hgb 8 on admission, stable from prior discharge
baseline. Last iron studies in ___ c/w AOCD with low retics
suggestive of hypoproliferation. Hgb remained stable throughout
discharge, Hgb 7.7 on discharge.
#Chest pain: The night prior to discharge he developed L sided
sharp chest pain which was completely new and happened at rest
and resolved spontaneously after less than an hour with no
intervention. His ECG and cardiac enzymes were negative and his
chest pain did not recur. He was able to walk comfortably
without recurrent pain so he was deemed safe for discharge.
Discharge:
# Esophagitis: Continued home omeprazole
# Seizure Disorder: Continued home LevETIRAcetam 1500 mg PO BID.
COncern that this dose is too high given recent worsening renal
function. He should discuss this with his outpatient
neurologist.
# Ruptured Cerebral Aneurysm: Continued home Pravastatin 40 mg
PO QPM.
Transitional Issues:
-Check creatinine at next visit.
-Spironolactone held on discharge due to ___. Please consider
restarting once kidney function stabilizes
-Consider starting ___ once renal function stabilizes
- Will need consultation with neurologist to discuss
Levetiracetam dose. We feel that it is too high for his kidney
function
-Consider PCP prophylaxis given newly prescribed chronic
prednisone.
-Make sure he has not had recurrence of L sided chest pain he
had the night prior to d/c
Full Code
Name of health care proxy: ___
Relationship: Wife
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild
2. Everolimus 2.25 mg PO BID
3. LevETIRAcetam 1500 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Pravastatin 40 mg PO QPM
7. Tacrolimus 3 mg PO Q12H
8. Vitamin D 1000 UNIT PO DAILY
9. IDN-___/Placebo Study Med ___ mg orally TWICE A DAY
10. amLODIPine 10 mg PO DAILY
11. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
12. Spironolactone 50 mg PO DAILY
13. Labetalol 200 mg PO BID
Discharge Medications:
1. PredniSONE 7.5 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth twice daily Disp #*28
Tablet Refills:*0
RX *prednisone 2.5 mg 1 tablet(s) by mouth twice daily Disp #*28
Tablet Refills:*0
2. Tacrolimus 2.5 mg PO Q12H
RX *tacrolimus 1 mg 2 capsule(s) by mouth twice daily Disp #*56
Capsule Refills:*0
RX *tacrolimus 0.5 mg 1 capsule(s) by mouth twice daily Disp
#*28 Capsule Refills:*0
3. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild
4. amLODIPine 10 mg PO DAILY
5. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
6. IDN-___/Placebo Study Med ___ mg orally TWICE A DAY
7. Labetalol 200 mg PO BID
8. LevETIRAcetam 1500 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Pravastatin 40 mg PO QPM
12. Vitamin D 1000 UNIT PO DAILY
13. HELD- Spironolactone 50 mg PO DAILY This medication was
held. Do not restart Spironolactone until you speak to your
transplant doctors on ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: ___ on CKD
Secondary: HCV cirrhosis c/b ___ s/p liver Transplant ___,
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Why were you admitted?
You were admitted to ___ because your kidney function was
slightly worse. We were concerned that this might have been
because of your immunosuppressant medications so we stopped your
Everolimus and decreased your Tacrolimus to 2.5 mg twice daily.
We also started Prednisone 7.5 mg daily.
What changes did we make?
We changed your immunosuppressant medications to: Decreased
Tacrolimus to 2.5 mg twice daily and we also started Prednisone
7.5 mg daily. We stopped your Everolimus.
What do you need to do when you leave?
-Please follow up with your PCP, your kidney specialist Dr.
___ your liver doctor Dr. ___ below)
We wish you all the best.
Sincerely,
Your care team at ___
Followup Instructions:
___
|
10048244-DS-9 | 10,048,244 | 21,880,058 | DS | 9 | 2120-08-10 00:00:00 | 2120-08-10 16:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin / Phenytoin / NSAIDS / Tetracycline / Carbamazepine /
Oxycodone / pantoprazole
Attending: ___
Chief Complaint:
fever, left leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with PMHx of hep C cirrhosis s/p liver
transplant complicated by recurrent cirrhosis of transplanted
liver, HCC, hx of CVA with residual right sided weakness
presenting to the ED with left leg pain and fevers. Patient
reports he developed left leg pain, over medial aspect of
posterior knee 2 days ago. Pain worse when walking. He had no
pain with passive R knee movement. He has been having associated
fever and chills at home for the past 2 days. Has been taking
Tylenol every ___ hours for pain and for fevers. Today fever
went up to 102 so patient presented to ED.
In the ED, initial vital signs were: T 102.7, ___, 18,
100% RA
- Exam was notable for: AOx3. Mild tenderness over medial
aspect of L knee, normal panless AROM and PROM of L knee
- Labs were notable for: wbc 5.3, H/H ___, plt 109, 82%
neutrophils. LFTs wnl. Na 141, K 3.7, Cl 104, Bicarb 26, BUN 18,
Cr 2, gluc 108. INR 1.3. UA moderate blood, 600 protein.
- ___ negative for DVT of left leg.
- CXR Right upper lobe pleural plaque. No acute cardiopulmonary
process.
- RUQ US with no ascites. Only able to tolerate part of Doppler
study, but patent hepatic arteries and right/main vein.
- The patient was given: 1g Acetaminophen, 2L NS, Levofloxacin
750mg IV, Cefepime 2g IV, Vanc 1g, Morphine 4mg IV, 650mg
- Consults: hepatology consulted, requesting admission to ___
10
Vitals prior to transfer were: 98.2, HR 79, 133/67, 18, 99RA
Upon arrival to the floor, patient febrile to 101.8, HR 107.
Patient slightly confused. Having trouble getting words out.
Unable to tell me full story. Says that he has had leg pain
before, but usually due to edema. He has frequent urination,
waking up 4x a night. Denies previous issues with prostate.
Denies weak stream, or difficulty initiating urination. Missed
both tacro doses today.
Per wife, he has difficulty with speech since his surgery, but
does all his own medications at home. He ambulates with cane. Of
note, spironolactone was increased the beginning of ___ to
50mg from 25mg for persistent hypertension. No one is sick at
home.
Past Medical History:
# Liver Transplant (___) -- HCV cirrhosis and HCC
-- c/b anastamotic bile leak and stricture (stented ___
-- c/b mild acute rejection (biopsy ___
-- c/b recurrent HCV (biopsy ___
# HCV Cirrhosis -- Genotype 1A
-- recurrent infection after transplant
# Hepatocellular Carcinoma
# Cavitary Pneumonia -- Mycobacterium fortuitum
# Severe Esophagitis -- EGD (___)
# Hypertension
# Alcohol Abuse History
# Seizure Disorder -- none in many years
# Ruptured Cerebral Aneurysm (___)
-- residual right hemiparesis and aphasia
# Craniotomy with Clot Evacuation (___)
# Left Knee Surgery
# Ulnar Neuropathy History
# CVA with right sided weakness
Social History:
___
Family History:
No family history of liver disease.
Physical Exam:
==================
ADMISSION EXAM
==================
VITALS - 101.8, 150/91, 105, 18, 96RA
WEIGHT: 95.8kg
Bladder scan: 92cc post void
GENERAL - middle aged, ___ man, lying in bed,
confused, difficulty getting words out
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear
NECK - supple
CARDIAC - tachycardic, normal S1/S2, no murmurs rubs or gallops
PULMONARY - clear to auscultation bilaterally, without wheezes
or rhonchi
ABDOMEN - well healing scar from liver transplant, normal bowel
sounds, soft, non-tender, non-distended, no organomegaly
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema. No erythema of left leg, no warmth, nontender. No
difference in size between left and right legs.
SKIN - without rash
NEUROLOGIC - A&Ox1-2 (name, hospital, not ___, right sided
facial droop, ___ strength in right arm and leg (baseline). No
asterixis.
==================
DISCHARGE EXAM
==================
VS: 98.3, 144/92, 86, 18, 98RA
GENERAL - middle aged, ___ man, lying in bed,
appears fatigued, slightly slurred speech
HEENT - normocephalic, atraumatic
CARDIAC - RRR, normal S1/S2, no murmurs rubs or gallops
PULMONARY - CTAB
ABDOMEN - well healing scar from liver transplant, normal bowel
sounds, soft, non-tender, non-distended, no organomegaly
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema. SKIN - without rash
NEUROLOGIC - A&Ox3), right sided facial droop, ___ strength in
right arm and leg (baseline). ___ strength in left arm and leg.
No asterixis in left (cannot raise right arm).
Pertinent Results:
ADMISSION LABS
===============
___ 02:30PM WBC-5.3 RBC-4.68 HGB-12.0* HCT-37.2* MCV-80*
MCH-25.6* MCHC-32.3 RDW-13.1 RDWSD-37.2
___ 02:30PM NEUTS-82.0* LYMPHS-13.8* MONOS-3.8* EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-4.33 AbsLymp-0.73* AbsMono-0.20
AbsEos-0.00* AbsBaso-0.01
___ 02:30PM PLT COUNT-109*
___ 02:30PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 02:30PM CRP-66.3*
___ 02:30PM ALBUMIN-3.4* URIC ACID-5.4
___ 02:30PM LIPASE-32
___ 02:30PM ALT(SGPT)-17 AST(SGOT)-33 CK(CPK)-445* ALK
PHOS-94 TOT BILI-0.4
___ 02:30PM GLUCOSE-108* UREA N-18 CREAT-2.0* SODIUM-141
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-26 ANION GAP-15
___ 02:39PM LACTATE-1.2
___ 02:40PM ___ PTT-32.3 ___
DISCHARGE LABS
==============
___ 05:36AM BLOOD WBC-5.2 RBC-3.90* Hgb-9.8* Hct-30.6*
MCV-79* MCH-25.1* MCHC-32.0 RDW-13.8 RDWSD-39.4 Plt ___
___ 05:36AM BLOOD Plt ___
___ 05:36AM BLOOD Glucose-118* UreaN-19 Creat-1.7* Na-142
K-3.5 Cl-108 HCO3-24 AnGap-14
___ 05:36AM BLOOD ALT-35 AST-38 AlkPhos-68 TotBili-0.3
___ 05:36AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.9
PERTINENT LABS
==============
___ 05:05AM BLOOD tacroFK-5.0
___ 05:05AM BLOOD tacroFK-3.4*
___ 05:05AM BLOOD tacroFK-4.0*
___ 05:05AM BLOOD tacroFK-4.1*
___ 10:24AM BLOOD tacroFK-4.5*
MICRO
=====
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
Blood Culture, Routine (Pending):
__________________________________________________________
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.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
__________________________________________________________
Blood Culture, Routine (Pending):
__________________________________________________________
Blood Culture, Routine (Pending):
__________________________________________________________
CMV Viral Load (Final ___:
CMV DNA not detected.
Blood Culture, Routine (Pending):
__________________________________________________________
Blood Culture, Routine (Pending):
__________________________________________________________
URINE CULTURE (Final ___: <10,000 organisms/ml.
__________________________________________________________
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
Blood Culture, Routine (Final ___: NO GROWTH.
STUDIES
=======
-CXR
Oblong opacity projecting over the right upper lung is
compatible with
calcified pleural plaque. The lungs are otherwise clear. No
obvious effusion identified noting that there is exclusion of
the right lateral costophrenic angle on the frontal view. The
cardiomediastinal silhouette is stable given differences in
projection.
IMPRESSION: No acute cardiopulmonary process.
-Left Lower Extremity Ultrasound
No evidence of deep venous thrombosis in the left lower
extremity veins.
-RUQ Ultrasound
Patent portal and hepatic veins. Patent hepatic arteries, the
right and main hepatic artery not interrogated by Doppler
ultrasound secondary to patient unable to remain still for the
remainder of the study. Normal left hepatic artery waveform. No
focal hepatic lesion.
-CT A/P w/o Contrast
1. Although the exam is somewhat limited given the lack of IV
contrast,
peripancreatic fat stranding and fullness of the pancreatic head
is compatible with pancreatitis. The chronicity of this finding
is difficult to accurately assess, but is new since at least
___.
2. No focal fluid collection or intra-abdominal or pelvic
abscess is
identified.
3. Prior hepatic transplant, with persistent central periportal
edema,.
4. Sequelae of portal hypertension includes persistent
splenomegaly and
perisplenic varices along with small volume intra-abdominal
ascites.
5. Punctate, nonobstructing left lower pole renal stone.
-CT Chest w/o Contrast
No evidence of new infectious process. Chronic abnormalities
including pleural effusion, pleural calcifications and bronchial
wall thickening in the right lower lobe. Interval decrease in
the right upper lobe pneumatoceles currently less than 5 mm in
diameter.
Brief Hospital Course:
___ year old man with PMHx of hep C cirrhosis s/p liver
transplant complicated by recurrent cirrhosis of transplanted
liver, HCC, hx of CVA with residual right sided weakness
presenting to the ED with left leg pain and fevers, found to
have ___.
ACTIVE ISSUES
==============
# Fever. He presented with fever to 103, with associated rigors
and tachycardia, meeting criteria for SIRS. He was started on
broad spectrum antibiotics with Vancomycin/Cefepime/Flagyl. He
required scheduled APAP and cooling blankets but remainder
persistently febrile for the first ___ hours of admission on
antibiotics. He defervesced with last fever on ___ in the
morning. Infectious work up was unrevealing, including CXR,
Chest CT, CT A/P, and left knee xray. CMV VL was negative. Blood
and urine cultures were negative. Antibiotics were discontinued
after 4 days and he was monitored for 48 hours. He continued to
improve without fevers and was discharged to home. The only
other possible contributor to his fevers could have been the
study drug he has been receiving.
# Left knee pain. He presented with left knee pain, however this
resolved spontaneously without intervention. Xray was without
fracture. Lower extremity ultrasound was without DVT.
# ___. Cr on admission was 2, elevated from recent baseline
around 1.6. Cr downtrended with holding spironolactone and
giving IV albumin. Spironolactone was restarted prior to
discharge and Cr was at baseline 1.7.
CHRONIC ISSUES
==============
# HTN: Initially held amlodipine and spironolactone given SIRS,
but restarted prior to discharge.
# Hep C cirrhosis s/p extended criteria liver transplant,
complicated by recurrent hep C cirrhosis. HCV of transplanted
liver cleared with simeprevir and sofosbuvir and he was enrolled
in a trial of antifibrotic therapy. He was continued on this
study drug while inpatient. His cirrhosis was compensated with
no LFT abnormalities, ascites ___ edema. He was continued on
home tacrolimus dosing 3mg BID.
# Seizure disorder. Continued keppra 1500mg BID
# HLD. Continued pravastatin 40mg QHS
TRANSITIONAL ISSUES
===================
Immunosuppression
- Tacrolimus 3mg BID
- Resume standing transplant lab order on discharge
# CONTACT: Patient, Taunia (Wife, HCP) ___
___
# CODE STATUS: Full code confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. LeVETiracetam 1500 mg PO BID
3. Pravastatin 40 mg PO QPM
4. Spironolactone 25 mg PO DAILY
5. Tacrolimus 3 mg PO Q12H
6. Acetaminophen 325-650 mg PO Q8H:PRN pain
7. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
8. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. LeVETiracetam 1500 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. Pravastatin 40 mg PO QPM
5. Spironolactone 25 mg PO DAILY
6. Tacrolimus 3 mg PO Q12H
7. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
8. IDN-___/placebo Study Med 25 MG PO 2X DAY
Discharge Disposition:
Home
Discharge Diagnosis:
Fever, unknown origin
Left knee pain
Encephalopathy
___
HTN
Hep C cirrhosis s/p extended criteria liver transplant
Seizure disorder
HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization. Briefly, you were hospitalized with fevers and
left knee pain. You were started on antibiotics and your fevers
improved. You did not have any factures in your left knee on
xray. We watched you in the hospital for 48 hours after stopping
antibiotics and you continued to improve. We did not find any
bacterial cause for your fevers in the blood or urine.
We wish you the best,
Your ___ Treatment Team
Followup Instructions:
___
|
10048262-DS-18 | 10,048,262 | 20,845,468 | DS | 18 | 2168-08-29 00:00:00 | 2168-08-29 21:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aloe / apple / egg
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
===================
___ 06:45PM BLOOD WBC-9.3 RBC-5.11 Hgb-15.2 Hct-44.8 MCV-88
MCH-29.7 MCHC-33.9 RDW-13.6 RDWSD-43.7 Plt Ct-UNABLE TO
___ 06:45PM BLOOD Neuts-88.0* Lymphs-4.0* Monos-7.0
Eos-0.0* Baso-0.2 Im ___ AbsNeut-8.22* AbsLymp-0.37*
AbsMono-0.65 AbsEos-0.00* AbsBaso-0.02
___ 06:45PM BLOOD ___ PTT-32.8 ___
___ 06:45PM BLOOD Glucose-130* UreaN-12 Creat-0.5 Na-140
K-3.2* Cl-98 HCO3-22 AnGap-20*
___ 06:45PM BLOOD ALT-30 AST-24 AlkPhos-60 TotBili-0.5
___ 06:45PM BLOOD cTropnT-<0.01
___ 06:45PM BLOOD Albumin-4.2 Calcium-9.1 Phos-1.9* Mg-1.6
___ 06:51PM BLOOD ___ pO2-121* pCO2-30* pH-7.50*
calTCO2-24 Base XS-1 Comment-GREEN TOP
___ 06:51PM BLOOD Lactate-3.8*
___ 10:10PM BLOOD Lactate-3.1*
___ 02:52AM BLOOD Lactate-4.3*
___ 06:37AM BLOOD Lactate-2.6*
PERTINENT LABS:
==================
___ 09:07AM BLOOD WBC-3.6* RBC-3.46* Hgb-10.2* Hct-31.0*
MCV-90 MCH-29.5 MCHC-32.9 RDW-14.3 RDWSD-46.5* Plt Ct-67*
___ 05:10AM BLOOD WBC-8.0 RBC-3.43* Hgb-10.2* Hct-32.2*
MCV-94 MCH-29.7 MCHC-31.7* RDW-14.2 RDWSD-48.0* Plt ___
___ 09:07AM BLOOD ___ PTT-32.3 ___
___ 05:10AM BLOOD ___ PTT-28.0 ___
___ 02:28AM BLOOD ALT-34 AST-34 AlkPhos-52 TotBili-0.7
___ 04:41AM BLOOD ALT-193* AST-161* AlkPhos-66 TotBili-0.4
___ 05:21AM BLOOD ALT-105* AST-38 AlkPhos-62 TotBili-0.3
___ 06:45PM BLOOD cTropnT-<0.01
___ 09:07AM BLOOD calTIBC-168* ___ Ferritn-1202*
TRF-129*
___ 09:07AM BLOOD ___ 09:07AM BLOOD Ret Aut-1.1 Abs Ret-0.04
___ 04:12AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
___ 04:12AM BLOOD HCV Ab-NEG
___ 05:38PM BLOOD Lactate-4.2*
___ 09:46AM BLOOD Lactate-1.3
MICRO:
===========
___ 6:45 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
___ ___. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
___
|
AMIKACIN-------------- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 R
TRIMETHOPRIM/SULFA---- <=1 S
___ 11:55 pm URINE **FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 5:05 pm BLOOD CULTURE Source: Venipuncture. **FINAL
REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
======================================
CTA CHEST Study Date of ___ 7:54 ___
1. Nonspecific 1.4 cm nodular left upper lobe opacity which may
represent
pneumonia. Recommend follow-up CT chest in 3 months to assess
for resolution.
Pulmonary nodule not excluded.
2. Malpositioned Foley catheter with balloon in the base of the
penis.
3. Moderate amount stool in the distal sigmoid
colon/rectosigmoid. Equivocal
associated mild wall thickening, possible early stercoral
colitis.
4. Chronic appearing left hip dislocation with adjacent soft
tissue
thickening, adjacent joint effusion not excluded.
KUB ___:
There are diffusely air-filled dilated loops of large bowel
involving the right and transverse colon with moderate
descending and sigmoid colonic stool burden. No dilated loops
of small bowel visualized. There is no evidence of free
intraperitoneal air. Right lower abdominal wall battery pack and
single spinal stimulator lead noted overlying the right lower
abdomen and pelvis. Surgical clips in the right upper quadrant
again noted. At least moderate bilateral hip degenerative
changes, incompletely assessed.
IMPRESSION:
1. No evidence of pneumoperitoneum.
2. Nonobstructive bowel gas pattern with moderate stool burden.
RUQ US ___:
LIVER: The left lobe of the liver is not adequately visualized
due to overlying bowel gas. Otherwise, the hepatic parenchyma
appears within normal limits. The contour of the liver is
smooth. There is no focal liver mass. The main portal vein is
patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 5 mm
GALLBLADDER: The gallbladder is not definitively visualized.
However, there is a rounded structure in the area of the
gallbladder fossa measuring 1.2 x 1.6 x 1.0 cm, which may
represent a contracted gallbladder.
IMPRESSION:
1. No evidence of intrahepatic or extrahepatic biliary
dilatation.
2. Likely contracted gallbladder.
3. Splenomegaly.
DISCHARGE LABS:
==================
No labs collected ___ 05:21AM BLOOD WBC-8.5 RBC-3.52* Hgb-10.5* Hct-32.7*
MCV-93 MCH-29.8 MCHC-32.1 RDW-14.6 RDWSD-48.3* Plt ___
___ 05:21AM BLOOD Plt ___
___ 05:21AM BLOOD Glucose-109* UreaN-11 Creat-0.4* Na-142
K-4.4 Cl-101 HCO3-26 AnGap-15
___ 05:21AM BLOOD ALT-105* AST-38 AlkPhos-62 TotBili-0.3
___ 05:21AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.0
DISCHARGE EXAM:
==================
VITALS: ___ 0809 Temp: 97.9 PO BP: 108/70 L Lying HR: 86
RR: 18 O2 sat: 94% O2 delivery: RA
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Clear to auscultation bilaterally, no wheezes, rales, or
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
or
gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding
Ext: Warm with 2+ pulses, trace pitting edema in the feet
bilaterally, boots on
Skin: No rashes or lesions
Neuro: responds appropriately to questions and follows commands,
unable to move ___ bilaterally.
LABS: Reviewed in ___
Brief Hospital Course:
SUMMARY:
=====================
Mr. ___ is a ___ man with a history of advanced
secondary progressive multiple sclerosis with cognitive decline,
who presented from his group home with sepsis and lactic
acidosis requiring brief MICU admission (<24h) and found to have
Providencia stuartii bacteremia. On presentation to the ED, his
UA was consistent with possible UTI, but his urine cultures
remained without growth during his hospital course. He had a CT
torso that showed a possible L lingular pneumonia and he was
briefly on CTX/azithro in the setting of new oxygen requirement
(___) but he was quickly weaned off of oxygen and did not have
other symptoms of pneumonia/URI and it was stopped.
Additionally, CT torso showed possible stercoral colitis and he
was briefly on flagyl. His hospital course was complicated by
constipation requiring manual disimpaction in the ED after which
he remained constipated and his bowel regimen was escalated
until he had several large bowel movements after 5 days without
any. On presentation to the ED, he had hematuria from a
traumatic foley in his urethera that was placed at the group
home. The foley was removed and he was voiding well with a
condom catheter although retaining ~500cc before urinating,
which per the patient and his family is what he usually uses.
For treatment of his Providencia stuartii bacteremia, he
underwent ___ guided R PICC placement and ID was consulted and he
was started on cefepime to complete a 2 week course from his
last negative blood culture (___) with a plan to switch
to ertapenem at discharge for ease of dosing. He was noted to
have transaminitis on ___ and RUQ US showed no evidence of
structural causes and his transaminitis was thought to be
secondary to cephalosporins and he was switched to meropenem on
___ with improvement of his transaminitis. He remained
hemodynamically stable and afebrile on IV antibiotics with
negative surveillance cultures and with resolution of his
thrombocytopenia, which was thought to be secondary to sepsis,
and he was discharged back to his group home on ertapenem to
complete his course of IV antibiotics (last day ___.
TRANSITIONAL ISSUES:
======================
[] He will need to continue IV antibiotics with ertapenem 1g q24
hours until ___ (last day ___. Okay to remove PICC line after
course of IV antibiotics completed.
[] He is due for a refill of his baclofen pump on ___.
Confirmed with group home that they will be able to refill it
there when he gets back.
[] Have physician at ___ home check CBC and LFTs in ~1 week
(___) to make sure that his thrombocytopenia and transaminitis
have resolved.
[] Please follow-up with his neurologist about management of his
possible early urinary retention/neurogenic bladder. Please
avoid foley as he is voiding well with a condom catheter but he
usually doesn't void until he is retaining 500-600ccs.
[] Please order a repeat CT chest in 3 months to evaluate for
resolution of L lingular opacity.
[] His CT imaging demonstrated left hip fluid collection/joint
effusion. Ortho reviewed the imaging and it appears chronic
since ___ based on prior Xray.
[] He is not immune to Hep B (surface ab neg) but has an egg
allergy (?sneezing). If allergy not severe, he should receive
the Hep B vaccine.
ACUTE ISSUES
=======================
#Fever
#Sepsis
#?UTI
#?L lingula pneumonia
#Provide___ bacteremia
Patient was febrile to 105 at outpatient facility and was 104 on
presentation to the ___ ED. His UA was grossly positive with
prior dysuria c/f UTI in the setting of recent foley (possibly
placed on ___ for possible chronic urinary retention although
usually urinates well with a condom cath. Of note, his urine
culture from the ER without growth. CT chest concerning for
possible L lingula pneumonia but patient clinically without
symptoms of pneumonia and stopped CTX/azithro (___) as
penumonia unlikely. BCx from ___ growing Providencia ___,
which is usually from a urinary source, but of note all his
urine cultures remained negative. ID was consulted and
recommended a 2 week course of abx from first negative culture
(___) with Cefepime 2 mg IV q12h while inpatient and plan
to discharge on ertapenem 1 g IV daily for ease of once daily
dosing. However, due to elevated transaminases thought to be due
to cephalosporins, he was changed from cefepime to meropenem
___ with improvement in his transaminitis. He remained
afebrile and hemodynamically stable with negative blood cultures
on IV antibiotics and was discharged back to his group home on
ertapenem 1 g q24h through ___.
#Elevated LFTs
#Transaminitis
#Drug induced liver injury
Elevated ALT/AST with normal alk phos and bili c/w
hepatocellular pattern. Notably LFTs were normal upon
presentation. Hepatitis panel with Hep B non-immune but
otherwise negative. RUQUS with poorly visualized left liver lobe
but otherwise normal hepatic parenchyma. Given no structural
deficits, transaminitis thought to be due to cephalosporins and
he was switched to meropenem on ___ with gradual improvement
in his LFTs.
#?Urinary retention
#Hematuria
#Traumatic foley placement
He has a questionable history of urinary retention and it is
unclear why he had a foley on presentation to the ED as he is
usually able
to void okay with a condom catheter per the patient and his
family but notes from the OSH state it was placed for urinary
retention. On CT A/P in the ED, his foley was misplaced in his
urethra and likely was the cause of his hematuria. The foley was
replaced in the ED and removed in the ICU and a condom cath was
placed. We paged urology several times about if he could be
straight cathed if necessary or if he would require another
foley if he was retaining urine but we did not get a response.
His hematuria resolved and he was voiding well with the condom
cath and did not require straight cath. Of note, he was
retaining 500-600 cc on bladder scan before voiding.
#?Stercoral colitis
#Constipation
CT A/P was concerning for stercoral colitis and he was manually
disimpacted in ED. In one of the notes from the group home,
there was mention of ulcerative colitis but per patient and
family there is no diagnosis of UC and he is not on treatment
for it. He has chronic constipation at baseline and his bowel
regimen was escalated, including miralax, senna, lactulose,
bisacodyl, and multiple enemas, until he finally had several
large bowel movements on the 5 day without any. He developed
nausea and abdominal cramping from his constipation and KUB at
that time showed moderate stool burden without evidence of
ileus, obstruction, or perforation.
#Multiple Sclerosis
#Baclofen pump
Patient has a history of advanced progressive MS with cognitive
decline and has a baclofen pump. He stated that his pump needs
to be refilled soon and anesthesia was consulted for baclofen
pump interrogation (on 299mcg/day) and he is due for a refill on
___. Before discharge, we confirmed with his group home that
they will be able to refill his pump when he returns.
#Dislocated Hip w/ Effusion
CT A/P demonstrated chronic appearing left hip dislocation with
complex fluid collection c/f hematoma vs. infection within the
hip joint without evidence of bone erosion. Ortho reviewed the
images and thought it was most likely chronic dislocation (since
___ in a patient that is mostly bedbound. We had low clinical
suspicion for a septic joint as he did not have any pain and
remained stable on antibiotics for treatment of his ___
bacteremia.
#Thrombocytopenia (resolved)
Patient presented with thrombocytopenia (plt 67 at lowest) and
initially it was unclear if it was chronic but was not present
as of ___ and his labs were negative for hemolylsis or DIC.
With treatment of his sepsis/bacteremia, his platelet count
gradually recovered and was normal on day of discharge (199) and
was thought to be secondary to sepsis.
#Lactic Acidosis (resolved)
He presented with lactic acidosis in the ED likely iso sepsis as
above. He was initially fluid responsive to 2L IVF, but his
lactic acidosis uptrended upon arrival to the ICU likely in the
setting of insufficient fluid resuscitation. His lactic acidosis
then resolved on ___ (1.3) after adequate fluid resuscitation
with an additional 2L of LR.
CHRONIC ISSUES
=======================
#Vitamin D deficiency
#Osteoporosis
He was continued on his home vitamin D and calcium.
#CODE STATUS: Full confirmed (MOLST in chart)
#CONTACT: HCP: ___ (Mother) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 1500 mg PO BID
2. Docusate Sodium 100 mg PO BID
3. Multivitamins 1 TAB PO BID
4. Senna 17.2 mg PO DAILY
5. Naproxen 440 mg PO Q12H:PRN Pain - Mild
6. Acetaminophen 650 mg PR Q6H:PRN Pain - Mild/Fever
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
8. Clotrimazole Cream 1 Appl TP BID:PRN rash
9. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP BID
10. Loratadine 10 mg PO DAILY:PRN allergy
11. Vitamin D 3000 UNIT PO DAILY
12. Lioresal (baclofen) 2,000 mcg/mL injection DAILY
13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Discharge Medications:
1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
2. Acetaminophen 650 mg PR Q6H:PRN Pain - Mild/Fever
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Calcium Carbonate 1500 mg PO BID
5. Clotrimazole Cream 1 Appl TP BID:PRN rash
6. Docusate Sodium 100 mg PO BID
7. Lioresal (baclofen) 2,000 mcg/mL injection DAILY
8. Loratadine 10 mg PO DAILY:PRN allergy
9. Multivitamins 1 TAB PO BID
10. Naproxen 440 mg PO Q12H:PRN Pain - Mild
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
12. Senna 17.2 mg PO DAILY
13. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP BID
14. Vitamin D 3000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=======================
# Providencia ___ bacteremia
# Sepsis
SECONDARY DIAGNOSIS:
======================
# Fever
# L lingular opacity without evidence of pneumonia
# Transaminitis
# Drug induced liver injury
# Hematuria secondary to traumatic foley placement
# Possible stercoral colitis
# Constipation
# Multiple sclerosis with baclofen pump
# Chronically dislocated left hip with effusion
# Thrombocytopenia (resolved)
# Lactic acidosis (resolved)
# Vitamin D deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You were admitted to the hospital because you had a fever (105
degrees)
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- You were found to have an infection in your blood (___
___) and were started on IV antibiotics
- The foley catheter in you bladder wasn't in the correct place
and it was removed and you were voiding okay without it
- You were not having bowel movements and you finally had a
bowel movement after lots of medications
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10048986-DS-18 | 10,048,986 | 28,592,015 | DS | 18 | 2127-04-10 00:00:00 | 2127-04-12 21:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
Emesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old male with AAA, BPH, GERD who
presents from home with one day of nausea and vomiting. He was
in his normal state of health until the day prior to admission
when he developed sudden nausea and 4 episodes of dark but
non-bloody emesis. He was at a ___ service commemorating
___ anniversary of son's death at the time. He ate food with
family, drank a very small amont of wine. He describes upper
abdominal discomfort with the vomiting. He had one episode of
loose stool yesterday. He denies antibiotic use during the past
six months. He denies dyspnea, chest pain.
In the ED, initial vs were: 98.6 72 150/72 16 99% RA. CTA abd:
no SBO, stable appearance of infrarenal aorta. Patient was given
zofran x 3 with improvement in symptoms. Vitals on Transfer:97.8
71 140/75 16 97% RA
He feels that his nausea and vomiting are improving. He feels
that he may need to have a bowel movement.
Past Medical History:
-GERD
-knee osteoarthritis
-AAA
-BPH
-spinal stenosis
-? hx of pancytopenia per PCP, MDS ___ hernia
-insomnia
-lower extremity edema wearing compression stockings
Social History:
___
Family History:
coronary artery disease
Physical Exam:
Vitals: T: 97.7 BP:104/58 HR:58 RR:18 O2: 98%R
General: comfortable, NAD
HEENT: anicteric sclera
Lungs: CTA bilaterally, unlabored
CV: S1, S2 regular rhythm, normal rate
Abdomen: soft, mild TTP epigastric area, no rebound, not
distended
Ext: 1+ edema, not wearing compression stockings
Neuro: alert, oriented, speech fluent
Pertinent Results:
ADMISSION LABS:
___ 12:50AM BLOOD WBC-16.7*# RBC-3.43* Hgb-10.9* Hct-33.8*
MCV-99* MCH-31.8 MCHC-32.3 RDW-14.8 Plt ___
___ 12:50AM BLOOD Neuts-86.4* Lymphs-6.9* Monos-4.3 Eos-1.9
Baso-0.6
___ 12:50AM BLOOD Glucose-121* UreaN-26* Creat-0.9 Na-136
K-4.0 Cl-102 HCO3-23 AnGap-15
___ 12:50AM BLOOD ALT-31 AST-43* AlkPhos-61 TotBili-0.8
___ 12:50AM BLOOD Lipase-60
___ 12:50AM BLOOD cTropnT-<0.01
___ 12:50AM BLOOD Albumin-4.5
___ 05:20AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.9
.
DISCHARGE LABS:
___ 09:10AM BLOOD Hct-30.7*
___ 06:30AM BLOOD Plt ___
___ 09:10AM BLOOD Glucose-106* UreaN-11 Creat-1.0 Na-141
K-3.9 Cl-108 HCO3-25 AnGap-12
___ 06:30AM BLOOD calTIBC-218* VitB12-687 Ferritn-213
TRF-168*
___ 06:30AM BLOOD TSH-3.0
___ 06:30AM BLOOD Calcium-8.0* Phos-2.3* Mg-1.8 Iron-24*
.
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.
CT ABDOMEN:
The imaged lung bases demonstrate bibasilar dependent
atelectasis without
pleural effusions. Heart is top normal in size without
pericardial effusion.
Small hiatal hernia is noted.
The liver demonstrates homogeneous enhancement without
suspicious focal
lesions. There is no evidence of intrahepatic or extrahepatic
biliary ductal
dilatation. The gallbladder is incompletely distended. There
is no
gallbladder wall edema or pericholecystic fluid collection to
suggest acute
inflammation. No calcified gallstones are seen within its
lumen. The spleen
is unremarkable. The pancreas enhances homogeneously without
ductal
dilatation or peripancreatic fluid collection. The adrenal
glands are normal.
The kidneys enhance and excrete contrast symmetrically without
evidence of
hydronephrosis or renal masses. Multiple renal hypodensities
bilaterally are
too small to characterize and are likely cysts. The largest
hypodense lesion
arising from the lower pole of the left kidney measures 5.1 x
4.8 cm with 12
Hounsfield units in attenuation, compatible with a simple cyst,
unchanged.
The small and large bowel loops are normal in caliber without
evidence of
bowel wall thickening or obstruction. The appendix is not
visualized;
however, there are no secondary signs to suggest inflammation in
the right
lower abdomen. There is no mesenteric or retroperitoneal
lymphadenopathy.
The imaged intra-abdominal aorta and its branches demonstrate
moderately
severe calcified atherosclerotic disease. Infrarenal aorta
measures 2.8 cm in
maximum dimension, with stable-appearing focal dissection.
CT OF THE PELVIS: The bladder, distal ureters, rectum and
sigmoid colon are
unremarkable. The prostate gland appears enlarged. There is no
free air or
free fluid within the pelvis. Post-surgical changes related to
bilateral
inguinal hernia repair are noted. There is no pelvic wall or
inguinal
lymphadenopathy.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic bony
lesion is seen.
IMPRESSION:
1. No acute CT findings to account for the patient's clinical
presentation.
2. Calcified atherosclerotic disease of the aorta. Stable
appearance of the
dilated infrarenal aorta measuring 2.8 cm in maximum dimension
with stable
focal dissection.
3. Bilateral renal hypodensities, most compatible with cysts.
4. Small hiatal hernia.
.
CXR:
FINDINGS:
Frontal and lateral views of the chest demonstrate low lung
volumes. There is
no focal consolidation, pleural effusion or pneumothorax. A
6-mm nodular
opacity projecting over the right upper lung is stable since
priors. Hilar
and mediastinal silhouettes are unchanged. The descending aorta
appears
tortuous. Heart size is top normal. Perihilar vascular
congestion is noted.
There is mild intersitial pulmonary edema.
IMPRESSION:
No focal consolidation. Mild interstitial pulmonary edema.
Brief Hospital Course:
#GASTROENTERITIS: The patient symptoms of emesis and loose
stool were most consistent with viral gastroenteritis. There
was no evidence on labs or imaging of hepatitis, pancreatitis,
colitis, appendicitis, or bowel obstruction. Infectious stool
studies - C. difficile and stool culture - were negative. He
was managed supportively with bowel rest, IVF, and anti-emetics.
His symptoms were already improving at the time of admission.
At the time of discharge, he was tolerating a regular diet and
bowel movements had improved.
#GERD:Continue PPI
#HX AAA: stable on CT
#Anemia: Patient with history of macrocytic anemia, presumed MDS
#BPH:Continue finasteride and tamsulosin
#RENAL CYST: Stable on CT abdomen
#PULMONARY NODULE: Stable on CXR
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Tamsulosin 0.4 mg PO HS
3. Omeprazole 20 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Lorazepam 0.5 mg PO HS:PRN insomnia
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Tamsulosin 0.4 mg PO HS
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Lorazepam 0.5 mg PO HS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Viral gastroenteritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure to participate in your care. You were admitted
to the hospital with vomiting and loose stool. This was likely
due to a viral gastroenteritis. Your symptoms improved and you
were discharged. Please follow up with your primary care
physician. Happy holidays!
Followup Instructions:
___
|
10048986-DS-19 | 10,048,986 | 22,347,741 | DS | 19 | 2127-10-13 00:00:00 | 2127-10-14 23:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
Right lower leg pain on ambulation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx spinal stenosis presents with RLE pain, which began
today, and is present only on walking/standing. He feels that
his pain is throughout his leg. He denies weakness, notes that
his ability to walk is limited by pain. He denies n/v/d, no
fevers or chills, no hx of cancer. He thinks his RLE may be more
swollen than usual. No new numbness, weakness or incontinence.
He denies any international travel, long car rides,
immoblization for >1wk, ortho surgerys (carpal tunnel ___,
but he was back to normal routine same day). He denies night
sweats, weight loss, change in bowel habits, bloodly stools, or
smoking.
Past Medical History:
-GERD
-knee osteoarthritis
-AAA
-BPH
-spinal stenosis
-? hx of pancytopenia per PCP, MDS ___ hernia
-insomnia
-lower extremity edema wearing compression stockings
Social History:
___
Family History:
coronary artery disease
Physical Exam:
Admission:
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera,
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: Irregular, distant S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly.
EXTREMITIES: moving all extremities well, no cyanosis or
clubbing, 2+ edema to mid lower extremity. RLE cool to touch,
LLE warm to touch. Sensation to touch decreased in both L and R
___. Signs of PVD present.
PULSES: Could not appreciate in Right, faint in left.
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
LABS: see below
Discharge:
97.5 117/62 60 18 99RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera,
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: Irregular, distant S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly.
EXTREMITIES: moving all extremities, no cyanosis or clubbing, 2+
edema to mid lower extremity now resolving with ___, worse on
the L. RLE cool to touch, LLE warm to touch. Sensation to touch
decreased in both L and R ___. Signs of PVD present.
PULSES: Could not appreciate in Right, faint in left.
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
___ 03:45PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
___ 03:45PM WBC-6.3 RBC-3.11* HGB-10.3* HCT-31.8*
MCV-102* MCH-33.2* MCHC-32.4 RDW-14.4
___ 03:45PM estGFR-Using this
___ 03:45PM ___ PTT-30.2 ___
___ 03:45PM PLT SMR-NORMAL PLT COUNT-128*
Brief Hospital Course:
___ with hx spinal stenosis presents with RLE pain, which began
today, and is present only on walking/standing. In the ED: RLE
u/s reveals + DVT.
Pt's pain likely d/t contribution from DVT. No evidence of cauda
equina syndrome, no evidence of cord compressiion.
In the ED, initial vitals were: 97.3 66 138/67 18 97% ra
On the floor, Pt has stable vitals and no complaints. He notes
mild pain in the RLE with walking.
#DVT:
Pt. started on Enoxoparin 70 mg SQ q12H and Warfarin 4 mg PO
DAYS (___). Education nurse attempted education
for ___ shots at home; however, pt did not feel comfortable
giving. VMA can only come once a day and with twice daily shots,
Mr. ___ had to stay with us until his INR reached
therapeautic levels. We monitored his INR and labs daily. No
signs of PE developed. On ___ his INR reached 1.9, and
outpatient ___ was arranged to follow INR ___
___ therapy saw and suggested in-home ___ ___
weekly. ___ visited him several times inpatient for evaluation
and early ambulation.
-For pain: TraMADOL (Ultram) 50 mg PO Q6H:PRN pain.
# BPH - We Continued his home regimen of Tamsulosin 0.4 mg PO HS
and Finasteride 5 mg PO DAILY
#GERD
-We continued his home dose of Omeprazole 20 mg PO DAILY
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Lidocaine 5% Patch 1 PTCH TD QAM
3. Omeprazole 20 mg PO DAILY
4. Tamsulosin 0.4 mg PO HS
5. Aspirin 81 mg PO DAILY
6. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID bug bites
7. Acetaminophen 500 mg PO Q8H:PRN pain
8. melatonin 1 mg oral QHS
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Glucosamine Sulf-Chondroitin (glucosamine ___ 2KCl-chondroit)
500-400 mg oral daily
11. flaxseed oil 1,000 mg oral daily
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Lidocaine 5% Patch 1 PTCH TD QAM
3. Omeprazole 20 mg PO DAILY
4. Tamsulosin 0.4 mg PO HS
5. Acetaminophen 650 mg PO Q8H:PRN pain
6. Docusate Sodium 100 mg PO DAILY:PRN Constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*0
7. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth q6 hr Disp
#*20 Tablet Refills:*0
8. Warfarin 4 mg PO DAILY
RX *warfarin 2 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet
Refills:*0
9. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID bug bites
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. flaxseed oil 1,000 mg oral daily
12. Glucosamine Sulf-Chondroitin (glucosamine ___ 2KCl-chondroit)
500-400 mg oral daily
13. melatonin 1 mg oral QHS
14. Outpatient Lab Work
Check INR on ___. ___ will schedule after this
date.
ICD-9: 453.4
Please fax results to ___ clinic fax:
___ (responsible provider ___, phone,
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
DVT
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 while at ___. You came to
us with pain in your lower leg while walking and we found a
blood clot in your deep leg veins. The treatment for this is to
thin your blood to prevent the clot from enlarging. Over time,
your body will dissolve the clot. The oral medication, Warfarin,
takes a few days to start working, so we had to give you a few
days of a medication called Lovenox (shots), which works much
faster. You are taking warfarin at the same time, so the lovenox
is a bridge to a therapuetic warfarin level. We had physical
therapy see you while here, and they would like to work with you
at home.
Followup Instructions:
___
|
10049041-DS-21 | 10,049,041 | 25,923,317 | DS | 21 | 2164-01-11 00:00:00 | 2164-01-11 20:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Precedex
Attending: ___
___ Complaint:
Date of ICU Admission: ___
Reason for ICU Admission: AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a history of COPD and HTN, recently
here with severe refractory hypercarbic respiratory failure ___
COPD exacerbation, MSSA Pneumonia, s/p trach placement ___, who
re-presents from LTACH with altered mental status.
Patient was recently admitted from ___ to ___ for refractory
hypercarbic respiratory failure with failure to wean off the
ventilator, ultimately requiring a tracheostomy and PEG tube
placement. That course was c/b MSSA pneumonia, acute sinusitis,
severe constipation. He was discharged to rehab. The day of
admission he was noted to be minimally responsive, with
hypercarbia (et CO2 ___ was transferred here.
In the ED, initial vitals notable for HR 110s-120s, BPs
___, RR 24. 97-100% vent/trach. Exam was notable for
minimal reactivity (grimaces to noxious stimuli but does not
withdraw to pain), distended abdomen, trach and PEG sites c/d/I.
VBG showed pH 7.3, PCO2 88. CBC WBC 12.7, Hgb 8.7, Plts 337.
LFTs
51/80. BMP notable for HCO3 of 37. BUN/Cr ___. Troponins
<0.01, flu negative. CXR without focal consolidation or edema.
He
was placed on assist control with improvement in mental status
to
baseline.
Patient was given vancomycin/Zosyn and 2L fluid. Due to
abdominal
distention, CT A/P was obtained which showed no acute process.
He
communicated to the ED team that people "are trying to kill me
at
rehab."
On arrival to the MICU, the patient is awake and alert, denies
pain, shortness of breath. Notes that he has been constipated.
No
chest pain. Mildly short of breath. No new rashes or lesions.
Appears somewhat disoriented and paranoid.
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
COPD
HTN
Appendectomy
Social History:
___
Family History:
No family history of cardiovascular disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: reviewed
GEN: alert, trach in place
HENNT: sclera anicteric
CV: RRR, nl s1, s2
RESP: Mild bilateral wheezes
GI: distended, mildly tender to palpation
EXTREM: no ___
SKIN: WWP
NEURO: Alert, responding to questions appropriately, moving all
extremities
DISCHARGE PHYSICAL EXAM:
VS: reviewed
GEN: alert + oriented, trach in place
HENNT: sclera anicteric
CV: RRR, nl s1, s2
RESP: Mild bilateral wheezes
GI: distended, mildly tender to palpation
EXTREM: no ___
SKIN: WWP
NEURO: Alert, responding to questions appropriately, moving all
extremities. Appears in better spirits.
Pertinent Results:
ADMISSION LABS
===============
___ 03:55PM BLOOD WBC-12.7* RBC-2.70* Hgb-8.7* Hct-29.1*
MCV-108* MCH-32.2* MCHC-29.9* RDW-15.9* RDWSD-62.0* Plt ___
___ 03:55PM BLOOD ___ PTT-25.8 ___
___ 03:55PM BLOOD Glucose-148* UreaN-26* Creat-0.6 Na-142
K-4.4 Cl-91* HCO3-37* AnGap-14
___ 03:55PM BLOOD ALT-80* AST-51* AlkPhos-101 TotBili-0.2
___ 03:55PM BLOOD proBNP-285*
___ 03:55PM BLOOD cTropnT-<0.01
___ 03:55PM BLOOD Lipase-16
___ 03:55PM BLOOD Albumin-3.3* Calcium-9.7 Phos-5.5* Mg-2.1
___ 04:02PM BLOOD ___ pO2-52* pCO2-88* pH-7.30*
calTCO2-45* Base XS-12
___ 04:02PM BLOOD Lactate-0.8 Creat-0.6 K-3.9
___ 04:02PM BLOOD Hgb-9.1* calcHCT-27
DISCHARGE LABS
===============
___ 02:32AM BLOOD WBC-11.8* RBC-2.27* Hgb-7.3* Hct-24.7*
MCV-109* MCH-32.2* MCHC-29.6* RDW-16.0* RDWSD-63.0* Plt ___
___ 02:32AM BLOOD ___ PTT-20.8* ___
___ 02:32AM BLOOD Glucose-87 UreaN-20 Creat-0.6 Na-140
K-3.6 Cl-91* HCO3-36* AnGap-13
___ 02:32AM BLOOD Calcium-9.6 Phos-3.1 Mg-1.9
IMAGING/STUDIES
================
___
CXR: COPD/pulmonary emphysema. No focal consolidation.
___ CT Head:
1. No evidence of acute intracranial process.
2. Air-fluid levels in the sphenoid and maxillary sinuses,
which can be seen with acute sinusitis in the appropriate
clinical setting. Correlation with clinical circumstances is
recommended.
___ CT a/p:
1. No acute findings. No findings to account for abdominal
distension.
2. PEG tube in place.
3. Areas of hepatic hypodensity, not fully characterized the
thought to represent benign cysts and likely focal fat
deposition.
Brief Hospital Course:
Mr. ___ is a ___ with history of COPD, HTN, and recent
admission for hypercarbic respiratory failure ___ COPD
exacerbation and MSSA pneumonia, s/p trach placement ___, who
presents from his LTAC with altered mental status, ultimately
attributed to sedating medications.
ACUTE ISSUES:
# Toxic metabolic encephalopathy
Initial concern for infection but ultimately, infectious work-up
negative. No evidence of metabolic derangements. Ultimately
contributed to sedation from home methadone. Mental status
improved after this medication was held, and patient was
transitioned to oxycodone PRN for pain control.
CHRONIC ISSUES:
# Anxiety: Continued home Seroquel at reduced dose (see
discharge med list)
# Acute sinusitis: Identified on CTH during prior admission.
Continued agumentin (last day ___.
# Constipation: Likely secondary to chronic opioid use. Continue
home standing bowel regimen and also trialed methylnaltrexone
with some improvement.
# Pain
Held home methadone on discharge, as above. Treated pain with
oxycodone PRN.
TRANSITIONAL ISSUES:
[] Noted to have hematuria - please consider further evaluation
if this continues
[] Consider PJP prophylaxis given long-term steroid use
[] Monitor blood sugars which were noted to be high in the
setting of steroid use
[] Watch out for adrenal insufficiency given long-term steroid
use and recently initiated taper
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H
2. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H
3. Albuterol 0.083% Neb Soln 2 NEB IH Q4H:PRN SOB
4. Bisacodyl ___AILY
5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
Reason for PRN duplicate override: Alternating agents for
similar severity
6. Heparin 5000 UNIT SC BID
7. Ipratropium Bromide Neb 1 NEB IH Q6H
8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
9. LORazepam 0.5 mg PO BID:PRN agitation
10. Lactulose 30 mL PO QD:PRN Constipation - Third Line
11. Methadone 10 mg PO Q6H
Tapered dose - DOWN
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Polyethylene Glycol 17 g PO DAILY
14. PredniSONE 10 mg PO DAILY
15. QUEtiapine Fumarate 50 mg PO QHS
16. QUEtiapine Fumarate 50 mg PO QID:PRN agitation
17. Senna 8.6 mg PO BID
18. Simethicone 40-80 mg PO QID:PRN gas
19. Nystatin Oral Suspension 5 mL PO QID
20. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
21. Tiotropium Bromide 1 CAP IH DAILY
22. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth q6hr Disp #*5 Tablet
Refills:*0
3. QUEtiapine Fumarate 25 mg PO QID:PRN agitation
4. Acetaminophen 650 mg PO Q6H
5. Albuterol 0.083% Neb Soln 2 NEB IH Q4H:PRN SOB
6. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
7. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H
8. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
Reason for PRN duplicate override: Alternating agents for
similar severity
9. Bisacodyl ___AILY
10. Heparin 5000 UNIT SC BID
11. Ipratropium Bromide Neb 1 NEB IH Q6H
12. Lactulose 30 mL PO QD:PRN Constipation - Third Line
13. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
14. LORazepam 0.5 mg PO BID:PRN agitation
15. Multivitamins W/minerals 1 TAB PO DAILY
16. Nystatin Oral Suspension 5 mL PO QID
17. Polyethylene Glycol 17 g PO DAILY
18. PredniSONE 10 mg PO DAILY
19. Senna 8.6 mg PO BID
20. Simethicone 40-80 mg PO QID:PRN gas
21. Tamsulosin 0.4 mg PO QHS
22. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Toxic metabolic encephalopathy
SECONDARY DIAGNOSIS:
- Constipation
- COPD
- HTN
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
You were admitted to the intensive care unit because you were
confused.
While you were in the hospital, you had imaging and labs to look
for signs of infection or electrolyte disturbances. Your pain
medications were adjusted and your mental status improved. We
are concerned that your methadone likely contributed to your
confusion, and recommend that you stop taking this medication.
When you leave the hospital, you will be going to the ___
___ facility to help work on improving your strength. Continue
taking all your medications as prescribed, and follow-up with
your primary care physician as needed.
Followup Instructions:
___
|
10049041-DS-22 | 10,049,041 | 22,620,123 | DS | 22 | 2164-01-21 00:00:00 | 2164-01-21 15:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Precedex
Attending: ___.
Chief Complaint:
Nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a history of COPD and HTN, recently
here with severe refractory hypercarbic respiratory failure ___
COPD exacerbation, MSSA Pneumonia, s/p trach placement ___,
ventilator dependent, who re-presents from LTACH with vomiting
and abdominal pain.
Patient was recently admitted from ___ to ___ for refractory
hypercarbic respiratory failure with failure to wean off the
ventilator, ultimately requiring a tracheostomy and PEG tube
placement. That course was c/b MSSA pneumonia, acute sinusitis,
severe constipation. He was discharged to rehab.
He was re-admitted on ___ for altered mental status
(sedation) and hypercarbia, both of which improved with
adjustment of his ventilator. Initial concern for was for
infection, but work-up for infection and metabolic derangements
were unremarkable. Ultimately, this period of altered mental
status was contributed to sedation from home methadone and
seroquel.
Last night, he developed vomiting x3. This was non-bloody,
non-bilious and associated with LLQ and LUQ pain with diarrhea.
Normal bowel movment yesterday. Also with Tmax of 99.9. Denies
HA, CP, SOB, dysuria. He was sent to the ED from his rehab for
concerns of intestinal ischemia/obstruction/perf.
In the ED, a CTA ABD & PELVIS was performed which was
unremarkable. He was noted to have worsening copious secretions
from trach and had episodes of satting into the ___.
Diaphoretic. Given no intra-abdominal infection, initial
suspicion is that it is possible pulmonary etiology. Portable
CXR initially read with RML PNA and was started on vancomycin
and Zosyn. CXR read finalized with no evidence of pneumonia.
Admitted to the ICU due to ventilation with trach.
Past Medical History:
COPD
HTN
Appendectomy
Social History:
___
Family History:
No family history of cardiovascular disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: Temp: 98.3, BP: 188/128, HR: 121, RR: 16, 97% O2 vent
General: Patient lying in bed, pleasant, no apparent distress,
awake aware and oriented Ãâ"3. nonverbal at baseline.
communicates with writing on paper and reading his lips
HEENT: Trach in place, attached to ventilator
Cardiovascular: Regular rate and rhythm no murmurs rubs or
gallops
Lungs: Clear to auscultation bilaterally
Abdomen: Minimally tender, abdomen distended
Extremities: 2+ pulses bilaterally
Neuro: ___ strength bilaterally in UE and ___. SLTIT.
DISCHARGE PHYSICAL EXAM
Mental status: He is alert. He resonds appropriately to
questions though has a delayed response. He will either write
our mouth words. At times, he does not respond and then will
say that he is tired of talking. He is agitated at times though
admits to feeling anxious.
General: Patient sitting upright in chair, pleasant, no apparent
distress, awake aware and oriented X3. nonverbal at baseline.
communicates with writing on paper and reading his lips
HEENT: Trach in place, attached to ventilator
Cardiovascular: Regular rate and rhythm, no murmurs rubs or
gallops
Lungs: Clear to auscultation bilaterally
Abdomen: Non-tender, mild distension with tympani to percussion
Extremities: 2+ pulses bilaterally
Neuro: ___ strength bilaterally in UE and ___. SLTIT.
Pertinent Results:
Admission labs:
===============
___ 03:49PM BLOOD WBC-15.9* RBC-2.97* Hgb-9.6* Hct-31.9*
MCV-107* MCH-32.3* MCHC-30.1* RDW-17.6* RDWSD-67.5* Plt ___
___ 03:49PM BLOOD Glucose-110* UreaN-4* Creat-0.4* Na-145
K-4.1 Cl-99 HCO3-36* AnGap-10
___ 03:49PM BLOOD ALT-97* AST-53* AlkPhos-108 TotBili-0.2
___ 03:58PM BLOOD ___ pO2-36* pCO2-65* pH-7.39
calTCO2-41* Base XS-10
Discharge labs:
===============
___ 03:04AM BLOOD WBC-9.0 RBC-2.69* Hgb-8.7* Hct-28.4*
MCV-106* MCH-32.3* MCHC-30.6* RDW-17.0* RDWSD-65.3* Plt ___
___ 03:04AM BLOOD ___ PTT-30.1 ___
___ 03:04AM BLOOD Plt ___
___ 03:04AM BLOOD Glucose-121* UreaN-5* Creat-0.4* Na-140
K-3.6 Cl-97 HCO3-31 AnGap-12
___ 03:04AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.7
Pertinent labs:
===============
___ 12:48PM BLOOD ___ pO2-46* pCO2-66* pH-7.36
calTCO2-39* Base XS-8
___ 09:43PM BLOOD ___ pO2-59* pCO2-59* pH-7.42
calTCO2-40* Base XS-10
___ 11:33AM BLOOD ___ pO2-78* pCO2-58* pH-7.41
calTCO2-38* Base XS-9
___ 06:19AM BLOOD ___ pO2-46* pCO2-68* pH-7.34*
calTCO2-38* Base XS-7
___ 01:11AM BLOOD ___ pO2-42* pCO2-79* pH-7.30*
calTCO2-40* Base XS-8
___ 03:58PM BLOOD ___ pO2-36* pCO2-65* pH-7.39
calTCO2-41* Base XS-10
IMAGING:
=========
___ Imaging CTA ABD & PELVIS
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. There is mild calcium
burden in the abdominal aorta and great abdominal arteries.
LOWER CHEST: Minimal atelectasis is noted in the lung bases.
There is no
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout. A 1.2 x 0.9 cm hypoattenuating lesion at the
hepatic dome may reflect a simple hepatic cyst or biliary
hamartoma (03:18). There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram. Bilateral renal cortical hypodensities are
too small to fully characterize. No hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: Patient is status post PEG tube placement.
Small bowel
loops demonstrate normal caliber, wall thickness and enhancement
throughout. Colon and rectum are within normal limits. There is
no evidence of mesenteric lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal
lymphadenopathy.
PELVIS: The urinary bladder is decompressed with Foley catheter
in place.
There is no evidence of pelvic or inguinal lymphadenopathy.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged. Seminal vesicles
are grossly unremarkable.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: Small foci of gas in the left upper abdomen may be
related to prior injection (3:100).
IMPRESSION:
No acute findings in the abdomen or pelvis to account for
patient's symptoms, specifically no convincing signs of bowel
ischemia.
___ Imaging PORTABLE ABDOMEN
IMPRESSION:
There is a percutaneous gastrostomy tube projecting over the
left upper
quadrant of the abdomen. The stomach is slightly distended with
air, similar to prior CT. There are no abnormally dilated loops
of large or small bowel. There is no free intraperitoneal air,
although evaluation is limited by supine technique. There are no
unexplained soft tissue calcifications or radiopaque foreign
bodies.
Brief Hospital Course:
ASSESSMENT
==========
Mr. ___ is a ___ with a history of COPD and HTN, recently
here with severe refractory hypercarbic respiratory failure ___
COPD exacerbation, MSSA Pneumonia, s/p trach placement ___,
ventilator dependent, who re-presents from LTACH with vomiting
and abdominal pain.
ACUTE ISSUES
=======================
#Trach and vent dependent
#Hypercarbic respiratory failure
#Primary Respiratory Acidosis with Secondary Metabolic
Alkalosis: No current concern for infection. Per history, he
has COPD, however he does not necessarily present as COPD,
though unclear what the underlying process is. Tolerated vent
mask for
approximately 20 min on ___ before requiring PSV. However PSV
decreased from ___ to ___ which he is tolerating well.
Unfortunately, we had to scale back to ___ at 30% an hour prior
to discharge due to an elevated CO2 (66). Moving forward, we
recommend daily trach mask trials as long as patient can
tolerate.
#Constipation
Tympanic abdominal percussion on exam, and has not had BM since
he was admitted. History of severe constipation which was
attributed to opioid use. With resolution of his initial GI
symptoms, he was restarted on tube feeds and his home bowel
regimen was slowly added back on. He had one bowel movement on
the day prior to discharge.
#Tachycardia
#HTN
Noted to have initially low UOP. Gave 1L of fluids with
improvement of UOP but only mild improvement of HR. ___ his
baseline HR or iso of anxiety. We recommend treating anxiety
appropriately though if pressures remain elevated, initiation of
anti-HTN therapy.
#Vomiting - resolved
#Diarrhea - resolved
#Leukocytosis - improving
Acute presentation of vomiting x3, diarrhea, abdominal pain, and
leukocytosis. However, he is now stating he had no abdominal
pain. Remainder of symptoms fully resolved by time he arrived to
ICU. Unclear exactly why he has been repeatedly sent in. CTA
abdomen and pelvis unremarkable for any acute etiology. Likely
gastroenteritis (given leukocytosis) vs constipation with
overflow vs medication
overuse (Bisacodyl PR, Docusate BID, Lactulose, miralax, Senna).
He was restarted on tube feeds.
#Pain
#Anxiety
During recent admission, patient was on prolonged fentanyl drip
iso of extended intubation. He was thus transitioned to
methadone, dilaudid, seroquel due to concern with potential
opioid withdrawal, and tapered to just Seroquel QHS and a
methadone at discharge. The methadone was then switched to
oxycodone PRN for pain control, and the Seroquel dose was
reduced on the most recent admission on ___ for concerns of
over sedation. He was continued on home home QUEtiapine Fumarate
25 mg PO QID + 25mg QHS. Currently getting a total of 125mg/25.
Per rehab documentation,
they have been slowly tapering the Seroquel off. He was
continued on home OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN
and home TraZODone 25 mg PO BID:PRN agitation, anxiety.
CHRONIC ISSUES
=======================
#RUE DVT
Ultrasound on ___ revealed acute DVT in right internal
jugular vein. Lovenox was started on ___. He was continued on
home lovenox.
#Abnormal liver tests
Persistently mildly elevated in hepatocellular pattern with
highLDH as well. Improved since prior admission one month ago.
LDH high but normal hemolysis labs and CK on prior admission.
#Hematuria
Noted on prior admissions and present during this
hospitalizations.
#BPH
Continue home Tamsulosin 0.4 mg PO QHS
TRANSITIONAL ISSUES:
=====================
[ ] Continue to taper his ventilation as tolerated. We were
initially able to reduce pressure support to ___ at 30% with no
change in VBG but had to scale back to ___ at 30% an hour prior
to discharge due to an elevated CO2 (66). His CO2 was 58 on
prior day. Please perform daily trach mask trials.
[ ] Follow up his bowel movements. He had one bowel movement on
the day prior to discharge.
[ ] Noted to have hematuria - please consider further evaluation
if this continues
[ ] Continue to taper his steroid
[ ] Continue to taper his Seroquel
[ ] Consider PJP prophylaxis given long-term steroid use
[ ] He is iron deficient. Suggest PO iron supplementation Q48H
for increased absorption and less constipation.
[ ] Recommend treatment of blood pressure if continually
elevated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl ___AILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Docusate Sodium (Liquid) 100 mg PO BID
4. Enoxaparin Sodium 70 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
5. Ipratropium Bromide Neb 2 NEB IH Q6H
6. Lactulose 10 mL PO DAILY
7. melatonin 3 mg oral QHS
8. Multivitamins 1 TAB PO DAILY
9. Nystatin Oral Suspension 5 mL PO QID
10. Omeprazole 40 mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
12. Potassium Chloride (Powder) 40 mEq PO DAILY
13. QUEtiapine Fumarate 25 mg PO QID
14. QUEtiapine Fumarate 25 mg PO QHS
15. senna leaf extract ___ mg oral BID
16. Tamsulosin 0.4 mg PO QHS
17. Thiamine 100 mg PO DAILY
18. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate
19. Albuterol Inhaler 1 PUFF IH Q6H SOB/WHEEZING/COUGH
20. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN
SOB/WHEEZING/COUGH
21. Simethicone 80 mg PO QID:PRN gas
22. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
23. TraZODone 25 mg PO BID:PRN agitation, anxiety
24. NovoLOG Mix 70-30 U-100 Insuln (insulin asp prt-insulin
aspart) 100 unit/mL (70-30) subcutaneous Q8H
25. PredniSONE 5 mg PO DAILY
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Moderate
3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN
SOB/WHEEZING/COUGH
4. Albuterol Inhaler 1 PUFF IH Q6H SOB/WHEEZING/COUGH
5. Bisacodyl ___AILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Docusate Sodium (Liquid) 100 mg PO BID
8. Enoxaparin Sodium 70 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
9. Ipratropium Bromide Neb 2 NEB IH Q6H
10. Lactulose 10 mL PO DAILY
11. melatonin 3 mg oral QHS
12. Multivitamins 1 TAB PO DAILY
13. NovoLOG Mix 70-30 U-100 Insuln (insulin asp prt-insulin
aspart) 100 unit/mL (70-30) subcutaneous Q8H
14. Nystatin Oral Suspension 5 mL PO QID
15. Omeprazole 40 mg PO DAILY
16. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
17. Polyethylene Glycol 17 g PO DAILY
18. Potassium Chloride (Powder) 40 mEq PO DAILY
Hold for K >
19. PredniSONE 5 mg PO DAILY
20. QUEtiapine Fumarate 25 mg PO QID
21. QUEtiapine Fumarate 25 mg PO QHS
22. senna leaf extract ___ mg oral BID
23. Simethicone 80 mg PO QID:PRN gas
24. Tamsulosin 0.4 mg PO QHS
25. Thiamine 100 mg PO DAILY
26. TraZODone 25 mg PO BID:PRN agitation, anxiety
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
=========
# Gastroenteritis
# Hypercarbic respiratory failure
SECONDARY:
===========
# Chronic constipation
# COPD
# Anxiety
# DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a privilege caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had vomiting and abdominal pain
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had imaging which did not show any issues with the bowels
- Your symptoms improved
- You were given fluids
- You were continued on the ventilator
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:
___
|
10049095-DS-15 | 10,049,095 | 22,362,949 | DS | 15 | 2128-10-09 00:00:00 | 2128-10-09 15:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / desipramine / verapamil
Attending: ___.
Chief Complaint:
Agitation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with history of bipolar
disease, depression, ___ disease, vascular dementia,
bilateral knee replacements, peripheral neuropathy, diabetes,
CKD, episodes of falls with head injury, bipolar disorder, heart
block status post PPM, DVT on Coumadin, who presents with wife
and son with complaint of 2 weeks of worsening mental status,
anxiety, and depression.
of note, he was referred to the ED from his psychiatrist for
concern of worsening mood due to organic etiology.
They state that he does have baseline dementia, but this is been
particularly bad over the past 2 weeks.
He has been very anxious and depressed. He has been complaining
of pain in the lower extremities, particularly around the left
heel, where he has an ulcer.
He denies fevers or chills. He has not been complaining of any
chest pain, shortness of breath, abdominal pain, vomiting,
diarrhea, urinary symptoms.
He has been eating and drinking well. His blood sugars have been
well controlled at home. No recent falls. He uses a walker but
is very limited in his ability to ambulate, he also uses a
transfer chair at home. He does have some visiting nurse
resources. Wife states that she spoke with his psychiatrist
today who sent him to the emergency department.
Of note, Mr. ___ follows with psychiatry here for post
concussive syndrome as well as dementia related to ___
and vascular dementia. He last saw psych on ___ where his
psychiatrist mentioned that the patient has had a turbulent
course over the past year, characterized by episodes of falls
with head injury. Mr. ___ has been confined to a wheelchair
for some time and has been cared for by his extended family.
His recent course has been complicated by periods of delirium,
impaired cognitive status. His baseline mental status is noted
to be the following:
"subdued, sad faced, not overtly tearful, complaining of
depression. Speech is reduced in rate, productivity.
There is a paucity of thought. No evidence of spontaneous
tearfulness during mental status evaluation. He appears to be
somewhat disoriented, not fully oriented in all spheres."
Past Medical History:
Bipolar disorder
___ disease
Vascular Dementia
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission Exam:
General: Elderly male lying in bed, no acute distress
HEENT: PERRL. EOMI. MMM. No regional lymphadenopathy. No
erythema of the oropharynx.
Neck: No regional lymphadenopathy or thyromegaly.
Lungs: Clear to auscultation bilaterally.
CV: RRR. S1-S2 present. No murmurs, rubs, gallops. No JVD.
GI: BS present. Soft, nontender, nondistended. No
hepatomegaly.
Ext: No peripheral edema. Heel of the left lower extremity has
a
well-healed 1x1 cm ulcer without any evidence of erythema,
purulence, or drainage.
Neuro: Patient states that he is at ___. He is
not alert to day of the week, month, or year. He states that he
lives with his parents. Cranial nerves II through XII intact.
Strength 5 out of 5 in the upper extremities B/L. Strength ___
in the lower extremities b/l).
Discharge Exam:
Vitals: Per OMR
General: Elderly male lying in bed, no acute distress
HEENT: Pupils small, reactive to light
Lungs: Clear to auscultation bilaterally.
CV: RRR. S1-S2 present. No murmurs, rubs, gallops. No JVD.
GI: BS present. Soft, nontender, nondistended.
Ext: No peripheral edema. Heel of the left lower extremity has
a
well-healed 1x1 cm ulcer without any evidence of erythema,
purulence, or drainage. Pulses present by palpation bilaterally.
Neuro: Patient states that he is at ___. He is
not alert to day of the week, month, or year. He states that he
lives with his parents. Cranial nerves II through XII intact.
Strength 5 out of 5 in the upper extremities B/L. Strength ___
in the lower extremities b/l).
Pertinent Results:
Labs:
___ 08:55AM BLOOD WBC-6.3 RBC-5.39 Hgb-14.6 Hct-45.9 MCV-85
MCH-27.1 MCHC-31.8* RDW-15.3 RDWSD-47.3* Plt ___
___ 06:55AM BLOOD WBC-5.2 RBC-5.26 Hgb-14.1 Hct-44.7 MCV-85
MCH-26.8 MCHC-31.5* RDW-15.5 RDWSD-47.4* Plt ___
___ 07:15AM BLOOD WBC-4.9 RBC-5.01 Hgb-13.4* Hct-43.4
MCV-87 MCH-26.7 MCHC-30.9* RDW-15.4 RDWSD-48.6* Plt ___
___ 07:02AM BLOOD WBC-8.5 RBC-4.99 Hgb-13.5* Hct-44.1
MCV-88 MCH-27.1 MCHC-30.6* RDW-15.3 RDWSD-49.1* Plt ___
___ 05:59AM BLOOD WBC-4.9 RBC-4.91 Hgb-13.3* Hct-42.3
MCV-86 MCH-27.1 MCHC-31.4* RDW-15.7* RDWSD-48.9* Plt ___
___ 06:30AM BLOOD WBC-6.3 RBC-4.78 Hgb-12.9* Hct-42.0
MCV-88 MCH-27.0 MCHC-30.7* RDW-15.8* RDWSD-49.3* Plt ___
___ 08:55AM BLOOD Glucose-89 UreaN-34* Creat-2.4*# Na-149*
K-4.4 Cl-103 HCO3-27 AnGap-19*
___ 06:55AM BLOOD Glucose-133* UreaN-35* Creat-2.4* Na-144
K-4.3 Cl-101 HCO3-27 AnGap-16
___ 06:48AM BLOOD Glucose-117* UreaN-32* Creat-2.3* Na-150*
K-4.1 Cl-107 HCO3-29 AnGap-14
___ 07:15AM BLOOD Glucose-97 UreaN-32* Creat-2.0* Na-146
K-4.2 Cl-107 HCO3-26 AnGap-13
___ 07:02AM BLOOD Glucose-151* UreaN-29* Creat-1.8* Na-150*
K-4.7 Cl-111* HCO3-28 AnGap-11
___ 08:55AM BLOOD ALT-10 AST-19 AlkPhos-44 TotBili-0.6
___ 06:48AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.1
___ 07:02AM BLOOD Calcium-9.2 Phos-2.4* Mg-2.1
___ 05:59AM BLOOD Glucose-128* UreaN-32* Creat-1.7* Na-146
K-4.7 Cl-106 HCO3-29 AnGap-11
___ 04:03PM BLOOD Glucose-119* UreaN-32* Creat-1.7* Na-143
K-4.7 Cl-104 HCO3-27 AnGap-12
___ 06:30AM BLOOD Glucose-169* UreaN-35* Creat-1.8* Na-145
K-5.2 Cl-106 HCO3-27 AnGap-12
INR:
___ 07:20PM BLOOD ___ PTT-35.5 ___
___ 07:15AM BLOOD ___ PTT-31.8 ___
___ 07:02AM BLOOD ___ PTT-25.1 ___
___ 06:30AM BLOOD ___ PTT-35.9 ___
___ 05:59AM BLOOD ___ PTT-37.6* ___
___ 06:30AM BLOOD ___ PTT-37.1* ___
Brief Hospital Course:
ASSESSMENT/PLAN:
Mr. ___ is a ___ male with history of bipolar
disorder, depression, peripheral neuropathy, diabetes, CKD,
who presented with 2 weeks of worsening mental status, anxiety,
and depression and was found to have mild hypernatremia and and
___ that improved with hydration. Mental status also improved
with correction of sodium and fluid balance. Please see below
for medication changes.
Acute Issues:
============
#Worsening mental status
#Anxiety
#Depression
The patient has a ___ year history of bipolar disorder, which is
characterized by periods of hypomania, irritability, but a more
chronic course of depression. Psychiatry evaluated patient and
got collateral from Psychiatrist Dr. ___. Psychiatry
confirmed his medications as below. Acute on chronic agitation
likely due to dehydration, and hypernatremia as his symptoms
resolved with resolution ___ and Hypernatremia. As per Dr.
___ sertraline and donepezil was discontinued. Home
___ will be held in the setting of initiation of
gabapentin to avoid over sedation. Dr. ___ will reinitiate
___ as appropriate. The patient was discharged on the
following medications:
-Olanzapine 2.5 mg daily
-Olanzapine 2.5mg daily PRN agitation.
-Trazodone 100 mg QHS
-Depakote 500 mg Daily
#Bilateral Lower extremity pain
The patient has a history of diabetes and has a history of pain
in bilateral legs.
Workup inpatient has included foot XR (neg for fx), ___ dopplers
(no evidence of DVT or ___ cyst). Most likely etiology
either diabetic neuropathy or osteoarthritis. In coordination
with outpatient psychiatrist Dr. ___ was started on
gabapentin 200mg TID with good effect.
#Hypernatremia
___
Cr 2.4 (previous Cr in ___ at ___ was 1.7). the
creatinine improved with oral hydration. The patient should
continue to drink at least four 16 oz glasses of water (64oz) a
day. The hypernatremia resolved with oral hydration. He should
have his CMP checked by his PCP on follow up in ___.
CHRONIC ISSUES
==============
#Hypertension
-Continueed home amlodipine and hydrochlorothiazide
#Vascular dementia
Continued home ASA 81
#History of DVT
-Continue home warfarin 2 mg daily
#Diabetes
Continued home regimen insulin
Transitional Issues:
====================
[] Please check INR next appointment and make adjustments as
needed
[] Re-evaluation for re-initiation of ___ as well as
increasing olabnzapine 2.5mg as per Dr. ___
___ Changes:
NEW:
Olanzapine 2.5mg daily
Olanzapine 2.5mg Daily PRN agitation
Gabapenitn 200mg TID
DOSE CHANGES:
Depakote 500mg BID to ___ daily
DISCONTINUED MEDICATIONS:
Sertraline 25mg daily
HELD MEDICATIONS:
Lamictal 100mg daily.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OLANZapine 2.5 mg PO DAILY
2. TraZODone 100 mg PO QHS
3. Divalproex (DELayed Release) 500 mg PO BID
4. Warfarin 3 mg PO DAILY16
5. NovoLOG Mix 70-30 U-100 Insuln (insulin asp prt-insulin
aspart) 100 unit/mL (70-30) subcutaneous BID
6. FoLIC Acid 1 mg PO DAILY
7. amLODIPine 10 mg PO DAILY
8. Hydrochlorothiazide 12.5 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Thiamine 100 mg PO DAILY
11. Cyanocobalamin 1000 mcg PO DAILY
12. melatonin 3 mg oral qhs
13. Atorvastatin 20 mg PO QPM
14. LamoTRIgine 100 mg PO DAILY
Discharge Medications:
1. Gabapentin 100 mg PO TID
2. OLANZapine 2.5 mg PO DAILY:PRN agitation
3. amLODIPine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Cyanocobalamin 1000 mcg PO DAILY
7. Divalproex (DELayed Release) 500 mg PO BID
8. FoLIC Acid 1 mg PO DAILY
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. melatonin 3 mg oral qhs
11. NovoLOG Mix 70-30 U-100 Insuln (insulin asp prt-insulin
aspart) 100 unit/mL (70-30) subcutaneous BID
12. OLANZapine 2.5 mg PO DAILY
13. Thiamine 100 mg PO DAILY
14. TraZODone 100 mg PO QHS
15. Warfarin 3 mg PO DAILY16
16. HELD- LamoTRIgine 100 mg PO DAILY This medication was held.
Do not restart LamoTRIgine until directed by Dr. ___
___ Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hypernatremia
Acute Kidney Injury
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 ___ was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- Because you were not feeling well.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We checked you labs and found that you were dehydrated.
- We gave you fluids and your got better
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please drink at least four 16oz containers of water a day to
prevent dehydration
-Continue to take all your medicines and keep your appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10049334-DS-16 | 10,049,334 | 24,032,789 | DS | 16 | 2183-07-17 00:00:00 | 2183-07-18 20:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
hip fracture
Major Surgical or Invasive Procedure:
Orthopedic Surgery ___: Intramedullary nailing with a long
TFN System, 10 x ___ mm, with 105 mm lag screw.
History of Present Illness:
___ with dementia, atrial fibrillation not on anticoagulation,
and history of traumatic subdural hematoma due to fall and
resulting TBI presents from home after a mechanical fall. The
patient was unable to provide history due to very poor mental
status. In discussion with the patient's daughter-in-law, the
patient is reported to have poor mental status at baseline. He
has moments of lucidity but often he has difficulty carrying on
conversation or following basic instructions. He does ambulate
at baseline. He is totally dependent in iADLs and now in most
ADLs (assistance with bathing, dressing, and toileting; able to
feed self if food provided). Of note, he had been on hospice a
year ago and was expected to survive days-weeks; however,
recovered surprisingly and has been living at home with wife
(also with advanced dementia) and his son and daughter, who are
their primary caretakers. He was in the living room with his
wife when he had a fall. It was only witnessed by his wife, but
his daughter-in-law says that it appeared he most likely was
turning and tripped, falling next to a table that he tried to
grab as he landed close to it.
In the ED, initial vitals were: 98.7 68 186/100 16 93% RA.
Exam was notable for: "Tender over right hip and femur only.
right leg mildly rotated, no appreciable limb length
shortening." Labs notable for Hgb 9.6 (from baseline ___,
and CXR notable for moderate pulmonary edema. Hip XR showed R
intertrochanteric fracture. Patient received: IV Furosemide 20
mg, IV Morphine Sulfate 2.5 mg x2. Orthopedics was consulted
and recommended operative management. He was admitted to
medicine for optimization of volume status. Vitals prior to
transfer were: 79 163/97 16 96% Nasal Cannula.
On arrival to the floor, patient was not interactive or
conversant.
Past Medical History:
- Atrial fibrillation not on warfarin
- Hypertension
- Hyperlipidemia
- BPH (benign prostatic hyperplasia)
- Gout
- History of traumatic subdural hemorrhage s/p evacuation
- Peripheral neuropathy
- Osteoarthritis
- Non-convulsive status epilepticus
- History of Clostridium difficile infection
- Urinary tract infection
- Edema
- Congestive heart failure
- Urinary incontinence
- Bullous disorder
Social History:
___
Family History:
Unable to be obtained due to patient's mental status.
Physical Exam:
ADMISSION
Vitals: 99.4 133-180/72-100 68-107 18 96% on 2L
Gen: Elderly gentleman lying in bed, asleep but rousable to
sternal rub, does not follow commands
HEENT: PERRL, pupils contracted 3mm to 2mm, head appears
atraumatic
Neck: supple, JVP difficult to appreciate but visibly distended
external jugular vein up 6-7 cm above clavicle
Cardiac: RRR, normal S1 and S2, no murmurs
Pul: CTAB, no wheezes or crackles
Abd: +BS, soft, non-tender, non-distended
Ext: warm, well perfused, +RLE 1+ pitting edema to knee, RLE
foreshortened and externally rotated
Skin: Multiple skin tears on arms and legs, as well as old
desquamated bullae.
Neuro: Patient does not follow commands, resists passive
extension of all extremities.
DISCHARGE
VS 98.0 143 83 18 98/ra
Gen: elderly, chronically ill, NAD
HEENT: EOMI, MMM
Neck: supple, JVP difficult to appreciate but visibly distended
external jugular vein up 5cm above clavicle
Cardiac: RRR, NMRG
Pul: Anterior crackles to midlung, improved from yesterday.
Breathing comfortably. NC in place.
Abd: soft, ntnd
Ext: wwp. +RLE 1+ pitting edema to knee
Skin: Multiple skin tears on arms and legs, as well as old
desquamated bullae.
Neuro: Alert. Nonverbal. Does not follow commands, resists
passive extension of all extremities.
Pertinent Results:
======================
LABS
======================
Admission:
___ 04:00PM BLOOD WBC-7.9# RBC-3.03* Hgb-9.6* Hct-29.9*
MCV-99* MCH-31.7 MCHC-32.1 RDW-13.9 RDWSD-48.6* Plt ___
___ 04:00PM BLOOD ___ PTT-30.4 ___
___ 04:00PM BLOOD Glucose-119* UreaN-21* Creat-0.8 Na-137
K-3.8 Cl-103 HCO3-26 AnGap-12
___ 07:00AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.2
H/H trend:
___ 04:00PM BLOOD WBC-7.9# RBC-3.03* Hgb-9.6* Hct-29.9*
MCV-99* MCH-31.7 MCHC-32.1 RDW-13.9 RDWSD-48.6* Plt ___
___ 07:00AM BLOOD WBC-7.1 RBC-2.76* Hgb-8.8* Hct-27.0*
MCV-98 MCH-31.9 MCHC-32.6 RDW-14.1 RDWSD-49.6* Plt ___
___ 05:21AM BLOOD WBC-5.7 RBC-2.56* Hgb-8.0* Hct-24.9*
MCV-97 MCH-31.3 MCHC-32.1 RDW-14.2 RDWSD-50.5* Plt ___
___ 10:28AM BLOOD WBC-11.7*# RBC-2.70* Hgb-8.4* Hct-27.5*
MCV-102* MCH-31.1 MCHC-30.5* RDW-14.3 RDWSD-53.1* Plt ___
___ 06:57AM BLOOD WBC-6.1 RBC-2.23* Hgb-7.0* Hct-22.3*
MCV-100* MCH-31.4 MCHC-31.4* RDW-14.4 RDWSD-51.6* Plt ___
___ 07:35PM BLOOD WBC-6.2 RBC-2.56* Hgb-7.9* Hct-25.2*
MCV-98 MCH-30.9 MCHC-31.3* RDW-15.9* RDWSD-56.5* Plt ___
___ 07:02AM BLOOD WBC-4.6 RBC-2.41* Hgb-7.3* Hct-24.8*
MCV-103* MCH-30.3 MCHC-29.4* RDW-16.1* RDWSD-60.2* Plt ___
___ 01:28PM BLOOD WBC-4.9 RBC-2.61* Hgb-8.0* Hct-26.3*
MCV-101* MCH-30.7 MCHC-30.4* RDW-15.9* RDWSD-57.1* Plt ___
DISCHARGE LABS:
___ 06:15AM BLOOD WBC-4.5 RBC-2.80* Hgb-8.6* Hct-28.6*
MCV-102* MCH-30.7 MCHC-30.1* RDW-15.4 RDWSD-56.9* Plt ___
___ 06:15AM BLOOD Glucose-107* UreaN-35* Creat-0.7 Na-148*
K-3.7 Cl-110* HCO3-27 AnGap-15
___ 06:15AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.4
======================
MICRO
======================
___ CULTURE-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTURE-FINAL {PROTEUS
MIRABILIS}INPATIENT
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 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
======================
IMAGING/STUDIES
======================
___ LOWER EXT VEINS ___
___
1. No evidence of deep venous thrombosis in the right lower
extremity veins.
2. Right calf subcutaneous edema.
___ (PORTABLE AP) ___
___
Previous moderate pulmonary edema has improved, moderate
bilateral pleural effusions have redistributed dependently, but
probably not enlarged, and nowobscure the right heart border.
Opacification at the lung bases is probably a combination of
atelectasis, dependent edema overlying pleural effusion. No
pneumothorax.
___ UNILAT MIN 2 VIEWS ___
___
Images from the operating suite show placement of a fixation
device about fracture of the proximal femur. Further
information can be gathered from the operative report.
___ EXTREMITY FLUORO ___
___
Images from the operating suite show placement of a fixation
device about fracture of the proximal femur. Further
information can be gathered from the operative report.
___.
Atrial fibrillation with a moderate ventricular response.
Occasional
ventriclar premature beats with one couplet. Left axis deviation
consistent with left anterior fascicular block. Non-specific
repolarization abnormalities. Possible old anteroseptal
myocardial infarction. Compared to the previous tracing of
___ no change except for ventricular ectopy now present.
___ (PORTABLE AP) ___
___
In comparison with the study of ___, there again is
enlargement of the cardiac silhouette with asymmetric pulmonary
edema. As previously, it would be difficult to unequivocally
exclude superimposed pneumonia, especially in the absence of a
lateral view.
Hazy opacifications bilaterally with poor definition of the hemi
diaphragms suggests layering pleural effusion with underlying
compressive atelectasis. No interval change. No evidence of
pneumothorax.
___.
Atrial fibrillation with a moderate ventricular response. Left
anterior
fascicular block. Possible old anteroseptal myocardial
infarction.
Non-specific repolarization abnormalities. Compared to the
previous tracing of ___ the rate is slower without other
significant change.
___ (AP & LAT) RIGHT
___
No acute fracture seen of the mid to distal right femur.
___ (SINGLE VIEW)
___
Prominent right greater than left perihilar is opacities
worrisome for severe pulmonary edema. Asymmetric increased
opacity on the right as compared to the left could be due to
asymmetric pulmonary edema versus underlying infection and/ or
aspiration. Pulmonary hemorrhage not excluded.
Subtle posterolateral right-sided rib deformities including
right fourth through seventh ribs consistent with rib fractures
; the right fourth and seventh rib fractures appear old. The
right fifth and sixth rib fractures are of indeterminate age,
but could be acute to subacute. Correlate with clinical history
and site of point tenderness. Findings are new since ___
___ (UNILAT 2 VIEW) W/P
___
Comminuted right intertrochanteric fracture with varus
angulation of the right femoral head.
Moderate to severe right hip osteoarthritic changes.
___ C-SPINE W/O CONTRAST
___
1. No acute fracture of the cervical spine. Multi-level
degenerative changes.
2. Partially imaged right greater than left pleural effusions.
Pulmonary edema.
___ HEAD W/O CONTRAST
___
Some patient motion limits the exam. No definite acute
intracranial process seen.
___.
Baseline artifact limits the sensitivity of interpretation. The
rhythm is probably atrial fibrillation with rapid ventricular
response. Occasional ventricular premature contraction and
aberrantly conducted complexes. Left axis deviation. Possible
inferior wall myocardial infarction of indeterminate age. Poor R
wave progression in leads V1-V3. Possible anteroseptal
myocardial infarction of indeterminate age. Delayed R wave
transition. Diffuse non-specific ST segment changes with
biphasic T waves in lead V6. Cannot exclude possible myocardial
ischemia. Clinical correlation is suggested.
Compared to the previous tracing of ___ the ventricular rate
has increased by about 20 beats per minute and the lateral ST-T
wave changes are slightly more pronounced.
Brief Hospital Course:
___ with dementia, atrial fibrillation not on anticoagulation,
and history of traumatic subdural hematoma due to fall and
resulting TBI presents from home after a mechanical fall, found
to have a right intertrochanteric fracture. This was repaired by
orthopedic surgery.
# s/p R intertrochanteric fracture: Hip was repaired ___,
complicated by mild bleeding into R thigh (R more swollen than
L, dopplers negative for DVT). His enoxaparin was stopped ___
and restarted ___.
# Anemia: Pt developed acute blood loss anemia from bleeding
into R thigh; he received 2u PRBCs and was monitored for
development of compartment syndrome. His H/H stabilized, by day
of discharge Hbg 8.6.
# dCHF: Patient had an episode of hypoxemia in the PACU that
resolved with diuresis, most likely a mild exacerbation of his
diastolic CHF. He was restarted on home diuretics but then these
were stopped as the patient was no longer volume overloaded and
developed hypernatremia (likely secondary to poor PO intake).
The patient was discharged off home Lasix, will need daily
weights to determine whether these should be restarted.
# Hypernatremia: Patient developed mild hypernatremia (Na on day
of discharge 148) likely secondary to poor PO intake. Received
mIVF of D5W. Consider need to continue D5W for hypernatremia.
# UTI: Pt developed UTI, tx'ed w/ cipro 500 bid x7d, which he
completed on ___.
# HTN: Patient's home carvedilol was continued, lisinopril held
but restarted on day of discharge given SBPs 120s-150s.
# Dementia: Of note, he is totally dependent in iADLs and now in
most ADLs (assistance with bathing, dressing, and toileting;
able to feed self if food provided). Of note, he had been on
hospice a year ago and was expected to survive days-weeks;
however, recovered surprisingly and has been living at home with
wife (also with advanced dementia) and his son and daughter, who
are their primary caretakers.
# Malnutrition: Nutrition provided recommendations. Pt
discharged on multivitamin. Likely contributing to INR of 1.3.
TRANSITIONAL ISSUES:
[] Please check CBC on ___. Discharge Hgb was 8.6. Transfuse
for Hbg <7
[] Patient was started on enoxaparin for prophylaxis; consider
continued need for this at outpatient follow up appointment.
[] F/u with orthopedics scheduled for ___.
[] Patient's home diuretics (Lasix 40 mg PO BID) were held in
the setting of hypernatremia. Please weigh the patient daily to
assess need to restart diuretics. Weight on ___: 71.67 kgs
[] The patient's sodium on day of discharge was 148 (likely
secondary to poor PO intake) and he was given D5W; please check
sodium regularly (every other day or so) and give D5W at a slow
rate PRN for hypernatremia.
[] Patient with minor coagulopathy (INR 1.3 on day of discharge)
likely secondary to malnutrition, consider nutritional
supplements. Pt started on multivitamin.
[] Patient's home BP lisinopril was restarted on day of
discharge; SBPs were 120s-150s and he had normal renal function
and normal K.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Potassium Chloride 10 mEq PO DAILY
2. Lisinopril 5 mg PO DAILY
3. Carvedilol 12.5 mg PO BID
4. Furosemide 40 mg PO BID
5. Terbinafine 1% Cream 1 Appl TP DAILY
Discharge Medications:
1. Carvedilol 12.5 mg PO BID
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
4. Lactulose ___ mL PO BID:PRN constipation
5. Milk of Magnesia 30 ml PO BID:PRN Dyspepsia
6. Acetaminophen 1000 mg PO TID Pain
7. Docusate Sodium 100 mg PO BID
8. Enoxaparin Sodium 30 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Lisinopril 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- R hip fracture
- acute blood loss anemia
- diastolic CHF, acute on chronic
- UTI, complicated
- ___
Secondary:
- coagulopathy
- malnutrition
- advanced dementia
- hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were seen at ___ for hip fracture. This was repaired by
orthopedic surgery, and we gave you blood to treat some expected
postsurgical thigh bleeding.
Please see your appointments and medications below. You have a
follow up appointment with orthopedic surgery.
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10049681-DS-15 | 10,049,681 | 29,545,170 | DS | 15 | 2117-11-22 00:00:00 | 2117-11-22 11:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Demerol
Attending: ___.
Chief Complaint:
Right arm pain
Major Surgical or Invasive Procedure:
Open reduction and internal fixation right upper extremity
fracture
History of Present Illness:
___ transferred from OSH after mechanical fall today in which
she likely fell onto her R elbow, sustaining a comminuted fx of
the medial epicondyle. Lives alone, normally walks with walker.
No head strike, no LOC.
Past Medical History:
-"large heart since birth"
- per ___: HTN, herniated disc
Social History:
___
Family History:
Non contributory
Physical Exam:
Admission Exam
T=97.7 BP=158/52 HR=69 RR=16 O2=94RA
PHYSICAL EXAM
GENERAL: Pleasant, well appearing in NAD
HEENT: Normocephalic, atraumatic. No scleral icterus.
PERRLA/EOMI. membranes are dry. OP clear
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. ___ SEM
heard best at the ___ RICS with carotid radiation
LUNGS: CTAB, good air movement biaterally, no wheezing
ABDOMEN: NABS. Soft, NT, ND
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses. Diffuse nontender erythema over the lower right
leg, but no edema, palpable cords. RUE in splint.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout. ___ reflexes,
equal ___. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
___ 05:10PM GLUCOSE-125* UREA N-30* CREAT-1.1 SODIUM-137
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-24 ANION GAP-16
___ 05:10PM estGFR-Using this
___ 05:10PM WBC-11.6* RBC-3.78* HGB-12.4 HCT-37.3 MCV-99*
MCH-32.7* MCHC-33.2 RDW-12.9
___ 05:10PM NEUTS-92.3* LYMPHS-4.6* MONOS-2.6 EOS-0.2
BASOS-0.3
___ 05:10PM PLT COUNT-216
___ 05:10PM ___ PTT-28.9 ___
___ 05:10PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
Brief Hospital Course:
The patient was admitted to the Orthopaedic Trauma Service for
repair of her right upper extremity fracture. The patient was
taken to the OR and underwent an uncomplicated repair. The
patient tolerated the procedure without complications and was
transferred to the PACU in stable condition. Please see
operative report for details. Post operatively pain was
controlled with a PCA with a transition to PO pain meds once
tolerating POs. The patient tolerated diet advancement without
difficulty and made steady progress with ___.
Weight bearing status: Non weight bearing right upper extremity.
The patient received ___ antibiotics as well as
Lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 4 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Medications on Admission:
-Norvasc 5mg daily
-tylenol #3 with codeine, 2 tabs TID PRN pain
-Atenolol 25mg daily
-Celebrex ___ daily PRN
-furosemide 30mg daily
-calcium 600+D twice daily
-centrum silver +zinc daily
Discharge Medications:
1. senna 8.6 mg Tablet Sig: ___ Tablets PO HS (at bedtime).
2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Dyspepsia.
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
QPM (once a day (in the evening)).
8. furosemide 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
10. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q3H (every 3 hours)
as needed for pain: Do not drink alcohol or drive while taking
this medication.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right medial epicondyle 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:
******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. No baths or swimming for at least 4 weeks.
Any stitches or staples that need to be removed can be removed
2-week after your surgery. This can be done at your
rehabilitation facility or by a ___. No dressing is needed if
wound continued to be non-draining.
******WEIGHT-BEARING*******
Non-weight bearing Right upper extremity
Range of motion as tolerated at elbow.
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 4 weeks post-operatively.
Physical Therapy:
Non weight bearing right upper extremity
Treatments Frequency:
Please assess wound daily for signs of infection.
If has staples/sutures that need to be removed, please take out
at post-operative day 14.
Followup Instructions:
___
|
10049736-DS-5 | 10,049,736 | 25,973,485 | DS | 5 | 2139-10-25 00:00:00 | 2139-10-26 06:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
RLQ pain
Major Surgical or Invasive Procedure:
Laparoscopic paratubal cystectomy
detorsion
History of Present Illness:
___ yo G4P4 dx with R ovarian vs paratubal cyst after presenting
to ___ with RLQ pain ~1 mo ago. She had severe pain which
improved after narcotics and rest. Was back to her usual state
of health until last night. Began having dull RLQ pain @
1030pm, subsequently had severe pain beginning @ 130am.
Presented to ___ initially and was transferred ___ concern
for torsion.
On arrival to ___, she was very uncomfortable. Vital signs
were normal. Got 2x morphine 5mg IV and had a pelvic US. Ate
crackers at 930am.
Currently states pain is ___, achy, RLQ, non-radiating
Past Medical History:
OB/GYN Hx:
- LTCS x 4
- denies h/o pelvic infections
- remote h/o cervical dysplasia, nl f/u
- diagnosis of R adnexal cyst ~1mo ago
- no current contraception
PMH: Denies
PSH:
- LTCS x4
- LSC appy
Social History:
___
Family History:
non-contributory
Physical Exam:
T 97.3, HR 57, BP 100/52, RR 20 100%
NAD
Abd soft, ND, +TTP RLQ/suprapubic region, no r/g
Pelvic: small av uterus with limited mobility. + soft, moblie
mass appreciated post to uterus, fairly uncomfortable with
palpation of the mass. Discomfort on R with mvmt of cervix
ext NT, NE
Pertinent Results:
___ 05:40AM BLOOD WBC-9.2 RBC-4.03* Hgb-12.2 Hct-35.2*
MCV-87 MCH-30.3 MCHC-34.7 RDW-12.8 Plt ___
___ 05:40AM BLOOD Neuts-85.5* Lymphs-11.0* Monos-3.1
Eos-0.2 Baso-0.3
___ 05:40AM BLOOD Glucose-122* UreaN-14 Creat-0.7 Na-140
K-3.9 Cl-106 HCO3-25 AnGap-13
___ 07:00AM URINE Color-Yellow Appear-Clear Sp ___
___ 07:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 07:00AM URINE UCG-NEG
PELVIC ULTRASOUND ___: Transabdominal and transvaginal
examinations performed, the latter to further evaluate the
endometrium and adnexal structures. The uterus is anteverted
and retroflexed and measures 10.8 x 4.4 x 6.0 cm. The
endometrium is homogeneous in echogenicity measuring 8 mm. A
C-section scar is noted.
Within the right adnexa, there is a large simple cyst measuring
6.4 x 5.0 x 6.6 cm. This likely represents a paraovarian cyst.
The adjacent ovary
appears slightly edematous and measures 2.6 x 3.2 x 3.3 cm. The
left ovary measures 2.6 x 2.2 x 3.1 cm. Small follicles are
noted. There is normal arterial and venous Doppler waveforms
within both ovaries. There is trace pelvic free fluid.
IMPRESSION:
1. Slightly edematous right ovary with normal arterial and
venous Doppler waveforms. Findings are indeterminate with
ovarian torsion not excluded. Gynecologic consultation with
clinical correlation is recommended.
2. Large 6.6 cm right paraovarian cyst. Follow-up pelvic
ultrasound in 3 months is recommended.
Brief Hospital Course:
Ms. ___ presented to the emergency department with RLQ pain.
Ultrasound was performed showing a large 6.6 cm right
paraovarian cyst and slightly edematous right ovary. Due to
concern for torsion, patient was taken to the operating room.
She was found to have a 10cm paratubal necrotic cyst causing
adnexal torsion and underwent laparascopic paratubal cyst
excision after adnexal detorsion. She had an uncomplicated
recovery and was discharged home on postoperative day #0 in good
condition: ambulating and urinating without difficulty,
tolerating a regular diet, and with adequate pain control using
PO medication.
Medications on Admission:
None
Discharge Medications:
1. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for Pain: do not administer
more than 4000mg acetaminophen in 24 hrs.
Disp:*30 Tablet(s)* Refills:*0*
2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
paratubal cyst
adnexal torsion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* No strenuous activity until your post-op appointment
* Nothing in the vagina (no tampons, no douching, no sex), no
heavy lifting of objects >10lbs for 6 weeks.
* You may eat a regular diet
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Call your doctor for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
Followup Instructions:
___
|
10049746-DS-22 | 10,049,746 | 24,332,085 | DS | 22 | 2137-01-10 00:00:00 | 2137-01-10 18:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Pravachol / Darvon / Carrot
Attending: ___.
Chief Complaint:
Broken femur, newly diagnosed DLBCL
Major Surgical or Invasive Procedure:
___ line placement
History of Present Illness:
___ w/ PMH hemochromatosis, hypothyroidism, anemia presents from
___ with a femur fracture s/p fall. She had a
previous hip fracture in ___ with replacement at that time.
Patient says that 6 weeks ago she began feeling weak and tired,
with intermittent nausea causing a 20 pound weight loss. She was
admitted to ___ as a result of these issues and
found to be severely anemic at the time and given 2 units of
blood. CT showed multiple liver masses and lymphadenopathy which
was recently discovered to be Non-Hodgkin Lymphoma.
Regarding her fall, she does not recall the entire circumstances
of the events leading up to the fall, but she notes that she
felt a little bit lightheaded. Denies loss of consciousness.
Denies head strike. Landed on her left side after striking the
bathtub. She was found wedged between the bathtub in the toilet.
She denied CP, SOB, or palpitations preceding the fall. Denies
recent urinary symptoms, abdominal pain, N/V/D.
Her Hb at ___ was 7. She was given 1 pRBC. Foley
in place from OSH.
She also has a new diagnosis of Non Hodgkin's lymphoma with
liver lesions and no evidence of lymphoma elsewhere. Daughter,
husband, and patient are aware of the diagnosis, she has not yet
seen an oncologist. She was informed by her primary care
physician. She was seen in the ED by trauma surgery and
orthopedics. Trauma surgery recommended touchdown weightbearing
on the left lower extremity in that she does not need operative
repair. They stated that the hardware appears well-positioned
given her periprosthetic femur fracture.
In the ED, initial vitals: T: 99.6 HR: 104 BP: 138/80 RR: 18
Sp02: 2L 95% Nasal Cannula
Labs notable for: - Leukocytosis to 11.7, H/H 8.7/25.5 (given 1
u for 7.0 ___ -Coags wnl - Lactate 1.3 - UA
with mod leuks, neg nitrites - Chem 7 wnl (Cr 0.7) - BNP 655 -
Trop 0.01 @ 0703 on ___. - Urine culture and blood cultures
drawn. - Active blood bank specimen.
Imaging notable for:
___ EKG: Sinus rhythm at 86, no ischemia or arrhythmia,
nonspecific TWI in V1, similar to prior EKG from ___. QTc: 425.
Possible ___.
___ CTA CHEST:
1. Left upper lobe segmental pulmonary embolism. Questionable
left lower lobe subsegmental pulmonary embolism which is likely
real given slight hypoenhancement of the lung supplied by this
branch which could represent component of infarct. No right
heart strain. 2. Rib fractures at the costovertebral junctions
of the left eighth and ninth ribs posteriorly to be correlated
clinically regarding acuity as these may be recent in nature. 3.
Evidence of metastatic disease in the partially visualized
abdomen.
___ CT C-spine: Degenerative changes without fracture or
acute malalignment.
___ CT Head W/O contrast: No acute intracranial
process.Complete opacification of the left frontal sinus and
ethmoid air cells. Given demineralized left ethmoid septa and
soft tissue extension into the left orbit, underlying mass
lesion with secondary obstruction would be of concern. A
mucocele is less likely given lack of expansion. Dedicated
nonurgent MRI suggested.
___ Left Hip IMPRESSION: Acute periprosthetic fracture at
the midportion of the femoral stem of the left hip arthroplasty.
Pt given: - 2 mg IV morphine for pain x 3 (approx. Q4-6H) - IVF
w/ NS @ 100 ml/hr. - CTX 1g x 1 at 13:16 - Lovenox 70 mg @ 14:35
- Levothyroxine 50 mcg 15:10 - Fluticasone/Salmeterol @ 15:17 -
Zofran 4 mg @ 16:15
Vitals prior to transfer: T: 98.1 HR: 86 BP:108/56 RR:22
Sp02:97% Nasal Cannula On the floor, she was seen with her
husband ___ and ___ daughter ___. She has some discomfort in
her left leg she points to her distal femur. She denies any
chest pain or tightness, she does endorse some mild shortness of
breath. She denies any abdominal pain, constipation, diarrhea,
dark or bloody stools, dysuria. Of note, she does endorse that
she had increased urinary frequency prior to the Foley
placement. She is anxious about the new cancer diagnosis. Review
of systems is otherwise negative.
Past Medical History:
Osteoarthritis
Hypothyroidism
Hemochromatosis
Asthma
HCV- resolved
Basal cell ca- forehead
Non-Hodgkin's lymphoma located in liver.
Social History:
___
Family History:
Her brother was diagnosed with kidney cancer at ___ and died
shortly thereafter. Her father died of a heart attack at ___.
Her mother died of coronary artery disease at ___. Her sister
died of COPD and she was a heavy smoker. She otherwise denies
any other history of cancer, hypertension, stroke in her family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=================================
VITALS: T: 98.2 BP: 144/80 HR: 97 RR: 18 Sp02: 90% 4L
General: Alert, oriented, no acute distress, nasal cannula in
place.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. distal pulses intact.
Lungs: On 4L (patient could not tolerate sitting up due to leg
pain), good air exchange, no increased work of breathing, no
wheezes, rales or rhonchi.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: Foley in place.
Ext: No peripheral edema, some minor bruises on lower
extremities
bilaterally, able to move toes on both sides, exam limited by
pain on LLE, able to move RLE normally.
Neuro: CNII-XII grossly intact, normal sensation.
DISCHARGE PHYSICAL:
===================================
VS: 0332 98.0 PO 131/62 86 19 95 Ra
tmax 98.5
ACCESS: Dual Lumen Non-Heparin Dependent Right Brachial PICC
(placed ___
PHYSICAL EXAM:
General: Sitting up in bed. NAD. A&Ox3. Very pleasant.
HEENT: Mucosa pink, moist, non-inflammed. No conjunctival
pallor.
CV: Tachycardic, Regular rhythm. No murmurs, rubs, gallops.
Lungs: Lungs CTAB. No wheezes, rales, rhonchi.
Abdomen: Soft, nontender, non distended.
Ext: 1+ edema of bilateral lower extremities, L>R.
Neuro: A&O x3. Conversant. Remainder of neuro exam is non-focal.
Skin: Multiple ecchymoses. no rashes, lesions, or petechiae
noted. B/l LEs with hyperpigmented patches and shiny taut
patches.
Pertinent Results:
ADMISSION LABS:
=
================================================================
___ 09:28PM GLUCOSE-136* UREA N-17 CREAT-0.7 SODIUM-136
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-20* ANION GAP-16
___ 09:28PM ALT(SGPT)-20 AST(SGOT)-52* LD(LDH)-541* ALK
PHOS-68 TOT BILI-3.6*
___ 09:28PM CALCIUM-7.9* PHOSPHATE-2.7 MAGNESIUM-2.0 URIC
ACID-4.2
___ 09:28PM HBsAg-NEG HBs Ab-NEG HBc Ab-NEG
___ 09:28PM HCV VL-NOT DETECT
___ 09:28PM WBC-13.5* RBC-3.08* HGB-9.5* HCT-28.7* MCV-93
MCH-30.8 MCHC-33.1 RDW-21.0* RDWSD-58.8*
___ 09:28PM PLT COUNT-357
___ 09:28PM ___ PTT-30.2 ___
___ 03:40PM WBC-11.1* RBC-2.76* HGB-8.7* HCT-25.5* MCV-92
MCH-31.5 MCHC-34.1 RDW-20.5* RDWSD-57.5*
___ 03:40PM NEUTS-78* BANDS-0 LYMPHS-15* MONOS-7 EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-8.66* AbsLymp-1.67
AbsMono-0.78 AbsEos-0.00* AbsBaso-0.00*
___ 03:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
___ 03:40PM PLT SMR-NORMAL PLT COUNT-318
___ 01:23PM LACTATE-1.3
___ 08:04AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:04AM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM* UROBILNGN-2* PH-6.0
LEUK-MOD*
___ 08:04AM URINE RBC-42* WBC-35* BACTERIA-NONE YEAST-NONE
EPI-0
___ 08:04AM URINE MUCOUS-RARE*
___ 07:03AM GLUCOSE-117* UREA N-19 CREAT-0.7 SODIUM-134
POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-22 ANION GAP-15
___ 07:03AM ALT(SGPT)-21 AST(SGOT)-66* LD(LDH)-656* ALK
PHOS-67 TOT BILI-5.8* DIR BILI-1.0* INDIR BIL-4.8
___ 07:03AM cTropnT-<0.01 proBNP-655*
___ 07:03AM CALCIUM-8.1* PHOSPHATE-3.2 MAGNESIUM-2.1 URIC
ACID-5.5
___ 07:03AM HAPTOGLOB-36
___ 07:03AM WBC-12.0* RBC-2.89* HGB-9.0* HCT-26.5*
MCV-92# MCH-31.1 MCHC-34.0 RDW-19.3* RDWSD-56.6*
___ 07:03AM NEUTS-76* BANDS-1 LYMPHS-16* MONOS-5 EOS-0
BASOS-0 ___ MYELOS-2* AbsNeut-9.24* AbsLymp-1.92
AbsMono-0.60 AbsEos-0.00* AbsBaso-0.00*
___ 07:03AM HYPOCHROM-NORMAL ANISOCYT-1+* POIKILOCY-1+*
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+*
___ 07:03AM PLT SMR-NORMAL PLT COUNT-331
___ 07:03AM ___ PTT-23.6* ___
DISCHARGE LABS:
===============================================================
___ 12:00AM BLOOD WBC-5.2# RBC-2.77*# Hgb-8.4*# Hct-25.8*#
MCV-93 MCH-30.3 MCHC-32.6 RDW-17.8* RDWSD-57.4* Plt ___
___ 12:00AM BLOOD Neuts-62 Bands-2 Lymphs-15* Monos-10
Eos-4 Baso-7* ___ Myelos-0 AbsNeut-1.60
AbsLymp-0.38* AbsMono-0.25 AbsEos-0.10 AbsBaso-0.18*
___ 12:00AM BLOOD Plt ___
___ 12:00AM BLOOD ___
___ 12:00AM BLOOD Glucose-87 UreaN-11 Creat-0.5 Na-138
K-3.9 Cl-99 HCO3-26 AnGap-13
___ 12:00AM BLOOD ALT-9 AST-12 AlkPhos-115* TotBili-0.5
___ 12:00AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.1
IMAGING/STUDIES:
===============================================================
___: NCHCT:IMPRESSION:
No acute intracranial process.
Complete opacification of the left frontal sinus and ethmoid air
cells. Given demineralized left ethmoid septa and soft tissue
extension into the left orbit, underlying mass lesion with
secondary obstruction would be of concern. A mucocele is less
likely given lack of expansion. Dedicated nonurgent MRI
suggested.
___ CTA:IMPRESSION:
1. Left upper lobe segmental pulmonary embolism. Questionable
left lower
lobe subsegmental pulmonary embolism which is likely real given
slight
hypoenhancement of the lung supplied by this branch which could
represent
component of infarct. No right heart strain.
2. Rib fractures at the costovertebral junctions of the left
eighth and ninth ribs posteriorly to be correlated clinically
regarding acuity as these may be recent in nature.
3. Evidence of metastatic disease in the partially visualized
abdomen.
___: CT C-Spine: Degenerative changes without fracture or
acute malalignment.
___: Hip XR: Acute periprosthetic fracture at the midportion
of the femoral stem of the left hip arthroplasty.
___: ECHO:IMPRESSION: Mild symmetric left ventricular
hypertrophy with preserved global and regional biventricular
systolic function. Mildly dilated aortic arch Mild mitral
regurgitation. Moderate pulmonary hypertension.
___: CT
1. No acute intracranial process.
2. Re-demonstration of complete opacification of the left
frontal sinus and ethmoid air cells with apparent
demineralization of the left ethmoid septa and extension into
the left orbit, again concerning for underlying mass lesion.
Nonurgent MRI is again recommended for further evaluation.
1. No infectious source identified in the abdomen and pelvis.
2. Upper abdominal lymphadenopathy, the largest conglomerate
measuring up to 2.6 x 2.4 cm in the gastrohepatic ligament,
compatible with provided history of lymphoma.
3. Multiple hypoenhancing hepatic masses, the largest measuring
up to 5.5 x 4.4 cm, likely representing lymphomatous
involvement. 4. Signs of excess fluid including small bilateral
pleural effusions, trace pelvic free fluid, and mild body wall
edema.
1. Oblique, mildly displaced left femoral periprosthetic
fracture is
re-demonstrated. Asymmetry of the muscle bulk surrounding the
periprosthetic fracture suggesting a component of intramuscular
hematoma, however no large hematoma is seen separate to this
region. No retroperitoneal hematoma.
2. Please refer to CT of the abdomen and pelvis performed with
contrast
earlier on the same day for additional details of intra pelvic
structures.
1. Oblique, mildly displaced left femoral periprosthetic
fracture is
re-demonstrated. Asymmetry of the muscle bulk surrounding the
periprosthetic fracture suggesting a component of intramuscular
hematoma, however no large hematoma is seen separate to this
region. No retroperitoneal hematoma.
2. Please refer to CT of the abdomen and pelvis performed with
contrast
earlier on the same day for additional details of intra pelvic
structures.
___: CT Chest: 1. Persistent small bilateral non
hemorrhagic pleural effusions, similar to ___ chest
radiograph given difference of technique, though increased since
___ chest CTA
2. Bibasilar pulmonary opacities most consistent with
compressive
atelectasis. Clinical correlation for superimposed infection is
recommended.
3. Small airways disease with bronchial wall thickening. No
mucus plugging.
4. 0.3 cm right upper lobe pulmonary nodule, unchanged since ___.
5. Innumerable hepatic masses, better characterized on CT
abdomen/pelvis from ___, most consistent with
lymphomatous involvement.
___ Video Swallow:
IMPRESSION:
Transient penetration with thin and nectar liquids. No
aspiration.
___ FEMUR (AP & LAT) LEFT:
IMPRESSION:
Unchanged periprosthetic left femur fracture. Degenerative
changes in the
left knee.
___ LLE Ultrasound:
IMPRESSION:
-No evidence of deep venous thrombosis in the left lower
extremity veins.
-2 small fluid collections in the popliteal fossa are likely
continuous with each other, likely representing a ruptured ___
cyst.
___ ECHO:
Conclusions
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). 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. Mild (1+) mitral regurgitation is
seen. There is at least mild pulmonary artery systolic
hypertension.
Compared with the prior study (images reviewed) of ___, the
left ventricular cavity appears smaller, c/w underfilling. Other
findings are similar.
___ MRI brain with and without contrast:
IMPRESSION:
1. The imaging findings are overall concerning for central
pontine
myelinolysis. Differential considerations subacute infarct or
other
demyelinating process is considered much less likely given the
symmetric
bilateral appearance of the abnormality with classic sparing of
the peripheral pons and cortical spinal tracts.
2. Scattered foci of gradient echo susceptibility artifact,
compatible with prior micro hemorrhages in a distribution
suggestive of underlying amyloid angiopathy.
3. Prominent periventricular subcortical T2/FLAIR white matter
hyperintensities the subcortical and periventricular white
matter are
nonspecific and nonenhancing, commonly seen in setting of
chronic microangiopathy in a patient of this age.
4. No evidence of abnormal enhancement to suggest intracranial
metastatic
disease at this time.
5. Additional findings described above.
___ CTA CHEST:
IMPRESSION:
1. No evidence of pulmonary embolism to the segmental level or
aortic
abnormality. Assessment of subsegmental pulmonary arteries is
limited due to respiratory motion artifact.
2. Interval resolution of pleural effusions.
3. Enlarged right and left main pulmonary arteries suggests
pulmonary arterial hypertension.
4. Known hepatic masses are better assessed on prior CT abdomen
and pelvis
dated ___ due to timing of the contrast bolus.
___ FEMUR (AP & LAT) LEFT
IMPRESSION:
Compared to the prior study there has been no significant
interval change. The left total hip arthroplasty is again
visualized. A periprosthetic oblique fracture through the
proximal feet femoral diaphysis is again noted. This is
unchanged in alignment compared to the prior study. No callus
formation is identified. No periprosthetic loosening is
visualized. Degenerative changes are again visualized in the
left knee.
___ MRI without contrast: IMPRESSION:
1. Previously identified periprosthetic fracture appears
slightly more
distracted than prior CT on ___ but likely similar to
x-ray from ___.
2. There is a large fluid collection posterior to the left
total-hip
replacement primarily centered deep to the gluteus maximus
muscle with
apparent extension to the neck of the femoral component and
insinuating
between the fracture fragment and the prosthesis.
3. Ovoid lesion centered within the proximal vastus
intermedius/vastus
lateralis demonstrating internal STIR heterogeneity with central
T1
hypointensity but peripheral T1 hyperintensity most likely
represents a
hematoma. Follow-up imaging should be performed to ensure
resolution.
4. There is a small amount of fluid deep to the hamstring
insertion at the
Left ischial tuberosity which may represent sequela of partial
tearing and/or calcific tendinitis as seen on prior CT
RECOMMENDATION:
___ week follow-up MRI to ensure resolution of presumed hematoma
in the
proximal thigh.
PATHOLOGY:
================
___ CSF cytology report: No malignant cells.
___ CSF Flow cytometry
INTERPRETATION:
Non-diagnostic study. Cell marker analysis was attempted, but
was non-diagnostic in this case due to insufficient numbers of
cells for analysis. Correlation with clinical, morphologic (see
separate cytology report ___-___) and other ancillary findings
is recommended. Flow cytometry immunophenotyping may not detect
all abnormal populations due to topography, sampling or
artifacts of sample preparation.
MICRO:
==========================================================
___ 12:15 am BLOOD CULTURE Source: Line-picc.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ @ 1710
ON
___.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ (___) @ ___,
___.
GRAM POSITIVE ROD(S).
CONSISTENT WITH CORYNEBACTERIUM OR
PROPIONIBACTERIUM SPECIES.
___ 8:23 am CSF;SPINAL FLUID Source: LP.
**FINAL REPORT ___
Enterovirus Culture (Final ___: No Enterovirus
isolated.
___ 8:23 am CSF;SPINAL FLUID Source: LP.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
___ 5:28 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 12:15 am BLOOD CULTURE Source: Line-picc.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ @ 1710
ON
___.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ (___) @ ___,
___.
GRAM POSITIVE ROD(S).
CONSISTENT WITH CORYNEBACTERIUM OR
PROPIONIBACTERIUM SPECIES.
Brief Hospital Course:
Ms. ___ is a ___ woman with a history of COPD,
hypothyroidism, and hemochromatosis who presented as a transfer
from an outside hospitalwith a new left femoral fracture, as
well as fatigue, nausea, anemia, and new liver lesions on
outside hospital abdominal CT, now biopsy-proven diffuse large
B-cell lymphoma. She also had new PEs (now on Lovenox). She
started treatment for DLBCL with mini R-CHOP. Her course was
complicated by persistently elevated bilirubin (likely due to
liver disease and hemolysis), warm hemolytic anemia (on
Rituxan), steroid psychosis/delirium, and hypoxia that
ultimately required a stay in the FICU. Her mental status
ultimately improved and she was weaned off oxygen. On the floor
she continued to improve, worked with ___ and was deemed stable
to continue chemo. She is now being discharged on C3D10 of
R-mini-CHOP.
ACUTE ISSUES
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# Diffuse Large B- Cell Lymphoma:
During an outpatient workup for anemia, a CT scan that showed
numerous liver lesions. Biopsies show high-grade diffuse large
B-cell lymphoma with high nuclear proliferation index (>90%).
She was initially started on treatment with only
cyclophosphamide on ___ and Solu-Medrol on ___ and ___ due to
an elevated bilirubin. The patient then developed severe
delirium and hypoxia from volume overload and was transferred to
the FICU on ___. While in the ICU the patient briefly required
BIPAP support and improved with diuresis. Her delirium improved
with the discontinuation of dilaudid and olanzapine 10 mg twice
per day. Following discharge from the ICU she subsequently
received dose-reduced vincristine and Adriamycin on ___ and
Rituxan on ___. Over the course of the next week the
patient was weaned to room air, her mental status returned to
baseline, and she began to work with ___. Per the recommendations
of her primary oncologist, it was decided to start her next
cycle of chemo inpatient. On ___ she received R-CHOP w/ a
dose-reduced prednisone regimen. She started a cycle of
R-mini-chop on ___, which she tolerated well. She started
G-CSF on ___ and is being continued on it upon discharge.
# Pulmonary embolism
# COPD
# Hypoxia (resolved)
On admission, CTA was notable for new segmental and subsegmental
PEs. She was started on therapeutic Lovenox. The patient was
stable on ___ NC/facemask and intermittently off of additional
oxygen. After receiving 4L of IVF during prep for her chemo, she
developed new onset increasing tachypnea, hypoxia and
tachycardia to the 140s. Her hypoxia and tachycardia
significantly improved in the ICU with diuresis. The patient
progressively was able to be weaned off of O2 on the ___
service, and returned to her baseline respiratory status. She
has been maintained on therapeutic Lovenox and will be
discharged on Lovenox.
# Femoral fracture:
The patient initially presented to an OSH w/ a left femoral
fracture in the setting of a mechanical fall. X-rays showed an
acute periprosthetic fracture at the midportion of the femoral
stem of the left hip arthroplasty. Orthopedic surgery determined
she could have surgery if desired but non-operative management
is fine as well. The pt did not wish to have surgery. The
patient received pain control initially with Tylenol, oxycodone,
and morphine with good effect. She worked with physical therapy
when she returned from the ICU and was reevaluated by ortho who
recommended no interventions and ___ until discharge to an acute
rehabilitation facility. She will continue getting ___ at her
rehab facility.
# Urinary retention:
Pt was not requiring a foley prior to this admission. Foley has
been present for almost entire admission; several voiding trials
during the week prior to discharge were unsuccessful.
Discontinued olanzapine, which was felt to be the only drug
contributing to urinary retention. She is being discharged with
a foley catheter to rehab. This will be a transitional issue for
the rehab facility to work on, and if the pt is unable to void,
she should follow up with outpatient urology.
# Hemolytic anemia:
The patient was noted to have an elevated indirect bilirubin.
Labs showed a warm hemolytic anemia with Coombs (+), anti-C3
(+), and haptoglobin <10. Her LFTs and LDH remained stable. An
eluate test was negative. Given that she was receiving Rituxan
as part of her DLBCL regimen, there was no need for additional
treatment. It was suspected that this was secondary to the
patient's hematologic malignancy.
# Psychosis (resolved:
The patient became psychotic/delirious after receiving high dose
steroids on ___, ultimately requiring ICU transfer due to a lack
of response to Haldol and increased nursing requirements. She
was started on standing Olanzapine and Dilaudid in the ICU,
which ultimately led to better control of agitation and pain.
However, she became non-responsive to questions and commands. On
transfer back to the ___ service, her mental status
progressively improved once Dilaudid was discontinued. Of note,
the patient underwent an EEG that showed epileptiform
discharges, but no organized seizure activity. When she
underwent her second cycle of chemotherapy w/ R-CHOP her
prednisone dose was modified to 4mg PO QD x3 days and she was
started on Olanzapine 10mg PO QD for 3 days for prophylaxis of
steroid induced delirium. This regimen worked and she underwent
her second round of chemo without issue. She was then continued
on Olanzapine 2.5mg thereafter. Olanzapine was eventually
discontinued several days prior to discharge(due to concern for
urinary retention), and the pt did not have any further sx of
psychosis or AMS once off the olanzapine.
# ?GPC bacteremia (determined to be contaminant).
Labs in the ICU showed a lactic acidosis and new leukocytosis.
She was started on Cefepime and Vancomycin. 1 culture bottle
grew coag negative staph and corynebacterium, which was deemed
to likely be a contaminant. She received a course of linezolid
for growth of GPC in the setting of vancomycin. Ultimately, she
was transitioned off of antibiotics on the ___ service without
incident.
CHRONIC ISSUES
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# Tachycardia
Baseline is 100-120s, was diagnosed w/sinus tachycardia as
outpatient and put on metoprolol XL 50mg PO. Also had new PEs on
admission w/ assoc tachycardia. EKGs showed NSR. Cardiology was
consulted and felt this is consistent with atrial tachycardia;
they agreed on continuing metoprolol. Her dose was increased to
100mg daily.
#Hypothyroidism: The patient was maintained on her home
levothyroxine.
TRANSITIONAL ISSUES
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[]Will need follow up w/ Ortho w/Dr. ___
___ -- this is scheduled for ___
[]Will need CBCs to monitor her blood counts. Please check them
on ___ and ___ and fax them to ___ to Dr.
___ for monitoring.
[]Will need Oncology follow up w/ Dr. ___ to discuss further
treatment -- this is scheduled for ___
[]Please monitor platelets while the pt is on lovenox. She is on
this for her pulmonary emboli. Should her plts drop to between
___, please reduce the dose in half (from 60bid to 30bid). If
plts drop below 30K, please stop lovenox.
DNR/DNI
Contact: ___ (daughter) ___, ___ (daughter, current
location of husband, ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Montelukast 10 mg PO DAILY
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. DiphenhydrAMINE ___ mg PO QHS:PRN insomnia
7. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea
Discharge Medications:
1. Acyclovir 400 mg PO TID
2. Atovaquone Suspension 1500 mg PO DAILY
3. Enoxaparin Sodium 60 mg SC Q12H
4. Filgrastim-sndz 300 mcg SC Q24H
RX *filgrastim [Neupogen] 300 mcg/0.5 mL 1 syringe SC q24 Disp
#*5 Syringe Refills:*0
5. Lidocaine 5% Patch 1 PTCH TD Q24H
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Multivitamins 1 TAB PO DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Albuterol Inhaler 1 PUFF IH Q4H:PRN dyspnea
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. Levothyroxine Sodium 50 mcg PO DAILY
13. HELD- Montelukast 10 mg PO DAILY This medication was held.
Do not restart ___ until your oncologist or PCP
determines it is ok to take it again.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Femur fracture
Diffuse large B cell lymphoma
Pulmonary emboli
Secondary:
Steroid psychosis/delirium
Hypoxemic respiratory failure
Warm agglutinin hemolytic anemia
Chronic obstructive pulmonary disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You fell at home and were found to have a broken hip
- We found out that you had blood clots in your lungs
- You were recently diagnosed with lymphoma and needed to begin
treatment
What was done while I was in the hospital?
- You were seen by the orthopedic surgeons who determined that
you did not need surgery for your broken hip.
- You were started on blood thinners for the blood clots in your
lungs.
- You received chemotherapy to treat your lymphoma.
- During the chemotherapy, you became very confused; this was
likely because of the steroids and pain medications you were
being given.
- You were moved to the ICU for several days because of your
confusion and difficulty breathing
- In the ICU you received medication to help you urinate, which
helped to improve your breathing
- Your confusion and breathing improved enough for you to be
moved back to the general lymphoma floor.
- While on the general floor, your cell counts came back up.
- We gave you a second cycle of chemotherapy which you tolerated
well.
- You worked with physical therapy and became strong enough to
go to an acute rehab facility.
What should I do when leave the hospital?
- You should work with physical therapy at the rehabilitation
facility
- You should have your blood counts checked about every three
days at the rehabilitation facility
- You should take all of your medications as prescribed,
especially the medications preventing bacterial and viral
infections
- Please attend your follow-up appointment with your oncologist
to discuss your future treatment plan
- If you have fevers, chills, feel more confused, have problems
breathing, chest pain, or generally feel unwell, please call
your oncologist
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
10049897-DS-6 | 10,049,897 | 20,562,419 | DS | 6 | 2176-06-10 00:00:00 | 2176-06-13 16:03:00 |
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 hip pain
Major Surgical or Invasive Procedure:
Left trochanteric femoral nail
History of Present Illness:
___ healthy male here with left hip pain s/p fall on bicycle.
Nonambulatory at the scene. Brought to ___, found to
have left femoral neck fracture. Transferred here. Reports
history of hip dislocation ___ years ago though he does not
remember which side. No other injury. Has not taken any PO
today.
Past Medical History:
OA
Social History:
___
Family History:
NC
Physical Exam:
Vitals: O2 sat 88-91% on RA, other vital signs stable
Gen: comfortable, NAD
LLE:
Incision c/d/i, no erythema, induration, drainage
SILT in DP/SP/S/S/T distributions
___
WWP
Pertinent Results:
___ Left hip films: Intertrochanteric fracture of the left
femur.
___ 07:15AM BLOOD Hct-31.0*
___ 05:38AM BLOOD Glucose-143* UreaN-17 Creat-0.8 Na-137
K-4.2 Cl-102 HCO3-28 AnGap-11
___ 05:38AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.8
___ Chest (AP/Lat): New acute fracture in the left
posterior eight rib with an associated small pleural effusion
and atelectasis.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left intertrochanteric fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for operative fixation with a left
trochanteric femoral nail, 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 home
with services was appropriate.
Of note, the patient began to complain of left sided-rib pain
while working with ___ on POD#2. A chest x-ray was obtained that
showed a left posterior fracture of the 8th rib. It was also
noted that the patient's O2 sats were in the high 80's to low
90's. He was intermittently requiring oxgen.
On POD#3, the patient continued to have O2 saturations in the
low 90's on room air, likely due to poor inspiratory effort from
rib fractures. He expressed that he wanted to go home. It
discussed with him that the orthopaedic team would prefer that
hestay in the hospital for another night for close monitoring
and until his O2 sats improve. Mr. ___ fully understood the
teams wishes but chose to leave against medical advice. He was
informed that he should to return to the emergency room if his
respiratory status changes.
At the time of discharge the patient was afebrile, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
left lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.
Medications on Admission:
None
Discharge Medications:
1. rolling walker
dx left hip fx s/p orif
px good
13 months
2. Acetaminophen 650 mg PO Q6H
3. Calcium Carbonate 1250 mg PO TID
4. Docusate Sodium 100 mg PO BID
Please take while taking prescription pain medication to
prevent/treat constipation.
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*50 Capsule Refills:*0
5. Enoxaparin Sodium 40 mg SC QPM
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC nightly Disp #*14 Syringe
Refills:*0
6. Multivitamins 1 CAP PO DAILY
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*100 Tablet Refills:*0
8. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left intertrochanteric femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks.
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Left lower extremity: weight bearing as tolerated
Physical Therapy:
Left lower extremity: weight bearing as tolerated
Treatments Frequency:
Wound Care
Wound: Surgical incision
Location: Left femur
Dressing: Inspect incision and change dressing daily with dry
gauze. If non-draining, can leave open to air.
Followup Instructions:
___
|
10050755-DS-12 | 10,050,755 | 23,782,628 | DS | 12 | 2132-10-19 00:00:00 | 2132-10-23 19:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right arm weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx of PD, HTN, HLD who was sitting at the lunch
table when he had the sudden onset of right sided arm weakness
(last seen normal 11am). He was eating with a spoon when he
suddenly stopped using his right hand. He used his left hand to
hold his spoon and his left hand to drink from his cup. He even
went as far as to pick up his right hand with his left hand
indicating that it was markedly weak. Per his daughter at the
bedside, he used to see a neurologist (Dr ___ in ___ but
quit
seeing him and now gets his ___ medications from his PCP.
At baseline, he is able to walk with a two person assist and
does
not pay bills. He is able to feed himself some of the time, some
of the time his family feeds him. He is able to recognize and
converse with his family. He has never had a stroke or any acute
neurological deficit in the past.
Unable to obtain a ROS as the patient is minimally verbal in
___ only. Per his daughter, he has not complained of any
pain, confusion, weakness, or numbness recently.
Past Medical History:
PD
HTN
HTL
chronic hearing loss requiring hearing aids
Social History:
___
Family History:
Per his daughter, no family history of strokes/seizures.
Physical Exam:
- Vitals: 98.9 52 133/49 18 100% RA
- General: drowsy, awake, ___ speaking only, very hard of
hearing
- 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.
NEURO EXAM:
- Mental Status: decreased verbal output, dysarthria, per his
daughter minimal verbal output with confused speech (A&O to name
only). Able to follow simple commands with lots of prompting
(hold arms up, squeeze hand, smile). Does not respond to more
complex commands.
- Cranial Nerves:
PERRL 5 to 3mm and brisk. Much prompting for EOM. Does bury
sclera to the left. Does not bury to the right. Decreased up
gaze. Down gaze intact. No obvious nystagmus. Right facial droop
with activation. Hearing intact to loud voice in ear only.
- Motor: Decreased tone in the right arm. Increased tone in BLE
and left arm. Decreased bulk throughout. Right pronation with
drift. Able to hold arm antigravity, drifts to gurney in ___. No
adventitious movements such as tremor or asterixis noted.
Delt Bic Tri FE IP Quad Ham TA ___
L 5 ___ 4
R 4 5- ___ ** unable to test BLE secondary to
comprehension difficulties.
- Sensory: moves all extremities to light pinch.
- DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was extensor in the right toe, flexor on the
left.
Pertinent Results:
___ 10:40AM BLOOD WBC-4.5 RBC-3.61* Hgb-12.0* Hct-33.6*
MCV-93 MCH-33.1* MCHC-35.5* RDW-13.5 Plt ___
___ 05:29AM BLOOD Neuts-71.4* ___ Monos-7.0 Eos-2.9
Baso-0.3
___ 10:40AM BLOOD Plt ___
___ 10:40AM BLOOD Glucose-102* UreaN-20 Creat-1.2 Na-140
K-3.8 Cl-105 HCO3-25 AnGap-14
___ 10:40AM BLOOD CK(CPK)-78
___ 05:29AM BLOOD ALT-13 AST-18 AlkPhos-68 TotBili-0.4
___ 05:29AM BLOOD Lipase-37
___ 10:40AM BLOOD CK-MB-2 cTropnT-<0.01
___ 10:40AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.9 Cholest-157
___ 09:51AM BLOOD %HbA1c-5.6 eAG-114
___ 10:40AM BLOOD Triglyc-92 HDL-53 CHOL/HD-3.0 LDLcalc-86
___ 10:40AM BLOOD TSH-1.3
___ 05:29AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Head CT ___
No acute intracranial process.
Brain MRI ___. Multiple small acute infarcts within the left frontal and
left parietal lobes, most of which are cortically based ,
suggesting embolic etiology.
2. Multiple chronic infarcts. Extensive supratentorial white
matter and
pontine signal abnormalities, likely sequela of chronic small
vessel ischemic disease.
3. Chronic microhemorrhages (likely hypertensive) versus
mineralization in bilateral basal ganglia and right thalamus.
Possible chronic blood products in the area of the left superior
parietal chronic infarct, versus artifact.
Carotid ultrasound ___
Less than 40% stenoses at bilateral internal carotid arteries
due to mild
heterogeneous plaque.
Echocardiogram ___
No cardiac source of embolism identified. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Diastolic dysfunction with
elevated PCWP. Mild aortic and mitral regurgitation. Pulmonary
hypertension.
Brief Hospital Course:
Mr ___ was admitted for acute onset speech difficulty and
right arm weakness. He had an MRI that demonstrated multiple
punctate areas of restricted diffusion in the left
frontal/parietal region. He had a carotid ultrasound that did
not demonstrate significant stenosis. He had an echocardiogram
that did not demonstrate evidence of a cardioembolic source. The
etiology of the stroke at the time of discharge was unclear but
it could be related to an slow flow in the distal vessels or an
irregular heart rhythm leading to cardioembolic infarct.
(although there were no irregularities noted on telemetry during
his admission). He had an echocardiogram that showed some
diastolic dysfunction but no other abnormalities to explain a
cardiac embolic source. He was evaluated by speech and swallow,
and they felt that he was safe to take thickened liquids and
purees. He was restarted on his home medications at that time.
He was evaluated by physical therapy and occupational therapy.
Both teams felt that he could benefit from ___
rehabilitation. However, in extensive discussions with the
family, they felt that he would be more agitated in an
unfamiliar setting, and they did not want that for him.
Therefore, they were trained in specific cares, and he was
discharged home with outpatient physical therapy and
occupational therapy.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented (required for all patients)? (x) Yes (LDL =
76) - () No
5. Intensive statin therapy administered? (x) Yes - () No
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
9. Discharged on statin therapy? (x) Yes - () No
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - (x) N/A
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Venlafaxine XR 75 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Vitamin B Complex 1 CAP PO DAILY
4. Carbidopa-Levodopa (___) 1 TAB PO TID
5. Zonisamide 100 mg PO BID
6. Lisinopril 10 mg PO DAILY
7. Creon 12 1 CAP PO TID W/MEALS
8. Exelon (rivastigmine;<br>rivastigmine tartrate) 13.3 mg/24
hour transdermal daily
9. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
10. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
11. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Atorvastatin 10 mg PO QPM
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
3. Carbidopa-Levodopa (___) 1 TAB PO TID
4. Creon 12 1 CAP PO TID W/MEALS
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
6. Lisinopril 10 mg PO DAILY
7. Venlafaxine XR 75 mg PO DAILY
8. Vitamin B Complex 1 CAP PO DAILY
9. Zonisamide 100 mg PO BID
10. Aspirin 81 mg PO DAILY
11. Exelon (rivastigmine;<br>rivastigmine tartrate) 13.3 mg/24
hour transdermal daily
12. Vitamin D 800 UNIT PO DAILY
13. Outpatient Occupational Therapy
Dx: acute ischemic stroke. Please evaluate and treat.
14. Outpatient Physical Therapy
Dx: acute ischemic stroke. Please evaluate and treat.
15. 3:1 Commode
Diagnosis: ischemic stroke (434.91), parkinsons disease (332)
Duration: lifetime
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke
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 ___,
You were hospitalized due to symptoms of speech difficulty and
right arm weakness 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:
Hypertension
We are changing your medications as follows:
Starting Aspirin 81mg 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:
___
|
10050755-DS-13 | 10,050,755 | 26,698,047 | DS | 13 | 2134-01-29 00:00:00 | 2134-01-29 22:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
altered mental status, right arm weakness
Major Surgical or Invasive Procedure:
___ PEG placement by ___
History of Present Illness:
The patient is an ___ year-old ___ speaking man with a
history of ___ disease, left hemisphere ischemic strokes
___, HTN and HLD who presents to the ED with worsening mental
status and right arm weakness.
FROM NEUROLOGY NOTE AND DAUGHTER
Per the patient's daughter, Mr. ___ has been unwell since
for the last two weeks and was seen by his PCP and started on
Levaquin for community acquired pneumonia. He became more
confused and agitated at home and speaking barely any words (not
far from his baseline of a man of few words). His family found
it difficult to care from him at home and he was barely able to
make transfers with 2 person assist. He was not eating well, but
somehow family was able to coax him to take his meds. Yesterday,
while cleaning the patient and attempting to bathe him they
noticed he was not moving his right arm. His daughter is not
exactly sure if this came on suddenly or gradually with the
onset of the pneumonia.
In the ED, initial vital signs were: 98.3 80 137/47 16 96% RA
- Exam was notable for:
- Labs were notable for: white cell count of 14.8, lactate of
2.5, creatinine of 1.6 and negative tox screen.
- Imaging: CT HEAD: Extensive chronic microvascular ischemic
disease and chronic infarcts. There is no intracranial
hemorrhage. Loss of gray-white differentiation in the superior
left precentral gyrus seen on a single slice (02:30) may
artifactual or represent acute ischemia. MRI is more sensitive
for detection of an acute ischemic event if there is high
clinical suspicion. There is an air-fluid level in the right
maxillary sinus
CT NECK:The left vertebral artery is dominant. There is
moderate calcified and noncalcified plaque in the left carotid
bulb and proximal left internal carotid artery. There is no
evidence of dissection, occlusion, or flow limiting stenosis
involving the internal carotid and vertebral arteries. Extensive
cavernous carotid calcifications are present. Tributaries of
circle ___ are patent. There is no large aneurysm.
CXR:Lower lung consolidations concerning for pneumonia versus
aspiration, new from prior.
- The patient was given:
___ 19:04 IVF 1000 mL NS 1000 mL ___
___ 20:48 IV CeftriaXONE 1 gm ___
___ 21:43 IV Azithromycin 500 mg ___
___ 21:44 IVF 1000 mL NS ___ Started 75 mL/hr
___ 21:59 PR Aspirin 600 mg
An NG tube was placed as the patient was so somnolent and
altered.
- Consults: Neurology recommended urgent MRI brain
Upon arrival to the floor, patient is somnolent but groans when
spoken to.
Past Medical History:
- ___ disease
- left hemisphere ischemic strokes - watershed area btw ACA/MCA
territory ___
- Detrusor over activity
- HTN
- HLD
- Bilateral hearing loss, wears hearing aids
Social History:
___
Family History:
Per his daughter, no family history of strokes/seizures.
Physical Exam:
ADMISSION EXAM:
VITALS: 98.1 138 / 43 61 18 96
GENERAL: Somnolent, and wakes up to name, otherwise not
responding to any questions
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Bilateral rhonchi at bases
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
NEUROLOGIC: Not co-operative with neuro exam. Left upper
extremity with increased tone compared to right. Withdraws to
pain in all four extremities. Normal biceps/triceps/knee jerk
reflexes
DISCHARGE EXAM:
Objective: Tmax 99.6 112-140/ 44-57 68 24 100% 1.5L.
General: Opens right eye to command, moves extremities with
stimulation. Non-verbal, mildly tachypenic, no cyanosis.
Increased respiratory muscle use in the neck accessory.
HEENT: NC/AT. No scleral icterus, conjunctival pallor
Cardiac: RRR, S1, S2. No extra sounds
Lungs: diffuse wheezes and crackles b/l
Abdomen: Soft. NTND
Extremities: Warm, well perfused, no cyanosis. Emaciated.
Neurologic: Difficult to assess. Rigid, L > R. Contracted.
Withdraws to pain and grossly moves all extremities.
Pertinent Results:
ADMISSION LABS:
___ 05:10PM BLOOD WBC-14.7*# RBC-3.60* Hgb-11.2* Hct-35.4*
MCV-98 MCH-31.1 MCHC-31.6*# RDW-13.2 RDWSD-46.4* Plt ___
___ 05:10PM BLOOD Neuts-86.4* Lymphs-7.1* Monos-5.2
Eos-0.5* Baso-0.3 Im ___ AbsNeut-12.97* AbsLymp-1.07*
AbsMono-0.78 AbsEos-0.07 AbsBaso-0.04
___ 05:10PM BLOOD ___ PTT-27.3 ___
___ 05:10PM BLOOD Glucose-127* UreaN-62* Creat-1.6* Na-147*
K-3.7 Cl-109* HCO3-26 AnGap-16
___ 05:10PM BLOOD ALT-7 AST-30 AlkPhos-87 TotBili-0.6
___ 05:10PM BLOOD Lipase-49
___ 05:10PM BLOOD Albumin-3.2*
___ 02:51AM BLOOD Albumin-2.7* Calcium-8.7 Phos-3.1 Mg-1.9
___ 05:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:30PM BLOOD Lactate-2.5*
___ 09:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:00PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 09:00PM URINE RBC-60* WBC-17* Bacteri-FEW Yeast-NONE
Epi-0
___ 02:51AM URINE Hours-RANDOM UreaN-1139 Creat-83 Na-82
K-46 Cl-84
___ 02:51AM URINE Osmolal-806
___ 09:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
PERTINENT LABS:
___ 05:55AM BLOOD calTIBC-114* Hapto-257* Ferritn-840*
TRF-88*
___ 05:22AM BLOOD Triglyc-77
___ 05:28AM BLOOD TSH-1.2
DISCHARGE LABS:
MICROBIOLOGY:
___ BLOOD CULTURE X2: NO GROWTH (FINAL)
___ URINE CULTURE: NO GROWTH (FINAL)
___ BLOOD CULTURE X2: NO GROWTH (FINAL)
STUDIES:
___ CXR: IMPRESSION:
Lower lung consolidations concerning for pneumonia versus
aspiration, new from prior.
___ CTA HEAD & NECK:
1. Patent circle of ___.
2. Patent vasculature in the neck with no evidence of internal
carotid artery stenosis by NASCET criteria.
3. New area of hypoattenuation in the left precentral gyrus,
which may
represent a chronic infarction. Unchanged chronic infarctions
in the
bilateral occipital, left frontal, and left parietal lobes with
probable
sequela of severe chronic small vessel ischemic disease. MRI
may be obtained for further evaluation.
4. Paranasal sinus disease.
5. Multiple pulmonary nodules, the largest measuring 3 mm in the
right lower lobe. If the patient is at low risk for malignancy,
no further follow-up is necessary. If the patient is at high
risk for malignancy, CT follow-up is recommended in 12 months.
These guidelines are based upon ___ criteria.
___ BRAIN MRI: 1. Please note the study is substantially
degraded by motion.
2. Multiple small acute infarctions in the left MCA and PCA
territory. No
definite associated hemorrhage, although markedly limited in
evaluation given motion artifact.
3. Confluent background of white matter signal abnormality,
likely secondary to extensive chronic microvascular ischemic
changes.
___ Imaging CHEST (PORTABLE AP) : Cardiomediastinal
silhouette is within normal limits. There is again seen an area
of consolidation within the right upper lobe which appears more
confluent. Additional opacities at the lung bases are
unchanged. No pneumothoraces are seen.
___ Imaging CHEST (PORTABLE AP) Heart size and
mediastinum are unchanged. There is interval progression of
multifocal consolidations in the right lung, substantial as well
as unchanged or minimally worse appearance of the left middle
lower lung consolidations. The findings are concerning for
multifocal infection.
>> DISCHARGE LABS:
___ 05:56AM BLOOD WBC-5.9 RBC-2.61* Hgb-8.0* Hct-25.7*
MCV-99* MCH-30.7 MCHC-31.1* RDW-15.0 RDWSD-53.3* Plt ___
___ 06:36AM BLOOD ___
___ 05:56AM BLOOD Glucose-130* UreaN-28* Creat-0.8 Na-137
K-4.9 Cl-106 HCO3-24 AnGap-12
.
>> MICROBIOLOGY ;
__________________________________________________________
___ 4:43 am URINE Source: ___.
URINE CULTURE (Pending):
__________________________________________________________
___ 12:20 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 9:31 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 5:49 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 3:45 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:18 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ ___ ON
___ @ 13:40.
GRAM POSITIVE COCCI IN CLUSTERS.
Brief Hospital Course:
Mr. ___ is an ___ year-old ___ speaking man with a
history of ___ disease, left hemisphere ischemic strokes
___, HTN and HLD who presented to the ED with worsening mental
status and right arm weakness in the setting of a persistent
pneumonia.
.
>> ACTIVE ISSUES:
# Acute Encephalopathy: Patient initially was hospitalized for
right sided weakness and worsening mental status. Patient was
found to be minimally verbal, and likely thought to have
multifactorial etiology for symptoms, including multifocal
pneumonia, multifocal CVA seen on brain MRI on ___, and
also hypernatremia. Furthermore, patient has underlying
___ disease. Patient required initially mits and these
were then discontinued and patient had likely new baseline
mental status after treatment for the above. Patient was treated
for a second pneumonia, and patient's mental status was
minimally verbal, favoring his left side, and intermittent
tracking.
.
# Multifocal Cerbrovascular Event: Patient initially was found
to have right sided weakness, and imaging revealed a multifocal
CVA in MCA/PCA watershed distribution similar to prior. He
continued to receive aspirin, Plavix and atorvastatin with plan
for 3 months per neurology stroke. Patient's outpatient
neurologist was contacted, and likely has had prior CVAs and
likely is responsible for patient's Parkinsons. Patient then
.
# Pneumonia. Patient initially presented with community acquired
pneumonia after failing outpatient levofloxacin treatment.
Patient s/p treatment with ceftriaxone and azithromycin for CAP.
However, during hospitalization and mental status, patient
continued to have aspiration. Patient had an aspiration event
leading to an acute hypoxia on ___, and patient then developed
a fever in ___. Patient then started on vancomycin and cefepime
for completion of true HCAP course. Patient finished IV
antibiotics on ___, and then to continue augmentin x 3 days for
continued aspiriation coverage. It was discussed with patient's
family several times during hospital stay, that likely G-tube is
not a prevention for an aspiration type event, and there is a
high likelihood for recurrent aspiration in the future.
.
# Severe Malnutrition: Patient intermittently received
peripheral parenteral nutrition x 4 days prior to Dobhoff being
placed on ___. Patient had previously had enteral access
attempts, and finally PEG tube placed on ___. Patient has
been getting tube feeds, and has been followed by nutrition
closely. It was discussed repeatedly that aspiration events are
not prevented with G-tube placement. Patient was tolerating tube
feeds well.
.
# Anemia: Normocytic, iron studies concerning for anemia of
chronic disease. Hemoglobin was trended during hospital stay
without obvious signs of bleeding.
.
# Acute Kidney Injury: patient's creatinine was trended during
hospital stay and remained at baseline.
.
# ___ Disease: Patient is currently on sinemet, this was
originally changed to dissolvable carbidopa-levodopa, and
Effexor and zonisamide for tremor were discontinued given non
enteral access and uncertain benefit. Patient's neurologist was
contacted, Dr. ___ discussion regarding potential
prognosis given underlying ___ Disease with no worsening
status. Patient was restarted on sinemet through G-tube without
difficulty. Neurologic exam as above.
.
#HTN: Lisinopril was held and not restarted, as it was not
necessary.
.
#HLD: Atorvastatin changed to 80 mg qd given new stroke.
.
TRANSITIONAL ISSUES:
# Aspiration Pneumonia: Patient now finishing course of
Vancomycin / Cefepime /Flagyl, and transitioned to Augmentin x 3
days for continued treatment until ___. Would consider repeat
chest imaging as an outpatient in ___ weeks pending clinical
status for resolution
# G-tube: Patient's G-tube functioning properly, patient to be
contacted by Interventional radiology department regarding
further maintenance and changing of tube
# Dyspnea: Discussed with family that patient would most likely
benefit from low dose morphine for apparent dyspnea, to be
further considered as outpatient.
# Pulmonary Nodules: Multiple pulmonary nodules, the largest
measuring 3 mm in the right lower lobe. If the patient is at low
risk for malignancy, no further follow-up is necessary. If the
patient is at high risk for malignancy, CT follow-up is
recommended in 12 months.
# Stroke: Patient to be continued on Plavix 75 mg/atorva 80 mg
until at least ___
# Aspiration: Patient remains NPO on aspiration precautions.
# ___ Disease: Patient to be continued on sinemet as
outpatient, with f/u with Dr. ___
# Goals of Care: It was discussed several times likelihood for
recovery back to baseline quite low, please continue to
readdress as outpatient. Patient remains full code.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 10 mg PO QPM
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
3. Carbidopa-Levodopa (___) 1 TAB PO TID
4. Creon 12 1 CAP PO TID W/MEALS
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
6. Lisinopril 10 mg PO DAILY
7. Venlafaxine XR 75 mg PO DAILY
8. Vitamin B Complex 1 CAP PO DAILY
9. Zonisamide 100 mg PO BID
10. Aspirin 81 mg PO DAILY
11. Exelon (rivastigmine;<br>rivastigmine tartrate) 13.3 mg/24
hour transdermal daily
12. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg NG QPM
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
3. Carbidopa-Levodopa (___) 1 TAB PO TID
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
5. Clopidogrel 75 mg NG DAILY
6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea/wheeze
7. Bisacodyl 10 mg PR QHS:PRN constipation
8. Aspirin 81 mg NG DAILY
9. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H Duration: 3 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Ischemic Cerebrovascular Accident
2. Multifocal Pneumonia
3. Hypernatremia
4. Acute Kidney Injury
SECONDARY DIAGNOSES:
___ Disease
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 hospital stay
at ___. You were admitted for a
change in your mental status and difficulty moving your right
arm.
You were found to have had another stroke similar to your
previous stroke. This is the cause of your right arm weakness.
We have added a new medication called clopidogrel and increased
the dose of your atorvastatin, in an attempt to reduce your risk
of another stroke.
You were found to have a pneumonia as well and we treated you
with intravenous antibiotics. Your sodium was also high so we
gave you intravenous fluids to improve this. You were unable to
eat on your own, so we had to give you a feeding tube through
which you will continue to receive nutrition. While here, you
likely developed a recurrent pneumonia likely from aspiration,
and finished antibiotics for this as well.
Please continue to take your home medications as prescribed.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
10051043-DS-4 | 10,051,043 | 24,363,293 | DS | 4 | 2192-06-26 00:00:00 | 2192-06-27 10:54:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left lower face weakness and left hand
clumsiness.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old woman with history of Lyme disease (diagnosed in
___ complicated by recurrent joint pain and headache
presenting
as OSH transfer for acute onset left lower face weakness and
left
hand clumsiness.
She was in her usual state of health this morning. She works as
a
___ and was typing at her computer when she noted that
she had clumsiness while typing and could not hit the "a"
button.
This was around 11AM on ___. Throughout the day she continued
to work and noticed only very subtle incoordination of her left
hand. This seemed to resolve after hours. After a few hours
however, she noticed that she began to slur her words when
speaking to her patients. Nurses in her clinic noted that she
had
some drooping of her face but because of her history of chronic
lyme she did not think that her symptoms were necessarily
concerning for acute stroke. She also noted feeling slight
confused and "not as sharp as usual" throughout the day. It was
not until she called her daughter this evening that her daughter
convinced her to go into the hospital. She has taken to ___ where NIHSS was 1 significant for only mild left facial
droop. She was evaluated by Tele Neuro consult there where
facial
asymmetry was noted, although could not exclude peripheral vs.
central etiology. CT scan showed no acute infarct, chronic left
internal capsule infarct. Full dose aspirin, MRI and admission
was recommended but ___ had no beds.
She has a history of lyme since ___ previously treated with
doxycycline. She has recurrent hip pain and headaches and has
been on erythromycin and hydroxychloriquine in the past. She
has
never had a facial droop associated with her lyme in the past.
3
weeks ago was placed on tertacycline 750mg BID for chronic lyme
symptoms. No associated fevers/chills/headache/neck pain or
stiffness.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No 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:
Lyme disease dx ___, on tetracycline
Social History:
___
Family History:
No family history of early stroke, heart disease.
Physical Exam:
Vitals: T: 98 HR: 90 BP: 171/97 RR:20 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward 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 slightly dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes. The pt had good
knowledge of current events. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 6 to 5mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Left facial droop with asymmetric smile, weakness of left
eye closure
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 tremor noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 4+ 4+ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
___ Tri ___ Pat Ach
L 2 2 2 3 2
R 2 2 2 3 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor on FNF, no dysdiadochokinesia
noted. No dysmetria on HKS bilaterally.
-Gait: Did not assess
Discharge exam: facial weakness abated prior to discharge and
face was symmetric in both upper and lower face. Subtle weakness
remained present in distal muscle groups of all 4 extremities,
but no focal weakness was present in the left arm. Gait was
steady and within normal limits.
Pertinent Results:
MRI Brain:
TECHNIQUE: MRI of the brain without gad. MRA of the brain
using 3D time-of-flight. MRA of the neck using 3D gad
technique.
HISTORY: New onset facial droop and left hand clumsiness.
FINDINGS: There is ___ acute infarction in the right posterior
putamen and corona radiata as well as in the left inferior
caudate head. There is no evidence for hemorrhagic
transformation or significant midline shift. Intracranial flow
voids are maintained. There is no hydrocephalus. There are
additional scattered small vessel ischemic changes in the white
matter which are mild.
MRA of the circle of ___ demonstrates no evidence for
high-grade vascular stenosis or major vascular occlusion. No
aneurysm within limits of the examination.
MRA of the neck demonstrates no evidence for high-grade stenosis
of the
carotid or vertebral arteries.
IMPRESSION: Acute infarction in the right putamen, corona
radiata and in the left inferior caudate head. On the ADC maps,
the area of diffusion
abnormality does not appear to be hypointense suggesting that
this could be a subacute infarct up to seven days.
ECHO:
The left atrium and right atrium are normal in cavity size. No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is normal (>=2.5L/min/m2). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal study. Normal biventricular cavity sizes with
preserved regional and global biventricular systolic function.
No valvular pathology or pathologic flow identified. No definite
structural cardiac source of embolism identified.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Brief Hospital Course:
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 48) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? () Yes - (x) No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Hospital course:
The patient was admitted to the stroke service. MRI brain showed
2 subacute ischmeic insults (see above MRI report). The patient
was started on aspirin. ECHO was obtained and was normal. The
patient's facial weakness and hand weakness improved to baseline
prior to discharge. The patient was found to have diffuse,
predominantly distal weakness and some diffusely brisk reflexes.
She also reported a history of shooting "zings" down her left
leg. With these there was some concern for subacute to chronic
spinal cord pathology. On the saggital T1 non-contrast image
from the MRI there was a hyperintensity seen at the C2 level of
the cervical cord. However, in discussion with neuroradiology,
this was felt to be artifactual, likely resulting from movement
of the soft palate during the study. The patient also reported
gradual weight loss over the past year and a feeling of general
weakness and fatigue over the same time period. These
complaints, as well as further investigation of cord pathology
will be condcted on ___ outpatient basis. The patient was
discharged to home with planned follow up with Dr. ___.
Medications on Admission:
tetracycline 750mg BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*5
2. Tetracycline 750 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge exam: Left facial droop has resolved. Mild weakness of
the distal extremities and diffusely brisk reflexes are
suggestive of possible cervical cord process.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the stroke service at ___ for evaluation
of your left face and hand weakness. Your MRI showed 2 strokes.
Your symptoms improved while you were here. We also found that
you have some weakness in both hands and feet, which may
indicate a spinal cord problem. These problems can be worked up
further when you see Dr. ___ your follow up appointment.
We made the following changes to your medications:
1) STARTED ASPIRIN 81mg daily
It was a pleasure taking care of you during this hospital stay.
Please follow up with Dr. ___ as below.
If you experience any of the below danger signs, please present
to your nearest emergency room or call ___ and ask
for the neurologist on call.
Followup Instructions:
___
|
10051043-DS-5 | 10,051,043 | 23,260,768 | DS | 5 | 2192-10-21 00:00:00 | 2192-10-26 12:02:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hemoptysis and anemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with a PMHx of lyme disease, Raynaud's
phenomenon, and sp CVA in ___, who presented with URI sx and
hemoptysis and was transferred from ___ for management of
anemia.
Patient notes that cough productive of yellow sputum, faigue and
rhinorrhea, which started 10 days ago. Pt also endorses DOE and
a sick contact with a co-worker, who was sick with PNA several
weeks prior to onset of symptoms.
___ days prior, pt began having hemoptysis (1 tsp blood x ___
times in the AM), as well as decreased appetite, pallor and
jaundice.
Pt presented to her PCP 1d PTA and was prescribed Keflex. Pt was
found to have low HCT and was referred for admission shorly
after the visit. At ___ patient noted to have Hct 16, CXR
showed diffuse bilateral infiltrates, and she was transferred to
___ ED.
In the ___ ED, initial VS: 98.6 90 114/84 24 99% 4L --> temp
later increased to 102.2, Labs: WBC 9.5, H/H 5.2/17.1, MCV 89,
plt 675, Cr 1.3, TB 0.5, trop < 0.01. EKG: HR 98, sinus rhythm,
TWI V2; CXR (___): showed diffuse b/l infiltrates. Chest CT:
Diffuse mixed attenuation consolidation most severe in the left
upper, left lower, and right lower lobe. Mediastinal and hilar
adenopathy. Likely multifocal pneumonia, though diffuse alveolar
hemorrhage possible. No definite lung carcinoma identified. If
treated for pneumonia would get follow up chest CT after
resolution of symptoms in 6 weeks to ensure radiographic
clearing. She received 1U PRBC, sputum cx, CTX for CAP.
On the floor, pt reports feeling well, without dyspnea or pain.
Past Medical History:
- Lyme disease (dagnosed in ___, with prior sx including
arthralgia, "inflammation behind the eye", Raynauds, rashes, and
extremity pain/weakness; treated with erythromycin/tetracycline
in the past)
- sp CVA ___
Social History:
___
Family History:
mother with history of unknown cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
====================
Vitals - T: 98.5 BP: 116/66 HR: 91 RR: 20 02 sat: 97%RA
GENERAL: NAD, breathing comfortably
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Crackles to mid-lung bl
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
==================
Pertinent Results:
ADMISSION LAB DATA:
===============
___ 03:40PM BLOOD WBC-9.5 RBC-1.92*# Hgb-5.2*# Hct-17.1*#
MCV-89 MCH-27.1 MCHC-30.3* RDW-13.4 Plt ___
___ 03:40PM BLOOD ___ PTT-26.1 ___
___ 10:10PM BLOOD Ret Aut-2.4
___ 03:40PM BLOOD Glucose-93 UreaN-20 Creat-1.3* Na-136
K-4.3 Cl-104 HCO3-22 AnGap-14
___ 03:40PM BLOOD ALT-10 AST-12 LD(LDH)-143 AlkPhos-90
TotBili-0.5
___ 07:42AM BLOOD CK(CPK)-12*
___ 03:40PM BLOOD cTropnT-<0.01
___ 03:40PM BLOOD Albumin-3.0* Iron-9*
___ 03:40PM BLOOD calTIBC-191* VitB12-807 Folate-16.7
Hapto-357* Ferritn-119 TRF-147*
___ 03:49PM BLOOD Lactate-1.0
RELEVANT LAB DATA:
==============
___ 04:07PM BLOOD ANTI-GBM- < 1.0, not detected
___ 11:37PM BLOOD CYCLIC CITRULLINATED PEPTIDE (CCP)
ANTIBODY, IGG- < 16, negative
___ 11:37PM BLOOD RNP ANTIBODY- Negative
___ 11:37PM BLOOD RO & LA- Negative
___ 02:28PM BLOOD HCV Ab-NEGATIVE
___ 11:37PM BLOOD C3-87* C4-17
___ 04:33PM BLOOD ___ *
Titer-1:160 , DIFFUSE PATTERN
___ 11:37PM BLOOD RheuFac-34* CRP-217.4*
___ 11:37PM BLOOD dsDNA-NEGATIVE
___ 01:36AM BLOOD CRP-21.1*
___ 03:21AM BLOOD ANCA-POSITIVE *
BY INDIRECT IMMUNOFLUORESCENCE
P-ANCA PATTERN
TITER 1:1280
MPO POSITIVE
___ 11:37PM BLOOD Smooth-NEGATIVE
___ 02:28PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 07:37AM BLOOD TSH-0.51
___ 05:02AM BLOOD Triglyc-189*
___ 10:37AM BLOOD Lipase-171*
___ 05:02AM BLOOD Lipase-381*
___ 05:14AM BLOOD Lipase-109*
___ 04:33AM BLOOD ALT-20 AST-27 AlkPhos-57 TotBili-1.1
___ 11:37PM BLOOD ESR-80*
___ 01:36AM BLOOD ESR-5
DISCHARGE LAB DATA:
==============
MICROBIOLOGY:
==========
___ blood cultures x 2 -NO GROWTH
___ blood culture - NO GROWTH
___ 5:24 pm SPUTUM Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
MTB Direct Amplification (Final ___:
M. TUBERCULOSIS DNA NOT DETECTED BY NAAT: A negative NAAT
cannot rule
out TB or other mycobacterial infection.
___ 9:12 pm Influenza A/B by ___
Source: Nasopharyngeal swab.
**FINAL REPORT ___
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
___ 3:56 am SPUTUM Source: Expectorated.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___ 7:41 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
MTB Direct Amplification (Final ___:
M. TUBERCULOSIS DNA NOT DETECTED BY NAAT: A negative NAAT
cannot rule
out TB or other mycobacterial infection.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
___:
Negative for Cytomegalovirus early antigen by
immunofluorescence.
Refer to culture results for further information.
___ 7:41 pm Rapid Respiratory Viral Screen & Culture
BRONCHIAL LAVAGE.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Respiratory Viral Antigen Screen (Final ___:
Less than 60 columnar epithelial cells;.
Specimen inadequate for detecting respiratory viral
infection by ___
testing.
ECG:
====
___ ECG
Sinus rhythm. Cannot exclude anteroseptal wall myocardial
infarction of
indeterminate age. However, changes may also be consistent with
lead
positioning. No previous tracing available for comparison.
CYTOLOGY:
========
___ SPECIMEN(S) SUBMITTED: BRONCHIAL LAVAGE, COMBINED RML
AND LEFT
LINGULAR BAL
Revised A: Special stains:
An iron stain displays staining within macrophages, consistent
with
hemosiderin. No microorganisms are identified on GMS, AFB and
gram
stains.
NEGATIVE FOR MALIGNANT CELLS.
Pigment-laden macrophages, bronchial cells, inflammatory cells
and red
blood cells. (See note.)
Note: An iron stain and stains for microorganisms are pending
and will
be reported in a revised report. No viral cytopathic effects
are
identified. See also corresponding microbiology lab studies.
IMAGING:
=======
___ CT Chest w/ contrast
IMPRESSION:
1. Diffuse solid and ground-glass consolidations predominantly
involving the
left upper and lower lobes and right lower lobe with
peribronchovascular
distribution. Findings are concerning for multifocal pneumonia
with
associated reactive adenopathy, though diffuse alveolar
hemorrhage is possible
in the appropriate clinical setting. Neoplastic process is also
not excluded.
2. 11 mm parafissural pulmonary nodule of uncertain etiology.
___ TTE
The left atrial volume is normal. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Quantitative (biplane) LVEF = XX %. The
estimated cardiac index is normal (>=2.5L/min/m2). Transmitral
and tissue Doppler imaging suggests normal diastolic function,
and a normal left ventricular filling pressure (PCWP<12mmHg).
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Mild
pulmonary artery hypertension. No valvular pathology or
pathologic flow identified.
Compared with the prior study (images reviewed) of ___,
the estimated PA systolic pressure is slightly higher and mild
tricuspid regurgitation is now present.
___ KUB
IMPRESSION: No intra-abdominal free air.
___ CT head w/o contrast
IMPRESSION: No evidence for acute intracranial abnormalities.
Chronic
infarctions in bilateral basal ganglia.
___ CT torso w/o contrast
IMPRESSION:
1. Severe progression of bilateral lung parenchymal
consolidations with
severe involvement of the upper lobes and apical segment of the
lower lobes is
compatible with progression of diffuse alveolar hemorrhage and
superimposed
pneumonia. Stable lung base involvement, characterized by
diffuse
peribronchovascular ground glass opacity due to pneumonia.
2. Central lymphadenopathy is stable since ___
and is likely
reactive.
3. New bibasilar non-hemorrhagic pleural effusion layering
posteriorly with
small compression atelectasis of the posterobasal segment of the
right lower
lobe.
4. Patient has been intubated. The ET tube ends 5.5 cm from
carina.
5. There is new ascites and anasarca with minimal
peripancreatic fat
stranding, compatible mild pancreatitis.
___ RUQ U/S
IMPRESSION:
1. Cholelithiasis. Mild focal gallbladder wall edema, however
no
pericholecystic fluid. No evidence of cholecystitis.
2. Small perihepatic ascites. Right pleural effusion.
___ portable CXR
IMPRESSION: AP chest compared to ___ through ___:
There is severe widespread pulmonary consolidation probably
worsened since
___ following earlier extubation. Right jugular line ends
centrally.
Pleural effusions small to moderate on the right, unchanged
since ___,
probably increased since ___. Heart size is normal.
Component of mild
pulmonary edema would be difficult to detect radiographically.
Brief Hospital Course:
___ year old female with reported history of "chronic lyme
disease" presented with hemoptysis, pulmonary hemorrhage, renal
failure, and Raynauds.
She was initially admitted to the ICU given progressive
desaturation, with chest x-ray and bronchoscopy revealing active
pulmonary hemorrhage. She underwent bronchoscopy with lavage
consistent with diffuse alveolar hemorrhage. A lung protective
strategy was employed, including increased sedation to limit
ventilator dyssynchrony. Although concomitant lung infection was
not considered very likely, she was continued upon broad
spectrum empiric antibiotics. Bronchoscopy and sputum
microbiology studies were unrevealing. Azithromycin was
discontinued upon arrival to the ICU, and she completed an
extended course of vancomycin and cefepime, with doses adjusted
as her renal function changed. Along with treatment for her
underlying condition, her ventilator settings were weaned. On
___ after a successful SBT, she was extubated. Initially
post-extubation her respiratory status was tenuous due to her
underlying disease exacerbated by anxiety and ICU delirium. Her
delirium was managed with as needed olanzapine and her air
hunger was minimized with very low dose dilaudid. She remained
extubated with decreasing oxygen requirement and improving
mental status, and was eventually stable enough for the medical
floor.
Overall studies revealed a positive ___ and RF,
hypocomplementemia (C4>C3), positive ANCA. ANCA pattern was
P-ANCA, titer 1:1280, MPO positive. Her serologies and organ
involvement were most consistent with microscopic polyangiitis.
Rheumatology and renal had been following along, and in
consultation with them, pulse dose steroids were started on
___ 1 g solumedrol x 3 days. She also received a dose of
cyclophosphamide on ___ accompanied by mesna with and 4
hours after infusion. Plasmapheresis was initiated, and she
underwent four sessions of plasmapharesis on ___
and ___. The ___ plasma exchange session was complicated by a
relatively mild urticarial transfusion reaction. After
solumedrol pulse, her steroids were gradually tapered, and she
was receiving a total of 72 mg methylprednisolone daily the day
of transfer out of the ICU. Given her overall improvement,
kidney biopsy for definitive pathologic diagnosis was deferred
while in the ICU.
Her creatinine peaked at 2.4 on ___, and on that day her
total urine output was < 250 mL. After that day, her urine
output began to improve as did her creatinine. Creatinine on the
day of discharge from the ICU was 1.4.
On ___ upon exam Ms. ___ was noted to grimace to palpation
in her right upper abdominal quadrant. Labs were significant for
a lipase of 381, mildly elevated triglycerides to 187, and
normal calcium. Imaging revealed cholelithiasis without
cholecystitis, and peripancreatic fluid. The GI pancreas service
was consulted. Overall her mild pancreatitis was felt to be
multifactorial due to her underlying vasculitis, antibiotics and
cyclophosphamide rather than gallstones. Her abdominal symptoms
improved and therefore her pancreatitis was without
complication.
Ms. ___ required multiple transfusions for downtrending
hematocrit. She was transfused upon arrival to the ICU on ___
with 1U, and then received 1U each on ___ and ___. After
___ her hematocrit stayed stable and actually improved on
subsequent days.
On ICU day 2, Ms. ___ developed significant bradycardia as
low as into the ___. With heart rates above 40 she was in sinus
bradycardia, but in the ___ she was noted to have a junctional
escape rhythm. During this bradycardia, she also became
hypotensive with MAPs in the ___. Her OG tube was removed to
eliminate vagal tone, pressors were added but only helped her
heart rate, and eventually her heart rate improved with atropine
x 1. Cardiology was consulted. They felt as though her
bradycardia and hypotension were likely not related. Both,
however, were attributed to her overall critical illness. A TTE
was obtained with no significant findings except for pulmonary
hypertension, which was attributed to her being on the
ventilator. Given the expectation that her bradycardia would
improve with her overall clinical picture, there was no
indication for transvenous pacing. After extubation, her blood
pressure became even more elevated, and her heart rate
normalized.
Noted to be hypertensive towards the end of her ICU stay. Ms.
___ was started on 5 mg amlodipine daily.
She was transferred to the floor on ___ where she was weaned to
room air. Although bilateral dry crackles were evident on
physical exam, she had no difficulty with respirations. Her
creatinine was stable at 1.4 with normal urine output and no
edema. She was transitioned to 60 mg PO prednisone and oral
cyclophosphamide daily. Her prednisone will be tapered over the
next several months under the guidance of nephrology and
rheumatology. She was continued on amlodipine. She was seen
by physical therapy who recommended continued ___ in rehab
setting or home. She was discharged to her friend's house in
the ___ area with continued ___. She has follow up
appointments set up with both nephrology and rheumatology.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___:
Microscopic polyangiitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure caring for you while you were here. You were
admitted for bleeding from the lungs. You had to be treated in
the ICU for this, where a procedure was done to clear the lungs
out. We performed several lab tests to confirm the cause of
this bleeding, along with many of your other symptoms. We feel
your symptoms are related to a disease called "microscopic
polyangiitis." This is an immune disorder that affects the
blood vessels. When the blood vessels get inflamed, this can
affect your blood supply to different organs. To treat this,
we started you on immunosuppressive drugs, including
cyclophosphamide and prednisone. You will need to stay on
these medicines until your outpatient doctors ___ and
rheumatology) decide to change their dose. You will also need
to take an antibiotic (bactrim) to prevent infections while you
are on these immune medications.
Please see below for prescriptions and dosages.
Followup Instructions:
___
|
10051043-DS-9 | 10,051,043 | 26,563,181 | DS | 9 | 2197-07-12 00:00:00 | 2197-07-12 18:25:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
___: Diagnostic angiogram
___: Left craniotomy for clipping of left ICA bifurcation
aneurysm
History of Present Illness:
___ is a ___ female on ASA 81 (last taken ___
being worked up for CNS vasculitis and recent admission for
embolic stroke secondary to a-fib who presents today for
suspected aneurysmal SAH. Patient awoke with WHOL this morning
at 3am. She denies having any neurologic symptoms, visual
changes or ___ at this time. She called EMS who took her to
___ where a ___ showed diffuse left-sided SAH. She was
transported to the ___ via life flight and Neurosurgery
was consulted to evaluate and determine the need for surgical
intervention.
Past Medical History:
Microscopic Polyangiitis
Chronic Kidney Disease
Paroxysmal Atrial Fibrillation
Acute ischemic stroke (multiple) in ___
History of subacute stroke
History of multifocal small vessel strokes
Diffuse Alveolar Hemorrhage
Suspected Lyme disease
-Has been seen by a Lyme specialist and has been treated with
multiple courses of Erythromycin/Tetracycline over ___ years
Social History:
___
Family History:
Patient does not believe there is a family history of aneurysms.
Mother with unknown cancer.
Physical Exam:
ON ADMISSION:
=============
___ and ___:
[ ]Grade I: Asymptomatic, mild headache, slight nuchal rigidity
[x]Grade II: Moderate to severe headache, nuchal rigidity, no
neurological deficit other than cranial nerve palsy.
[ ]Grade III: Drowsiness/Confusion, mild focal neurological
deficit.
[ ]Grade IV: Stupor, moderate-severe hemiparesis.
[ ]Grade V: Coma, decerebrate posturing.
___ Grade:
[ ]1 No hemorrhage evident
[ ]2 Subarachnoid hemorrhage less than 1mm thick
[x]3 Subarachnoid hemorrhage more than 1mm thick
[ ]4 Subarachnoid hemorrhage of any thickness with IVH or
parenchymal extension
WFNS SAH Grading Scale:
[x]Grade I: GCS 15, no motor deficit
[ ]Grade II: GCS ___, no motor deficit
[ ]Grade III: GCS ___, with motor deficit
[ ]Grade IV: GCS ___, with or without motor deficit
[ ]Grade V: GCS ___, with or without motor deficit
___ Coma Scale:
[ ]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
_15___ Total
VS:
HR 114; BP 142/72; RR 22; 100% RA
Gen: No acute distress - complains of HA. Appears well.
HEENT: Pupils: 3-2.5mm bilaterally, EOMs intact.
Extremities: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative, normal affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: PERRL 3-2.5mm. Visual fields are full to confrontation.
III, IV, VI: EOMI bilaterally without nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact.
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
ON DISCHARGE:
=============
___ ___ Temp: 97.5 PO BP: 143/93 L Sitting HR: 79 RR: 19
O2
sat: 98% O2 delivery: ra
Exam:
Sitting in bed, comfortable. Anxious and awaiting plan for
discharge.
Opens eyes: [x] Spontaneous [ ] To voice [ ] To noxious
Orientation: [x] Person [x] Place [x] Time
Follows commands: [ ] Simple [x] Complex [ ] None
Pupils: PERRL (3mm to 2mm)
EOM: [x] Full [ ] Restricted
Face Symmetric: [x] No - Very slight left ptosis, left facial,
activates symmetrically
Tongue Midline: [x] Yes [ ] No
Pronator Drift: [ ] Yes [x] No
Speech Fluent: [x] Yes [ ] No
Comprehension intact: [x] Yes [ ] No
Motor:
No drift.
Moves all extremities symmetric, full strength throughout.
Sensation:
Grossly intact to light touch
Wound:
Clean, dry, intact
Sutures removed today- wound well approximated, no signs of
infection
Pertinent Results:
Please see OMR for pertinent lab results and imaging.
Brief Hospital Course:
#Subarachnoid hemorrhage
On ___, Ms. ___ was admitted to the Neuro ICU with diffuse
left-sided SAH. She was started on keppra, nimodipine and
nicardipine. Diagnostic angiogram was initially negative for
aneurysm. She was admitted to the stroke neurology service to
evaluate for CNS vasculitis as etiology for hemorrhage. MRI
brain w/w contrast was obtained revealing multiple
lobar-distributed microhemorrhages suspicious of CAA and an
acute left thalamic stroke. She was transferred to ___ on
___. LP was performed ___ and was revealing for elevated OP
and elevated RBC's as well as HSV for which she was started of
Acyclovir for a total course of 10 days. Repeat CTA on ___
revealed a 2mm aneurysm superior to left carotid terminus. She
was transferred back to Neuro ICU and arterial line was placed
for close blood pressure control. On ___, she was taken to
the OR for elective clipping of left ICA aneurysm.
postoperatively, she was noted to have new expressive aphasia.
___ revealed infarct in the left internal capsule and thalamus
which were present on prior imaging. Speech improved during her
ICU stay. Her mental status continued to improve, she continued
her nimodipine for 21 days post SAH. ___ continue to express
concerns for cognition and home safety and recommended home with
24h supervision. Social work was consulted. On ___, the
patient was transferred to the floor. She completed her
Dexamethasone taper. Left craniotomy site sutures were removed
on ___ prior to discharge.
#Dispo
Patient had an argument with her healthcare proxy because she
felt the HCProxy was sabotaging her discharge to go home
independently. She discontinued communication with the health
care proxy and named her daughter HCP. The patient's son and
daughter are unable to provide 24h supervision upon discharge
home. She has 2 sisters in ___, one is ___ old and unable to
provide care while the other she has a turbulent relationship
with per her daughter. Psychiatry was consulted for capacity
evaluation and a team meeting was held to discuss a safe dispo
plan. ___ and social work are in agreement that patient would
be safe to go home with ___ services at home and frequent
checks from family and friends. Patient's daughter to
tentatively return to the ___ on ___ for work
business and will stay with her mother. ___ re-evaluated
patient on ___ and deemed the patient to have capacity to make
her own medical decisions. The patient has agreed to discharge
home with maximum services including ___ and social work
has assisted the patient to set up elder services upon return
home. The patient reports that her friend ___ has agreed
that the patient can stay with her tonight after discharge.
Patient's daughter has been in touch with case management and is
aware of this current plan for discharge home with maximum
services.
#Hyponatremia
On admission, the patient was hyponatremic to 129. She was
bolused with normal saline and sodium normalized. She was again
hyponatremic to 127 on ___ and started on hypertonic saline,
this was eventually weaned and she remained stable on Salt tabs
1G PO TID. Plan to wean salt tabs to off after discharge and the
patient will follow-up with PCP upon discharge.
#Hyperkalemia
The patient was noted to have intermittent hyperkalemia with K
up to 5.8 on morning of discharge. Subsequent lab draw in ___ was
5.1. The patient was encouraged to increase PO intake and she
will follow-up with her PCP as an outpatient for further
monitoring and management.
#Fever
The patient was febrile on ___ and pancultured. CXR was
concerning for infection vs underlying airway disease. HSV PCR
was positive and she was started on acyclovir on ___ with end
date of ___. Further work up revealed UTI and she was started
on MacroBID which was completed on ___.
AHA/ASA Core Measures for ICH:
1. Dysphagia screening before any PO intake? [x]Yes []No
2. DVT prophylaxis administered? [x]Yes []No
3. Smoking cessation counseling given? []Yes [x]No [Reason:
(x)non-smoker ()unable to participate]
4. Stroke Education given in written form? [x]Yes []No
5. Assessment for rehabilitation and/or rehab services
considered? []Yes [x]No -> at baseline functional status.
Stroke Measures:
1. Was ___ performed within 6hrs of arrival? [x]Yes []No
2. Was a Procoagulant Reversal agent given? []Yes [x]No
[Reason: Stable, small SAH]
3. Was Nimodipine given? [x]Yes []No [Reason:]
Medications on Admission:
Aspirin 81mg
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
2. NiMODipine 60 mg PO Q4H
RX *nimodipine 30 mg 2 (Two) capsule(s) by mouth every four (4)
hours Disp #*16 Capsule Refills:*0
3. Sodium Chloride 1 gm PO BID
RX *sodium chloride 1 gram 1 tablet(s) by mouth BID x2 days then
QD x2 days Disp #*7 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Subarachnoid hemorrhage
Left ICA bifurcation aneurysm
HSV-2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were hospitalized due to symptoms of headache resulting
from a subarachnoid hemorrhage. This is a condition caused by a
leakage of blood within the brain.
While you were here in the hospital, you had an angiogram to
look for an aneurysm. Fortunately this showed no evidence of
hemorrhage.
You also had a lumbar puncture. This showed HSV and you were
started on Acyclovir for a total course of 10 days.
Please take your medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Aneurysmal Subarachnoid Hemorrhage
Please do NOT take any blood thinning medication (Aspirin,
Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on a medication called Nimodipine.
This medication is used to help prevent cerebral vasospasm
(narrowing of blood vessels in the brain).
What You ___ Experience:
Mild to moderate headaches that last several days to a few
weeks.
Difficulty with short term memory.
Fatigue is very normal
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site or puncture site.
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
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
While you were hospitalized an additional CTA was performed
revealing a new 2mm left ICA bifurcation aneurysm for which you
underwent a left craniotomy for clipping treatment of your
aneurysm.
Discharge Instructions for:
Elective Aneurysm Clipping
Call your neurosurgeons office and speak to the Nurse
Practitioner if you experience:
- Any neurological issues, such as change in vision, speech or
movement
- Swelling, drainage, or redness of your incision
- Any problems with medications, such as nausea vomiting or
lethargy
- Fever greater than 101.5 degrees Fahrenheit
- Headaches not relieved with prescribed medications
Activity:
- Start to resume all activities as you tolerate but start
slowly and increase at your own pace.
-Do not operate any motorized vehicle for at least 10 days after
your surgery your Nurse Practitioner can give you more detail
at the time of your suture removal. Your sutures will be
removed prior to discharge.
Incision Care:
- Keep your wound clean and dry.
- Do not use shampoo until your sutures are removed.
- When you are allowed to shampoo your hair, let the shampoo run
off the incision line. Gently pad the incision with a towel to
dry.
- Do not rub, scrub, scratch, or pick at any scabs on the
incision line.
- You need your sutures removed 7 to 10 days after surgery
Post-Operative Experiences: Physical
- Jaw pain on the same side as your surgery; this goes away
after about a month
- You may experience constipation. Constipation can be
prevented by:
o Drinking plenty of fluids
o Increasing fiber in your diet by eating vegetables, prunes,
fiber rich breads and cereals, or fiber supplements
o Exercising
o Using over-the-counter bowel stimulants or laxatives as
needed, stopping usage if you experience loose bowel movements
or diarrhea
- Fatigue which will slowly resolve over time
- Numbness or tingling in the area of the incision; this can
take weeks or months to fully resolve
- Muffled hearing in the ear near the incision area
- Low back pain or shooting pain down the leg which can resolve
with increased activity
Post-Operative Experiences: Emotional
- You may experience depression. Symptoms of depression can
include
o Feeling down or sad
o Irritability, frustration, and confusion
o Distractibility
o Lower Self-Esteem/Relationship Challenges
o Insomnia
o Loneliness
- If you experience these symptoms, you can contact your Primary
Care Provider who can make a referral to a Psychologist or
Psychiatrist
- You can also seek out a local Brain Aneurysm Support Group in
your area through the Brain Aneurysm Foundation
o More information can be found at ___
Followup Instructions:
___
|
10051074-DS-19 | 10,051,074 | 21,350,747 | DS | 19 | 2180-02-14 00:00:00 | 2180-02-16 18:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / trimethaphan
Attending: ___.
Chief Complaint:
NSTEMI
Major Surgical or Invasive Procedure:
___ - cardiac catheterization with normal arteries
History of Present Illness:
___ female with h/o afib on Coumadin, severe
diverticular disease s/p partial colectomy with end ostomy,
extensive tobacco use, and NIDDM presenting from outside
hospital with chest pain, dyspnea, nausea. Patient reports the
pain awoke her from sleep this morning, sharp stabbing pain that
radiated to her jaw and left shoulder. She reports associated
dyspnea which is slightly worsened her baseline. She also has
had multiple sets of vomiting, continues to feel nauseous. She
denies fevers or recent illnesses. She denies any abdominal
pain. She does report having intermittent periods of chest pain
similar to this for the past several months. She also reports
noting occasional blood from her ostomy. She is on Coumadin for
A. fib.
She presented to ___ with chest pain, ekg does not meet
STEMI criteria. Global ischemia on ekg, In Afib HR 115 BP 100.
Trop <0.01 at OSH. Given 5mg Lopressor on transport with brief
decrease in HR to ~100, now back to 110s. Guiac positive from
her ostomy was noted, and was not given heparin given
therapeutic INR. The patient was then transferred to ___ for
further management.
Upon arrival here, ECG showed AF @ 119 with slightly improved
diffuse ST depressions and STE in aVR. The patient continued to
have severe chest pain and was found to be hypotensive to
___. Norepinephrine was started and aspirin 325mg was given.
Labs notable for INR 2.8 and TnT 0.05, normal creatinine. During
my interview with the patient, she spontaneously converted to
sinus rhythm with near total resolution of ischemic ST changes
on ECG. Down-titration of norepinephrine was attempted but the
patient became again hypotensive to the ___ systolic, so she
remained on norepninephrine 0.2mg/kg/min. With stabilization of
her hemodynamics on vasopressors, her chest pain improved to
___. She denied any recent illnesses, and has not had sick
contacts, productive cough, diarrhea, etc. She notes occasional
scant light blood on her ostomy, but denies any frank bloody
output or any other bleeding. She has not been on any long trips
recently or had recent surgeries, denies other PE risk factors
(and is therapeutically Anticoagulated.)
On arrival to the CCU the patient was weaned off of levophed and
remained in sinus rhythm. The patient had no new acute
complaints.
REVIEW OF SYSTEMS:
Positive per HPI.
Current cardiac review of systems is notable for absence of
chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope, or presyncope.
On further review of systems, denies fevers or chills. Denies
any prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis. Denies exertional buttock or
calf pain. All of the other review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes: YES
- Hypertension: YES
- Dyslipidemia: YES
2. CARDIAC HISTORY
- Coronaries: Unknown
- Systolic function: Unknown
- Rhythm: Paroxysmal Afib with RVR
OTHER PAST MEDICAL HISTORY
1. AFib on Coumadin
2. ostomy s/p diverticular resection
3. NIDDM
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Mother and brother with "heart disease".
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: reviewed in metavision
GENERAL: Well developed, obese resting in bed. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP unble to assess due to body habitus.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. significant bibasilar
crackles.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: cool but, well perfused. No clubbing, cyanosis, or
peripheral edema. No evidence of mottling, however chronic skin
changes consistent with diabetes are present
PULSES: Distal pulses doplerable and symmetric.
DISHCARGE PHYSICAL EXAM:
========================
VS: 98.2, 108-128/55-68, 66-74, 18, 91-94% RA
I/O: not saving urine
weight 114kg
GENERAL: Well developed, obese resting in bed. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP unble to assess due to body habitus.
CARDIAC: Regular rate and rhythm. Normal S1, S2. ___
holosystolic murmur best auscultated at the base of the heart.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Resolution of bibasilar
crackles
ABDOMEN: obese, non-tender, distended. No hepatomegaly. No
splenomegaly. Colostomy with erythematous skin surrounding it.
Colostomy bag in place.
EXTREMITIES: warm, well perfused. No clubbing, cyanosis, or
peripheral edema. No evidence of mottling, however chronic skin
changes consistent with diabetes are present
PULSES: Distal pulses doplerable and symmetric.
Pertinent Results:
ADMISSION LABS:
===============
___ 05:34PM GLUCOSE-95 UREA N-19 CREAT-1.1 SODIUM-138
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-26 ANION GAP-19
___ 05:34PM CALCIUM-8.9 PHOSPHATE-5.2* MAGNESIUM-1.5*
___ 01:49PM ___ TEMP-36.4 PO2-37* PCO2-56* PH-7.32*
TOTAL CO2-30 BASE XS-0
___ 01:49PM LACTATE-1.8
___ 01:49PM O2 SAT-63
___ 12:13PM GLUCOSE-159* UREA N-20 CREAT-1.2* SODIUM-135
POTASSIUM-4.7 CHLORIDE-95* TOTAL CO2-24 ANION GAP-21*
___ 12:13PM CK(CPK)-103
___ 12:13PM CK-MB-8 cTropnT-0.24* proBNP-1459*
___ 12:13PM CALCIUM-8.9 PHOSPHATE-5.5* MAGNESIUM-1.5*
___ 12:13PM TSH-1.8
___ 12:13PM WBC-13.2* RBC-4.47 HGB-13.8 HCT-42.1 MCV-94
MCH-30.9 MCHC-32.8 RDW-14.3 RDWSD-49.5*
___ 12:13PM PLT COUNT-295
___ 12:13PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 12:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 12:13PM URINE RBC-1 WBC-10* BACTERIA-FEW YEAST-NONE
EPI-1
___ 12:13PM URINE GRANULAR-4* HYALINE-24*
___ 12:13PM URINE AMORPH-FEW
___ 12:13PM URINE MUCOUS-OCC
___ 08:59AM ___ PO2-42* PCO2-63* PH-7.26* TOTAL
CO2-30 BASE XS-0
___ 08:59AM O2 SAT-66
___ 07:52AM LACTATE-2.8*
___ 07:44AM GLUCOSE-162* UREA N-15 CREAT-1.0 SODIUM-135
POTASSIUM-3.6 CHLORIDE-95* TOTAL CO2-24 ANION GAP-20
___ 07:44AM estGFR-Using this
___ 07:44AM cTropnT-0.05*
___ 07:44AM CK-MB-4
___ 07:44AM CALCIUM-9.1 PHOSPHATE-4.7* MAGNESIUM-1.5*
___ 07:44AM ASA-NEG ETHANOL-NEG ACETMNPHN-7* bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 07:44AM WBC-13.9* RBC-4.63 HGB-14.3 HCT-43.7 MCV-94
MCH-30.9 MCHC-32.7 RDW-14.4 RDWSD-49.7*
___ 07:44AM NEUTS-72.5* LYMPHS-17.1* MONOS-7.4 EOS-0.7*
BASOS-0.4 IM ___ AbsNeut-10.06* AbsLymp-2.37 AbsMono-1.02*
AbsEos-0.10 AbsBaso-0.05
___ 07:44AM PLT COUNT-278
___ 07:44AM ___ PTT-48.5* ___
MICRO:
======
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
WORKUP REQUESTED PER ___ ___.
STAPHYLOCOCCUS EPIDERMIDIS.
Isolated from only one set in the previous five days.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
VANCOMYCIN------------ 1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ ON ___, 12:42PM.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
IMAGING and STUDIES
====================
TTE ___
The left atrium is mildly dilated. The estimated right atrial
pressure is at least 15 mmHg. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
are mildly thickened (?#). There is severe aortic valve stenosis
(valve area <1.0cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Severe aortic valve stenosis. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Moderate pulmonary artery systolic
hypertension. Mild mitral regurgitation. Increased PCWP.
CLINICAL IMPLICATIONS:
The patient has severe aortic valve stenosis. Based on ___
ACC/AHA Valvular Heart Disease Guidelines, if the patient is
asymptomatic, it is reasonable to consider an exercise stress
test to confirm symptom status. In addition, a follow-up study
is suggested in ___ months. If they are symptomatic (angina,
syncope, CHF) and a surgical or TAVI candidate, a mechanical
intervention is recommended.
BILATERAL LENIS ___
No evidence of DVT in right or left lower extremity veins.
CXR ___
IMPRESSION:
1. Cardiomegaly.
2. Engorgement of the pulmonary vasculature, concerning for mild
pulmonary edema.
3. No focal consolidations to suggest pneumonia.
+ ECHO ___
The left atrium is mildly dilated. The estimated right atrial
pressure is at least 15 mmHg. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
are mildly thickened (?#). There is severe aortic valve stenosis
(valve area <1.0cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Severe aortic valve stenosis. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Moderate pulmonary artery systolic
hypertension. Mild mitral regurgitation. Increased PCWP.
___ Cardiac Catheterization:
Intra-procedural Complications: Retained small segment of wire
subcutaneously
Impressions:
Normal coronary arteries
Moderately severe aortic stenosis - mean AVG 27 mm Hg, ___ 1.2
cm2
Mild elevation of PCW pressure 17 mm Hg
Moderate elevation of PA pressure - ___
Normal cardiac index 2.8 L/min/m2
Recommendations
Continued medical therapy
Prevention of AF
Consideration of AVR at later time if further progression
Followup of retained short segment of 0.018 wire in L femoral
area which is not intravascular - would
require surgical retrieval which is unlikely to be necessary
DISCHARGE LABS:
===============
Brief Hospital Course:
___ female with h/o afib on Coumadin, severe
diverticular disease s/p partial colectomy with end ostomy,
extensive tobacco use, and NIDDM presenting from outside
hospital with chest pain, dyspnea, nausea. She was found to be
in a fib with RVR, and have and NSTEMI. She was also found to
have a staph epidermidis bacteremia.
# Acute on chronic diastolic heart failure
Patient presented as transfer from ___ with afib with
RVR with diffuse downsloping ST depressions and ST elevation in
aVR and chest pain. On arrival to ___ ED, EKG with Afib with
RVR and rates to 119 with slighty improved ST depressions and
STE in aVR. Echo with an EF of 55% and aortic stenosis. Levophed
was started given hypotension ___. She spontaneously
converted to sinus rthym in the ED with near total resolution of
ischemic changes on EKG. Levophed was unable to be weaned in ED
and patient remained on Levophed for several days in the CCU.
BNP ~1500 with mild pulmonary edema on CXR. TTE with severe
aortic stenosis. Do not suspect obstructive (PE) given
therapeutic INR and negative LENIS. The patient was initially
diuresed with IV Lasix, and transitioned to PO Lasix 40mg daily
several days before discharge. Her metoprolol was held
initially, and then gradually titrated back to her home dose of
Metoprolol XL 100mg. Her lisinopril was discontinued since she
did not have evidence of systolic heart failure on echo.
#Septic Shock
# Staph Epidermidis Bacteremia:
On ___, two out of two bottles of blood cultures grew what
turned out to be staph epidermidis. Although this is usually a
contaminant, the medical team thought that this may have
precipitated the afib with RVR. It may be iatrogenic, from the
central line that was inserted at the OSH, or from the skin
breakdown around her ostomy. She was started on IV vancomycin on
___, and she will need to complete a 14 day course of
antibiotics, through ___.
# Atrial Fibrillation with RVR:
Precipitant likely bacteremia. Patient reports episodes of
palpitations intermittently, and spontaneously converted to
sinus rhythm. Her Chads-Vasc Sore is 5. An extensive
conversation was had about starting apixaban, but the patient
did not want to start it at this time. She was discharged on her
home warfarin with a Lovenox bridge given a subtherapeutic INR.
Her metoprolol was continued for rate control once blood
pressures increased.
# NTEMI. Likely demand. Coronary arteries on cardiac
catheterization without evidence of atherosclerosis. ASA was
stopped on ___. Her simvastatin was changed to Atorvastatin 80mg
given her high ASCVD risk score.
# Moderate Aortic Stenosis
Severe aortic stenosis was noted on TTE ___, but the cardiac
catheterization on ___ suggested moderate AS. Patient was not
symptomatic. Her aortic stenosis should be monitored and she
should be considered for further management if she becomes
symptomatic.
#Acute kidney Injury: Likely ___ to ATN from hypotension. Cr was
0.7 at time of dischare.
CHRONIC ISSUES
==============
# HLD: Patient was started on atorvastatin 80 mg daily in light
of high ASCVD risk score.
# HTN: HCTZ and Lisinopril held because of normotension.
Maintained on home Metoprolol. Started on PO Lasix 40mg daily.
# NIDDM: Metformin was held and the patient was on an insulin
sliding scale.
# Chronic Back Pain: Continued tramadol. Held naproxen in the
setting of possible intervention.
TRANSITIONAL ISSUES
===================
[] Complication during procedure: guidewire broke, and is in
soft tissue of groin. Monitor for signs of infection.
[] Patient was discharged to complete a 14 day course of
vancomycin 1500mg IV Q12H for coag negative staph bacteremia
(last day ___
[] Patient was discharged on enoxaparin bridge to warfarin. The
patient will go to her PCP's office to have her INR drawn on
___. Once INR > 2.0, enoxaparin should be stopped.
[] Patient was discharged on Lasix 40mg daily due to volume
overload. Her weight should be monitored, and her kidney
function and electrolytes should be checked at her next
appointment.
[] Patient's anti lipid therapy was switched from simvastatin
5mg to atorvastatin 80mg.
[] Patient was normotensive while in the hospital. Her
lisinopril and HCTZ were held at time of discharge, and could be
restarted in the outpatient setting if needed.
[] Patient was discharged with hydrocortisone cream for
___ irritation.
[] Please assist patient with smoking cessation.
# CODE: Full
# CONTACT/HCP: ___ (Husband) verbally designated HCP:
___
# DRY WEIGHT: Unknown
# Discharge weight: 114kg
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Naproxen 500 mg PO Q8H:PRN Pain - Mild
7. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
8. Simvastatin 5 mg PO QPM
9. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
10. Warfarin 8 mg PO DAILY16
11. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
12. umeclidinium 62.5 mcg/actuation inhalation DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
2. Enoxaparin Sodium 110 mg SC BID
RX *enoxaparin 100 mg/mL 110 mg/mL INJ twice a day Disp #*14
Syringe Refills:*0
3. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Hydrocortisone Cream 1% 1 Appl TP QID ___ irritation
RX *hydrocortisone 1 % apply small amount around the ostomy site
four times a day Refills:*0
5. Vancomycin 1500 mg IV Q 12H
RX *vancomycin 1 gram 1.5 g IV twice a day Disp #*22 Vial
Refills:*0
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
7. Levothyroxine Sodium 50 mcg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Naproxen 500 mg PO Q8H:PRN Pain - Mild
11. ProAir HFA (albuterol sulfate) 90 mcg inhalation Q6H:PRN
wheezing
12. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
13. umeclidinium 62.5 mcg/actuation inhalation DAILY
14. Warfarin 8 mg PO DAILY16
15.Outpatient Lab Work
Please draw a ___, and fax results to ___ ATTN:
___
ICD10: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
- Cardiogenic shock
- Acute on chronic diastolic heart failure
Secondary Diagnoses:
- NSTEMI
- Moderate Aortic Stenosis
- Coagulase Negative Staph bacteremia
- Atrial Fibrillation with RVR
- Acute kidney injury
- Hyperlipidemia
- Hypertension
- Non-insulin dependent diabetes mellitus
- Chronic 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 a pleasure to be a part of your care team at ___
___.
Why did you come to the hospital?
=================================
- You came to the hospital with chest pain, trouble breathing,
and nausea. You were transferred to ___ for further
workup for your heart.
What did we do for you?
=======================
- You were found to have a rapid, irregular heartrate called
atrial fibrillation.
- We think this atrial fibrillation was triggered by an
infection in your blood stream.
- We started you on strong antibiotics for an infection in your
blood stream (vancomycin).
What do you need to do?
=======================
- It is important that you follow up with a Cardiologist
(appointment information below)
- It is important that you continue your vancomycin antibiotic
infusions twice per day up through and including ___.
- MEDICATION CHANGES:
-- STOP taking simvastatin. START taking Atorvastatin 80 mg
daily.
-- STOP taking lisinopril
-- CONTINUE taking warfarin 8mg per day. START Lovenox
injections twice per day until your INR is greater than 2.
Follow up with your ___ clinic for INR monitoring.
It was a pleasure caring for you. We wish you the best!
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10051074-DS-21 | 10,051,074 | 28,928,117 | DS | 21 | 2180-08-02 00:00:00 | 2180-08-02 17:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / trimethaphan
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y F with h/o aortic stenosis, paroxysmal AFib on Coumadin and
amiodarone, severe diverticular disease s/p partial colectomy
with end ostomy, extensive tobacco use, COPD, and T2DM, recent
TAVR placement ___ complicated by CHB with pacer placement
complicated by RV perforation and discharged to rehab on ___
presents with chest pain, dyspnea, N/V that started acutely
___.
Her episode of chest pain began the evening of ___, although
patient doesn't have clear memory of the exact time or what she
was doing. She believes she was lying in bed resting, then had
sudden onset, sharp pain with some pressure in epigastrum and
radiating to the neck and back. Pain was ___. Had nausea with
vomiting x1 and improvement of symptoms. No blood noticed in
vomit. The chest pain varies based on her position. Her
shortness of breath was better with sitting up than lying down.
Patient was admitted ___ for TAVR complicated by
complete heart block, pacemaker placement, which was complicated
by RV perforation and cardiac tamponade, cardiac arrest with
ROSC, and groin hematoma. She had an attempted TAVR on ___,
complicated by a groin hematoma, then had TAVR on ___, which
was complicated by complete heart block. She had an attempted
permanent pacemaker placed on ___, which was complicated by RV
perforation and cardiac tamponade, had a drain placed and
underwent sternotomy on ___, at which time her RV was repaired
and epicardial leads were placed. During her course she also
sustained cardiac arrest with ROSC after 1 min of chest
compressions.
Of note, patient had cath in ___ that showed normal
coronary arteries. Also, post-TAVR deployment films ___
showed good flow through RCA and left main arteries at the end
of the procedure. Recent device interrogation ___ showed
normal pacemaker function.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- HFpEF (EF > 55%)
- Paroxysmal AFib
- NSTEMI ___
3. OTHER PAST MEDICAL HISTORY
Ostomy s/p diverticular resection
COPD
Hypothyroidism
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
VS: T 97.8 PO BP 114/50 R Lying HR 81 RR 18 O2 95 RA
GENERAL: Well developed, well nourished obese female in NAD.
Oriented x3. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. EOMI. Moist
mucous membranes
NECK: Supple.
CARDIAC: regular rate and rhythm. Normal S1, S2. Soft systolic
murmur, no rubs or gallops. No thrills or lifts.
CHEST: Midline sternotomy scar, non-erythematous, without
drainage. Some scab formation. Diffusely tender to palpation
over the chest, pt unclear whether this reproduces pain from
previous night.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended, morbidly obese. Ostomy
bag in mid-lower abdomen.
EXTREMITIES: Cool to touch. No clubbing, cyanosis. 1+ pitting
edema bilateral lower ext.
SKIN: No significant skin lesions or rashes.
DISCHARGE SUMMARY
==================
VITALS: 98.6 PO 103 / 66 L Sitting 72 18 100 1L
GENERAL: morbidly obese, no acute distress, complaining of some
diffuse chest pain
HEENT: Normocephalic atraumatic. Sclera anicteric. EOMI. Moist
mucous membranes
NECK: Supple.
CARDIAC: regular rate and rhythm. Normal S1, S2. Soft systolic
murmur, no rubs or gallops. No thrills or lifts.
CHEST: Midline sternotomy scar, non-erythematous, c/d/i. Some
scab formation. Diffusely tender to palpation over the chest.
LUNGS: CTABL, no wheezes or crackles
ABDOMEN: Soft, non-tender, non-distended, morbidly obese. Ostomy
bag in mid-lower abdomen.
EXTREMITIES:No clubbing, cyanosis, edema
SKIN: No significant skin lesions or rashes.
Pertinent Results:
ADMISSION LABS
===================
___ 05:50AM BLOOD WBC-8.7 RBC-3.02* Hgb-9.2* Hct-30.0*
MCV-99* MCH-30.5 MCHC-30.7* RDW-19.1* RDWSD-69.0* Plt ___
___ 05:50AM BLOOD Neuts-62.1 ___ Monos-13.0 Eos-2.4
Baso-0.2 Im ___ AbsNeut-5.41# AbsLymp-1.82 AbsMono-1.13*
AbsEos-0.21 AbsBaso-0.02
___ 09:15PM BLOOD ___
___ 05:50AM BLOOD Plt ___
___ 09:15PM BLOOD Glucose-174* UreaN-21* Creat-1.6* Na-139
K-3.8 HCO3-25 AnGap-14
___ 05:50AM BLOOD Glucose-119* UreaN-19 Creat-1.6* Na-139
K-4.7 Cl-98 HCO3-24 AnGap-17*
___ 05:50AM BLOOD ALT-22 AST-47* AlkPhos-157* TotBili-0.9
___ 05:50AM BLOOD Lipase-82*
___ 11:12AM BLOOD cTropnT-<0.01
___ 05:50AM BLOOD cTropnT-<0.01
___ 05:50AM BLOOD proBNP-1340*
___ 09:15PM BLOOD Calcium-8.4 Phos-3.9 Mg-1.8
___ 05:50AM BLOOD Albumin-3.4* Calcium-9.0 Phos-4.1 Mg-1.8
___ 09:15PM BLOOD TSH-3.8
___ 05:50AM BLOOD HoldBLu-HOLD
___ 09:15PM BLOOD
___ 09:26PM BLOOD Lactate-1.6
___ 06:00AM BLOOD Lactate-2.3*
ECHO ___
==============
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Right ventricular chamber size is normal with
borderline normal free wall function. There is abnormal septal
motion suggestive of pericardial constriction (clip 38). The
diameters of aorta at the sinus, ascending and arch levels are
normal. An Evolut aortic valve bioprosthesis is present. The
aortic valve prosthesis appears well seated, with normal leaflet
motion and transvalvular gradients. The effective orifice
area/m2 is moderately depressed (0.7; nl >0.9 cm2/m2) No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen (clip 48).
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion. The echo findings are suggestive but
not diagnostic of pericardial constriction. A right pleural
effusion is present.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global biventricular systolic function. No pericardial
effusion, but abnormal septal motion suggestive of pericardial
constriction. Normal functioning Evolute TAVR with normal
gradient and no aortic regurgitation.
Compared with the prior study (images reviewed) of ___,
the pericardial effusion has resolved and abnormal septal motion
is now present suggesting possible pericardial constriction.
CXR ___
============
IMPRESSION:
No acute process. Small left pleural effusion.
DISCHARGE LABS
==================
___ 05:50AM BLOOD ___ PTT-26.0 ___
___ 05:50AM BLOOD Glucose-121* UreaN-19 Creat-1.5* Na-138
K-3.8 Cl-98 HCO3-26 AnGap-14
___ 12:00AM BLOOD UreaN-20 Creat-1.5* Na-138 K-4.0
___ 05:50AM BLOOD ___ PTT-26.0 ___
___ 12:00AM BLOOD CK(CPK)-35
___ 12:00AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:50AM BLOOD Calcium-8.5 Phos-4.1 Mg-1.8
___ 12:00AM BLOOD Phos-3.7 Mg-1.8
___ 05:50AM BLOOD
Brief Hospital Course:
Ms. ___ is a ___ year old woman with past medical history of
aortic stenosis, paroxysmal AFib on Coumadin and amiodarone,
severe diverticular disease s/p partial colectomy with end
ostomy, COPD, recent TAVR placement ___ complicated by CHB with
pacer placement complicated by RV perforation s/p sternotomy
with RV repair, discharged to rehab on ___, who presented with
chest pain found to most likely be of musculoskeletal etiology.
Problems addressed during this hospital admission are as
follows:
ACTIVE ISSUES:
====================================
#Chest Pain:
Sudden onset on ___, sharp, epigastric, radiating to the neck
and back, relieved with vomiting x1. On second day of admission,
described as dull ache in anterior chest surrounding sternotomy
scar. Initially concerning for ACS v dissection v pericarditis v
cardiac effusion/restriction v PE v GI (gastroparesis,
pancreatitis, GERD). Vital signs stable and workups all
negative: EKG nl (LBBB), trops negative, chest x-ray nl, lipase
82, lactate 2.3-->1.6, CBC nl, BMP nl. Blood pressures were
equal in both arms. Echo revealed no effusion, some pericardial
constriction, most likely related to sternotomy. Most likely
musculoskeletal due to relief of pain with oxycodone,
reproducible chest tenderness on physical exam. Managed with
pain control (oxycodone, Tylenol, lidocaine patch).
#Nausea/Vomiting:
No episodes of vomiting during admission, tolerated regular
diet. Received metoclopramide x1 on admission.
#Severe AS s/p TAVR ___
#Complete Heart Block s/p PPM ___ complicated by RV
perforation:
Last hospitalization (___), patient had TAVR complicated
by complete heart block. PPM placed, complicated by RV
perforation, cardiac tamponade, cardiac arrest w/ ROSC, s/p
sternotomy with RV repair and epicardial lead placement. Repeat
echo on this admission revealed good gradients. Continued ASA.
#Paroxysmal AFib.
Admitted with subtherapeutic INR (___), as warfarin held at
rehab due to hematoma, discharge paperwork from pervious
admission stated warfarin should have been continued. Restarted
home warfarin.
CHRONIC/STABLE ISSUES:
====================================
#Heart Failure w/ preserved Ejection Fraction:
EF >55% on ___ echo. Thought to be secondary to severe AS.
Admission weight: 103.3 kg, discharge weight 103.3 kg. Remained
euvolemic, Cr stable. Continued home lasix, spironolactone.
#GERD: Switched from ranitidine to omeprazole to better manage
GERD. Discharged with ranitidine, continued calcium carbonate.
#Normocytic Anemia: Stable, remained at baseline (___).
Continued ferrous sulfate.
#T2DM: Standing lantus and HISS.
#HLD: Continued atorvastatin.
#Hypothyroidism. Continued levothyroxine.
TRANSITIONAL ISSUES:
-Please be sure patient continues to take home warfarin, was
discharged on warfarin during last admission (___),
however was held at rehab due to a hematoma despite discharge
recommendations stating to continue warfarin, admitted with
subtherapeutic INR ___ (goal INR ___.
-Please check INR on ___, and adjust warfarin dosing as needed.
-Can consider switching from ranitidine to PPI for GERD
management.
#CODE STATUS: Full (presumed)
#CONTACT: ___ (husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Potassium Chloride 20 mEq PO DAILY
2. Epoetin ___ ___ units SC QWEEK
3. Ferrous Sulfate 325 mg PO BID
4. Furosemide 40 mg PO BID
5. Spironolactone 25 mg PO BID
6. Calcium Carbonate 1000 mg PO QID:PRN GERD
7. umeclidinium 62.5 mcg/actuation inhalation DAILY
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 40 mg PO QPM
11. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
12. Milk of Magnesia 30 mL PO DAILY constipation
13. Amiodarone 200 mg PO DAILY
14. Cyanocobalamin 100 mcg PO DAILY
15. Ranitidine 150 mg PO DAILY
16. Miconazole 2% Cream 1 Appl TP BID rash
17. Miconazole Powder 2% 1 Appl TP BID rash
18. Levothyroxine Sodium 50 mcg PO DAILY
19. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
20. Levalbuterol Neb 0.63 mg NEB Q6H:PRN shortness of breath
21. GuaiFENesin 10 mL PO Q4H:PRN cough
22. Bisacodyl 10 mg PR QHS:PRN constipation
23. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
24. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using aspart Insulin
Discharge Medications:
1. Nicotine Patch 14 mg TD DAILY
2. Warfarin 6 mg PO DAILY16
3. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using aspart Insulin
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
6. Amiodarone 200 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. Bisacodyl 10 mg PR QHS:PRN constipation
10. Calcium Carbonate 1000 mg PO QID:PRN GERD
11. Cyanocobalamin 100 mcg PO DAILY
12. Epoetin ___ ___ units SC QWEEK
13. Ferrous Sulfate 325 mg PO BID
14. Furosemide 40 mg PO BID
15. GuaiFENesin 10 mL PO Q4H:PRN cough
16. Levalbuterol Neb 0.63 mg NEB Q6H:PRN shortness of breath
17. Levothyroxine Sodium 50 mcg PO DAILY
18. Lidocaine 5% Patch 1 PTCH TD QAM
19. Miconazole 2% Cream 1 Appl TP BID rash
20. Miconazole Powder 2% 1 Appl TP BID rash
21. Milk of Magnesia 30 mL PO DAILY constipation
22. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*9 Tablet Refills:*0
23. Potassium Chloride 20 mEq PO DAILY
Hold for K >
24. Ranitidine 150 mg PO DAILY
25. Spironolactone 25 mg PO BID
26. umeclidinium 62.5 mcg/actuation inhalation DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Chest Pain
SECONDARY DIAGNOSES
=====================
aortic stenosis s/p TAVR
Paroxysmal Atrial fibrillation
chronic diastolic heart failure
GERD
HLD
T2DM
COPD
Diverticulitis s/p partial colectomy
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at the ___
___. You came to the hospital because you had chest
pain. We performed blood tests, EKGs, which measure the
electrical activity of the heart, and a heart ultrasound to
evaluate your chest pain. The results of the tests we performed
were all normal. We believe the chest pain is related to the
joints and muscles surrounding your heart, especially because
you recently had a surgical procedure in your chest. Your
symptoms improved with pain medications which you will be able
to take after you leave the hospital.
Please be sure to follow up with your doctors as listed below
and to take all of your prescribed medications.
We wish you all the best!
-Your ___ care team
Followup Instructions:
___
|
10051555-DS-3 | 10,051,555 | 22,193,102 | DS | 3 | 2170-03-01 00:00:00 | 2170-03-01 20:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / lisinopril / atenolol / Erythromycin Base /
clindamycin / Sulfa (Sulfonamide Antibiotics) / ciprofloxacin /
Benadryl / Effient
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with history of CAD, s/p cardiac
cath with stents placed at an OSH one week ago via right femoral
axis. She has been on aspirin and plavix for anticoagulation.
She
states that she began to have right lower quadrant abdominal
pain
one day after the procedure, and that it worsened over the
course
of the week. Over the same period she began to have increased
urinary frequency, and went to her PCP to be evaluated for a
UTI.
Her PCP started ___, but was concerned about her RLQ pain
and sent her to the ED for further evaluation. Her Hct at that
time was 33, down from 43 prior to her cath, and a CTA
demonstrated a retroperitoneal hematoma. She was transferred to
___ for further evaluation.
At time of consult in the ED, she states that her abdominal pain
has improved over the past two days. She denies back or leg
pain,
weakness, light-headedness, or difficulty walking. Her blood
pressure and heart rate are stable.
Past Medical History:
PMH: CAD, HTN, HLD
PSH: cardiac cath with stents placed
Social History:
___
Family History:
No Significant Inheritable Disorder
Physical Exam:
Discharge Physical Exam
VITALS: T 98.0, HR 68, BP 128/55, RR 14 99%RA
GEN: alert and oriented x3, NAD
HEENT: palpable carotid pulse
CV: RRR, no audible murmurs
PULM: CTA bilaterally, no extra work of breathing
ABD: soft, TTP RLQ, no rebound/gaurding. Small area of
ecchymosisover right groin, soft, no palpable hematoma
EXT: WWP, all distal pulses palpable
Pertinent Results:
___ 10:20AM BLOOD Hct-34.1*
___ 08:24AM BLOOD WBC-10.2 RBC-3.61* Hgb-11.3* Hct-33.4*
MCV-93 MCH-31.3 MCHC-33.8 RDW-12.1 Plt ___
___ 01:11AM BLOOD Hct-30.5*
___ 05:30PM BLOOD Hct-32.8*
___ 10:40AM BLOOD Hct-30.8*
___ 07:24AM BLOOD WBC-7.0 RBC-3.39* Hgb-10.8* Hct-31.5*
MCV-93 MCH-31.9 MCHC-34.3 RDW-11.9 Plt ___
___ 09:10PM BLOOD WBC-8.8 RBC-3.88* Hgb-12.2 Hct-36.0
MCV-93 MCH-31.4 MCHC-33.8 RDW-12.3 Plt ___
___ 08:24AM BLOOD ___ PTT-30.4 ___
___ 08:24AM BLOOD Glucose-81 UreaN-14 Creat-0.6 Na-141
K-4.2 Cl-104 HCO3-27 AnGap-14
___ 09:10PM BLOOD Glucose-108* UreaN-15 Creat-0.7 Na-142
K-3.2* Cl-107 HCO3-25 AnGap-13
___ 09:30PM BLOOD Lactate-1.9
___ CTA abdomen/pelvis
AWAITING FINAL INTERPRETATION
Brief Hospital Course:
Mrs. ___ is a ___ year old female with retroperitoneal hematoma
after cardiac cath. She was transferred from OSH and admitted
on ___. She abdominal pain was stable over the course of
her admission as was her hemodynamic status. Serial hematocrits
were obtained throughout her admission which were stable. Her
admission Hct was 36.0 and her discharge Hct was 34.1 There
were no signs of ongoing bleeding or extravasation. On hospital
day 1 her diet was advanced and all of her home medications were
started. She had an uneventful hospital stay and on ___ a
repeat CTA abdomen/pelvis was obtained which revealed a
stable-to-slightly decreased hematoma.
At the time of discharge on ___, the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The patient was discharged home without
services. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. She was instructed to call the office to
set up a follow-up appointment with Dr. ___.
Medications on Admission:
1. Aspirin 325 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Metoprolol Tartrate 25 mg PO BID
5. Valsartan 20 mg PO DAILY
6. Simvastatin 10 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Metoprolol Tartrate 25 mg PO BID
5. Valsartan 20 mg PO DAILY
6. Simvastatin 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
retroperitoneal hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted on ___ for management of your right
lower quadrant retroperitoneal hematoma. You were observed with
serial blood tests to check your blood levels which remained
stable throughout your admission. You had a repeat CTA
abd/pelvis on ___ prior to your discharge which showed a stable
hematoma. You will have a follow-up appointment with Dr.
___. Please call Dr. ___ office on ___ to schedule,
the number is ___. We will also notify the office of
your discharge and follow-up appointment needs. Otherwise, you
should continue all of your home medications and notify your PCP
if anything changes in your health.
Followup Instructions:
___
|
10051850-DS-2 | 10,051,850 | 21,845,745 | DS | 2 | 2163-12-14 00:00:00 | 2163-12-14 15:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right hip pain/fracture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ pleasant Femail with pmhx of anemia, schizophrenia, dementia,
who was transferred from an outside hospital for a fall with R
hip pain. Unable to elicit history ___ patient mental status. CT
head/C-spine negative.
Past Medical History:
None on File
Social History:
___
Family History:
None on File
Physical Exam:
AVSS
NAD
RLE
No open wounds
observed to move legs, wiggles toes/moves feet; limited by pain
Sensation exam deferred ___ mental status
wwp distally.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have Right hip fracture and was admitted to the orthopedic
surgery service. After long discussion with the surgical team,
family, palliative care team, nursing staff, and hospice care
team. The decision was made to forego surgery at this point and
pursue hospice care for comfort.
If any questions or concerns arise regarding the hip fracture,
may contact Dr. ___ in the ___ Trauma Clinic
___ to schedule appointment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 125 mcg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Metoprolol Tartrate 25 mg PO BID
9. Atorvastatin 40 mg PO QPM
10. TraZODone 12.5 mg PO QHS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. Fentanyl Patch 12 mcg/h TD Q72H
RX *fentanyl 12 mcg/hour Apply to affected area q72 Hrs Disp
#*100 Patch Refills:*0
5. Glycopyrrolate 0.1-0.2 mg IV Q6H:PRN Dry Mouth
6. Milk of Magnesia 30 mL PO Q6H:PRN constipation
7. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___
mg PO Q1H:PRN Pain - Mild
RX *morphine concentrate 20 mg/mL 4 mg by mouth ___ q1H Disp
#*100 Syringe Refills:*0
8. OLANZapine (Disintegrating Tablet) 5 mg PO TID:PRN Agitation
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
R hip fracture (previous hardware in femoral shaft)
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC INPATIENT ADMISSION:
- You were in the hospital after fracturing your hip. It is
normal to feel tired or "washed out" after this injury.
ACTIVITY AND WEIGHT BEARING: per patient comfort
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue medications prescribed under palliative care/hospice
team
- 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.
Physical Therapy:
NWB - Activity per patient comfort
Treatment Frequency:
Per Hospice service
Followup Instructions:
___
|
10051872-DS-13 | 10,051,872 | 21,380,555 | DS | 13 | 2174-08-09 00:00:00 | 2174-08-10 16:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of T1D on Humalog insulin pump (followed by
Dr. ___ at ___, HTN, hypothyroid, and recent stroke 2
weeks ago without residual deficits who is admitted for DKA.
He reports that his blood sugar has been under good control
today (low 200s) until this morning when he noted it to be 220
prior to breakfast. He then went out to eat and when he
returned noted his glucose to be in the 500s. He set his pump
to deliver additional insulin boluses and reports that he
received approximately 1500 units between 3pm and 9pm when he
presented to the ___. He typically receives a basal
infusion plus boluses of ___ for meals. He reports 3
episodes of NBNB vomiting, no fevers, chills, abdominal pain,
diarrhea, dysuria, or cough. No known sick contacts. He was
initially diagnosed with T1D in ___ and received an insulin
pump ___ years ago. His BG was initially very difficult to
control and he reports three prior episodes of DKA, last being
in ___ at which time he was thought to have a pump malfunction
and it was replaced.
At ___, he was found to have a BG in the 500s, Bicarb 11, and
anion gap 29 c/w DKA, with WBC of 17. CXR concerning for a
possible pneumonia and he was initiated on vanc/zosyn. He was
started on an insulin drip, given 2 L of fluids and transferred
here since no ICU beds available at ___.
The patient felt well on arrival to our ___. Denied any pain and
breathing comfortably. Clear lungs and normal heart sounds. Soft
and non-tender abdomen. Mild tachycardia (90s-100s) with stable
BPs 120-130s/40-50s, SaO2 94-96% RA.
He was continued on an insulin drip. ___ L NS administered.
Additional ___ L with K running at 250 per hour. Antibiotics
continued with Vanc and Zosyn.
Labs: WBC 17 -> 20.5, Bicarb 11 -> 8, Glucose 519 -> 425 ->
372,
Anion gap 29 - > 25, K 4.7.
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
T1DM
Hypothyroid
Hypertension
Prior CVA
Social History:
___
Family History:
Not obtained
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: HR 78, BP 134/59, O2 99% RA, BG 465
GEN: Well appearing
HEENT: No JVD
CV: RRR
RESP: CTAB
GI: Soft, non-tender, non-distended
MSK: No abnormalities
SKIN: WWP
NEURO: Mentating appropriately, neurologic exam grossly intact
DISCHARGE PHYSICAL EXAM:
=======================
24 HR Data (last updated ___ @ 807)
Temp: 97.6 (Tm 98.7), BP: 161/88 (139-181/63-92), HR: 64
(55-68), RR: 18 (___), O2 sat: 94% (94-98), O2 delivery: RA
GEN: Alert, NAD, appears comfortable
CV: RRR; no m/r/g
PULM: breathing comfortably, clear to auscultation bilaterally,
no wheezes, ronchi or crackles
NEURO: AAOx3, grossly intact, moving all 4 extremities
spontaneously and with purpose
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 01:20AM BLOOD WBC-20.5* RBC-4.74 Hgb-14.7 Hct-46.4
MCV-98 MCH-31.0 MCHC-31.7* RDW-13.8 RDWSD-49.8* Plt ___
___ 05:01AM BLOOD ___ PTT-26.5 ___
___ 01:20AM BLOOD Glucose-425* UreaN-30* Creat-1.4* Na-144
K-4.7 Cl-111* HCO3-8* AnGap-25*
___ 01:20AM BLOOD Phos-4.4 Mg-2.0
___ 03:25AM BLOOD Beta-OH-4.1*
___ 01:26AM BLOOD Glucose-419* Lactate-2.9* Na-138 K-4.1
Cl-115* calHCO3-9*
___ 03:25AM BLOOD ___ pO2-48* pCO2-20* pH-7.22*
calTCO2-9* Base XS--17
==========================================
DISCHARGE AND PERTINENT LABORATORY STUDIES
==========================================
===========================
REPORTS AND IMAGING STUDIES
===========================
___
IMPRESSION:
Low lung volumes. No good evidence for cardiopulmonary
abnormality.
Although no acute or other chest wall lesion is seen,
conventional chest radiographs are not sufficient for detection
or characterization of most such abnormalities. If the
demonstration of trauma, or other osseous soft tissue
abnormality involving the chest wall is clinically warranted,
the location of any referable focal findings should be described
in the imaging request, clearly marked, and imaged with either
bone detail radiographs or Chest CT scanning.
============
MICROBIOLOGY
============
___ Blood Culture #1 =
___ Blood Culture #2 =
============================
DISCHARGE LABS
==============================
___ 04:43AM BLOOD WBC-9.6 RBC-4.72 Hgb-14.5 Hct-43.0 MCV-91
MCH-30.7 MCHC-33.7 RDW-13.4 RDWSD-45.1 Plt ___
___ 04:43AM BLOOD Plt ___
___ 04:43AM BLOOD Glucose-66* UreaN-14 Creat-0.8 Na-144
K-4.0 Cl-108 HCO3-26 AnGap-10
___ 04:43AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ year old man with a history of T1D on
Humalog insulin pump (followed by Dr. ___ at ___, HTN,
hypothyroid, and recent stroke 2 weeks ago without residual
deficits who is admitted for DKA.
#Diabetic Ketoacidosis
Mr. ___ presented in DKA with anion gap of 25, serum glucose
of 425, elevated beta hydroxybuterate and a metabolic acidosis.
He was initiated on an insulin infusion, normal saline boluses,
and potassium and phosphate repletion. His gap rapidly closed
and his beta hydroxy-buterate trended to zero. His acidosis also
rapidly resolved. His insulin infusion was eventually weaned
down per protocol and when it reached 4u/hour we initiated
insulin subcutaneously with a initial basal dose of 28u
glargine, standing humalog of 3u per meal and a sliding scale.
He was able to eat at this time and he was then transferred to
the floor.
The etiology of his DKA was not immediately clear. He reports
multiple prior episodes. CXR did not reveal pneumonia and a UA
at an OSH did not show evidence of infection. His leukocytosis
was thought to be reactive. There was concern that his insulin
pump may have malfunctioned, though there was no clear evidence
this was the case. ___ endocrinology was consulted.
FLOOR COURSE:
# DKA now resolved:
# Type I DM
Patient was continued on SC insulin at the time of transfer to
the floor. Due to some issue with his insulin order, the patient
did not receive his QHS glargine on the evening of ___.
Subsequently had high BG readings the next AM w/ sugars in the
400s. He received 28u of lantus and IVF w/ improvement in his
sugars. He had his insulin adjusted by ___ and ___ be
discharged with a regimen of #######. He will follow up with his
endocrinologist, Dr. ___.
#Hx recent CVA
#Mild aphasia: Patient and his wife were concerned about him
exhibiting word-finding difficulties (cardinal symptom noted
during stroke a couple weeks ago) and some fine motor
difficulties (he was unable to write in his usual cursive and
instead tried to write in print, unable to draw his wife a
picture and per her is usually a great artist) at the time of
his admission to the MICU. This was thought to be most likely
recrudescence in the setting of his DKA as it improved w/
treatment of that condition. Patient notably with a recent CVA
(2 weeks ago) during which ___ neuro noted reported "L
subcortical location and distribution of the stroke is most
consistent with a small vessel occlusive mechanism." Carotid U/S
noting "Bilateral carotid bulb and proximal ICA soft
atherosclerotic plaque, left >right." Carotid disease thought to
be possibly the culprit though no residual disease which would
be amenable to surgical intervention. TTE fairly unremarkable
and w/o e/o intracardiac thrombi. Sent home w/ holter monitor
(no results communicated to
patient yet). He reports history of intermittent "fast heart
rate" but is not sure if it is a-fib and no documented history
of this. Per ___ notes appears to be some unspecified SVT, w/
AVNRT noted on tele on the AM of ___. He was monitored for the
rest of the admission and with no concern for new deficits which
might suggest a CVA. He will be referred to neuro at the time of
discharge.
#SVT
#Likely AVNRT: Patient w/ self-limited episodes of SVT which
appeared to be AVNRT on the AM of ___. He was hemodynamically
stable and asymptomatic. He reports having palpitations in the
past and having "fast heart rates" followed by Dr. ___.
Notably not on any nodal blockade as an outpatient. He was
started on a low dose of metoprolol, but was limited by
bradycardia so he was not discharged on this.
# Hypertension: SBP in the 200s overnight on ___ but
reassuringly asymptomatic. He continued to have elevated BPs
during this admission and so had his antihypertensive regimen
titrated. He was on a regimen including an increased dose of
lisinopril at the time of discharge.
# Leukocytosis: Admitted w/ a WBC of 20K. Thought to be reactive
in the setting of DKA. WBC downtrended over the course of the
admission, and the patient had no localizing signs/symptoms of
infection.
CHRONIC ISSUES
===============
# Hyperlipidemia: Continued home atorvastatin
# Hypothyroid: Continued home levothyroxine
TRANSITIONAL ISSUES:
==================
[]Patient discharged on basal/bolus insulin regimen. He should
follow up with his endocrinologist, Dr. ___.
[]Discharged on Lisinopril 40 for hypertension. Follow up BP for
titration of his antihypertensives
[]Patient referred to neuro for follow up after his recent CVA
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 40 mg PO QPM
2. Clopidogrel 75 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. tadalafil 2.5 mg oral DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU Frequency is Unknown
6. Levothyroxine Sodium 150 mcg PO DAILY
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Glargine 28 Units Bedtime
Humalog 7 Units Breakfast
Humalog 7 Units Lunch
Humalog 7 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Basaglar KwikPen U-100 Insulin] 100
unit/mL (3 mL) AS DIR 28 Units before BED; Disp #*1 Syringe
Refills:*0
RX *insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR
Up to 5 Units QID per sliding scale 7 Units before LNCH; Units
QID per sliding scale 7 Units before DINR; Units QID per sliding
scale Disp #*1 Syringe Refills:*0
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY nasal
congestion
3. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Clopidogrel 75 mg PO DAILY
7. Levothyroxine Sodium 150 mcg PO DAILY
8. tadalafil 2.5 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
DKA
SVT
Hypertensive urgency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were confused and feeling unwell at home and were found to
be in a dangerous condition called diabetic ketoacidosis.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were admitted to the ICU where you were given insulin,
fluid, and electrolytes. Your condition improved quite quickly.
- You were evaluated by the doctors from ___. Your insulin
regimen was adjusted, and you will go out on injectable insulin
instead of your insulin pump.
- You had elevated blood pressures and had your blood pressure
medications increased.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please take your medications and go to your follow up
appointments as described in this discharge summary.
- If you experience any of the danger signs listed below, please
call your primary care doctor or go to the emergency department
immediately.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10052077-DS-15 | 10,052,077 | 21,740,946 | DS | 15 | 2143-02-03 00:00:00 | 2143-02-04 21:14:00 |
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, Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F with history of chronic abdominal presents wtih 10 days
of worsening LLQ pain, now radiating to the back. Pt reports the
pain is ___, sharp in character, and focused to the left of her
umbilicus. She was admitted for this pain on ___ and the
middle ___ at ___, treated for constipation and discharged
on both occassions. Her bowel movement frequency improved, but
pain did not subside. It has been more generalized in the past,
but is now primarily in the LLQ. After her most recent d/c, she
was sent out on metamucil, lactulose, and senna. After
discharge, she developed fevers to 100.5F with chills over the
past 3 days, although currently has no fevers or chills. She
says she now has intermittent liquid and hard stools. Also, she
has experiened ___ episodes of bilious vomiting over the past 3
days with associated nausea. Last episode of vomiting was
yesterday. No blood, mucous in stools. Abdominal pain is
relieved by tylenol, not improved or worsened with bowel
movements. Regarding her recent w/u of her abdominal pain, she
has seen numerous providers and MR enterography, colonoscopy,
and egd have not identified an etiology. Additionally, it has
been unresponsive to gabapentin, cymbalta, sucralfate, and
omeprazole.
.
She also reports 6 episodes of syncope over the past 4 days,
most recently occurred yesterday. Occurrs with standing or
bending over, preceded by dizziness. No bowel/bladder
incotenence, palpiations, tongue biting, or postictal period.
She has attempted to maintain adequate PO but admits that with
vomiting and diarrhea, she may not have kept up. Spoke with PCP,
reports history of narcotics addiction and rehab wtih chronic
abdominal pain. Per patient, no current narcotic use.
.
She was seen in her urgent care with BP 87/64 and P ___. She
was given IV fluids and told to d/c desipramine, start miralax,
and hold clonidine.
.
In the ED, initial vitals 6 98.8 96 98/68 16 99% RA
Exam notable for significant LLQ tenderness, rebound pain, but
otherwise soft belly, also tenderness throughout back including
the CVA. Labs notable for Lip: 49 ALT: 17 AP: 62 Tbili: 0.1
Alb: 4.6
AST: 17. Lactate:1.2 WBC 8.2 PMN:61.0%, U/A was negative, UCG
was negative. The pt underwent a CT abdomen whichh showed
equivocal wall thickening in the descending colon. She received
Dilaudid, 1mg, Ketorlac 30mg Ondansetron 4mg and 1L D51/2NS,
Cipro 400mg and Flagyl 500mg. While in the ED, her peripheral IV
became infiltrated with IV contrast and she complained of left
arm numbness and swelling, seen by plastics who recommended
volar splint and elevation. Vitals prior to transfer: Temp: 98
°F (36.7 °C), Pulse: 75, RR: 18, BP: 104/57, O2Sat: 98%, O2Flow:
RA, Pain: 1.
.
Currently, she still complains of abdominal pain adn mild
nausea. States that she feels quite a bit better after fluids
in the ED.
.
ROS were otherwise negative in detail.
Past Medical History:
Chronic abdominal/pelvic pain since ___
fibrocystic breast disease
depression
anxiety
TAH ___ c/b pelvic abscesses
c-section ___
Chole ___
Social History:
___
Family History:
Father deceased from colon cancer ___ ___
Sister cholecystectomy at ___ ___
Brother with UC
Physical Exam:
Admission:
VS afebrile 106/70 95 18 98% RA
Orthostatic 92/55; 55 sitting--> 106/70; ___ standing
GENERAL - well-appearing woman in some discomforg
HEENT - NC/AT, EOMI grossly in tact, sclerae anicteric, semidry
mm, OP clear
NECK - supple, no JVD
LUNGS - CTA bilat, no r/rh/wh
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, no masses or HSM, TTP (mild rebound) in
LLQ without guarding, or other peritoneal signs
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs). Left arm in volar splint with swelling of the upper arm
noted.
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+
Discharge:
VS afebrile, normotensive, not tachy
Orthostasis resolved
GENERAL - well-appearing woman
HEENT - MMM, EOMI, PERRL
NECK - supple, no JVD
LUNGS - CTAB, no w/r/r
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, no masses or HSM, mild TTP in LLQ
without peritoneal signs
EXTREMITIES - WWP, 2+ peripheral pulses (radials, DPs), no edema
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+
Pertinent Results:
Admission:
___ 07:55AM BLOOD WBC-8.2 RBC-4.57 Hgb-13.9 Hct-42.7 MCV-93
MCH-30.4 MCHC-32.6 RDW-13.4 Plt ___
___ 07:55AM BLOOD ___ PTT-27.1 ___
___ 07:10AM BLOOD ESR-4
___ 07:55AM BLOOD Glucose-85 UreaN-6 Creat-0.7 Na-139 K-4.5
Cl-103 HCO3-28 AnGap-13
___ 07:55AM BLOOD ALT-17 AST-17 AlkPhos-62 TotBili-0.1
___ 07:55AM BLOOD Albumin-4.6 Calcium-9.8 Phos-3.7 Mg-2.1
___ 08:05AM BLOOD Lactate-1.2
.
Discharge:
___ 07:10AM BLOOD WBC-8.4 RBC-4.19* Hgb-12.9 Hct-39.6
MCV-94 MCH-30.8 MCHC-32.6 RDW-13.2 Plt ___
___ 07:10AM BLOOD UreaN-5* Creat-0.7 Na-140 K-4.0 Cl-107
HCO3-24 AnGap-13
.
Studies:
CT A/P ___
1. Underdistended descending colon with equivocal wall
thickening. This
raises the possibility for colitis, but may be an artifact of
underdistension
and intramural debris; however colonoscopy could be considered
for further
work-up if there is clinical concern regarding the possibility
of mild
colitis.
2. Symptomatic extravasation of intravenous contrast (left
arm).
Brief Hospital Course:
Ms ___ is a ___ yo female with a PMH notable for chronic
abdominal pain who presents today with 10 days of LLQ pain
associate with intermittent nausea/vomitting with subsequent
development of syncope
Acute
#Abdominal Pain - Pt has a long history of abdominal pain and
several recent admissions at outside hospitals for constipation.
Per the patient, this represents acute on chronic abdominal
pain associated now with occasional diarrhea, nausea, vomiting,
and syncopal episodes over the past 3 days. CT scan in ED
demonstrated equivocal wall thickening with an underdistended
colon, concerning for colitis. Pt received cipro and flagyl in
ED. However, she had no fever or white count on admission, and
antibiotics were not continued. We did not suspect constipation
given bowel underdistention and aggressive bowel regimen started
at outside hospitals. Additionally IBD was less likely given
negative w/u thus far (colonoscopy, EGD, MR enterography in
outpatient settings) and normal ESR. IBS or functional
abdominal pain remain possible causes of her pain. Would also
consider viral gastroenteritis in setting of nausea, vomiting,
and diarrhea. Pain was treated with tylenol and toradol and
improved by discharge. Her home gabapentin, sucralfate, and
omeprazole were continued. Patient was advised to use naproxen
for pain management at home. She will follow-up with Dr.
___ in ___ as an outpatient
# Syncope - Differential included seizure, cardiogenic syncope,
and orthostasis. On admission, she was found to be orthostatic
and history was not consistent with seizure. She was monitored
on telemetry and no events were observed. Positive orthostatics
with recent history of vomiting/diarrhea made orthostasis the
most likely cause of syncope. She was aggressively rehydrated
with IV fluids. Orthostatics were negative and discharge, and
the patients symptoms had improved. She was encouraged to
continue hydrating at home.
# Nausea/vomiting/loose stools - Pt had three days of nausea,
vomiting, and loose stools prior to admission. She had some
nausea during her stay, but no vomiting or loose stools. Her
nausea was controlled with zofran. In setting of worsened
abdominal pain, viral gastroenteritis was suspected.
# IV contrast infiltration of arm - CT A/P was complicated by
contrast infiltration into the left arm. Patient was seen by
plastics who placed arm in volar splint and elevated arm x 2
days. Swelling in arm resolved and pt had full range of motion
without pain, numbness, or tingling by day 2. Splint was
removed on discharge.
Chronic
#Anxiety - Continued clonazepam while in house.
#Depression - Continued desipramine while in house
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Omeprazole 20 mg PO DAILY
2. Psyllium 1 PKT PO BID:PRN constapation
3. Senna 2 TAB PO HS
4. Desipramine 25 mg PO QHS
5. Ibuprofen 600 mg PO Q8H:PRN pain
6. CloniDINE 0.1 mg PO TID
7. Vivelle-Dot *NF* (estradiol) 0.05 mg/24 hr Transdermal 2x
weekly
8. Methocarbamol 1000 mg PO QID
9. Clonazepam 1 mg PO BID
10. Ondansetron 4 mg PO DAILY
11. Gabapentin 400 mg PO TID
12. Acetaminophen 500 mg PO Q6H:PRN pain
13. Sucralfate 1 gm PO BID
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Clonazepam 1 mg PO BID
3. Desipramine 25 mg PO QHS
4. Gabapentin 400 mg PO TID
5. Omeprazole 20 mg PO DAILY
6. Ondansetron 4 mg PO DAILY
7. Sucralfate 1 gm PO BID
8. Vivelle-Dot *NF* (estradiol) 0.05 mg/24 hr Transdermal 2x
weekly
9. Methocarbamol 1000 mg PO QID
10. Psyllium 1 PKT PO BID:PRN constapation
11. Senna 2 TAB PO HS
12. Naproxen 250 mg PO Q12H Duration: 2 Weeks
Take with food
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Syncope
Secondary: Abdominal Pain, Anxiety, IV contrast infiltration of
arm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms ___,
It was a pleasure taking care of you while you were admitted
here at ___. You were hospitalized because of several
episodes of fainting as well as abdominal pain. As you know,
your abdominal pain is chronic in nature. The worsened pain
could have been due to a virus that caused some inflammation of
your colon. This would also explain your nausea, vomitting, and
diarrhea, all of which have improved now. We believe your
syncope was related to your vomiting and diarrhea. Therefore we
treated you with tylenol, IV pain meds, and IV antinausea meds,
as well as IV hydration. Your pain improved over the 2 days and
your dizziness has, as well. Please continue to hydrate very
well. You may take naproxen (aleve) and tylenol for your pain
if it persists. Please followup with your PCP and Dr. ___
___ GI.
Followup Instructions:
___
|
10052193-DS-20 | 10,052,193 | 26,526,599 | DS | 20 | 2178-10-18 00:00:00 | 2178-10-18 16:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
morphine
Attending: ___
Chief Complaint:
Fall with R orbital fracture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o female presents with right orbital fracture on CT from
OSH and right knee pain after a fall this morning. The fall
occurred at 2am while she was walking downstairs in her home.
She fell forward on the last step and recalls hitting her knee
and the right side of her face on the floor. The fall was not
witnessed. She lives with her daughter's family, and they found
her down immediately after the incident. She remembers the event
and there are no reports of LOC by family members. She was taken
to an OSH where CT imaging showed evidence of a right orbital
fracture. Was referred to ___ to assess need for surgical
intervention. She has no reported falls in the past. She has
right knee pain ___, some pain on her right flank, and a
headache. She denies nausea/vomiting.
Past Medical History:
Past Medical History:
Diabetes
HTN
Arthritis
Past Surgical History:
Left knee surgery
Cholecystectomy
Cataract surgery
Social History:
___
Family History:
Non-contributory
Physical Exam:
Discharge Physical Exam:
Gen: AAOx3, NAD, lying comfortably in bed
HEENT: MMM, no scleral icterus
*****
Resp: nl effort, CTABL, no wheezes/rales/rhonchi
CV: RRR, nl S1/S2, no S3/S4, no murmurs/rubs/gallops
Abd: +BS, soft, ND, appropriately tender to palpation
Ext: WWP, no edema, 2+ DP
Physical examination upon discharge: ___
Pertinent Results:
___ 12:34AM GLUCOSE-198* UREA N-19 CREAT-1.3* SODIUM-137
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-21* ANION GAP-19
___ 12:34AM estGFR-Using this
___ 12:34AM WBC-10.7* RBC-3.70* HGB-9.8* HCT-32.4* MCV-88
MCH-26.5 MCHC-30.2* RDW-15.4 RDWSD-49.0*
___ 12:34AM NEUTS-79.2* LYMPHS-11.8* MONOS-6.5 EOS-1.1
BASOS-0.5 IM ___ AbsNeut-8.48* AbsLymp-1.26 AbsMono-0.70
AbsEos-0.12 AbsBaso-0.05
___ 12:34AM PLT COUNT-224
___ 12:34AM ___ PTT-31.7 ___
___ 09:28PM URINE HOURS-RANDOM
___ 09:28PM URINE HOURS-RANDOM
___ 09:28PM URINE UHOLD-HOLD
___ 09:28PM URINE GR HOLD-HOLD
___ 09:28PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:28PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 09:28PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
Imaging:
Head CT at OSH showed right orbital fracture.
CT of high lower extremity w/o contrast:
1. Moderate-to-large high-density joint effusion suggests the
possibility of
hemarthrosis.
2. No fracture identified.
3. Moderate-to-severe tricompartmental degenerative changes.
CT Torso: NO traumatic injuries
Assessment/Plan:
___ y/o female with right orbital fracture and right knee
pain/swelling s/p fall w/o LOC while walking down the stairs
this
morning. No concern for neurological injury based on history and
physical exam and thus no need for operative management.
Right knee is tender with mild swelling, but there is no
evidence
of fracture on imaging. Plan to discharge home with c
Brief Hospital Course:
Ms. ___ is a ___ old woman who had fallen down stairs,
landing on her right side. She was transferred to ___ on
___ from ___ for further management of a
right orbital fracture and R knee swelling and pain.
Ophthalmology was consulted and recommended sinus precautions
for 1 week, including no nose blowing, no drinking out of straw,
no smoking. They also recommended follow up with her regular
ophthalmologist in 1 week for dilated fundus exam. She should
also seek ophthalmic evaluation sooner as outpatient if she
experiences new onset flashes/floaters, diplopia, decrease in
vision or other significant ophthalmic concerns.
A right lower extremity CT was obtained on ___, which
showed knee joint effusion with possible hemarthrosis, no
fracture, and severe tricompartmental degenerative changes.
Orthopedic surgery was consulted and recommended ACE wrap to
right knee for support, weight bearing as tolerated, follow up
with PCP and follow up in ___ clinic as needed.
On ___, the patient was reported to have a decreased urine
output and was given additional intravenous fluids. She had
kidney studies done and was reported to be in ___. Her
creatinine peaked at 2.8. Her kidney function tests were
measured and at the time of discharge her creatinine was 1.2
with a bun of 26. The patient's vital signs remained stable and
she was afebrile. She was tolerating a regular diet. She did
have some bacteria in her urine but was asymptomatic.
In preparation for discharge, she was evaluated by physical
therapy who made recommendations for discharge to a
rehabilitation facility where the patient could regain her
strength and mobility. The patient was discharged on HD #5 in
stable condition. Appointments for follow-up were made with the
Plastic surgery service and with her primary care provider.
Medications on Admission:
Atenolol 25 mg PO DAILY Hypertension
GlipiZIDE 5 mg PO BID
MetFORMIN (Glucophage) 1000 mg PO BID
NIFEdipine CR 30 mg PO DAILY Hypertension
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Heparin 5000 UNIT SC BID
___ d/c when patient ambulatory
3. Simethicone 40-80 mg PO QID:PRN bloating
4. TraMADol 25 mg PO Q6H:PRN pain
5. Atenolol 25 mg PO DAILY Hypertension
6. GlipiZIDE 5 mg PO BID
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. NIFEdipine CR 30 mg PO DAILY Hypertension
9. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right orbital floor fracture
Right knee effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for
evaluation and treatment of your injuries after a fall. Please
follow the instructions below to continue your recovery:
Apply ice: Ice helps decrease swelling and pain. Ice may also
help prevent tissue damage. Use an ice pack or put crushed ice
in a plastic bag. Cover it with a towel and place it on your
face for 15 to 20 minutes every hour as directed.
Keep your head elevated: Keep you head above the level of your
heart as often as you can. This will help decrease swelling and
pain. Prop your head on pillows or blankets to keep it elevated
comfortably.
Avoid putting pressure on your face:
-Do not sleep on the injured side of your face. Pressure on the
area of your injury may cause further damage.
-Sneeze with your mouth open to decrease pressure on your broken
facial bones. Too much pressure from a sneeze may cause your
broken bones to move and cause more damage.
-Try not to blow your nose because it may cause more damage if
you have a fracture near your eye. The pressure from blowing
your nose may pinch the nerve of your eye and cause permanent
damage.
Contact your primary healthcare provider ___:
You have double vision or you suddenly have problems with your
eyesight.
You have questions or concerns about your condition or care.
Return to the emergency department if:
You have clear or pinkish fluid draining from your nose or
mouth.
You have numbness in your face.
You have worsening pain in your eye or face.
You suddenly have trouble chewing or swallowing.
You suddenly feel lightheaded and short of breath.
You have chest pain when you take a deep breath or cough. You
may cough up blood.
Your arm or leg feels warmer, more tender, or more painful. It
may look swollen and red.
Regarding your knee injury:
Rest your knee so it can heal. Limit activities that increase
your pain.
Ice can help reduce swelling. Wrap ice in a towel and put it on
your knee for as long and as often as directed.
Compression with a brace or bandage can help reduce swelling.
Use a brace or bandage only as directed.
Elevation helps decrease pain and swelling. Elevate your knee
while you are sitting or lying down. Prop your leg on pillows to
keep your knee above the level of your heart.
Followup Instructions:
___
|
10052340-DS-2 | 10,052,340 | 23,427,451 | DS | 2 | 2145-04-06 00:00:00 | 2145-04-06 17:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / Penicillins
Attending: ___.
Chief Complaint:
New Atrial Fibrillation with Rapid Ventricular Response
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old lady with a history of anemia
requiring blood transfusions in the past, hypertension,
arthritis, and non-obstructive CAD who presented via EMS for
weakness, found to have tachycardia and concern for STEMI in the
ambulance.
Ms. ___ is accompanied by her son and grandson. Today, she
was shopping with her grandson when she became short of breath,
and initially went to rest in the car for a few minutes while he
continued shopping. They went home and then she developed
acutely
a "funny feeling all over" and right-sided chest discomfort. She
has difficulty describing this further. She did have shortness
of
breath at the time, as well as abdominal discomfort and nausea.
She denied lightheadedness, presyncope, syncope, dizziness or
radiation. She took a SL nitroglycerin and after her son noticed
that she was very pale he called EMS at 2:50. On arrival, they
found her to be normotensive but tachycardic to the 200s. She
was
given 100mg IV amiodarone with improvement in HR. Rhythm strip
was concerning for STEMI in III and aVF and code STEMI
activated.
In the ambulance on the way to BI, she returned to feeling
completely normal.
On arrival to the ED, she stated she was feeling well, denied
nausea and vomiting. She denies any history of arrhythmia or MI.
She has never had an experience similar to that of today before.
In the ED...
- Initial vitals: T 98, HR 90, BP 139/87, RR 18, O2 97%RA
- EKG: LLB, no sgarbossa criteria; New afib with rvr
- Labs/studies notable for:
CBC 6.9>-110.5/32.7-<216
BUN 23, Cr 1.3 (baseline)
Trop < 0.01
VBG 7.32 | 48
Lactate 2.5
Serum tox notable for acetaminophen level of 14; o/w negative
BNP 1647 (no baseline)
Coags wnl
CXR with mild pulmonary edema, possible retrocardiac
opacification.
- Patient was given: ASA 324
On arrival to the floor, she confirmed the above history and
feels well without symptoms. Her last bowel movement was this
morning. She denies any recent changes in medications, any
recent
illnesses, any recent travel.
REVIEW OF SYSTEMS: Positives in HPI. Otherwise negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
- Constipation
- Osteoarthritis
- Hypothyroidism
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
================================
VS: ___ 1830 Temp: 97.9 PO BP: 117/68 HR: 99 RR: 18 O2 sat:
96% O2 delivery: ra Dyspnea: 0 RASS: 0 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.
NECK: Supple, thyroid midline and symmetric. No JVD at 30
degrees.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. NR, RR. Normal S1, S2. No murmurs/rubs/gallops. No
thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Warm. No ___ edema.
SKIN: No rashes.
PULSES: ___ pulses 1+ bilaterally
NEURO: Alert and Oriented x3. Some difficulties with counting
backwards from 10.
DISCHARGE PHYSICAL EXAM:
==========================
98.2 PO 152/75 57 20 95 Ra FSBG: 95
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple, No JVD at 90 degrees.
CARDIAC: irregular rhythm, but regular rate. No
murmurs/rubs/gallops.
LUNGS: Resp unlabored, no accessory muscle use. No crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NT, mildly distended. No HSM or tenderness.
EXTREMITIES: Warm. No ___ edema. Varicose veins b/l lower
extremities.
SKIN: No rashes.
PULSES: ___ pulses 1+ bilaterally
NEURO: Alert and Oriented x3.
Pertinent Results:
ADMISSION LABS:
==================
___ 03:52PM WBC-6.9 RBC-3.49* HGB-10.5* HCT-32.7* MCV-94
MCH-30.1 MCHC-32.1 RDW-13.8 RDWSD-46.9*
___ 03:52PM NEUTS-65.1 ___ MONOS-10.4 EOS-2.3
BASOS-0.6 IM ___ AbsNeut-4.46 AbsLymp-1.45 AbsMono-0.71
AbsEos-0.16 AbsBaso-0.04
___ 06:50PM BLOOD cTropnT-0.32*
___ 07:28AM BLOOD CK-MB-16* cTropnT-0.48*
___ 10:59PM BLOOD cTropnT-0.76*
___ 03:30PM BLOOD cTropnT-<0.01
___ 03:37PM GLUCOSE-104 LACTATE-2.5* NA+-141 K+-4.5
CL--104
___ 03:37PM PO2-28* PCO2-48* PH-7.32* TOTAL CO2-26 BASE
XS--2 COMMENTS-GREEN TOP
___ 03:37PM freeCa-1.16
___ 03:30PM cTropnT-<0.01
___ 03:30PM CK-MB-3 proBNP-1647*
___ 03:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-14 bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 03:30PM ___ PTT-28.7 ___
___ 03:30PM ___
DISCHARGE LABS:
====================
___ 07:50AM BLOOD WBC-8.7 RBC-3.59* Hgb-10.7* Hct-33.4*
MCV-93 MCH-29.8 MCHC-32.0 RDW-14.0 RDWSD-47.5* Plt ___
___ 07:50AM BLOOD Plt ___
___ 07:50AM BLOOD ___ PTT-28.3 ___
___ 07:50AM BLOOD Glucose-91 UreaN-25* Creat-1.3* Na-139
K-4.4 Cl-103 HCO3-25 AnGap-11
___ 07:50AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.1
PERTINENT OTHER STUDIES:
===========================
___ Cardiovascular TTE Report
CONCLUSION:
The left atrial volume index is normal. The right atrium is
mildly enlarged. There is no evidence for an
atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is ___ mmHg. There is
moderate symmetric left ventricular hypertrophy with a
moderately increased/dilated cavity. There is
mild global left ventricular hypokinesis. There is beat-to-beat
variability in the left ventricular
contractility due to the irregular rhythm. The visually
estimated left ventricular ejection fraction is
40-45%. There is no resting left ventricular outflow tract
gradient. No thrombus or mass is seen in the
left ventricle. Normal right ventricular cavity size with normal
free wall motion. The aortic sinus
diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch diameter
is normal. An aortic coarctation cannot be fully excluded. The
aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral leaflets are
mildly thickened with no mitral valve prolapse. There is a
valvular jet of moderate [2+] mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is mild [1+] tricuspid
regurgitation. The pulmonary artery systolic pressure could not
be estimated. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Moderate symmetric left
ventricular hypertrophy with moderate cavity dilation and mild
global systolic dysfunction. Moderate mitral regurgitation. Mild
tricuspid regurgitation.
Brief Hospital Course:
Ms. ___ is a ___ y/o F with a history of anemia
requiring blood transfusions in the past, hypertension,
arthritis, hypothyroidism, and non-obstructive CAD who presented
via EMS for weakness, found to have atrial fibrillation with
RVR,
asymptomatic on arrival to ___.
# CORONARIES: Unknown
# PUMP: EF 40-45%
# RHYTHM: Irregularly irregular
ACUTE ISSUES
============
# Paroxysmal Atrial Fibrillation with RVR
# Non sustained ventricular tachycardia versus Afib with
Aberrancy
Presented with weakness, dyspnea with HR 200s with initiation of
amiodarone gtt by EMS while en route to ___. No history of
known atrial fibrillation. Her hospital course was c/b WCT with
rates up to 180s concerning for atrial fibrillation with
aberrancy vs. ventricular tachycardia. She was monitored on
telemetry which was notable for frequent episodes of Non
sustained VT as well as intermittent conversion to sinus rhythm.
She was initiated on metoprolol PO with ultimate uptitration to
37.5mg every 6 hours. Her blood pressure and heart rates
tolerated this well. She was started on a heparin gtt for
CHADS-VASc of 5 without significant bleeding history and
transitioned to apixaban 2.5 mg BID prior to discharge
(secondary to fluctuating renal function per pharmacy). TTE was
performed without evidence of focal wall motion abnormalities.
# Troponemia
Presented with initial concern for STEMI by EMS due to STE in
III, aVF. On arrival she was noted to be asymptomatic with LBBB
with negative sgarbossa and these elevations were felt to be
more likely consistent with early repolarization or demand in
setting of tachyarrhythmia. Initial trop negative x 1, however
then peaked at 0.76 in the absence of symptoms. She reportedly
had a cardiac catheterization at ___ ___ years ago
with evidence of non-obstructive CAD per family report. Records
were requested from ___ daily, but did not arrive.
Her troponemia was felt to most likely be due to demand ischemia
in the setting of rapid atrial fibrillation, and in discussion
with patient and her son, cardiac catheterization would not be
consistent with her goals of care at this time. She was started
on aspirin 81 mg daily, and will continue on statin, metoprolol,
and imdur.
# Heart failure with reduced ejection fraction
On arrival, patient was dyspneic while in a-fib with RVR, with
elevated BNP, pulmonary edema on CXR. She appeared euvolemic on
exam. TTE was obtained with evidence of mild GLOBAL left
ventricular hypokinesis, EF 40-45%. TSH nl. Was given
intermittent iv diuresis. Discharged on 20mg furosemide PO
daily, metoprolol, imdur (home med), statin (home med)
CHRONIC ISSUES
==============
# Hypothyroidism
TSH wnl at 0.63 at last appointment. Continued home synthroid.
# CKD
Cr 1.32 and eGFR 39 at last PCP ___. Cr remained 1.2-1.4
during admission.
# Normocytic Anemia
Hb 11.8 with MCV 92.4 at last PCP ___. RDW not elevated.
Hgb ranged between ___ during admission without evidence of
active bleeding.
# Osteoarthritis
- Continue Tylenol prn
# Hypertension
- Continued imdur
# HLD
- Continued pravastatin
TRANSITIONAL ISSUES
===================
#discharge weight: 99.57 kg (219.51 lb)
#d/c BUN/Cr: ___
[] will need close monitoring of weights while initiating Lasix
and chem 7 chem check. Will need to check labs ___
[] Started Aspirin 81mg EC daily
[] has f/u with ___ cardiology
[] Consider cardiac stress test as outpatient
[] consider holter monitor/ziopatch to determine NSVT vs
Aberrant afib and overall burden of episodes
# CODE: Ok to resuscitate, DNI. - to be discussed with each
admission as appropriate. Made aware of conflict between
# CONTACT: Son/HCP ___ (___)
___ time 40 min
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
2. Pravastatin 40 mg PO QPM
3. Psyllium Powder 1 PKT PO DAILY
4. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
5. Vitamin D 1000 UNIT PO DAILY
6. LOPERamide 2 mg PO 8X/DAILY
7. Levothyroxine Sodium 88 mcg PO DAILY
8. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*11
3. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
4. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 100 mg 1.5 tablet(s) by mouth daily
Disp #*45 Tablet Refills:*1
5. LOPERamide 2 mg PO QID:PRN constipation
6. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Pravastatin 40 mg PO QPM
11. Psyllium Powder 1 PKT PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13.Outpatient Lab Work
Dx: Systolic Heart Failure; ICD 10: I50.2
Labs: chem 10
For/By: ___
Attention: ___, MD
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Atrial fibrillation
Troponemia
Heart failure with reduced ejection fraction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___.
Why was I here?
- You came to the hospital because you were feeling weak
- You were found to have an abnormal heart rhythm called atrial
fibrillation with fast heart rates
What was done while I was here?
- You were started on a medication called metoprolol to help
with your heart rates
- You were also started on a medication called apixaban which is
a blood thinner
- You had an ultrasound of your heart which showed it wasn't
pumping as well as it could be, but the medications you were
already on and the new medications we started for you help with
this.
What should I do when I get home?
- Please take all of your medications as prescribed and attend
all of your follow up appointments, as listed below. Please
review this list carefully and you MUST bring this list and this
documentation with you to your upcoming appointments that we
have made for you with Dr. ___ here at ___ Cardiology.
- You should weigh yourself first thing every morning at the
same time. You may need to purchase a scale. You should call
your primary care doctor if your weight goes up greater than
three pounds between any two days or slowly goes up five pounds
over a week or two. They may have to change your new medication,
"furosemide" also known as "Lasix."
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
10052530-DS-12 | 10,052,530 | 27,361,644 | DS | 12 | 2186-01-27 00:00:00 | 2186-01-27 11:49:00 |
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:
Laparoscopy Appendectomy ___
History of Present Illness:
Patient presents with 12 hours of acute abdominal pain. Symptoms
began
suddenly upon waking this AM. Pain was initially at
periumbillical area but now radiated to his RLQ. Reports one
episode of emesis and anorexia. Denies fever, chills, diarrhea,
and urinary symptoms. Has not tried analgesics for symptoms.
Upon evaluation. No acute distress. VSS. Abdomen soft,
non-distended. He has localized tenderness with rebound at RLQ.
Otherwise his abdomen is soft. Pain is reproducible with RLE
extension. Also has psoas sign. No rovsing. Work up notable for
leukocytosis to ___ with left shift. Imaging demonstrating
inflamed retrocecal appendix without signs of perforation.
Past Medical History:
none
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: 98.9, 60, 122/68, 16, 99% 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: Tenderness with localized rebound at RLQ. Otherwise is
soft,
nondistended, nontender. + psoas sign
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 97.8 PO 116 / 68 54 18 97 Ra
GEN: Awake, alert, pleasant and interactive.
CV: RRR
PULM: Clear bilaterally.
ABD: Soft, mildly tender incisionally as anticipated, mildly
distended.
EXT: Warm and dry. 2+ ___ pulses.
NEURO: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 12:37PM BLOOD Neuts-91.3* Lymphs-4.3* Monos-3.2*
Eos-0.2* Baso-0.5 Im ___ AbsNeut-13.96* AbsLymp-0.66*
AbsMono-0.49 AbsEos-0.03* AbsBaso-0.07
___ 12:37PM BLOOD WBC-15.3* RBC-4.99 Hgb-15.0 Hct-43.0
MCV-86 MCH-30.1 MCHC-34.9 RDW-12.5 RDWSD-38.6 Plt ___
___ 12:37PM BLOOD Glucose-114* UreaN-11 Creat-0.8 Na-141
K-4.5 Cl-100 HCO3-24 AnGap-17
___ 03:03AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.7
___ 6:___BD & PELVIS WITH CONTRAST Clip # ___
IMPRESSION:
Acute appendicitis without evidence of gross perforation.
Brief Hospital Course:
Mr. ___ is a ___ yo M who was admitted to the Acute care
surgery Service on ___ with abdominal pain and found to
have acute appendicitis on CT scan. Informed consent was
obtained and the patient underwent laparoscopic appendectomy on
___. Please see operative report for details. After a
brief, uneventful stay in the PACU, the patient arrived on the
floor tolerating clear liquid diet, on IV fluids, and IV
dilaudid for pain control. The patient was hemodynamically
stable.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*50 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*5 Tablet Refills:*0
4. Simethicone 40-80 mg PO QID:PRN gas pain
Discharge Disposition:
Home
Discharge Diagnosis:
Appendicitis
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 abdominal pain and found
to have an infection in your appendix. You were taken to the
operating room and had your appendix removed laparoscopically.
You tolerated the procedure well and are now being discharged
home to continue your recovery with the following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10052875-DS-13 | 10,052,875 | 28,599,142 | DS | 13 | 2139-09-08 00:00:00 | 2139-09-08 21:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hay fever / oxycodone
Attending: ___.
Chief Complaint:
fall, fever
Major Surgical or Invasive Procedure:
Flex sig ___
History of Present Illness:
___ history of HTN, recently diagnosed anal fistulas who
initially presented to an OSH after falling at the golf course
in
the setting of fevers to 102.7 and a month of LLQ abdominal
pain.
The patient also reports associated intermittent diarrhea,
non-bloody. Denies po intolerance or dysuria. Denies prior
episodes of similar pain. At the OSH, she underwent CT imaging
initially read as concerning for microperforated colitis or
diverticulitis, prompting her transfer here. Repeat CT imaging
was obtained here due to inability to transfer the imaging from
the OSH.
Of note, the patient was seen by Dr. ___ in clinic on ___
due to her PCP's concern for perianal disease. She was noted to
have a perianal fistula on exam and underwent an MRI pelvis on
___ showing multiple complex anal fistulas; no further
work-up or intervention has been performed. Her last colonoscopy
was in ___ without concern for IBD and no evidence of
diverticulosis; 4 sessile polyps were removed with hyperplastic
pathology.
Past Medical History:
PMH:
complex fistula-in-ano
HTN
PSH:
vein stripping (b/l)- ___
excision R breast papillomatosis- ___
Social History:
___
Family History:
Denies FH of IBD.
Father with colon cancer at age ___.
Mother with colon cancer in ___.
Physical Exam:
ADMISSION EXAM:
==========
Vitals-98.00 81 122/71 22 95RA
General- no acute distress
HEENT- face flushed, PERRL, EOMI, sclera anicteric, moist mucus
membranes
Cardiac- RRR
Chest- no increased WOB
Abdomen- soft, moderately tender to palpation in the suprapubic
region and LLQ with involuntary guarding, nondistended. No
rebound. Rectal exam without palpable mass or gross blood,
posterior midline fistula tract noted with scant purulent
drainage.
Ext- WWP, no edema
DISCHARGE EXAM:
==========
VS: ___ 1126 Temp: 98.5 PO BP: 116/71 L Lying HR: 86 RR: 16
O2
sat: 97% O2 delivery: 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. No
carotid bruit
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 GU catheter in place
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: abrasion in R temporal area and R shoulder
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
=============
___ 09:38PM BLOOD WBC-9.9 RBC-3.36* Hgb-7.6* Hct-26.7*
MCV-80* MCH-22.6* MCHC-28.5* RDW-16.4* RDWSD-46.8* Plt ___
___ 09:38PM BLOOD Neuts-79.9* Lymphs-9.4* Monos-9.7
Eos-0.1* Baso-0.2 Im ___ AbsNeut-7.92* AbsLymp-0.93*
AbsMono-0.96* AbsEos-0.01* AbsBaso-0.02
___ 09:38PM BLOOD ___ PTT-26.4 ___
___ 09:38PM BLOOD Glucose-112* UreaN-11 Creat-1.0 Na-138
K-4.1 Cl-99 HCO3-25 AnGap-14
___ 09:38PM BLOOD ALT-12 AST-17 AlkPhos-63 TotBili-0.2
___ 09:38PM BLOOD Lipase-13
___ 09:38PM BLOOD Albumin-3.2* Calcium-8.9 Phos-3.9 Mg-2.0
___ 09:38PM BLOOD CRP-89.8*
___ 09:44PM BLOOD Lactate-0.8
IMPORTANT INTERIM RESULTS:
=============
___ 05:13AM BLOOD calTIBC-170* Ferritn-726* TRF-131*
___ 05:00AM BLOOD Triglyc-168*
___ 05:13AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
MICRO:
=============
___ 8:07 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ Blood Culture x1 - NEGATIVE
___ C Diff PCR - NEGATIVE
___ O/P - NEGATIVE
___ O/P - NEGATIVE
___ MRSA SCREEN - NEGATIVE
IMAGING:
=============
___ CT ABD/PEL W/ CO
1. Extensive inflammatory change and adjacent phlegmon involving
the sigmoid
colon greater than the rectum. These findings are consistent
with a severe
proctocolitis, and Crohn's disease is favored given the presence
of a perianal
fistula and appearance of penetrating disease. An infectious
etiology could
also be considered. The appearance and distribution are less
compatible with
ischemia.
2. No fluid collection. No evidence of perforation. No
intrapelvic fistula.
3. Known perianal fistula is better seen on the recent MRI
performed ___.
___ CT ABD/PEL W/ CO
1. Redemonstration of extensive inflammatory changes associated
with
surrounding phlegmon in the sigmoid colon and to a lesser extent
the rectum
consistent with severe proctocolitis. No evidence of small
bowel involvement.
2. Please refer to recent rectal MR for more details on the
known perianal
fistula, which was incompletely evaluated today.
3. At least 3 hypodense nodules in the pancreas likely dilated
side branch
ducts, the largest measuring 2.0 cm. See recommendations below.
RECOMMENDATION(S): For pancreatic cysts measuring more than
1.5cm, patients should be referred to the pancreas cyst clinic
for consultation. These
referrals can be made by emailing
___
or by calling ___.
For cysts measuring up to 1.5 cm:
(a) These guidelines apply only to incidental findings, and not
to patients
who are symptomatic, have abnormal blood tests, or have history
of pancreas
neoplasm resection.
(b) Clinical decisions should be made on a case-by-case basis
taking into
account patient's comorbidities, family history, willingness to
undergo
treatment, and risk tolerance.
Local ___ follow-up guidelines adopted from:
___
___ TTE
Mild symmetric left ventricular hypertrophy with mild regional
systolic dysfunction most consistent with single vessel coronary
artery disease (PDA distribution). Trace aortic regurgitation.
Borderline mildly dilated ascending aorta.
DISCHARGE LABS:
=============
___ 05:03AM BLOOD WBC-7.3 RBC-3.25* Hgb-7.4* Hct-26.0*
MCV-80* MCH-22.8* MCHC-28.5* RDW-17.5* RDWSD-49.4* Plt ___
___ 05:03AM BLOOD Glucose-89 UreaN-9 Creat-0.6 Na-141 K-4.2
Cl-105 HCO3-24 AnGap-12
___ 05:03AM BLOOD CRP-13.1*
Brief Hospital Course:
Ms. ___ presented to ___ on ___, arriving from an
OSH, after having a fall (syncope) at a golf course, fevers of
102.7F, 1 month LLQ abd pain, with nonbloody diarrhea
intermittently. She was transferred from the OSH to surgical
service after being found on CT to have a possible
microperforated colitis/diverticulitis.
SURGERY HOSPITAL COURSE:
She was seen colorectal surgeon Dr. ___ had an MRI in
___ showing multiple complex anal fistulas.
Upon admission, pt was admitted to the colorectal surgery
service treated with Zosyn, made NPO w IVFs, received serial
abdominal exams, had her CRP trended, stool studies (Cdiff, O&P
- r/o infectious colitis), with a GI and medicine consult.
CV: Medicine was consulted for a syncope work up and had EKGs,
TTE, as well as telemetry performed.
EKGs - showed NSR with PACs
TTE - IMPRESSION: Mild symmetric left ventricular hypertrophy
with mild regional systolic dysfunction most consistent with
single vessel coronary artery disease (PDA distribution). Trace
aortic regurgitation. Borderline mildly dilated ascending aorta.
Telemetry - no arrhythmias reported.
Syncope work up was not pursued further inpatient with a stress
test recommended outpatient.
Pulm: The patient remained stable from a pulmonary standpoint;
oxygen saturation was routinely monitored. She had good
pulmonary toileting, as early ambulation were encouraged
throughout hospitalization.
GI: Pt initially received a repeat CT abd/pelvis with contrast
because of inability to obtain OSH records.
CT abd/pelvis w contrast showed -
IMPRESSION:
1. Redemonstration of extensive inflammatory changes associated
with
surrounding phlegmon in the sigmoid colon and to a lesser extent
the rectum
consistent with severe proctocolitis. No evidence of small
bowel involvement.
2. Please refer to recent rectal MR for more details on the
known perianal fistula, which was incompletely evaluated today.
3. At least 3 hypodense nodules in the pancreas likely dilated
side branch
ducts, the largest measuring 2.0 cm. See recommendations below.
She was started on Zosyn and then changed to
ceftriaxone/metronidazole -> swapped during admission to
___/metronidazole, to be continued outpatient until repeat CT
scan in 2 weeks (which abx can be d/c'ed if improvements on
imaging).
Pt was made NPO w IVF and had a PICC placed with Nutrition
recommending initiation of TPN. GI was consulted and recommended
infectious colitis work up (O&P, c.diff), hepatitis serologies,
a quant gold, clear liquid diet attempt, abx, planned scope,
CRP trending.
GI also recommended a repeat CT in 2 weeks to ensure improvement
with long term management including a full colonoscopy (luminal
and TI eval w dx biopsies - prior to antiTNF initiation).
She received a flexible sigmoidoscopy during her stay which
showed:
Erosions, friability and severe inflammation of the rectum and
sigmoid though with preferential involvement of the rectum.
Biopsies taken. In combination with anal fistulae, as discussed
before, this most likely represents new diagnosis of Crohn's
disease.
GU: UA and urine cultures were negative. At time of discharge,
the patient was voiding without difficulty. Urine output was
monitored as indicated.
ID: Pt was tested for C.diff, HBV serologies, TB quantiferon
gold (pre-biologic rx initiation testing), blood and urine cxs,
MRSA. MRSA, HBV, blood and urine cx's, cdiff were negative.
She was started on Zosyn and then changed to
ceftriaxone/metronidazole -> swapped during admission to
cipro/metronidazole, to be continued outpatient until repeat CT
scan in 2 weeks (which abx can be d/c'ed if improvements on
imaging).
Heme: The patient received subcutaneous heparin and ___ dyne
boots during this stay. She was encouraged to get up and
ambulate as early as possible.
MEDICINE HOSPITAL COURSE:
Patient was transferred to medical team on ___ given ongoing
need for inpatient monitoring on antibiotics for treatment of
intra-abdominal infection. Antibiotics continued with
ciprofloxacin and flagyl. On ___, CRP down to 13 and patient
feeling significantly better. After discussion with GI team,
patient stable for discharge. Plan to continue these antibiotics
on discharge, with final course to be determined by GI after
follow-up arranged in Dr. ___. GI will arrange
repeat imaging at that time.
In regards to syncope, patient did not seem to actually
syncopize, rather fell over and hit her head on the ground with
minor abrasions. EKG with nonspecific T wave changes and TTE
with mild hypokinesis in distribution of single vessel. Very low
suspicion for acute coronary event. Patient will follow up with
PCP for outpatient stress test.
TRANSITIONAL ISSUES:
[] Outpatient stress test scheduled by PCP to evaluate changes
on TTE
[] GI follow-up will be arranged by their clinic and patient
will be contacted
[] QUANT-GOLD pending on discharge (drew on ___ but issue with
tubes, so re-drawn on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. raloxifene 60 mg oral DAILY
2. Rosuvastatin Calcium 20 mg PO QPM
3. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO BID
Take until your GI follow-up, final course to be determined by
repeat imaging.
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*42 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO TID
Take until your GI follow-up, final course to be determined by
repeat imaging.
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*63 Tablet Refills:*0
3. raloxifene 60 mg oral DAILY
4. Rosuvastatin Calcium 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Inflammatory bowel disease/Crohn's Disease
Fistula with abscess
Fall
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___,
You were admitted to the hospital for fever, fall, and found to
have GI fistula with infection. You were started on antibiotics
and seen by GI, who performed a flexible sigmoidoscopy which
showed inflammation in your colon consistent with likely new
diagnosis of Crohn's Disease.
You will continue antibiotics, and will need to follow-up
closely with GI after discharge to determine the further course
of action and have discussions about treating the Crohn's.
It was a pleasure taking care of you!
Sincerely, your ___ Team
Followup Instructions:
___
|
10052992-DS-11 | 10,052,992 | 27,186,164 | DS | 11 | 2124-09-05 00:00:00 | 2124-09-09 12:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
Colonoscopy ___
Percutaneous cholecystostomy tube placement ___
History of Present Illness:
___ yo M, ___ dialect) speaking, w/ hx of HBV/HCV
cirrhosis (c/b portal HTN, no varices; c/b HCC s/p resection
___, HTN presenting with BRBPR.
He was admitted last week ___ an incidental
finding of acute cholecystitis found on an MRI that was
performed to assess for HCC recurrence. He was treated
non-operatively with abx (unasyn -> cipro/flagyl); discharged
___ to complete 14 day course.
He now re-presents with 2 days of bright red blood per rectum.
History is obtained from the patient's son via an interpreter.
The patient's son reports that he has been newly passing bright
red blood mixed with stool. He estimates the quantity at ___
tbsp per episode. He has not had any melena, and further denies
abdominal or rectal pain. His son was concerned because this
reminded him of a prior episode in which his father had bloody
emesis; however, he denies that his father has had any emesis
since discharge. ROS further negative for fever/chills, nausea,
diarrhea.
ED COURSE:
- VS 97.9; HR 63-68; BP 97/67-122/71; RR 18; 99% on RA
- Initial exam: well-appearing, minimal epigastric tenderness,
guiac positive stool in vault
On admission to the floor he is well-appearing, in no distress,
and has not yet had a bowel movement.
Past Medical History:
HBV, HCV, h/o hepatitis E infection
HCC (presumed) s/p resection in ___
Cirrhosis c/b UGIB ___ (EGD: portal hypertensive gastropathy,
no varices)
HTN
HLD
GERD
Hearing loss
Resection of HCC (segment V/VI) in ___ ___
Social History:
___
Family History:
No liver disease, problems with bleeding or anesthesia.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=
=
================================================================
VS - 97.3; 119/71; 63; 18; 96% on RA (beta blocked)
Gen - very pleasant elderly M in no distress; lying comfortably
in bed with his home blankets; ___ speaking; hard of
hearing
HEENT - anicteric, PERRL, MMM, upper dentures; erythema in the
posterior oropharynx
Cor - regular, no MRG
Pulm - comfortable on room air; clear throughout
Abd - soft, normoactive bowel sounds, non-tender throughout
Rectal - deferred, guiac positive in ED, known hemorrhoids
Extrem - warm, no edema
Neuro - no asterixis
DISCHARGE PHYSICAL EXAM:
=
=
=
================================================================
Vitals - T 97.7 120/78 51 18 99%RA, PTBD output 100 cc
overnight
General - Lying in bed in NAD, speaking with interpreter in
___
HEENT - Conjunctiva clear/sclera anicteric, EOMI, MMM.
Heart - S1/S2 no m/r/g.
Pulm - CTAB, normal respiratory effort
___ - Soft, no tenderness in RUQ, negative ___ sign,
nondistended, normoactive bowel sounds, no peritoneal signs or
palpable organomegaly, PTBD in place, draining thick sanguineous
fluid
Extr - warm, no edema
Neuro - A/Ox3, awake/appropriate, no asterixis
Skin - non-jaundiced, no spider angiomata or distension of
abdominal wall vessels
Pertinent Results:
ADMISSION LABS:
=
================================================================
___ 06:24PM BLOOD WBC-10.0 RBC-4.39* Hgb-15.0 Hct-43.0
MCV-98 MCH-34.1* MCHC-34.8 RDW-13.6 Plt ___
___ 06:24PM BLOOD Neuts-73.8* ___ Monos-6.3 Eos-1.4
Baso-0.3
___ 06:24PM BLOOD ___ PTT-41.7* ___
___ 06:24PM BLOOD Glucose-113* UreaN-12 Creat-0.9 Na-134
K-4.1 Cl-101 HCO3-24 AnGap-13
___ 06:24PM BLOOD ALT-40 AST-61* AlkPhos-115 TotBili-0.7
___ 06:24PM BLOOD Albumin-3.4*
___ 06:40AM BLOOD Albumin-3.0* Calcium-8.2* Phos-2.7 Mg-2.1
___ 06:26PM BLOOD Lactate-2.1*
INTERVAL STUDIES & IMAGING:
=
================================================================
___ ECG
Sinus rhythm. Respiratory variation in QRS morphology. Compared
to the
previous tracing of ___ the rate is slower. Computed QRS
duration is
slightly narrower. Q waves are no longer seen in leads III and
aVF arguing against prior myocardial infarction. Previously
described non-specific repolarization abnormalities have
improved with taller T wave amplitudes throughout.
___ COLONOSCOPY
Findings:
Protruding Lesions A circumferential mildly bleeding 5 cm mass
was found in the sigmoid colon at around 25cm. The scope could
not traverse the lesion and the examination was interrupted.
Cold forceps biopsies were performed for histology at the
sigmoid mass.
Impression: Mass in the sigmoid colon (biopsy)
Otherwise normal colonoscopy to sigmoid colon
Recommendations: - Differential diagnosis includes neoplastic,
ischemic, or inflammatory process which explains patient's
hematochezia. Most likely and concerning diagnosis is
malignancy.
- Recommend CT torso and CEA for staging
- Pathology results will be rushed and patient informed as soon
as they become available
- Follow-up with inpatient Liver team
___ CT ABDOMEN + PELVIS
1. Interval development of a lobulated fluid collection inferior
to the inflamed gallbladder consistent with perforated
cholecystitis, with gallstones layering within the collection.
2. Approximately 2.5-3 cm partly circumferential mass in the
sigmoid colon consistent with the reported malignancy. Lymph
nodes in the adjacent mesocolon do not meet CT criteria for
pathologic enlargement and mesenteric stranding is nonspecific.
No definite evidence of metastatic disease in the abdomen or
pelvis.
3. Re- demonstration of 1.5 cm lesion in hepatic segment 7,
better depicted on previous MRI, but with probable observation
of washout on today's study. This remains suspicious for ___
although today's examination does not meet criteria to assess
OPTN features.
4. 7 mm nodularity of the right adrenal gland, which might
represent a tiny adenoma, is stable. Nonenhancing possible
chronic hematoma inferior to the right adrenal gland is also
stable.
5. Stranding along the inferior mesenteric artery distribution.
Given thickwalled appearance of the inferior mesenteric artery,
superimposed vasculitis is not excluded.
___ CT CHEST
1. Moderate to severe centrilobular and paraseptal emphysema. No
metastatic lesions within the lungs.
MICROBIOLOGY
=
================================================================
___ 12:00 pm FLUID,OTHER Site: GALLBLADDER
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS:
=
================================================================
___ 06:45AM BLOOD WBC-7.1 RBC-4.06* Hgb-13.7* Hct-40.9
MCV-101* MCH-33.6* MCHC-33.4 RDW-13.7 Plt ___
___ 06:45AM BLOOD Glucose-95 UreaN-9 Creat-1.1 Na-136 K-4.0
Cl-103 HCO3-27 AnGap-10
___ 06:45AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ yo M, ___
speaking, with history of HBV/HCV cirrhosis (c/b grade 1
esophageal varices, and ___ s/p resection ___, now presenting
with painless BRBPR.
Active issues.
# Ruptured gallbladder: The patient presented for a recent
hospitalization (___) where he was found to have
cholecystitis. He was managed medically with a 14 day course of
ciprofloxacin and metronidazole. While in house for this current
admission (CC: ___, he underwent colonscopy, where he was
discovered to have a sigmoid mass. He underwent CT imaging of
the torso for staging, given his new sigmoid adenocarcinoma, and
was incidentally found to have a perforated gallbladder (see
IMAGING reports above). He complained of ___ pain in the RUQ
and remained hemodynamically stable, with a rather benign
abdominal exam, and afebrile. He is s/p PTBD on ___, with
tube in place, draining well. The patient will retain the PTBD
for decompression and plan for an interval cholecystectomy with
Dr. ___. Continue ciprofloxacin 500mg BID, Flagyl 500mg q8h
until seen by Dr. ___ as outpatient.
# Sigmoid colon mass: on colonoscopy yesterday, a partially
obstructing, circumferential mass was identified in the sigmoid
colon. Hemoglobin is stable and within normal limits (14.3
mg/dL). Staging torso scan showed no evidence of pulmonary or
intra-abdominal metastases. Pathology report of the mass biopsy
is consistent with adenocarcinoma. At this point, the patient is
still having bowel movements and has a non-distended abdomen;
therefore he does not appear to be clinically obstructed. The
patient is OK to have a regular diet, but was educated about
warning signs of obstruction. It is planned that is to have an
interval laparoscopic resection of the mass and interval
management of the perforated gallbladder as well.
# HBV/HCV cirrhosis: history of decompensated cirrhosis in the
setting of upper GI bleed. Currently, MELD 9, ___ class A
cirrhosis. No thrombocytopenia, mild elevation of INR to 1.3.
Continued home tenofovir for HBV and propranolol for variceal
hemorrhage prophylaxis.
# Dizziness: the patient reported dizziness, that was improved
when sitting. He did not endorse any signs/symptoms of vertigo.
His orthostatic vital signs were negative. He denied headache,
difficulty hearing, otorrhea or instability. He had no focal
neurologic findings. His dizziness/lightheadedness was
attributed to fluid status, infection and concomittant use of
antibiotics.
Inactive issues.
# LGIB: Resolved. He remained hemodynamically stable and found
on admission to have H/H ___ mg/dL range), which is above his
baseline without coagulopathy. He did not require any
transfusion of blood products or fluid resuscitation while in
house. The etiology of the LGIB was determined to be the sigmoid
adenocarcinoma.
# HCC: He has history of ___ s/p excision in ___ in ___, now
with suspicious 1.8cm lesion seen on repeat liver MRI; this will
need to be followed in the outpatient ___ clinic.
- Outpatient hepatology follow up
# HTN: Currently normotensive, so holding home antihypertensives
other than propanolol. Given reports of dizziness, propranolol
was held, withotu change in his dizziness. His orthostatic vital
signs were negative and he appeared well hydrated.
# Portal Hypertensive Gastropathy: discovered on EGD in early
___. Currently managed on propranolol. Plan for 3 month
interval EGD to follow up. Outpatient hepatology follow up in
___ for EGD and evaluation of PHG.
****TRANSITIONAL ISSUES:*****
- He will continue on cipro 500mg BID, flagyl 500mg q8h (D1 ABX
___ - originally planned for 14 day course, however
continued given GB rupture & PTBD placement
- He will need outpatient management for laparoscopic
cholecystectomy after completion of his antibiotic course
- He will need outpatient management for laparoscopic resection
of his sigmoid cancer
- He has history of ___ s/p excision, now with suspicious 1.8cm
lesion seen on repeat liver MRI; this will need to be followed
in the outpatient ___ clinic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H
4. Docusate Sodium 100 mg PO BID
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
6. Acetaminophen 500 mg PO Q6H:PRN pain or fever
7. Gemfibrozil 600 mg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Potassium Chloride 10 mEq PO DAILY
11. Propranolol 20 mg PO BID
12. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain or fever
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
5. Pantoprazole 40 mg PO Q24H
6. Propranolol 20 mg PO BID
7. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
8. Amlodipine 10 mg PO DAILY
9. Gemfibrozil 600 mg PO DAILY
10. Losartan Potassium 100 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: lower GI bleed secondary to mass in the colon
Secondary diagnoses: cholecystitis, HBV + HCV cirrhosis, HCC s/p
partial resection, HTN, portal hypertensive gastropathy
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 being part of your care at ___. You were
admitted to the hospital due to blood in your stools. You
underwent a colonoscopy which showed a mass in your colon. You
were also continued on antibiotics for cholecystitis
(inflammation of the gallbladder).
After discharge, please follow up with your outpatient providers
as described below, including your liver doctor, and the
surgeons for your gallbladder and colon mass.
It was a pleasure caring for you! We wish you a speedy recovery.
- Your team at ___
Followup Instructions:
___
|
10052992-DS-18 | 10,052,992 | 21,083,113 | DS | 18 | 2128-10-25 00:00:00 | 2128-10-25 15:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
bright red blood in stools
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
PCP: ___. ___ -- ___
(___)
CC: ___ bleeding
HISTORY OF PRESENT ILLNESS:
===========================
Mr. ___ is a ___ with history of HTN, HLD, CRC s/p
sigmoidectomy/FOLFOX (___) and HCV + HBV c/b cirrhosis and HCC
s/p resection/adjuvant chemo c/b recurrence and lung mets
(___) who presents with BRBPR in setting of anticoagulation
for recent PE.
History taken from son and chart.
Mr. ___ was discharged from ___ ___ for hospitalization
where he was found to have metastatic HCC to the lung as well as
new PE. He was discharged on 3 days of Lovenox, with
instructions to switch to apixaban on ___. Son reports that
patient only just filled the apixaban script prior to presenting
to the ED on ___ and has not been taking any anticoagulation
since his Lovenox ran
out on ___.
By report, the patient has been experiencing rectal urgency and
tenesmus for the last ~20 days. 3 days PTA, he began noticing
blood in the toilet bowl. Since then, he has been having ___
very small bowel movements per day, all with bright red blood.
He denies pain with defecation, lightheadedness or presyncope,
and his appetite is minimal at baseline. He endorses 2 episodes
of non-bloody emesis- toward the end of his second episode he
had streaks of emesis but no frank blood.
He denies generalized itchiness and his son reports he does not
look more jaundiced than usual. He reports ~10 days of mild
hemoptysis that he attributed to his lung met, but he has not
had any hemoptysis since the rectal bleeding began.
Yesterday morning (in the ED) he began experiencing ___
right frontal headaches that are non-positional and do not
change withneck flexion, as well as mild lower
abdominal/suprapubic pain.
He had a paracentesis ___ with removal 3.4L, negative for SBP -
PMNs 60. Since then his son reports that his abdominal swelling
has slowly re-accumulated but is not as tense or distended as it
was prior to the paracentesis. He does not get regular
paracenteses.
In the ED, vitals were:
T 96.7 HR 76 BP 113/77 RR 18 O2 Sat 98% RA
Exam:
No acute distress
RRR, no m/r/g
Lungs CTAB
Distended abdomen w/ ascites, nontender
No spider angiomas/nail changes
No asterixis
Labs:
CBC: WBC 3.4, Hb 11.6 from nadir of 10.8, Plt 89
BMP: Na 137, K 4.9, Cl 110, HCO3 19, BUN 14, Cr 1.0, Ca 8.2, Mg
2.4, Ph 1.9
LFT: ALT 176, AST 685, AP 238, Tbili 7.7. Alb 2.5
Lactate 2.4
UA with 2+ urobilinogen, otherwie unremarkable
UCx pending
Studies:
Colonoscopy ___: internal hemorrhoids, no active bleeding.
Also showed small angiodysplasia and submucosal mass
RUQUS ___
1. Cirrhotic liver morphology with heterogeneous echotexture and
multiple masses compatible with known malignancy. These masses
are better evaluated on the previously performed CT abdomen
pelvis.
2. Nonocclusive thrombus in the main portal vein with reversal
flow. Main portal vein velocity is 12.2 cm/s.
3. Reversal of normal directional flow in the right portal vein.
There is appropriate directional flow in the left portal vein.
4. Moderate volume ascites in all 4 abdominal quadrants.
5. Splenomegaly.
He was given:
For GIB: 2L LR, CTX 1g IV (ppx)
For BP: home amlodipine
He also got fleet enema in preparation for his colonoscopy.
On arrival to the floor, patient reports that he has ___
headache which is improved compared to the ED. He also reports a
little abdominal discomfort and fullness. He feels cold which is
his baseline. He does not have any dizziness or lightheadedness.
He does not have any blurred vision, palpitations, or shortness
of breath.
He denies any fever, chills or sweats. No abdominal pain. His
last bowel movement was ___ in the evening. He has not had
anything to drink for most of the day.
Past Medical History:
HCV
HBV
Cirrhosis
HCC s/p resection (___) and RFA (___) c/b recurrence and lung
mets (___)
Colon CA stage 3B KRAS+ s/p sigmoid colectomy and adjuvant chemo
(___)
Acute cholecystitis s/p CCY ___
HTN
Dyslipidemia
GERD
Hearing loss
Social History:
___
Family History:
No pertinent family history
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 98.2, HR 75, BP 120/79, RR 18, SpO2 97% RA
GENERAL: Alert and interactive. In no acute distress.
___.
HEENT: PERRL, EOMI. MMM. Sclera and soft palate are icteric.
Bilateral hearing aids in place. Wearing glasses.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, no organomegaly. Abdomen is
visibly distended with shifting dullness to percussion. No
tenderness to deep palpation in ___ quadrants or suprapubic
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Diffusely jaundiced with some palmar erythema, no spider
angiomata. Warm. Cap refill <2s. No rash.
NEUROLOGIC: AOx3 but confused about longterm history. Defers to
son. Moving all 4 limbs spontaneously. CN2-12 intact.Normal
sensation. No asterixis
DISCHARGE PHYSCIAL EXAM
========================
24 HR Data (last updated ___ @ 024)
Temp: 98.2 (Tm 98.2), BP: 109/62 (102-115/62-75), HR: 78
(78-82), RR: 18 (___), O2 sat: 95% (95-98), O2 delivery: RA
GENERAL: NAD, ___. Son at bedside.
CARDIAC: RRR, nml s1 s2, no mrg.
LUNGS: On RA. CTAB.
ABDOMEN: well-healed scar in RUQ from prior procedure. Firm
particularly in RUQ, mildly distended, no ttp.
EXTREMITIES: Trace ___.
SKIN: Diffusely jaundiced in lower extremities.
NEUROLOGIC: Awake, not oriented to time (per son, this is
baseline). No focal neurologic deficits. Normal gait.
Pertinent Results:
ADMISSION LABS:
___ 06:15PM BLOOD WBC-4.6 RBC-4.17* Hgb-13.1* Hct-39.0*
MCV-94 MCH-31.4 MCHC-33.6 RDW-30.5* RDWSD-102.2* Plt ___
___ 06:15PM BLOOD Neuts-59.8 Lymphs-17.2* Monos-14.9*
Eos-3.4 Baso-1.5* Im ___ AbsNeut-2.77 AbsLymp-0.80*
AbsMono-0.69 AbsEos-0.16 AbsBaso-0.___ 06:15PM BLOOD ___ PTT-38.1* ___
___ 06:15PM BLOOD Glucose-91 UreaN-15 Creat-1.1 Na-137
K-4.9 Cl-105 HCO3-21* AnGap-11
___ 06:15PM BLOOD ALT-176* AST-685* AlkPhos-238*
TotBili-7.7*
___ 07:45AM BLOOD Calcium-8.1* Phos-1.9* Mg-1.8
___ 06:27AM BLOOD calTIBC-122* Ferritn-397 TRF-94*
___ 06:27AM BLOOD IgM HAV-NEG
___ 07:45AM BLOOD HBV VL-NOT DETECT HCV VL-NOT DETECT
___ 08:06AM BLOOD pO2-70* pCO2-38 pH-7.40 calTCO2-24 Base
XS-0 Comment-GREEN TOP
___ 06:24PM BLOOD Lactate-2.8*
___ 12:13AM BLOOD Lactate-3.3*
___ 03:04AM BLOOD Lactate-3.0*
___ 03:25PM BLOOD Lactate-2.4*
___ 08:06AM BLOOD Lactate-2.0
DISCHARGE LABS:
___ 07:35AM BLOOD WBC-5.1 RBC-3.01* Hgb-9.8* Hct-29.2*
MCV-97 MCH-32.6* MCHC-33.6 RDW-32.1* RDWSD-110.6* Plt Ct-65*
___ 07:35AM BLOOD Glucose-108* UreaN-17 Creat-1.1 Na-141
K-4.1 Cl-112* HCO3-21* AnGap-8*
MICRO:
___ 3:16 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 3:16 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
Fluid Culture in Bottles (Pending): No growth to date.
REPORTS:
___ PERITONEAL FLUID CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS
___ LIVER U/S:
1. Cirrhotic liver morphology with heterogeneous echotexture and
multiple
masses compatible with known malignancy. These masses are
better evaluated on
the previously performed CT abdomen pelvis.
2. Nonocclusive thrombus in the main portal vein with reversal
flow. Main
portal vein velocity is 12.2 cm/s.
3. Reversal of normal directional flow in the right portal vein.
There is
appropriate directional flow in the left portal vein.
4. Moderate volume ascites in all 4 abdominal quadrants.
5. Splenomegaly.
___ COLONOSCOPY: POLYPS IN COLON, ANGIOECTASIAS IN COLON,
INTERNAL HEMMORHOIDS, PREVIOUS SURGERY IN COLON.
Brief Hospital Course:
Mr. ___ is a ___ y.o. male patient with HBC, HCV cirrhosis c/b
HCC with newly diagnosed lung mets (___), s/p resection ___,
RFA to segment VIII lesions, RFA to recurrent lesion ___,
adenocarcinoma of colon (s/p sigmoid colectomy and FOLFOX ___,
and non-occlusive L portal vein thrombus who was recently
admitted for acute RLL subsegmental PE from ___ and
re-admitted on ___ for BRBPR likely ___ internal hemorrhoids.
Given metastatic HCC, new lesion c/f recurrence of colon
adenocarcinoma, all c/b acute PE, Palliative Care was consulted
and family decision was made to make pt DNR/DNI with plan to
transition to home with hospice.
ACUTE ISSUES:
=============
# Rectal bleeding
# Normocytic anemia
# History of colon cancer s/p sigmoid resection in ___ in ___
+ FOLFOX: Stage IIIB, T3N1cM0 ___
# New 2cm lesion in neo-sigmoid colon ___ CT abd)
Patient presenting with BRBPR likely ___ internal hemorrhoids
though possibly also rectal varices given cirrhosis. ___
colonoscopy notable for internal hemorrhoids, non-bleeding
angioectasias in colon. Of note patient also restarted apixaban
for cancer-associated PE, but did not take this due to inability
to fill the medication. He was initially started on hep gtt and
apixaban for recent diagnosis of PE, but this was discontinued
on ___ given ongoing BRBPR. He continued to have ongoing BRBPR,
but reported this decreased compared to admission. He was
hemodynamically stable and did not require any transfusions
during his hospitalization.
#Recent dx PE
We discussed the risks of not angicoagulating, to which pt's son
agreed to stopping anticoagulation given ongoing BRBPR.
# Decompensated cirrhosis c/b coagulopathy
# ___ s/p liver resection in ___ ___
# History of HBC and HCV
Patient has a long h/o cirrhosis ___ viral hepatitis (HCV and
HBV) and c/b HCC. Has historically been well-compensated but
presents now in decompensation i/s/o hyperbilirubinemia,
elevated LFTs and tumor markers, and coagulopathy. He has a h/o
ascites with last outpatient paracentesis on ___, with removal
of 3.4L; studies negative for SBP. Repeat para on ___ removed
~2L fluid while inpatient and studies neg for SBP. He was
started on PO Lasix 20mg qd + PO spironolactone 50mg qd
(___) for abd distension discomfort.
#GOC
After discussion w/ Pall Care on ___, decision was made to make
pt DNR/DNI and plan for home with hospice. He continues to have
repeated episodes of BRBPR, though appears to have improved
after stopping apixaban for PE. They prefer to have a hospice
agency that works with ___ pts. DNR/DNI as of
___. MOLST in chart.
#Hemoptysis
Presented with blood-tinged sputum during this admission,
reportedly had this in the past as well. Likely ___ re-starting
AC, though improving. Predisposed to bleeding given pt has
cirrhosis, coagulopathy. Per pt, this resolved.
# Elevated lactate: 2.8 on arrival increased to 3.0 and then
back down to 2.4 with some fluids. UA with trace blood and
protein, 11 WBC but no signs of infection. Lactate was wnl on
___.
===============
CHRONIC ISSUES:
===============
# HCV
# HBV
# Transaminitis
Has a nonocclusive thrombus on RUQUS. Continued tenofovir for
now given possible flare of hepatitis if stopped.
# Cancer associated pain
Received Tylenol up to 2g daily and oxy 5mg prn for pain.
# HTN
d/c'ed home amlodipine, losartan due to soft pressures (SBP
~100s).
# GERD
Continued home omeprazole for discomfort from acid reflux.
#CODE: DNR/DNI (as of ___ - MOLST in chart).
#CONTACT: ___
Relationship: son
Phone number: ___
TRANSITIONAL ISSUES
===================
[]FYI: Pt is DNR/DNI, MOLST form in chart (signed ___.
[]Holding home lenvatinib (Onc) for the time being. Can consider
restarting if within goals of care/offers symptomatic support.
[]Continued Viread (tenofovir) due to concern for possible
hepatitis flare if stopped. Can discontinue if not within GOC.
[]Consider using dark towels/wipes. Suspect he will have ongoing
bleeding from rectum.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Apixaban 2.5 mg PO BID
3. Lenvima (lenvatinib) 12 mg oral DAILY
4. Omeprazole 20 mg PO DAILY
5. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
6. Propranolol 20 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. Losartan Potassium 100 mg PO DAILY
9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. Calcium Carbonate 500 mg PO QID:PRN acid reflux
2. Furosemide 20 mg PO DAILY
3. Lactulose 15 mL PO DAILY:PRN Constipation - Second Line
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
6. Senna 8.6 mg PO DAILY
7. Spironolactone 50 mg PO DAILY cirrhosis c/b ascites
8. Docusate Sodium 100 mg PO BID
9. Omeprazole 20 mg PO DAILY
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
11. Tenofovir Disoproxil (Viread) 300 mg PO DAILY
12. HELD- Lenvima (lenvatinib) 12 mg oral DAILY This medication
was held. Do not restart Lenvima until you discuss with Dr
___
___ Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hematochezia
Internal hemmorhoids
Acute on chronic anemia
Colon cancer
Recent diagnosis pulmonary embolism
Decompensated cirrhosis
Coagulopathy
Hepatocellular carcinoma
Hemoptysis
Elevated lactate
Transaminitis
Secondary Diagnoses:
Hypertension
Acid reflux
History of Hep B, Hep C
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital for blood in your stools.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We did a colonoscopy (taking a look inside your gut to figure
out where the bleeding was coming from). The bleeding is due to
hemorrhoids (dilated veins in your rectum). Your bleeding
improved, but you still had some bleeding when you left.
-We had our Palliative Care doctors ___. They helped arrange
home with hospice services. Hospice is type of care you receive
to make people comfortable as they near the end of their lives.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please call hospice if you have any questions or concerns
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10053000-DS-6 | 10,053,000 | 28,772,209 | DS | 6 | 2160-11-25 00:00:00 | 2160-11-25 15:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / Tetracycline
Attending: ___.
Chief Complaint:
acute diverticulitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ man with history of ANCA positive vasculitis on
chronic prednisone,who presents to the ED after 3 days of
abdominal pain. Patient reports that he has been having
periumbilical bandlike pain since 3 days ago that worsened 1 day
ago after a large meal. He continues to pass gas his last bowel
movement was yesterday and that was normal, and he does not
endorse nausea vomiting. Patient reports that his last episode
of diverticulitis was in ___ and his last colonoscopy was done
to ___ years ago and was negative. He is admitted to the ED for
evaluation of his acute diverticulitis that was found on CT that
shows 1.6 cm phlegmonous change in the ascending colon. No
drainable collection. He is otherwise feeling well.
Past Medical History:
HYPERTENSION
Hypercholesterolemia
ANCA-associated vasculitis
Wegener's granulomatosis (granulomatosis with polyangiitis) I do
not think he will likely need the medicine
BPH (benign prostatic hyperplasia) The patient is having really
like seeing the patient because he was cutting the
Mosaic Klinefelter syndrome
Social History:
___
Family History:
No family history of IBD, grandfather with colon
cancer at age of ___
Physical Exam:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, mildly tender to palpation on the right
lower quadrant, no rebound or guarding, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 02:40PM GLUCOSE-107* UREA N-18 CREAT-0.9 SODIUM-141
POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-28 ANION GAP-17
___ 02:40PM estGFR-Using this
___ 02:40PM ALT(SGPT)-7 AST(SGOT)-17 ALK PHOS-81 TOT
BILI-0.9
___ 02:40PM LIPASE-42
___ 02:40PM ALBUMIN-4.4
___ 02:40PM NEUTS-84.2* LYMPHS-5.8* MONOS-8.4 EOS-0.9*
BASOS-0.2 IM ___ AbsNeut-14.52* AbsLymp-1.01* AbsMono-1.45*
AbsEos-0.16 AbsBaso-0.04
___ 02:40PM PLT COUNT-238
___ 02:40PM PLT COUNT-238
___ 02:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
Brief Hospital Course:
___ w h/o ANCA+ vasculitis on chronic steroid p/w acute
diverticulitis. The patient was placed on IV abx and pain meds.
The patients pain improved on HD2. ON HD3, Mr. ___ was
transitioned to PO Abx and pain peds. He was given a regular
diet. Mr. ___ was discharged from the hospital on HD3 in
stable condition. He was tolearing a regular diet, voiding, but
still mildly tender on abdominal exam. He was asked to follow up
in ___ clinic and placed on a total of 10 days of cipro/flagyl.
Medications on Admission:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 capsule(s) by mouth Q6H:PRN Disp #*10
Capsule Refills:*0
3. amLODIPine 2.5 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*16 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*25 Tablet Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 capsule(s) by mouth Q6H:PRN Disp #*10
Capsule Refills:*0
5. amLODIPine 2.5 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
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:
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:
___
|
10053139-DS-11 | 10,053,139 | 26,871,759 | DS | 11 | 2179-05-09 00:00:00 | 2179-05-09 13:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
penicillin
Attending: ___
Chief Complaint:
jaundice
Major Surgical or Invasive Procedure:
ERCP w sphincterotomy and stent placement ___
History of Present Illness:
Ms. ___ is a ___ female with past medical
history of type 2 diabetes, diabetic neuropathy, and
hypercholesterolemia who presents with painless jaundice.
Patient states that 3 weeks ago she had an acute diarrheal
illness with frequent frothy stools lasting for approximately 7
days. Symptoms resolved and patient has been feeling relatively
well however ___ days ago has noticed yellowing of her eyes and
skin. On questioning has remarked that her urine has been quite
dark over the last several weeks as well.
Otherwise denies fevers, chills, headache, sore throat, cough,
lymph node swelling, chest pain, palpitations, dyspnea, nausea,
vomiting, abdominal pain, blood in her stools, dysuria, unusual
joint pains or muscle aches, focal weakness. Endorses bilateral
lower extremity neuropathy that has been chronic. Estimates
that
she may have lost approximately 5 pounds in the last week.
Past Medical History:
# T2DM
# Diabetic neuropathy
# Hyperlipidemia
Social History:
___
Family History:
No family history of cancer of liver disease.
Physical Exam:
ADMISSION EXAM
VITALS: ___ Temp: 98.0 PO BP: 129/60 R Sitting HR: 70
RR: 16 O2 sat: 95% O2 delivery: RA
GENERAL: Alert and in no apparent distress, markedly jaundiced
EYES: Scleral icterus
ENT: OP clear with MMMs
JVP: Not elevated
CV: S1 S2 RRR without audible M/R/G
RESP: Lungs clear to auscultation bilaterally without rales or
wheeze.
GI: Abdomen soft, mildly distended, non-tender to palpation.
Bowel sounds present. Palpable liver edge.
GU: No suprapubic fullness or tenderness to palpation
EXTREM: No edema
SKIN: Jaundiced.
NEURO: Alert, detailed and fluent historian. No pronator drift.
No asterixis.
PSYCH: pleasant, appropriate affect
=========
DISCHARGE EXAM
AVSS
pleasant, NAD
NCAT, scar over forehead well-healed, mild dysarthria per
baseline
RRR
CTAB
sntnd
wwp, neg edema
jaundice, icteric, subglossal icterus
A&O grossly, MAEE, gait wnl, CN II-XII intact except mild
scarring effect causing decreased L facial asymmetry on smiling
Pertinent Results:
ADMISSION RESULTS
___ 02:04PM BLOOD WBC-8.3 RBC-3.30* Hgb-10.1* Hct-30.2*
MCV-92 MCH-30.6 MCHC-33.4 RDW-19.9* RDWSD-66.6* Plt ___
___ 02:04PM BLOOD Neuts-66.8 ___ Monos-7.7 Eos-1.2
Baso-0.2 Im ___ AbsNeut-5.53 AbsLymp-1.91 AbsMono-0.64
AbsEos-0.10 AbsBaso-0.02
___ 08:50AM BLOOD ___ PTT-32.7 ___
___ 02:04PM BLOOD Glucose-238* UreaN-14 Creat-0.4 Na-136
K-3.6 Cl-103 HCO3-22 AnGap-11
___ 02:04PM BLOOD ALT-221* AST-146* AlkPhos-1315*
TotBili-13.5*
___ 02:04PM BLOOD Albumin-3.4*
___ 02:04PM BLOOD ___ pO2-59* pCO2-40 pH-7.41
calTCO2-26 Base XS-0
==========
PERTINENT INTERVAL RESULTS
___ BCx NGTD x2
___
Conclusion:
Intrahepatic, extrahepatic Biliary dilatation with distended
Courvo___ appearance of gallbladder. Gallbladder contains
sludge, no
definite stones. Common duct 12.4 mm.
2. No pancreas duct dilatation seen. Pancreas head obscured by
gas.
Further evaluation of the pancreas with CT recommended.
3. Otherwise Normal ultrasound survey of upper abdomen and
retroperitoneum.
ERCP: 1.5cm indeterminate stricture at distal CBD, successful
ERCP with brushing and biliary stent placement across CBD
stricture; biliary duct deeply cannulated with sphincterotome,
cannulation moderately difficult, ___ 7cm straight plastic
biliary stent placed successfully
CTA PANCREAS PROTOCOL:
Final Report
EXAMINATION: CTA PANCREAS (ABDOMEN AND PELVIS)
INDICATION: ___ year old woman with painless jaundice, head of
pancreas
obscured on ___ at ___// r/o pancreatic cancer
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic
post-contrast
images were acquired through the abdomen and pelvis.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.3 s, 47.2 cm; CTDIvol = 18.8 mGy
(Body) DLP = 874.5
mGy-cm.
Total DLP (Body) = 875 mGy-cm.
COMPARISON: None.
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. There is moderate
calcium burden in
the abdominal aorta and great abdominal arteries.
LOWER CHEST: Minimal atelectasis is noted in the lung bases.
There is no
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout. There
is no evidence of focal lesions. A biliary stent is in place.
There is mild
intrahepatic biliary ductal dilatation, and few foci of air
within the biliary
tree. The common bile duct is dilated, measuring up to 1.3 cm,
with abrupt
cutoff in the pancreatic head (05:40). Gall bladder is
distended. The wall
is not thickened. Hyperdense content suggests presence of
stones or sludge
within the gall bladder lumen.
PANCREAS: The pancreatic body and tail are atrophic. The main
pancreatic duct
is dilated, measuring up to 8 mm, with abrupt cutoff within the
pancreatic
head (05:36). A side branch in the uncinate process is dilated
to 5 mm
(05:42). There is a 6 mm hypodensity in the pancreatic head,
just anterior to
the stent (03:45). No discrete masses visible, but these
finding suggest
presence of an occult pancreatic masses causing biliary and
pancreatic ductal
obstruction. There is no peripancreatic stranding. There is no
vascular
involvement.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
There are bilateral renal cysts, measuring up to 1.5 cm in the
interpolar
region of the right kidney and 2.2 cm in the interpolar region
of the left
kidney, as well as additional bilateral subcentimeter
hypodensities too small
to characterize by CT. There are also peripheral striations to
the nephrogram
of each kidney suggesting either acute or chronic parenchymal
disease versus
fairly uniform bilateral appearance of scarring. There is no
renal stenosis.
There is no evidence of stones or hydronephrosis. There are no
urothelial
lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber,
wall thickness
and enhancement throughout. Colon and rectum are within normal
limits. There
is no evidence of mesenteric lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal
lymphadenopathy.
There are few prominent lymph nodes, for example, a hepatic
artery lymph node
measuring 8 mm (03:30) and a porta hepatis lymph node measuring
8 mm (___:43).
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no
evidence of pelvic or inguinal lymphadenopathy. There is no
free fluid in the
pelvis.
REPRODUCTIVE ORGANS: Calcifications are noted within the uterus,
likely
representing degenerated fibroids.
BONES: There is a mild anterior compression deformity of L2.
There are
moderate multilevel degenerative changes. No suspicious bone
lesions are
found.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Mild intrahepatic biliary dilatation, and dilation of the
CBD, with abrupt, within the pancreatic head, with biliary stent
in place, as well as dilation of the main pancreatic duct and of
a pancreatic side branch in the uncinate process, also with
abrupt cutoffs in the pancreatic head. Findings are highly
suggestive of an otherwise occult pancreatic head mass. There
is no evidence of local invasion or metastatic disease.
2. Mild anterior compression deformity of L2 is likely chronic.
========
DISCHARGE RESULTS
___ 05:40AM BLOOD WBC-6.4 RBC-3.36* Hgb-10.2* Hct-31.3*
MCV-93 MCH-30.4 MCHC-32.6 RDW-19.8* RDWSD-67.6* Plt ___
___ 05:40AM BLOOD Glucose-150* UreaN-9 Creat-0.5 Na-140
K-3.9 Cl-102 HCO3-24 AnGap-14
___ 05:40AM BLOOD ALT-204* AST-138* LD(LDH)-152
AlkPhos-1105* TotBili-8.3*
___ 07:21AM BLOOD %HbA1c-6.3* eAG-134*
___ 05:40AM BLOOD CA ___ -PND
Brief Hospital Course:
___ w DM, neuropathy p/w painless jaundice and weight loss c/f
malignant stricture.
ACUTE/ACTIVE PROBLEMS:
# Painless jaundice, with ultrasound evidence of intra- and
extra-hepatic biliary dilatation, CBD 12.4mm. No signs/symptoms
of active cholangitis at this time. Underwent ERCP on ___ with
sphincterotomy and stent placement. CTA pancreas obtained with
findings concerning for occult pancreatic malignancy. Brushings
pending at time of discharge. Pt will be contacted by ___ team
with results and if results c/f malignancy, ERCP will arrange
outpatient oncology follow up. If brushings are negative (only
60% sensitive in pancreatic malignancy) will need endoscopic
ultrasound. Bilirubins improved with above mgmt. with
improvement in clinical jaundice.
CHRONIC/STABLE PROBLEMS:
# T2DM: held home metformin while inpt, continued home humalin
(70/30) at 16u qam, 10 qpm per home regimen. A1c 6.8, so
decreased home 70/30 insulin to 10u BID.
# Diabetic neuropathy: continued home duloxetine, pregabalin
# Hyperlipidemia: continued home simvastatin
>30 minutes spent on patient care and coordination on day of
discharge.
TRANSITIONAL ISSUES
- biliary brushing cytology results pending at time of
discharge; to be followed up by ___ team; if positive, patient
will be referred by ___ team to ___ oncology; if negative,
patient will require EUS; please ensure this process occurs
- please monitor LFTs as outpatient within next week and monitor
for resolution of jaundice; if does not resolve, may require
further procedures e.g. PTBD versus repeat ERCP
- stent placed by ___, removal will be arranged by their
service; please ensure patient has follow up scheduled
- given A1c 6.8 and age/co-morbidities, decreased insulin to 10U
BID from 16 qam /10 qpm
- ___ pending at time of discharge; please follow up final
result
- blood cultures at ___ and ___ pending at time of
discharge but do not expect these to be positive; please follow
up final results
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO DAILY
2. Simvastatin 40 mg PO QPM
3. DULoxetine 60 mg PO DAILY
4. Pregabalin 50 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Calcium 600 (calcium carbonate) 600 mg calcium (1,500 mg)
oral DAILY
8. NovoLIN 70/30 U-100 Insulin (insulin NPH and regular human)
100 unit/mL (70-30) subcutaneous BID
Discharge Medications:
1. NovoLIN ___ FlexPen U-100 (insulin NPH and regular human)
100 unit/mL (70-30) subcutaneous BID
Please now take 10 units twice a day.
2. Aspirin 81 mg PO DAILY
3. Calcium 600 (calcium carbonate) 600 mg calcium (1,500 mg)
oral DAILY
4. DULoxetine 60 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO DAILY
6. Pregabalin 50 mg PO DAILY
7. Simvastatin 40 mg PO QPM
8. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
jaundice
biliary stricture
pancreatic mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ was a pleasure caring for you.
You were admitted for yellowing of your eyes and skin
("jaundice").
We believe this was caused by a mass in your pancreas leading to
a blockage in your bile ducts. We are concerned this mass is a
cancer, but we are awaiting test results.
You will be contacted with the results of the brushings and will
make a plan with the ERCP doctors for follow up, including when
to replace your stent as an outpatient.
Please contact your PCP and have your labs checked again in the
next week to ensure the jaundice is continuing to resolve.
We also decreased your insulin because your sugars were a little
more tightly controlled than necessary.
We wish you the best in your recovery!
Followup Instructions:
___
|
10053207-DS-9 | 10,053,207 | 29,999,444 | DS | 9 | 2199-12-22 00:00:00 | 2199-12-22 13:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Haldol
Attending: ___.
Chief Complaint:
Abdominal Pain, Diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o F with history of bipolar disorder, prior TKA with
subsequent C.diff infection in ___ in setting of prolonged
antibiotic course, and subsequent recurrent infection ___
presents with cough, diarrhea, and vomiting. Patient states
she's had abd pain for "some time" but can't clarify. Also
endorses intermittent diarrhea but is unable to provide
additional details. She lives at a nursing home where she states
everyone has been coming down with a similar virus. Recent flu
swab negative on ___ and there is report she was seeen recently
at ___. E___ ED for similar symptoms. per nursing home, pt is
incontinent of urine at baseline. Received Rocephin IM
yesterday.
ED Course (labs, imaging, interventions, consults):
- Initial Vitals/Trigger: Triage 13:18 0 96.8 127 122/69 18
96%
- EKG: Sinus tach @126, LAD, NI, nonspecific ST-T changes, STP
- labs showed:
Lactate:1.4. UA positive for nitrites, >182 WBC.
chem: (hemolyzed) 134/5.1; 105/17; 61/2.9 <96
(b/l creatinine several years ago 1.2). Mg 1.4.
ALT: 51 AP: 89 Tbili: 0.2 Alb: 3.0 AST: 63. Lip 26.
CBC: 6.9 > 9.3/29.5 <341. PMNs 45%, 2 bands.
- imaging: CXR: R base lung opacity, dilated loops of bowel
- KUB: Markedly distended colon, similar to prior scan from
___. Deferred CT abd at this time
- Rectal temp: 100.6. Guiac+
- interventions: Pt received 3L NS, 1gm vanc, 750mg IV levaquin,
and 1g CTX
Pt admitted to medicine for UTI, PNA, ___, drop in Hct. v/s
prior to transfer: sleeping 99.6 129 136/80 26 95% RA
On arrival to the MICU, she is comfortable with normal stable
vitals with the exception of HR in the 130 range. She reports
abdominal pain, no recent nausea/vomiting, and has several large
watery bowel movements. Denies hematochezia or melena.
Past Medical History:
1. Bipolar disorder.
2. Nonhealing cellulitis ___.
3. Spinal stenosis.
4. Osteoarthritis.
5. History of delirium.
6. Left ___ complicated by PJI of unknown
etiology, s/p IV vancomycin and oral suppressive doxycycline x 6
months which finished on ___.
7. Right ___.
8. Cholecystectomy.
9. C. diff colitis in ___, treated with flagyl, followed by
recurrent C. diff infection ___ s/p course of flagyl
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION EXAM:
General- well-appearing obese woman in no distress fully
oriented.
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- diffuse crackles, distant breath sounds
CV- tachycardia, normal S1 + S2, no murmurs, rubs, gallops
Abdomen- tender to palpation diffusely
GU- foley in place
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal no
asterixis/tremor
Pertinent Results:
ADMISSION LABS:
___ 01:55PM BLOOD WBC-6.9 RBC-3.28* Hgb-9.3* Hct-29.5*
MCV-90 MCH-28.3 MCHC-31.4 RDW-16.2* Plt ___
___ 01:55PM BLOOD Neuts-45* Bands-2 ___ Monos-31*
Eos-0 Baso-0 ___ Metas-3* Myelos-0
___ 03:28AM BLOOD ___ PTT-35.9 ___
___ 01:55PM BLOOD Glucose-96 UreaN-61* Creat-2.9*# Na-134
K-5.1 Cl-105 HCO3-17* AnGap-17
___ 01:55PM BLOOD ALT-51* AST-63* AlkPhos-89 TotBili-0.2
___ 01:55PM BLOOD Lipase-26
___ 03:28AM BLOOD CK-MB-5
___ 01:55PM BLOOD Albumin-3.0* Calcium-8.4 Phos-2.8 Mg-1.4*
___ 02:07PM BLOOD Lactate-1.4
OTHER RELEVANT LABS:
___ 03:28AM BLOOD CK-MB-5
___ 03:28AM BLOOD TSH-0.79
___ 04:12AM BLOOD tTG-IgA-PND
___ 02:20PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 02:20PM URINE Blood-MOD Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 02:20PM URINE RBC-36* WBC->182* Bacteri-MANY Yeast-NONE
Epi-4
___ 02:21PM URINE Hours-RANDOM UreaN-327 Creat-21 Na-77 K-7
Cl-75
___ 02:20PM URINE Hours-RANDOM Creat-47 Na-30 K-23 Cl-32
HCO3-LESS THAN
___ 02:21PM URINE Osmolal-298
___ 02:20PM URINE Osmolal-273
MICRO LABS:
___ BLOOD CX: PENDNG
___ URINE CX: NEGATIVE
___ URINE LEGIONELLA: NEGATIVE
___ C. DIFF: NEGATIVE
IMAGING:
___ Chest (Pa & Lat)
IMPRESSION: Right basilar opacity likely due to at least some
atelectasis, noting that infection is also possible. Distended
loops of bowel visualized in the upper abdomen for which
clinical correlation suggested regarding need for additional
imaging.
___ KUB
Diffuse gaseous distention of the colon. Appearances are
similar compared to the prior radiographs from ___.
Findings ___ be suggestive of chronic pseudoobstruction, but if
there is continued concern, CT is recommended. No small bowel
obstruction.
___ CT Abd/pelvis w/o contrast
IMPRESSION:
1. Perinephric stranding, left worse than right, is
non-specific, but pyelonephritis cannot be excluded.
Additionally, the left proximal ureter is mildly prominent with
urothelial thickening, a finding that can also be seen with
infection.
2. Consolidation in the posterior aspect of the right lower
lobe ___ be secondary to atelectasis but infectious or
inflammatory processes cannot be excluded.
3. Diffuse mild colonic dilatation without wall thickening or
evidence of obstruction ___ be secondary to chronic
pseudo-obstruction, particularly as prior abdominal radiographs
have shown a diffusely distended colon. Fluid in the colon is
compatible with a history of diarrhea.
4. Left adrenal nodule which does not meet strict criteria for
an adenoma, but in the absence of prior malignancy is likely
benign. Consider follow up adrenal CT or MRI in 12 months.
EKG: sinus tachycardia, left axis deviation, evidence of left
anterior fascicular block, no concerning ST-segment or T-wave
___:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thicknesses are normal. The left ventricular cavity is
unusually small. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF=75%). The
estimated cardiac index is normal (>=2.5L/min/m2). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve is not well seen. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Small biventricular cavity
size with borderline hyperdynamic systolic function. Small
collapsable IVC.
Brief Hospital Course:
___ with PMH significant bipolar disorder, recurrent cdiff in
the setting of antibiotic use who presents with 1 week of
nausea, vomiting, and diarrhea found to have a UA suggestive of
infection.
She was initially admitted to the ICU for tachycardia - this was
felt to be in the setting of her underlying UTI, although her
heart rate is elevated at baseline. She was also noted to have
significant diarrhea which resolved, felt to be secondary to a
viral gastroenteritis. She was transferred to the floor after
receiving fluids and after she was noted to be hemodynamically
stable. On the floor, a midline was placed for continued
administration of IV ceftriaxone to treat her UTI. She will
need to continue this up through ___. She was constipated
and was treated with kayexalate especially in the setting of a
potassium near 5.5. She also had mild ___ in the setting of
her fluid losses which improved during the course of her
hospitalization. She was discharged to rehab following
stabilization of her hemodynamics, resolution of her diarrhea,
___, and constipation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraMADOL (Ultram) 50 mg PO BID
2. Ascorbic Acid ___ mg PO BID
3. ClonazePAM 1 mg PO QHS
4. Colchicine 0.6 mg PO BID
5. Allopurinol ___ mg PO DAILY
6. Florastor (saccharomyces boulardii) 250 mg oral BID
7. Divalproex (DELayed Release) 500 mg PO BID
8. Docusate Sodium 100 mg PO BID
9. Famotidine 20 mg PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Gabapentin 100 mg PO TID
12. Multivitamins 1 TAB PO DAILY
13. RISperidone 1 mg PO HS
14. Senna 17.2 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Ascorbic Acid ___ mg PO BID
3. ClonazePAM 1 mg PO QHS
4. Divalproex (DELayed Release) 500 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Famotidine 20 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Gabapentin 100 mg PO TID
9. Multivitamins 1 TAB PO DAILY
10. RISperidone 1 mg PO HS
11. Senna 17.2 mg PO DAILY
12. TraMADOL (Ultram) 50 mg PO BID
13. CeftriaXONE 1 gm IV Q24H
14. Colchicine 0.6 mg PO BID
15. Florastor (saccharomyces boulardii) 250 mg oral BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
acute pyelonephritis
chronic intestinal pseudo-obstruction
___, likely ATN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted to the hospital with a kidney infection. This
improved slowly after starting antibiotics and receiving IV
fluids. You will need to complete antibiotics over a 10 day
course - the last day of antibiotics will be on ___. You
also had some kidney damage however you recovered during the
hospitalization.
Followup Instructions:
___
|
10053782-DS-14 | 10,053,782 | 22,388,958 | DS | 14 | 2156-06-10 00:00:00 | 2156-06-11 16:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness, nausea and slurred speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ F with recent diagnosis of
___ disease (but has not taken Sinemet) who presents
with
left cerebellar IPH. The patient has had a progressive decline
in
function over the past year, becoming less and less mobile. She
was recently diagnosed with ___ disease by an outside
neurologist, but has not taken any sinemet due to her concerns
about side effects. As a result she has become immobile to the
point that she only gets up, using a walker, to go to and from
the bathroom, but does not otherwise move much. Last ___ (1
week ago) the patient had the sudden onset of dizziness, nausea
and slurred speech. Her blood pressure was noted to be 220/100
at
that time. She presented to ___ with these
complaints
and also complained of some abdominal pain at that time. She had
a CT scan of her abdomen which reportedly showed a pancreatic
mass which could not be fully characterized and labs were
unrevealing (per the daughter-in-law). She was briefly admitted
to the hospital, but discharged the next day, apparently without
neurologic or physical therapy evaluation. Since that time she
has been even more immobile than her previous baseline, unable
to
get to and from the bathroom on her own and essentially has been
laying flat for the past ___ days. She has continued to report
dizziness. Her speech continued to sound slurred (there have
been
no problems with language content), but did improve some
yesterday. The patient's family has become more and more
concerned and called the PCP today who recommended presentation
to the ___ ED. Upon presentation to ___ she was found to
have
a left cerebellar hemorrhage on ___.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysphagia, tinnitus or hearing difficulty.
Denies difficulties producing or comprehending speech. Denies
focal 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:
Hypothyroidism
___ disease (new diagnosis)
Patient's daughter-in-law denies h/o of HTN, HLD, DM
Social History:
___
Family History:
Mother and ___ aunt with ___ disease
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
98.0 86 159/82 18 94%
GEN: Awake, cooperative, NAD.
HEENT: NC/AT, anicteric, MMM, no lesions noted in oropharynx
NECK: Supple
RESP: CTAB
CV: RRR
ABD: soft, NT/ND
EXT: No edema, no cyanosis
SKIN: Pressure ulcer on left calf covered with bandage clean,
dry and intact
NEURO EXAM:
MS:
Alert, oriented to person, place and time. Patient is ___
speaking and
daughter-in-law translates. She reports that language is fluent
with intact comprehension.
Normal prosody.
There were no paraphasic errors.
Speech is reportedly somewhat dysarthric.
Able to follow both midline and appendicular commands.
No evidence of apraxia or neglect.
CN:
II: PERRLA 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI, no nystagmus. Normal saccades.
V: Sensation intact to LT.
VII: Facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate rise symmetric.
XI: Trapezius and SCM ___ bilaterally.
XII: Tongue protrudes midline.
Motor:
Normal bulk, tone is increased in the RUE>LUE, cogwheeling noted
at the wrists bilaterally. Mild downward drift of both arms
without pronation.
No adventitious movements. No asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ 5 5 * * * * * *
R ___ ___ ___ ___ 5 5
*unable to assess left leg due to severe pain from pressure
ulcer
Sensory: No deficits to light touch, pinprick throughout. No
extinction to DSS.
Reflexes:
Bi Tri ___ Pat Ach
L ___ 2 1
R ___ 2 1
Brisk withdrawal of toes bilaterally
Coordination:
No tremor observed. Dysdiadochokinesia noted on left FNF.
============================
DISCHARGE PHYSICAL EXAM
============================
General examination unchanged apart from normalization of blood
pressure.
NEURO EXAM:
Mental status and cranial nerve examination unchanged apart from
improvement in dysarthria.
Motor:
Normal bulk and tone, mild cogwheeling noted at the wrists
bilaterally. No drift. No adventitious movements. No asterixis.
Strength is grossly 4+ in the bilateral upper extremities and
right lower extremity, partially due to effort. Strength is 3 in
left lower extremity due to burning sensation limiting movement.
Sensory: No deficits to light touch, pinprick throughout. No
extinction to DSS.
Reflexes:
Bi Tri ___ Pat Ach
L ___ 2 1
R ___ 2 1
Toes extensor bilaterally
Coordination:
No tremor observed. Dysdiadochokinesia and dysynergia noted on
left > right finger-nose-finger.
Gait:
Deferred
Pertinent Results:
=======
LABS
=======
___ 02:10AM BLOOD CK-MB-2 cTropnT-<0.01
___ 02:10AM BLOOD %HbA1c-5.3 eAG-105
___:10AM BLOOD Triglyc-71 HDL-40 CHOL/HD-3.6 LDLcalc-90
___ 02:10AM BLOOD TSH-19*
___ 07:10AM BLOOD Free T4-1.3
==========
IMAGING
==========
NCHCT (___):
Acute left cerebellar intraparenchymal hemorrhage with
surrounding edema.
Small amount of hemorrhage layering within the lateral
ventricles. Mild
effacement of the fourth ventricle without hydrocephalus.
Underlying mass is not excluded on this study and can be further
evaluated with an MRI.
Echo (___):
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is high normal. There is no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Mildly dilated ascending aorta. No definite structural cardiac
source of embolism identified.
MRI HEAD WITH AND WITHOUT CONTRAST (___):
1. Left cerebellar hemispheric hemorrhage with mild mass effect
on the fourth ventricle, but no evidence of hydrocephalus or
herniation,
2. No definite underlying mass or evidence of cerebral venous
thrombosis.
3. No large flow voids in the region of the hemorrhage to
indicate a large underlying vascular malformation.
Re-evaluation can be performed after resolution of blood
products, which may require ___ weeks. However, given the
scattered foci of susceptibility representing micro-bleeds, in
quite typical locations, hypertensive hemorrhage is the likely
etiology of both current and previous hemorrhage.
CTA HEAD WITH AND WITHOUT CONTRAST (___):
1. Stable left cerebellar intraparenchymal hematoma with
layering
intraventricular hemorrhage within the posterior horns of the
lateral
ventricles.
2. No evidence of new intracranial hemorrhage or mass effect.
3. No evidence of hemodynamically significant stenosis or
aneurysm within the arterial vasculature of the head.
CT ABDOMEN AND PELVIS (___):
1. No evidence of focal pancreatic lesion.
2. Diverticulosis without diverticulitis.
MRI L, T, C-SPINE WITHOUT CONTRAST (___):
1. Degenerative disc and joint disease of the lumbar spine
superimposed on congenital spinal canal stenosis. The worst
level of spondylosis is at L4-5 where there is impingement of
the bilateral L5 nerve roots, right greater than left.
2. No disc herniation of the thoracic spine.
3. Small disc herniations at C3-4 and C6-7 but without cord
contact.
4. Left cerebellar hemorrhage, not significantly changed from
recent MRI on ___.
Brief Hospital Course:
___ is a ___ year old woman with a past medical
history of hypothyroidism and recent diagnosis of ___
disease who presented to the ___ ED ___ with worsening
dizziness, nausea and slurred speech over 1 week. ___ showed a
left cerebellar intraparenchymal hemorrhage. Neurosurgery was
consulted who deferred to medical management. Ms. ___ was
consquently admitted to the neurology stroke service for further
management.
Etiology of the intraparenchymal hemorrhage was investigated
during Ms. ___ hospitalization. As her blood pressure
was found to be 220/100 at outside hospital at initial
presentation 1 week prior to admission (see HPI for details),
hypertension was believed to be the likely contributing factor.
Upon admission to ___, blood pressure was only found to be
elevated to 159/82 but did fluctuate during hospitalization. She
was started on lisinopril with blood pressure control (SBP <
140) at time of discharge.
To rule out other factors, Ms. ___ also underwent an
echo, CT abdomen and pelvis, CTA head and MRI head. Echo did not
show any ASD, PFO, or clot. CT abdomen and pelvis did not show
any malignancy; there was no pancreatic lesion visualized. The
CTA head did not show any AVM or aneurysm. MRI head did not show
definite underlying mass, cerebral venous thrombosis or large
underlying vascular malformation. Ms. ___ was scheduled
for a repeat MRI at time of discharge to confirm these findings
following the resolution of the blood products. She also had a
LDL of 90 and hemoglobin A1C of 5.3%. Telemetry did not show any
arrhythmias.
For her history of newly diagnosed ___ disease, she was
started on Sinemet during hospitalization. She was started on
0.5 tab TID and this was increased to 1 tab TID at time of
discharge. This medication was gradually helping to decrease
tone and improve bradykinesia at time of discharge.
Ms. ___ also described persistent, chronic left lower
extremity burning pain which sounded like sciatica. As she had
an episode of bowel incontinence, she underwent an MRI of the
L-, C- and T-spine. This MRI showed lumbar spondylosis and
congenital spinal canal stenosis with no concern for cord
compression. She was started on gabapentin for pain at time of
discharge; this medication can be increased gradually to a goal
of 200 mg TID over weeks.
Ms. ___ was continued on her home levothyroxine while in
the hospital. TSH was checked and found to be elevated to 19
with a normal free T4 of 1.3. She will need these values
re-checked as an outpatient.
On day of discharge, Ms. ___ was feeling improved and
eager to leave the hospital. Her presenting symptoms had
resolved and she worked with physical therapy.
=====================
TRANSITIONS OF CARE
=====================
-TSH was elevated to 19 and free T4 was normal at 1.3. Will need
repeat thyroid function tests in 6 wks.
-Has repeat MRI scheduled for ___. This will further evaluate
for mass or AVM following resolution of blood products.
-She was started on gabapentin 100mg BID. Please increase
gradually by 100mg every 5 days to a goal of 200mg TID.
-She was started on lisinopril 10mg daily for blood pressure
control.
-She was started on Sinemet 1 tab TID for new diagnosis of
___, please further adjust as an outpatient.
====================================================
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?
(X) Yes - () 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. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Carbidopa-Levodopa (___) 1 TAB PO TID
3. Gabapentin 100 mg PO BID
4. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Left cerebellar intraparenchymal hemorrhage
Secondary diagnoses:
Hypertension
___ disease
Spondylosis of lumbar spine
Small disc herniations cervical spine
Hypothyroidism
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 hospitalized due to symptoms of dizziness, nausea and
slurred speech resulting from a brain bleed, 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 being deprived of its blood supply can result in a variety
of symptoms.
Brain bleeds can have many different causes, so we assessed you
for medical conditions that might raise your risk of having this
again. In order to prevent future brain bleeds, we plan to
modify those risk factors.
Your risk factors are:
High blood pressure
We are changing your medications as follows:
Starting lisinopril for blood pressure control
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. We wish you all the best!
Followup Instructions:
___
|
10053810-DS-10 | 10,053,810 | 26,647,692 | DS | 10 | 2164-09-16 00:00:00 | 2164-09-16 15:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
dapagliflozin
Attending: ___.
Chief Complaint:
Abnormal head CT, nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ year old active woman with diabetes
type 2, hypertension, atrial fibrillation on eliquis, mild
cognitive decline (presumed), who presents as
hospital-to-hospital transfer for evaluation of abnormal finding
on head CT. History obtained by patient and patient's daughter
and niece at bedside.
Per patient (who digresses quite a bit on conversation), she was
feeling well up until about 4 days ago when she became nauseous
and started to vomit. She thought she had a stomach bug because
she just was not feeling well at all and didn't even good enough
to get up out of bed to dust the TV. The patient cannot say if
her symptoms suddenly came on. She does endorse some double
vision when she does not wear her glasses that "comes and goes"
and "gets better" after she puts her glasses on. Additional
details regarding nausea and vomiting limited as patient
continues to digress in conversations.
Her daughter notes that she last saw her mother 5 days ago for
___. She had picked her mother up to celebrate
Thanksgiving with the family down at the ___. During that week,
while she was watching her mother throughout the day she noticed
that her mother's word-finding difficulty was worse and that her
appetite was significantly decreased. She also noted that her
mother's gait was worse, wobbling to both the left and the right
despite use of a cane. The daughter does note that this decline
has been ongoing for the past several months, however despite
this decline the patient is completely independent at home and
continues to work 15 hrs a week at Stop and Shop and continues
to
drive at night. When asked to elaborate on the decline over the
last few months, the daughter notes a slow decline in the
patient's word-finding difficulty, disorientation to day and
month sometimes. She also notes a ___ weight loss over the
past ___ months.
ROS challenging as patient continues to digress without clarity
of specific details regarding timing/intensity of symptoms
noted.
She does endorse transient double vision that resolves with
wearing glasses, nausea that has subsided, and denies vertigo.
She had a frontal throbbing headache but that has since
resolved.
She thinks her gait is steady with her cane.
Her daughter notes that several weeks ago the patient broke out
in a rash in her thighs that resolved with a 14d course of
doxycycline.
Regarding cancer history/risk factors, the patient is a former
smoker but quit ___ years ago. She has never carried a diagnosis
of cancer.
At OSH, she was noted to be hypochloremic (97) and
hypomagnesemic
(1.4), which was corrected with electrolyte repletion.
Past Medical History:
diverticulitis s/p surgery
diabetes
atrial fibrillation
hypertension
hyperlipidemia
bilateral cataract repair
bilateral hip repair ___ years ago)
Social History:
___
Family History:
Sister with skin cancer and then glioblastoma diagnosed at the
age of ___
Brother with throat cancer and then died of brain tumor ___ years
later
Physical Exam:
Vitals: T97.6, HR80-110, BP119/70, RR17, 98RA glucose 222
General: Awake, cooperative, appears younger than stated age
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: irregular rate, warm and well-perfused
Abdomen: Soft, non-distended.
Extremities: trace bipedal edema
Skin: inner thighs with maculopapular rash that appears to be
resolving (confirmed with daughter that looks better than in
prior days)
Neurologic:
-Mental Status: Alert, oriented to name, location (hospital in
___ but not ___, ___ but not date. Able
to relate general history but with significant digressions in
story, taking time to describe how she felt too tired to dust
the
TV then noting that it didn't matter because "they are coming to
see her and not the TV" and then telling me how kind they are to
visit her and proceeding to elaborate on her family support
network. ___ forward is rapid. ___ backwards is slower and the
patient only reaches ___ and then digresses. She is able
to
follow two-step commands. Has ocassional paraphasic errors,
referring to "novels" regarding the book she likes to read as
"novelities." Repetition intact. Normal prosody. Able to name
both high frequency objects but some errors with low-frequency
objects. No dysarthria. Able to follow both midline and
appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
post cataract surgery bilateral, PERRL 2>1 and sluggish, EOMI no
nystagmus, no ptosis, face appears symmetric hearing diminished
to conversation tongue deviates to right, uvula deviates to
right
right pupil, dysmetria on left finger.
-Motor: Decreased bulk, normal tone. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
**Full
confrontational strength testing limited largely by best effort
but to best of ability, patient gives symmetric resistance
throughout.
[___]
L 5 5 5 5 5 5 4 4 4 4 5 5
R 5 5 5 5 5 5 4 4 4 4 5 5
-Sensory: Diminished sensation to pinprick in stocking-glove
pattern. Light touch, temperature, vibratory sense intact.
-Reflexes: Plantar response was flexor bilaterally.
-Coordination: Dysmetria on left FNF, left HKS. Diminished
amplitude with fast movements on left hand.
-Gait: Deferred secondary to fatigue (patient refused) and
absence of cane at bedside. No leaning to one side with sitting
on bed with eyes closed.
====================================
DISCHARGE
Vitals: Tm/c: 99.1 BP: 107/49 HR: 60 RR: 22 SaO2: 99
General: Awake, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: skin warm, well-perfused.
Extremities: Symmetric, no edema.
Neurologic:
-Mental Status: Awake, alert, and oriented to person and time,
but thinks she is at a hospital in ___. Attentive, able to
name ___ forward and backward without difficulty. Language is
fluent with intact comprehension and slightly impaired
repetition
("no ifs ands and buts"). There were no paraphasic errors.
Naming
intact to high and low frequency objects. Able to follow both
midline and appendicular commands.
-Cranial Nerves: PERRL. EOMI without nystagmus. Facial sensation
intact to light touch. Face symmetric at rest and with
activation. Hearing impaired bilaterally to conversation. Palate
elevates symmetrically. Tongue protrudes in midline. No
dysarthria.
-Motor: Decreased bulk. No adventitious movements, such as
tremor, noted. Remainder of exam deferred.
-Sensory: Deferred.
-DTRs: ___.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Patient able to walk evenly with assistance on either
side. No wide-based gait or unsteadiness inconsistent with
muscle
bulk noted.
Pertinent Results:
___ 07:29PM BLOOD WBC-4.6 RBC-3.71* Hgb-12.6 Hct-37.0
MCV-100* MCH-34.0* MCHC-34.1 RDW-13.6 RDWSD-49.5* Plt ___
___ 05:08AM BLOOD WBC-4.8 RBC-3.47* Hgb-11.8 Hct-35.9
MCV-104* MCH-34.0* MCHC-32.9 RDW-14.4 RDWSD-54.4* Plt ___
___ 07:29PM BLOOD ___ PTT-27.5 ___
___ 12:40PM BLOOD ___ PTT-26.5 ___
___ 05:08AM BLOOD ___ PTT-27.1 ___
___ 07:29PM BLOOD Glucose-230* UreaN-20 Creat-0.7 Na-133*
K-4.1 Cl-99 HCO3-22 AnGap-12
___ 12:40PM BLOOD Glucose-240* UreaN-21* Creat-0.7 Na-137
K-4.7 Cl-101 HCO3-26 AnGap-10
___ 06:40AM BLOOD Glucose-299* UreaN-30* Creat-0.7 Na-137
K-4.9 Cl-103 HCO3-25 AnGap-9*
___ 05:08AM BLOOD Glucose-257* UreaN-34* Creat-1.0 Na-139
K-4.9 Cl-104 HCO3-28 AnGap-7*
___ 12:40PM BLOOD ALT-8 AST-11 LD(LDH)-160 CK(CPK)-15*
AlkPhos-67 TotBili-0.6
___ 12:40PM BLOOD GGT-15
___ 07:29PM BLOOD Lipase-20
___ 07:29PM BLOOD CK-MB-2 cTropnT-<0.01
___ 12:40PM BLOOD CK-MB-1 cTropnT-<0.01
___ 07:29PM BLOOD Albumin-3.6 Calcium-9.1 Phos-2.9 Mg-1.7
___ 12:40PM BLOOD Albumin-3.3* Cholest-102
___ 05:08AM BLOOD Phos-2.6* Mg-1.6
___ 12:40PM BLOOD %HbA1c-9.4* eAG-223*
___ 12:40PM BLOOD Triglyc-79 HDL-53 CHOL/HD-1.9 LDLcalc-33
___ 07:29PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 07:40PM BLOOD Lactate-1.5
CTA HEAD ___
FINDINGS: CT HEAD WITHOUT CONTRAST: A 3 x 3.7 cm intra-axial
hypodense focus is seen in the left cerebellar hemisphere
exerting mass effect on the adjacent fourth ventricle without
evidence of associated hydrocephalus. Subtle hyperdensity within
the left cerebellar hemisphere lesion suggests possible
underlying microhemorrhage. The ventricles and sulci are
prominent, consistent global cerebral volume loss. Patchy
periventricular hypodensities are most consistent with chronic
microvascular ischemic disease. The left mastoid air cells are
underpneumatized with a small effusion. The visualized portion
of the paranasal sinuses,right mastoid air cells,andbilateral
middle ear cavities are clear. The visualized portion of the
orbits demonstrates sequela of prior bilateral cataract surgery.
CTA HEAD: Infundibular origin of the right posterior cerebral
artery. Otherwise, the vessels of the circle of ___ and their
principal intracranial branches appear normal without stenosis,
occlusion, or aneurysm formation. The dural venous sinuses are
patent. CTA NECK: Atherosclerotic changes of the carotid
bifurcations are seen without narrowing of the internal carotid
arteries, by NASCET criteria. Mild atherosclerotic disease
narrows the origin of the left common carotid and vertebral
arteries. The vertebral arteries appear otherwise unremarkable
with no evidence of stenosis or occlusion. The bilateral
subclavian arteries are unremarkable allowing for mild
atherosclerotic disease.
OTHER: The visualized portion of the lungs demonstrates an 8 mm
nodule in the right upper lobe, is seen on the prior chest
x-ray. A smaller 2 mm right upper lobe nodule also noted. A
multinodular goiter is seen, with largest nodule measuring
approximately 2.0 cm on the left.. There is no lymphadenopathy
by CT size criteria.
IMPRESSION:
1. 3 x 3.7 cm intra-axial hypodense focus in the left cerebellar
hemisphere likely represents a late acute to subacute infarct.
No large hemorrhage identified. Possible microhemorrhages within
the region of infarct.
2. Allowing for atherosclerotic disease, essentially
unremarkable CTA of the head and neck. No evidence of occlusion.
No stenosis of the cervical internal carotid arteries by NASCET
criteria.
3. 8 mm nodule in the right upper lobe. A smaller 2 mm right
upper lobe nodule also noted.
4. Multinodular goiter. Largest discrete nodule appears to be
approximately 2 cm in the left lobe.
5. Small left mastoid effusion.
RECOMMENDATION(S): For incidentally detected single solid
pulmonary nodule measuring 6 to 8 mm, a CT follow-up in 6 to 12
months is recommended in a low-risk patient, optionally followed
by a CT in ___ months. In a high-risk patient, a CT follow-up
in 6 to 12 months, and a CT in ___ months is recommended. See
the ___ ___ Guidelines for the Management of
Pulmonary Nodules Incidentally Detected on CT" for comments and
reference: ___ Thyroid
nodule. Ultrasound follow up recommended. ___ College of
Radiology guidelines recommend further evaluation for incidental
thyroid nodules of 1.0 cm or larger in patients under age ___ or
1.5 cm in patients age ___ or ___, or with suspicious findings.
Suspicious findings include: Abnormal lymph nodes (those
displaying enlargement, calcification, cystic components and/or
increased enhancement) or invasion of local tissues by the
thyroid nodule.
MRI BRAIN ___
IMPRESSION:
1. 4 x 5 x 2.3 cm left cerebellar hemisphere focus of diffusion
and gradient echo susceptibility artifact, felt to be most
compatible with late acute infarct in hemorrhagic
transformation. Associated linear foci of enhancement,
predominantly located within the cerebellar folia is felt to be
secondary to luxury perfusion rather than nodular enhancement of
underlying mass lesion.
2. Associated edema pattern results in mass effect and mild
effacement of the fourth ventricle. No definite evidence of
hydrocephalus. The size of the ventricles are unchanged from
outside hospital examination of ___.
3. Recommend repeat MRI head with without contrast in
approximately 1 month to document stability or resolution of
linear enhancement to exclude underlying lesion.
4. Additional findings as described above.
TTE ___
CONCLUSION: The left atrial volume index is mildly increased.
The right atrium is mildly enlarged. There is no evidence for an
atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is ___ mmHg. There is normal left ventricular
wall thickness with a normal cavity size. There is normal
regional and global left ventricular systolic function. No
thrombus or mass is seen in the left ventricle. Quantitative 3D
volumetric left ventricular ejection fraction is 63 %. There is
a mild (peak 10 mmHg) resting left ventricular outflow tract
gradient. No ventricular septal defect is seen. Tissue Doppler
suggests an increased left ventricular filling pressure (PCWP
greater than 18mmHg). There is echocardiographic evidence for
diastolic dysfunction (grade indeterminate). Normal right
ventricular cavity size with normal free wall motion. The aortic
sinus diameter is normal for gender with normal ascending aorta
diameter for gender. There is a normal descending aorta
diameter. There is no evidence for an aortic arch coarctation.
The aortic valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. There is no aortic
valve stenosis. There is no aortic regurgitation. The mitral
valve leaflets are mildly thickened with no mitral valve
prolapse. No masses or vegetations are seen on the mitral valve.
There is trivial mitral regurgitation. The tricuspid valve
leaflets appear structurally normal. No mass/vegetation are seen
on the tricuspid valve. There is mild to moderate [___]
tricuspid regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular wall thickness, cavity size,
and regional/global systolic function. Increased PCWP. Diastolic
dysfunction. Mild to moderate tricuspid regurgitation. Mild
pulmonary artery systolic hypertension.
MR PERFUSION ___
FINDINGS: Again seen is cerebellar abnormality on T1
postcontrast images, stable since yesterday. ASL Perfusion:
There is decreased perfusion in the left inferior cerebellar
hemisphere corresponding to the left cerebellar hemisphere
infarct identified on brain MRI 1 day prior.. MR Spectroscopy:
Relatively preserved spectroscopy pattern, no evidence of tumor
spectra.
IMPRESSION: Findings consistent with left cerebellar infarct.
Brief Hospital Course:
Ms. ___ is a ___ year old right-handed female with a h/o
afib on eliquis, TIIDM, and HTN who presents with ___ days of
nausea, unsteady gait, and word finding difficulty and was
transferred to ___ from OSH after abnormal findings on NCHCT.
#Left intrapernchymal cerebellar lesion
The patient complains of nausea and gait disturbance lasting ___
days, and the patient's daughter began to notice word finding
difficulty and gait disturbance during this same period. The
patient's daughter also reported that the patient has been
declining cognitively and lost approximately 15 pounds over the
past several months. The patient's family history is notable for
two incidences of brain cancer, with one confirmed GBM. The
patient's physical exam did not provide any localizing or
alarming findings, demonstrating minor ataxia that has improved
since admission, and the patient is now able to ambulate with
assistance. Initial NCHCT showed a hypodense focus in the left
cerebellar hemisphere, and CTA did not show any evidence of an
occlusion in the head or neck. MRI w/ and w/o contrast showed a
left cerebellar hemisphere lesion with restricted diffusion and
gradient echo susceptibility. F/u MR perfusion scanning
demonstrated hypoperfusion in that region and did not show any
evidence of tumor spectra. This lesion most likely represents a
subacute venous infarct with surrounding edema and hemorrhagic
transformation given the hypoperfusion on MR spectroscopy and
preserved spectroscopy pattern. Mass unlikely, Abscess/infection
is unlikely given lack of elevated WBC or fever/constitutional
symptoms. Stroke risk factor labs show HbA1c 9.4, LDL 33.
-Repeat MRI 2 weeks after discharge to monitor concerning
changes
in lesion (e.g. continued bleed, change in morphology that could
suggest mass)
-Hold Eliquis for 2 weeks, continue ASA
#Cognitive decline
-Patient has inattention, difficulty with recall. Will need more
thorough mental status/memory/cognition work-up and rehab after
discharge.
#Afib:
-Eliquis held, aspirin continued. This should be re-started
AFTER a repeat MRI brain is done in about 2-weeks if the
hemorrhage is stable/improved. Her atenolol was decreased from
50mg to 12.5mg daily due to bradycardia.
#Diabetes:
-The patient was initially started on steroids (decadron) when
this lesion was thought to be a mass. Her sugars prior to even
starting the steroids however were also elevated and her A1C was
elevated at 9.4.
-A ___ diabetes consult was placed as her glucose levels were
still elevated on a sliding scale insulin regiment and she was
discharged on insulin
#Gait unsteadiness:
-Due to cerebellar stroke, ___ recommended rehab
Transitional Issues:
-Follow blood sugars very carefully
-Repeat MRI in 2 weeks before starting Eliquis
-Follow-up with Neurology
-Incidental pulmonary and thyroid nodules found on CT, follow-up
with PCP for further ___ imaging
==========================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL =33 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? () Yes - (x) No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[x ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No - If no, why not (I.e.
bleeding risk, etc.) () N/A - bleeding risk due to hemorrhagic
conversion of ischemic infarct
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 2.5 mg PO BID
2. Atenolol 50 mg PO DAILY
3. Donepezil 5 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. WelChol (colesevelam) 6.25 gram oral BREAKFAST
Discharge Medications:
1. Glargine 12 Units Bedtime
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using REG Insulin
2. Atenolol 12.5 mg PO DAILY
3. Donepezil 5 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. WelChol (___) 6.25 gram oral BREAKFAST
6. HELD- Apixaban 2.5 mg PO BID This medication was held. Do
not restart Apixaban until after your doctor says it is okay
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute cerebellar infarct with hemorrhagic conversion
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ because you were having difficulty
walking, nausea, and some confusion resulting from an ACUTE
ISCHEMIC STROKE, a condition where a blood vessel providing
oxygen and nutrients to the brain is blocked by a clot. The
brain is the part of your body that controls and directs all the
other parts of your body, so damage to the brain from being
deprived of its blood supply can result in a variety of
symptoms.
You went to an outside hospital where a cat scan of your brain
was done which showed a worrisome lesion. You then were
transferred to ___ in ___ where we ran two more tests
including two MRI brain scans. We initially thought that the
lesion in your brain could have been a mass but on further
testing the finding is more consistent with a stroke.
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:
ATRIAL FIBRILLATION
DIABETES
HYPERLIPIDEMIA
HYPERTENSION
We are worried that you were not taking your medications because
your sugar was also high in your blood, therefore we have
started you on INSULIN. Your heart rate was low and your blood
pressure was good while you were in the hospital, so we
decreased your ATENOLOL from 50mg daily to 12.5mg daily.
You worked with physical therapy who recommended rehab to get
you better and safe as you had this stroke affecting your
balance.
In two weeks we would like to repeat a scan to ensure that your
stroke is improving. In the meantime, do not re-start the
eliquis (apixaban) until the scan is done. Once the repeat brain
scan has been completed, your facility should re-start the blood
thinner at that time.
Thank you for involving us in your care.
Sincerely,
___ Neurology
Followup Instructions:
___
|
10054622-DS-4 | 10,054,622 | 20,480,182 | DS | 4 | 2155-05-09 00:00:00 | 2155-05-11 16:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Pelvic cramping
Major Surgical or Invasive Procedure:
Dilation and curettage
Physical Exam:
Discharge physical exam
Vitals: VSS
Gen: NAD, A&O x 3
CV: RRR
Resp: no acute respiratory distress
Abd: soft, appropriately tender, no rebound/guarding
Ext: no TTP
Pertinent Results:
LABS
====================
___ 03:15AM BLOOD WBC-5.5 RBC-3.07* Hgb-8.7* Hct-26.0*
MCV-85 MCH-28.3 MCHC-33.5 RDW-13.8 RDWSD-42.3 Plt Ct-87*
___ 07:16AM BLOOD WBC-6.1 RBC-2.90* Hgb-8.3* Hct-24.5*
MCV-85 MCH-28.6 MCHC-33.9 RDW-13.6 RDWSD-42.4 Plt Ct-74*
___ 07:50PM BLOOD WBC-8.8 RBC-3.22* Hgb-9.3* Hct-27.0*
MCV-84 MCH-28.9 MCHC-34.4 RDW-13.5 RDWSD-41.2 Plt Ct-64*
___ 02:25PM BLOOD WBC-13.5* RBC-3.51* Hgb-10.1* Hct-30.0*
MCV-86 MCH-28.8 MCHC-33.7 RDW-13.5 RDWSD-41.6 Plt Ct-75*
___ 08:50AM BLOOD WBC-18.5* RBC-3.94 Hgb-11.4 Hct-33.6*
MCV-85 MCH-28.9 MCHC-33.9 RDW-13.5 RDWSD-41.7 Plt Ct-86*
___ 07:00PM BLOOD WBC-14.9*# RBC-3.88* Hgb-11.4 Hct-32.9*
MCV-85 MCH-29.4 MCHC-34.7 RDW-13.2 RDWSD-40.3 Plt Ct-92*
___ 07:16AM BLOOD Neuts-78.7* Lymphs-12.0* Monos-8.2
Eos-0.3* Baso-0.3 Im ___ AbsNeut-4.80 AbsLymp-0.73*
AbsMono-0.50 AbsEos-0.02* AbsBaso-0.02
___ 07:50PM BLOOD Neuts-73* Bands-21* Lymphs-5* Monos-1*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-8.27*
AbsLymp-0.44* AbsMono-0.09* AbsEos-0.00* AbsBaso-0.00*
___ 07:00PM BLOOD Neuts-84.2* Lymphs-8.7* Monos-6.1
Eos-0.3* Baso-0.2 Im ___ AbsNeut-12.52*# AbsLymp-1.29
AbsMono-0.90* AbsEos-0.05 AbsBaso-0.03
___ 07:50PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-2+ Polychr-NORMAL
___ 07:50PM BLOOD Plt Smr-VERY LOW Plt Ct-64*
___ 03:15AM BLOOD Plt Ct-87*
___ 07:16AM BLOOD Plt Ct-74*
___ 02:25PM BLOOD Plt Ct-75*
___ 08:50AM BLOOD Plt Ct-86*
___ 08:50AM BLOOD ___ PTT-27.1 ___
___ 07:00PM BLOOD Plt Smr-LOW Plt Ct-92*
___ 07:00PM BLOOD Glucose-83 UreaN-7 Creat-0.4 Na-135 K-3.5
Cl-99 HCO3-24 AnGap-16
___ 07:00PM BLOOD Genta-<0.2*
___ 07:50PM BLOOD Lactate-1.5
___ 09:00AM BLOOD Lactate-1.3
___ 09:00AM BLOOD Hgb-12.3 calcHCT-37
___ 08:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:35PM URINE Color-Yellow Appear-Hazy Sp ___
___ 08:30PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 06:35PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 08:30PM URINE RBC->182* WBC-6* Bacteri-FEW Yeast-NONE
Epi-<1
MICROBIOLOGY
====================
___ 9:50 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 8:30 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
BETA STREPTOCOCCUS GROUP B. 10,000-100,000 CFU/mL.
___ 7:50 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
___ 6:35 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING
====================
___ Pelvic Ultrasound
Final Report
EXAMINATION: EARLY OB US <14WEEKS
INDICATION: ___ G2P0 @ 12w p/w abdominal pain// eval for ___
trimester
pregnancy
LMP: ___
TECHNIQUE: Transabdominal and transvaginal examinations were
performed.
Transvaginal exam was performed for better visualization of the
embryo.
COMPARISON: None.
FINDINGS:
An intrauterine gestational sac is seen and a single living
embryo is
identified with a crown rump length of 62 mm representing a
gestational age of
12 weeks 5 days. This corresponds satisfactorily with the
menstrual dates of
12 weeks 2 days. The uterus is normal. The ovaries are normal.
There is funnel shaped dilation of the cervix measuring 7 mm at
its widest
point, at the internal os.
IMPRESSION:
1. Single live intrauterine pregnancy with size = dates.
2. Cervical dilation measuring up to 7 mm at its widest point,
at the internal os.
___ Pelvic Ultrasound
Final Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: ___ w/ SAB. Evaluate for retained placenta. Most
fetal tissue has passed.// ___ w/ SAB. Evaluate for retained
placenta. Most fetal tissue has passed.
TECHNIQUE: Grayscale ultrasound images of the pelvis were
obtained with
transabdominal approach followed by transvaginal approach for
further
delineation of uterine and ovarian anatomy.
COMPARISON: Pelvic ultrasound ___.
FINDINGS:
The uterus is anteverted. Previously noted gestational sac and
fetus are no longer present. The endometrial cavity is
distended with heterogeneous
echogenic material, with vascularized products seen posteriorly
at the level of the uterine body, measuring at least 5.3 x 3.8
cm in transverse ___, compatible with vascularized
retained products of conception. In addition, there is
heterogeneous echogenic material without vascularity in the
endocervical canal concerning for blood products.
Small amount of free fluid in the pelvis. Normal ovaries
bilaterally.
IMPRESSION:
Findings consistent with vascularized retained products of
conception
measuring at least 5.3 x 3 8 cm in transverse ___ with
additional
echogenic blood products in the endocervical canal. Small
amount of free
fluid.
Brief Hospital Course:
Ms. ___ is a ___ yo G3P0 who presented to the ED at 12weeks
gestational age with cramping. She underwent a pelvic ultrasound
on ___ which demonstrated a live single intrauterine pregnancy.
While in the ED, she developed worsening cramping and vaginal
bleeding, and she passed fetal tissue. Repeat pelvic ultrasound
revealed retained products of conception.
In the ED, pt was noted to be tachycardic (HR max 117) with Tmax
100.2. Her labs were notable for increasing leukocytosis (14 ->
18), thought to be secondary to an inflammatory reaction to her
miscarriage (differential included uterine infection i.e.
endometritis). The decision was made to proceed with a dilation
and curettage for complete removal of pregnancy tissue.
On ___ Ms. ___ underwent an uncomplicated
ultrasound-guided dilation and curettage. Please refer to the
operative note for full details. She had an estimated blood loss
of 350mL and received methergine and cytotec intraoperatively.
She was continued on PO methergine for 24 hours
post-operatively. She also received IV doxycycline
intra-operatively due to concern for developing endometritis.
Her hematocrit was trended: 33.6 (pre-operative) -> 30.0 (PACU)
-> 24.5 (post-operative day #1)-> 26 (post-operative day #2
am).
Her post-operative course was complicated by fever and
thrombocytopenia:
- Fever: Pt spiked a fever to 103.1 on post-operative day #1.
Her CBC at the time was notable for WBC 8.8 with 21 bands. UA
was negative for UTI. She was treated for presumed endometritis,
and received IV gentamicin and IV clindamycin for 24 hours
(___). She was then transitioned to PO doxycycline and PO
flagyl.
- Thrombocytopenia: Pt was noted to have downtrending platelets,
with nadir of 64 (___), thought due to ITP vs. gestational
thrombocytopenia. Her vaginal bleeding was minimal following the
procedure, and her platelet count improved prior to discharge
(platelet=87 on ___. NSAIDs were held during this admission in
the setting of thrombocytopenia.
Thee remainder of her post-operative course was uncomplicated.
She received PO Tylenol and oxycodone prn pelvic pain. Her diet
was advanced without difficulty. She voided spontaneously on
post-operative day #0.
By hospital day #2, pt was tolerating a regular diet, voiding
spontaneously, ambulating independently, and her pain was
well-controlled with oral medications. She was discharged to
home with outpatient follow-up scheduled.
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
do not exceed 4000mg in 24 hours
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*30 Tablet Refills:*1
2. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*1
3. Doxycycline Hyclate 100 mg PO Q12H Duration: 7 Days
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice daily
Disp #*14 Tablet Refills:*0
4. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate [___] 325 mg (65 mg iron) 1 tablet(s)
by mouth daily Disp #*60 Tablet Refills:*1
5. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth twice
daily Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Retained products of conception
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the gynecology service after your
procedure. You have recovered well and the team believes you are
ready to be discharged home. Please call Dr. ___ office with
any questions or concerns. Please follow the instructions below.
General instructions:
* Take your medications as prescribed.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* Please avoid NSAIDs (ex. ibuprofen) in the setting of your low
platelet counts
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation.
* Do not combine narcotic and sedative medications or alcohol.
* No strenuous activity until your post-op appointment.
* Nothing in the vagina (no tampons, no douching, no sex) until
your post-operative appointment
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* You may walk up and down stairs.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
10054634-DS-8 | 10,054,634 | 25,928,444 | DS | 8 | 2181-01-28 00:00:00 | 2181-02-01 10:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Demerol / morphine
Attending: ___
Chief Complaint:
generalized weakness, muscle aches, intermittent fevers, sore
throat and wakes up with HA, now with + BCx
Major Surgical or Invasive Procedure:
TEE (___)
PICC line Insertion (___)
History of Present Illness:
Patient is a ___ M with PMH HLD, duodenal ulcer c/b GIB, and
BPH who presents with chills, HA, and positive blood cultures.
6 weeks ago ___ developed, waxing and waning, generalized
muscle aches, with subjective chills but no objective fever.
bifrontal mild headache without other associated neurological
signs. No recent travel other than ___ and upstate ___.
No history of IVDU. He had a dental cleaning 2 weeks ago after
the onset of symptoms. He did have a colonoscopy 4 days prior to
developing symptoms.
Per referral: Pt has gram positive cocci growing out of each
anaerobic blood culture (two sets were drawn) after 14 hours. He
presented with 7 weeks of headache, fatigue and myalgias.
ESR=42. Has dropped his HCT to ___ yesterday from 41 on ___. I
consulted with ID who recommended ED eval and likely admit for
repeat cx, r/o endocarditis and imaging of head (given headache
and concern for mycotic aneurysm) and abdomen to look for a
source. He did have a colonoscopy with polypectomy on ___. He
had dental cleaning after the onset of his sx.
In the ED, initial VS were 4 98.3 92 115/70 16 98% RA .
Exam notable for:
Exam normal neuro, rectal heme negative
___ soft systolic murmur in RUSB.
Labs showed Hgb 12.5.
Imaging showed:
CXR
No acute cardiopulmonary process.
Head CT
No acute intracranial process.
Received vanc/cefazolin
Transfer VS were 75 122/66 18 98% RA
On arrival to the floor, patient reports that he has been having
myalgias and HA x 6 weeks on and off. He endorses slight fever.
His HA is mild, dull, all over, and occurs in the mornings but
does not wake him up. No associated photophobia, phonophobia,
neck stiffness, blurry vision, dizziness, or nausea. Tylenol
helps.
He also endorses various wandering muscle pains but no joint
pains. He was tested for lyme but it was negative and he denies
tick exposure. He did have a colonoscopy around the time his sx
started but denies abdominal pain, constipation, or diarrhea. HE
denies chest pain or dizziness. He denies trauma or sick
contacts.
REVIEW OF SYSTEMS:
(+)PER HPI
Past Medical History:
Hypercholesterolemia
Rhinitis, allergic
Duodenal ulcer with hemorrhage
Dermatitis, seborrheic
Serrated adenoma of colon
Sleep disturbance
BPH (benign prostatic hyperplasia)
Cholecystectomy (___)
Social History:
___
Family History:
Mother with ___. Father with hairy cell leukemia &
stroke. MI in maternal uncle and MGM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.4 PO 141 / 74 70 16 95 RA
GENERAL: Pleasant, alert, NAD . Appears younger than stated age
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, oropharynx clear
NECK: supple, intact chin-to-chest, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, + RUQ scar
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
VS: 98.4PO 116/64 R 74 18 96 Ra
GENERAL: Pleasant, alert, NAD. Appears younger than stated age
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, oropharynx clear
NECK: supple, no LAD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, + RUQ scar
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
==============
___ 02:01PM BLOOD WBC-9.3 RBC-4.24* Hgb-12.5* Hct-37.4*
MCV-88 MCH-29.5 MCHC-33.4 RDW-12.3 RDWSD-39.6 Plt ___
___ 02:01PM BLOOD Neuts-84.5* Lymphs-6.2* Monos-7.9
Eos-0.9* Baso-0.2 Im ___ AbsNeut-7.83* AbsLymp-0.57*
AbsMono-0.73 AbsEos-0.08 AbsBaso-0.02
___ 02:01PM BLOOD Glucose-112* UreaN-20 Creat-1.0 Na-136
K-5.0 Cl-100 HCO3-24 AnGap-17
___ 02:19PM BLOOD Lactate-1.7
MICROBIOLOGY:
==============
___ 2:02 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. FINAL
SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (___)
GROUP
|
CEFTRIAXONE-----------<=0.12 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.12 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ 0.5 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CHAINS.
Reported to and read back by ___ @ 1255 ON
___.
PATIENT CREDITED.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CHAINS.
====
___ 1:45 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STREPTOCOCCUS ANGINOSUS (___) GROUP.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___,
___.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CHAINS.
Reported to and read back by ___ @ 1255 ON
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
====
___ Blood Culture, Routine (Final ___: NO GROWTH.
PERTINENT IMAGING:
================
CT HEAD W/O CONTRAST: No acute intracranial process.
TTE:
Mildly thickened aortic valve with moderate aortic
regurgitation. Myxomatous mitral leaflets with mild-moderate
late systolic mitral regurgitation. Normal biventricular cavity
sizes with preserved regional and global biventricular systolic
function.
If clinically indicated, a transesophageal echocardiographic
examination is recommended to better assess the aortic and
mitral valve morpholgy for possible vegetations/endocarditis.
TEE:
Mildly thiickened aortic valve leaflets with moderate aortic
regurgitation but without discrete vegetation. Mild bileaflet
mitral valve prolapse with mild late systolic mitral
regurgitation.
DISCHARGE LABS:
=============
___ 08:20AM BLOOD WBC-7.7 RBC-4.16* Hgb-12.4* Hct-36.9*
MCV-89 MCH-29.8 MCHC-33.6 RDW-12.3 RDWSD-39.8 Plt ___
___ 03:02PM BLOOD CRP-44.3*
Brief Hospital Course:
Patient is a ___ M with PMH HLD, duodenal ulcer c/b GIB, and
BPH who presented with chills, myalgias, and headache, admitted
with viridans strep sepsis.
#VIRIDANS STREP SEPSIS:
Initial cultures at ___ grew GPCs that resulted in
viridans strep species. Initial blood cultures on admission to
___ ___ were also positive for viridians strep. All culture
sensitivities were pan sensitive (see microbiology section for
specific sensitivity data). The patient was started on
vancomycin empirically and ultimately narrowed to ceftriaxone
based on culture sensitivities. Etiology of GPC sepsis was
unclear. TTE was negative for vegetations but showed bileaflet
mitrial prolapse and aortic regurgitation. A TEE was performed
that was negative for vegetations. There were no localizing
symptoms. Dentition was good, though patient had previous dental
instrumentation prior to admission. A Panorex was performed and
the result will be followed up after discharge. A PICC was
placed prior to discharge. The patient will continue CTX as an
outpatient for a total course of 4 weeks (D1: ___
projected end date: ___.
#Normocytic Anemia: Hgb during admission was ___. Previous
baseline in ___ was 14.2. No evidence of bleeding. Hgb remained
stable. Workup with iron studies if anemia does not resolve
after acute illness.
#Headache: Patient was experiencing intermittent headaches on
admission that were relieved with Tylenol. He did not experience
nausea, photo/phonophobia, blurry vision, or any worrisome signs
or symptoms. A CT Head was negative. He was continued on Tylenol
PRN during hospitalization.
CHRONIC:
#HLD: Continued home atorvastatin
#BPH: Continued home tamsulosin
#Seasonal allergies: Continued Flonase, Claritin
=====================
TRANSITIONAL ISSUES:
=====================
NEW MEDICATIONS:
[ ] Ceftriaxone 2mg IV Daily for a total course of 4 weeks (D1:
___ projected end date: ___
ITEMS FOR FOLLOW-UP:
[ ] Follow-up final panorex read (Date of exam: ___
[ ] Lab draw every week: CBC with differential, BUN, Cr, AST,
ALT, Total Bili, ALK, PHOS, CRP, ESR
[ ] Infectious Disease OPAT will arrange outpatient follow-up
[ ] Continue CTX as an outpatient for a total course of 4 weeks
(D1: ___ projected end date: ___, or instructed
by infectious disease
[ ] Follow-up weekly CBC, if Hgb trending down (Hgb at discharge
> 12), send for iron studies and work up. Patient has had a GI
bleed in the past.
[ ] ECHO showed bileaflet mitrial valve prolapse and mild aortic
regurgitation. Please continue to monitor patient and consider
referral to cardiology for surveillance.
Name of health care proxy: ___
Relationship: wife
Phone number: ___
Code: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraZODone 50 mg PO QHS:PRN insomnia
2. Tamsulosin 0.4 mg PO QHS
3. Atorvastatin 20 mg PO QPM
4. Loratadine 10 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ASDIR
Discharge Medications:
1. CefTRIAXone 2 gm IV Q 24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 mg IV Q24H
Disp #*28 Intravenous Bag Refills:*0
2. Atorvastatin 20 mg PO QPM
3. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ASDIR
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. Loratadine 10 mg PO DAILY
6. Tamsulosin 0.4 mg PO QHS
7. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
-- SEPSIS, GRAM POSITIVE
-- HEADACHE
-- ANEMIA
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! You were admitted to the
hospital because you had bacteria in your blood. You were given
antibiotics through your vein. You were seen by the infection
doctors who recommended ___ through your vein for four
weeks.
We do not know what caused the infection. We looked at your
heart valves with an ultrasound and did not find an infection
hiding in your heart. We did a scan of your brain because of
your headaches and the scan was normal. Finally, we took XRays
of your mouth. The results of the mouth XRAY are pending and you
will go over these results when you follow up with your regular
doctors.
Someone from the infectious disease department will call you to
schedule a follow up appointment. If you don't hear from them in
a week, you can call at ___.
It was a pleasure caring for you!
Sincerely,
Your Medical Team
Followup Instructions:
___
|
10054639-DS-23 | 10,054,639 | 28,464,531 | DS | 23 | 2139-03-06 00:00:00 | 2139-03-07 11:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Spitting up blood
Major Surgical or Invasive Procedure:
Upper endoscopy ___
History of Present Illness:
Ms. ___ is an ___ year-old woman with HTN, HLD, osteoporosis,
possible giant cell arteritis and AAA who presenting w/ several
months of intermittent spitting up blood that has worsened over
the past 3 days.
Patient reports that in ___ she presented to walk in clinic
with a several day history of spitting up blood. Per notes, at
the time pt reported concomitant epistaxis and exposure to dry
air but was otherwise asymptomatic. A CXR was performed and was
read as negative for any acute intrapulmonary process. Patient
subsequently followed up with her PCP ___ ___, at which time
her symptoms had resolved.
Patient now presents with a three day history of "spitting up
blood." She denies epistaxis, cough, fever, chills, night
sweats, chest pain, dyspnea, orthopnea, PND, ___ edema, change in
exercise tolerance, nausea, emesis, diarrhea, melena,
hematochezia, weight loss, change in appetite. Denies dysphagia,
denies difficulty swallowing pills, denies pain with swallowing
pills.
Reports that prior to ___, she had no prior similar
episodes. She reports that she had a history of childhood asthma
in ___, but that it resolved by the time she was a
teenager. Denies any other history of respiratory issues.
On arrival to the ED, initial vitals were 97.8 74 ___
100% RA. Labs including CBC, Chem7 and Coags were reassuring.
CXR showed no acute process. CTA chest showed ascending thoracic
aortic aneurysm, approximately slightly increased to 5.1 cm from
4.7 cm on ___ without evidence of dissection. Scope by ER
team, who did not note nasal bleeding. Vitals on transfer were
79 124/90 18 100% RA.
Currently, the patient appears comfortable and is without
additional complaints.
Past Medical History:
___: HTN, hypercholesterolemia, h/o hyperplastic colonic polyp,
h/o H. Pylori in ___ s/p rx, GERD
PSH: Hysterectomy for urinary incontinence and uterine prolapse,
B/l laser cataract surgeries
POBHx: SVD x7
Social History:
___
Family History:
Brother recently died of cancer, but doesn't know what type. No
known FH of diabetes, lung disease, or cardiac disease. Daughter
has hypertension.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.3 83 131/89 18 100% RA
Gen: Appropriately interactive, appears comfortable
HEENT: NCAT, EOMI, bright red blood in pharynx
Neck: JVP 6cm, no LAD, no thyromegaly
Card: RRR, no m/r/g.
Resp: CTAB without wheezes or crackles. Full expansion
Abd: Soft, +BS, mildly tender to palpation in the epigastrium.
Ext: 2+ ___ pulses, non-tender, no edema
Skin: Chronic sun changes, no rashes
Neuro: Full strength throughout. Sensation intact. Toes
downgoing bilaterally.
DISCHARGE PHYSICAL EXAM:
VS - Temp: 98.6F, BP 106-137/61-74, HR:44-52, R:18, O2-sat 97%
RA
Gen: Appropriately interactive, thin ___ woman who
appears her stated age, appears comfortable
HEENT: Pharyx benign with no blood in oral cavity, cauterized
area of hard palate with no bleeding, no teeth, small white
patch on right buccal mucosa, NCAT, EOMI, PERRL with b/l
post-surgical cataract changes
Neck: No pain on palpation, no JVD, no LAD, No thyromegaly
Card: RRR, no m/r/g.
Resp: Breathing comfortably, CTAB without wheezes or crackles
Abd: Soft, +BS, mildly tender to palpation in the epigastrium.
Ext: 2+ ___ pulses, non-tender, no edema
Skin: Chronic sun changes, no rashes
Neuro: CN III-XII grossly intact, ___ motor throughout, normal
sensation throughout. No tremor.
Pertinent Results:
___ 10:12AM WBC-6.3 RBC-4.12* HGB-12.0 HCT-37.0 MCV-90
MCH-29.0 MCHC-32.3 RDW-13.1
___ 10:12AM NEUTS-63.2 ___ MONOS-3.5 EOS-0.8
BASOS-1.1
___ 10:12AM GLUCOSE-91 UREA N-13 CREAT-0.9 SODIUM-138
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-31 ANION GAP-11
___ 10:12AM PLT COUNT-300
___ 10:12AM ___ PTT-29.9 ___
___ 07:05PM HCT-34.9*
___ 05:55AM HCT-33.9*
___ 12:55PM BLOOD Hct-37.5
___ 06:15AM BLOOD WBC-4.6 RBC-3.68* Hgb-10.3* Hct-32.5*
MCV-88 MCH-27.9 MCHC-31.6 RDW-12.8 Plt ___
___ 01:49PM BLOOD Hct-35.1*
___ 06:50AM BLOOD WBC-4.9 RBC-3.64* Hgb-10.2* Hct-32.1*
MCV-88 MCH-27.9 MCHC-31.6 RDW-12.7 Plt ___
___ 06:45AM BLOOD WBC-5.1 RBC-3.74* Hgb-10.6* Hct-33.9*
MCV-91 MCH-28.3 MCHC-31.1 RDW-12.9 Plt ___
___ 07:15AM BLOOD Hct-30.2*
___ 03:35PM BLOOD Hct-28.9*
___ 07:10AM BLOOD WBC-3.7* RBC-2.69*# Hgb-7.9*# Hct-24.2*
MCV-90 MCH-29.2 MCHC-32.4 RDW-13.0 Plt ___
___ 01:05PM BLOOD Hct-28.0*
___ 07:05AM BLOOD Hct-27.5*
___ Chest Xray
IMPRESSION: No acute cardiopulmonary process.
___ Chest CT with contrast
IMPRESSION:
1. No evidence of pulmonary embolism or other finding to explain
the patient's symptoms of hemoptysis.
2. Potentially slightly enlarged ascending aortic aneurysm, with
no evidence of dissection.
___ CT Neck with contrast
1. Asymmetric soft tissue density along the left aspect of the
lower
nasopharynx, of uncertain etiology. Direct visualization is
recommended.
2. Ascending aortic aneurysm, similar to prior.
3. Infundibulum of the origin of the right posterior
communicating artery, similar to prior.
___ EGD
Findings:
Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Recommendations: Normal endoscopy. No GI cause of bleeding.
Recommend ENT eval and MRI head/neck
Brief Hospital Course:
Ms. ___ is an ___ year-old woman with HTN, HLD, and AAA who
presenting w/ several months of intermittent spitting up blood
that has worsened over the past 3 days.
ACTIVE ISSUES:
#Spitting up blood: Patient does not report any coughing and was
not observed to be coughing, but was spitting up teaspoonfuls of
bright red blood on admission. CXR and CT chest were unrevealing
for a source. CT neck showed a small soft tissue density in the
posterior nasopharynx, but this did not correlate to an area of
bleeding on direct visualization. Pulmonary consult had a low
suspicion for pulmonary source and deferred bronchoscopy. GI
consult performed EGD and was normal on ___. ENT consult
conducted laryngoscopy and found no source in the head and neck
on the first two examinations. On the third examination, they
found an ectasia on the left hard palate and cauterized it on
___ and again on ___. Following the cauterizations, pt
had two episodes of very small amounts of blood (about 1 tsp),
but was otherwise asymptomatic. Her hematocrit was monitored
throughout her admission. It was initially 37 and decreased to
28 with one reading of 24 on ___. She was hemodynamically
stable and follow up was recommended for monitoring and possible
treatment of anemia.
# Blood pressure control/ Hypertension: Home atenolol, HCTZ and
lisinopril were continued. She had low blood pressures to
___ the evening of ___ and was dizzy but otherwise
asymptomatic, after taking her BP medications earlier that
evening. BPs improved with IVF hydration. She reports that she
often feels dizzy at home at night after taking her medications,
but has not had any further symptoms. We advised proper
hydration and being careful not to fall in the evenings after
taking her medications. We recommended outpatient follow up with
her primary care physician for further BP management.
INACTIVE ISSUES:
# Headache: Pt mentioned some headaches she gets at home, but
did not complain of headache while in the hospital. The
headaches are pulsatile, right worse than left, and associated
with visual changes and muscle tension, and last hours to days.
They are most likely migraines. She also describes very short,
<1 minute head pains, that may be cluster headaches, but she did
not experience any during her hospitalization. Tylenol was made
available to her for pain, but she did not require any for
headaches.
#Ascending Thoracic Aortic Aneurysm: CTA visualized ascending
thoracic aortic aneurysm, approximately 5.1 cm, slightly
increased in size since prior CT from ___ when it
measured 4.7 cm. No evidence of dissection. Patient was
monitored for signs of dissection or rupture and was stable.
Follow up with cardiovascular surgery is recommended after
discharge, per PCP ___.
# GERD: PPI was continued.
# Chronic back pain: Lidocaine patch and tylenol PRN were
continued.
TRANSITIONAL ISSUES:
Dr. ___ ENT
- Bleeding from mouth- ENT outpatient follow up, consider biopsy
PCP ___
- ___ ~28
- Ascending thoracic aortic aneurysm- consider CV surgery
referral
- Hypertension with low BPs at night
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium (Liquid) 100 mg PO BID
2. Omeprazole 40 mg PO BID
3. Atenolol 25 mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Atorvastatin 20 mg PO DAILY
6. Lidocaine 5% Patch 1 PTCH TD DAILY
7. Lisinopril 20 mg PO DAILY
8. Acetaminophen 325-650 mg PO Q4H:PRN pain
9. Calcium 500 With D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral BID
Discharge Medications:
1. Omeprazole 40 mg PO BID
2. Lisinopril 20 mg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD DAILY
4. Docusate Sodium (Liquid) 100 mg PO BID
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Atenolol 25 mg PO DAILY
7. Atorvastatin 20 mg PO DAILY
8. Acetaminophen 325-650 mg PO Q4H:PRN pain
9. Calcium 500 With D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral BID
Discharge Disposition:
Home
Discharge Diagnosis:
Hard palate ectasia
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized at ___ because you were spitting up
blood. While you were here, you received a Chest x-ray that was
normal. You had a chest CTA that did not show a cause for the
bleeding.
The pulmonary medicine team evaluated you and felt that the
cause of your bleeding was not likely your lungs. The
gastroenterology team evaluated you and used a camera to look at
your esophagus, stomach, and the beginning of the small
intestine, and they did not find a cause for your bleeding. The
ENT (Ear, Nose, and Throat) team also evaluated you and looked
into your nose, mouth and throat with a camera. Initially they
did not find a cause for your bleeding, but on ___ they
found a small area of bleeding on the roof of your mouth. They
cauterized that area to stop the bleeding. After this, there was
only very minimal bleeding. Please follow up in clinic with the
ENT doctor, ___.
During your admission, we followed your red blood cell levels in
your blood and they were low. This is called anemia. Please
continue to eat a varied diet and talk to your primary care
doctor about iron supplements and follow up for your anemia.
The chest CT you had showed that you still have a acending
thoracic abdominal aneurysm, which was increased from 4.7cm to
5.1cm since ___. Please follow up with your PCP about referral
to a cardiovascular surgeon.
Followup Instructions:
___
|
10054639-DS-24 | 10,054,639 | 29,496,424 | DS | 24 | 2139-04-05 00:00:00 | 2139-04-07 18:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year-old woman with HTN, HLD, osteoporosis,
AAA, and recent ENT procedure who presented to ED with AMS after
taking roxicet.
Notably, she was recently admitted to ___ for hemoptysis and had
ENT procedure last week to cauterize an ectatic vessel on her
hard palate. Since then, she was taking pain medicaiton
(roxicet) in the morning. This am, she was feeling fine and took
her roxicet without eating breakfast. Few mintues later her
daughter was concerned because she was lethargic, however she
was responsive the entire time and breathing normally. No focal
motor deficits noted. Her daughter gave her something to eat and
her mental status returned to normal. Nonetheless her daughter
called EMS who brought her to the ED.
In the ED, initial vital signs were 97.5 58 120/73 14 100% RA.
Initial labs and CXR were unremarkable. After talking to family,
there was some confusion as to whether the patient was
unresponsive or just lethargic and given this concern she was
admitted. However, after further clarification, it was clear
that she did not lose consciousness and was never unresponsive.
On the floor, initial vitals were 98.1 119/74 64 16 100RA. She
denied complaints.
Review of Systems:
(+) as per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
HTN
HLD
h/o hyperplastic colonic polyp
h/o H. Pylori in ___ s/p rx
GERD
Uterine prolaps s/p hysterectomy
B/l laser cataract surgeries
AVM on palate s/p ENT cautery
Social History:
___
Family History:
Brother recently died of cancer, but doesn't know what type. No
known FH of diabetes, lung disease, or cardiac disease. Daughter
has hypertension.
Physical Exam:
Admission Physical Exam:
VS - 98.1 119/74 64 16 100RA
Gen: Appropriately interactive, oriented x3, appears comfortable
HEENT: NCAT, EOMI, 4mm diameter circular area on left palate s/p
cautery, healing well.
Neck: JVP flat, no LAD, no thyromegaly
Card: RRR, no m/r/g.
Resp: CTAB without wheezes or crackles. Full expansion
Abd: Soft, +BS, NTND.
Ext: 2+ ___ pulses, non-tender, no edema
Neuro: CN ___ grossly intact. Full strength throughout.
Sensation intact. Toes downgoing bilaterally.
Discharge Physical Exam:
Vitals: T98, 57-64 (57), ___ (128/74) RR16-18
98-100%RA
General: NAD, alert and oriented, conversing with family members
in room, ambulating to bathroom well.
HEENT: EOMI, MMM with healing surgical lesion on hard palate
with cautery.
Cardiac: Bradycardic, regular, no m/r/g
Resp: Clear bilaterally, no crackles, rhonchi or wheezes
Abdomen: Nondistended, nontender, BS present
Extremities: No c/c/e
Pertinent Results:
ADMISSION LABS:
___ 11:25AM BLOOD WBC-5.2 RBC-3.64*# Hgb-10.3*# Hct-32.9*
MCV-90 MCH-28.3 MCHC-31.3 RDW-12.9 Plt ___
___ 11:25AM BLOOD Neuts-59.1 ___ Monos-5.3 Eos-1.2
Baso-1.0
___ 11:25AM BLOOD ___ PTT-29.3 ___
___ 11:25AM BLOOD Glucose-81 UreaN-15 Creat-0.8 Na-139
K-4.0 Cl-101 HCO3-32 AnGap-10
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-4.8 RBC-3.57* Hgb-10.2* Hct-31.7*
MCV-89 MCH-28.4 MCHC-32.0 RDW-13.3 Plt ___
___ 07:20AM BLOOD Glucose-87 UreaN-13 Creat-0.7 Na-140
K-3.9 Cl-103 HCO3-31 AnGap-10
___ 07:20AM BLOOD Calcium-9.4 Phos-3.5 Mg-2.3
=================
MICROBIOLOGY: NONE
ECG:
___ Sinus rhythm. Diffusely low QRS voltage. Probable prior
anteroseptal myocardial infarction Compared to the previous
tracing of ___ the rate is faster. Other findings are
similar.
IMAGING:
CXR ___ No evidence of acute cardiopulmonary process
Brief Hospital Course:
Ms. ___ is an ___ year-old woman with HTN, HLD, osteoporosis,
AAA, and recent ENT procedure who presented to ED with lethargy
after taking roxicet.
#Altered mental status: Patient was brought into the ED by
daughter following episodes of confusion. She had no loss of
consciousness, and her confusion was thought to be due to
roxicet. EKG and chest x-ray in the emergency department showed
no acute processes. Patient was admitted for telemetry
monitoring with no events overnight. She had resolution of
confusion and ambulated throughout the floor without symptoms.
Patient and family were told to stop roxicet or other pain
medication administration other than Tylenol and tramadol.
#Recent oral surgery w/hard palate cautery:
The site of surgery appeared to be healing well with adequate
cautery at margins. The patient was continued on amoxicillin
Oral Susp. 800 mg PO/NG Q8H (5day course, from ___, and
pain was managed with Tylenol.
CHRONIC DIAGNOSES:
#Hypertension:
Patient was continued on home antihypertensives atenolol,
hydrochlorothiazide and lisinopril with adequate blood pressure
control.
#Hyperlipidemia:
She was continued on home dose of atorvastatin.
# GERD:
Patient was continued on home omeprazole.
# Chronic back pain:
Patient had no complaints of back pain during hospitalization
and was continued on home lidocaine patch and tylenol PRN
TRANSITIONAL ISSUES:
There are no outstanding tests at time of discharge, and patient
was scheduled to follow-up with PCP at appointment on ___.
Family and patient were advised to refrain from roxicet and
other pain medication intake other than tylenol and tramadol.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO BID
2. Lisinopril 20 mg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Atenolol 25 mg PO DAILY
6. Atorvastatin 20 mg PO DAILY
7. Acetaminophen 325-650 mg PO Q4H:PRN pain
8. Lidocaine Viscous 2% 20 mL PO TID:PRN pain
9. OxycoDONE-Acetaminophen Elixir 5 mL PO Q4H:PRN pain
10. AMOXicillin Oral Susp. 800 mg PO Q12H
post surgical, 5 day rx starting ___
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q4H:PRN pain
2. AMOXicillin Oral Susp. 800 mg PO Q12H
3. Atenolol 25 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Lidocaine 5% Patch 1 PTCH TD DAILY
7. Lidocaine Viscous 2% 20 mL PO TID:PRN pain
8. Lisinopril 20 mg PO DAILY
9. Omeprazole 40 mg PO BID
10. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Take for pain every 6 hours as needed for pain.
RX *tramadol 50 mg 1 tablet(s) by mouth 4 times a day Disp #*26
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Altered mental status
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 admitted to
___. You were admitted because your family was concerned
about a change in your mental status. Most likely this was a
result of your pain medication that you have been taking after
ENT surgical procedure last week. The blood tests and heart
monitoring we did in the hospital were all reassuring.
When you return home, please take only tylenol or tramadol for
pain control.
Followup Instructions:
___
|
10054992-DS-19 | 10,054,992 | 25,004,394 | DS | 19 | 2125-02-23 00:00:00 | 2125-02-24 08:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Paranoia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Ms. ___ is a ___ year old female, with prior history of
Bipolar Disorder / Psychosis, now presenting with acute
agitation.
Patient with potentially prior late diagnosis of Bipolar
Disorder / Psychosis? was previously living in ___ for the
past year, and returned to ___ because of mental status
changes. 6 weeks prior, Husband reports that she had become
depressed secondary to potentially stress. She was also drinking
alcohol, and she was being self-medicated with lorazepam and
Haldol (which she had been previously described before). She now
is a "basket case", and feels more paranoid and has potentially
lost perception with reality. Patient thinks that everyone is
against her. Her husband notes that she can be somewhat
aggressive sometimes. She does endorse "emptiness" in her head,
and her husband believes that she may have suffered several
strokes in the past as well. She does not have any headaches,
numbness/tingling, focal neurological deficits, or loss of
function. Patient was first evaluated and found to have
potentially an exacerbation of bipolar disorder vs. alcohol use
vs. organic neurologic process. Patient was then evaluated to
potentially need geriatric psych management.
Past Psychiatry History: Reviewed in OMR. Patient was initially
diagnosed with a bipolar disorder and had a psychotic break a
few years ago. At that time, she was treated with Haldol and
Ativan, and had somewhat improvement. Patient was then
potentially tailored off medications, and then went into a
"manic phase" that lasted ? "about a year". Patient was very
energetic previously, and then mood stable. She was also
drinking alcohol at that time. Last year, she and her husband
then moved to ___ for financial reasons and returned to the
___ because of mental status changes.
In the ED, initial vitals: 97.9 76 125/81 16 98% RA
Labs were significant for: Sodium 145, Potassium 3.6, BUN 24, Cr
0.7. Serum Tox pending. TSH 1.3. Vitamin B12: Pending. Hgb 11.1.
CT Head Imaging without contrast showed no acute intracranial
abnormality.
In the ED, she received:
___ 12:27 PO Lorazepam 1 mg
Vitals prior to transfer: UA 97.9 72 124/78 18 100% RA
Currently, patient is standing in the room, refusing all care.
Patient states that she would like to leave the hospital.
Patient states that she feels that she is being kept here
against her will.
ROS: Unable to assess. Patient is not able to assess.
Past Medical History:
1. Bipolar Disorder, Psychotic Break
Social History:
___
Family History:
Declines answering questions.
Physical Exam:
>> ADMISSION PHYSICAL EXAM:
GEN: Patient is refusing to acknowledge name, date of birth or
place. She continues to state that she does not need to be here.
Patient also continues to state that she would like to leave.
HEENT: Anicteric scleare. no conjunctival pallor. Patient
refusing mouth examination.
CV: RRR, S1, S2.
Lungs: Refusing exam.
ABD: Refusing exam.
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, extremities grossly intact. She
was able to walk to the restroom by herself, without help. Gait
appears normal.
.
>> DISCHARGE PHYSICAL EXAM:
GEN: Patient repeats name, year, declines answering more
questions.
HEENT: Anicteric scleare. no conjunctival pallor.
CV: RRR, S1, S2.
Lungs: Refusing exam.
ABD: Refusing exam.
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, extremities grossly intact. She
was able to walk to the restroom by herself, without help. Gait
appears normal.
Pertinent Results:
>> Pertinent Labs:
___ 11:03AM BLOOD WBC-7.0 RBC-3.56* Hgb-11.1* Hct-35.2
MCV-99* MCH-31.2 MCHC-31.5* RDW-13.5 RDWSD-48.6* Plt ___
___ 11:03AM BLOOD Neuts-65.1 ___ Monos-12.0
Eos-0.9* Baso-0.6 Im ___ AbsNeut-4.57 AbsLymp-1.47
AbsMono-0.84* AbsEos-0.06 AbsBaso-0.04
___ 11:03AM BLOOD Glucose-101* UreaN-24* Creat-0.7 Na-145
K-3.6 Cl-107 HCO3-27 AnGap-15
___ 11:03AM BLOOD VitB12-303
___ 11:03AM BLOOD TSH-1.3
___ 11:03AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
>> PERTINENT REPORTS:
___ Imaging CT HEAD W/O CONTRAST : There is no
intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular
territorial infarction. Ventricles and sulci are normal in
overall size and configuration. There is a mucus retention cyst
in the left maxillary sinus with thickening of the lateral wall
of the left maxilla suggesting chronic inflammation. The
remaining imaged paranasal sinuses are clear. Mastoid air cells
and middle ear cavities are well aerated. The bony calvarium is
intact.
IMPRESSION: No acute intracranial process.
___ Imaging MR HEAD W & W/O CONTRAS :
Study is mildly degraded by motion. There is no evidence of
hemorrhage,
edema, masses, mass effect, midline shift or infarction. There
is prominence of the ventricles and sulci suggestive
involutional changes. Few subcortical T2 and FLAIR
hyperintensities are noted. There is no abnormal enhancement
after contrast administration. The major vascular flow voids
are preserved. There is partial opacification of the mastoid air
cells. Mucosal thickening with an air-fluid levels noted in the
left maxillary sinus. Mild mucosal thickening of the ethmoid
sinuses seen. There is a 0.9 cm Tornwaldt cyst versus mucous
retention cyst in the posterior nasopharynx. The orbits and
visualized soft tissues are otherwise normal. Nonspecific
bilateral mastoid fluid is present.
Degenerative changes are noted in the upper cervical spine.
IMPRESSION:
1. Study is mildly degraded by motion.
2. No acute intracranial abnormality.
3. Few scattered white matter signal abnormalities, likely
secondary to
chronic microvascular ischemic changes.
4. Air-fluid level in the left maxillary sinus, which may
represent acute
sinusitis.
Brief Hospital Course:
Ms. ___ is a ___ year old female, with past history of ?
bipolar disorder / psychosis, now presenting with acute on
chronic paranoia.
.
>> ACTIVE ISSUES:
# Paranoia: Patient initially presented to ___ given increased
paranoia and inability to care for herself. She was brought in
by her husband, and history obtained by both patient and
collateral from her husband. Patient had previously been
diagnosed with a Bipolar disorder syndrome, and then patient
moved to ___ ___ year ago. Over the past several months, patient
had worsening paranoia and agitation, and therefore presented to
___. Patient had initial blood work which was unrevealing for
an organic cause of her symptoms, and evaluated by psychiatry.
Psychiatry felt that much of her symptoms were likely secondary
to a depression with psychotic features type diagnosis instead
of worsening of a prior diagnosis of Bipolar. Patient was
initially started on treatment with Zyprexa 2.5 mg QHS, and
Ativan given prior history of this. She was monitored serially,
and underwent CT head and MRI imaging which was also negative
for an acute organic cause of her symptoms. Therefore, patient
was medically clear. Patient was started on empiric therapy for
depression with mirtazapine, and was continued on standing
anti-psychotic. Patient was also placed under ___ on ___
given inability to make full healthcare decisions. Patient was
started on thiamine given nutritional needs.
.
# Elevated SBP: patient was noted to have an elevated SBP on
admission, however this resolved during serial vital signs as an
inpatient and therefore likely secondary to stress than true
hypertension.
.
>> TRANSITIONAL ISSUES:
# Paranoia: Patient to have f/u with geriatric psych unit.
Patient may benefit from further behavioral stabilization,
potentially ECT, and then will require further formal neurologic
workup when behavirorally stable.
# Discharge Psychiatric Regimen: Patient was started on
mirtazapine 7.5 mg QHS, and also Zyprexa 2.5mg QHS.
# Social Situation: Patient and her husband recently moved back
from ___, likely need follow-up regarding resources.
# CODE STATUS: Full
# CONTACT: ___, Husband, ___
Medications on Admission:
None
Discharge Medications:
1. Mirtazapine 7.5 mg PO QHS
2. OLANZapine (Disintegrating Tablet) 2.5 mg PO QHS
3. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: 1. Paranoia
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 hospital stay
at ___. You were hospitalized
here because of an acute paranoia and change in mood, and we did
blood tests and head imaging with a CT scan and an MRI which
were negative. Therefore, we believe that you will benefit from
psychiatric treatment.
Please follow up with you physicians upon discharge from the
hospital.
Take Care,
Your ___ Team.
Followup Instructions:
___
|
10055072-DS-23 | 10,055,072 | 21,137,288 | DS | 23 | 2119-03-08 00:00:00 | 2119-03-08 14:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abd pain, n/v
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Mr ___ is a pleasant ___ year old male with hx of ccy ___,
prior ERCP with stone removal ___ who presented to OSH with
a three day history of RUQ abdominal pain and vomiting, was
found to have a 5 mm CBD stone and was therefore transferred to
___ for ERCP and stone removal. He had subjective fevers at
the OSH and was therefore given cipro/flagyl. He also received
pain control and fluids prior to transfer.
In the ED, the patient had no additional complaints but did have
ongoing pain/nausea. Initial vitals were 97.8 100 131/84 16 99%
RA. He received morphine and zofran.
Currently, the patient c/o sharp ___ pain in the RUQ,
occassionally radiating to the L-side. It has been relatively
constant for the last 2 days but worse with food. He also has
had persistent vomiting which has resulted in poor PO intake.
ROS: per HPI, denies chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
-cleft palate repair
-knee surgery (torn ligaments)
-Anxiety
-GERD
Social History:
___
Family History:
mother - HTN, DM,
No hx of malignancy in his family
Physical Exam:
On admission:
VS - 99.3 72 18 125/78 99% RA
GENERAL - uncomfortable appearing man
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
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/ND, no masses or HSM. L-side non-tender,
no rebound/guarding. Pt refused to let me exam the R side due
to pain
EXTREMITIES - WWP, no c/c/e
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII intact, muscle grossly intact
PSYCH: appropriate, nl affect
Discharge exam:
ViVS - 98.4 70 16 127/78 99% RA
GENERAL - comfortable
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
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/ND, no masses or HSM. mild tenderness in
RUQ.
EXTREMITIES - WWP, no c/c/e
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII intact, muscle grossly intact
PSYCH: appropriate, nl affect
Pertinent Results:
___ imaging:
___ CT abd/pelvis: choledochalithiasis with 5 mm stone, 4 mm
pulmonary nodule in RML, 5 mm pulm nodule in RLL.
___ labs ___:
WBC: 8.9
HCT: 48.9
PLT: 206
UA: + leuk esterase, 15 WBCs
Na 141
K 3.6
Cl 104
CO2 29
Alb 4.1
Ca 8.8
Cr 1.0
Discharge labs/studies:
139 ___ AGap=14
3.9 26 0.8
Ca: 8.4 Mg: 1.8 P: 2.5
ALT: 29 AP: 61 Tbili: 0.4 Alb:
AST: 29
4.2 13.3 157
39.8
___: 13.0 PTT: 29.4 INR: 1.2
ERCP ___:
Impression: Evidence of prior sphincterotomy was seen.
Successful biliary cannulation was achieved with the
sphincterotome.
Cholangiogram revealed very mild diffuse dilation, but no
filling defects were noted. Several balloon sweeps were
performed and no debris/stones were extracted.
Because no adequate explanation for the patient's presentation
was identifed within the CBD/CHD, attention was then turned
towards the cystic duct.
The cystic duct was selectively cannulated with the wire, and
the balloon was advanced into the duct. A filling defect was
seen consistent with an impacted stone near the cystic duct
orifice.
Several balloon sweeps were performed and a small amount of
debris, as well as a moderate amount of pus was extracted from
the cystic duct. The stone could not be completely cleared.
Because of the cystic duct stone impaction, the angle of duct
takeoff, and the resistance to instrument passage, we did not
feel that stent placement into cystic duct would be feasible. We
therefore placed a double pigtail biliary stent successfully
into the CBD.
Otherwise normal ERCP to ___ part of duodenum.
Recommendations: Antibiotics x 2 weeks until next ERCP.
Repeat ERCP in ___ re-evaluation and
possible ___ for cystic duct stone extraction.
Juices when awake and alert, then advance diet as tolerated
.
___ AXR
FINDINGS: No evidence of free intraperitoneal air. Minimally
dilated,
gas-filled loops of small bowel are seen in the upper abdomen on
two of the
four images obtained later in the study. The two images
obtained three
minutes earlier do not depict the distended loops, making it
unlikely that
these represent normal transit of gas as opposed to an
obstruction or ileus.
The gas pattern in the colon is normal and there is residual
contrast in the
ascending portion. The double-J biliary stent is present.
There are
cholecystectomy clips overlaying the liver.
.
CXR ___
FINDINGS: As compared to the previous radiograph, there is no
relevant change
of the chest x-ray. No free subdiaphragmatic air. Multiple
linear opacities
reflecting atelectasis. Low lung volumes. No pneumonia. No
pleural
effusions. No pneumothorax.
.
Brief Hospital Course:
HX: ___ with hx of ___, prior ERCP with stone removal
___ who presented to OSH with a three day history of RUQ
abdominal pain and vomiting, found to have 5mm CBD stone and
biliary duct of 8mm on CT abdomen transferred for ERCP.
# h/o choledocholithiasis:
The patient underwent ERCP ___ and was found to have a
cystic duct stone with pus. Debris was removed but the stone
would not be removed. In addition, the patient had significant
amount of pain post-procedure so checked lipase (normal). The
patient received cipro/flagyl and will need to continue the
antibiotics indefinitely until repeat ERCP in 2 weeks w/ Dr.
___. The repeat ERCP will be for re-evaluation and possible
___ for cystic duct stone extraction. Pt.
tolerated BRAT diet on discharge with minimal pain.
# h/o GERD with evidence of ___ on ERCP
The patient was noted to have findings consistent with
esophagitis on his ERCP. His ranitidine was stopped and a high
dose ppi was started. The patient should follow up with a
general GI physician for consideration of a EGD and biopsy.
# Transitional issues:
- Follow-up ERCP in ___ weeks
- Follow-up regarding possible ___ esophagus. Patient
needs biopsies for the same.
- Follow-up with PCP regarding routine medical care
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.5 mg PO DAILY:PRN anxiety
2. Ranitidine 150 mg PO DAILY:PRN heartburn
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth q 6hrs Disp #*90
Tablet Refills:*1
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth Q 12 hrs
Disp #*42 Tablet Refills:*0
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth q 8 hrs
Disp #*63 Tablet Refills:*0
4. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*3
5. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth Q 8 hrs Disp #*30
Tablet Refills:*2
6. Lorazepam 0.5 mg PO DAILY:PRN anxiety
7. Baclofen 10 mg PO TID:PRN hiccups
RX *baclofen 10 mg 1 tablet(s) by mouth three times a day Disp
#*60 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Cystic duct stone
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a stone in your biliary tract. ERCP was
performed on ___ and found to have cystic duct stone with
pus. Cleared some debris but could not remove the stone. You are
getting cipro/flagyl for 3 weeks until repeat ERCP is done by
Dr. ___ to try to remove cystic duct stone.
Please call your primary care doctor ___
tomorrow to schedule an appointment in 1 week and with Dr.
___ ___ in 2 weeks.
PLEASE DO NOT DRINK ALCOHOL WHILE YOU ARE ON METRONIDAZOLE AS IT
COULD BE DANGEROUS. PLEASE DO NOT TAKE ANY IRON OR CALCIUM
SUPPLEMENTS WHILE YOU ARE ON CIPROFLOXACIN.
Followup Instructions:
___
|
10055694-DS-18 | 10,055,694 | 26,718,205 | DS | 18 | 2116-10-25 00:00:00 | 2116-10-26 15:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Allopurinol And Derivatives / Penicillins / Ace Inhibitors
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with CHF, COPD, ESRD s/p renal transplant on MMF and
Tacro, atrial fibrillation, pulmonary HTN, HTN presenting with
shortness of breath.
.
The patient reports her symptoms initially began in ___
when she visited ___ and ate salty foods throughout her visit.
She developed lower extremity edema and dyspnea when she
returned to ___, and was started on Lasix. She reports her
symptoms improved with the Lasix, which was titrated as an
outpatient by Dr. ___ cardiologist. However, two weeks
ago, she developed a cold with sore throat, cough, and
laryngitis with loss of her voice for several days. She then
began experiencing progressively worsening dyspnea, worse with
exertion, increased lower extremity edema, and orthopnea
requiring her to sit upright when sleeping at night. This is a
change from her baseline 2 pillow orthopnea. She also reports
significant cough productive of white sputum and wheezing, which
she has not had in the past. She denies chest pain, recent
fevers/chills, abdominal pain, nausea/vomiting, diarrhea, or
dysuria. She does report that since her severe coughing, she
has developed rib cage pain that is reproducible with palpation.
She also reports she feels her heart heaving when she puts her
hand to her chest, and reports her occasional chronic
palpitations have become more marked in the past two weeks.
.
The patient was seen by her PCP ___ ___ for shortness of breath
and was found to have crackles and wheezes on exam. CXR showed
unchanged pulmonary vascular congestion and evidence of recent
pulmonary edema but nothing acute. She was planned to have
repeat PFT's and an echocardiogram for further evaluation, and
was scheduled to see her cardiologist, Dr. ___ on ___.
However, her progressive dyspnea, coughing, and wheezing
prompted her to present to the ED for further evaluation.
.
In the ED, initial vitals: 98.8 75 151/82 20 99% 4L Nasal
Cannula
She received Lasix 20 mg IV, Azithromycin 500 mg po, Albuterol
and Ipratropium nebs. CXR and EKG were obtained. Vitals prior
to transfer: 98.1, 72, 142/82, 20, 99% 4LNC
.
Currently, the patient reports continued dyspnea, coughing, and
wheezing and also reports chest wall pain with palpation.
.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
-ESRD previously on HD x ___ years, s/p renal transplant ___
on MMF and Tacro
-COPD, FEV1 of 57% predicted ___
-Hypertension
-Atrial fibrillation
-Congestive heart failure
-Pulmonary hypertension
-Anemia
-GERD
-Depression
.
Past Surgical History:
-L brachiobasilic AV fistula ___
-Open cholecystectomy ___
-Tubal ligation, with incision from midline to pubis
-Exploratory laparotomy for ovarian cyst, negative
Social History:
___
Family History:
Mother was on dialysis from DM. Niece has ESRD, s/p transplant.
Physical Exam:
VS - 98.1 142/77 84 18 94%RA Wt 76.9kg
GENERAL - Alert, interactive, NAD
HEENT - Strabismus, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, JVP difficult to assess ___ continuous coughing
HEART - Difficult to hear ___ prominent wheezes/coughing, RRR,
nl S1-S2, no MRG
LUNGS - Diffuse wheezing bilaterally, crackles at bases b/l,
resp unlabored, no accessory muscle use. Tender to palpation
along left rib cage and xyphoid area
ABDOMEN - NABS, soft/NT/ND, no masses
EXTREMITIES - WWP, 1+ pitting edema b/l, no c/c, 2+ peripheral
DP pulses b/l
SKIN - no rashes or lesions
NEURO - A&Ox3, CNs II-XII grossly intact, muscle strength ___
throughout, sensation grossly intact throughout
Pertinent Results:
___ 04:50PM GLUCOSE-101* UREA N-49* CREAT-3.5*#
SODIUM-138 POTASSIUM-8.1* CHLORIDE-106 TOTAL CO2-22 ANION GAP-18
___ 04:50PM WBC-6.6# RBC-3.91* HGB-11.4* HCT-38.7 MCV-99*
MCH-29.1 MCHC-29.4* RDW-17.3*
___ 04:50PM PLT COUNT-227
___ 04:50PM NEUTS-62.2 ___ MONOS-8.2 EOS-4.6*
BASOS-2.8*
___ 04:50PM ALBUMIN-4.5 CALCIUM-9.4 PHOSPHATE-5.4*#
MAGNESIUM-2.2
___ 04:50PM ALT(SGPT)-13 AST(SGOT)-36 ALK PHOS-92 TOT
BILI-0.9
___ 04:50PM LIPASE-25
___ 04:50PM cTropnT-<0.01
___ 04:50PM ___
___ 05:02PM LACTATE-1.1 K+-5.5*
___ 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5
LEUK-NEG
___ 05:30PM URINE RBC-<1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-13
Micro:
BCx ___ pnd
UCx ___ negative
UCx ___ negative
Imaging:
EKG: Probable atrial flutter with vertrical axis. Non-specific
ST-T wave
abnormalities. Compared to the previous tracing atrial flutter
is now seen. The axis is a bit more shifted to the right.
Renal Transplant US ___:
Mild upper pole caliceal dilatation. No frank hydronephrosis.
Suboptimal Doppler analysis. Resistive index in the mid pole is
minimally elevated measuring 0.81. Close ultrasound followup
exam is recommended.
PFT's ___:
SPIROMETRY 2:31 ___ Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 0.72 2.66 27
FEV1 0.66 1.96 34
MMF 1.08 2.62 41
FEV1/FVC 91 74 124
CXR ___:
Given differences in positioning and technique, there has been
no significant interval change. There is engorgement of the
central pulmonary vasculature with indistinctness of the vessels
peripherally, not significantly changed from prior. There is no
new confluent consolidation or pleural effusion. Cardiac
silhouette is enlarged but stable compared to prior.
IMPRESSION: No significant interval change since prior.
CXR ___:
Mild pulmonary edema has improved since ___ and ___,
but the heart is still severely if not chronically enlarged and
hilar vessels are also chronically dilated. There is no
appreciable pleural effusion.
TTE ___:
IMPRESSION: Right ventricular cavity dilation with basal free
wall hypokinesis ___ sign). Pulmonary artery systolic
hypertension. Mild symmetric left ventricular hypertrophy with
preserved regional and global left ventricular systolic
function.
Compared with the prior study (images reviewed) of ___,
the right ventricular cavity is now dilated and hypokinetic, the
severity of tricuspid regurgitation is increased, and PA
systolic hypertension is now present. The rhythm is now atrial
fibrillation.
Is there a history to suggest and acute pulmonary process (e.g.,
pulmonary embolism)?
VQ Scan ___:
The above findings are consistent with a pulmonary flow
redistribution and
low-likelihood ratio for recent pulmonary embolism. Cardiomegaly
is noted.
IMPRESSION: Low-likelihood ratio for recent pulmonary embolism.
Brief Hospital Course:
___ with CHF, COPD, ESRD s/p renal transplant on MMF and
Tacro, atrial fibrillation, pulmonary HTN, HTN presenting with
shortness of breath.
.
#. Dyspnea: The patient first developed dyspnea in the recent
past after visiting ___ and ingesting salty foods. She was
started on lasix by her Cardiologist as an outpatient, with
improvement of her symptoms. However, the patient currently
presents with recurrence of progressive dyspnea that began after
she developed a URI, which likely triggered an acute on chronic
CHF exacerbation. Initial infectious workup with UA and urine
culture was negative, CXR was negative for infiltrate, and blood
cultures are currently pending but are negative to date. She
presented in atrial flutter (rate controlled with 4:1 block)
which may be ___ volume overload, less likely to have been the
inciting trigger for her CHF exacerbation. She had a
significant cardiac wheeze and cough due to volume overload, and
she was aggressively diuresed with Lasix 80 mg IV boluses.
There was low suspicion of ischemia, CE's negative x2, and she
may be considered for an outpatient stress test in the future.
TTE was obtained, and showed mild symmetric LVH, ___, concern
for PE, given RV dilation, RV basal free wall hypokinesis, and
pulmonary hypertension, but VQ scan overnight showed low
probability for PE. A Heparin gtt was initiated empirically and
was discontinued following return of the VQ scan results. Her
symptoms improved with aggressive diuresis, and she was
discharged on a higher dose of PO Lasix for further diuresis as
an outpatient. She was discharged with close outpatient
cardiology follow-up.
.
#. Atrial flutter/fibrillation: The patient was in atrial
flutter with rate control in the 90's on Metoprolol. CHADS2
score of 2, on ASA 325 as an outpatient. She had been on
Coumadin in the past for atrial flutter but this was
discontinued due to bleeding from her fistula site, per OMR
records. As she is no longer on hemodialysis following her
renal transplant in ___, her outpatient cardiologist was
contacted and she was started on Coumadin prior to discharge.
She was set up with the ___ clinic again and
she will have follow-up with her cardiologist. She was
continued on her home Metoprolol 50 mg daily. Her Aspirin 325
mg daily was continued, but should be decreased in dose when her
INR becomes therapeutic.
.
#. Acute Renal Failure/ESRD: The patient was previously on
hemodialysis for ___ years, prior to receiving a renal
transplant ___. She is on MMF and Tacrolimus as an
outpatient. She presented with a Cr 3.5 from baseline 1.4-1.6,
likely ___ CHF exacerbation and poor forward flow leading to
renal hypoperfusion, as well as supratherapeutic Tacrolimus
level. She was diuresed with Lasix IV and Tacrolimus was
initially held, then re-started at a lower dose with decrease of
Tacro levels to within goal range. Given her renal transplant,
a renal ultrasound with dopplers was obtained and showed mild
upper pole caliceal dilatation, no frank hydronephrosis,
resistive index in the mid pole minimally elevated measuring
0.81. Close ultrasound followup exam is recommended, with an
outpt ultrasound in 4 weeks. The Renal transplant team was
following the patient in-house. She was continued on her home
MYCOPHENOLATE MOFETIL 500 mg bid (decreased to half dose
recently as an outpatient) and was discharged on a decreased
dose of TACROLIMUS 5 mg bid. She was continued on Bactrim ppx.
.
#. Low Grade Temperature: The patient had a low grade
temperature of 100.5 over the last day with continued cough.
She had no white count, but given her immunosuppression, she was
ruled out for infection with a UA, urine cultures, and repeat
CXR. Also, VQ scan showed no abnormalities in uptake that would
suggest pneumonia. She has blood cultures that are currently
pending, negative to date.
.
#. Hyperkalemia: Patient with hyperkalemia likely in the
setting of worsening renal function and supratherapeutic Tacro
level, no EKG changes. She was diuresed aggressively with Lasix
IV and Tacro was decreased with down-trending levels back to
goal range. She was also given a dose of Kayexalate 15 gm x1
for up-trending K+ on initial presentation. Hyperkalemia
resolved with the above interventions.
.
#. Chest Wall Pain: Patient with reproducible chest wall pain
since the onset of her severe coughing, likely musculoskeletal
pain and costochondritis ___ strain. Her pain was well
controlled with Tylenol.
.
#. COPD: Patient has a history of COPD, FEV1 of 57% predicted
___ with plans for repeat outpatient PFT's. She had PFT's
performed on ___. She was continued on Albuterol and
Ipratropium nebs standing to help symptoms of cough and wheeze,
and was discharged with nebulizers.
.
#. Hypertension: The patient was mildly hypertensive on
presentation, and was diuresed with Lasix as above. She was
continued on her home Metoprolol 50 mg daily, Hydralazine 25 mg
bid, and Aspirin.
.
#. Diastolic congestive heart failure: The patient had multiple
stress echos showing normal EF, and TTE in ___ showed mild
symmetric LVH and left-to-right shunt across the interatrial
septum is seen at rest consistent with a small atrial septal
defect or stretched patent foramen ovale. She currently
presents in an acute CHF exacerbation, likely ___ URI in the
setting of diastolic CHF and chronic renal impairment.
#. Anemia: Stable at baseline.
#. GERD: Continued home Omeprazole 40 mg daily.
.
.
#CODE STATUS: Full (confirmed)
====================
Transitions of Care:
====================
- Repeat renal ultrasound in 4 weeks as an outpatient to f/u on
mildly abnormal renal ultrasound in-house
- Evaluation of volume status on higher discharge dose of Lasix
for continued diureses
- f/u INR with initiation of Coumadin, goal INR ___ for atrial
flutter
- When INR ___, decrease Aspirin from 325 mg daily to 81 mg
daily
- f/u blood cultures
- f/u Tacrolimus level on decreased dose
Medications on Admission:
ALBUTEROL SULFATE 90 mcg HFA Aerosol Inhaler - 1 puff q6h prn
FUROSEMIDE 20 mg daily
HYDRALAZINE 25 mg bid (decreased from tid)
METOPROLOL SUCCINATE 50 mg Extended Release daily
MYCOPHENOLATE MOFETIL 500 mg bid (decreased to half dose)
NYSTATIN 100,000 unit/mL Suspension - 1 tsp po qid
OMEPRAZOLE 40 mg Capsule daily
SULFAMETHOXAZOLE-TRIMETHOPRIM 400 mg-80 mg Tablet daily
TACROLIMUS 7 mg bid (decreased from 9 mg bid)
ASPIRIN 325 mg daily
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
2. hydralazine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
4. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
5. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Disp:*60 Capsule(s)* Refills:*2*
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler
Sig: One (1) puff Inhalation every six (6) hours.
Disp:*1 inhaler* Refills:*2*
11. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: One (1) nebulizer Inhalation every six (6)
hours for 10 days: After 10 days, switch to inhaler form of
albuterol and inhaler form of ipratropium.
Disp:*qs qs* Refills:*0*
12. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day:
Take 5 mg daily total until otherwise directed.
Disp:*60 Tablet(s)* Refills:*2*
13. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day: Take
60 mg total daily until follow up with Dr. ___ your primary
care physician.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute on chronic congestive heart failure exacerbation
Acute on chronic renal insufficiency secondary to
supratherapeutic Tacrolimus levels
Hyperkalemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for coughing, wheezing, and
shortness of breath and were found to be in a congestive heart
failure exacerbation with excess fluid in your body. You were
given high doses of Lasix with removal of the fluid and
improvement of your respiratory status.
You underwent an echocardiogram to determine the cause of your
congestive heart failure exacerbation, and this showed signs
concerning for a blood clot in your lungs, called a pulmonary
embolism. You underwent a test called a ventilation-perfusion
scan to evaluate for this, which showed that you do not have
evidence for a clot.
Your kidney function was also abnormal, and you were found to
have a supratherapeutic level of Tacrolimus based on your blood
tests. Your dose of Tacrolimus was decreased as recommended by
the kidney transplant specialists. An ultrasound of your
kidneys showed mild abnormalities that should be followed up in
4 weeks with a repeat ultrasound of your kidneys.
Additionally, your blood tests showed a high potassium level
when you were admitted, which is likely due to your worsened
kidney function. This improved in the hospital, and is expected
to remain normal as your kidney function improves.
The following changes were made to your home medications:
- Coumadin was STARTED
- Lasix was INCREASED
- Tacrolimus was DECREASED
- Ipratropium inhaler was STARTED
Followup Instructions:
___
|
10055694-DS-22 | 10,055,694 | 25,049,824 | DS | 22 | 2118-07-27 00:00:00 | 2118-08-02 19:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Allopurinol And Derivatives / Penicillins / Ace Inhibitors
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with a history of dCHF (65%EF, 3+TR),
severe pulmonary hypertension (PASP 69+RASP), afib/flutter, COPD
on 2L home O2, ESRD s/p cadaveric transplant ___ with chronic
rejection, with a recent CHF admission requiring dialysis who
presents today with shortness of breath and hallucinations. On
___ she presented to our ED with dyspnea and weight of 163
from baseline 158, JVD, crackles, peripheral edema, BNP 8000 and
CXR c/w pulmonary edema. She was thought to have both a CHF and
COPD exacerbation and was treated with IV lasix, prednisone, and
azithromycin. At the time she was satting 85% on room air but
she refused admission and left AMA. Per patient's husband she
has had progressive dyspnea since then, with acute worsening
today leading her to return to the ED today where she presented
with acute respiratory distress; unable to provide history.
Husband states that patient has been hallucinating as well today
and "not making sense." Per daughter O2 sats were in the 60's at
home. Initial VS in ED: 10 98.0 100 128/86 30 60% on RA. On
exam JVP was elevated, lung exam significant for wheezes and
crackles. Labs notable for K 8.1, hemolyzed and found to be
6.3, Cr 5.2 (baseline 3's in ___, trending up), Phos 8.4,
HCO3 19 with gap of 16, Hct 27.8 slightly lower than baseline
low ___, BNP 13,000 from 8000. ABG ___. Patient placed on
BiPap. ABG at ___ 50% was 7.___. Lactate 1.4. CXR showed
pulm edema and worsening L sided pleural effusion, with ?focal
infiltrate. She was treated for COPD exacerbation/PNA with nebs
and vanc/levo/cefepime and tried off BiPap but gas worsened.
Cardiology consulted and she was given 120mg IV lasix. Renal
also consulted; no acute need for HD but will start
ultrafiltration via her LUE fistula if acidosis and hyperkalemia
do not respond to BiPap and diuresis.
Got 120mg IV lasix at 3pm and as of 16:40 only put out 50cc's.
Prior to transfer she's setting 97% RR ___ FiO2 50%. Repeat
ABG pending.
Upon arrival to the CCU she is not able to provide additional
history as she is on bipap and somnolent.
Past Medical History:
-dCHF, required dialysis during ___ admission
-ESRD previously on HD x ___ years, s/p renal transplant ___
on MMF and Tacro
-COPD, FEV1 of 57% predicted ___
-Hypertension
-Atrial fibrillation
-Pulmonary hypertension
-Anemia
-GERD
-Depression
Past Surgical History:
-L brachiobasilic AV fistula ___
-Open cholecystectomy ___
-Tubal ligation, with incision from midline to pubis
-Exploratory laparotomy for ovarian cyst, negative
Social History:
___
Family History:
Mother was on dialysis from DM. Niece has ESRD, s/p transplant
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
General: On BiPap, somnolent but opens eyes and converses
HEENT: NCAT, PERRL
Neck: supple, JVP elevated
CV: irregularly irregular, ___ blowing HSM
Lungs: coarse rhonci, crackles, wheezes throughout
Abdomen: soft, BS+, non-tender
Ext: WWP, +2 PE bilaterally to knees, 1+ distal pulses
bilaterally
Neuro: moving all extremities grossly, speech is fluent but
inappropriate; perserverates about steroid taper
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================================================================
DISCHARGE PHYSICAL EXAMINATION
VS: 98.8/98.5, HR 113-121, RR 18, BP 119-139/69-71, O2 sat 97%
2L
Weight 64.4 (65.8)
GENERAL - well-appearing woman, no longer using accesory
muscles.
HEENT - NC/AT, PERRLA, strabismus
NECK - JVP at mid-neck, no carotid bruits
LUNGS Scattered rhonchi, insp and exp wheeze with dec BS. \
HEART - irreg irreg, normal S1, loud S2 (P2). No m/r/g.
ABDOMEN - NABS, soft/NT/ND.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), No c/c/e.
SKIN - no rashes or lesions.
Neurologic: AOx3. thought process is clear.
Pertinent Results:
ADMISSION LABS
===============
___ 11:05AM BLOOD WBC-10.5# RBC-2.93* Hgb-8.0* Hct-27.8*
MCV-95 MCH-27.3 MCHC-28.7* RDW-17.7* Plt ___
___ 11:05AM BLOOD Neuts-76* Bands-0 Lymphs-15* Monos-9
Eos-0 Baso-0 ___ Myelos-0 NRBC-11*
___ 11:05AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-OCCASIONAL
Macrocy-1+ Microcy-NORMAL Polychr-1+ Target-OCCASIONAL
Burr-OCCASIONAL
___ 11:05AM BLOOD ___ PTT-31.1 ___
___ 11:05AM BLOOD Glucose-119* UreaN-126* Creat-5.2* Na-134
K-8.1* Cl-99 HCO3-19* AnGap-24*
___ 11:05AM BLOOD ALT-14 AST-38 AlkPhos-97 TotBili-0.8
___ 11:05AM BLOOD CK-MB-4 ___
___ 11:05AM BLOOD Albumin-4.1 Calcium-9.1 Phos-8.4*# Mg-2.6
___ 09:18PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
___ 11:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:38AM BLOOD Type-ART Rates-/___ Tidal V-300 PEEP-5
FiO2-50 pO2-88 pCO2-69* pH-7.14* calTCO2-25 Base XS--6
Intubat-NOT INTUBA Vent-SPONTANEOU
___ 11:21AM BLOOD Lactate-1.4 K-6.3*
___ 08:20PM BLOOD Lactate-0.7 K-5.9*
___ 10:07AM BLOOD Lactate-0.9
___ 07:11PM BLOOD O2 Sat-90 ___ MetHgb-0
NOTABLE LABS
=============
___ 05:24AM BLOOD WBC-9.9 RBC-2.47* Hgb-6.7* Hct-22.9*
MCV-93 MCH-27.2 MCHC-29.4* RDW-17.8* Plt ___
___ 04:09AM BLOOD WBC-13.1* RBC-3.23* Hgb-8.9* Hct-29.6*
MCV-92 MCH-27.6 MCHC-30.1* RDW-17.5* Plt ___
___ 04:45AM BLOOD WBC-12.8* RBC-3.15* Hgb-8.4* Hct-29.5*
MCV-94 MCH-26.8* MCHC-28.6* RDW-16.9* Plt ___
___ 04:09AM BLOOD Neuts-90.9* Lymphs-4.3* Monos-3.5 Eos-1.3
Baso-0.1
___ 06:15AM BLOOD ___ PTT-33.6 ___
___ 02:30AM BLOOD ___ PTT-36.9* ___
___ 04:45AM BLOOD ___ PTT-31.1 ___
___ 05:24AM BLOOD Glucose-100 UreaN-60* Creat-3.3*# Na-138
K-3.8 Cl-96 HCO3-29 AnGap-17
___ 06:15AM BLOOD Glucose-106* UreaN-73* Creat-4.4*# Na-137
K-4.5 Cl-93* HCO3-26 AnGap-23*
___ 02:30AM BLOOD Glucose-125* UreaN-25* Creat-2.7* Na-136
K-4.1 Cl-95* HCO3-32 AnGap-13
___ 04:45AM BLOOD Glucose-132* UreaN-45* Creat-4.0*#
Na-132* K-4.1 Cl-91* HCO3-30 AnGap-15
___ 11:05AM BLOOD cTropnT-<0.01
___ 05:24AM BLOOD Calcium-8.5 Phos-4.2# Mg-2.0
___ 04:09AM BLOOD Calcium-9.2 Phos-5.3*# Mg-2.2
___ 04:45AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2 Iron-18*
___ 04:45AM BLOOD calTIBC-286 Ferritn-140 TRF-220
___ 11:57AM BLOOD Vanco-11.8
___ 06:15AM BLOOD Vanco-29.0*
___ 06:35AM BLOOD Vanco-17.6
___ 05:24AM BLOOD Cyclspr-71*
___ 02:30PM BLOOD Type-ART pO2-65* pCO2-68* pH-7.12*
calTCO2-23 Base XS--8 Intubat-NOT INTUBA
___ 09:17PM BLOOD Type-ART pO2-69* pCO2-65* pH-7.28*
calTCO2-32* Base XS-1
___ 11:23PM BLOOD Type-ART pO2-67* pCO2-59* pH-7.35
calTCO2-34* Base XS-4
___ 05:38AM BLOOD Type-ART pO2-72* pCO2-57* pH-7.37
calTCO2-34* Base XS-5
___ 10:29PM BLOOD Type-ART pO2-83* pCO2-62* pH-7.30*
calTCO2-32* Base XS-1
___ 10:07AM BLOOD Type-ART Temp-36.7 FiO2-40 pO2-52*
pCO2-58* pH-7.31* calTCO2-31* Base XS-0 Intubat-NOT INTUBA
___ 09:17PM BLOOD O2 Sat-91
___ 05:38AM BLOOD O2 Sat-92
___ 10:29PM BLOOD O2 Sat-94
___ 10:07AM BLOOD O2 Sat-84
DISCHARGE LABS
================
___ 04:55AM BLOOD WBC-13.7* RBC-3.05* Hgb-8.2* Hct-28.8*
MCV-94 MCH-26.8* MCHC-28.4* RDW-17.0* Plt ___
___ 04:55AM BLOOD Glucose-102* UreaN-33* Creat-3.1* Na-137
K-4.5 Cl-101 HCO3-27 AnGap-14
___ 05:00PM BLOOD Cyclspr-PND
STUDIES
=========
CXR (___): Cardiomegaly with pulmonary edema. Focal
opacities in the left mid lung and right upper lung could
represent infection in the appropriate clinical setting.
CXR (___): Increased cardiomegaly with signs of volume
overload. Opacities in the bilateral mid lungs could represent
atelectasis or edema; however, superimposed infection is
possible.
CXR (___):
The widespread, asymmetric pulmonary opacification, still
responsible for a consolidation in the right upper lobe, and now
more so at the right lung base. What was probably concurrent
pulmonary edema in the left lung has improved. Small right
pleural effusion has increased. Severe cardiomegaly persists,
although another indication of improved cardiac function is a
decrease in mediastinal venous engorgement. No pneumothorax.
Renal Transplant US (___): FINDINGS: Transplanted kidney
is seen in the right lower quadrant. The transplant measures
11.5 cm, similar to prior. There is no hydronephrosis or
perinephric fluid collection. The renal sinus fat is normal in
echogenicity and the cortical thickness is unchanged. There is
no nephrolithiasis or mass.
Doppler: The flow within the main renal artery and upper, mid
and lower
intraparenchymal renal arteries shows a high resistance flow
with reversal
during end diastole. As such, resistive indices are not
applicable. The main renal vein is patent.
IMPRESSION:
1. High resistance flow is consistent with transplant
dysfunction.
2. No hydronephrosis.
ECGs
======
Admission ECG ___: Most likely atrial fibrillation with a
rapid ventricular response. Poor R wave progression.
Non-specific inferolateral ST-T wave changes. Compared to the
previous tracing of ___ the heart rate is faster.
ECG ___: Atrial fibrillation with rapid ventricular
response with some organization. Rightward axis. Compared to
the previous tracing of ___ no diagnostic interim change.
MICRO DATA:
============
Respiratory Virus Identification (Final ___:
Reported to and read back by ___ ___ 1100.
RESPIRATORY SYNCYTIAL VIRUS (RSV).
Viral antigen identified by immunofluorescence
Brief Hospital Course:
BRIEF SUMMARY STATEMENT: Ms. ___ is a ___ with ESRD s/p
DDRT with rejection, COPD on home O2, current 1ppd smoker, afib,
___ presenting with acute decompensated diastolic heart failure
and RSV and ultimately required reinitiation of hemodialysis.
# Acute Decompensated Diastolic Heart Failure with mod-severe
TR. Likely precipitant infection with RSV, in addition to
possible medication non-compliance and/or hypervolemia from
renal failure and recent prednisone administration. Had HD on
___, removed nearly 2 L and BiPap was discontinued. She was
back on her baseline oxygen requirements at the time of
discharge. Volume status much improved with dialysis, -6L LOS.
# COPD, RSV: . Wheeze could have been cardiogenic, but patient
had known COPD on home 2L O2, prolonged expiratory phase and
high CO2. As she was on a prednisone taper recently, she may
have stopped in the middle of the taper. In the ED she initially
received vanc/cefepime/levofloxacin which was later d/c'ed since
she tested + for RSV. Significantly improved O2 requirement
with dialysis.
# Acute on Chronic Renal Failure with chronic rejection of renal
transplant. Suspect cardiorenal syndrome in addition to graft
rejection. Transfused 1 unit pRBC on ___. Nitrogenated
retention significatly improved with HD. She had outpatient
dialysis plans initiated.
# Delirium. Somnolence resolved with improving respiratory
status. She was back to her baseline mental status on discharge.
TRANSITIONAL:
#Hemodialysis on SUN/TUE/FRI HD for holiday week. She will get
HD SAT morning, then won't need it again until TUE .
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Aspirin 81 mg PO DAILY
3. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Mycophenolate Mofetil 500 mg PO BID
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
7. Furosemide 120 mg PO BID
8. HydrALAzine 25 mg PO Q8H
9. Diltiazem Extended-Release 240 mg PO DAILY
10. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
11. Omeprazole 40 mg PO DAILY
12. PredniSONE Dose is Unknown PO DAILY gout flares
13. Acetaminophen 650 mg PO Q8H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose
one puff inhaled twice a day Disp #*1 Inhaler Refills:*2
4. HydrALAzine 37.5 mg PO Q8H
RX *hydralazine 25 mg 1.5 tablet(s) by mouth three times a day
Disp #*135 Tablet Refills:*2
5. Mycophenolate Mofetil 500 mg PO BID
6. Omeprazole 40 mg PO DAILY
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. Diltiazem Extended-Release 360 mg PO DAILY
RX *diltiazem HCl 360 mg one capsule, extended release(s) by
mouth daily Disp #*30 Capsule Refills:*2
9. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
RX *isosorbide mononitrate 120 mg one tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*2
10. Nephrocaps 1 CAP PO DAILY
RX *B complex-vitamin C-folic acid [Nephrocaps] 1 mg one
capsule(s) by mouth daily Disp #*30 Capsule Refills:*2
11. Nicotine Patch 21 mg TD DAILY smoking cessation
RX *nicotine 21 mg/24 hour one patch daily Disp #*30 Transdermal
Patch Refills:*2
12. Nystatin Oral Suspension 5 mL PO QID
RX *nystatin 100,000 unit/mL 5 ml by mouth four times a day Disp
#*1 Bottle Refills:*0
13. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
14. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
15. Aspirin 81 mg PO DAILY
16. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg one
capsule inhaled daily Disp #*30 Capsule Refills:*2
17. PredniSONE 5 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute on chronic diastolic heart failure
Acute on Chronic Kidney injury
RSV infection
Acute COPD exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for ___ at ___. ___ were admitted
with shortness of breath and needed diuretics to remove extra
fluid. It was decided that your kidneys were not working well
enough to keep the fluid from building up so dialysis was
restarted. ___ are now at your goal weight of 141 pounds and
will have dialysis three times a week to remove extra fluid.
YOur furosemide has been stopped. ___ have a lung infection
called RSV and had a large dose of prednisone for 5 days to
decrease inflammation in your lungs. ___ need to make sure that
___ take your spiriva and advair every day to prevent lung
inflammation and wheezing. Your diltiazem was also increased
because your heart rate was high.
Followup Instructions:
___
|
10055694-DS-23 | 10,055,694 | 22,141,743 | DS | 23 | 2120-10-16 00:00:00 | 2120-10-17 20:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Allopurinol And Derivatives / Penicillins / Ace Inhibitors
Attending: ___.
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo woman with past history of ESRD s/p
transplant now on dialysis ___ (anuric), last received dialsis
on ___, COPD on 3L home O2, atrial fibrillation (not on
anticoagulation), she presented with 2 days of shortness of
breath and back pain which has been worsening. She was in her
normal state of health at her dialysis on ___.
On ___ she endorsed a productive cough (no sick
contacts, fevers, but subjective chills) and some back pain
which she initially described as a constant burning throughout
her whole back. This sensation has now resolved. Denies CP,
worsening orthopnea.
In the ED, initial vitals: 0 99.0 ___ 18 99% Nasal
Cannula. She had one rectal temp of 100.4 early on the morning
of admission.
- Exam notable for diffuse crackles on pulmonary examination.
- Labs were notable for WBC 6.8, HgB 8.9 Hct 29, Platelet 189.
INR 1.3.
Serum ASA 8.4, Serum APAP 31. Lactate 1.0.
- Imaging showed: Negative CTA for PE, multiple intrathoracic
lymph nodes. Bedside U/S showed no pericardial effusion.
- Patient was given:
___ 06:10 PR Acetaminophen 650 mg
___ 06:23 IH Albuterol 0.083% Neb Soln 1 NEB
___ 06:23 IH Ipratropium Bromide Neb 1 NEB
___ 06:23 IV Vancomycin 1000 mg
___ 06:23 IVF 1000 mL NS 500 mL
___ 07:12 IV Insulin Regular 10 units
___ 07:12 IV Dextrose 50% 25 gm
___:43 IV Calcium Gluconate 1 gm
___ 07:54 IV Levofloxacin 750 mg
___ 12:25 PO Metoprolol Succinate XL 25 mg
- Consults: Renal, recommended possible CRRT vs. IHD today
depending on blood pressure stability. Recommended empiric
treatment for HCAP.
On arrival to the MICU, she confirmed the above story stating
that her burning back pain has now dissipated. She denies any
increased shortness of breath. She endorses continued diarrhea
___ daily, but denies any abdominal pain.
Past Medical History:
PAST MEDICAL HISTORY:
- ESRD s/p Transplant in - FSGS by biopsy, on HD ___. s/p
DCDKD in ___ c/b chronic allograft nephropathy in ___ with
reinitiation of HD (on MWF schedule). Complicated by
intradialytic hypotension
- Atrial Fibrillation - not on anticoagulation due to
significant gastrointestinal as well as AV fistula site bleeding
- Bradycardia
- COPD - on ___ home oxygen; FEV1 of 57% predicted ___
- Diastolic CHF - Last TTE in ___ with EF>55%, symmetric LVH,
dilated RV with borderline systolic function and severe
pulmonary HTN; small septum secundum
- Claudication with concern for peripheral vascular disease - no
formal arterial duplex studies on record
- GERD
- Gout
- HSV II
- HTN
- Pulmonary HTN - no prior documentation, but likely group 3
- Tobacco abuse
- Anemia
- GI Bleed
- Recurrent C. Diff Colitis - Initially diagnosed in ___ and
treated with flagyl 500mg x 10 days; again in ___ s/p flagyl
500mg x 14 days, persistent infection still later in ___,
treated with vanco 125mg PO x14days
- H/O syphilis
- H/O Breast Cysts
PAST SURGICAL HISTORY:
- Open cholecystectomy ___
- Tubal ligation, with incision from midline to pubis
- Exploratory laparotomy for ovarian cyst, negative
Social History:
___
Family History:
Mother was on dialysis from DM. Niece has ESRD, s/p transplant
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
Vitals: T: 97.9 BP: 124/78 P: 89 Sp02: 91% on RA.
GENERAL: Lethargic but arousable, falling asleep intermittently.
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: On RA, mild increase work of breathing, fair air
exchange, crackles and wheezes in lower to mid lung fields.
CV: Irregularly irregular rhythm, normal S1 S2, no murmurs,
rubs, gallops
ABD: soft, non-tender, slightly distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, mild ___ edema 1+ to ankles.
NEURO: CN II-XII grossly intact, moving all extremities
appropriately.
ACCESS: LUE fistula, 2 PIVs
DISCHARGE PHYSICAL EXAM:
===========================
VS: 98.3, 90/47, 69, 20, 98% RA
I/O: -3L during HD
Gen: Well nourished appearing, dark-skinned woman, sitting up in
bed in NAD
HEENT: NT/AT, white hair, disconjugate gaze; mild scleral
icterus, EOMI (both eyes track, but right eye unable to pass
midline/this is her baseline), PERRLA, MMM moist but tongue
coated in thick white/yellow plaques (improved compared to prior
day)
Neck: supple, symmetric, no AC, PC, or supraclavicular chain
LAD; JVP difficult to assess I/s/o afib, but external jugular
vein very prominent on exam today
CV: variable S1, S2; regular rate; no m/r/g
Pulm: breathing comfortably on NC, with slightly increased rate
and mildly increased WOB; good air movement throughout
posteriorly; bronchial breath sounds in b/l bases; no frank
wheezes, rhonchi, or crackles
Abd: Soft, mildly distended, non-rigid, mildly tender to
palpation diffusely, worst in the epigastrium; no r/g; BS+
Ext: Warm, well-perfused, no pitting edema in BLE; DP palpable
b/l
Skin: no appreciable rashes; hyperpigmented scar in RUQ from
prior cholecystectomy; hypopigmented skin over recently accessed
LUE AVF
Neuro: Alert, interactive on exam; no gross deficits appreciated
ACCESS: PIV, LUE AVF (with palpable thrill)
Pertinent Results:
ADMISSION LABS:
___ 05:50AM BLOOD WBC-6.8 RBC-3.09* Hgb-8.9* Hct-28.5*
MCV-92 MCH-28.8 MCHC-31.2* RDW-18.5* RDWSD-60.7* Plt ___
___ 05:50AM BLOOD Neuts-54.3 ___ Monos-14.5*
Eos-1.6 Baso-0.9 Im ___ AbsNeut-3.66 AbsLymp-1.91
AbsMono-0.98* AbsEos-0.11 AbsBaso-0.06
___ 05:50AM BLOOD ___ PTT-34.5 ___
___ 05:50AM BLOOD Glucose-92 UreaN-72* Creat-7.6* Na-137
K-7.0* Cl-96 HCO3-29 AnGap-19
___ 05:50AM BLOOD ALT-14 AST-26 AlkPhos-149* TotBili-0.9
___ 05:50AM BLOOD Lipase-31
___ 05:50AM BLOOD cTropnT-0.01
___ 05:50AM BLOOD Albumin-3.6 Calcium-9.7 Phos-2.6*# Mg-1.9
___ 05:50AM BLOOD ASA-8.4 Ethanol-NEG Acetmnp-13
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:59AM BLOOD Lactate-1.0
OTHER IMPORTANT LABS:
None
MICROBIOLOGY:
___ Influenza A: Positive
___ Influenza B: Negative
___ Blood Culture x2: NGTD, pending
___ Blood Culture x2: NGTD, pending
___ HIV Serologies: Negative
___ H.Pylori Serologies: Pending at time of discharge
IMAGING AND OTHER STUDIES:
___ CTA Chest:
1. Mild pulmonary edema.
2. Cardiomegaly, moderate with biatrial chamber enlargement.
3. Innumerable mediastinal lymph nodes, mildly enlarged,
indeterminate, difficult to exclude lymphoma or other
etiologies. Clinical correlation is advised.
4. No pulmonary embolism or acute aortic dissection.
5. Partially visualized abdominal ascites.
___ Portable CXR:
Bilateral airspace opacities with a central predominance likely
reflect pulmonary vascular congestion and mild pulmonary edema.
Difficult to exclude superimposed infection in the appropriate
clinical setting.
___ RUQ Ultrasound:
1. Enlarged liver along with a dilated IVC and hepatic veins is
concerning for underlying fluid overload. This may also be seen
in right heart failure.
2. Slightly heterogeneous and coarsened liver echotexture. No
focal lesions. No intrahepatic biliary ductal dilation.
3. Trace ascites.
DISCHARGE LABS:
___ 09:30AM BLOOD WBC-6.2 RBC-2.92* Hgb-8.4* Hct-28.0*
MCV-96 MCH-28.8 MCHC-30.0* RDW-18.6* RDWSD-65.1* Plt ___
___ 07:16AM BLOOD ___ PTT-32.0 ___
___ 07:16AM BLOOD Glucose-95 UreaN-24* Creat-5.4*# Na-140
K-4.4 Cl-96 HCO3-34* AnGap-14
___ 07:16AM BLOOD ALT-30 AST-51* LD(LDH)-214 AlkPhos-157*
TotBili-0.8
___ 07:16AM BLOOD Calcium-8.1* Phos-3.5 Mg-1.8
Brief Hospital Course:
Ms. ___ is a ___ y/o woman with past history of ESRD s/p
transplant on HD (___), COPD, and recurrent C. diff infection,
presenting with volume overload and influenza. She had a brief
FICU stay for urgent HD, was transferred to the floor with
improving respiratory and volume status, and monitored closely
for downtrending Hgb and reported melena prior to discharge
home.
ACTIVE ISSUES:
--------------------
# Hypoxia of Multifactorial Etiology: The patient presented with
hypoxia likely due to combination of fluid overload in setting
of known CHF, ESRD, COPD, and active influenza A infection. Her
active afib with intermittent RVR was likely further worsening
her respiratory status. With management of these individual
problems, as detailed below, her respiratory status improved and
she was discharged on her home O2 requirement of ___ by NC.
# Influenza A Infection: The patient was found to be FluA
positive per PCR on admission and started on Tamiflu for ___ue to HD dosing (___). She
did have infectious work-up for potential superinfection with
PNA, but chest imaging was without notable findings. She was
briefly on empiric abx and had blood cultures drawn, with no
growth at time of discharge.
# Anemia of unclear etiology: At baseline, the patient had a
hemoglobin of ~9, likely due to ESRD. The patient did not appear
malnourished on exam, but of note, nutritional studies had not
been performed in several years. As detailed below, there was
concern for underlying liver disease in this patient, which
could have been contributing to her overall anemia.
Additionally, active influenza infection could possibly have
caused transient myelosuppression. During this admission, the
patient further endorsed black stool (new for several days prior
to and during this admission) and was found to be guaiac
positive in the FICU. With trending, her hemoglobin did
downtrend from her baseline to 7.7 at time of transfer to the
general medicine service, concerning for upper GI bleed
especially given her prior history of bleeding. She was briefly
put on IV PPI and had H.Pylori serologies sent. The patient was
found still to be guaiac positive but without melena on rectal
exam and her hemoglobin did return to her baseline prior to
discharge. The patient was arranged for outpatient follow-up
with GI for further evaluation of possible GI bleed. She was
also instructed to follow up with her outpatient providers
regarding results of her H.Pylori serologies.
# Anuric End-Stage Renal Disease s/p DCDRT complicated by
allograft failure, re-initiated on HD: The patient has had a
history of ESRD since ___, initially on HD. She underwent DCDRT
in ___, with subsequent allograft failure and re-initiation on
HD in ___. She has an estimated dry weight of ~66kg and was
continued on her home ___ HD schedule. She was also continued on
her home calcium supplements and phosphorus binders. She was
followed closely by the renal HD service during this admission
and discharged home following her last dialysis session on
___ at her dry weight of 66.2kg.
# Recurrent C. Diff Colitis: The patient has failed multiple
courses of treatment for C diff Colitis and was treated for
another episode of recurrent C. Diff during this admission. She
was initiated on Vancomycin 125mg PO q6H and Flagyl 500mg IV q8H
on ___ while in the ICU and continued on a planned 14 day
course of PO Vancomycin. She was discharged home with enough
Vancomycin capsules to complete her 14 days course (last dose on
___. She should also follow up with her PCP and GI about
potentially pursuing stool transplant given her multiple
relapses.
# Atrial Fibrillation: The patient has had a history of poorly
controlled afib due to inability to effectively rate control in
the setting of intradialytic hypotension. She was rate
controlled with fractionated metoprolol equivalent in dosage to
her home metoprolol XL 25mg PO daily during this admission. She
was continued on ASA 81mg PO daily for stroke prophylaxis during
this admission as she has been unable to tolerate systmic
anticoagulation in the setting of active and prior GI bleeding
as well as prior AV Fistula site bleeding (despite a CHADS2VASC
of ___.
# Diastolic Congestive Heart Failure complicated by Right Heart
Failure: The patient has moderate diastolic dysfunction with
preserved EF per last TTE in ___ ___s elevated right
heart pressures as well as RV systolic dysfunction (seen on TTE
as well as right heart cath). Her CHF was felt to be a major
contributor to her overall volume overload, which improved with
treatment of her influenza and dialysis.
# COPD on Home O2: The patient has PFTs from ___ c/w
restrictive lung disease but prior PFTs showing obstructive
disease. She was continued on her home inhaler regimen with
added duonebs PRN and discharged on her home oxygen regimen of
___ per NC.
# Mediastinal Lymphadenopathy: The patient was noted to have
mediastinal LAD on chest imaging, likely reactive due to
influenza. However, there was concern given poor follow that
this could be due to an alternate etiology such as lymphoma or
perhaps sarcoidosis. Initial work-up in the hospital was
unrevealing with normal LDH and negative ACE levels. Her 1,25
hydroxy Vitamin D levels to evaluate for Sarcoidosis were still
pending at time of discharge. She was instructed to follow up
with her PCP regarding results of this test and she should had
repeat Chest CT to re-evaluate for finding of mediastinal
lymphadenopathy.
# Thrush: The patient was found to have thrush on exam during
this admission, likely due to underlying ESRD as well as use of
oral steroid inhalers. She was provided nystatin swish and spit
with improvement in her thrush. She also had HIV serologies
re-sent, which were still pending at time of discharge. She
should follow up with her PCP regarding results of this test.
#Hypertension: The patient has history a history of hypertension
with blood pressures largely within normal limits during this
admission. She did have low blood pressures, likely triggered by
dialysis. She responded well to gentle intravenous fluid boluses
in the setting of her tenuous respiratory status. She was
continued on her fractionated metoprolol and her fluid status
was managed with HD as above. Her blood pressures were normal at
time of discharge.
CHRONIC/STABLE/RESOLVED ISSUES:
# Concern for Underlying Liver Disease: The patient was admitted
with elevated transaminases and INR as well as history of
concern for underlying liver disease. She had CT in ___ showing
nodular liver disease and perihepatic ascites. Prior Hep A,B,C
studies negative with Hep A/C negative as recently as ___.
The patient had RUQUS this admission, showing signs of
congestive hepatopathy suggesting acute contribution from her
volume overload. However, cirrhosis could not be ruled out. Her
transaminases were monitored closely during this admission and
she was treated for her CHF and ESRD as above. With these
measures, her liver function tests downtrended prior to
admission. She should have further work-up for possible
cirrhosis as an outpatient.
#GERD: The patient was admitted on oral PPI therapy, which was
briefly changed to IV PPI due to concern over active GI
bleeding. As above, her H&H stabilized and she was resumed on
her home omeprazole prior to discharge.
#Breast Cysts: The patient has a history of breast cysts and was
continued on her home topical clindamycin throughout this
admission.
TRANSITIONAL ISSUES:
-The patient had >1 point hemoglobin drop with self-reported
melena and guaiac positive stool. As her blood counts stabilized
prior to discharge, she did not receive further work-up as an
inpatient. She should follow-up with GI after discharge for
further evaluation.
-The patient should have repeat CBC drawn on ___ with
results faxed to Dr. ___ (PCP, fax number: ___
-As part of work-up for GI Bleed, the patient had H.Pylori
serologies sent during this admission. Results were still
pending at time of discharge and the patient should follow up on
these with her PCP.
-The patient was discharged with instructions to complete 14-day
course of Vancomycin 125mg PO q6H for her recurrent C. Diff
Colitis (First dose on ___ last dose on ___
-Given the patient's recurrent C Diff Colitis, the patient
should be arranged for stool transplant evaluation
-The patient should follow up with Dr. ___
(Pulmonology) for management of her Pulmonary Hypertension
-The patient received hemodialysis per her home schedule of
___. Her last HD session was on ___.
-On discharge, the patient's dry weight was 66.2kg
-The patient should follow up with her outpatient Nephrologist
regarding further management of her ESRD. Given her history of
hypotension during dialysis, would consider potentially starting
patient on Midodrine or other form of blood pressure support on
dialysis days.
-During this admission, the patient had elevated LFTs and mild
markers of synthetic liver dysfunction. He had RUQ Ultrasound
showing likely congestive hepatopathy but cirrhosis was not
ruled out. She should have further work-up for cirrhosis as an
outpatient.
-The patient was found to have incidental finding of mediastinal
lymphadenopathy on CTA of the Chest this admission. This should
be followed up with repeat CT as an outpatient. Inpatient
work-up for possible sarcoidosis was initiated with 1,25-OH
Vitamin D levels (pending at time of discharge). This should be
followed up with her PCP ___ pulmonologist.
-The patient was discharged on her home O2 requirement of ___
liters per nasal cannula
-Patient was discharged home on PO nystatin for thrush, likely
due to inhaled corticosteroid use
-The patient has endorsed leg pain both prior to and during this
admission, concerning for possible peripheral vascular disease.
She should have formal ABI's to evaluate as an outpatient.
-CODE STATUS: FULL CODE
-DRY WEIGHT: 66.2kg
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. albuterol sulfate 90 mcg/actuation inhalation Q6H
2. Nephrocaps 1 CAP PO DAILY
3. Calcium Acetate 667 mg PO DAILY
4. Cinacalcet 60 mg PO DAILY
5. Clindamycin 1% Solution 1 Appl TP DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Lidocaine-Prilocaine 1 Appl TP 3X/WEEK (___)
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO Q6H
Will need total 14 day course. First day ___ Last day
___.
RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp
#*39 Capsule Refills:*0
2. Clindamycin 1% Solution 1 Appl TP DAILY
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Lidocaine-Prilocaine 1 Appl TP 3X/WEEK (___)
5. Nephrocaps 1 CAP PO DAILY
6. Nystatin Oral Suspension 5 mL PO QID
RX *nystatin 100,000 unit/mL 5 ml by mouth four times a day
Refills:*0
7. albuterol sulfate 90 mcg/actuation inhalation Q6H
8. Aspirin 81 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Outpatient Lab Work
Please draw repeat CBC on ___ and have results faxed to Dr.
___ at ___.
Diagnosis: Anemia (ICD10: D64.9)
11. Calcium Acetate 667 mg PO TID W/MEALS
12. Omeprazole 40 mg PO DAILY
13. terconazole 0.8 % vaginal QHS:PRN vaginitis
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS/ES:
-Hypoxia due to Influenza A Infection
-Recurrent Clostridium Difficile Colitis
-Anemia of unclear etiology
-Thrombocytopenia of unclear etiology
-End-Stage Renal Disease on Hemodialysis
-Diastolic Congestive Heart Failure with Right Heart Failure
-Mediastinal Lymphadenopathy without Clear Etiology
-Thrush
-Congestive Hepatopathy
SECONDARY DIAGNOSIS/ES:
-Atrial Fibrillation
-Chronic Obstructive Pulmonary Disease on Home Oxygen
-History of Kidney Transplant with Allograft Nephropathy/Failure
-Gastroesophageal Reflux Disease
-Hypertension
-History of Breast Cysts
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 ___ because you were having trouble
breathing and were noted to have low blood pressures. You were
initially cared for in the intensive care unit (ICU) because
your potassium levels were high and needed urgent dialysis. In
the ICU, you received 2 sessions of dialysis, which helped your
breathing. As you were found to have the flu, you were treated
with a medication called Tamiflu. You were also started on an
antibiotic to treat your C Diff infection.
Upon transferring to the general medicine service, you were
found to have slowly decreasing blood counts. As you were having
black stools, there was significant concern for an intestinal
bleed. With close monitoring, your blood counts stabilized and
you were sent home with instructions to follow up with the
Gastroenterologists as an outpatient.
Prior to discharge, you received 1 more dialysis session and
were breathing more comfortably. You had also completed
treatment for the flu. It is important that you continue to take
your medications and follow up with your outpatient doctors ___
detailed in the rest of your discharge paperwork).
It is also very important that you weigh yourself every morning
and call your primary care physician if your weight changes by
more than 3 lbs.
Thank you for allowing us to be a part of your care,
Your ___ Team
Followup Instructions:
___
|
10055694-DS-25 | 10,055,694 | 24,232,904 | DS | 25 | 2121-03-06 00:00:00 | 2121-03-14 21:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Allopurinol And Derivatives / Penicillins / Ace Inhibitors
Attending: ___
Chief Complaint:
Hypotension (SBP in ___
Major Surgical or Invasive Procedure:
EGD ___
Capsule endoscopy ___
History of Present Illness:
Mrs. ___ is a ___ y/o woman with past history of ESRD from
focal segmental glomerulosclerosis s/p failed transplant on HD
(___), COPD, GERD (w/out PUD), atrial fibrillation not on
coumadin, congestive heart failure and severe right heart
failure, pulmonary hypertension, recurrent cdiff infection,
upper GI bleed from erosive gastritis and gastric ulcer, chronic
anemia, who was transferred from her dialysis center to the ED
for hypotension with SBP in ______s.
She was recently admitted to ___ in
___ with melena, hypotension, and acute on chronic anemia, and
was found to have upper GI bleed from two linear ulcerations in
the cardia. On the day of admission, she was found to have
hypotension with SBP in ___'s during dialysis, so she was sent to
the ED. She reported dark stools for approximately a week, which
she attributed to "recurrent C.dif". She denied dizziness, chest
pain, shortness of breath, abdominal pain, diarrhea. She noted
significant recent distention of her abdomen and some peripheral
edema. She denied jaundice in the past. On review of her
systems, she admits to shortness of breath and dyspnea on
exertion.
Patient was recently evaluated in outpatient ___ clinic
for new liver disease. She was noted to have an enlarged liver
and considered to have congestive hepatopathy. Her most recent
liver function tests show an alkaline phosphatase of 162 with a
normal ALT and AST of 15 and 24 respectively, negative test for
her serum ACE and ___, negative hepatitis B and hepatitis C
markers, normal C3 and C4. Rheumatoid factor is increased to 32.
She has elevated IgG. Alpha-1 antitrypsin was mildly elevated.
An ultrasound of the liver showed dilated inferior vena cava and
hepatic veins, consistent with right heart failure. She had
trace ascites at that time in ___. Of note, a chest CT from
___ showed innumerable mediastinal lymph nodes, mildly
enlarged, indeterminate, difficult to exclude lymphoma or other
etiologies.
In the ED initial vitals: 97.2 82 84/49 18 98% RA
Exam was notable for: Gauaic + dark stool
- Labs were notable for:
WBC 6.3 H/H 7.3/25.3 Platelets 260
___: 12.8 PTT: 32.6 INR: 1.2
ALT: 10 AP: 171 Tbili: 0.7 Alb: 3.8
AST: 25 LDH: 201
Na 136 K 3.5 Cr 2.3
Ca: 8.8 Mg: 1.8 P: 1.6
Lactate:1.2
Diagnostic para: WBC 733 RBC ___ Poly 5 Lymph 30
Protein 5.0 Glucose 104
Patient was given:
Octreotide Acetate 100 mcg IV Q8H
Ciprofloxacin 400 mg IV ONCE
Pantoprazole 40 mg IV ONCE
2units pRBCs
Imaging included CT abdomen and CXR (see below for details)
Vitals prior to transfer: 98.9 71 90/47 20 100% RA
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, dysuria, hematuria.
Past Medical History:
PAST MEDICAL HISTORY:
- ESRD s/p Transplant- FSGS by biopsy, on HD ___. s/p
DCDKD in ___ c/b chronic allograft nephropathy in ___ with
reinitiation of HD (on MWF schedule). Complicated by
intradialytic hypotension
- Atrial Fibrillation - not on anticoagulation due to
significant gastrointestinal as well as AV fistula site bleeding
- Bradycardia
- COPD - on ___ home oxygen; FEV1 of 57% predicted ___
- Diastolic CHF - Last TTE in ___ with EF>55%, symmetric LVH,
dilated RV with borderline systolic function and severe
pulmonary HTN; small septum secundum
- Claudication with concern for peripheral vascular disease - no
formal arterial duplex studies on record
- GERD
- Gout
- HSV II
- HTN
- Pulmonary HTN - no prior documentation, but likely group 3
- Tobacco abuse
- Anemia
- GI Bleed
- Recurrent C. Diff Colitis - Initially diagnosed in ___ and
treated with flagyl 500mg x 10 days; again in ___ s/p flagyl
500mg x 14 days, persistent infection still later in ___,
treated with vanco 125mg PO x14days
- H/O syphilis
- H/O Breast Cysts
PAST SURGICAL HISTORY:
- Open cholecystectomy ___
- Tubal ligation, with incision from midline to pubis
- Exploratory laparotomy for ovarian cyst, negative
Social History:
___
Family History:
Mother on dialysis from diabetes mellitus
Niece with ESRD, s/p transplant
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
VITAL: Afebrile 100/70 80 18 99% RA
GENERAL: Well appearing in NAD.
HEENT: Exostropia bilaterally, sclera anicteric
CARDIAC: Irregular with no excess sounds appreciated
LUNGS: Unlabored resp, adequate air movement, prolonged
expiratory phase
ABDOMEN: soft, distended, non-tender to palpation, hepatomegaly
is present
EXTREMITIES: Trace pitting edema in ___ bilaterally, warm and
well perfused, tender to palpation
NEUROLOGY: No asterixis, no sensory or motor deficits noted
PHYSICAL EXAM ON DISCHARGE:
===========================
VS: 98.7 85 111/57 18 97 RA
GENERAL: NAD, pleasant, sitting comfortably in chair
HEENT: OP clear, anicteric sclera, apparent proptosis and
exotropia, pale conjunctiva
CARDS: Irregularrly irregular, no murmurs, rubs, gallops
PULM: CTAB, no wheezes, rales, rhonchi
ABDOMEN: Soft, mild epigastric tenderness, mild distension but
soft, normoactive bowel sounds, no organomegaly
EXTREMITIES: Warm, no edema
ACCESS: LUE AVG; good thrill/bruits heard
NEURO: No asterixis
Pertinent Results:
LAB RESULTS ON ADMISSION:
=========================
___ 10:45AM BLOOD WBC-6.3 RBC-2.40* Hgb-7.3* Hct-25.3*
MCV-105* MCH-30.4 MCHC-28.9* RDW-20.8* RDWSD-78.9* Plt ___
___ 10:45AM BLOOD ___ PTT-32.6 ___
___ 10:45AM BLOOD Glucose-89 UreaN-14 Creat-2.3*# Na-136
K-3.5 Cl-95* HCO3-30 AnGap-15
___ 10:45AM BLOOD ALT-10 AST-25 LD(LDH)-201 AlkPhos-171*
TotBili-0.7
___ 10:45AM BLOOD Albumin-3.8 Calcium-8.8 Phos-1.6* Mg-1.8
___ 06:30PM BLOOD Hgb-8.6* calcHCT-26
___ 12:00PM ASCITES WBC-733* ___ Polys-5* Lymphs-30*
___ Mesothe-6* Macroph-59* Other-0
___ 12:00PM ASCITES TotPro-5.0 Glucose-104
PERTINENT INTERVAL LABS:
========================
___ 06:08AM BLOOD CA125-276*
___ 03:10PM ASCITES TotPro-5.2 Albumin-2.5
___ 05:47AM BLOOD Albumin-3.6 Calcium-8.6 Phos-6.6* Mg-1.9
___ 13:11
IGG SUBCLASSES 1,2,3,4
Test Result Reference
Range/Units
IMMUNOGLOBULIN G SUBCLASS 1 1850 H 382-929 mg/dL
IMMUNOGLOBULIN G SUBCLASS 2 ___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 3 74 ___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 4 359 H ___ mg/dL
IMMUNOGLOBULIN G, SERUM 2402 H ___ mg/dL
LAB RESULTS ON DISCHARGE:
=========================
___ 06:08AM BLOOD WBC-6.4 RBC-2.73* Hgb-8.2* Hct-28.6*
MCV-105* MCH-30.0 MCHC-28.7* RDW-20.1* RDWSD-76.2* Plt ___
___ 06:08AM BLOOD ___ PTT-31.7 ___
___ 06:08AM BLOOD Glucose-140* UreaN-12 Creat-3.8* Na-136
K-3.6 Cl-94* HCO3-32 AnGap-14
___ 06:08AM BLOOD ALT-7 AST-14 AlkPhos-124* TotBili-0.8
___ 06:08AM BLOOD Albumin-3.4* Calcium-8.2* Phos-3.8 Mg-1.7
RADIOLOGY:
==========
___ CT ABDOMEN/PELVIS:
1. Abnormal soft tissue prominence in the bilateral adnexa,
right-greater-than-left. Recommend correlation with prior
clinical history
(including prior fallopian tube exploration?) and cytology
results from recent
paracentesis. If results are nondiagnostic, an MRI of the
pelvis with IV
contrast should be considered to exclude underlying malignancy,
especially in
light of enlarged retroperitoneal lymph nodes.
2. Cirrhotic liver morphology.
3. Moderate amount of nonhemorrhagic ascites.
4. Prominent intramural fat in the cecum and ascending ___,
___ reflect
chronic inflammation.
5. Right lower quadrant transplanted kidney is abnormal in
appearance ;
atrophic with loss of normal corticomedullary differentiation.
6. Renal osteodystrophy.
RECOMMENDATION(S): Correlation with clinical history and
cytology results. Consider pelvis MRI for further evaluation.
___ CXR:
--------------
Mild pulmonary edema. No focal consolidation.
PATHOLOGY:
==========
___ CYTOLOGY, ASCITIC FLUID
NEGATIVE FOR MALIGNANT CELLS.
- Predominantly blood with scattered admixed mesothelial cells
and lymphocytes.
GI ENDOSCOPY:
=============
___ EGD
--------------
Large hiatal hernia was noted
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
Mrs. ___ is a ___ y/o woman with complicated past history
most notable for severe right heart failure, pulmonary
hypertension, upper GI bleed from erosive gastritis and gastric
ulcer and ESRD from focal segmental glomerulosclerosis s/p
failed transplant on HD (___), who was transferred from her
dialysis center to the ED for hypotension with SBP in ___ in
setting of melena.
CT abdomen/pelvis performed in ED is notable for abnormal soft
tissue prominence in bilateral adnexa, R>L; cytology of ascitic
fluid negative for malignancy, and diagnostic paracentesis was
negative for SBP. ___ EGD only notable for hiatal hernia, no
bleed. She had an additional episode of melena on ___ and the
decision was made to proceed with capsule endoscopy on ___. The
preliminary read showed some possible AVMs in the jejunum, but
no active source of bleeding. She had no further episodes of
melena, her blood pressure improved to SBP 100s and her
hemoglobin was stable. We planned to do an echocardiogram during
this admission to reassess her right heart failure, but we were
unable to get this study done and she was eager to be
discharged. She received 2 U pRBC throughout stay; discharge Hgb
was 8.2; she was hemodynamically stable.
# Hypotension/ acute on chronic anemia/ melena: One week history
of melena prior to presentation, in context of recent admission
for upper GI bleed with endoscopy showing linear gastric ulcer
as well as erosive gastritis as well as prior history of
recurrent C.diff. She was initially treated with IV pantoprazole
q12H, octreotide gtt, and ciprofloxacin 400 mg IV q24H due to
concern for UGIB. ___ EGD only notable for hiatal hernia, no
bleed; hence octreotide was discontinued at that time. She had
an additional episode of melena on ___ and the decision was
made to proceed with capsule endoscopy on ___. The preliminary
read showed some possible AVMs in the jejunum, but no active
source of bleeding. She had no further episodes of melena, her
blood pressure improved to SBP 100s and her hemoglobin was
stable; 8.2 on discharge.
# Ascites: CT abdomen notable for cirrhotic liver morphology,
moderate ascites, and abnormal soft tissue prominence in
bilateral adnexa, R>L. She has had prior work up with negative
hepatitis B and C serologies, no alpha 1 antitrypsin deficiency,
normal C3, C4, ___. Differential diagnosis for her includes
cardiac cirrhosis given elevated protein at 5 (>2.5) and her
history of R heart failure which would be consistent with
elevated SAAG of 1.1 on ___. Meig's syndrome/malignancy is also
under consideration given the fullness in adnexa and ascites, in
setting of an elevated CA 125. Cytology negative for malignant
cells. Typically would consider MRI pelvis with contrast to
further evaluate however patient is very claustrophobic; please
discuss further work up as an outpatient.
# Elevated IgG: IgG was recently found to be elevated to 2455,
raising concerns for plasma cell disorders, leukemia, and
lymphoma among other disease, especially with abnormal findings
on CT chest and abdomen. IgG 1 and 4 ___s total IgG were
found to be elevated on the sub-type analysis. Please consider
immunology referral
# Anuric End-Stage Renal Disease s/p cadaveric donor renal
transplant complicated by allograft failure, re-initiated on HD
___.
- Continue dialysis per renal team
# Atrial Fibrillation: CHADS2-VASC score 3, not currently on
anticoagulation given history of GI and AV fistula bleed. Home
metoprolol was held due to concern for hypotension.
# Diastolic Congestive Heart Failure complicated by Right Heart
Failure: The patient has moderate diastolic dysfunction with
preserved EF per last TTE in ___ ___s elevated right
heart pressures as well as RV systolic dysfunction (seen on TTE
as well as right heart cath). Patient mildly volume up on exam,
but saturating well on home O2 requirement. We had planned on
obtaining a repeat echocardiogram, however this was not done and
patient was eager to leave. Home metoprolol was held due to
concern for hypotension.
# Chronic obstructive pulmonary disease: Patient last had
pulmonary function testing in ___, which showed moderately
reduced FVC, moderately severe reduction in FEV1, with elevated
FEV1/FVC, thought to reflect moderately severe obstructive
disease. She was continued on home albuterol neb Q4H as needed
and advair (250/50) twice a day
# GERD: Patient takes PO omeprazole 40mg QD at home, which was
switched to IV pantoprazole 40mg BID in setting of melena
TRANSITIONAL ISSUES
===================
[ ] Findings of new ascites and adnexal fullness on CT are
concerning for malignancy especially in setting of elevated CA
125 to 276 (though it is noted that CA 125 is nonspecific and
shouldn't be used as screening test for ovarian cancer).
Cytology negative. Please consider MRI to further evaluate,
though patient reports she is extremely claustrophobic.
[ ] Capsule study results are pending at the time of discharge.
Please follow up and refer to outpatient GI or book further
testing/procedures as needed. Hgb on discharge is 8.2
[ ] Consider outpatient echocardiogram given new ascites, known
right heart failure and last echo ___.
[ ] Given recent finding of elevated total IgG on testing sent
by outpatient hepatology, IgG subclasses were sent and revealed
elevated IgG1 and IgG 4. Further workup per outpatient
hepatology.
# Code: Full
# Communication: ___ (sister and HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation Q6H
2. Aspirin 81 mg PO DAILY
3. Calcium Acetate 667 mg PO TID W/MEALS
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Lidocaine-Prilocaine 1 Appl TP 3X/WEEK (___)
6. Nephrocaps 1 CAP PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q24H Duration: 4 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth once a
day Disp #*4 Tablet Refills:*0
2. albuterol sulfate 90 mcg/actuation inhalation Q6H
3. Aspirin 81 mg PO DAILY
4. Calcium Acetate 667 mg PO TID W/MEALS
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Lidocaine-Prilocaine 1 Appl TP 3X/WEEK (___)
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Nephrocaps 1 CAP PO DAILY
9. Pantoprazole 40 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Upper GI bleed
Secondary: Congestive heart failure, ESRD
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 ___
because your blood pressure was low.
As you were recently in the hospital because of a bleeding ulcer
in your stomach, we wanted to make sure that you are no longer
bleeding. Therefore we did a upper endoscopy, which did not show
any bleeding. However, you had some more dark stools and your
blood counts dropped. Hence we gave you blood, and did a capsule
endoscopy, which can look further for sources of bleeding. A
very preliminary look at the study did not show any active
bleeding, but showed some possible culprits in the first part of
your small intestine. The full report will be done soon and
should be available to your PCP at your follow up appointment.
We also noticed that your belly was very distended with fluid.
This can happen for many reasons- for instance, right sided
heart failure (which you have a history of) causing liver
problems, a sick liver, or cancer. We took some of the fluid out
to both take a closer look and to make you feel better. We also
did a CT scan, and obtained an ultrasound of your heart (Echo).
The CT scan showed that you have some fullness in your adnexa
(where your ovaries and tubes are), and we are waiting for the
results of the fluid we sent out to look for cancer. We also
planned to check an echocardiogram (an ultrasound of your
heart). Unfortunately, we were not able to get this study done
for you while you were here. This can be ordered by your PCP or
your cardiologist and done as an outpatient.
Please follow up with your primary care doctor this week. Please
also follow up with your liver doctor, ___ in the
next few weeks.
Best wishes,
Your ___ Team
Followup Instructions:
___
|
10055694-DS-26 | 10,055,694 | 26,271,755 | DS | 26 | 2121-09-24 00:00:00 | 2121-09-24 22:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Allopurinol And Derivatives / Penicillins / Ace Inhibitors /
lisinopril
Attending: ___.
Chief Complaint:
fistula ulceration
Major Surgical or Invasive Procedure:
AV Fistula Revision ___
___ guided paracentesis ___
History of Present Illness:
___ w/ PMH of ESRD s/p failed renal transplant on HD, AFib, COPD
on 3L O2, CHF, pulmonary HTN, cryptogenic cirrhosis, presents
with ulceration over her AV fistula.
Patient notes that the ulcer developed one week ago after she
had removed tape from the site of ulcer (note: she reports that
she normally applies cream to the fistula site and covers it
with tape). Ulceration then noticed by outpatient HD RN two days
ago and advised patient to come in, however patient refused at
that time. This morning, she went to dialysis, who referred her
here as they were unable to access her HD site. Her last HD
session was ___. She reports that the ulceration has been
present for approximately one week and that she has been
applying lidocaine-prilocaine cream to the area. It is pruritic.
She denies purulence, erythema, or discharge. No fevers, chills,
chest pain, shortness of breath.
In the ED, initial vital signs were: T98 HR94 BP101/53 RR 15
SaO2 95% Nasal Cannula
- Exam notable for: L arm fistula w/ palpable thrill, ~1 cm
healed ulceration with mild tenderness, no erythema or
discharge, RRR, scattered wheezes bilaterally, breathing
comfortably, abdomen distended, tense, non-tender, 1+ edema
bilaterally.
- Labs were notable for Cr 5.9, Hgb 9.2, WBC 6.3, AP 231, LFTs
normal, Albumin 3.3, INR 1.3.
- Studies performed include CXR (demonstrated pulmonary vascular
congestion, diffuse bilateral interstitial edema, small right
pleural effusion, bilateral linear atelectasis)
- Patient was given midodrine, calcium acetate, gabapentin 100
mg, albuterol neb, diskus, Tylenol. She had an HD session prior
to arriving on the floor.
- Vitals on transfer: 98.1, 91/50, 80, 20, 98% 3L
Upon arrival to the floor, the patient was hungry and wanted to
eat. Also endorsed pain and numbness in her right foot, which
she often has after dialysis. Denies abdominal pain
REVIEW OF SYSTEMS:
(+) per HPI
(-) otherwise
Past Medical History:
PAST MEDICAL HISTORY:
- ESRD s/p Transplant- FSGS by biopsy, on HD ___. s/p
DCDKD in ___ c/b chronic allograft nephropathy in ___ with
reinitiation of HD (on MWF schedule). Complicated by
intradialytic hypotension
- Atrial Fibrillation - not on anticoagulation due to
significant gastrointestinal as well as AV fistula site bleeding
- Bradycardia
- COPD - on ___ home oxygen; FEV1 of 57% predicted ___
- Diastolic CHF - Last TTE in ___ with EF>55%, symmetric LVH,
dilated RV with borderline systolic function and severe
pulmonary HTN; small septum secundum
- Claudication with concern for peripheral vascular disease - no
formal arterial duplex studies on record
- GERD
- Gout
- HSV II
- HTN
- Pulmonary HTN
- Tobacco abuse
- Anemia
- GI Bleed
- Recurrent C. Diff Colitis
- H/O syphilis
- H/O Breast Cysts
- PELVIC MASS
- ASCITES
- Cryptogenic CIRRHOSIS
PAST SURGICAL HISTORY:
- Open cholecystectomy ___
- Tubal ligation, with incision from midline to pubis
- Exploratory laparotomy for ovarian cyst, negative
Social History:
___
Family History:
She denies a family history of liver disease. Family history of
father with atherosclerotic CVD. Mother with diabetes on
dialysis. No history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.1, 91/50, 80, 20, 98% 3L
GENERAL: AOx3, NAD
HEENT: Scleral icterus, MMM
NECK: normal ROM
CARDIAC: Regular rate and rhythm, normal s1 and s2
LUNGS: Coarse crackles in left lower lung fields, otherwise
clear to auscultation
ABDOMEN: Distended tense abdomen, dull to percussion, +shifting
dullness, nontender to palpation
EXTREMITIES: 1+ lower extremity edema, pitting to mid-shins
SKIN: LUE fistula with 2cm area of ulceration without active pus
or overlying erythema
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation.
DISCHARGE PHYSICAL EXAM:
VS: 98.3, 94/58, 76, 20, 100% RA
GENERAL: AOx3, NAD
HEENT: Scleral icterus, significant exotropia OD, MMM
NECK: normal ROM
CARDIAC: Regular rate and rhythm, normal s1 and s2
LUNGS: breathing nonlabored, CTA anteriorly
ABDOMEN: Distended abdomen, dull to percussion, somewhat tense,
nontender, hypoactive BS
EXTREMITIES: WWP, no extremity edema
SKIN: LUE fistula with surgical dressing c/d/i
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation.
Pertinent Results:
ADMISSION LABS:
---------------
___ 08:05AM BLOOD WBC-6.3 RBC-3.24* Hgb-9.2* Hct-30.5*
MCV-94 MCH-28.4 MCHC-30.2* RDW-19.5* RDWSD-66.9* Plt ___
___ 08:05AM BLOOD Neuts-61.6 ___ Monos-12.7 Eos-3.0
Baso-0.8 Im ___ AbsNeut-3.87 AbsLymp-1.36 AbsMono-0.80
AbsEos-0.19 AbsBaso-0.05
___ 08:05AM BLOOD ___ PTT-36.5 ___
___ 08:05AM BLOOD Plt ___
___ 08:05AM BLOOD Glucose-111* UreaN-41* Creat-5.9* Na-139
K-4.2 Cl-98 HCO3-27 AnGap-18
___ 08:05AM BLOOD ALT-11 AST-21 LD(LDH)-145 AlkPhos-231*
TotBili-0.8
___ 08:05AM BLOOD Albumin-3.3* Calcium-9.0 Phos-4.1 Mg-1.9
DISCHARGE LABS:
----------------
___ 09:35AM BLOOD WBC-6.8 RBC-3.23* Hgb-9.0* Hct-30.4*
MCV-94 MCH-27.9 MCHC-29.6* RDW-19.5* RDWSD-65.1* Plt ___
___ 09:35AM BLOOD Plt ___
___ 09:35AM BLOOD Glucose-97 UreaN-32* Creat-6.1*# Na-135
K-5.0 Cl-93* HCO3-31 AnGap-16
___ 09:35AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.9
IMAGING:
---------
CXR ___
1. Mild-to-moderate pulmonary vascular congestion, diffuse
bilateral
interstitial edema, and trace right pleural effusion suggest
volume overload.
2. Bilateral linear atelectasis.
PARACENTESIS ___
Technically successful ultrasound-guided therapeutic
paracentesis, yielding 4
L of clear, straw-colored ascitic fluid.
Brief Hospital Course:
___ w/ PMH of ESRD s/p failed renal transplant on HD, AFib, COPD
on 3L O2, CHF, pulmonary HTN, cryptogenic cirrhosis, presenting
with ulceration over her AV fistula.
# AVF ulceration: New ulceration on site of AVF, perhaps from
patient self-applying tape over the fistula. Underwent fistula
revision ___.
# ESRD s/p ECD kidney transplant in ___ c/b chronic allograft
nephropathy: Chronic focal segmental glomerulosclerosis. Was on
dialysis from ___. Had a transplant in ___, but failed in
___. Resumed dialysis in ___, MWF with LUE AVF. Continued home
medications. Had session of HD ___ prior to discharge without
complications. Resume MWF schedule.
# Anemia: Likely from low epo and anemia of chronic disease.
Continued Epo 60,000U qHD
# Cryptogenic cirrhosis: Perhaps cardiac cirrhosis in setting of
right-sided heart failure. Complicated by portal hypertension
with ascites and splenomegaly. Up to date on variceal and HCC
screening based on most recent Hepatology note. Last EGD ___ found large hiatal hernia. Has q2 week paracentesis, due
again on ___. Received ___ guided paracentesis on ___ with
4L fluid removed.
#Concern for gyn malignancy: Concern for ovarian or other
malignancy as a cause of ascites, elevated CA-125 (276 on
___. Patient was offered MRI as an inpatient (both
sedated or regular with premedication) but declined despite
counseling of the risks. She reports that she did not want to be
out of it with breathing support but also could not be enclosed.
She raised the idea of an open MRI and discussed that image
quality is not as good but patient was adamant. Primary care
doctor was contacted regarding open MRI.
# Aflutter
# Afib: Was previously on Coumadin and carvedilol. The Coumadin
was stopped in ___ secondary to frequent fistula bleeding
events. It was restarted in ___. Risk of hemorrhagic
stroke is higher with warfarin use in ___ HD patients. No
current anticoagulation.
# COPD: On 3L home O2 since ___. Continued home management.
# Chronic diastolic heart failure
# Pulmonary hypertension: Seen by cardiology in ___. Not
on any cardiac meds due to hypotension. Unable to aggressively
remove fluid with UF due to hypotension as well.
# GERD: Continued home pantoprazole
TRANSITIONAL ISSUES:
- Patient needs open MRI to evaluate for possible malignancy
#Code Status: Presumed full code
#Emergency Contact/HCP: ___ (___),
alternate contact is ___, sister (___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Nephrocaps 1 CAP PO DAILY
5. Calcium Acetate 667 mg PO TID W/MEALS
6. Pantoprazole 40 mg PO Q24H
7. HydrOXYzine 25 mg PO Q4H:PRN pruritis
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
3. Calcium Acetate 667 mg PO TID W/MEALS
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. HydrOXYzine 25 mg PO Q4H:PRN pruritis
6. Nephrocaps 1 CAP PO DAILY
7. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
AV Fistula Ulceration
ESRD on HD
Cryptogenic cirrhosis
COPD on home O2
atrial fibrillation/flutter
portal hypertension with ascites and splenomegaly
chronic diastolic heart failure
pulmonary hypertension
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you had a problem with
your fistula.
It was fixed in a procedure called a fistula revision.
You had a dialysis session on ___ that went well so you can
continue your regular dialysis schedule.
You had a lot of fluid in your abdomen that was removed by our
radiology team. You need an MRI of your abdomen to help figure
out why you have all of this fluid building up. You were offered
this test while you were here but you felt claustrophobic and
you did not want to be sedated either. Instead you were hoping
to have an open MRI. Please talk to your primary care doctor
about scheduling this important test.
Please see your follow-up appointments below.
It was a pleasure caring for you and we wish you the best,
Your ___ Team
Followup Instructions:
___
|
10056223-DS-14 | 10,056,223 | 28,021,043 | DS | 14 | 2121-11-16 00:00:00 | 2121-11-16 20:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
No paracentesis
History of Present Illness:
___ yo ___ speaking M with HCV, EtOH cirrhosis, ___ s/p TACE
x2 and RFA, current MELD score 9, on transplant list recurrent
C. diff presents with abdominal pain and hepatic encephalopathy.
Of note, patient was admitted to ___ (___) x 8 days for
increased hepatic encephalopathy and supposed discharged on
___. However, he was noted to have abdominal pain with
tremulousness. The abdominal pain started about 1 day ago. He
endorses subjective fever and chill but it is not documented. He
thinks that his encephalopathy is improving. He reports having
3BM a day.
In the ED, initial vitals were 98.4 81 118/52 20 100% ra. Exam
was notable for A&Ox3, + abdominal distention with + fluid wave.
However, ultrasound did not show drainable pocket. Paracentesis
was not done. Blood culture x 1 was sent. Labs are notable for
normal WBC, 10.1/31.6, Plt 123, normal neutrophils %, ALT 51,
AST 77, TBili 0.5, AP 163, Albumin 2.8, normal creatinine 0.7,
normal electroltyes, normal lactate. INR is 1.3. RUQ U/S showed
patent portal vein, patent umbilical vein, an ecogenic focus ~ 2
cm at the right lobe correlating with previous RFA site, a 1.5
cm echogenic site along the medial right lobe without clear
correlate compared to prior images. Patient was given zofran 2
mg x1 IV, lactulose 30 mL x 1. Upon transfer, VS 98.0 76 104/67
16 100%
Past Medical History:
1. HCC s/p TACEx 2 with CT in ___ negative for recurrence
2. HCV
3. H/O ETOH abuse with resulting cirrhosis
4. Hypertension
5. Thrombocytopenia.
6. s/p chole ___
7. 3 episodes of C diff infection: ___
Social History:
___
Family History:
He is divorced, has two kids in ___. There is no
known liver cancer or liver disease in his family.
Physical Exam:
ADMISSION
VS: 97.5 130/83, 72, 100% RA respiratory rate is not labored or
fast,
GENERAL: NAD, slightly jaundiced
HEENT: Sclera icteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, S1 S2 clear and of good quality without murmurs, rubs
or gallops. No S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Distended but Soft, tender to palpation R>L, no
guarding. + fluid wave shift.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
___ bilaterally to knees.
DISCHARGE
VS: Tc 98.3 Tmax 99.2 BP 107/83 (101-113) HR 69 (69-82) RR 18
100% RA
GENERAL: NAD, slightly jaundiced
HEENT: Sclera icteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, S1 S2 clear and of good quality without murmurs, rubs
or gallops. No S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Distended but Soft, tender to palpation R>L, no
guarding. Dull to percussion.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
___ bilaterally to knees.
Pertinent Results:
___ 08:20PM BLOOD WBC-5.3 RBC-3.51* Hgb-10.1* Hct-31.6*
MCV-90 MCH-28.7 MCHC-31.9 RDW-15.8* Plt ___
___ 08:37PM BLOOD ___ PTT-35.1 ___
___ 08:20PM BLOOD Glucose-160* UreaN-12 Creat-0.7 Na-133
K-3.9 Cl-101 HCO3-27 AnGap-9
___ 08:20PM BLOOD ALT-51* AST-77* AlkPhos-163* TotBili-0.5
___ 08:20PM BLOOD Albumin-2.8*
___ 06:33AM BLOOD Albumin-4.3 Calcium-8.7 Phos-1.9* Mg-1.9
___ 08:30PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
IMAGING
U/S ___
1. Patent main portal vein with hepatopetal flow. Recanalized
umbilical
vein.
2. Echogenic focus in the right lobe of the liver, most likely
correlates to
patient's RFA site. Additional 1.5 cm echogenic focus along the
medial edge
of the right lobe of the liver, difficult to discern whether
intra- or
extra-hepatic, no clear correlate on recent prior CT/MRI.
Correlate with
nonurgent, multiphase CT or MRI for better characterization.
3. Status post cholecystectomy. Common bile duct not
identified.
MRI ___ Prelim
1. Stable size of the previously RF ablated lesion within the
right lobe of the liver. Perilesional hyperenhancement is again
noted which may be
perfusional in nature; however continued surveillance is
advised.
2. No lesions suspicious for hepatocellular carcinoma.
3. Features consistent with cirrhosis and portal hypertension.
4. Replaced left hepatic artery arising from the left gastric
artery and
replaced right hepatic artery arising from the superior
mesenteric artery.
5. Stable left retroperitoneal cystic lesion, likely
lymphangioma.
DISCHARGE
___ 06:25AM BLOOD WBC-4.5 RBC-3.47* Hgb-10.1* Hct-31.3*
MCV-90 MCH-29.0 MCHC-32.1 RDW-15.7* Plt ___
___ 06:25AM BLOOD ___ PTT-40.9* ___
___ 06:25AM BLOOD Glucose-138* UreaN-16 Creat-0.8 Na-131*
K-4.6 Cl-98 HCO3-23 AnGap-15
___ 06:25AM BLOOD ALT-39 AST-61* AlkPhos-131* TotBili-0.9
___ 06:25AM BLOOD Calcium-9.3 Phos-4.0 Mg-1.7
___ 11:51AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-14
___ ___ 11:51AM CEREBROSPINAL FLUID (CSF) TotProt-28 Glucose-72
Brief Hospital Course:
HOSPIAL COURSE
___ yo ___ speaking M with HCV, EtOH cirrhosis, HCC s/p TACE
x2 and RFA, current MELD score 9, on transplant list recurrent
C. diff presents with abdominal pain and possible hepatic
encephalopathy. RUQ U/S showed patent portal vein and a new
echogenic area in the medial aspect of the right lobe. We
treated empirically for SBP with CTX and gave albumin, however
repeat attempt at para found nothing to drain. CTX discontinued
after one dose and patient remained afebrile. MRI done ___ to
assess for the mass seen on RUQ did not show changes concerning
for HCC and AFP was wnl. Lipase/Amylase also normal. Pt was
maintained on lac/rif. On ___ patient developed headache and
neck pain. Was afebrile. Given a dose of acyclovir overnight. LP
in AM showed no evidence of bacterial or viral meningitis. RPR
negative, C.diff negative. Discharged with lab draw to take
place on ___ with results to be faxed to Dr. ___ in
transplant clinic where he has follow up on ___. Sent out on
home meds (furosemide 40, spironolactone 150, nadolol 20,
omeprazole 40bid).
ACTIVE ISSUES
# Abdominal Pain. RUQ U/S did not show obstructive pathology as
portal vein and umbilical veins are patent. However, it did show
a new echogenic area in the medial aspect of the right lobe that
is unable to get correlated with previous scans. In addition,
given recent report of worsening mental status and abdominal
pain, we are treating empirically for SBP, however repeat
attempt at ___ found nothing to drain. Records from ___
___ show he did not have a tap then. MRI showed no changes
concerning for HCC.
# AMS. Likely ___ hepatic encephalopathy vs. infectious (such as
SBP). UA is unremarkable. RUQ U/S without portal vein
thrombosis. Lung exam is benign. He denied any respiratory
symptoms. Continued on lac/rif. Developed headache on ___.
Initial LP unsuccessful. Overnightw as given a dose of acyclovir
but LP on ___ showed no signs of meningitis.
# HCV/EtOH cirrhosis and HCC w/p TACE and RFA. On transplant
list. RUQ initially concerning for new mass, but AFP wnl and MRI
did not show changes concerning for new cancer.
# Hct Drop: On ___ had a hematocit drop. Guiaic negative. Pt
did not endorse melena. Repeat Hct stable. Continued omeprazole
and nadalol.
INACTIVE ISSUES
# Ascites. No tapable pocket found on repeat U/S. Initially held
home lasix and spironolactone, but restarted him on home dose of
furosemide 40mg and spironolactone 150.
# RENAL: Crt stable at 0.7
TRANSITIONAL ISSUES
# f/u CSF HSV PCR, BCX data (NGTD), Lyme serology, EBV IgG, IgM
# f/u ___ lab draw for LFTs, CBC, ___, Chem 7
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient discharge summary from
___.
1. Clotrimazole 1 TROC PO 5X/DAY
2. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
3. Furosemide 40 mg PO DAILY
4. Nadolol 20 mg PO DAILY
5. Omeprazole 40 mg PO BID
6. Spironolactone 150 mg PO DAILY
7. Lactulose 30 mL PO QID
8. Rifaximin 550 mg PO BID
Discharge Medications:
1. Clotrimazole 1 TROC PO 5X/DAY
RX *clotrimazole 10 mg 1 troche five times a day Disp #*150 Unit
Refills:*2
2. Lactulose 30 mL PO QID
RX *lactulose 20 gram/30 mL 30 mL by mouth four times a day Disp
#*1 Bottle Refills:*0
3. Nadolol 20 mg PO DAILY
RX *nadolol 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
4. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Tablet Refills:*2
5. Simethicone 80 mg PO QID:PRN gas pain
RX *simethicone 80 mg 1 tab by mouth four times a day Disp #*120
Tablet Refills:*2
6. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*2
7. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
RX *ergocalciferol (vitamin D2) [Vitamin D2] 50,000 unit 1
capsule(s) by mouth QWeek Disp #*4 Capsule Refills:*2
8. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
9. Spironolactone 150 mg PO DAILY
RX *spironolactone 50 mg 3 tablet(s) by mouth daily Disp #*90
Tablet Refills:*2
10. Outpatient Lab Work
Please draw LFTs, CBC, ___, Chem 7 on ___ and fax to
liver transplant clinic ___
Discharge Disposition:
Home
Discharge Diagnosis:
Alcoholic Cirrhosis
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. You were admitted
for abdominal pain and some confusion. Initially we were
concerned about infection of the fluid in your abdomen. We tried
to sample fluid from your abdomen to look for infection but
found none to drain. You remained without signs of infection
after we stopped antibiotics.
An ultrasound also showed a new mass in your liver, so we did an
MRI to better assess this mass, and currently we are NOT
concerned about recurrence of liver cancer.
Please have laboratory studies drawn on ___ and they will
fax your results to the Transplant Clinic.
Also please keep your appointment with Dr. ___
primary care doctor.
We have given you a medicine, SIMETHICONE for gas pain.
Otherwise we have not made any changes to your medicines from
admission. We have given you a prescription for all your
medicines so that you can be sure of what you should be taking.
Followup Instructions:
___
|
10056223-DS-15 | 10,056,223 | 21,531,192 | DS | 15 | 2121-12-17 00:00:00 | 2121-12-20 18:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending: ___
Chief Complaint:
Chest Pa
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with HCV and EtOH cirrhosis on the transplant
list, complicated by ___ s/p TACE x2 and RFA and ascites, and
recurrent C. difficile colitis presents with increasing
abdominal distention, bilateral lower extremity swelling, and
occasional non-pleuritic, non-exertional chest pain for 3 days.
Patient denies fevers, chills, or cough. Patient states that he
is otherwise feeling well, with mild RUQ pain. He does report
medication compliance and has not had any changes in bowel or
bladder habits and is passing gas.
He was recently admitted from ___ with abdominal
pain and ?hepatic encephalopathy. A liver mass was noted on
ultrasound, but follow-up MRI and AFP were within normal limits.
LP was performed due to new onset headache and altered mental
status and was also within normal limits. He was maintained on
lactulose and rifaximin. C. diff was negative on this admission
and no etiology was ascribed to his pain. He was sent home
without medication changes.
In the ED, initial vitals were: 98.2 72 113/65 14 100% RA. Exam
was notable for bilateral lower extremity edema and atypical
chest pain. EKG was consistent with prior, showing NSR and TWI
inferiorly. RUQ ultrasound ruled out PVT and bedside ultrasound
did not show any ascites or pericardial effusion. KUB was done
to assess the abdominal distension and the read is pending.
Hepatology was consulted and recommended admission to complete
rule out.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
1. ___ s/p TACEx 2 with CT in ___ negative for recurrence
2. HCV and EtOH abuse with resulting cirrhosis
3. Hypertension
4. Thrombocytopenia
5. s/p chole ___
6. 3 episodes of C diff infection: ___
Social History:
___
Family History:
He is divorced, has two kids in ___. There is no
known liver cancer or liver disease in his family.
Physical Exam:
ADMISSION:
VS: T 98.3, BP 122/78, BR 73, RR 18, 100%RA
GENERAL: middle-aged ___ male, somewhat restless in bed,
but appropriate and oriented
HEENT: Sclera anicteric. PERRL, EOMI.
NECK: Supple with no evidence of JVD
CARDIAC: RRR, S1/S2 clear with soft II/VI holosystolic murmur,
no rubs or gallops. No S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Distended but Soft, mildly tender to palpation over
RUQ, without rebound/guarding. No fluid wave or tympany
appreciated to suggest ascites, spleen tip palpated just lateral
to the umbilicus
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
lower extremity edema extending through the thighs.
DISCHARGE:
VS: T 98.3, BP 122/78, BR 73, RR 18, 100%RA
Gen: NAD
HEENT: no iceteric sclera
Pulm: CTAB
CV: NR, RR, no murmurs, pain with chest wall sternal palpation
Abd: mild distention, minimal TTP in RUQ, soft, +BS
Ext: 1+ pitting edema to knees bilaterally
Neuro: A&O
Psych: appropriate
Pertinent Results:
___ 06:55PM BLOOD WBC-4.0 RBC-3.20* Hgb-8.6* Hct-27.6*
MCV-86 MCH-26.7* MCHC-31.0 RDW-17.1* Plt Ct-80*
___ 07:50AM BLOOD WBC-2.8* RBC-3.19* Hgb-8.7* Hct-27.4*
MCV-86 MCH-27.3 MCHC-31.8 RDW-17.0* Plt Ct-84*
___ 07:50AM BLOOD ___ PTT-39.3* ___
___ 07:50AM BLOOD Glucose-119* UreaN-10 Creat-0.6 Na-135
K-3.6 Cl-104 HCO3-29 AnGap-6*
___ 07:50AM BLOOD ALT-34 AST-53* LD(LDH)-185 AlkPhos-141*
TotBili-1.0
___ 06:55PM BLOOD Lipase-66*
___ 06:55PM BLOOD cTropnT-<0.01
___ 07:50AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:50AM BLOOD Albumin-2.5* Calcium-8.2* Phos-3.3 Mg-1.7
EXERCISE STRESS TEST ___:
This ___ year old man with h/o hepatitis/cirrhosis
was referred to the lab for evaluation of new onset chest pain
and
dyspnea prior to possible liver transplant. The patient
exercised for
14 minutes of a Gervino protocol (~ ___ METS), representing a
fair
exercise tolerance for his age. The test was stopped due to
fatigue.
At minute 5.5 of exercise, the patient noted vague ___ isolated
left
sided chest pain, tender with palpation. This discomfort waxed
and
waned throughout the study with the patient noting in recovery
that the
discomfort was present prior to starting the test. There were no
significant ST segment changes throughout the study. Rhythm was
sinus
with rare, isolated apbs and vpbs and one atrial couplet
throughout the
study. Appropriate blood pressure response to exercise. Slightly
blunted heart rate response to exercise in the presence of beta
blocker
therapy. IMPRESSION: Atypical/non-anginal type symptoms in the
absence of
ischemic EKG changes.
ABD Xray Supine/Erect ___:
IMPRESSION: Prominent small bowel loops with air-fluid levels.
Early or
partial small bowel obstruction cannot be excluded.
Liver Ultrasound ___ IMPRESSION:
1. Coarse liver echotexture, compatible with patient's history
of cirrhosis.
A hyperechoic area within the liver likely relates to patient's
known RFA
site. Hepatic vasculature is patent.
2. Splenomegaly. No ascites.
Brief Hospital Course:
Mr. ___ is a ___ year old male with history of HCV and EtOH
cirrhosis, complicated by HCC s/p TACE + RFA as well as ascites,
who presented with bilateral lower extremity edema in setting of
mild abdominal distension and complaining of substernal chest
pain for past few days most consistent with musculoskeletal
etiology.
# Chest Pain: Likely musculoskeletal since pleurtic and cardiac
enzymes neg x2. No SOB at rest, oxygen requirements, or
tachycardia that would suggest PE however cannot rule out.
Patient is at increased risk with his malignancy.
-cardiac exercise stress on ___ was negative for
ACS/ischemic changes
# Lower Ext swelling: He is clearly volume overloaded, but
without evidence of worsening portal hypertension/cirrhotic
decompensation or pulmonary edema. His last TTE in ___
showed an EF 60% with trivial MR, a patent foramen ovale, and
elongated LA. E/A or E/E' ratios not suggestive of diastolic
failure. He maintains that he is compliant with his medications,
but he may need uptitration of his current diuretic regimen.
-given extra dose of Lasix
-continued spironolactone at 150mg daily
# Abdominal Distention: SBO is less likely given good bowel
sounds and normal BMs/flatus. No ascites on ultrasound.
# HCV and EtOH cirrhosis: Prior decompensations include ascites
with treated HCC. No evidence of current decompensation with no
ascites, clear mental status, and no PVT on ultrasound with
dopplers. MELD is quite low with normal creatinine, bilirubin,
and INR.
- continued lactulose and rifaximin
- continued nadolol
- diuretic management as above
# HCC s/p TACE + RFA
# Anemia/thrombocytopenia: Currently at his baseline, and likely
due to his liver disease.
# Hypertension: Currently normotensive
-continued diuretics
### TRANSITIONAL ISSUES:
-f/u with PCP
-___ with Hepatology
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clotrimazole 1 TROC PO 5X/DAY
2. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
3. Furosemide 40 mg PO DAILY
4. Lactulose 30 mL PO QID
titrate ___ BMs per day
5. Nadolol 20 mg PO DAILY
6. Omeprazole 40 mg PO BID
7. Rifaximin 550 mg PO BID
8. Spironolactone 150 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Simethicone 80 mg PO QID:PRN gas pain
11. Sodium Chloride Nasal Dose is Unknown NU Frequency is
Unknown
Discharge Medications:
1. Clotrimazole 1 TROC PO 5X/DAY
2. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Lactulose 30 mL PO QID
titrate ___ BMs per day
4. Nadolol 20 mg PO DAILY
5. Omeprazole 40 mg PO BID
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Rifaximin 550 mg PO BID
8. Simethicone 80 mg PO QID:PRN gas pain
9. Spironolactone 150 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
RX *spironolactone 50 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
10. Sodium Chloride Nasal 1 SPRY NU BID:PRN dryness
11. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
Discharge Disposition:
Home
Discharge Diagnosis:
chest pain, likely musculoskeletal
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 while you were admitted to
___. You were admitted to the hospital because you were having
chest pain and abdominal distension with lower extremity
swelling. We did some blood tests and we do NOT think that you
were having a heart attack. We also did another test of your
heart (stress test), that was also ok.
We gave you some extra Lasix to help take off some extra fluid
from your legs. An XRAY of your abdomen showed that there was
no obstruction.
Please continue to take all of your medications as prescribed,
and please follow up with your outpatient providers, as listed
below.
Followup Instructions:
___
|
10056223-DS-19 | 10,056,223 | 25,634,906 | DS | 19 | 2122-02-28 00:00:00 | 2122-03-02 01:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending: ___.
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ male with h/o HCV and alcoholic cirrhosis
decompensated by jaundice, ascites, SBP, HCC s/p TACE and RFA,
on transplant list presenting with hematemesis. Pt states that
he had episode of hematemesis after drinking soup. His clothes
were all covered in blood and he felt dizzy/lightheaded and he
called his friends. He was able to open the door for his friends
and then passed out and woke up on his bed. Denies fevers,
melena or bloody stools. Last BM was yesterday morning and was
non-bloody.
Of note, last EGD and colonoscopy was on ___. EGD showed no
esophageal varices, mild GAVE like antral erythema. Colonoscopy
only positive for few scattered small aphthous ulcers in the
rectum, sigmoid and descending colon.
In the ED, initial vitals were 99.4 83 131/78 18 100 RA. Exam
notable for heme pos yellow stool. Labs notable for Hct at
baseline. UA was negative. He received pantoprazole IV. Vitals
prior to transfer: BP 115/87 HR 78 RR 18 O2 sat 97% RA.
On arrival to the floor, he reports abdominal pain in RUQ under
his R ribcage. Describes pain as sharp that comes and goes.
Patient with hx of multiple hospitalization for similar
abdominal pain most recently from ___ without any
clear etiology. Continues to report dizziness however seen
ambulating to the bathroom and back to his bed without any
problems.
ROS:
per HPI, +headache that is now improving, + nausea
denies fever, chills, night sweats, vision changes, rhinorrhea,
congestion, sore throat, shortness of breath, chest pain,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
1. HCV and EtOH abuse with resulting cirrhosis, c/b ascites, HE,
jaundice, SBP
2. biopsy-proven ___ s/p TACE ___ & TACE ___
(1.6 cm segment II lesion) and RFA ___ (2.3 x 2.8 cm segment
VI/VI lesion) with CT in ___ negative for recurrence
3. Hypertension
4. Thrombocytopenia
5. s/p cholecystectomy ___
6. 3 episodes of C diff infection: ___
Social History:
___
Family History:
He is divorced, has two kids in ___. There is no
known liver cancer or liver disease in his family.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - 98.4, 118/75, 84, 18, 100% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate,
no jaundice
HEENT - NC/AT, PERRLA, EOMI, sclerae icteric, slight dried MM,
OP clear
NECK - supple, no JVD, no LD
LUNGS - CTA bilat, no r/rh/wh, resp unlabored, no accessory
muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, no rebound/guarding, distended, no shifting
dullness, no fluid wave, mild tenderness to palpation diffusely
throughout but most significantly on R upper quadrant
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses, no palmar
erythema
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs III-XII grossly intact, muscle
strength ___ throughout, sensation grossly intact throughout, no
asterixis but mild R hand tremor
DISCHARGE PHYSICAL EXAM
VS - 98.3, 104/70 (104-112/56-70), 81-95, 20, 100% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate,
no jaundice
HEENT - NC/AT, PERRLA, EOMI, sclerae icteric, slight dried MM,
OP clear
NECK - supple, no JVD, no LD
LUNGS - CTA bilat, no r/rh/wh, resp unlabored, no accessory
muscle use
CHEST- no spider angiomata noted
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, no rebound/guarding, distended, no shifting
dullness, no fluid wave, mild tenderness to palpation in RUQ
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses, no palmar
erythema
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs III-XII grossly intact, muscle
strength ___ throughout, sensation grossly intact throughout, no
asterixis but mild R hand tremor
Pertinent Results:
ADMISSION LABS
___ 12:40PM BLOOD WBC-4.6 RBC-3.42* Hgb-8.9* Hct-28.9*
MCV-85 MCH-26.0* MCHC-30.7* RDW-18.8* Plt Ct-82*
___ 12:40PM BLOOD Neuts-55 Bands-0 ___ Monos-22*
Eos-5* Baso-0 ___ Myelos-0
___ 12:40PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-1+ Target-1+
___ 12:40PM BLOOD ___ PTT-34.9 ___
___ 12:40PM BLOOD Glucose-74 UreaN-12 Creat-0.8 Na-136
K-4.0 Cl-107 HCO3-24 AnGap-9
___ 12:40PM BLOOD ALT-38 AST-61* LD(LDH)-235 AlkPhos-150*
TotBili-0.6
___ 12:40PM BLOOD Albumin-2.7* Calcium-7.8* Phos-2.6*
Mg-1.9
___ 12:57PM BLOOD Lactate-1.3
DISCHARGE LABS
___ 06:00AM BLOOD WBC-3.8* RBC-3.17* Hgb-8.1* Hct-26.5*
MCV-84 MCH-25.5* MCHC-30.6* RDW-18.9* Plt Ct-80*
___ 06:00AM BLOOD ___ PTT-37.5* ___
___ 06:00AM BLOOD Glucose-135* UreaN-9 Creat-0.7 Na-136
K-3.7 Cl-105 HCO3-27 AnGap-8
___ 06:00AM BLOOD Calcium-7.9* Phos-3.4 Mg-1.7
URINE
___ 03:29PM URINE Color-Yellow Appear-Clear Sp ___
___ 03:29PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
IMAGING
___ LIVER ULTRASOUND
FINDINGS: The liver is coarse and nodular in echotexture
consistent with
known cirrhosis. No focal liver lesion is identified. The main
portal vein is patent and displays hepatopetal flow. The
gallbladder is absent. There is no intra- or extra-hepatic
biliary ductal dilatation and the common bile duct measures 3
mm. The spleen is enlarged measuring 14.4 cm. The whole liver
and pancreas are not well seen, likely due to overlying bowel
gas and limited acoustic windows. There is no ascites.
IMPRESSION:
1. Patent main portal vein with antegrade flow.
2. Cirrhosis.
3. Splenomegaly.
Brief Hospital Course:
___ ___ speaking man with HCV and alcoholic cirrhosis c/b
HCC s/p TACE and RFA on transplant list presents after 1 episode
of hematemesis followed by dizziness.
# Hematemesis/dizziness: recent EGD on ___ showed GAVE and
no esophageal varices. Hematemesis was likely secondary to GAVE
and hct remained stable in the mid to high ___. No other
episodes of hematemesis and vital signs remained stable. RUQ
ultrasound with doppler obtained and was negative for PVT and
ascites. He was started on PPI gtt on admission and transitioned
to high dose po PPI. He was also continued on his home SBP ppx
with cipro 500mg daily and started on carafate QID.
# RUQ abdominal pain: during last admission, patient had MR
enterography which showed malrotation of jejunal loops located
in the right upper quadrant and ileal loops located in the left
aspect of the abdomen and superior mesenteric artery located
immediately posterior to the superior mesenteric vein. Likely
that he may have intermittent obstruction causing abdominal
pain.
# HCV/alcoholic Cirrhosis and HCC: c/b ascites, SBP, , hepatic
encephalopathy jaundice. On transplant list. LFTs remained at
baseline with INR at 1.2. No signs of HE or ascites. He was
continued on cipro ppx, lactulose for goal of ___, and
nadolol.
# HTN: patient continued on nadolol, furosemide, and
spironolactone. BP controlled, in the 110s.
# iron deficiency anemia: last ferritin was 20 on ___.
Patient was not started on iron therapy during last admission
given persistent GI symptoms which would have been exacerbated
on iron therapy.
# thrombocytopenia: likely in the setting of splenomegaly in
addition to his previous alcohol use
# TRANSITIONAL ISSUES
-patient with iron deficiency anemia, please consider starting
iron supplementation once abdominal pain has resolved
*) medication changes:
-carafate QID was started
*) CODE STATUS: Full
*) CONTACT: ___ (sister): ___ (c), ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 500 mg PO Q24H
2. Clotrimazole 1 TROC PO 5X/DAY
3. Lactulose 30 mL PO TID
Titrate to ___ day
4. Nadolol 20 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Rifaximin 550 mg PO BID
7. Sodium Chloride Nasal ___ SPRY NU BID:PRN dryness
8. Omeprazole 40 mg PO DAILY
9. Vitamin D2 *NF* (ergocalciferol (vitamin D2)) 50,000 unit
Oral 1x/week (MO)
10. Furosemide 40 mg PO DAILY
11. Spironolactone 150 mg PO DAILY
12. Metoclopramide 10 mg PO TID
13. Ondansetron 4 mg PO Q8H:PRN Nausea
Discharge Medications:
1. Lactulose 30 mL PO TID
Titrate to ___ day
2. Nadolol 20 mg PO DAILY
3. Ondansetron 4 mg PO Q8H:PRN Nausea
4. Rifaximin 550 mg PO BID
5. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*120 Tablet Refills:*0
7. Clotrimazole 1 TROC PO 5X/DAY
8. Furosemide 40 mg PO DAILY
9. Metoclopramide 10 mg PO TID
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Sodium Chloride Nasal ___ SPRY NU BID:PRN dryness
12. Spironolactone 150 mg PO DAILY
13. Vitamin D2 *NF* (ergocalciferol (vitamin D2)) 50,000 unit
Oral 1x/week (MO)
14. Ciprofloxacin HCl 500 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: GAVE, hematemesis, dizziness, abdominal pain
SECONDARY: iron deficiency anemia, hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted to the
hospital because you vomited blood and passed out. You were
treated with a medication (pantoprazole) to help prevent further
bleeding. Your blood count remained stable and you did not have
further bleeding. Imaging of your liver showed no difference,
especially not blood clots. You will need to continue to take
pantoprazole and carafate to help prevent further bleeding.
Make sure you follow up with your primary care physician and
liver doctor.
Followup Instructions:
___
|
10056223-DS-22 | 10,056,223 | 24,549,272 | DS | 22 | 2122-05-25 00:00:00 | 2122-06-01 19:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin / Prochlorperazine / metoclopramide
Attending: ___.
Chief Complaint:
Chills s/p TACE
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old gentleman with ___ s/p TACE, HCV, and EtOH cirrhosis
with new onset fevers/chills. MELD of 12 on ___. Was doing well
at home until last night, when he developed shaking chills and
rigors, and felt feverish. He presented to the ED and did not
have any fevers while in ED but was admitted for infectious
work-up of chills. In the ED, he was noted to have leukopenia,
no pyuria, no e/o acute cardiopulmonary process of CXR. His
incision site was noted to be non fluctuant and not
erythematous.
In the ED, initial vitals were 97.6 66 124/68 18 99%
Vitals on transfer: 97.8 64 106/59 18 100%
Interviewed w/ ___ interpreter.
On the floor, he notes mild R sided abdominal pain at the site
of his previous TACE which is not changed from his previous
abdominal pain. He reports it started at the same time as teh
fever. The fever (he does not have a thermometer at home but
felt warm) and chills started last night. Pain is sharp, strong,
not related to eating, and he's had it before. He started having
scar pain.
He notes dysarthria, R hand shaking which he attributes to
morphine, it started the day after he started morphine as an
outpatient around ___ (of note, he was dc'ed on
hydromoprhone, not morphine, and on prochlorperazine prn as
well). He reports he flushed his morphine/dilaudid down the
toilet. He says he had difficulty w/ handwriting and speaking
(speaking improved).
Denies dysuria, reports a little cough, no phlegm, that sarted
last night. No sick contacts, no new diarrhea except what's
chronic and related to lactulose.
ROS: per HPI, denies night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, shortness of breath, chest
pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
1. HCV and EtOH abuse with resulting cirrhosis, c/b ascites, HE,
jaundice, SBP
2. biopsy-proven HCC s/p TACE ___ & TACE ___,
(1.6 cm segment II lesion) and RFA ___ (2.3 x 2.8 cm segment
VI/VI
lesion) with CT in ___ negative for recurrence
3. Hypertension
4. Thrombocytopenia
5. s/p cholecystectomy ___
6. 3 episodes of C diff infection: ___
7. Colitis
Social History:
___
Family History:
(per OMR) There is no known liver cancer or liver disease in his
family.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.1 - 91/60 - 68 - 18 - 100ra
admission weight: 101.1 kg
GENERAL: Well appearing, appears stated age, no resp distress,
pleasant
HEENT: Sclera anicteric. EOMI.
NECK: Supple with low JVP
CARDIAC: RR, no murmurs, rubs or gallops. No S3 or S4
appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Distended but Soft. anteriorly tympanitic, very
posterior dullness to percussion over obese dependent areas.
mild hepatomegaly, mninimal tenderness in RUQ.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis.
NEURO: no asterixis. resting tremor R hand, which improves
somewhat w/ intentional movements. mild resting tremor of left
thumb. very mild dysmetria which improves w/ repetition.
cogwheeling of R wrist only. cn ___ intact. muscfle strength
___ throughout, finger strength ___. alert, oriented x3.
DISCHARGE PHYSICAL EXAMINATION:
VS: 97.4 - 102/64 - 68 - 20 - 96 ra
weight 100.4kg
admission weight: 101.1 kg. ___ kg
GENERAL: Well appearing, appears stated age, no resp distress,
pleasant
HEENT: Sclera anicteric. EOMI.
NECK: Supple with low JVP
CARDIAC: RR, no murmurs, rubs or gallops. No S3 or S4
appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Distended but Soft. anteriorly tympanitic, very
posterior dullness to percussion over obese dependent areas.
mild hepatomegaly, no tenderness in RUQ.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis.
NEURO: no asterixis. improved resting tremor R hand, improves
somewhat w/ intentional movements. mild resting tremor of left
thumb. very mild dysmetria which improves w/ repetition.
cogwheeling of R wrist only. cn ___ intact. muscfle strength
___ throughout, finger strength ___. alert, oriented x3.
Pertinent Results:
ADMISSION LABS
===============
___ 10:50AM BLOOD WBC-3.5* RBC-3.33* Hgb-10.5* Hct-32.7*
MCV-98 MCH-31.7 MCHC-32.2 RDW-18.3* Plt Ct-82*#
___ 10:50AM BLOOD Neuts-67 Bands-0 Lymphs-12* Monos-17*
Eos-3 Baso-0 Atyps-1* ___ Myelos-0
___ 10:50AM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-1+
Macrocy-OCCASIONAL Microcy-NORMAL Polychr-1+ Ovalocy-1+
___ 11:33AM BLOOD ___ PTT-33.3 ___
___ 10:50AM BLOOD Glucose-111* UreaN-17 Creat-0.9 Na-132*
K-5.0 Cl-101 HCO3-28 AnGap-8
___ 10:50AM BLOOD ALT-90* AST-104* AlkPhos-154* TotBili-1.1
___ 10:50AM BLOOD Albumin-2.2*
___ 12:54PM BLOOD Lactate-0.9
DISCHARGE LABS
================
___ 06:35AM BLOOD TSH-4.4*
___ 06:35AM BLOOD Cortsol-6.4
___ 06:35AM BLOOD WBC-3.6* RBC-3.36* Hgb-10.9* Hct-33.4*
MCV-99* MCH-32.4* MCHC-32.6 RDW-17.9* Plt Ct-80*
___ 06:35AM BLOOD ___ PTT-44.2* ___
___ 06:35AM BLOOD Glucose-86 UreaN-11 Creat-0.7 Na-133
K-4.3 Cl-100 HCO3-30 AnGap-7*
___ 06:35AM BLOOD ALT-68* AST-82* LD(LDH)-235 AlkPhos-143*
TotBili-1.1
___ 06:35AM BLOOD Albumin-2.5* Mg-1.9
___ 06:35AM BLOOD Calcium-7.6* Phos-3.0 Mg-1.7
URINE STUDIES
==============
___ 01:40PM URINE Color-Straw Appear-Clear Sp ___
___ 01:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
MICROBIOLOGY
============
___ SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
___ SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
___ URINE CULTURE-FINAL
___ Blood Culture, Routine-FINAL
___ Blood Culture, Routine-FINAL
STUDIES
=======
CXR IMPRESSION: Low lung volumes with minimal bibasilar
atelectasis.
EKG
Sinus rhythm. Poor R wave progression which may be a normal
variant. Compared to the previous tracing of ___ the
findings are similar.
Rate PR QRS QT/QTc P QRS T
68 172 76 424/438 -3 -1 3
RUQ U/S CONCLUSION: No ascites (confirmed verbally with
radiology).
Brief Hospital Course:
BRIEF HOSPITAL COURSE
======================
Mr. ___ is a ___ year old gentleman with HCC s/p TACE, HCV, and
EtOH cirrhosis with new onset subjective fevers/chills at home
after TACE two weeks ago. He was afebrile throughout his hosital
course. Chills were likely due to mild bronchitis (vs. post-TACE
syndrome). Blood cultures, urine culture, and chest xray were
all unremarkable. He was noted to have a new right upper
extremity resting tremor with mild rigidity. This was felt to be
a side effect from the metochlopramide and/or prochlorperizine
he got after TACE. He had mild nausea (normal TSH, cortisol) and
was tolerating a low sodium diet prior to discharge. He was
discharged home w/ follow up in the transplant clinic and with
his oncologist, as well as neurology. He was instructed to try
lidocaine jelly, tramadol BID, and acetaminophen (<2g daily) for
his pain, and to avoid compazine and reglan.
ACTIVE ISSUES
==============
# Subjective fever and chills: Given his history of HCC and
cirrhosis, he is at increased risk for infection. He reported
fevers and chills at home (though did not take his temperature),
but there were no documented fevers in the ED or on the floor.
Cultures were negative x24 hours, and infectious work-up was
unrevealing (CXR showed atelectasis). Overall this seems most
consistent w/ bronchitis given his mild non-productive cough and
lack of opacities on CXR. This could also be indicative of
postembolization syndrome, which occurs in ~90% of patients
following TACE, manifested by fever, malaise, right upper
quadrant pain, nausea, and vomiting. He was never febrile, but
did complain of chronic RUQ pain, nausea.
# Extrapyramidal side effects of anti-emetics: He was noted to
have cog-wheeling + resting tremor on exam by the accepting
team. He reports that these symptoms began the day after his
last hospitalization, during which he got large doses of
metoclopramide and prochlorperazine. He reported initial
dysarthria, which was not noted during this admission. We added
both metoclopramide and prochlorperazine to his allergy list
(ondansetron is less likely to cause EPS). He will follow up
with neurology as an outpatient. Some studies have shown
anti-cholinergics can treat EPS; as such, he was given oral
diphenhydramine at night. In terms of his nausea, cortisol was
normal. He tolerated a low sodium diet despite nausea (could be
post-TACE picture, as above).
- QTc 438 on ___.
- Avoid metoclopramide and compazine.
# Hepatocellular CA s/p TACE: He is currently listed on the
transplant list with ___ MELD exception points. Lab MELD was ~10.
He had recurrent HCC at site of prior HCC, but was still within
criteria. As such, he underwent TACE ___, which was
complicated by N/V, abdominal pain, severe transaminitis (which
was treated symptomatically). For pain at the site of the
procedure (no concerning findings on RUQ u/s), he was started on
tramadol 50mg q12 hours, with lidocaine patch for flank.
CHRONIC ISSUES
===============
# Chronic hepatitis C and alcoholic cirhosis: Complicated by
ascites, hepatic encephalopathy, SBP, and recurrent
hepatocellular CA. He was continued on SBP prophylaxis. He was
continued on home lactulose, rifaximin,
furosemide/spironolactone, and nadolol.
# Pancytopenia (Anemia/leukopenia/thrombocytopenia): Chronic,
likely due to liver disease.
# Hypertension: Continued home nadolol, spironolactone, and
furosemide.
# Ulcerative colitis: Continued home mesalamine.
TRANSITIONAL ISSUES
===================
- Code status: Full code, confirmed
- Emergency contact: ___, sister/HCP, ___
- Studies pending on discharge: all microbiology has been
finalized as negative.
- If patient is amenable to continuing lidocaine patch, please
help him complete prior auth for this.
- QTC on ___ was 428.
- Avoid metoclopramide and compazine, as well as any other
medications that may cause extra-pyramidal side effects.
- He will follow up with neurology and his oncologist after
discharge.
- Currently listed for transplant with MELD 31.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 500 mg PO Q24H
2. Furosemide 40 mg PO DAILY
3. Lactulose 30 mL PO QID
4. Mesalamine 1000 mg PO BID
5. Nadolol 20 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Rifaximin 550 mg PO BID
9. Spironolactone 150 mg PO DAILY
10. Acetaminophen 650 mg PO Q6H:PRN fever, pain
11. TraMADOL (Ultram) 50 mg PO BID:PRN pain
12. Prochlorperazine ___ mg PO Q6H:PRN Nausea
13. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain
(not taking as prescribed)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever, pain
Do not take more than 2g daily to avoid further liver damage.
2. Ciprofloxacin HCl 500 mg PO Q24H
3. Furosemide 40 mg PO DAILY
4. Lactulose 30 mL PO QID
5. Mesalamine 1000 mg PO BID
6. Nadolol 20 mg PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Rifaximin 550 mg PO BID
10. Spironolactone 150 mg PO DAILY
11. TraMADOL (Ultram) 50 mg PO BID:PRN pain
12. DiphenhydrAMINE 50 mg PO HS Duration: 10 Days
This can cause sedation/confusion. Do not take with tramadol.
RX *diphenhydramine HCl [Allergy Relief(diphenhydramin)] 25 mg
___ capsule(s) by mouth HS Disp #*20 Capsule Refills:*0
13. Lidocaine 5% Ointment 1 Appl TP BID pain
Apply to back or other area of pain
RX *lidocaine HCl 3 % twice a day Disp #*30 Gram Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: viral bronchitis
.
Secondary: resting tremor
hepatocellular carcinoma
Discharge Condition:
Mental Status: Clear and coherent (___).
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
.
You were admitted to the hospital because you were having
chills. You had no fevers while in the hospital. We checked your
urine and blood and found no evidence of infection. We also did
a chest xray that did not show any pneumonia. You had a cough
that was due to bronchitis, inflammation of the airways that is
usually due to a virus, that improved.
.
You have a tremor in your right arm. This is likely a side
effect of medicines you were given for nasuea. You should avoid
Reglan (metochlopramide) and Compazine (prochlorperizine) in the
future. We have made you an appointment with Neurology to follow
this tremor. The Neurology office is trying to move this
appointment up if possible.
You should follow up with transplant and Dr. ___ as
below.
Followup Instructions:
___
|
10056223-DS-24 | 10,056,223 | 25,591,002 | DS | 24 | 2122-07-13 00:00:00 | 2122-07-15 07:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin / Prochlorperazine / metoclopramide
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: ___ with history of HCV and EtOH cirrhosis complicated by
episodes of hepatic encephalopathy, ascites, SBP, HCC s/p RFA
and TACE x3 who now presents with 3 day history of fullness, PO
intolerance, weakness, occasional abdominal pain, and possibly
an episode of hematemesis. He also reports black stools since
___. He has not eaten for the past two day due to fullness
and abdominal pain. On the morning of admission, he began
bleeding from the mouth and nose which required many tissues.
He has not had fever, nausea, vomiting, diarrhea, chest pain,
constipation, BRBPR, dysuria, or. hematuria. The patient
recently had a colonoscopy/EGD on ___ which revealed
scattered apthous ulcers in the rectum/colon. He is currently
listed for liver transplant at ___.
In the ED, initial vitals:(Temp 98.2,HR 66,BP 110/65,RR
14,Sat100%RA)
He reported having one episode of vomiting in ED. Stool was
yellow
green and guaiac positive. A liver US was notable for patent
veins and moderate ascites. Hapatology was consulted and he was
admitted to the ED for further managment.
Vitals prior to transfer: (HR68, BP 108/67, RR 18, sat 99%RA )
Currently, the patient reports feeling abominal fullness without
nausea or abdominal pain.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- HCV and EtOH abuse with resulting cirrhosis, c/b ascites, HE,
jaundice, SBP
- biopsy-proven ___ s/p TACE ___ & TACE ___
(1.6 cm segment II lesion) and RFA ___ (2.3 x 2.8 cm segment
VI/VI lesion) with CT in ___ negative for recurrence
- Hypertension
- Thrombocytopenia
- s/p cholecystectomy ___
- C diff infection: ___
- Ulcerative Colitis
Social History:
___
Family History:
No illnesses run in the family.
Physical Exam:
ADMISSION EXAM
Temp 98.1. BP 108/61 , HR 67 , RR 20, Sat 100% RA.
Gen: NAD, AOx0, unable to remember last name correctly, state
date or location, or name days of week in order.
HEENT: normocephalic / atraumatic. Conjunctiva clear. Scleral
icterus. PERRL, EOM intact. Hearing intact to finger rub. Oral
mucosa pink w/ MMM.
Neck: Carotid pulses brisk; no bruits were auscultated.
Pulm: Lungs resonant to percussion. Clear to auscultation.
Cor: Nondisplaced PMI. RRR. Normal S1/S2. ___ systolic murmer at
upper sternal borders. JVD at 8cm.
Abd: Soft, non distended. Tenderness to palpation in RUQ.
Shifting dullness present.
Ext: No swelling or deformity. Extremities WWP w/o
clubbing,cyanosis, or edema.
Skin: Skin warm without petechiae or ecchymoses. Mild palmar
erythema present.
Neuro: Asterixis present. Sensation and strength grossly intact
DISCHARGE EXAM
Temp 98.2, BP 98/70 , HR 77 , RR 18, Sat 98% RA.
Gen: NAD, comfortable
HEENT: normocephalic / atraumatic. Conjunctiva clear. Mild
scleral icterus.
Pulm: Lungs resonant to percussion. Clear to auscultation.
Cor: Nondisplaced PMI. RRR. Normal S1/S2.
Abd: Soft, non distended. Tenderness to palpation in RUQ.
Ext: No swelling or deformity. Extremities WWP w/o
clubbing,cyanosis, or edema.
Skin: Skin warm without petechiae or ecchymoses.
Neuro: No asterixis. Sensation and strength grossly intact
Pertinent Results:
ADMISSION LABS
--------------
___ 09:40PM GLUCOSE-125* UREA N-14 CREAT-0.7 SODIUM-134
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-26 ANION GAP-7*
___ 09:40PM WBC-4.7 RBC-3.37* HGB-11.1* HCT-33.5* MCV-99*
MCH-33.1* MCHC-33.3 RDW-15.2
___ 09:40PM PLT COUNT-64*
___ 09:40PM ___ PTT-36.3 ___
___ 11:47AM ___ PTT-31.3 ___
___ 11:38AM GLUCOSE-95 UREA N-17 CREAT-0.9 SODIUM-134
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-28 ANION GAP-6*
___ 11:38AM estGFR-Using this
___ 11:38AM ALT(SGPT)-48* AST(SGOT)-87* ALK PHOS-172* TOT
BILI-1.0
___ 11:38AM ALBUMIN-2.1*
___:38AM WBC-4.2 RBC-3.36* HGB-11.2* HCT-33.7*
MCV-100* MCH-33.2* MCHC-33.1 RDW-15.2
___ 11:38AM NEUTS-64.4 ___ MONOS-9.3 EOS-2.9
BASOS-0.8
___ 11:38AM PLT COUNT-65*
DISCHARGE LABS
--------------
___ 08:56AM BLOOD Glucose-127* UreaN-11 Creat-0.8 Na-132*
K-4.4 Cl-98 HCO3-28 AnGap-10
___ 08:56AM BLOOD ALT-52* AST-84* AlkPhos-192*
MICROBIOLOGY
-----------
___ Urine culture: no growth
___ Stool C.diff DNA: negative
___ Blood culture: pending
IMAGING
-------
___ Liver U/S w/ doppler: Coarse, nodular liver with
nodules/prior RFA/TACE sites better evaluated on prior MR.
___ hepatic veins. Patent main portal vein with slow, forward
flow without clot. Study limited for evaluation of portal
branches. Moderate ascites.
___ Bedside abdomone U/S: No ascites ammenable to
Brief Hospital Course:
___ with history of HCV and EtOH cirrhosis with multiple
complications who presented with abdominal pain and black stools
who subsequently developed encephalopathy.
ACTIVE ISSUES
-------------
#. Encephalopathy: Upon initial arrival to the floor, the
patient was initially alert and oriented (A&O) x2 but was AOx0
on repeat examination. He did not have asterixis however and
the remainder of the exam was not indicative of possible
underlying pathology. Liver ultrasound in the ED showed patent
portal veins. He was afebrile, vital signs stable. No
electrolyte abnormalities were present. Has been compliant with
mediation. His lactulose dose was managed until stooling ___
times daily and he was on his home rifaxamin. Stool cultures
and C. Diff PCR were sent. A bedside ultrasound did not reveal
ascites, making SBP unlikely, and he was switched off
ceftriazone back to his dose of ciprofloxacin. On the morning of
hospital day 2 he was AOx2, but later once again developed
confusion. A "trigger" was called and the patient was
reassessed. Vitals were still stable and no indication of
infection was present. Chest Xray, blood cultures, and urine
analysis were ordered to assess for any underlying pathology but
did not suggest a possible source of infection. Throughout
hospitalization his abdominal pain was around baseline of mild
right upper quadrant pain. On discharge, he did not exhibit
confusion and asterixis was abscent. He was instructed to follow
up with his regularly scheduled outpatient appointments.
#. GI bleeding: The patient was admitted for report of one week
of black stools, in the setting of recent known GI bleed.
Stools were brown, guaiac positive. HCT was 33.5 on admission
(at his baseline) and 33.8 at time of discharge.
#. Cirrhosis: On admission, his LFTs were at baseline. His
cirrhosis continued to be managed with his home medications
while admitted. No ascitic fluid on ultrasound. No episodes of
frank bleeding during admission. Continued to received
ciprofloxacin after a single dose of ceftriaxone.
#. Vomiting: He had one episode of vomiting late on the evening
of planned discharge. He was cleared for home, was awaiting
arrival of transportation, when he had non-bloody, non-bilious
vomiting x1 after dinner. His vitals were stable and he was able
to ambule without dizziness. He was discharged the following
day.
#. Depression: While hospitalized, he was noted to have a
depressed affect and admitted low mood. Though possibly
stemming from his chronic medical condition, he has also had
less energy recently. Escitalopram was started at a reduced dose
for hepatic disease of 5mg PO daily. ECG prior to start was
normal without QTc prolongation (QTc 410). Given concurrent use
of escitalopram with tramadol, he was educated about symptons
concerning for Seratonin Syndrome. Titration and a repeat ECG
should be done as an outpatient by his regular providers.
INACTIVE ISSUES
---------------
#. Ulcerative Colitis: He was continued on home dosing
mesalamine.
TRANSITIONAL ISSUES
------------------
#. Titration of escitalopram: He will be followed as an
outpatient by his primary care doctor ___ at ___
___.
#. Follow-up: He was instructed to follow up with his primary
doctor, ___, and hematology as scheduled.
#. Code status: Full Code
#. Contact: ___, ___ as his HCP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 500 mg PO Q24H
2. Ferrous Sulfate 325 mg PO BID
3. TraMADOL (Ultram) 50 mg PO BID
4. Rifaximin 550 mg PO BID
5. Pantoprazole 40 mg PO Q12H
6. Furosemide 40 mg PO DAILY
7. Lactulose 30 mL PO QID Please titrate lactulose to have ___
bowel movements a day
8. Nadolol 20 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Spironolactone 150 mg PO DAILY
11. Mesalamine 1000 mg PO BID
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Ferrous Sulfate 325 mg PO BID
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
3. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Lactulose 30 mL PO QID Please titrate lactulose to have ___
bowel movements a day
RX *lactulose 10 gram/15 mL 30 ml by mouth four times a day Disp
#*480 Milliliter Refills:*0
5. Nadolol 20 mg PO DAILY
RX *nadolol 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth twice a day Disp #*60 Tablet Refills:*0
7. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
8. Spironolactone 150 mg PO DAILY
RX *spironolactone 50 mg 3 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
9. TraMADOL (Ultram) 50 mg PO BID
10. Mesalamine 1000 mg PO BID
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Escitalopram Oxalate 5 mg PO DAILY Depression
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain, compensated cirrhosis
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 while at ___. You were
admitted to the liver service for belly pain and concern for
bleeding. During admission, your blood counts remained stable
and you had no evidence of bleed. At time of discharge, your
pain had improved and you were able to eat normally.
While admitted you also had episodes of confusion. The liver
doctors ___ and there was no indication of worsening
liver disease. Your confusion resolved on your home
medications.
An anti-depressant medication was added to your home
medications; please take as prescribed along with the remainder
of your usual home medications. This medication takes a few
weeks to fully work. Call your doctor if you experience any of
the side effects we discussed during your admission (listed
below in warning signs). Also, please follow up with your
scheduled appointments as below.
Followup Instructions:
___
|
10056223-DS-26 | 10,056,223 | 23,527,958 | DS | 26 | 2122-09-01 00:00:00 | 2122-09-03 15:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin / Prochlorperazine / metoclopramide
Attending: ___.
Chief Complaint:
Nausea, fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx HCV and EtOH cirrhosis complicated by episodes of hepatic
encephalopathy, ascites, SBP, HCC s/p RFA and TACE x3, currently
on the transplant list presents after fall this am. He describes
waking up, taking a shower and feeling weak. He has been
persistently nauseas (getting worse) over the past 2 weeks since
discharge, and this AM vomited possibly 10 times after
showering. Denies any hematemesis, vomitus was bilious. During
this episode of vomiting he experienced abdominal pain that has
since resolved, and denies any constipation/diarrhea.
Immediately after the episode of vomiting he felt weak and
states he "could not feel his legs" and fell to the ground,
hitting his head without LOC. He presented to OSH where per pt
they d/c'ed him, with pain meds for his HA and negative head CT.
He now comes to ___ for further eval due to persistent
headache and nausea.
In the ED, initial vitals were Pain 8 97.8 62 97/65 16 100% RA.
The pt was given zofran for n/v. Repeat head CT showed no acute
process, but there was presence of findings c/w right maxillary
acute on chronic sinusitus. ECG was normal. Admitted for syncope
workup.
Of note, pt recently admitted and discharged on ___ for lower
extremity edema with uptitration of his sprinolactone from 200
mg to 300 mg daily.
Past Medical History:
- HCV and EtOH abuse with resulting cirrhosis, c/b ascites, HE,
jaundice, SBP
- biopsy-proven HCC s/p TACE ___ & TACE ___
(1.6 cm segment II lesion) and RFA ___ (2.3 x 2.8 cm segment
VI/VI lesion) with CT in ___ negative for recurrence
- Hypertension
- Thrombocytopenia
- s/p cholecystectomy ___
- C diff infection: ___
- Ulcerative Colitis
Social History:
___
Family History:
No illnesses run in the family.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.7 109/67 49 18 96%RA
General: NAD, appears well
HEENT: EOMI PERRL
Neck: supple without JVD
CV: RRR s1/s2 -mrg
Lungs: CTAB
Abdomen: soft minimally TTP in the RUQ (baseline), non distended
Ext: 1+ pitting edema to the upper shins, improved per pt
Neuro: AOx3. CN2-12 intact. STrength ___ ___ bilaterally.
Sensation intact in the ___.
Skin: no rash
DISCHARGE PHYSICAL EXAM
Vitals: T: 98.1 Tm 98.4 BP:106-120/59-65 ___ R:18 98% RA
General: Alert, oriented, no acute distress
HEENT: abrasion over right supraorbital process, Sclera
minimally icteric, MMM, oropharynx clear
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, no MRG
Abdomen: minimally tender to palpation in all quadrants,
hypoactive bowel sounds, no rebound tenderness or guarding, no
fluid wave
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes, petechiae or ecchymoses
Neuro: II-XII grossly intact, alert and oriented x3,
coordination intact, no asterixis, able to follow commands
Pertinent Results:
ADMISSION LABS
Brief Hospital Course:
___ yo man with history of HCV and EtOH cirrhosis complicated by
episodes of hepatic encephalopathy, ascites, SBP, HCC s/p RFA
and TACE x3 presents after multiple vomiting episodes w
presyncope and fall.
# Presyncope: Episode most likely vasovagal or orthostatic given
recent increase in aldactone and decreased PO intake ___
nausea/vomiting. CT head negative. No signs or symptoms
concerning for arrythmia, new valvular disease, or seizure
activity. Did hit his head at home. CT head negative. Small
abrasion on head. Did not have syncopal episodes here. Received
albumin IVF. No events on telemetry.
# Nausea: persistent and worsening with vomiting. Started after
his last discharge when aldactone was increased. No
fevers/chills or diarrhea to suggest GI infection. Most likely
secondary to portal gastropathy and gastroparesis in setting of
cirrhosis. Also could have been a viral gastroenteritis v.
medication effect from cipro ppx or aldactone. Infectious workup
was negative. Had one positive BCx with GPC which was a
contaminant. Received vancomycin until final culture available.
Per our discussion with the hepatology team, symptoms will most
likely be persistent until transplant. Did not have emesis
during hospitalization. Had persistent nausea. Received zofran
IV prn. Sent home with zofran PO. Allergic to compazine and
reglan. QTc normal on discharge. Able to tolerate PO liquids on
discharge.
# HCC: s/p RFA and TACE x3: Did not have evidence of ascites on
bedside US. Continue monitoring with ultrasound and AFP as
outpatient.
# Cirrhosis: c/b hepatic encephalopathy, ascites, SBP, ___ s/p
RFA
and TACE x3, currently on the transplant list. Admission MELD
was 11. Continued home lactulose and rifaximin, nadolol, and
cipro for SBP ppx. Currently on top of transplant list for his
blood type.
# Ulcerative colitis: Continued home mesalamine. No acute
issues.
TRANSITIONAL ISSUES
- has outpatient f/u with transplant doctors
- often returns to the hospital for persistent nausea requiring
IV antiemetics
- needs adequate nutrition for transplant
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 500 mg PO Q24H
2. Escitalopram Oxalate 5 mg PO DAILY Depression
3. Ferrous Sulfate 325 mg PO BID
4. Furosemide 60 mg PO DAILY
5. Lactulose 30 mL PO QID Please titrate lactulose to have ___
bowel movements a day
6. Mesalamine 1000 mg PO BID
7. Nadolol 20 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Rifaximin 550 mg PO BID
10. Spironolactone 300 mg PO DAILY
11. TraMADOL (Ultram) 50 mg PO BID
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q24H
2. Escitalopram Oxalate 5 mg PO DAILY Depression
3. Ferrous Sulfate 325 mg PO BID
4. Furosemide 60 mg PO DAILY
5. Lactulose 30 mL PO QID Please titrate lactulose to have ___
bowel movements a day
6. Mesalamine 1000 mg PO BID
7. Nadolol 20 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Rifaximin 550 mg PO BID
10. Spironolactone 300 mg PO DAILY
11. TraMADOL (Ultram) 50 mg PO BID
12. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours as
needed for nausea Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Nausea
Secondary Diagnosis: Pre-syncope, Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You came in with nausea and vomiting. You also
had an episode where you fell at home. We admitted you because
of your symptoms. A scan of your head was done which was normal.
We got a number of labs to determine what was causing your
nausea. We treated you with IV medication to help your nausea.
We treated you with an antibiotic (vancomycin) to treat a
bacteria that was found in your blood. The bacteria ended up
being a contaminant and we were not concerned about it. We
stopped antibiotics. You will need to follow up with your liver
doctor ___ below) when you leave the hospital. You are
at the top of the transplant list for your blood type. We want
to encourage you to take in adequate nutrition. If you cannot
take in solid foods, please try to drink nutritious shakes, like
ensure.
Followup Instructions:
___
|
10056612-DS-12 | 10,056,612 | 24,412,612 | DS | 12 | 2191-01-09 00:00:00 | 2191-01-09 17:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Influenza Virus Vaccines / latex / atorvastatin / Ativan /
clopidogrel / lisinopril / chlorthalidone
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ yo female with a history of laryngeal cancer and a right
temporal mass who is admitted with headaches and hypertensive
urgency. The patient states she has been having intermittent
headaches, weakness, nausea, and vision changes for three days.
She denies any fevers, shortness of breath, diarrhea,
constipation, dysuria, or rashes. She states she is taking
carvedilol twice a day and atenolol once a day for her blood
pressure. She reports not taking losartan. She does seem
confused
about her medications and per report her daughter also is
concern
about her management of medications at home. She reportedly
lives
with her son who is bipolar and causes he significant stress.
She presented to the ED on ___ and was found to be
hyptertensive. A head CT was done and unchanged from prior and
she was sent home.
In the ED this evening she was again found to be hypertensive to
200s/100s. She was given carvedilol with improvement in her
blood
pressure. On arrival to the floor she states that her headache
and other symptoms have significantly improved.
Past Medical History:
Laryngeal cancer, ___
CVA/TIA
Hypertension
HLD
Hypothyroidism after thyroid surgery for nodule
___ stenosis status post right carotid stents
Cervical cancer, hysterectomy
Tonsilectomy
Appendectomy
Right ankle fracture, pins placed
Bilateral cataracts
Social History:
___
Family History:
She had two brothers, one died in his ___ with liver
cancer and one died in his ___ with lung cancer. Multiple elder
family members developed severe vision loss.
Physical Exam:
ADMISSION EXAM:
===============
General: NAD
VITAL SIGNS: T 97.3 BP 149/68 HR 61 RR 16 O2 97%RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
ABD: Soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, no focal deficits, Cranial nerves
II-XII are within normal limits excluding visual acuity which
was
not assessed; strength is ___ of the proximal and distal upper
and lower extremities.
DISCHARGE EXAM:
===============
VITAL SIGNS: T 98.6 BP 128/60 HR 76 RR 18 O2 98%RA
General: Pleasant, animated woman, sitting up comfortably in
bed.
HEENT: MMM, no nystagmus. PERLL. EOMI. OP clear.
CV: RR, NL S1S2 no S3S4, no MRG
PULM: CTAB, respirations unlabored
ABD: BS+, soft, NTND
LIMBS: No edema, normal bulk, wwp
SKIN: No rashes on extremities
NEURO: Alert and interactive. Oriented x3. No focal
weakness including symmetric ___ upper extremity strength and
___ lower extremity strength. FTN intact. CN III-XII intact.
Pertinent Results:
ADMISSION LABS:
==============
___ 09:40PM BLOOD WBC-4.1 RBC-4.44 Hgb-12.2 Hct-38.9 MCV-88
MCH-27.5 MCHC-31.4* RDW-14.4 RDWSD-46.0 Plt ___
___ 09:40PM BLOOD Neuts-51.4 ___ Monos-10.0 Eos-2.7
Baso-0.5 Im ___ AbsNeut-2.10 AbsLymp-1.42 AbsMono-0.41
AbsEos-0.11 AbsBaso-0.02
___ 09:40PM BLOOD Plt ___
___ 09:40PM BLOOD Glucose-87 UreaN-21* Creat-0.8 Na-142
K-3.9 Cl-106 HCO3-24 AnGap-16
___ 07:44AM BLOOD ALT-21 AST-19 LD(LDH)-179 AlkPhos-108*
TotBili-<0.2
___ 09:40PM BLOOD Calcium-9.1 Phos-3.0 Mg-2.1
___ 10:15PM BLOOD CRP-3.0
DISCHARGE LABS:
===============
___ 07:44AM BLOOD WBC-4.6 RBC-4.16 Hgb-11.5 Hct-35.8 MCV-86
MCH-27.6 MCHC-32.1 RDW-15.2 RDWSD-47.3* Plt ___
___ 07:18AM BLOOD Glucose-77 UreaN-25* Creat-0.8 Na-141
K-3.7 Cl-112* HCO3-18* AnGap-15
___ 07:18AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.2
IMAGING:
========
___ Imaging MRV HEAD W/O CONTRAST
1. No evidence of cerebral venous thrombosis.
2. Unchanged 13 x 7 mm enhancing right middle cranial fossa
extra-axial lesion.
3. Previously noted subtle area of right medial occipital
leptomeningeal enhancement is not well appreciated on the
current examination, likely due to difference in technique.
4. No new enhancing lesion.
5. Multiple chronic infarcts, as described.
6. Confluent areas of white matter signal abnormality in a
configuration most suggestive of chronic small vessel ischemic
disease.
___ Imaging MR HEAD W & W/O CONTRAS
1. New small evolving acute or early subacute infarct within the
left posterior inferior cerebellar hemisphere.
2. Stable enhancing extraaxial mass along the medial right
temporal lobe.
3. Stable small area of leptomeningeal enhancement along the
medial right occipital lobe dating back to ___,
etiology uncertain.
4. Stable chronic infarctions within bilateral cerebellar
hemispheres and left pons. 5. Stable extensive confluent white
matter changes in right greater than left temporal white matter,
and bilateral frontal and parietal white matter, as well as in
the middle cerebellar peduncles and bilateral pons, likely a
combination of posttreatment changes and sequela of chronic
small vessel ischemic disease.
6. Stable left frontal developmental venous anomaly.
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION:
___ w/ CAD, TIA, HTN, DL, brainstem CVA, h/o submandibular
cystic carcinoma, diagnosed in ___, followed by modified
radical neck dissection, R temporal mass (most likely XRT
necrosis) stable since ___, carotid stenosis s/p ___ stents,
and history of hypertensive emergency causing headaches due to
medication noncompliance, p/w HA dizziness and nausea, found to
have hypertensive emergency and new cerebellar CVA. Now with
persistent/intractable headache.
# Hypertensive emergency:
# Hypertension: Etiology of hypertensive emergency thought due
to noncompliance of her home medications, and she improved with
resumption of home carvedilol 12.5 and losartan 50. However, her
headache persisted, and after staring IV dexamethasone, her
blood pressures again worsened. We uptitrated her carvedilol to
25mg bid and increased losartan to 100mg daily. She continued
to require intermittent po labetolol and IV hydralazine. On ___
we restarted her on chlorthalidone 25mg daily (she had
previously taken this, but was stopped due to urinary
frequency). Day of discharge blood pressure was better
controlled in the 120's-130's. She was discharged with these
medications and po potassium 10 meq daily. She should have blood
pressure and chemistry panel checked on ___ consider
investigating secondary causes of hypertension, at her primary
team's discretion.
# Stroke: Etiology thought from HTN disease. 48 hours of
telemetry were unremarkable and prior carotid imaging was
normal. Last LDL ___ was 124; last A1c 5.5%. No clear/focal
neurologic deficits despite new CVA on imaging. Patient was
previously on ASA and plavix but she discontinued plavix due to
dizziness some time ago. Unclear if she was taking ASA at home.
We restarted Plavix. Statin was held given patient's reported
statin allergy, although this should continually be discussed
with her PCP.
# Persistent L sided HA
# Status migranosis: Etiology of headache initially thought due
to uncontrolled HTN. However, headaches persisted despite better
BP. Head MRI revealed small Cerebellar ischemic stroke, as
above, which was out of proportion to her headaches. MRV was
negative for venous thrombosis. CRP/ESR not indicative of
temporal arteritis. Deferred LP given no suspicion for
infection. She was initially treated with fioricet and tramadol.
Received small amounts of IV morphine. Ulitmately opiods and
tramadol limited due to concern for rebound headache/overuse
headache. She was given 3 days of IV dexamethasone starting
___ and started acetazolamide 500mg twice daily on ___.
Headache broke on evening of ___ and patient was discharged pain
free. She will continue acetazolamide indefinitely per her
neuro-oncologist, Dr. ___ should follow up with him in
~2 weeks.
# Metabolic acidosis: Patient developed non-gap hyperchloremic
metabolic acidosis, likely due to acetazolamide. Will continue
acetazolamide and continue to monitor.
# Hypothyroidism: Continued home synthroid. Last TSH 30,
rechecked TSH here and 0.3
# GERD: Continued home omeprazole.
# Social: On admission there was some concern regarding
patient's safety at home.
SW was consulted and safe discharge plan was developed.
Ultimately felt to be safe for home discharge in light of her
extensive support system and ability to call ___ should there be
an emergency. This plan was made in accordance to the patient's
wishes, as well. Please see SW noted for further information.
# Billing: >30 minutes spent planning and executing this
discharge plan
TRANSITIONAL ISSUES:
===================
- Close monitoring of blood pressures and medication compliance
- Increased losartan to 100mg daily and carvedilol to 25mg twice
daily
- Started chlorthalidone 25mg daily on ___ and discharged with
10meq potassium supplements
- Please recheck Chemistry on ___
- Resumed Plavix. Currently holding aspirin
- Discuss statin use with patient given recurrence
cerebrovascular disease
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Topiramate (Topamax) 50 mg PO DAILY
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
5. Aspirin 81 mg PO DAILY
6. Carvedilol 12.5 mg PO BID
7. Atenolol Dose is Unknown PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Losartan Potassium 50 mg PO DAILY
Discharge Medications:
1. AcetaZOLamide 500 mg PO Q12H
RX *acetazolamide 500 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
2. Chlorthalidone 25 mg PO DAILY
RX *chlorthalidone 25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Potassium Chloride 10 mEq PO DAILY
Hold for K >
RX *potassium chloride [Klor-Con 10] 10 mEq 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
5. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
6. Losartan Potassium 100 mg PO DAILY
RX *losartan 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 650 mg 1 tablet(s) by mouth q6 hours Disp #*60
Tablet Refills:*0
8. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puff IH q4 hours
Disp #*1 Inhaler Refills:*0
9. Levothyroxine Sodium 100 mcg PO DAILY
RX *levothyroxine 100 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
10. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
11. Topiramate (Topamax) 50 mg PO DAILY
RX *topiramate [Topamax] 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
CVA
Hypertensive Emergency
Status Migraine
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 severe headaches. You were
found to have a hypertensive emergency and your blood pressures
improved with restarting your home carvedilol and losartan. We
ultimately increased your carvedilol and losartan doses and
started an new medication called chlorthalidone. You cannot miss
these medications, and you must follow up with Dr. ___
very close monitoring of your blood pressure and blood work.
Additionally, ___ had a brain MRI which revealed a small stroke.
You continued to have very severe headaches, so we gave you a
three day course of IV dexamethasone (steroids) and started a
medication called acetazolamide.
You will need to follow up with Drs. ___.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10056612-DS-13 | 10,056,612 | 20,943,307 | DS | 13 | 2191-01-17 00:00:00 | 2191-01-17 16:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Influenza Virus Vaccines / latex / atorvastatin / Ativan /
lisinopril / chlorthalidone
Attending: ___
Chief Complaint:
Headache and dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo woman with history of laryngeal cancer and L
temporal lesion as well as history of multiple lacunar infarcts
and microvascular disease as well as recent admission for
hypertensive emergency and headache during which she was found
to
have small L cerebellar infarct who presents to the ED with
headache and dizziness.
Ms. ___ was recently admitted from ___ through ___ to the
medicine service after presenting with hypertensive emergency.
Course complicated by status migrainosus, which resolved after 3
days of IV dexamethasone and for which she was started on
acetazolamide. Course also complicated by incidental tiny left
cerebellar infarct thought by medicine team to be likely related
to hypertension. This was treated as an aspirin failure and she
was switched to Plavix. She is not on a statin due to reported
statin allergy. During admission she was evaluated by her
outpatient neuro-oncologist, Dr. ___. At that time
neurologic exam is documented as normal except brisk but
symmetric reflexes, as well as moderate ataxia and aphasia with
ambulation.
Ms. ___ reports that her headache had resolved after discharge,
but returned this afternoon. The headache started at the vertex
at approx 1700, and became severe by 1800, and also spread to
the
R hemicranium. The headache is sharp in character. Associated
with photophobia and nausea, no phonophobia, no emesis. She
states that she has had headaches like this in the past, though
they all started after age ___.
She also describes 'dizziness' that started around the same time
as the headache. She has great difficulty describing the
dizziness, but states it was episodic, lasting seconds at a
time,
and is best described as vertigo when given choices. She says
that the last time she had the vertigo was "when I was upstairs
in a bed like this one". She is unable to provide an answer when
asked if there are any provoking factors.
She also reports chest pain, and states she did not tell the
emergency room doctors because she did not want to stay
overnight.
Unable to complete ROS due to mental status.
Past Medical History:
Right submandibular cystic carcinoma diagnosed in ___, treated
with modified radical neck dissection and radiation
Hypertension
Hypothyroidism
Anemia
Right ICA stenosis status post right carotid stenting
Cervical cancer status post hysterectomy
Tonsillectomy
Appendectomy
Dyslipidemia
Pontine lacune
Bilateral cataracts
Social History:
___
Family History:
She had two brothers, one died in his ___ with liver cancer and
one died in his ___ with lung cancer. Multiple elder family
members developed severe vision loss.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Sleepy, lying in bed covered up in multiple blankets.
Intermittently appears to be in pain, stated secondary to chest
discomfort.
HEENT: no scleral icterus, dry MM, no oropharyngeal lesions.
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: Skin warm, well-perfused. Tenderness to palpation at
right costochondral junction.
Abdomen: soft, ND
Extremities: Symmetric, no edema.
Neurologic Examination:
- Mental status: Sleepy, keeps eyes closed during most of the
examination, opening only when necessary. Requires repeated
stimulation to participate in exam. Oriented to 'hospital' but
not which. States date is ___, though I needed
to
ask her the year, month, and date multiple times each because
she
kept replying ___. Difficulty providing history; provides
few details, answers to direct questions are at times tangential
or absent, states she is still working even though prior records
indicate that she has retired. Attention severely impaired,
unable to name days of week forward nor repeat a forward digit
span of 4. Anomia to low frequency words though interpretation
is limited by the fact that ___ is her second language.
Repetition intact. Comprehension intact to simple but not
complex commands. Perseverative.
-Cranial Nerves: PERRL 3->2. EOMI without nystagmus. Facial
sensation intact to light touch. Face symmetric at rest and with
activation. Hearing intact to conversation. Palate elevates
symmetrically. ___ strength in trapezii bilaterally. Tongue
protrudes in midline.
- Motor: Normal bulk, increased tone bilateral lower
extremities. Keeps arms outstretched for pronator drift testing
only momentarily, during which bilateral pronation without
downward drift is noted, before putting her arms down despite
coaching.
Patient has significant difficulty participating in the
confrontational motor testing, but gives at least some
resistance
in all muscle groups, and the resistance reaches full strength
for the first 3 muscle groups tested (Delt Bic Tri), and then
patient has progressive difficulty cooperating with exam and
symmetric 4 range effort is noted throughout the remainder of
the
exam.
-DTRs:
Bi Tri ___ Pat Ach Pec jerk Crossed Abductors
L 2 2 2 2 2 + +
R 2 2 2 2 2 + +
Plantar response was obscured by marked withdrawal bilaterally.
-Sensory: Intact to LT, temperature throughout. Unable to
participate in vibration or proprioceptive testing
- Coordination: Subtle dysmetria with left finger to nose
testing.
- Gait: Patient refuses.
DISCHARGE PHYSICAL EXAM:
Neurologic:
- Mental Status: alert and oriented x3, attention: states DOWB
without difficulty, memory: ___ recall ___ with MCQ/cue),
speech: normal rate, rhythm, volume, comprehension and naming
intact. Able to follow complex commands
- Cranial Nerves:
I: not tested
II: left lower quadrantopia on visual field examination
III, IV, VI: EOMI without nystagmus, PERRL, no ptosis
V: sensation intact to light touch
VII: no facial musculature asymmetry
VIII: hearing diminished but equal bilaterally
IX, X: palate elevates symmetrically
XI: ___ strength in trapezii and SCM bilaterally
- Motor: Normal bulk and tone. No pronator drift.
[___]
[C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response showed withdrawal b/l
-Sensory: Intact to LT throughout.
- Coordination: Subtle dysmetria with left finger to nose
testing.
- Gait: Deferred.
Pertinent Results:
___ 05:45AM BLOOD WBC-4.5 RBC-4.17 Hgb-11.5 Hct-34.8 MCV-84
MCH-27.6 MCHC-33.0 RDW-15.1 RDWSD-45.8 Plt ___
___ 08:40PM BLOOD WBC-5.8 RBC-4.56 Hgb-12.7 Hct-40.2 MCV-88
MCH-27.9 MCHC-31.6* RDW-15.4 RDWSD-49.3* Plt ___
___ 06:10AM BLOOD ___ PTT-29.2 ___
___ 05:45AM BLOOD Glucose-94 UreaN-26* Creat-1.0 Na-138
K-3.6 Cl-105 HCO3-20* AnGap-17
___ 08:40PM BLOOD Glucose-108* UreaN-36* Creat-1.2* Na-138
K-3.7 Cl-105 HCO3-16* AnGap-21*
___ 08:40PM BLOOD ALT-18 AST-16 AlkPhos-120* TotBili-0.3
___ 12:00PM BLOOD cTropnT-<0.01
___ 05:45AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.9
___ 08:40PM BLOOD Albumin-4.3 Calcium-8.9 Phos-4.4 Mg-2.3
___ 10:02AM BLOOD %HbA1c-5.4 eAG-108
___ 10:02AM BLOOD Triglyc-80 HDL-51 CHOL/HD-4.3
LDLcalc-150*
___ 08:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ CTA H&N
Notable finding - Atherosclerotic vascular calcifications
resulting in mild-to-moderate luminal narrowing of the petrous
segment of the right ICA, similar to the prior study. Moderate
luminal narrowing of the proximal to mid basilar artery again
seen, likely atherosclerotic.
___ MRI head w/o contrast
- Acute to subacute infarction is seen involving the right
parieto-occipital lobe, left parietal lobe, and right
cerebellum. Possible punctate focus of infarction is seen
within the left cerebellum. Distribution appears to be embolic
in etiology.
- Stable extensive confluent white matter changes, right greater
than left temporal white matter, bilateral frontoparietal white
matter as well as middle cerebellar peduncles likely combination
of posttreatment changes and sequelae of chronic small vessel
ischemic disease.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with PMH hypertension, carotid
stenosis s/p R ICA stent, multiple prior strokes, CAD c/b MI,
laryngeal cancer s/p surgery and radiation therapy who was
admitted to Neurology stroke service with headache and
dizziness. She was evaluated on telemetry and started on aspirin
therapy. She was seen to have elevated LDL and due to previous
statin intolerance was started on Zetia. She was seen on MRI to
have ischemic stroke in the right parieto-occiptal lobe, left
parietal lobe and left cerebellar lobe as well as moderate
narrowing of basilar artery. These findings were suggestive of
thrombotic etiology of her stroke. She underwent echocardiogram
without concern. She was started on dual anti-platelet therapy
with aspirin and Plavix. Her deficits (left visual field
impairment, dysmetria) improved prior to discharge. She was
discharged home with outpatient ___ and ___ services.
Transition Issues:
-Pt will need to continue taking Aspirin and Plavix for
secondary stroke prevention
-pt will need to continue taking Zetia for hyperlipidemia
-Will f/u pt's Echocardiogram final results; if anything
concerning that is pertinent to patient's recent stroke, will
contact pt to inform
-Pt will need to f/u with PCP and ___
___ on Admission:
ALBUTEROL SULFATE [VENTOLIN HFA] - Ventolin HFA 90 mcg/actuation
aerosol inhaler. ___ puffs(s) inhaled every four (4) hours as
needed for cough/wheeze/chest congestion/short of breath mdi
with
dose counter
CARVEDILOL - carvedilol 12.5 mg tablet. 1 tablet(s) by mouth
twice daily - ___ DC med rec)
LEVOTHYROXINE - levothyroxine 100 mcg tablet. 1 tablet(s) by
mouth once a day - ___ DC med rec)
LOSARTAN - losartan 50 mg tablet. 1 tablet(s) by mouth daily -
___ DC med rec)
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1
capsule(s) by mouth qday
SERTRALINE - sertraline 25 mg tablet. 1 tablet(s) by mouth -
(Prescribed by Other Provider: per pt in ___ Therapist f/u So
End, w/plan for ___ MD) (Not Taking as Prescribed: last filled
in ___)
TOPIRAMATE - topiramate 50 mg tablet. 1 tablet(s) by mouth twice
a day - (Prescribed by Other Provider: ___. ___
TRIAMCINOLONE ACETONIDE - triamcinolone acetonide 0.1 % topical
cream. apply to rash, hands three times a day
Medications - OTC
ASPIRIN - aspirin 81 mg tablet,delayed release. 1 tablet(s) by
mouth daily - ___ admission med rec)
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*2
2. Ezetimibe 10 mg PO DAILY
RX *ezetimibe 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*2
3. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
4. Carvedilol 12.5 mg PO BID
5. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth Dao;u Disp #*30
Tablet Refills:*2
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Topiramate (Topamax) 50 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Stroke
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 headache and dizziness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
High blood pressure
High cholesterol
We are changing your medications as follows:
- Aspirin 81 mg daily (for stroke prevention)
- Clopidegrel (Plavix) 75mg daily (for stroke prevention)
- Ezetimibe (Zetia) 10mg daily (for cholesterol)
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10056612-DS-8 | 10,056,612 | 26,462,956 | DS | 8 | 2189-09-04 00:00:00 | 2189-09-06 10:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Influenza Virus Vaccines
Attending: ___.
Chief Complaint:
Headache, dizziness, nausea.
Major Surgical or Invasive Procedure:
There were no major surgical or invasive procedures during
hospitalization.
History of Present Illness:
___ year who was sent in by ___ on ___ after
experiencing headache and emesis. The headache was acute in
onset however no headstrike or injuries were reported. She also
developed bilateral lower extremity weakness requiring her to
have to walk as she was unsteady on her feet. There was concern
regarding her presentation as she experienced similar symptoms
when she had a prior stroke.
In the ED, initial vitals were: Pain 8, Temperature 96.8, HR
101, BP 155/93, RR 16, Pulse Ox 99% on RA. Urine/serum
toxicology screen was negative. UA was negative. Chemistry
panel was normal except for a BUN of 24. LFT's were normal
except for an alk phos of 144. CBC was within normal limits.
She underwent a CTA head and neck with preliminary reading
showing "no flow limiting stenosis in the intracranial and
cervical vessels. No evidence of aneurysm greater than 3 mm or
dissection. Patent stent graft in the right common carotid
artery. Calcified and non-calcified plaque at the left carotid
bifurcation causing mild narrowing. Atherosclerotic
calcification involving the left greater than right cervical
vertebral arteries. Severe atherosclerotic disease of the aortic
arch and descending aorta with both calcified and non-calcified
plaque. Unchanged 8 mm right upper lobe pulmonary nodule, follow
up per prior chest CT's." The patient was evaluated by neurology
who suspected that the patient's current presentation was due to
sub-acute spinal pathology coupled with ongoing medical illness
and stress due to home situation. The patient was evaluated by
___ in the ED who recommended ___ visits or discharge to rehab.
The patient was admitted to medicine for coordination of care
and symptomatic management.
On the floor, the patient reports improvement in her nausea and
abdominal pain. She has some persistent left lower extremity
weakness compared to right. She reports intermittent dizziness
which she describes as the sensation that the room is spinning
around her. She reports stress regarding her son and his issues
with addiction, which she has dealt with for some time. She
reported headache on presentation bi-temporal, which has
improved. The patient does not remember the exact events when
she was walking to her closet yesterday morning, but she did not
experience any prodromal symptoms, nor changes in vision.
Past Medical History:
? CVA, ? MI
ANEMIA
APPENDECTOMY
BACK PAIN, RIGHT SCIATICA
CATARACTS
HYPERTENSION
HYPOTHYROIDISM S/p thyroidectomy ___ years ago, now on
levothyroxine.
RIGHT ANKLE SURG/PINS
THROAT CANCER ___, FOLLOWED AT ___
THROAT CANCER SURGERY,
THYROIDECTOMY
TOBACCO ABUSE
TONSILECTOMY
STENOSIS R CAROTID ARTERY/DEVICE PLACED AND ? REMOVED, ___
BRAIN TUMOR
ADENOID CYSTIC CARCINOMA
DEPRESSION
DYSPNEA ON EXERTION
RECHECK CHEST CT ___
? SEASONAL AFFECTIVE D/O
___: Admitted to ___ for dizziness, thought to be
secondary to Benign Paroxysmal Positional Vertigo. Also thought
that symptoms exacerbated by stress due to verbal abuse
experienced at home from her son.
Social History:
___
Family History:
- Strong family history of malignancy. One brother deceased in
his ___ with liver malignancy, another in his ___ with Lung
Cancer. Mother deceased (reportedly at ___) in the setting of
multiple medical problems plus a stroke. Her father died at ___.
- Patient denies other neurologic family history other than the
above.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: 97.1, 138/70, 64, 18, 98% on RA
General: alert, oriented, tearful when discussing son, otherwise
not in acute distress
HEENT: pale conjunctiva, JVP not visualized, hard
post-surgical/post-radiation changes in left submandibular area,
left cheek not tender to light palpation, no oropharnygeal
lesions visualized
CV: RRR, nl S1 S2, no murmurs, rubs, gallops; no carotid bruit
b/l
Lungs: CTA b/l, no wheezes, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no edema
Neuro: CNII-XII intact (though patient refuses to extend tongue
for testing of CN12), ___ strength upper/lower extremities,
grossly normal sensation, upgoing babinskin on left, downgoing
on right, gait deferred, ___ negative b/l, mild left
lateral end-gaze nystagmus
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 98.2 ___ 44-70 18 95-100%RA
General: AOx3, lying in bed, appears comfortable, very pleasant
HEENT: MMM, hard post-surgical/post-radiation changes in left
submandibular area, left cheek not tender to light palpation
CV: RRR, normal S1 and S2 no m/r/g.
Lungs: Clear to auscultation bilaterally.
Abdomen: soft, nt, nd, no rebound or guarding.
Ext: Warm, well perfused, no edema.
Neuro: AOx3, EOMI, CNII-XII intact, strength/sensation grossly
intact
Pertinent Results:
ADMISSION LABS
==============
___ 01:45PM BLOOD WBC-4.6 RBC-5.18 Hgb-13.8 Hct-43.4 MCV-84
MCH-26.6 MCHC-31.8* RDW-16.2* RDWSD-49.3* Plt ___
___ 01:45PM BLOOD Neuts-67.6 ___ Monos-7.4 Eos-0.4*
Baso-0.7 Im ___ AbsNeut-3.10 AbsLymp-1.08* AbsMono-0.34
AbsEos-0.02* AbsBaso-0.03
___ 01:45PM BLOOD Glucose-99 UreaN-24* Creat-1.1 Na-140
K-3.8 Cl-101 HCO3-29 AnGap-14
___ 01:45PM BLOOD Albumin-4.4 Calcium-9.6 Phos-3.9 Mg-2.1
___ 01:45PM BLOOD ALT-31 AST-26 AlkPhos-144* TotBili-0.4
DISCHARGE LABS
==============
___ 07:32AM BLOOD WBC-3.8* RBC-5.17 Hgb-13.7 Hct-42.5
MCV-82 MCH-26.5 MCHC-32.2 RDW-16.2* RDWSD-48.2* Plt ___
___ 07:32AM BLOOD Glucose-95 UreaN-17 Creat-0.9 Na-139
K-3.7 Cl-101 HCO3-29 AnGap-13
___ 07:32AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.0
SERUM TOXICOLOGY
================
___ 01:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
URINE TOXICOLOGY
================
___ 03:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
URINE STUDIES
=============
___ 03:00PM URINE Color-Straw Appear-Clear Sp ___
___ 03:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
IMAGING
=======
___: CTA HEAD AND CTA NECK
IMPRESSION:
1. Extensive periventricular and subcortical white matter
hypodensities,
relatively unchanged compared to the prior MRI allowing for the
differences in technique. Please note that evaluation for an
underlying acute infarct is limited given the extensive
hypodensities. MRI of the brain can be performed for further
evaluation as clinically indicated.
2. Vasogenic edema in the inferior right temporal lobe. The
previously known enhancing lesion in the right temporal lobe is
not well visualized on the CT scan.
3. Patent right internal and common carotid artery stent.
4. Atherosclerosis involving the left carotid bifurcation
without any stenosis by NASCET criteria.
5. Atherosclerosis involving V2 segment of left vertebral artery
causing focal areas of mild luminal narrowing.
6. Stable 9 mm nodule in the right upper lobe. Further
evaluation with
dedicated CT of the chest can be performed as clinically
indicated.
___: PELVIS (AP ONLY)
FINDINGS:
No fracture or dislocation. Bilateral hip joint spaces are
relatively well
preserved with only minimal degenerative change. Pubic
symphysis and SI
joints are preserved. No radiopaque foreign body. Contrast is
seen within
the bladder.
IMPRESSION:
No fracture or dislocation.
Brief Hospital Course:
ASSESSMENT AND PLAN: ___ with PMH of HTN, hypothyroidism, head
and neck cancer s/p neck dissection x2 who presented with
complaints of vertigo and leg weakness after fall with complex
social situation concerning for abuse.
# Vertigo secondary to BPPV versus Social Stressors/Anxiety: Ms.
___ presented with nausea and dizziness. Based on description
it appeared the vertigo appeared to be position in nature. Given
her history of carotid stenosis, a CTA head and neck was
obtained which did not show any evidence of new acute stroke.
Neurology was consulted during hospitalization who did not
believe symptoms could be explained by an acute stroke. Rather,
they believed the symptoms were consistent with benign
paroxysmal positional vertigo as neurologic exam was completely
benign.
During hospitalization, it was also noted that Ms. ___
symptoms occurred when she was talking about her stressful home
situation (a son at home who has a drug addiction and is
verbally abusive to her). When talking to her son on the phone,
Ms. ___ would experience the dizziness and nausea. She also
experienced these symptoms when she described her stressful home
situation to the medical team. These symptoms would resolve
after she had time to relax.
Neurology did not believe any further work-up was necessary as
an inpatient and recommended follow up with her Neurologist, Dr.
___.
# Social Stressors/Verbal Abuse: Ms. ___ described her
stressful home situation with her son. She describes her son as
addicted to crack. She also described numerous episodes of
verbal abuse to her. She denied any physical abuse. Elder
services had been involved in the past. Given this description,
social work was heavily involved during this hospitalization and
initial mandated reporting was done upon admission. She was
hesitant to be discharged from the hospital until ___
discharge plan was in place. Social work attempted to find other
places for her to stay, however, patient elected to be
discharged home. To facilitate a safe discharge plan, plans were
made with ___ Police if any abuse at home (plan would be
contact Police at Precinct B2 with ___ ___
___ cell). These plans were also communicated with
patient's daughter (___) to instruct on when to call the
police. Prior to her discharge, Elder Protective Services were
called for wellness and home safety evaluations to occur at
home. Ms. ___ was able to voice back the safety plan that was
developed and reported she felt comfortable with the safety
plan. Attempts were made to locate safe housing prior to
discharge,but patient denied further services.
# Bacterial pneumonia: patient recently diagnosed with atypical
pneumonia at PCP, started on course of levofloxacin ___.
She completed her 10 day course of levofloxacin on ___. She
was not experience cough or fever, and remained hemodynamically
stable during hospitalization.
# Hypertension: Continued atenolol, chlorthalidone, and aspirin
during hospitalization.
# Hypothyroidism: Continued levothyroxine during
hospitalization.
TRANSITIONAL ISSUES
===================
- Stable 9 mm nodule in the right upper lobe. Further evaluation
with dedicated CT of the chest can be performed as clinically
indicated. Of note, this lesion has been documented on previous
CT scans of the chest.
- CTA Head and Neck: Marked atherosclerosis involving the aortic
arch with penetrating atherosclerotic ulcer as seen on image
5:27. Further evaluation with dedicated CT of the chest can be
performed as clinically indicated.
- Please continue to follow up with patient's safety situation
at home
- If further concerns for elder abuse, please contact Elder
Services.
- Patient was noted to have mild leukopenia on labs. Please
consider repeat CBC as outpatient and consider further
evaluation.
-Code Status: DNR/DNI.
- Safety Plan: Patient will be calling Officer ___
___ cell) if there are any further
safety issues.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 100 mg PO DAILY
2. Chlorthalidone 25 mg PO QAM
3. Levofloxacin 500 mg PO Q24H
4. Aspirin 81 mg PO DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Acetaminophen 1000 mg PO Q4H:PRN headache/cold
7. Fish Oil (Omega 3) ___ mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q4H:PRN headache/cold
2. Aspirin 81 mg PO DAILY
3. Atenolol 100 mg PO DAILY
4. Chlorthalidone 25 mg PO QAM
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Fish Oil (Omega 3) ___ mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
=================
-Benign Paroxysmal Positional Vertigo
-Post-traumatic stress disorder thought to be secondary to
verbal abuse at home.
Secondary Diagnosis
===================
-Hypertension
-Hypothyroidism
-Prior CVA
-Throat Cancer ___
-s/p Thyroidectomy
-Depression
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 ___ ___ due to
nausea and dizziness. You were seen by the Neurologists who
recommended you undergo a CT scan of your head and neck. This
did NOT show evidence of a new stroke.
The dizziness you experienced seemed to be related to the
movement of your head. This is known as "Benign positional
vertigo." This usually resolves on its own.
We also noticed that your symptoms of nausea/dizziness occurred
when you were talking about your very stressful home situation.
Stressors can make your symptoms worse. To help find a safe
place for you to be discharged to, you were seen by Social Work.
Their recommendations included a safety plan to contact the
Police if you feel unsafe at home. Your friend, Officer ___
___, can be reached at ___ cell), and
was contacted to ensure you have more safety checks at home.
Further, Elder Services were also contacted so that they can see
you at home to ensure that it is a safe environment.
Please follow up with your primary care physician and your
specialists upon discharge from the hospital. It was a pleasure
taking care of your during your hospitalization! We wish you all
the best in the upcoming new year!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10056612-DS-9 | 10,056,612 | 23,069,501 | DS | 9 | 2189-11-13 00:00:00 | 2189-11-14 17:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Influenza Virus Vaccines
Attending: ___.
Chief Complaint:
Episodes of confusion, dizziness, subjective lower extremity
weakness and "out of body" experience
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI:
___ is a ___ year-old right-handed woman with PMH
significant for laryngeal cancer s/p neck dissection and
radiation therapy (___) with a chronic stable right temporal
brain lesion felt to be radiation necrosis who presents with
multiple transient episodes of ___ weakness, dysarthria and
headache.
The patient reports that the first of these episodes was in
___ (see Neurology ED consult note by ___
___ The then restarted about 2 weeks ago (shortly after
she
missed a neurology appointment because she was at a court
hearing
- having her son evicted from her house and placed in an
inpatient psych facility). She reports having about 5 events in
the last 2 weeks with 2 today. She describes the events as
follows:
The onset always starts with a sense of dizziness - which she
describes as a floating detached feeling "like im in the air" or
"like I don't have a body". She denies a ___ out-of-body
experience or vertigo. She then will feel "shaky" especially in
her legs followed by a feeling of fear/anxiety. She feels like
"I
don't have any legs", describing them as numb and weak. Her
speech will then sound funny. The event concludes in a
non-pulsatile headache with nausea and occasional emesis. each
event lasts about 10 min.
She also describes a very similar episode (which she calls her
stroke) at ___ in the months following her CA treatment. She
denies any significant headache history.
On neuro ROS: the pt denies loss of vision, blurred vision,
diplopia, oscilopsia, dysphagia, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness, paresthesias (outside
of
the events). No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general ROS: 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:
? CVA, ? MI
ANEMIA
APPENDECTOMY
BACK PAIN, RIGHT SCIATICA
CATARACTS
HYPERTENSION
HYPOTHYROIDISM S/p thyroidectomy ___ years ago, now on
levothyroxine.
RIGHT ANKLE SURG/PINS
THROAT CANCER ___, FOLLOWED AT ___
THROAT CANCER SURGERY,
THYROIDECTOMY
TOBACCO ABUSE
TONSILECTOMY
STENOSIS R CAROTID ARTERY/DEVICE PLACED AND ? REMOVED, ___
BRAIN TUMOR
ADENOID CYSTIC CARCINOMA
DEPRESSION
DYSPNEA ON EXERTION
RECHECK CHEST CT ___
? SEASONAL AFFECTIVE D/O
___: Admitted to ___ for dizziness, thought to be
secondary to Benign Paroxysmal Positional Vertigo. Also thought
that symptoms exacerbated by stress due to verbal abuse
experienced at home from her son.
Social History:
___
Family History:
- Strong family history of malignancy. One brother deceased in
his ___ with liver malignancy, another in his ___ with Lung
Cancer. Mother deceased (reportedly at ___) in the setting of
multiple medical problems plus a stroke. Her father died at ___.
- Patient denies other neurologic family history other than the
above.
Physical Exam:
ADMISSION MEDICAL EXAMINATION
T: 97.8 HR: 76 BP: 164/107 RR: 18 Sat: 99% on RA
GENERAL MEDICAL EXAMINATION:
General appearance: alert, in no apparent distress,
conversing/interacting appropriately
HEENT: Sclera are non-injected. Mucous membranes are moist.
CV: Heart rate is regular
Lungs: Breathing comfortably on RA
Abdomen: soft, non-tender
Extremities: No evidence of deformities. No contractures. No
Edema.
Skin: No visible rashes. Warm and well perfused.
NEUROLOGICAL EXAMINATION:
Mental Status: Alert and oriented to person place and time. Able
to relate history without difficulty. Attentive to conversation.
Language is fluent and appropriate with intact comprehension,
repetition and naming of both high and low frequency objects.
Normal prosody. There were no paraphasic errors. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. No neglect, left/right confusion or finger agnosia.
During a witnessed event the patient's speech became slow and
effortful but not dysarthric. She was still able to repeat and
follow complex commands. She did not demonstrate any weakness
during the event.
Cranial Nerves:
I: not tested
II: visual fields full to confrontation
III-IV-VI: pupils equally round, reactive to light. Normal
conjugated, extra-ocular eye movements in all directions of
gaze.
No nystagmus or diplopia.
V: Symmetric perception of LT in V1-3
VII: Face is symmetric at rest and with activation; symmetric
speed and excursion with smile.
VIII: Hearing intact to finger rub bl
IX-X: Palate elevates symmetrically
XI: Shoulder shrug ___ bl
XII: No tongue deviation or fasciculations
Motor: Normal muscle bulk and tone throughout. No pronator drift
or rebound.
Strength:
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
Reflexes: brisk and symmetric.
Toes are equivocal bilaterally.
Sensory: decreased perception to pin on the left (80%)
(documented in prior exams). normal and symmetric perception of
light touch, vibration and temperature. Proprioception is
intact.
Coordination: Finger to nose without dysmetria bilaterally. No
intention tremor. RAM were slow but with regular cadence and
good
accuracy.
Gait: Good initiation. Narrow-based, normal stride and arm
swing.
**DISCHARGE PHYSICAL EXAMINATION:**
General: awake, alert woman in bed reporting mild headache in no
acute distress
HEENT: No conjunctival injection or discharge, MMM
Resp: Breathing comfortably in room air
CV: no cyanosis
Abd: Non-distended
Ext: WWP
Neuro:
Mental status: Awake, alert, oriented to place; conversant, able
to answer basic history questions
CN: PERRL, EOMI, face grossly symmetric with grossly normal
facial sensation
Motor: at least anti-gravity throughout with no orbiting
Gait: deferred
Pertinent Results:
EEG: preliminary report (see full, final report for further
details) multiple push button events without evidence of
electrographic correlate (no evidence of seizure), no sharp
waves; intermittent right temporal slowing as expected given
known lesion
___ 06:50AM BLOOD WBC-4.1 RBC-4.94 Hgb-13.4 Hct-41.8 MCV-85
MCH-27.1 MCHC-32.1 RDW-15.9* RDWSD-49.1* Plt ___
___ 06:50AM BLOOD WBC-4.1 RBC-4.94 Hgb-13.4 Hct-41.8 MCV-85
MCH-27.1 MCHC-32.1 RDW-15.9* RDWSD-49.1* Plt ___
___ 01:00PM BLOOD WBC-4.4 RBC-5.08 Hgb-13.8 Hct-43.0 MCV-85
MCH-27.2 MCHC-32.1 RDW-15.7* RDWSD-47.8* Plt ___
___ 06:50AM BLOOD Neuts-54.6 ___ Monos-8.8 Eos-1.7
Baso-0.7 Im ___ AbsNeut-2.22 AbsLymp-1.37 AbsMono-0.36
AbsEos-0.07 AbsBaso-0.03
___ 01:00PM BLOOD Neuts-58.3 ___ Monos-9.1 Eos-1.8
Baso-0.7 Im ___ AbsNeut-2.56 AbsLymp-1.29 AbsMono-0.40
AbsEos-0.08 AbsBaso-0.03
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD ___ PTT-30.8 ___
___ 01:00PM BLOOD Plt ___
___ 01:00PM BLOOD ___ PTT-29.5 ___
___ 06:50AM BLOOD Glucose-89 UreaN-17 Creat-0.9 Na-141
K-3.5 Cl-104 HCO3-26 AnGap-15
___ 01:00PM BLOOD Glucose-89 UreaN-21* Creat-1.1 Na-137
K-4.8 Cl-97 HCO3-29 AnGap-16
___ 06:50AM BLOOD ALT-20 AST-25 LD(LDH)-212 AlkPhos-95
TotBili-0.6
___ 06:50AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.7
___ 06:50AM BLOOD TSH-36*
___ 01:06PM BLOOD Lactate-1.2
Brief Hospital Course:
Patient was admitted to the Neurology Service where she was
placed on long term EEG to capture events. Multiple episodes
were captured and were typical of the events of interest. There
were multiple push button events for these episodes without EEG
correlate (no evidence of seizure). As a result, these episodes
were felt to be most likely due to stress (e.g. possible panic
attacks). No medication changes were made, and no new
medications were added. She was discharged home with a plan to
follow up with her primary care physician, ___, and
psychiatry.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Lisinopril 5 mg PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Lisinopril 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro exam: non focal
Discharge Instructions:
Dear Ms. ___,
You were admitted for episodes of feeling dizzy, confused,
"floating" and scared. We placed you on EEG to look at your
brain waves. You had a few of these episodes while under EEG
monitoring and they were not seizures. We think that your
episodes are most likely from anxiety. Please talk to your
primary care doctor to arrange for a psychiatry appointment for
management of your anxiety.
Followup Instructions:
___
|
10057005-DS-22 | 10,057,005 | 24,537,613 | DS | 22 | 2175-03-01 00:00:00 | 2175-03-01 12:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Malfunctioning DBS batteries.
Major Surgical or Invasive Procedure:
___- Bialteral removal and replacement of DBS internal
pulse generators.
History of Present Illness:
Mr. ___ is a ___ y/o gentleman with a long standing history of
___ who has been managed with DBS for aprox ___ years.
Per patient's wife the patient has had a subacute decline over
the past few months and in the past three weeks the patient has
had a significant decline and has been unable to swallow solid
foods w/o vomiting. His wife took him to ___ because of their
proximity to the hospital.
Patient was admitted to ___ from ___ for care. Records
from ___ state that the patient has had a rapid decline over the
past two weeks. He was previously able to ambulate with two
person assist, but now is bed or chair bound with increased
dysphagia complicated by choking, gagging and occasional emesis.
Patient has a history of complicated UTIs and is followed by
urology. Wife stated at the time of admission to ___ that the
patient's presentation was much like his UTIs. patient underwent
a fever ___ and had pyuria and urine cultures that grew low CFU
enterococcus, he was treated with IV ampicillin, but his mental
status did not improve.
Neurology was consulted at ___ and his DBS batteries were
interrogated and his left chest wall unit was found to be
completely depleted and the right unit was low. At this time
Neurosurgery was consulted and was prepared to replace the
batteries, but patient's wife request transfer to ___ for
continuity of care and to have Dr. ___ the surgery.
Past Medical History:
BPH
___ Disease
Urge Incontinence
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
Gen: cachetic
HEENT: NcNT
Neck: UA
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft
Extrem: Warm and well-perfused.
Neuro:
Mental status: Lethargic, non verbal, not making eye contact or
following commands. Attempts to mumble inaudible words.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to 3
mm bilaterally.
Remainder of exam difficult to asses
Motor: Some rigidity in all four extremities, able to maintain
arms off the bed briefly with assistance, some spontaneous
movement of the lowers L>R
PHYSICAL EXAMINATION ON DISCHARGE:
Gen: cachetic
HEENT: NcNT
Neck: UA
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft
Extrem: Warm and well-perfused.
Neuro:
Mental status: Lethargic, non verbal, not making eye contact or
following commands. Attempts to mumble inaudible words.
Cranial Nerves:
Patient is non-verbal but follows commands.
Pupils equally round and reactive to light, 3-2 mm bilaterally.
Motor: Rigidity in all four extremities, able to maintain
arms and legs off the bed briefly with assistance
Chest wall incision has steri strips placed over it. Clean, dry
and intact.
Pertinent Results:
Cardiovascular Report ECG Study Date of ___ 2:38:26 ___
Sinus rhythm with baseline artifact. Frequent atrial premature
depolarizations. Low QRS voltage in the limb leads. Diffuse
non-specific
repolarization abnormalities. No previous tracing available for
comparison.
TRACING #1
Read by: ___
Intervals Axes
Rate PR QRS QT/QTc P QRS T
83 0 84 404/444 0 0 -30
________________________________________________
Cardiovascular Report ECG Study Date of ___ 9:31:56 ___
Sinus rhythm with frequent atrial premature depolarizations and
baseline
artifact. Compared to the previous tracing there is no
diagnostic change.
TRACING #2
Read by: ___
Intervals Axes
Rate PR QRS QT/QTc P QRS T
79 0 94 ___
__________________________________________________
Radiology Report CHEST (PORTABLE AP) Study Date of ___
6:58 ___
FINDINGS:
Nasogastric tube tip terminates at the thoracoabdominal
junction, with the side port several cm above this level.
Cardiomediastinal contours are stable in appearance with
persistent tortuosity of the thoracic aorta. Lungs are grossly
clear, and there are no pleural effusions or pneumothoraces
Radiology Report CHEST (PORTABLE AP) Study Date of ___
12:35 ___
FINDINGS:
As compared to the recent radiograph of 1 day prior, a
nasogastric tube has been advanced into the stomach, but the
side port is still above the level of the diaphragm. No other
changes since recent study.
Radiology Report CHEST (PORTABLE AP) Study Date of ___
4:37 ___
IMPRESSION:
Nasogastric tube is been advanced, now ends in the upper stomach
with also reports beyond the gastroesophageal junction. Heart
normal. Lungs clear. No pleural abnormality. Bilateral pectoral
generators send leads superiorly and of view.
Radiology Report PORTABLE ABDOMEN Study Date of ___ 10:32
AM
IMPRESSION:
Preliminary Report: NG tube terminates over the stomach. No
evidence of bowel obstruction.
___ CXR
As compared to ___ radiograph, pulmonary vascular
congestion has
developed. Additionally, a new patchy bibasilar opacities are
present, and may
correspond to provided clinical history of acute aspiration
event. Followup
radiographs are suggested to evaluate for resolution.
___ CXR
There has been interval appearance of mild pulmonary and
interstitial edema. In addition, there is increasing
consolidation in the retrocardiac region which would be
concerning for aspiration pneumonia. There is likely a small
left effusion. No pneumothorax. Overall cardiac and mediastinal
contours are unchanged. Stimulator generators overlie both upper
lungs limiting evaluation in this vicinity.
Brief Hospital Course:
The patient was transferred from ___ to the Emergency Department
at ___ on ___ with malfunctioning bilateral DBS
batteries. He was admitted and underwent a pre-operative
evaluation in anticipation for going to the operating room the
following day.
On ___, the patient underwent a bilateral removal and
replacement of DBS internal pulse generators. He tolerated the
procedure well and was transferred to the PACU from the
operating room for close monitoring. His pulse generators were
reprogrammed.
On ___, his urine cultutre grew yeast, but his WBC was 7 and
he was afebrile. After talking to ID, there was no need for
treatment. His foley was replaced with a new foley. The patient
was neurologically unstable. The Nutritionist reccomended a
nasogastric tube for feedings. The patient was alert but
uncooperative. Placement of a peg tube for feeding was discussed
as the patient had not recieved any nutrition for the past one
week. A nasogastric tube was placed but patient pulled it back
and tybe feedings were unable to be initiated.
On ___, The ___ Gastric tube was advanced. The Acute Care
Service was consulted for PEG tube placement. Subcutaneous
heparin was held for elevated INR. The foley catheter was not
exchanged due to clots and bleeding into urine. The intravenous
fluid was increased and the foley catheter irrigated.
On ___, The patients K and magnesium were repleated. The
patient's left chest wall incision draining sanguinous drainage.
A urine analysis was resent with plan to not change out the
foley given recent clots and bleeding noted in urine. The
patient was made NPO at midnight for peg tube by acs in am.
On ___, The patient was mobilized oob to chair. The serum
potassium was low and was repleated. The INR was stable at 1.6.
The foley catheter was discontinued and at 1800 the bladder was
scanned for 1 liter. A foley catheter was replaced. A urine
analysis was resent for culture and was consistent with NO
GROWTH. The phosphorus was repleated.
On ___, The INR was 1.8. The patient went to the OR to have a
peg placed by the ___ team.
On ___ TF were restarted. INR 2.2. Hematology curbsided- given
long period of poor nutrition this is likely the cause of
elevated INR. Recommended repeating level in a few days. They
did not recommend no reversal of INR and recommended to continue
holding SQH upon discharge.
On ___ Seroquel was started for agitation.
On ___ Febrile to 100.3 axillary overnight. TF noted in patient
mouth. New O2 requirement. CXR revealed Development of pulmonary
vascular congestion. Additionally, a new patchy bibasilar
opacities are present, and may correspond to provided clinical
history of acute aspiration event. Medicine was consulted who
recommended repeat CXR in 24 hours.
On ___, CXR consistent with pulmonary edema but no obvious
focal opacity to suggest a pneumonia. Patient was stable on room
air, afebrile, downtrending WBC. As such, he was started on
gentle diuresis and maintenance IV fluids were turned off in
order to keep him net negative.
On ___ His tube feeds were restarted. Cleared for discharge
from a medical standpoint. Wrist restraints were discontinued.
___, Mr. ___ was discharged to rehab in stable condition.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atropine Sulfate Ophth 1% 1 DROP BOTH EYES DAILY
2. Finasteride 5 mg PO DAILY
3. Amantadine Syrup 100 mg PO BID
4. Myrbetriq (mirabegron) 50 mg oral qd
5. Oxybutynin 2.5 mg PO BID
6. Hyoscyamine 0.125 mg SL BID
Discharge Medications:
1. Amantadine Syrup 100 mg PO BID
2. Atropine Sulfate Ophth 1% 1 DROP BOTH EYES DAILY
3. Finasteride 5 mg PO DAILY
4. Acetaminophen 650 mg PO Q6H:PRN PAIN
5. Bisacodyl 10 mg PO/PR DAILY
6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID:PRN
mouth care
7. Docusate Sodium 100 mg PO BID
8. Heparin 5000 UNIT SC TID
9. HydrALAzine 20 mg IV Q6H:PRN for SBP > 160
10. OLANZapine (Disintegrating Tablet) 2.5 mg PO BID:PRN
agitation
11. Ondansetron 4 mg IV Q8H:PRN vomiting / nausea
12. QUEtiapine Fumarate 12.5 mg PO BID
13. Senna 8.6 mg PO BID
14. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
___ Disease
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You are being discharged after undergoing a DBS battery change.
¨ 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.
¨ Dressing may be removed on Day 2 after surgery.
¨ **Your wound was closed with non-dissolvable sutures then
you must wait until after they are removed to wash your hair.
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) &
Senna 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.
¨ 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.
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: increasing
redness, increased swelling, increased tenderness, or drainage.
¨ Fever greater than or equal to 101.5° F.
Followup Instructions:
___
|
10057009-DS-10 | 10,057,009 | 28,491,028 | DS | 10 | 2150-02-12 00:00:00 | 2150-02-15 12:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cough, SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of HTN, HLD who presents with cough and SOB. This
has been developing over several weeks. She denies fever,
chills. Found to have an elevated BNP to >15000 with EKG showing
atrial fibrillation, LAD, mildly prolonged QRS c/w LAFB, 1mm STE
in III with STD in I - unchanged from prior; TWI in V1-V5, new
from prior, w/ new T wave flattening in II, V6. Trops x 3
negative. Also found to have hyponatremia to 129. Started on IV
heparin for ? ACS vs. afib, transitioned to apixiban. ECHO
pending. Getting IV diuresis
Past Medical History:
1. Hypertension.
2. Osteoarthritis.
3. Hypercholesterolemia.
Social History:
___
Family History:
Father had prostate surgery at ___ years and
passed away at ___. Mother died at a younger age with MI, a
brother had myocardial infarction as well and he was a smoker.
No history of dementia in the family.
Physical Exam:
ADMISSION EXAM:
Physical Exam:
Vitals- T:97.3 BP:128 87 HR:94 RR:16 O2:94 RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE EXAM:
Vitals- T:98.2 BP:107-126/65-84 HR:80's RR:16 O2:95 RA
General- Alert, oriented, sitting up in bed and eating
breakfast. No acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, 1+ edema in lower
extremities bilaterally.
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 07:39PM ___ PO2-39* PCO2-36 PH-7.40 TOTAL CO2-23
BASE XS--1
___ 07:39PM LACTATE-2.2*
___ 07:30PM ALT(SGPT)-47* AST(SGOT)-65* ALK PHOS-94 TOT
BILI-1.1
___ 07:30PM ___
___ 07:30PM CALCIUM-9.4 MAGNESIUM-2.0
___ 07:30PM ___
___ 05:25PM GLUCOSE-106* UREA N-22* CREAT-0.9 SODIUM-129*
POTASSIUM-4.8 CHLORIDE-94* TOTAL CO2-17* ANION GAP-23*
___ 05:25PM estGFR-Using this
___ 05:25PM cTropnT-<0.01
___ 05:25PM CALCIUM-9.4 MAGNESIUM-2.1
___ 05:25PM WBC-9.7 RBC-4.90 HGB-13.8 HCT-42.6 MCV-87#
MCH-28.2 MCHC-32.4 RDW-14.1 RDWSD-44.0
___ 05:25PM NEUTS-69.7 ___ MONOS-9.1 EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-6.78* AbsLymp-1.99 AbsMono-0.88*
AbsEos-0.01* AbsBaso-0.02
___ 05:25PM PLT COUNT-210
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-5.6 RBC-4.40 Hgb-12.7 Hct-39.0 MCV-89
MCH-28.9 MCHC-32.6 RDW-14.7 RDWSD-45.8 Plt ___
___ 06:00AM BLOOD Plt ___
___ 03:24PM BLOOD Glucose-116* UreaN-25* Creat-1.1 Na-136
K-5.1 Cl-99 HCO3-24 AnGap-18
___ 03:24PM BLOOD Calcium-9.4 Phos-4.8* Mg-2.0
Imaging:
IMPRESSION:
Limited exam without definite acute cardiopulmonary process.
Specifically, no
visualized focal consolidation concerning for pneumonia.
Brief Hospital Course:
Ms. ___ is an ___ with PMH of HTN, HLD who presented to the
___ ED with cough and DOE for 2 weeks. She was found to have
hyponatremia, an elevated AG, changes on ECG concerning for
ischemia, new onset atrial fibrillation and elevated BNP
concerning for CHF. She was discharged on ___.
# Dyspnea/cough: most likely multifactorial, related to new AF,
possibly cardiac ischemia and some element of volume overload
given elevated BNP. Of note pt endorsed a chronic dry cough for
years which was, per notation by cardiology likely related to
lisinopril. This episode was more acute. However, we changed to
losartan to simplify future clinical presentations.
CXR did not show evidence of pulmonary edema or infection,
though exam was limited given patient's habitus w/kyphosis.
Possibly new diagnosis of CHF, perhaps provoked by cardiac
ischemia (see below) vs. tachycardia induced cardiomyopathy in
the setting of AF and h/o of intermittent palpitations with
PACs. The latter seems less likely as patient's HR has been
controlled throughout admission and she is on metoprolol at
baseline. Lactate was slightly elevated to 2.2 on admission, at
1.4 on ___. Acutely decompensated CHF was less likely as she
was warm on exam. Beta blockers were continued. Prior cardiology
note described cough as possibly being ACEI-induced. She was
switched from lisinopril to losartan given concern for
ACEI-induced cough. She was given IV Lasix 10 mg boluses and had
good urine output. She will need a TTE as an outpatient and
cardiology follow up.
Patient stated if she were to have evidence of ischemia on her
echo she would not want a stent, however with son in the room he
stated she did not fully understand the implications. They had
many questions which will need to be concretly and clearly
stated at follow up visits.
-started on 10mg furosemide
-pt with follow up ___ for weight, lytes.
# Atrial Fibrillation: patient with AF on ECG at presentation
and was never noted on prior ECGs. Patient does have history of
"skipped beats" for which she was evaluated by cardiology and
treated with metoprolol. It is possible that this may have
represented AF, not captured on ECG. Her current presentation
may be AF-provoked in the setting of CHF vs. cardiac ischemia or
vice versa. Patient with CHADSVASC 4 given age, HTN and female
sex. Heparin was initiated on admission for anticoagulation. She
was switched to apixaban 2.5 mg BID and continued on home
metoprolol.
# TWI on ECG: patient had TWI on ECG at admission, may be rate
related changes in the setting of new AF vs. related to cardiac
ischemia. She was without symptoms of chest pain, but did have
DOE. Trops x 3 were negative, MB 7. In discussion regarding
further work-up, patient indicated that she would not like to
have any invasive procedure should she be found to have CAD. She
was continued on ___, statin. Will follow up with
her cardiologist as an outpatient.
# Hyponatremia: her hyponatremia on admission was likely
hypervolemic in the setting of elevated BNP and possible volume
overload. She had a prior history of hyponatremia which was
attributed to poor PO intake and improved with IVF. Na was 129
on admission and improved to 137 on ___ with diuretics.
# Transaminitis: Elevated AST and ALT on admission, possibly due
to congestion in the setting of possible CHF. Transaminitis
resolved on ___.
# Elevated AG: Patient with AG 18 on admission that resolved on
___. Had normal pH on VBG. Lactate was slightly elevated.
Delta/Delta 1 suggestive of pure AG process. Evaluated with
serum ___ to r/o salicylate toxicity in the ED, which was
negative. Patient with no history of other exposure of
ingestion. Other possible etiology is ketonemia in the setting
of decreased PO intake. This resolved on admission.
# Hypertension: H/o HTN. Swtiched from lisinopril 10 mg to
losartan 50 mg given concern for ACE-induced cough.
# HLD: Continued on statin.
Transitional Issues:
- Will need outpatient ECHO for ? diagnosis of CHF
- Discussed with patient and son the need for assistance with
___ services, however, declined at this time over what he
described were privacy issues of the patient and would need to
discuss slowly over time. We would like to be offered this
option at a later time.
- Provided with a script for outpatient ___
- Will need outpatient cardiology evaluation and possible stress
test
# CODE STATUS: Full
Name of health care proxy: ___
Relationship: sons
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Simvastatin 5 mg PO HS
4. Vitamin D 800 UNIT PO DAILY
5. ammonium lactate 12 % topical DAILY:PRN
6. Ketoconazole 2% 1 Appl TP BID
7. Metoprolol Succinate XL 75 mg PO DAILY
8. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Fluticasone Propionate NASAL 1 SPRY NS DAILY
RX *fluticasone 50 mcg/actuation 1 spray nasal daily each nare
Disp #*1 Spray Refills:*0
3. Furosemide 10 mg PO DAILY
RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*0
4. Losartan Potassium 50 mg PO DAILY
RX *losartan 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. ammonium lactate 12 % topical DAILY:PRN
6. Aspirin 81 mg PO DAILY
7. Ketoconazole 2% 1 Appl TP BID
8. Metoprolol Succinate XL 75 mg PO DAILY
9. Senna 8.6 mg PO BID:PRN constipation
10. Simvastatin 5 mg PO HS
11. Vitamin D 800 UNIT PO DAILY
12.Outpatient Physical Therapy
___ with PMH of HTN, HLD who presents with cough and SOB, new
dx of afib
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial Fibrillation
Hypervolemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with trouble breathing and a cough.
We found you to have extra fluid in your body so we gave you an
intravenous form of the water pill to help you pee it out. We
thought your cough might be related to one of your medications,
called lisinopril, so we switched it to another blood pressure
medication, losartan.
You were also found to have an abnormal heart rhythm called
atrial fibrillation. We started you on a medication called
Eliquis (apixaban)to thin out your blood and decreases your risk
of having a stroke. It was a pleasure caring for you.
Wishing you the best,
Your ___ Team
Followup Instructions:
___
|
10057482-DS-12 | 10,057,482 | 25,416,257 | DS | 12 | 2145-04-26 00:00:00 | 2145-04-26 13:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
sulfa drugs / Coumadin / lisinopril / Celebrex
Attending: ___
Chief Complaint:
Fatigue, weakness, dyspnea on exertion
Major Surgical or Invasive Procedure:
___: Emergent Right femoral cannulation, Emergent repair of
type A dissection with 30mm straight gelweave graft with
sidebranch. Repair of small liver laceration.
___: Chest re-exploration and washout, sternal closure
___: Percutaneous tracheostomy (8 cuffed tracheostomy),
percutaneous endoscopic gastrostomy tube (___)
___: RUE PICC placement (Hub Rt. ___. 40 cm. DLumen)
History of Present Illness:
Ms. ___ is an ___ year old woman with a history of amyloid
angiopathy, atrial fibrillation, cerebrovascular accident,
hypertension, osteoarthritis, and Sjogren's syndrome. She
presented to ___ with back pain radiating to
her left arm and jaw. She underwent a CTA of the chest and
abdomen. The visualized portion of the ascending thoracic aorta
is dilated measuring up to 6.3 cm. An intimal flap is also seen
at the visualized portion of the ascending thoracic aorta. Great
vessels are not evaluated. She was transferred to ___ for
surgical intervention.
Past Medical History:
Amyloid Angiopathy
Atrial Fibrillation
Cerebrovascular Accident with left sided weakness/pronator drift
Chronic Back Pain
Hyperlipidemia
Hypertension
Osteoarthritis
Peripheral Neuropathy
Rheumatic Fever
Sjogrens Syndrome
PSH:
Breast biopsy x 2 (negative)
Ex-lap for SBO
Lumbar surgery ___
Social History:
___
Family History:
Mother - died ___ ? cause
Father - died ___ with skin ca and ___ stroke
Sibs - 1 brother ___ on dialyssi for renal failure, sister age ___
Children - 2 sons with T1dm and 1 daughter with T2DM and has had
some seizures
There is no history of developmental disability, learning
disorders, migraine headaches, strokes less than 50,
neuromuscular disorders, dementia or movement disorders.
Physical Exam:
Admission Exam:
BP: 74/40, HR 100
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema [x] ___none__
Varicosities: None [x]
Neuro: Left sided upper and lower extremity weakness
Pulses:
DP Right: 2+ Left: 2+
___ Right: 2+ Left: 2+
Radial Right: 1+ Left: 1+
Discharge Exam:
110/49 79SR 16 95% trach collar
.
General: NAD [x]
Neurological: Moves all extremities spontaneously[x]
Chemically
paralyzed [] sedated [] Follows commands: weak L hand grasp and
bilat toe wiggle/extension [x]
HEENT: PEERL [x] MMM[x]
Cardiovascular: RRR [x] Irregular [] Murmur, II/VI upper LSB
[x]
Respiratory: Clear but decreased L>R [x] No resp distress [x]
Intubated [] trach site c/d/I [x] increased secretions [x]
GU/Renal: Urine clear [x]
GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] mild
tenderness w/deep palp LUQ [x] flexiseal ___ place [x] PEG
c/d/i-no erythema [x]
Extremities:
Right Upper extremity Warm [x] Edema tr
Left Upper extremity Warm [x] Edema tr
Right Lower extremity Warm [x] Edema tr
Left Lower extremity Warm [x] Edema tr
Pulses:
DP Right:1 Left:1
___ Right:1 Left:1
Radial Right:1 Left:Aline ___ place
Skin/Wounds: Dry [x] intact [x]
Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [x] Prevena []
R SC TLC: c/d/I [x]
Pertinent Results:
STUDIES:
PA/LAT CXR ___ (Preliminary): RUE PICC line placed with tip
___ mid SVC.
PA/LAT CXR ___
___ comparison with the study ___, the monitoring support
devices are
unchanged, as is the left pleural effusion with compressive
basilar
atelectasis and enlargement of the cardiac silhouette.
Indistinctness of
pulmonary vessels is consistent with some elevation of pulmonary
venous
pressure.
Chest CTA ___
1. Type A dissection originating at the aortic root with
extension into the right brachiocephalic and extending into the
abdomen, inferior extent not included on the images. On this
study, extends beyond the SMA. Relative decreased enhancement of
the left kidney and left adrenal gland suggests that they are
supplied by the false lumen.
2. Small to moderate amount of hemopericardium. Mediastinal
blood/hematoma
exerts mass-effect with resultant narrowing of the main left and
right
pulmonary arteries. No active extravasation seen.
Transesophageal Echocardiogram ___
PRE-OPERATIVE STATE: Sinus rhythm.
Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC):
Normal RA size. No atrial septal defect by 2D/color flow
Doppler.
Left Ventricle (LV): Moderate symmetric hypertrophy. Normal
cavity size, though the ventricle is significantly underfilled.
Normal regional & global systolic function Normal ejection
fraction.
Right Ventricle (RV): Normal cavity size. Normal free wall
motion.
Aorta: SEVERE ascending dilation. Type A ascending, arch and
descending DISSECTION.
Aortic Valve: Mildly thickened (3) leaflets. Mild leaflet
calcification. Mild (>1.5cm2) stenosis. Mild-moderate [___]
regurgitation. Central jet. The dissection flap does not involve
the aortic valve.
Mitral Valve: Normal leaflets. No stenosis. Moderate annular
calcification. Mild [1+] regurgitation. Central jet.
Tricuspid Valve: Normal leaflets.
Pericardium: Moderate effusion. RA systolic collapse/early
tamponade.
Miscellaneous: Left pleural effusion.
POST-OP STATE: The TEE was performed at 21:00:00. Atrial
fibrillation.
Support: Vasopressor(s): epinephrine.
Left Ventricle: Similar to preoperative findings. Global
ejection fraction is normal. LV remains underfilled.
Right Ventricle: New/worse global dysfunction. RV function is
mildly depressed.
Aorta: Aortic tube graft ___ position. Dissection ___ aortic arch
and descending aorta unchanged.
Aortic Valve: No change ___ aortic valve morphology from
preoperative state. No change ___ aortic
regurgitation.
Mitral Valve: No change ___ mitral valve morphology from
preoperative state. No change ___ valvular regurgitation from
preoperative state.
Pericardium: No effusion.
Miscellaneous: No pleural effusions.
Notification: The surgeon/proceduralist was notified of the
findings at the time of the study.
Renal Artery Ultrasound ___
Magnitude of vascularity of the left kidney is lower on the left
than on the right, suggesting the left renal artery arises from
the false lumen and right renal artery from the true lumen as
seen on prior CT imaging. However, it was not possible to
directly visualize the renal artery origins sonographically due
to poor visualization at this time.
Left upper extremity ultrasound ___
1. Deep vein thrombosis with complete occlusion of flow
involving the mid to low left internal jugular vein.
2. No evidence of additional deep vein thrombosis ___ the left
upper extremity.
MR ___ ___
1. Numerous, scattered acute or early subacute infarcts,
majority of which are punctate, however there is a larger
approximately 3.0 cm left frontal area of acute or early
subacute infarct. No evidence of hemorrhagic conversion. Chronic
lacunar infarcts are also noted.
2. Innumerable areas of susceptibility on gradient echo imaging,
compatible with amyloid angiopathy.
3. Moderate paranasal sinus disease, as detailed above,
including air-fluid levels, suggestive of acute sinusitis.
___ CT ___
1. Evolving acute infarct ___ the left frontal lobe. No evidence
of
hemorrhagic conversion.
2. Additional smaller infarcts ___ the bilateral cerebral
hemispheres and
cerebellar hemispheres are better appreciated on prior MRI.
Chest CT ___
1. Multifocal bilateral ground-glass, nodular opacities and
consolidation ___ both lower lobes, worse on the left are likely
secondary to multifocal
pneumonia.
2. New small bilateral pleural effusions.
3. Type A aortic dissection incompletely characterized ___ this
study, with new hyperdense material at the ascending aorta,
likely related to the repair. Atherosclerotic plaque CT outline
the true lumen ___ the remainder thoracic aorta which appears not
significantly changed ___ caliber from prior.
Chest CT ___
1. Nodular peribronchovascular airspace disease ___ the
dependent aspect of the right upper lobe and basal aspects of
the right middle and lower lobes most likely represents
bronchopneumonia. The overall disease burden is decreased
(especially ___ the dependent aspect of the right upper lobe)
compared to prior CT studies.
2. Please note that it is difficult to differentiate
atelectasis from
consolidation on a non contrasted study. However, airspace
opacification ___ the dependent aspect of the left upper lobe and
superior segment of the left lower lobe most likely represents
atelectasis. Ground-glass airspace
opacification ___ the left lower lobe is nonspecific.
3. Small left-sided pleural effusion.
4. Patient is status post aortic root repair. Residual post
dissection
changes are difficult to assess on a noncontrast study.
CT Aorta and branches ___
The aorta measures 3.5 cm ___ the proximal portion, 3.5 cm ___ mid
portion and 3.4 cm ___ the distal abdominal aorta. There is
suboptimal visualization of the mid and distal aorta due to
overlying bowel gas, tortuosity of the aorta, and body habitus.
The known aortic dissection is re-demonstrated. There is
echogenic material within the distal aorta which is consistent
with thrombus, however size comparison to prior exam is
difficult due to limited sonographic windows. The iliac arteries
are not visualized.
IMPRESSION:
Technically limited assessment of the distal abdominal aorta
however
intraluminal echogenic material corresponds to the known
thrombus, however
size comparison is difficult. If further comparison is desired
and the
patient cannot tolerate a CTA, non-contrast MRI with multiplanar
imaging could be performed.
MICRO:
___ 1:08 pm Mini-BAL
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
CFU/mL.
YEAST. ___ CFU/mL.
___ 11:15 am STOOL CONSISTENCY: FORMED Source:
Stool. **FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
___ 8:39 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 CFU/mL.
___ 9:41 pm Mini-BAL
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. ~5000 CFU/mL.
___ 11:30 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. MODERATE GROWTH.
ASPERGILLUS FUMIGATUS COMPLEX.
SUSCEPTIBILITIES REQUESTED PER ___ ___ (___) ON
___.
Refer to sendout/miscellaneous reporting for results.
SENT TO ___ ON ___.
LABS:
Admit:
___ 02:05PM BLOOD WBC-10.7* RBC-3.83* Hgb-10.8* Hct-34.4
MCV-90 MCH-28.2 MCHC-31.4* RDW-14.2 RDWSD-46.2 Plt ___
___ 02:05PM BLOOD ___ PTT-27.2 ___
___ 08:15AM BLOOD HIT Ab-NEG HIT ___
___ 08:15AM BLOOD HIT Ab-NEG HIT ___
___ 02:05PM BLOOD Glucose-141* UreaN-21* Creat-0.9 Na-137
K-4.7 Cl-103 HCO3-20* AnGap-14
___ 03:45AM BLOOD ALT-12 AST-40 LD(LDH)-476* AlkPhos-27*
Amylase-23 TotBili-0.7
___ 03:26PM BLOOD Lipase-1429*
___ 03:45AM BLOOD Albumin-2.5* Calcium-8.7 Phos-3.7 Mg-2.4
___ 08:15AM BLOOD Triglyc-187*
___ 03:00AM BLOOD Cortsol-20.9*
Discharge:
___ 03:04AM BLOOD WBC-10.0 RBC-2.64* Hgb-7.9* Hct-25.6*
MCV-97 MCH-29.9 MCHC-30.9* RDW-16.5* RDWSD-56.2* Plt ___
___ 03:04AM BLOOD ___ PTT-85.3* ___
___ 12:52AM BLOOD ___ PTT-68.7* ___
___ 02:06AM BLOOD ___ PTT-66.2* ___
___ 09:38AM BLOOD ___ PTT-70.2* ___
___ 02:40AM BLOOD ___ PTT-82.5* ___
___ 01:37PM BLOOD ___ PTT-76.1* ___
___ 03:03AM BLOOD ___ PTT-77.7* ___
___ 03:04AM BLOOD Glucose-126* UreaN-45* Creat-0.8 Na-139
K-4.3 Cl-99 HCO3-24 AnGap-16
___ 12:52AM BLOOD Glucose-147* UreaN-51* Creat-0.8 Na-142
K-3.7 Cl-102 HCO3-25 AnGap-15
___ 02:06AM BLOOD ALT-16 AST-24 LD(LDH)-259* AlkPhos-97
Amylase-368* TotBili-0.2
___ 03:08AM BLOOD ALT-8 AST-19 LD(LDH)-390* AlkPhos-69
Amylase-716* TotBili-0.6
___ 02:06AM BLOOD Lipase-403*
___ 02:58PM BLOOD Calcium-8.3* Phos-4.8* Mg-1.8
Brief Hospital Course:
She was admitted emergently on ___. A CTA of the chest
confirmed a type A dissection originating at the aortic root
with extension into the right brachiocephalic and extending into
the abdomen. On this study, extends beyond the SMA. Relative
decreased enhancement of the left kidney and left adrenal gland
suggests that they are supplied by the false lumen. She was
taken to the operating room and under went Emergent repair of
type A dissection with 30mm straight gelweave graft with
sidebranch and repair of small liver laceration. Please see
operative note for full details. She tolerated the procedure and
was transferred to the CVICU on multiple pressors and inotropes
and paralytics with an open sternotomy for recovery and invasive
monitoring. She was volume overloaded on arrival and was started
on a Lasix infusion for aggressive diuresis. She returned to the
OR for chest closure on ___. She was weaned off of paralytics
and sedation. The patient remained lethargic and given her prior
history of CVA neurology was consulted. An MRI was obtained
which revealed a frontal CVA. A follow up ___ CT showed no
evidence of hemorrhagic conversion. Given her embolic CVA,
evidence of left IJ thrombus on ultrasound and clot seen on CTA
___ the abdominal aorta, she was started on heparin. The
patient's mental status continued to wax and wane and she had
persistent encephalopathy and weakness. On ___ an EEG showed
discharges consistent with early seizure activity. She was
loaded with Keppra. A repeat CT did not show evidence of further
CVA. The patient developed fevers and cultures were sent. A
chest CT showed evidence of PNA and she had continued difficulty
weaning from the ventilator. She was started on empiric
Vanco/Cefepime which was then narrowed to an empiric course of
cefepime per the ID team. She grew Aspergillus from sputum
cultures and the decision was made to treat this with
Voriconazole then changed to Isavuconazole due to a prolonged
QTc. Cefepime was stopped due to her seizure activity. She was
extubated on ___ however she became acutely short of breath and
was reintubated. Given her other comorbities the decision was
made to proceed with Trach/PEG on ___. She gradually
continued with trach collar trials. She has a history of atrial
fibrillation and developed intermittent atrial fibrillation that
was treated with Lopressor, Amiodarone was held due to prolonged
QTc.
During this prolonged ICU stay she also developed
___. Nephrolgy was also consulted, her
diuretics were limited and she was started on free water flushes
via PEG. Slowly her renal function trended back to her baseline
levels. She continues to receive free water flushes for
hypernatremia.
She continues to be encephalopathic but this has been improving
slowly, she is responsive and follows some simple commands. She
has been tolerating progressively longer periods of time on
trach collar (daytime trials began ___ and she began 24h ATC TC
___. She is ___ sinus rhythm and has not had any post-op Afib
for several weeks. Her anticoagulation is for afib/DVT and
aortic thrombus, continues on heparin bridging and slowly being
converted to Coumadin. Goal INR is ___, goal PTT is 50-70. She
is tolerating her tube feeds, did have elevated pancreatic
enzymes initially. These trended down when she was placed on
elemental tube feeds and have continued to trend down for the
past 2 weeks. She had yeast ___ both BAL and urine and was
started on antifungals (Isavuconazole), this therapy will
continue for 6 weeks from start date of ___ with end date ___
and she requires weekly CBC/LFTs per ID recs. Regarding her
Keppra and Coumadin duration, these will be reviewed by her
neurologist Dr. ___ at a 1 month ___ clinic visit with
CTA Torso. She will also need 1 month clinic visit with
Vascular team. On, ___ LUE PICC was attempted but could not
thread wire and then successfully placed RUE PICC. CXR at that
time showed L collapse, so recruitment maneuver done and placed
back on PEEP 10. Speech recommdation is that she will likely
need trach downsize prior to tolerance of PMV.
She was discharged POD 34 to ___ ___ ___ with
follow up instructions.
Medications on Admission:
1. Diltiazem Extended-Release 180 mg PO Q12H
2. Gabapentin 300 mg PO BID
3. Gabapentin 600 mg PO QHS
4. amLODIPine 1.25 mg PO DAILY
5. Simvastatin 10 mg PO QPM
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
4. Artificial Tears GEL 1% 1 DROP BOTH EYES Q4H
5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
8. Glucose Gel 15 g PO PRN hypoglycemia protocol
9. HydrALAZINE 10 mg IV Q6H:PRN HTN
10. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
12. Isavuconazonium Sulfate 372 mg PO DAILY Aspergillus PNA
Duration: 6 Weeks
start date ___
expected finish date ___
13. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
14. LevETIRAcetam 500 mg PO Q12H
15. Metoprolol Tartrate 25 mg PO TID
Hold for HR<60,SBP<90
16. Miconazole Powder 2% 1 Appl TP QID:PRN fungal rash
17. Nystatin Oral Suspension 5 mL PO TID
18. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
19. Ramelteon 8 mg PO QHS:PRN insomnia
20. Senna 8.6 mg PO BID:PRN Constipation - First Line
21. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
22. ___ MD to order daily dose PO DAILY16
23. Warfarin 5 mg PO ONCE Duration: 1 Dose
(h/o: postop Afib, aortic thrombus and LIJ DVT)
goal INR ___
24. Simvastatin 10 mg PO QPM
25. HELD- Aspirin 325 mg PO DAILY This medication was held. Do
not restart Aspirin until cleared by neurology (Dr. ___
26. HELD- Diltiazem Extended-Release 180 mg PO Q12H This
medication was held. Do not restart Diltiazem Extended-Release
until you see cardiologist
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary:
Type A Aortic Dissection s/p ascending aortic replacement
Hosp acquired pneumonia/Resp failure s/p trach & PEG placement
Acute kidney injury
CVA-left frontal infarct w/associated seizure activity
postop Atrial Fibrillation
Deep Vein Thrombosis
Liver Laceration
Hypernatremia
Aspergillus Pneumonia
elevated Pancreatic enzymes
Secondary:
PMH: CVA(left sided weakness/pronator drift), Sjogrens syndrome,
HLD, HTN, peripheral neuropathy.
PSH: Ex-lap for SBO, Lumbar surgery ___, breast biopsyx2
(negative)
Discharge Condition:
Neuro: opens eyes to voice, moves UE spontaneously, lightly
squeezes both hands
Full care and lift
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: trace
PICC RUE- c/d/i
Discharge Instructions:
Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then ___ the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
___
|
10057731-DS-7 | 10,057,731 | 26,763,521 | DS | 7 | 2155-12-13 00:00:00 | 2155-12-19 09:09:00 |
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, jaundice
Major Surgical or Invasive Procedure:
ERCP/EUS with biopsies and Biliary stenting ___
History of Present Illness:
___ yo M with seizure disorder and chronic low back pain who
presents with abdominal pain and jaundice. Pt reports abdominal
pain that started in the LUQ on ___ and progressed to
include the RUQ over the following day. He noticed that he was
jaundiced on ___ w/ tea colored urine and pale stools. He also
endorses pruritus. He went to the ED at ___ on ___ and
reportedly was found to have a mass at the head of the pancreas
and hepatic lesions. He saw his PCP today who referred him to
___ for evaluation.
In the ED, pt afebrile w/ WBC 8.5k. Labs notable for ALT 79, AST
43, Alk 829, Tb 22.6. ERCP was consulted who recommended NPO for
ERCP tomorrow and antibiotic ppx w/ cipro/flagyl.
Pt otherwise denies any weight loss, chronic abdominal pain, or
diarrhea.
ROS: As above. Denies headache, lightheadedness, dizziness, sore
throat, sinus congestion, chest pain, heart palpitations,
shortness of breath, cough, nausea, vomiting, diarrhea,
constipation, urinary symptoms, muscle or joint pains, focal
numbness or tingling, skin rash. The remainder of the ROS was
negative.
Past Medical History:
PMHx:
- Distant ex-lap ___ stabbing
- chronic back pain w/ prior lumbar discectomy
- seizure disorder, currently off meds
- HTN
- depression
Social History:
___
Family History:
No family history of GI illness or malignancy.
Pertinent Results:
HBsAg: NEG
HBs Ab: NEG
HBc Ab: NEG
HAV Ab: NEG
Hep C Ab: POS** --> Viral load negative
*Cytology Pending
___
ALT: 48* AST: 37 AlkPhos: 649* TotBili: 24.4*
___
ALT: 46* AST: 51* AlkPhos: 587* TotBili: 23.9*
MRCP ___: Results
IMPRESSION:
1. 6.0 cm centrally necrotic mass in the tail the pancreas
obliterating the splenic vein, intimately associated with the
splenic artery, and abutting but not clearly involving the
inferior aspect of the stomach, consistent with primary
pancreatic neoplasm. No extension to the splenic hilum.
2. Numerous hepatic metastases including to the hepatic hilum
causing diffuse intrahepatic biliary ductal dilation and
multifocal areas of intrahepatic iliary ductal tree stricturing,
including involving the left and right anterior and posterior
hepatic ducts as well as more distal segmental biliary
tree branches.
3. Peribiliary enhancement is concerning for superimposed
cholangitis.
4. Enlarged periportal lymph nodes are concerning for nodal
metastases.
5. Right portal vein is occluded. Patent left and main portal
vein. Patent SMV.
6. Upper abdominal varices are noted including along the lesser
curvature of the stomach. No splenomegaly or ascites.
7. 2 cm right adrenal adenoma. Other incidental findings, as
above.
ERCP ___
The scout film was normal.
There was mild duodenitis.
The bile duct was deeply cannulated with the sphincterotome.
Contrast was injected and there was brisk flow through the
ducts.
Contrast extended to the entire biliary tree. The CBD was 6 mm
in diameter.
Opacification of the gallbladder was incomplete.
There was evidence of a hilar stricture involving both the CHD,
as well as left and right main intrahepatic ducts.
The total length of the stricture was 3 cm.
This is compatible with a Type IV hilar stricture.
A biliary sphincterotomy was made with a sphincterotome.
There was no post-sphincterotomy bleeding.
Both the right and left IHD were cannulated with wires using
standard double-wire technique.
A 6 mm hurricane dilation balloon was used to dilaton the right
and left main ducts as well as CHD. Cytology brushings of the
hilum were performed.
A ___ x 15 cm biliary plastic straight stent was placed into
the
right IHD.
An 8.5 F x 14 cm biliary plastic straight stent was attempted
to
be placed into the left IHD but was unable to traverse the
stricture and thus was removed with a snare.
A ___ x 14 cm biliary plastic straight stent was then placed
into
the left main IHD successfully after repeat hurricane dilation
with 6 mm balloon.
Excellent bile and contrast drainage was seen endoscopically
and
fluoroscopically.
Otherwise normal ercp to third part of the duodenum
EUS ___
Impression: A focused EUS was performed using a linear
echoendoscope at ___ MHz frequency: The head and uncinate
pancreas were imaged from the duodenal bulb and the second /
third duodenum. The body and tail [partially] were imaged from
the gastric body and fundus.
Pancreas Tail Mass: A 6 cm X 7 cm ill-defined mass was noted in
the tail of the pancreas. The mass was hypoechoic and
heterogenous in echotexture. The borders of the mass were
irregular and poorly defined.
FNB was performed of the mass. Color doppler was used to
determine an avascular path for needle aspiration. A 22-gauge
Sharkcore needle with a stylet was used to perform biopsy. Four
needle passes were made into the mass.
25 gauge FNA was also performed of the mass with two passes.
No appreciable liver lesions were identified for biopsy.
Otherwise normal upper eus to third part of the duodenum
Brief Hospital Course:
___ yo M with h/o HTN, chronic back pain, who presents with
jaundice and outside imaging with finding of mass within the
pancreas
# Necrotic Pancreatic Mass - Pancreatic tail mass with possible
metastasis to liver and regional lymph nodes. EUS/ERCP done on
___ and obtained FNA of tumor and cytology brushings of bile
duct for pathology (with preliminary findings of adenocarcinoma;
Onc aware and will be followed up outpatient). At time of
discharge d/c'd home with PO oxycodone for moderate pain
(increased from home dose of 10mg to 15mg)
# Hyperbilirubinemia and Elevated LFTs - Most likely from mass
and obstruction from lymph notes. Stenting ___. To follow up
with
ERCP team in 4 weeks
# Periportal enhancement on MRCP - Possible Cholangitis? Will
treat for duration of Cholangitis course ___ days -
intervention on ___. Cipro/flagyl - End date ___
# Portal vein thrombosis as above - STarted on heparin ggt due
to thrombosis. Restarted on Subcutaneous lovenox prior to
discharge.
# Hep C Ab + - Viral Load negative
# HTN - continue metoprolol 50 daily. Restart losartan and
chlorthalidone on discharge
# Depression/Anxiety - continue sertraline. Started Alprazolam
inpatient due to overwhelming anxiety during diagnosis stage of
his pancreatic cancer
# Adrenal Adenoma - Incidental 2cm mass. If indicated, repeat
imaging in ___ months
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Chlorthalidone 25 mg PO DAILY
2. Losartan Potassium 25 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
5. Sertraline 100 mg PO DAILY
Discharge Medications:
1. ALPRAZolam 1 mg PO TID:PRN Anxiety
RX *alprazolam 1 mg 1 tablet(s) by mouth Three times a day as
needed for anxiety Disp #*15 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth Every
12 hours Disp #*12 Tablet Refills:*0
3. Enoxaparin Sodium 110 mg SC Q12H
RX *enoxaparin 100 mg/mL 110 mg Subcutaneous injecton Every 12
hours Disp #*60 Syringe Refills:*0
4. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth Every 8
hours Disp #*18 Tablet Refills:*0
5. Nicotine Lozenge 2 mg PO Q4H:PRN Cravings
RX *nicotine (polacrilex) [Nicorette] 2 mg Every 4 hours as
needed for craving Every 4 hours as needed for craving Disp #*60
Lozenge Refills:*0
6. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour 1 patch daily for smoking cravings 1
patch daily for smoking cravings Disp #*30 Patch Refills:*0
7. Chlorthalidone 25 mg PO DAILY
8. Losartan Potassium 25 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
11. Sertraline 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatic Cancer
Hyperbilirubinemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
You were admitted for abdominal pain and jaundice. It was found
that you had a large mass in your pancreas that looks like it
had spread to your lymph nodes and to your liver. During you
stay you had an MRI of your biliary system and also a procedure
called an ERCP in which we took biopsies of your lesion and also
brushings of your bile duct. We stented your bile duct so it
should be draining OK.
The ERCP team want to see you back in 4 weeks to re-evaluate and
pull the stent.
The final results of the brushings and samples taken will be
followed up by oncology. Please expect a call from them or call
them within 1 week of discharge.
You were also started on Lovenox for a clot in your right portal
vein.
It was a pleasure being part of your care
Your ___ Team
Followup Instructions:
___
|
10058150-DS-11 | 10,058,150 | 23,585,194 | DS | 11 | 2161-11-05 00:00:00 | 2161-11-10 19:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a ___ year old woman with DMII, HTN, HLD,
depression/anxiety who presented to the ED after one episode of
syncope that lasted minutes in duration while she was eating at
a restaurant with family. The patient reports sitting at the
table eating with family members when she spontaneously lost
consciousness without dizziness or any other prodrome. She
denies any other symptoms that she has experienced in recent
days. The patient does report decreased PO intake during the
days prior to her presentation. No fevers, malaise, cough, N/V,
abdominal pain, changes in urination, leg pain, leg swelling.
She denies a recent travel history or recent prolonged periods
of immobility. There is no evidence that she became incontinent
during the syncope event.
Past Medical History:
Past Medical History
-DM
-HTN
-Hyperlipidemia
-Depression
-Anxiety
-right hip trochanteric bursitis/gluteus medius tendinosis
-lumbar spinal stenosis
Social History:
___
Family History:
No pertinent cardiac history or sudden cardiac death.
Physical Exam:
Admission Physical Exam
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Vitals: 98.2 158/88 105 18 100%RA
GENERAL: Pleasant, well appearing Hispanic female.
___ only in NAD.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: irregularly irregular. Normal S1, S2. ___ SEM at LUSB.
JVP low
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/
posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout. ___ reflexes,
equal ___. Normal coordination. Gait assessment deferred
Discharge Physical Exam
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Vitals: 97.6 130/60 64 18 100%RA
Exam:
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
HEART - RRR, nl S1-S2, no significant murmur appreciated
LUNGS - CTAB
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c, no edema, 2+ DP pulses
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
Labs on Admission
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___ 07:30PM BLOOD WBC-8.6 RBC-4.26 Hgb-11.7 Hct-39.9 MCV-94
MCH-27.5 MCHC-29.3* RDW-13.6 RDWSD-46.5* Plt ___
___ 07:30PM BLOOD Neuts-53.5 ___ Monos-9.1 Eos-2.1
Baso-0.8 Im ___ AbsNeut-4.61 AbsLymp-2.90 AbsMono-0.78
AbsEos-0.18 AbsBaso-0.07
___ 07:30PM BLOOD ___ PTT-35.4 ___
___ 07:30PM BLOOD Plt ___
___ 07:30PM BLOOD Glucose-146* UreaN-18 Creat-1.8* Na-134
K-3.8 Cl-96 HCO3-15* AnGap-27*
___ 07:30PM BLOOD ALT-11 AST-14 TotBili-0.3
___ 07:30PM BLOOD Lipase-66*
___ 07:30PM BLOOD proBNP-2689*
___ 07:30PM BLOOD cTropnT-<0.01
___ 04:29AM BLOOD cTropnT-<0.01
___ 07:30PM BLOOD Albumin-4.3 Calcium-11.2* Phos-2.8
Mg-1.5*
___ 07:30PM BLOOD D-Dimer-1365*
___ 11:10PM BLOOD Osmolal-305
___ 07:30PM BLOOD TSH-4.7*
___ 07:30PM BLOOD ASA-NEG Ethanol-15* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:41PM BLOOD Lactate-9.1*
___ 11:09PM BLOOD Lactate-5.7*
Discharge Lab Results
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___ 05:16AM BLOOD WBC-6.1 RBC-3.62* Hgb-10.0* Hct-32.6*
MCV-90 MCH-27.6 MCHC-30.7* RDW-13.7 RDWSD-44.7 Plt ___
___ 05:16AM BLOOD Plt ___
___ 05:16AM BLOOD ___ PTT-69.8* ___
___ 01:10PM BLOOD Na-133 K-5.3* Cl-99
___ 05:16AM BLOOD Glucose-332* UreaN-22* Creat-1.5* Na-132*
K-4.5 Cl-98 HCO3-23 AnGap-16
___ 05:16AM BLOOD Calcium-9.5 Phos-3.7 Mg-1.7
___ 04:29AM BLOOD PTH-80*
___ 04:29AM BLOOD 25VitD-33
___ 04:43AM BLOOD ___ pO2-106* pCO2-43 pH-7.38
calTCO2-26 Base XS-0
___ 04:43AM BLOOD Lactate-1.7
ECHO ___ EF=65%
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Mild-moderate aortic regurgitation. Mild mitral regurgitation.
Mild symmetric left ventricular hypertrophy with preserved
regional and global biventricular systolic function.
CTA ___. No evidence of pulmonary embolism or aortic abnormality.
2. Dilated main pulmonary arteries suggestive of pulmonary
artery
hypertension.
3. Although this exam is not tailored for the evaluation of the
airways note
is made of anterior motion of the posterior membrane of the
trachea and
narrowing of the left mainstem and right bronchus intermedius
which can be
seen in the setting of tracheobronchial malacia.
4. Cholelithiasis
Brief Hospital Course:
___ female w/PMH significant for HTN, DM, HLD,
depression/anxiety who presents by EMS for syncope thought to be
due to orthostatic hypotension ___ poor PO intake.
# Syncope: Possible etiologies explaining her syncope include
neurologic, cardiogenic, and orthostatic. Patient interview and
collateral story from family members did not suggest any seizure
activity at the time of the syncope and was most consistent with
vasovagal event. TTE did not reveal AS, and EKG was notable for
sinus rhythm with RBBB and frequent PACs which was unchanged
from prior EKGs ___ years ago (provided by PCP's office). The
patient was orthostatic upon arrival to the floor, even after
receiving 1 liter on IVFs in the ED. The patient was given
another liter O/N into hospital day 2. Her orthostatics improved
by the time she was discharged such that she was no longer
orthostatic with ambulation. Given the patient's RBBB
appreciated on EKG in the ED and her syncope, a ddimer was
ordered and found to be elevated. Without a another plausible
explanation for an elevated ddimer, a PE was ruled out. A V/Q
scan was attempted before giving the patient IV contrast,
however the results were inconclusive due to inadequate
inspiration so a CTA was pursued. The patient was hydrated with
IV fluids prior to the start of the study per protocol given her
CKD. CTA did not show PE.
# Tachycardia: The patient was found to be tachycardic in the
ED. This was likely a result of hypovolemia. EKG in the ED was
read as AFib with RVR, however subsequent examination with
additional EKGs and comparison with prior EKGs suggest the
patient has stable sinus rythym with PACs. The RBBB was also
stable from prior EKGs. The patient's atenolol was stopped given
its dependence on renal clearance and the patient was started on
metoprolol. She was monitored on telemetry without evidence of
afib or other arrythmia.
#CKD: Her baseline Cr is 1.4-1.6 with a GFR of 27. She was given
IV fluids before CTA chest per protocol to protect her renal
function. She was treated with her home valsartan throughout her
hospital stay. At discharge her Cr was stable at 1.5.
#hypercalcemia: The patient was admitted with a Ca of 11.2. With
an elevated PTH, this would most consistent with primary
hyperparathyroidism. Given the patient was not symptomatic
during this hospitalization, further workup deferred to the
outpatient setting.
#Hyperkalemia: The patient was noted to have potassium of 5.3
prior to discharge without EKG changes, likely related to
holding Lasix for orthostasis. The patient should have this
repeated on ___ at her follow up appointment with her PCP. Her
home lasix was restarted upon discharge.
# Anion Gap metabolic acidosis: The patient was admitted with an
anion gap of 23 in setting of elevated lactate. The patient's
home medication list included metformin thus acidosis may have
been due to metformin use in addition to global hypoperfusion
related to syncope as above. The patient had evidence of DKA at
admission and no evidence of uremia on exam, although patient
has CKD, as above. The patient also came in with a positive EtOH
on serum tox. Her VBG was relatively benign, not significant for
alkalosis or acidosis. And her serum osm gap was only 10.37
suggesting against ingestion. Her metformin was stopped on this
admission and at discharge.
#HTN: Her hypertension was controlled using her home doses of
valsartan and amlodipine. She was switched from atenolol to
metoprolol given her CKD. Her furosemide was initially held and
restarted at discharge.
#DM: The patient's last A1c was 9.4 in ___. She is on
Levemir 30U daily at home. Patient was not clear on her dosing
initially and received OMR dosing of 35u BID of glargine with
occasional lows into the ___. Per further discussion with
patient, she was started back on 30u long acting insulin
(levemir) as she stated she never took BID dosing, she should
continue taking insulin as she has been at home.
=============================
Transitional Issues
=============================
[] Please repeat sodium, potassium and glucose at PCP on ___
___. Na 133 on discharge with K of 5.3 (likely from
holding Lasix for orthostasis)
[] switched patient from atenolol to metoprolol 50mg PO extended
release
[] stopped metformin given lactic acidosis on presentation
[] Noted to have hypercalcemia with elevated PTH on admission.
Please trend calcium as outpatient and consider further work-up
if persistent. Calcium and vitamin D held on discharge given
hypercalcemia
[]TSH elevated to 4.7 on admission. Consider repeat TSH in 6
weeks to evaluate for hypothyroidism
[] Ongoing medication education, assistance with administration
# CONTACT: ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Valsartan 320 mg PO DAILY
3. Gabapentin 100 mg PO BID
4. Atenolol 100 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Alendronate Sodium 70 mg PO Frequency is Unknown
7. Amlodipine 10 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Levemir 30 Units Breakfast
10. Furosemide 20 mg PO DAILY
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Fluticasone Propionate 110mcg 1 PUFF IH BID
13. Cilostazol 100 mg PO BID
14. Omeprazole 20 mg PO DAILY
15. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3)
600 mg(1,500mg) -200 unit oral BID
16. Aspirin 81 mg PO DAILY
17. Sertraline 50 mg PO DAILY
18. GlipiZIDE 10 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Cilostazol 100 mg PO BID
6. Fluticasone Propionate 110mcg 1 PUFF IH BID
7. Gabapentin 100 mg PO BID
8. Levemir 30 Units Breakfast
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Sertraline 50 mg PO DAILY
12. Valsartan 320 mg PO DAILY
13. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet by mouth Daily Disp #*30
Tablet Refills:*0
14. Alendronate Sodium 70 mg PO QTHUR
15. GlipiZIDE 10 mg PO BID
16. Furosemide 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
syncope likely secondary to orthostasis
Lactic Acidosis
Sinus tachycardia
Hypercalcemia
Hyponatremia
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 ___ after you lost consciousness
while eating dinner with family. You were evaluated to
determine the cause of your loss of consciousness. You heart
was examined and it had normal rhythm and normal contractile
function. You were not found to have a blood clot in the lungs.
The most likely cuase of your loss of consciousness is
dehydration and decreased intake of food and liquid prior to the
event. Your symptoms of dehydration improved with fluids in the
hospital.
You were also noted to have a low sodium level in your blood.
This was likely from fluids that you received in the hospital.
You will need to get your blood sodium level checked at your
PCP's office on ___.
You were also found to have an elevated blood calcium level. It
is important that you stop taking your calcium and vitamin D
supplements for now until you follow-up with your primary care
physician.
For your diabetes, we have stopped one of your oral medications
called metformin because this can cause elevated lactate levels
due to your poor kidney function. Please STOP taking metformin
when you return home.
Finally, for your blood pressure, we stopped atenolol and
started metoprolol which is better for patients with kidney
disease.
Please continue to take all of your medications as prescribed
below.
It was a pleasure taking care of you.
Your ___ Care Team
Followup Instructions:
___
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Subsets and Splits